1 01.

Transfer of Multiple Injured Patients

Introduction: The simple sets of moving of multiple injured patients from one position to another may aggravate further trauma if done improperly, so transfer should be rapid but smooth and in proper way (Safe and rapid transfer of a multiple injured patient is vital because it may aggravate further trauma). When patient should be transferred/ Criteria for safe transfer: Airway clearance and establishment of breathing. Control any external bleeding by elevation or pressure, tourniquets. Protect the neck and spine by semi rigid cervical collar, sand bag, or forehead strapping. Splint obvious fracture Covering or sealing a sucking chest wound. I.V. channel if facilities available. Ways of Transport: 1. Ambulance 2. Truck 3. Passenger car 4. Helicopter if available Care during transportation: Resuscitation should be continued, with special attention to airway, obstruction and .. if patient is vomiting. Position of patient during transport: Supine except unusual circumstances. Accompanying persons: Trained person.. Time: Should not exceed 15 minutes. Pre-hospital time should not exceed 30 minutes.

Conclusion: Rapid but proper and safe transfer of multiple injured patients or reduce the (death rate) morbidity and mortality.

02. Choledocal Cyst

Introduction: It is a congenital anomaly (rare anomaly) of biliary tree by abnormal dilatation of either extra and intrahepatic biliary tree or both. It is a premalignant condition. Incidence: Female : Male = 4 : 1 1 : 100,000 to 150,000 live birth Aetiology: 1. Common channel theory: Reflux of pancreatic enzyme into bile duct. 2. Genetic factors 3. Infectious agent 4. Biliary autonomic dysfunction Type: 1. 2. 3. 4. 5. Type-I: Cystic fusiform Type-II: Supra-duodenal diverticulum Type-III: Choledochocele Type-IV: Combination of extra and intra-hepatic cyst Type-V: Intrahepatic cyst (Carolis disease)

Presentation: Episodic abdominal pain Intermittent jaundice Fever Abdominal lump Incidental dx Investigation: 1. USG of abdomen: Confirm the presence of cyst 2. Liver function test: Serum bilirubin: May Alkaline phosphatase: May 3. ERCP: Anatomical and morphological diagnosis Types of cyst 4. CT scan: In suspected malignancy 5. MRI: Reveals the anatomy Treatment: 1. Type - I: Excision of cyst followed by Roux-en-y hepatico-jejunostomy 2. Type - II: Excision and close the opening over T-tube 3. Type - III: Sphincteroplasty 4. Type - IV: Excision and Roux-en-y hepatico-jejunostomy 5. Type - V: Very difficult a) Liver resection b) Liver transplantation Importance: It is a premalignant condition. Complication: Stone formation Cholangitis Pancreatitis Obstructive jaundice Malignancy Conclusion: As it is a pre-malignant condition, it should always be excised.

03. Brain Death

Introduction: Brain death is defined as permanent functional death of the brain stem where neither consciousness nor spontaneous respiration is possible. It is intimately related with organ transplantation. Importance: Implications for organ transplantation before their circulation failed as it allow the removal of viable organs. Cause: 1. Traumatic head injury 2. Sudden intracranial haemorrhage Diagnosis: 1. Major brain damage of known aetiology 2. Deeply unconscious

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3. Require artificial ventilation Clinical tests for brain death: 1. Absence of cranial nerve reflex a) Papillary reflex b) Corneal reflex c) Gag and tracheal (cough) reflex d) Occulovestibular reflex 2. Absence of motor response 3. Absence of spontaneous respiration Who can declare? Two clinicians, one of this should be consultant; neither should be connected with transplant team. Examine in two separate occasions. Special Attention: To diagnose the brain death in neonates and infants. Conclusion: Most of the organs used for transplantation are obtained from brain steam dead and heart beating cadaveric donors, but it is not sufficient to need, so require increased awareness of both public and doctors for organ donation.

04. Priapism
Introduction: Painful persistent erection of penis with sexual stimulation. This patient needs management in special urological unit as it may lead to impotence. Cause: 1. 2. 3. 4. 5. 6. 7. Sickle cell disease Leukaemia Prolonged abnormal sexual ability Injection of .. into corpora cavernosa Pelvic malignancy Malignancy of corpora cavernosa After spinal cord injury

Pathology: Glans and corpora spongiosum are normal. Thrombosis at corpora cavernosa (is pathological where thrombosis occurs). Presentation: Sudden painful sensation at penis. Investigation: 1. Hb% 2. PBF: Exclude leukemia, sickle cell disease 3. Hb Electrophoresis 4. USG of abdomen: To exclude pelvic malignancy Treatment: It is difficult and no Rx is satisfactory 1. Needle aspiration of sludged blood from corpora cavernosa. 2. Injection of Metaraminol or 1:100,000 Adrenaline in corpora cavernosa. 3. Surgery: Anastomosis a) Between corpora cavernosa and one corpora spongiosum or b) Sapheneous Vein to corpora cavernosa 4. Selective arterial embolization. Complication: Impotency.

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Conclusion: It should be managed by specialist urologist but outlook for normal erectile function is poor.

05. Management of Torsion Testis

Introduction: It is an uncommon urological emergency where it can easily be confused with other causes of acute scrotum like acute epididymo-orchitis (A urological emergency and needs urgent intervention to save the testis). Presentation: Age: 10 and 25 years. H/O straining during defecation, lifting heavy weight, during sexual intercourse or during sleep. Complaints of sudden agonizing pain in the groin and lower abdomen. Vomiting O/E: High lie of testis to the diseased side. Testis becomes swollen and tender. Tender, thickened, twisted spermatic cord Elevation of testis worsens pain. Opposite testis may be horizontal in position.

D/D: 1. Acute epididymo-orchitis 2. Small strangulated inguinal hernia 3. Idiopathic scrotal oedema Investigation: 1. Urine R/E: To exclude UTI 2. Blood: TC, DC to exclude infection 3. Colour Doppler ultra sound: Lack of testicular blood flow (torsion) blood flow (Acute epididymoorchitis) 4. Radio-nucleotide scanning (Tc99m Pertechnetate scan): uptake (Torsion) uptake (Acute epididymoorchitis) Treatment: Treatment plan is operative. Operation: Exploration of testis. Option: It testis is viable Orchidopexy. If testis is not viable orchidectomy. In both cases - opposite testis should be fixed to prevent torsion. Conclusion: In bilateral cases Infertility may develop. So high index of suspicion is important.

06. Sacrococcygeal Teratoma

Introduction: It is a rare but most common large tumour seen during first 3 months of life. Cell of origin: Primitive node which is a group of totipotential cells. Site: Sacrococcygeal region, between sacrum and rectum attached to the coccyx and last piece of sacrum occasionally.

Nature: Benign Majority of newborn teratoma but malignancy increases with age of diagnosis. Type: 1. 2. 3. 4. Predominately external Both external and internal (presacral) Predominantly presacral Entirely presacral

Presentation: Female predominant. H/O twin may be present or complicated pregnancy. Mass in the sacrococcygeal region at birth. May present lately. Treatment: Excision of tumour and coccyx as soon as possible after birth. Approach: Type l, ll: Perineal Type lll, lV: Combined abdominal and perineal If malignant: Surgery + Chemotherapy Complication: Ulceration Infection Rectal and urinary obstruction Malignancy Recurrence Follow Up: At regular interval AFP DRE Conclusion: Prognosis is good if operation is done early after birth.

07. Rectal Prolapse in Infant

Introduction: Rectal prolapse in infant is usually partial and treatment is usually conservative. Prevention: Treatment of diarrhea and chronic cough. Improvement of nutritional status if malnutrition. Treatment: A. Conservative Treatment: i. Digital reposition: For 6 Weeks usually successful ii. Submucus injection: 5% e in almond oil under G/A If digital reposition fails. B. Surgery: Thiersens operation if conservative measure fails. Conclusion: Most of the patient improves with conservative treatment and some need surgical intervention, but it is associated with complication.

08. Preparation of Bowel in Colonic Surgery

Introduction: Large bowel is full of faecal matter and bacteria. So it is essential to prepare the bowel before colonic surgery. Aims: Eliminate the faecal mass. Reduce the number of bacteria.

Advantage: Decrease the chance of post-operative wound infection. Decrease the chance of anastomotic leakage. Prevent soiling. Methods: A. Elective gut preparation: 3 days preparation, mechanical clearance i. Low residual diet: Day 3rd and 2nd ii. Liquid diet: From day before operation iii. Laxative: a) Pieolax b) Polyethylene glycol + E.. c) Duralax : 2 tabs tds for 3 days iv. Enema simplex- 8pm before day of operation and at morning of day of operation. B. Bacteriological: Parenteral Inj Cefuroxime 250mg + Inj. Metronidazole 500mg at the time of induction and next C. Emergency preparation: On table lavage infusion fluid caccostomy or . D. Other methods of gut preparation: i. Whole gut irrigation: by N/S,12L/3 hours through NG tube ii. Oral Mannitol: 20% 300 ml Contraindication of mechanical clearance: GIT obstruction Perforation Severe inflammatory bowel disease Toxic .. Mega colon Weight < 20 kg Complication: Fluid and electrolytes imbalance Super infection Nausea Abdominal cramp Vomiting Anal .. Urticaria

Conclusion: Adequate gut preparation is essential for good outcome of patient after colonic surgery.

09. Idiopathic Scrotal Gangrene (Fourniers Gangrene)

Introduction: It is an uncommon and nasty condition of scrotum which needs immediate surgical intervention to prevent fatal complications characterized by sudden onset of scrotal inflammation, rapid onset of gangrene with exposure of scrotal contents and absence of any obvious cause in most of the cases. Pathology: Vascular disaster of infective origin where obliterative arteritis of arterioles to the scrotal skin. Aetiology: 1. 2. 3. 4. 5. Unknown Minor injury to the perineum e.g. bruise, scratch Urethral dilation Infection of haemorrhoid Drainage of periurethral abscess

Organisms: Mixed infection by Haemolytic streptococcus Staphylococcus E. coli Clostridium welchii Presentation: Sudden scrotal pain Prostration Pallor Pyrexia Sloughing out of scrotal wall and exposure of scrotal content Complication: Infection spread into anterior abdominal wall Sloughing of scrotal wall with exposure of both testis Bacteraemia, septicaemia

Treatment: A. Conservative: i. Wound swab for C/S ii. Antibiotic: a) Gentamycin b) Cephalosporin B. Surgery: i. Wide excision of necrotic scrotal skin ii. Wound closure by a) Secondary stitch or b) Skin grafting when clean wound and satisfactory general condition Conclusion: Despite active treatment many patients die.

10. Surgical Management of Impotence

Introduction: Impotence is a frustrating disorder which breaks the social and sexual life of the patient where 50% are due to organic disorder and surgery has a good role to improve this condition. Surgical causes of impotence:

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A. Vascular: i.

Arteriogenic: a) Cardiac: Myocardial ischaemia CCF b) Aortoiliac disease: .syndrome Atherosclerosis Embolic phenomena ii. Venogenic: a) Venous leak b) Abnormal venous drainage B. Disease of the penis: i. Inability to erect properly ii. Priapism iii. Penile fracture iv. Penile hypospaedias v. Severe vi. .. disease Clinical Feature: Inability to erect sufficiently for sexual intercourse. Investigation: History and physical examination suggest the cause in most cases but confirmatory tests are needed to ensure appropriate therapy 1. Lipid profile: Exclude atherosclerosis 2. Blood sugar: to exclude diabetes 3. Estimation of hormone level: Testosterone, LH, FSH, Thyroid 4. Evaluation of penile arterial system: Doppler-penile-brachial index: <0.6 suggests vascular cause 5. Evaluation of penile venous system: Cavernosography Cavernosometry Treatment: 1. Penile prosthesis: a) Semi rigid b) Inflatable 2. Arterial revascularization of penile arteries 3. Venous ligation 4. Surgery for other surgically correctable causes. These above methods can be used according to cause, experienced surgeons and availability of prosthetic materials. Conclusion: Satisfactory results are achieved by surgical treatment and many patients can enjoy their sexual and social life.

11. Mx of an Obstructed Ureter in a patient with Solitary Kidney

Introduction: It is a urological emergency, so immediate drainage above the obstruction is important to save the kidney function. Cause: 1. 2. 3. 4. Stone Blood clot Tumour Outflow pressure

Presentation:

9
Ureteric colic H/O haematuria Lump in the loin due to hydronephrosis Features of uraemia

O/E: Anaemia Dehydration Lump in the loin Investigation: 1. Blood urea: 2. Serum creatinine: 3. Serum electrolyte 4. USG of W/A: Hydronephrosis Associated pathology Causes of obstruction Treatment: 1. Immediate percutaneous nephrostomy under ultrasound guidance for drainage of obstructed kidney. 2. Immediate dialysis if needed. 3. After improving the renal function through evaluation of the patient and treatment according to cause. Complication:

Conclusion: This patient should be managed in specialized centre where all facilities are available.

12. Investigations for Haematuria

Introduction: Haematuria is always abnormal and it may be the only indication of pathology in the urinary tract. So thorough investigation is vital. Investigation: 1. Blood 2. Biochemical 3. 4. Urine: Macroscopic: Colour: Red Clear if microscopic Dipstick test: Presence of blood Microscopic: Cell: RBC, WBC, Pus cell: To exclude infection Bacteria by GM stain: To exclude infection Cast: RBC cast: GN

10
WBC cast: Pyelonephritis Granular cast: Renal TB Crystals: Exclude stone Cytology: Malignant cell to exclude malignancy BTA Bard: To exclude bladder neoplasm Culture: Routine culture For AFB Plain X-ray of KUB: To see stone disease USG o KUB: To see bladder tumour, kidney function Any upper tract change Blood urea: Serum creatinine: To see renal function IVU: To see both functional and anatomical abnormality of kidney Any filling defect in UT Clotting screening: To exclude blood dyscrasia Urethro-cystoscopic evaluation CT or MRI: To see tumour and extent

5. 6.

7. 8.

9. 10. 11.

Conclusion: It should be taken seriously and prompt investigations to detect the cause and its treatment are essential.

13. Post-operative Use of Physiotherapy

Introduction: It is the important part of management in a patient of post-operative care which starts pre-operatively. Aim: To reduce chest complications To prevent DVT Early recovery Prevent joint contracture

Indication: 1. Abdominal surgery 2. Neurosurgery 3. Thoracic surgery 4. Urological 5. Gynaecological 6. Orthopaedic surgery Pre-operative: Introduce the patient with the physiotherapist. Assessment of lung function. Post-operative: Reduce chest complication: o Sit up (Expansion of basilar lung segment): On the evening of surgery o Cough o Take deep breathe

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o Chest percussion Prevent DVT: o Encourage walking: It the circulation in the lower extremity. o Passive joint movement

Conclusion: Frequently we ignore this important aspect of post-operative care, so we need more consciousness about these measures.

14. Investigations of a Young Patient with BAT & Hypotension

Introduction: This patient needs resuscitation and assessment side by side. The patient is sent for investigations when stable. Investigation: 1. Blood grouping and cross matching: For immediate transfusion 2. Blood urea, electrolyte and haematocrit 3. X-ray chest (P/A view): Rib fracture close to the liver and spleen 4. Plain X-ray abdomen (supine): To show splenic, hepatic and renal shadow Ground glass appearance in intra-abdominal bleeding Psoas shadow: Obliteration in splenic injury Pelvic fracture 5. USG of abdomen: To detect intra-peritoneal collection of blood or fluid. 6. Focused assessment (abdominal) with sonography for trauma (FAST): Rapid and accurate detection of intra-abdominal blood or fluid. 7. Four quadrant tap 8. Peritoneal lavage: Inconvenient and time consuming 9. CT scan abdomen: Detection of the site of injury 10. IVU: To detect kidney injury 11. Diagnostic laparoscopy: In stable patient Conclusion: Tests must not interfere with life- saving treatment.

15. Clinical Features of Strangulated Inguinal Hernia

Introduction: A hernia becomes strangulated when the blood supply of its contents is seriously impaired and contents become ischaemic. Risk factor: 1. Indirect inguinal hernia 2. Worn a . for long time 3. Partially reducible or irreducible hernia Presentation: Varies according to the contents of the hernia H/O inguinal hernia for long time Symptoms: o If the content is intestine, then a sudden pain at the site of hernia which is followed by Generalized colicky abdominal pain Nausea and vomiting Sudden increase in hernial size Absolute constipation o If the content is omentum: Similar to strangulated bowel but no vomiting and constipation. O/E:

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o Tense, tender, irreducible hernia o No expansile cough impulse Late presentation: No pain: If perforation occurs Generalized peritonitis Septicaemia Strangulated inguinal hernia without obstruction: Richters hernia Ulters hernia Omentocele

Conclusion: Sometimes diagnosis not often obvious so careful examination of hernia orifices in all abdominal cases is essential.

16. Pancreatic Ascites

Introduction: Chronic generalized accumulation of pancreatic fluid in the peritoneal cavity without peritonitis or severe pain. Cause: 1. Leakage from pancreatic pseudo cyst 2. Pancreatic duct disruption History: H/O severe upper abdominal pain H/O abdominal trauma Symptom: Marked recent weight loss Ascites unresponsive to diuretics O/E: Anaemia Ascites Abdominal lump (pseudo cyst)

D/D: 1. Cirrhosis of liver 2. Abdominal TB Investigation: 1. USG of W/A: To see pancreatic pseudocyst Ascites Pancreatic oedema 2. Ascitic fluid analysis: Colour: Straw to blood stained Elevated amylase Protein: >2.9 gm/dl 3. ERCP: Confirm the dx: Point of fluid leak Plan for surgery 4. CT scan in combination with ERCP: Can diagnose tiny leakage from pancreatic leakage. Treatment: A. Conservative: 2 to 3 weeks i. Parenteral nutrition ii. Somatostatin B. Surgery: Roux-en-y pancreatico-jejunostomy or cysto-jejunostomy Indication: if conservative treatment fails.

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Conclusion: With appropriate treatment outlook is excellent.

17. Hartmanns Procedure

Introduction: It is a form of end colostomy made on sigmoid colon (to divert the faeces and flatus to the exterior and collected in an external appliance) usually on emergency basis. Indication: 1. Temporary: Volvulus of sigmoid colon where sigmoid colon was gangrenous. Rectal injury Acute large gut obstruction due to e.g. Malignant growth After resection . diverticulitis of sigmoid 2. Permanent: Ca rectum with old and debilitated patient Procedure: Through an abdominal incision Diseased bowel is removed Proximal colon is brought out as a colostomy and distal colonic stump is closed. Advantage: Defunctioning colostomy Less time consuming. Disadvantage: Need further laparotomy for closure. Complication: During operation: o Haemorrhage o Injury to the small gut o Injury to the bladder Post-operative: o Necrosis o Prolapse o Stenosis o Herniation Conclusion: It is an emergency procedure. so every doctor should know this procedure to save the life of the patient

18. Pathogenesis of Acute Haematogenous Osteomyelitis

Introduction: Acute osteomyelitis is a rapidly destructive pyogenic infection (usually haematogenous in origin) common in infant and children which needs immediate attention to prevent complications. Predisposing Factor: Age: Infancy and childhood, rarely other age Sex: Male : female = 4:1

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Trauma Haematogenic Penetrating injury Suppurative Bacteria, Septicaemia Poor nutrition Unhygienic surrounding Any focus of infection (boil, tonsillitis)

Location: Growing end of long bone (metaphysic of long bone due to peculiar arrangement of blood supply). Organism: 1. Staphylococcus aureus 2. Streptococcus 3. Pneumococcus 4. Salmonella typhi 5. Pseudomonas 6. Others: H. influenza, E. coli Specific: 1. TB 2. Syphilis Mechanism: 5 stages of acute osteomyelitis 1. Inflammation 2. Suppuration 3. Necrosis 4. New bone formation 5. Resolution and healing Pathogenesis: First marrow space infection Havarsian canal . canal .. 2nd bone infection Inflammatory cell Proteolytic enzyme Destruction of bone Pus formation in H. canal (Nertrophil, Macrophage) Infection reach the periosteum P. .. Necrosis soft tissue skin sinus Bone destruction Sequestrum ( bone in living body) Osteoblast found new bone .. Peculiar arrangement of blood vessels: 1. End artery: Branch of nutritional artery . Hairpin loop 2. Vascular stasis: Organism trapped 3. Bacterial colonization Site: 1. Upper end of Tibia 2. Lower end of Femur 3. Upper end of Humerus X-ray Finding: Involu..: Hyper opaque area parallel to hypodense area.. Type: 1. Infant group: <2 years of age a) Infection spread to the epiphysis as communication of epiphyseal and metaphyseal blood vessels b) Periosteum thin, so pus through the periosteum 2. Child group: > 2 years of age

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a) Infection not goes to epiphysis b) Thick periosteum Pus elevate the periosteum More sequestrum Presentation: Infant: o Irritability o Anorexia (constit.. symptom) o Reluctant to feed o Fever (toxaemia) Children: o Fever o Severe pain o Malaise

O/E:

Temperature Pulse Tenderness in the local area Fluctuation test: (+ve) Pus: Chronic osteomyelitis X-ray (. to 10 days):.. Leucocytosis: 30,000/cmm Blood C/S: 2 sample Pus C/S

Dx:

Rx of acute Osteomyelitis: 1. Immobilization of the limb 2. Antibiotic as early as possible: Flucloxacillin I.V Fusidic acid 3. Operation: Tourniquete Long incision Pus evacuation Multiple drill hole different . Open or Close (2 irrigation drain) Rx of chronic Osteomyelitis: 1. Sequestrum + No involve Splint 2. Antibiotic after blood C/S 3. .. involvement: Sequstrostomy + Sa..zation Conclusion: It may run in fulminating septic course and terminate . So early diagnosis and treatment is essential.

19. Froments Sign

Introduction: It is a sign of ulnar nerve palsy. Muscle examined: 1. Adductor policis longus 2. First palmar interossous

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Procedure: Sitting on bedside, if the patient holds a card between thumb and index finger Distal phalanx of the thumb becomes flexed as weakness of adductor policis permits over action of flexor policis longus. Falasy: This test becomes negative if associated with median nerve palsy. Conclusion: It is an important clinical test of ulnar nerve palsy, so every clinician should know this test.

20. Rehabilitation of an Amputee

Introduction: It is a great demand of an amputee to regain his independent life, so he requires motivation to achieve the best result multidisciplinary approach. Aim: 1. To return to independent life as far as possible. 2. To restore full social and work capacity as much as possible. Elements of Rehabilitation: 1. Ambulation: Prosthesis Wheel chair Crutch 2. Occupational support: Adaptation Change 3. Social support 4. Family support: Care at home 5. Spiritual support 6. Psychological support Involve Personnel: 1. Surgeon 2. Occupational therapist 3. Physiotherapist 4. Prosthetic therapist 5. Vocational training assistant Conclusion: It is a multidisciplinary approach but surgery has a major role to communicate with involve personnel for proper rehabilitation of his patent.

21. CDH (Congenital Dislocation of Hip)/ DDH (Developmental Dysplasia of Hip)

Introduction: It is a common congenital anomaly of hip (Now it is called more accurately DDH because it is associated with dysplasia or natural shallowness of acetabulum and anteverted femoral neck). It has wide spectrum presentation and suspicious is important for early dx. Incidence: 1 in 1000 infants. Aetiology: 1. Family history 2. Birth history: Breech presentation 3. Foot deformity

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4. . 5. Neuromuscular disease 6. Skeletal dysplasia Presentation: More in female (5 : 1) According to age: o Neonate: Clinical hip instability Barlows test Ortalani test o Infant: Limited hip abduction, extra thigh crease shortening of limb o Toddler: Limping o Child or adolescent: Pain Dysplasia Limps Lumbar lordosis o Adult: Degenerative change Pain in the hip Investigation: 1. X-ray of hip: More usual after the age of 3 months Displaced head lies laterally and superiorly Subluxation Dysplasia 2. CT scan of hip: In unossified hip 3. USG: Helps in unossified hip D/D: 1. Congenital abduction contracture of the hip 2. Congenital coxa vara 3. Muscle imbalance in CP Treatment: According to age A. Hip reduction (open flexed) B. Corrective osteotomy, acetabuloplasty, arthroplasty i. Infant: Hip reduction (Ortalani) and held in position by harness or splint for 8 weeks. ii. Toddler and young children: a) Closed methods or b) Open methods with or without femoral and innominate osteotomy c) Sometimes acetabuloplasty iii. Adolescent or young children: Realignment of joint through pelvic or femoral osteotomy with or without shelf arthroplasty Complication: Reduction cant be maintained AVN of femoral head Limitation of movement Conclusion: CDH is associated with other congenital anomalies which require special attention. Counseling is important.

22. Compartment Syndrome of Leg

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Introduction: Leg is the most common site of developing compartment syndrome as it is a fixed fascial compartment (especially on the anterior and deep posterior compartment). So it require special attention and strong suspicious for early dx to prevent its complication. Type: 1. Acute 2. Chronic Cause: 1. Acute: a) Trauma to leg b) Post-surgical c) Prolonged ischaemia due to reperfusion injury d) Burn 2. Chronic: Athlete Pathophysiology: Pressure within the compartment High pressure cut off blood supply to the limb Permanent damage to the muscle, nerves and vessels VIC Presentation: Acute: H/O trauma or operation followed by o Increasing pain in spite of splintage and analgesia o Pain in the muscle of the compartment with passive stretching Chronic: o Cramping pain during exercise o Relieve by rest Investigation: 1. Diagnosis mostly clinical 2. Measurement of compartment pressure in unconscious patient Complication: VIC. Treatment: A. Acute: i. Remove all plaster and cast ii. Fasciotomy if above measures fail B. Chronic: i. Correct abnormalities in gait and training methods ii. Subcutaneous fasciotomy if above measures fail Conclusion: It is a surgical emergency and urgent treatment is necessary to prevent devastating complication.

23. Tumour Marker in Thyroid Medullary Carcinoma (TMC)

Introduction: Tumour marker is a substance present in the body in a concentration which is related to the presence of a tumour. For early detection and follow up of TMC tumour marker is very helpful. As the TMC has familial prediction, tumour marker helps for screening, early dx and follow up in a patient with the family history. Name of tumour marker in TMC: 1. Serum calcitonin 2. Calcitonin gene related peptide Use: Screening: In follow up of TMC

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Diagnosis of TMC: > 0.08 ngm/ml Prognostic value Monitoring therapy: after surgery Early diagnosis of relapse: Raise again if tumour recur.

Disadvantage: Calcitonin is not specific for TMC, as bronchogenic and breast carcinoma also produce calcitonin. Conclusion: Raised calcitonin level with (+ve) family history of TMC [+ RET oncogene mutation prophylactic total thyroidectomy is advised prior to age of 6 years) needs genetic screening for prophylactic total thyroidectomy.

24. Hypercalcaemia
Introduction: When plasma calcium level > 2.5 mmol/L or 5mEq/L or 10mg/dl, it is called hypercalcaemia. It affects multiple organ system of the body. So early dx is vital. Normal value: 2.5 mmol/L. Cause: 1. Most common: a) Hyper parathyroidism b) Multiple boney secondaries 2. Other cause: a) Vit D intoxication b) Prolonged immobilization c) -alkali syndrome d) Sarcoidosis e) Thyrotoxicosis Affected organ: 1. CNS 2. GIT 3. Kidney Polyuria 4. Heart Cardiac . in systole Presentation: Sedation Vomiting Thirst Polyuria or oliguria Features related to cause In hypocalcaemia: Shvostek sign Trousseaus sign Investigation: 1) 2) 3) Serum calcium: > 2.5 mmol/L ECG: Prolonged P-R interval Wide QRS complex Shortened Q-T interval Plain x-ray of abdomen:

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4) Treatment: A. i. ii. iii. iv. B. Complication: Renal stone: Nephrocalcinosis Pancreatic calculi Other investigations related to cause Rx of hypercalcaemia: Hydration (4-6 liter/ 1st 24 hours) with N/S: a) Dilution b) Renal absorption Frusemide: Calcium excretion Bisphosphonates (Per enteral) : Bone resorption Avoid calcium containing diet: a) Calcitonin bone resorption b) Corticosteroid bone resorption Treatment of cause & complications Nephrolithiasis Nephrocalcinosis Pancreatic calculi Psychiatric disturbance Unconsciousness

Conclusion: Early detection and treatment of the cause is important to prevent complications.

25. Carcinoid syndrome

Introduction: It is a syndrome characterized by cutaneous flushing, diarrhea, bronchoconstriction and right sided cardiac valvular disease due to secretion of some active substance into blood by carcinoid tumour. Substance: 1. Serotonin 2. Histamine 3. Substance P 4. Motilin 5. Pancreatic peptide 6. PG Cause: 1. Metastatic carcinoid tumour in the liver from GIT 2. Carcinoid tumour other than GIT: Primary ovarian carcinoid Bronchial carcinoid Presentation: o o Features of carcinoid syndrome Features of primary tumour: GIT: Pain Bleeding obstruction Bronchus: Haemoptysis Cough

Investigation: 1. Urinary 5-hydroxy indoleacetic acid (5HIAA) Elevated (Hallmark of dx) 2. Provocation test: By injection of pentagastrin serum serotonin & substance P

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Symptoms 3. USG of W/A: To detect primary tumour in the gut, ovary 4. CT scan chest: To detect bronchial tumour Treatment: A. Medical treatment: To control symptoms by i. Octrcotide: Flushing, wheezing, diarrhoea ii. Phenothiazine, corticosteroid iii. Interferon : Tumour suppression, so of symptoms iv. Methysergide: For diarrhea + bronchospasm (5HT antagonism) v. -Methyldopa : For flushing B. Surgical treatment: i. Removal of primary tumour ii. Resection or multiple enucleation from hepatic metastases iii. Hepatic artery chemoembolization iv. 5FU if unresectable hepatic metastases Conclusion: It is a notorious disease but prognosis is good if no metastases before resection of primary tumour.

26. Investigation of Pheochromocytoma

Introduction: The diagnosis of pheochromocytoma is best made by simple laboratory investigations, the basis is measurement of elevated catecholamines and their metabolites in urine and blood. Like all other endocrine tumours pheochromocytoma dx is made first biochemically then localization and other investigations to exclude MEN-ll before operation. Diagnostic Test: 1. Urine: 24 hours urinary excretion of Free catecholamine > 100 gm Estimation of metanephrines > 1.3 mg Estimation of .. > 7 mg 2. Plasma: Total plasma catecholamine > 1000 gm/ml Localization Test: 1. USG of W/A: Most tumour visible 2. CT scan of abdomen: 90 95% accuracy 3. MRI: Characteristics bright appearance 4. Radionuclide imaging: Iodine labeled MIBG only abnormal area of adrenergic tissue uptake MIBG Normal adrenal tissue dont visualize For general assessment: Serum electrolyte Cardiac function Lung function Other foci of infection Operation for investigation: some drugs and diet may interfere the assay, so discontinue these drugs 2 weeks before measurement Drugs: o Paracetamol o -blocker o -blocker o Nitroglycerine

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o Diet: o o o Ca-channel blocker Tea, coffee Smoking Banana

Conclusion: Preparation for investigation is important for accurate diagnosis. Pheochromocytoma is a part of MEN ll, so exclude other components of MEN-ll before operation. Through assessment by other investigation along with diagnostic test is vital before operation.

27. Canulization by Exposure of Vein (Cut Down)/ Venesection

Introduction: Canulization of veins is required for administration of drugs, i/v fluids, transfusion of blood or perenteral bleeding. In most cases percutaneous puncture is used but sometimes cut down is needed. Venous cut down is frequently needed in clinical practice when superficial veins become collapse or large bore canulization is needed. Indication: 1) When superficial veins are thrombosed or collapsed. 2) Larger canula is required for rapid infusion. 3) Skill of placing central canula is not available. Commonly uses: Burn Shock Extensive soft tissue injury Exfoliative dermatitis. Procedure: 1) With all aseptic precautions under L/A, a small transverse incision is made over the vein 2) Superficial fascia is cleared by scissors and identification of vein is done 3) 2 ligatures are passed around it Distal is tied Proximal is half tide 4) A neck is made in the vein by pointed scissor 5) A canula is quickly inserted and proximal ligature is tied to enclose it 6) A stitch is passed to the skin and to tie the canula at its base 7) Skin incision is closed with two mattress suture Site: 1. Cephalic vein 2. Great saphenous vein Complication: Injury to the nerve Injury to artery Thromboembolism infection. Conclusion: It is a life-saving procedure and every doctor should know this procedure.

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28. Management of Asymptomatic Aortic Aneurysm

Introduction: Aortic aneurysm rarely produces symptoms and most of the cases are diagnosed incidentally on examination or by some other investigations. Common site: Below the renal artery (45%). O/E: Pulsatile upper abdominal mass just above the umbilicus may be found. Investigation: 1. USG of abdomen: Site and position of aneurysm. 2. CT scan of abdomen: Precise delineation of aneurysm Associated anomalies eg. Horseshoe kidney Retroaortic renal vein Duplicated vena cava Pancreatic mass 3. Aortogram: To see extent of aneurysm for plan of surgery Treatment: Depends upon the diameter of aneurysm 1. If > 5.5 cm diameter, surgery Open surgical repair Endoluminal stent graft 2. If < 5.5 cm: Follow up by serial USG Rate of expansion (0.4 cm per year) Indication of operation during observation: 1. Expansion rate > 0.5 1 cm/ year 2. Enlarging tender aneurysm Complication: Erosion of vertebral body Duodenal obstruction Aorto-duodenal fistula Rupture Conclusion: Proper follow up and decision making for surgery is important to prevent devastating complications.

29. Pre-emptive Analgesia

Introduction: Pre-surgical use of analgesia is called pre-emptive analgesia. It is a modern method of post operative pain control which is started pre-operatively. Aim: To reduce post-operative pain. Drugs used: Parenteral opioids Regional blocks NSAIDS These drugs are used either individual or in combination. Mechanism: Surgery sensitizes the CNS which enhances post-operative pain. Pre-emptive analgesia prevents this sensitization. So reduces post-operative pain.

24
Advantage: Early recovery Prevent complication Short hospital stay Disadvantage:

Conclusion: Concept of pre-emptive analgesia is effective for pos- operative pain relief which encouragse early mobilization and hospital discharge. For smooth PD recovery pre-emptive analgesia should be used in every patient.

30. Tissue Expansion

Introduction: It is a recent concept of reconstructive procedure by which extra skin can be gained. Aim: To gain extra skin from local area. The idea comes from abdominal expansion during pregnancy. Procedure: Subcutaneous insertion of a silicon bag which is gradually expanded by insertion of normal saline over a period of several weeks (6-8). Common site: 1. Scalp: To replace an area of alopecia by hairy scalp. 2. In breast reconstruction: To cover silicone implant. 3. For burn scar reconstruction. Advantage: Create a large flap of tissue Ideal flap can be reconstructed at the site of defect. Tissue is transferred by simple technique Sensation can be preserved Donor sit can be closed directly if sufficient tissue can be created. Disadvantage: Needs second operation. Infection, deflation and exposure of prosthesis. Skin necrosis when expansion is too rapid. Conclusion: The demand of this reconstructive surgery is gradually increasing.

31. Complication of Pneumonectomy

Introduction: Complications following pneumonectomy is three times greater on right than on the left. Although it is a major operation, complication is relatively less. Risk factor: 1. Elderly 2. COPD 3. Smoking

25
Complication: A.

B.

During operation: Haemorrhage: From hilar vessels, can be minimized by careful surgical technique. ii. Injury to trachea, pericardium, heart, oesophagus, aorta, thoracic duct and phrenic nerve. Post-operative: i. Early: a) Hypoxaemia: Due to pulmonary oedema, atelectasis, bronchopneumonia Rx: Underlying cause Breathing exercise b) Reactionary haemorrhage c) Cardiac complications: Atrial fibrillation, MI d) Pulmonary embolism e) Respiratory infection: Particularly in smoker Rx: Antibiotic Breathing exercise f) Persistent air leak: Rx: Chest tube drain If chronic: Re-thoracotomy and seal the leak. g) Broncho-pleural fistula: Small fistula: Diagnosed by x-ray to see the fluid level in the pneumonectomy space. Large fistula: Fluid re-enter into airway and severe respiratory distress. Rx: Chest tube drain Closure of fistula by resuturing the stoma ii. Late: a) Chronic thoracotomy wound pain. i.

Prevention of complication: Proper pre-operative assessment Stop smoking Meticulous surgical technique Good post-operative care Conclusion: Overall mortality after pneumonectomy is 6% but this can be reduced by adequate pre-operative work-up.

32. Ectopia Vesicae/ . Of the Bladder

33. Acute Scrotum

Introduction: Sudden onset of painful condition of scrotum which may need surgical intervention. Cause: A. Inflammatory: i. Acute epididymoorchitis:

26
Specific infection: TB Syphilis b) Non-specific: E. coli Staphyloccus. ii. Infected hydrocele B. Vascular: i. Torsion of testis ii. Acute haematocele C. Neoplastic: Hurricane tumour D. Skin condition: i. Cellulitis of scrotum ii. Infected sebaceous cyst iii. Fourniers gangrene (Vascular of infective organ) Presentation: Pain Fever Tachycardia Pain aggravate on elevation of testis: Torsion Pain relieved on elevation of testis: Epididymo-orchitis Investigation: 1. CBC 2. Urine R/M/E & Urine C/S 3. USG of testis 4. Radionucloides scan Treatment: A. General: i. Rest ii. Analgesic iii. Antibiotic B. Specific: Surgery for tumour . C. According to cause Conclusion: This emergency condition should be treated promptly. a)

34. Pheochromocytoma
Introduction: A patient with pheochromocytoma is hypovolaemic and hypertensive due to contraction of vascular bed by excessive circulating catecholamines, so careful pre-operative preparation is vital. Investigation: Dx is made first biochemically then localization and then investigation to exclude. Diagnostic test: 1. Urine: 24 hours urinary excretion of Free catecholamine > 100 gm Estimation of metanephrines > 1.3 mg Estimation of .. > 7 mg 2. Plasma: Total plasma catecholamine > 1000 gm/ml Localization test: 1. USG of W/A: Most tumour visible 2. CT scan of abdomen: 90 95% accuracy

27
3. 4. MRI: Characteristics bright appearance Radionuclide imaging: Iodine labeled MIBG only abnormal area of adrenergic tissue uptake MIBG Normal adrenal tissue dont visualize

For general assessment: Serum electrolyte Cardiac function Lung function Other foci of infection Operation for investigation: some drugs and diet may interfere the assay, so discontinue these drugs 2 weeks before measurement. Drug: o Paracetamol o -blocker o -blocker o Nitroglycerine o Ca-channel blocker Diet: o Tea, coffee o Smoking o Banana Aim: 1. To restore blood volume. 2. To prevent severe . With its potential complication 3. To allow the patient to recovery from cardiomyopathy Duration: 1 to 3 weeks. Methods: 1. Drugs: blocking drug: Phenoxy benzamine Initial dose: 20 to 40 mg/day, increased until hypotension is controlled and mild hypotension. blocker: Propanolol 3 to 7 days pre-operatively to control tachycardia and arrhythmia 2. Fluid: Preoperative fluid over load is advisable. 3. Drug available in OT: Nitropruside to treat .., sudden hypertension 4. blocker: To treat cardiac dysrhythmias. 5. Pre-operative consultation with cardiologist. Conclusion: It is a challenge to both surgeon and anesthetist. So adequate pre-operative preparation is essential to minimize complications.

35. Vesical Diverticulum with Stone Treatment

Introduction: Bladder diverticulum with stone is usually due to complication of BOO, so primary treatment is directed towards the cause, along with stone and diverticulum. Prevention: Early treatment of BOO Treatment of urinary infection and stagnation to prevent stone formation.

28
Surgical Treatment: 1. Treatment of the cause: a) BEP: TURP or open prostatectomy b) Stricture urethra: Urethroplasty. 2. Treatment of diverticula: Removal of stone with diverticulectomy. 3. Rx of complications: a) UTI: Antibiotic + H2O inflow b) Hydroureter + Hydronephrosis: PCN followed by specific Rx Follow up: Regular follow up to detect recurrent urinary obstruction. Conclusion: Early detection and treatment of BOO is important to prevent diverticula and stone formation.

36. Diabetic Foot

Introduction: Foot is the common site of various changes in a patient with uncontrolled diabetes mellitus. Pathophysiology: 1. Arterial disease: For example Atherosclerosis, 10 times more common than normal population 2. Microvascular disease 3. Susceptible to infection due to altered cellular and humoral response and excess glucose in tissue 4. Neuropathic change: Motor: Paralysis of small muscle of foot Sensory: Altered sensation Autonomic: Dry foot Presentation: H/O uncontrolled DM Typical presentation of deformed and infected fore foot with patchy gangrene. Investigation: 1. Blood and urine for sugar 2. Lipid profile: Hyperlipidaemia 3. X-ray Chest: To see cardiac abnormality 4. ECG: Cardiac anomalies 5. X-ray foot: To see bony change 6. Doppler study of lower limb: To see level of vascular obstruction Treatment: 3D diet , drug & discipline: 1. Control of diabetes by diet, exercise & insulin. 2. Treatment of local part (foot) Gangrene: local amputation Infection: Control by appropriate antibiotic Pus: Incision and drainage Wound: Dressing and kept open After control of infection wound is closed either by secondary suture or skin grafting. Prevention: Control of DM Care of foot: o Avoid trauma o Careful .

29
Conclusion: Control of diabetes and protection of foot is essential to prevent complications.

37. Use of Synthetic Material in Surgery

Introduction: In modern surgical practice the use of synthetic material is gradually increasing day by day due to its availability and good surgical outcome. Commonly used synthetic materials: 1. Suture: Natural Absorbable: Catgut, collagen Non-absorbable: Silk, cotton, Synthetic: Non-absorbable: Nylon, polyster : Dexon, vicryl, .. 2. Stunts 3. Graft 4. Catheter 5. Mesh 6. Lens 7. Orthopedic implant 8. Lap clip 9. Prosthesis: Penile Breast Various stent: GIT: o Self-expanding metallic stent o Elastin tube o Atkinsons suttar tube Hepatobiliary: o Biliary endoprosthesis o Self expanding tube Urinary: o Double J stent o Nephrostomy tube Vascular surgery: o Dacron graft o PTFE graft Mesh for hernia repair: o Prolene mesh o Dacron mesh Various orthopaedic implants: o Plate o Screw o Nail o Wire o DHS o DCA Eye surgery: Artificial lens for cataract surgery Laparoscopic clip Advantage: 1. Relatively inert

30
2. 3. 4. 5. Less tissue reaction Less chance of infection Gives adequate tissue strength Easily available

Disadvantage: 1. costly 2. Need experts for use 3. Not good handling property 4. Chance of implant failure 5. Blockage of stent Conclusion: Use of synthetic material makes the surgery easier with good outcome. Now-a-days use of synthetic materials is an essential part of various surgical practice.

38. Acute Respiratory Distress Syndrome

Introduction: It is a fulminating condition which may lead to MODS and death of the patient even after appropriate measures have been taken, so prevention is always vital. It is one of the important causes of pulmonary failure in surgical patient. Cause: 1. Direct lung injuries (respiratory cause): a) Blunt injury to the chest resulting pulmonary contusion b) Aspiration of gastric contents c) Inhalation of toxic fumes d) Bacterial, viral or drug induced pneumonia e) Oxygen toxicity 2. Indirect Cause (non-respiratory cause): a) Major and multiple trauma b) Sepsis c) Shock due to any cause d) Massive transfusion e) Massive burn f) Pancreatitis g) DIC Pathophysiology: Shock, Causative agents, Hypoxia Neutrophils, Platelets, Macrophage all are activated Mediator release, toxic free radicals Wide spread endothelial damage Plasma extravasates into interstitium, alveoli and pulmonary oedema Thickening of alveolar capillary membrane Impaired ventilation and oxygenation ARDS and multiple organ failure. Diagnostic Criteria: 1. A cause 2. Severe hypoxia PaO2 < 60 mm of Hg PaCO2 > 50 mm of Hg 3. New bilateral infiltrate on chest x-ray 4. Pulmonary capillary wedge pressure < 18 mm of Hg Clinical Feature: Lethargy Restlessness Coma Cyanosis Features of respiratory and metabolic acidosis

31
Treatment: 1. 2. 3. 4. 5. 6.

Management is entirely supportive Patient must be transferred to ICU Ventilation: spontaneous, assisted or via ETT Medication: Ionotropic and vasoactive drugs eg. Dobutamine, Dopamine Antibiotics Steroids: Methyl prednisolone (large dose) Diuretic (Frusemide) H2 blocker Rx of primary causes Monitoring: Cardiac function parameter Pulse BP ECG Arterial pressure CVP with pulmonary arterial pressure (Swan-ganz catheter) Blood gas analysis Acid base balance Urine output Development of bed sore

Conclusion: Prognosis is poor even if effective treatment is started. Counseling is vital.

39. Early Carcinoma Breast: Roll of Screening

Introduction: Prognosis of breast cancer is closely related to stage at diagnosis. Screening program which can detect early breast cancer may reduce mortality from breast cancer. Objective: 1. Early detection of breast cancer before clinically evident. 2. Reduce the morality and morbidity related to advance breast carcinoma. Advantage: Avoid expensive and toxic treatment of advanced breast cancer. Extra year of productivity. Reassurance is negative. 5 years survival rate near about 30% patient. Disadvantage: Cost of additional case treated. Morbidity of .. Over diagnosis Anxiety in positives False reassurance of false negative Conclusion: Every woman of > 50 years should attend the screening program regularly to detect early breast cancer.

40. Study Protocol

Introduction: It is a set of rules or uniform methods of approaching a problem.

32

Contains: 1. A paragraph on the back ground of the proposed study 2. Aims and objectives 3. A clear methodology 4. Definition of population 5. Sample size and methods of proposed analysis 6. Patient number 7. Inclusion and exclusion criteria and 8. The timescale for the work Prerequisites: 1. Fund collection 2. Obtaining ethical approval 3. Data collection form should be designed 4. Computer collection package 5. Safeguards for privacy and confidentiality Involve personnel: Other specialties Clinicians Conclusion: A universal study protocol should be constructed in our country to improve medical science. .

41. Problem of Operating a Sliding Inguinal Hernia

Introduction: Unlike other hernia surgeon may face greater difficulties during operation of a sliding hernia as posterior wall of sac is formed by colon or bladder. Problem of operation: 1. Failure to identify organ incorporated into posterior wall sac results in inadvertent entry into lumen of the bowel or bladder. 2. If the sac has been opened it is difficult to close the sac. 3. Ordinary ligature and removal of the sac at its neck are impossible. 4. Sometimes ureter may accompany with the viscus and risk of injury. 5. Posterior wall of inguinal canal may result in difficulty of repair 6. May need laparotomy to reduce hernia. Conclusion: Patience, careful and meticulous dissection is vital to avoid complication during sliding hernia repair.

42. Toxic Megacolon

Introduction: Acute dilatation of colon with a diameter of > 6 cm is called toxic magacolon. It is a fulminating colitis which needs immediate hospitalization and combined core of both medical and surgiery for better outcome. Site: Usually transverse colon. Cause: 1. Ulcerative colitis 2. Crohns disease

33
3. Other type of colitis eg. amoebiasis, salmonellosis Pathology: Inflammation involving all layers of colon. Risk Factor: 1. Hypokalaemia 2. Opioid use 3. Anticholinergic drug Presentation: O/E: 1. 2. Severe abdominal pain Diarrhoea

Toxic, tachycardia Signs of peritonitis may be present if perforation occurs.

DRE: Finger stained with Blood Mucous Pus. Investigation: 1. Plain x-ray of abdomen: > 6cm diameter 2. Serum electrolyte with other investigations for assessment Treatment: A. Conservative: NPO Hydrocortisone Broad spectrum antibiotic Cyclosporine Fluid and electrolyte balance Surgery: i. If conservative treatment fails ii. Complication Option: Total abdominal colectomy with ileostomy followed by restorative operation. i. ii. iii. iv. v.

B.

Complication: Perforation Peritonitis. Prognosis: Mortality rate is 6% in emergency colectomy. Conclusion: Need regular follow up.

43. How Do You Care a Cancer Patient Who Cant be Cured?

Introduction: This is a terminally ill patient and care is entirely palliative which will increase the equality of rest of the life and ensure painless death. Aims of palliation: 1. To restore the quality of living (symptom control) 2. To take the fear out of dying (spiritual support) Place of care: Home

34
Hospital Hospice Care: Symptom control General care If fracture: Stabilization Bone pain: Local radiation Agitation: Midazolam 4 hourly Catheterization of bladder Respiratory secretion & cough: Anticholinergic drugs Haemoptysis/ haematemesis: No blood transfusion No I.V Midazolam Nausea and vomiting, may be due to hypercalcaemia: Stemetil Largactil Prednisolone Constipation: Laxative Diarrhoea: Antiparasitic eg. Loparamide Dyspnoea: Bronchodilator Diuretic Position `Depression: Amitryptyline Muscle spasm Anorexia: Feabrable diet Fit and convulsion: Diazepum Urinary incontinence: Catheterization

1.

2.

3. 4.

5.

6. 7. 8.

9. 10. 11. 12. 13.

General Measure: Room set up for proper care Mobility aid eg. wheel chair Support of his relatives Reassurance to the patient Conclusion: Terminal care is an interdisciplinary team approach which includes the patient and their family.

44. D/D of Low Back Pain Which Radiates to Leg

Introduction: Low back pain is the commonest symptom encountered in orthopaedic practice which commonly affects children and young adult and occasionally make them crippled. So proper evaluation is vital for management. D/D: A. In adult: i. Spinal: a) Mechanical derangement (traumatic): PLID Spinal stenosis Spondylolisthesis Vertebral fracture b) Infection: TB spine

35
Vertebral osteomyelitis Discitis Tumour: Primary: Multiple myeloma Second to lumbar vertebra eg. breast, prostate. Others: Osteoporosis with vertebral collapse ii. Extra-spinal: Abdominal aortic aneurysm Any pelvic tumour involving sacral plexus B. Children: i. Tubercular osteomyelitis ii. Discitis due to infection iii. Malunited old vertebral fracture iv. Disc protrusion in adolescent Diagnosis: For diagnosis proper history, thorough physical examination and relevant investigations should be done. Conclusion: The knowledge of anatomy of spine and nerve distribution is vital for dx and treatment of LBP.

45. Prevention of DVT in Routine Surgery

Introduction: DVT is not uncommon in surgical practice particularly in orthopaedic and urological surgery. It is a life threatening condition which may lead to sudden death of a patient. So prevention is vital especially in high risk patients. Risk Factor: 1. Age > 60 years 2. Obesity 3. Immobility 4. OCP 5. Heart failure, previous DVT 6. Types of surgery eg. orthopaedic surgery Prevention: A. Pre-operative: i. Weight reduction ii. Stop OCP one month prior to surgery iii. Correction of dehydration iv. Identification of high risk group B. Per-operative: i. Physical means: a) External intermittent pneumatic compression b) Passive leg exercise c) Electrical stimulation of calf ii. Chemical: Low dose s/c heparin on premedication C. Post-operative: i. Early mobilization ii. Massage and leg movement iii. Adequate hydration iv. Continued s/c heparin and start oral anticoagulant when patent can take orally Conclusion: It is a serious life threatening complication which may lead to sudden death or postthrombotic limb or venous ulceration. So prevention is vital. Every effort should be made to prevent this complication.

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46. Care of Tracheostomy

Introduction: Tracheostomy is a life-saving procedure but post-operative care of tracheostomy is essential for proper functioning. Care: 1. Maintain patent airway: Frequent atromatic suction Humidification Mucolytic agent or isotonic saline to liquefy mucus Encourage coughing and physiotherapy Bronchial lavage 2. Prevent infections and other complications: Aseptic suction, handing and tube changing Prophylactic antibiotic Avoid tube impinging on post tracheal wall Deflate cuffed tube for 5 min in every hour Repeated daily clinical and radiological assessment 3. Replacement of tube: 1st change at 3 days, then daily 4. Final removal of tube: Depends on the blood gas before and after removal Conclusion: Post-operative care is vital to prevent complication.

47. Tracheo-oesophageal Fistula

Introduction: It is an abnormal communication between trachea and oesophagus which needs immediate treatment to prevent complications. Incidence: 1 in 3000 birth. Cause: 1. Mostly congenital 2. Advanced oesophageal malignancy involving the trachea Embryology: Error in the separation of primitive foregut. Associated anomalies: Oesophageal atresia Duodenal stenosis Cardiac anomalies Imperforated anus Type: 1. Lower segment of oesophagus opens into the trachea 2. Upper segment open into trachea 3. Both segment open into trachea Clinical Feature: Regurgitation of first and subsequent feeds Trickling of saliva Cough, cyanosis during feeding In advanced oesophageal malignancy: Features of oesophageal malignancy.

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Confirmation: Clinical: via N-G tube Comes against an obstruction within 10 cm Radiological: Chest X-ray (Lateral view) o Radiolucent proximal pouch which displace the trachea anteriorly o Bowel gas: Fistula to the distal oesophagus Treatment: A. Congenital: Surgery Separation of oesophagus from trachea and closure of fistula and anastomosis between two segments. B. Malignancy: Palliativei. Stenting ii. Radiotherapy Complication: Aspiration pneumonia. Conclusion: After surgery long term prognosis is excellent in congenital cases but in malignancy outlook is poor.

48. GI Complications of Radiotherapy

Introduction: Complications of radiotherapy is mainly related to destruction of rapidly proliferating cells. GIT is one of them. Mechanism: Complication results from damage to normal tissue particularly stem cells of GIT. Complication: Acute/ early: Due to inflammation, oedema, erythema and desquamation of epithelial cells within 5 days o Vomiting o Diarrhea o Ulceration o GI bleeding o GI perforation Chronic/ Late within weeks or months o Gastroenteritis o Intestinal obstruction o Fistula formation o GI malignancy Factors on which complication depends: 1. Age of the patient 2. Presence of co-morbid disease 3. Use of adjuvant chemotherapy 4. Total dose 5. Fraction and time course of treatment Conclusion: Proper selection of patient, adjustment of dose and duration of treatment is vital to minimize the complications.

49. Treatment of Umbilical Discharge

Introduction: The umbilicus is a central abdominal scar, so that leak from any viscus can be tracked to the surface of this point.

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Cause: A. Congenital: i. Patent vitellointestinal duct ii. Patent urachus B. Acquired: i. Inflammatory: a) Omphalitis b) Umbilical granuloma c) Umbilical dermitis d) Pilonidal sinus ii. Neoplastic: a) Benign: Adenoma Endometrioma b) Malignant: Primary Secondary: Stomach Colon Ovary, uterus Breast C. Miscellaneous: i. Biliary fistula ii. Faecal fistula iii. TB peritonitis Investigation: 1. Discharge for C/S 2. USG of W/A: To find out the cause 3. Fistulogram: If fistula to see internal communication 4. Chest x-ray: To exclude tuberculosis 5. Exclude urinary tract obstruction 6. Incisional biopsy: To exclude malignancy Treatment: According to cause 1. Patent vitellointestinal duc: Excision together with Meckels diverticulum 2. Patent urachus: Remove obstruction of urinary tract if any Umbilectomy and excision of urachus down to its insertion into the apex of urinary bladder if leak continued after removal of obstruction 3. Omphalitis: Antibiotic Warm, moist dressing Separation of crust and drainage of pus Application of silver nitrates 4. Umbilical granuloma: Once application of silver nitrate Dry dressing 5. Pilonidal sinus: Excision 6. Umbilical adenoma: Application of ligature around it .. Umbilectomy If above measures fail Recurrence 7. Endometrioma: Umbilectomy 8. Secondary: Palliative Conclusion: Proper evaluation is vital for effective treatment.

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50. Patient for ICU and HDU

Introduction: ICU and HDU is a specialized unit which provides a safe environment for treating the critically ill patient. ICU: ICU is an area to which patient are admitted for treatment of actual or impending organ failure who may require technological vital organ support eg 1. Mechanical ventilation of lungs 2. Invasive cardiopulmonary monitoring 3. Haemofiltration or haemodialysis mechanism 4. Extra corporeal oxygenator Here nurse and patient ratio is 1:1 Criteria of patient for ICU admission: 1. Mechanical support for vital function 2. Patient needs close monitoring eg. Patient need BT Infusion of ionotropic drug 3. Heavy nursing eg. care of skin, wound, drain and fluid and electrolyte balance and nutrition HDU: It is an intermediate care unit between general ward and intensive care unit where more intensive observation and/ or nursing care is expected than general ward. Here nurse and patient ratio is 1:2 Monitoring: Continuous monitoring of pulse, ECG and body temperature Each bed station has piped O2 Criteria of HDU: 1. Patient needs close monitoring 2. Heavy nursing Patients need mechanical ventilation or invasive monitoring would not admit in this area. Advantage: Safe environment for ill patient Close monitoring Heavy nursing Disadvantage: Costly Cross infection Conclusion: It should be offered only to patients who really need it as it is very costly.

51. Screening of Prostatic Cancer

Introduction: Carcinoma of the prostate is the commonest malignant tumour in men over the age of 65 years. When it presents it is already in advanced stage, so for early detection screening is very important. Aim: To detect and treat the disease at an early curable stage.

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Who should be screened? 1. All male patient > 50 years of age 2. Family history of Ca prostate at 40 years of age Tools: 1. DRE 2. PSA 3. TRUS Combination of DRE & PSA is most effective Advantage: Improved prognosis Less radical curative treatment Reassurance for negative test result Disadvantage: Cost of additional case treated Morbidity of test Over diagnosis Anxiety in positives False reassurance of false negative Conclusion: Every male > 50 years should attend the screening program regularly to detect early prostatic cancer.

52. Mx of Clot Retention of Urine

Introduction: Clot retention is a urological emergency, this patient needs immediate relief of retention. Cause: 1. Post-operative: a) Prostatectomy b) TURP c) TURBT 2. Non operative: Urinary bladder tumour a) RCC b) Stone c) Disease d) Trauma e) Renal TB Presentation: H/O operation, trauma or haematuria Painful distension of lower abdomen Inability to pass urine O/E: Distended bladder. Treatment: A. Post operative retention: i. Stop irrigation ii. Evacuate the clot by tommy syringe iii. If not relieve, remove the catheter and put another catheter iv. If still not relieved: Cystoscopic removal of clot and coagulation of bleeding vessels. B. Non operative:

41
i. ii. iii. Catheterization and bladder wash, then Cystoscopy and removal of clot if not successful Treatment of definitive cause

Conclusion: Every effort should be made to prevent the clot retention.

53. Complications of Catheterization

Introduction: It is a common urological procedure but there is every chance of complications if we do not care during catheterization and post procedure Mx. Complication: A. During procedure: i. False passage ii. Haemorrhage iii. Injury to the urethra B. Post procedure: i. Early: a) Infection: Urethritis Cystitis b) Catheter block c) Bacteraemia d) Urine leakage by the side of the catheter e) Accidental removal of catheter ii. Late: a) Encrustation and stone formation of the catheter tip b) Stricture urethra: Penoscrotal Meatal Prevention: Aseptic precaution Prophylactic antibiotic Well lubrication and adequate local anaesthesia Proper size of catheter Gently during procedure Fixation of catheter to the anterior abdominal wall Post catheter care Treatment: 1. 2. 3. 4. False passage: SPC Infection: Urine C/S and antibiotic Encrustation: regular deflation and inflation of balloon post procedure Stricture urethra: Urethroplasty

Conclusion: Every effort should be made to prevent complication.

54. Clinical Application of LASER

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Introduction: Laser (Light Amplification by Stimulated Emission of Radiation) is a high power source of light energy leading to coagulation obstruction of tissue protein on striking human tissue. In the modern medical science uses of laser is increasing rapidly because it covers wide spectrum of medical subspecialty and has less side effect. Type: 1. Argon 2. CO2 3. Nd-YAG Mechanism of action: 1. Tissue destruction by: Thermal Non-thermal Vaporization 2. Haemostasis by: Denaturation of protein by coagulation and contraction of fibrous tissue Thrombosis of blood within vessels Clinical use: General surgery 1. Bleeding peptic ulcer 2. Mucosal vascular malformation of GIT 3. Early gastric carcinoma 4. Obstructing of bleeding colorectal carcinoma 5. Liver resection 6. Laparoscopic surgery 7. Haemorrhoidectomy

55. Prevention of Post-burn Contracture

Introduction: Post-burn contracture is a major disabling and disfiguring complication of burn contracture which makes the patient disable and disfigured, but it can be prevented by proper care of burn wound. Objective: 1. To maintain optimum joint function of affected part. 2. To prevent disfigurement during recovery phase. Prevention: 1. Proper wound care by Provide aseptic environment as possible to prevent infection. Topical antibiotics Occlusive dressing: Minimize exposure Re-epithelialization Wound debridement if needed 2. Splints of joint 3. Elevation of part to maintain a functional position 4. Start immediate physiotherapy 5. Use of pressure dressing and elastic garments to limit scar hypertrophy. 6. Prevention of re-injury 7. Cover the wound by skin as soon as possible Conclusion: Every effort should be made to prevent post-burn contracture.

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56. Tubercular Tenosinovitis

Introduction: It is an uncommon condition involving synovium and tendon sheath by tubercular infection. It can produce disability and disfigurement if not treated properly. Causative agents: Atypical mycobacterium. Presentation: 1. Features of chronic synovitis eg. pain, swelling, tenderness 2. In hand: Present as multi-loculated compound palmer ganglia Cross . Test positive Pain along median nerve distribution 3. Constitutional symptoms of tuberculosis Investigation: 1. Local x-ray 2. CBC 3. Chest x-ray to exclude tuberculosis 4. Synovial biopsy Treatment: A. Conservative: i. Immobilization of joint ii. Anti TB B. Surgery: In severe and intractable case Synovectomy (synovial effusion containing melon-seeds) + Anti TB Complication: Tendon rupture Joint stiffness Muscle wasting

57. Subangual Melanoma

Introduction: It is an acral lentigious melanoma which occurs beneath the nail bed. It is more aggressive than other melanoma and usually needs finger amputation. Incidence: 2 to 8% all melanoma. Type: Acral lentigious. Cell of origin: Epidermal melanocytes. Behaviour: Malignant (more aggressive than other melanoma). Mode of spread: 1. Local 2. Lymphatic: Embolism Permession 3. Blood

44

Presentation: Local lesion: Beneath the nail bed Satellite nodule Intransit deposit Inguinal lymph nodes (Region LN) Features of metastases Investigation: 1. Excisional biopsy: Always needed 2. CXR: To detect metastases 3. USG of W/A: To detect metastases 4. FNAC: From regional lymph nodes if present Treatment: Depends upon stage of the disease 1. Stage l: Amputation via neck of proximal phalanx/ . amputation 2. Stage ll: Above + LN dissection + removal of satellite nodule 3. Stage lll: Palliative Prognosis: Very poor. Follow up: Follow up at regular interval.

59. Triage
Introduction: Triage means to shift or sort and refers to the allocation of injured patients into certain categories for action by emergency teams. Type: A. Triage sieve: Quick survey to separate the dead and the walking from the injured. B. Triage sort: Remaining casualities are assessed and allocated into 3 or 4 groups. i. Category l: Critical and cant wait, ega) Airway obstruction b) Catastrophic haemorrhage ii. Category ll: Urgent, eg. Serious injury but can wait for a short time 30 minutes. iii. Category lll: Less serious injury, not endangered by delay. iv. Category lV: Expectant, severe multisystem injury, survival not likely. Involved personnel: 1. Triage sieve: Done by paramedics 2. Triage sort: Done by experienced doctor Advantage: Categorize the injured patients on the basis of need. Disadvantage: Need expertise Resources Extensive training program Conclusion: Failure to perform correct triage will disrupt optimal management for the need.

60. Pseudomyxoma Peritoni

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Introduction: It is a rare disease characterized by copious production of mucinous ascites that fills the peritoneal cavity. It is usually secondary to intra-abdominal malignancy. Incidence: 1 : Per million/year. Cause: 1. Mucinous cyst adenocarcinoma of ovary and appendix 2. Tumour from other intra-abdominal organs eg. Stomach Colon GB Bile duct Behaviour: Borderline malignant. Spread: No lymphatic or haematogenous spread. Presentation: Variable Gradual abdominal distension Acute appendicitis New onset inguinal hernia Pain in the abdomen Investigation: 1. USG of W/A: Peritoneal scalloping of liver margin Calcified plaques Ascites Low density masses 2. CT scan of abdomen 3. Image guided percutaneous biopsy 4. Diagnostic laparotomy: Jelly belly appearance Treatment: Options1. Surgery: Debulking of mucous and tumour by blunt dissection Radical peritonectomy 2. Adjuvant chemotherapy: 5FU based 3. Adjuvant intracavitory radiotherapy Complication: Recurrence IO Perforation Prognosis: 50% 5 years survival with treatment. Follow Up: At regular interval as recurrence is common. Radical peritonectomy: Principles of complete cyto reduction in pmp 1. Greater omentectomy with splenectomy 2. Stripping of hemi-diaphragm 3. Stripping of right hemi-diaphragm 4. Cholecystectomy and lesser omentectomy 5. Distal gastrectomy 6. Pelvic peritonectomy with resection of rectosigmoid by anterior resection.

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61. Post-traumatic Amnesia

Introduction: It is the time between the head injury and the return of continuous memory. Cause: Head injury due to RTA Assault Fall from height. Type: 1. Retrograde: Forgetting events before the injury 2. Antigrade: Forgetting injuries and subsequent events Importance: It is a good guide to assess the severity of head injury Amnesia: 0 1 hour (mild) Amnesia: 1 24 hours (moderate) Amnesia: 1 7 days (severe) Amnesia > 7 days (very severe) Presentation: H/O head injury followed by loss of memory. Investigation: 1. X-ray of skull: To see fracture 2. CT scan of brain: If amnesia > 24 hours Treatment: Expectant. Conclusion: Most of the patients recover and return to work within 8 weeks.

62. Paraneoplastic Syndromes

Definition: Symptom complex in cancer bearing patients that can readily be explained, either by the local or distant spread of the tumour or by the elaboration of hormone indigenous to the tissues from which the tumour arose, are known as paraneoplastic syndrome. Incidence: 10% of all patients with advanced malignancy. Factors producing paraneoplastic syndromes 1. Hormones: ACTH or ACTH like molecule ADH Insulin or insulin like peptide PTH related peptide 2. Cytokines: TNF IL1 Antibody to tumour antigen Clinical Syndromes: 1. Endocrinopathies: Cushings syndromes Syndrome of inappropriate ADH secretion Hypercalcaemia

47
Hypoglycaemia Neurologic: Myasthenia Neuropathies Cerebellar atrophy Dermatologic: Achanthosis nigricans Dermatomyositis Haematologic: Venous thrombosis DIC Osseous: Hypertrophic osteo-arthropathy

2.

3.

4. 5.

Tumour producing syndromes: 1. Small cell carcinoma lung 2. Carcinoma breast, renal, prostate, ovary 3. Carcinoma pancreas, adrenal, GIT Investigation: Related to primary disease. Treatment: Treatment of primary disease according to staging. Conclusion: It is not always indicated in advanced malignancy. Treatment of primary tumour can eliminate the related symptoms.

63. Ludwigs Angina: Treatment & Dangers

Introduction: It is a cellulitis involving the sublingual and submandibular spaces beneath the deep cervical fascia. It is a life threatening condition which needs immediate attention and appropriate measures should be taken to save the patients life. Cause: 1. 2. Invariably due to dental sepsis Associated with carcinoma of floor of mouth

Organism: 1. Virulent streptococci 2. Anaerobic organism Treatment: A. Prophylactic treatment: Early detection and treatment of dental sepsis B. Conservative treatment: In early stage i. I.V. broad spectrum antibiotic eg. Amoxicillin/ Cefuroxime + Metronidazole. ii. Supportive treatment C. Surgical treatment: In advanced stage i. Drainage of both submandibular triangles by a curved submental incision and decompress the floor of mouth by incising the myelohyoid muscle. ii. Wound closed keeping a drain iii. Supportive treatment with broad spectrum I.V. antibiotics Dangers: Dysphagia (Due to tongue displaced upwards and backwards) Airway obstruction (Due to tongue displaced upwards and backwards) Spread and involve the larynx causing glottic oedema Septicaemia

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Conclusion: Prompt and adequate treatment is vital to prevent complications.

64. Diagnosis of Intracranial Tumour

Introduction: All most all brain tumours behave in a malignant manner because of their infiltrating and progressive nature and they lead to death if not treated, so early diagnosis and Rx is vital. Criteria: 1. Age: 2 peak ages At 2 years of age Late adulthood (50 60years) 2. Sex: Male predominant Presentation: Features of raised ICP: o Headache: Dull to stretching the dura o Nausea and vomiting o Visual disturbance due to papilloedema o Deterioration of level of consciousness Focal neurological sign: Related to area of cortex involved o Motor o Sensory o Visual disturbance o Aphasia o Change in personality and behaviour Seizure: Due to irritation of cortical tissue o Focal o Generalized Symptoms of primary tumour in metastatic brain tumour O/E: Bradycardia HTN Papillooedema If pituitary tumour Findings related to hormone secretion by tumour itself

Investigation: 1. X-ray skull: Widening of sella tursica Copper . appearance 2. CT scan of brain: Before and after contrast Localize the lesion Confirm the lesion 3. MRI: More accurate than CT scan specially for low grade lesion. 4. Other investigations: Related to hormone secreted pituitary tumour. For metastatic tumour- Search for primary tumour accordingly. Conclusion: Early diagnosis and prompt treatment is essential for better out come.

65. Explain the Deformity of Claw Hand

Introduction: Claw hand is a deformity which makes the patient deformed and less functioning hand. It has both neurological and non-neurological causes. Though mechanism is different, Deformity is similar.

49
Neurological causes: Hyperextension of metacarpo-phalangeal joint and flexion of inter-phalangeal joint due to paralysis of intrinsic muscles of hand and unopposed contraction of long flexors and extensors of hand is called claw hand. Types: 1. True claw hand 2. Ulnar claw hand Explanation: Of true claw hand Normal function of intrinsic muscle of hand Flexion of MP joint and extension of IP joint In claw hand Lesion of both ulnar and median nerve causes paralysis of intrinsic muscle, so unopposed action of long flexor and extensor of hand produces claw hand. Explanation of ulnar claw hand: Due to injury to the ulnar nerve claw hand involve only little finger and ring finger due to paralysis of interossi and 3rd and 4th lumbricals. 1st and 2nd lumbricals are escaped as it is supplied by median nerve. Non-neurological cause: Contracture of both flexor and extensor tendons associated with boney deformity. Conclusion: In spite of early treatment outcome is not satisfactory.

66. Carotid Body Tumour ( ..)

Introduction: It is a rare tumour arising from carotid body which is located at the postero-medial side of the carotid bifurcation. It is a rare primary tumour of the neck usually occurs in a patient living in high altitude. Cells of origin: Chemoreceptor cells of carotid body. Behaviour: Usually benign but in 10% cases metastases may occur. Aetiology and pathogenesis: Chronic hypoxia leading to carotid body hyperplasia. Susceptible Individual: Those living in high altitude. Clinical Feature: Age: 5th decade Sex: 1 :1 Painless, slow growing lump at the lateral side of neck May present with pharyngeal mass O/E: Solitary, pulsatile neck mass Firm to rubbery in consistency Moves more on side to side than up and down Bruit may be present

Investigation: 1. Duplex study: Confirm the Dx 2. Angiography: Characteristic tumour blush at carotid bifurcation Separation of internal and external carotid artery

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3. FNAC/ Biopsy: Contra-indicated Treatment: 1. Complete excision: It is the preferred treatment with or without vascular reconstruction. 2. Elderly and unfit patient: No surgery, only follow up. 3. No role of radiotherapy and chemotherapy. Complication: Local extension Metastases Conclusion: Prognosis is good after surgical excision but needs special vascular unit where all facilities exist.

67. Thoracic Outlet Syndrome/ Sclenus Syndrome/ Shoulder Girdle Syndrome/ Adsons or Cervical Rib Syndrome
Introduction: It is the variety of disorders caused by abnormal compression of arterial, venous or neural structures in the base of the neck. Cause: 1. Bones: a) Cervical rib b) Clavicle fractures c) Transverse process of C7 2. Muscles: a) Scelenus anterior b) Pectoralis minor 3. Bands: Fibro-muscular band Presentation: 3 groups of presentation Local: Lump in the lower part of the neck which is boney hard, fixed and tender. Neurogenic: Along the distribution of lower trunk of brachial plexus o Sensory: Tingling, numbness and pain along the medial side of forearm and hand o Motor: Wasting of thenar and hypothenar eminence of hand Loss of power of hand o Vasomotor: Excessive sweating of hand and circulatory impairment leading to gangrene. Vascular: Due to stenosis or thromboembolic manifestation o Pale on elevation o Blue on prolonged dependent position o Pain ischaemic O/E: Muscle wasting Diminished radial pulse Bruit over subclavian artery Lump on the neck Adsons test: May be +ve

D/D: 1. Raynauds phenomenon 2. Cervical spondylosis

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Investigation: 1. X-ray cervical spine( AP and lateral view) To see cervical rib To exclude spondylosis 2. Arteriogram: To see subclavian and axillary artery stenosis Treatment: According to cause 1. Cervical rib: Extraperiosteal excision (with periosteum) 2. Scelenus anterior: Scelenotomy 3. Bands: Removal of bands 4. First rib removal 5. Sympathectomy Conclusion: This annoying and disabling condition should be treated promptly to avoid complications.

68. Effects of Commonly Used Antiseptic Solution on Skin Bacterial Flora during Routine Operation
Introduction: Antiseptics used for skin preparation are chemical solutions which destroy usually vegetative form of organisms. Antiseptics used for skin preparation should be broad spectrum and bactericidal without affecting the host tissue. Commonly used antiseptic solution and their effects: A. Povidone iodine: Broad spectrum bactericidal activity Some sporicidal activity and antifungal Advantage: o Fast acting o Less staining o Less irritant Disadvantage: o Moderately expensive o Some hypersensitivity and local wound toxicity B. Chlorhexidine: Acts on both Gm (+)ve and Gm (-)ve organisms Advantage: o Persistent action o Non toxic o Stable in presence of pus and body fluid Disadvantage: Moderately expensive. C. Cetrimide (Savlon): Moderately Gm (+)ve activity but poor Gm(-)ve activity Advantage: o Cheap o Odorless o Nonirritant D. Alcohol (70% ethyl alcohol/ Isopropyl alcohol) Advantage: o Broad spectrum activity o Rapid action Disadvantage: Flammable Moderately expensive

52

Conclusion: For better effect skin should be scrubbed first with soap water before application of antiseptic solution.

69. Commonly Used Antiseptics in Surgical Practice

Introduction:

Ideal criteria: Broad spectrum against organism and spore. Rapid action Not be inactivated by blood, pus and faeces Non-toxic, non-irritant and non-hypersensitive Type: 1. Inorganic 2. Organic Inorganic: 1. Iodine (Lugols iodine): Advantage: Cheap Broad spectrum activity Disadvantage: Stains and irritates the skin Hypersensitivity and contact dermatitis 2. Povidone Iodine: Advantage: Cheap Broad spectrum activity Disadvantage: Stains and irritates the skin Hypersensitivity and contact dermatitis 3. Chlorine: Eusol (Edinburgh University Solution of Limes) Advantage: Cheap Broad spectrum in activity Disadvantage: Locally toxic. 4. H2O2: Cheap, slow and weak bactericidal activity. Organic: 1. Alcohol 2. Phenol: Toxic Expensive Irritate the skin 3. Lysol: Cheap Less toxic Active in presence of organic matter 4. Dettol: Less effective

53
5. 6. 7. 8. Chlorhexidine Cetrimide Formalin: 120 ml of 40% formalin is used for killing the hydatid cyst Mixture: a) Alcohol + Chlorhexidine b) Alcohol + Povidone iodine c) Chlorohexidine + cetrimide

Conclusion: For better effect skin should be scrubbed first with soap water before application of antiseptic solution.

70. Management of Inguinal Hernia in a 9 Months Old Baby

Introduction: Inguinal hernia is a common condition in infancy and childhood occurring in 1% of all children. Inguinal hernia in infancy needs always surgery as it may lead to life threatening complications. Opposite site must be evaluated at the same time. Aetiology: Due to patent processus vaginalis. Type: Nearly always indirect variety. Clinical Feature: Male more than female More on right side (60%) Inguinal bulge more when baby strains or cries May present with complications: o Strangulation o Incarceration O/E: Both testis must be examined. Treatment: Operation is the treatment of choice and done as soon as the diagnosis is made. Name of operation: Herniotomy. Incarcerated Hernia: Initially reduced by sedation and elevation of foot of bed with gentle constant pressure over the internal inguinal ring. If not reduced within 1 hour Operation If reduced, operation is done after 48 hours In strangulated hernia: Emergency operation. Dealing of opposite site: Laparoscopic exploration to see patient processus vaginalis. If present treat it at the same sitting. Conclusion: Urgent treatment is necessary to prevent complications.

71. Steroid Dependent Patient & Surgery

Introduction: Adrenocortical suppression occurs in steroid dependant patient and it carries additional risk in surgery. So proper pre-operative preparation is vital to prevent complications. Risk:

54
1. 2. 3. 4. Collapse and shock after unrecognized blood loss MI Septicaemia Infection and poor wound healing

Additional risk: HTN OM GI Bleeding. Preparation: Emergency: o For minor surgery: 24 hour additional steroid cover - Hydrocortisone 100mg I/M 6 hourly o For major surgery: 3 days additional steroid cover - Hydrocortisone 100mg I/M 6 hourly Routine: o Stop steroid 2 months before o If possible start with premedication then either tapered or abruptly withdraw. Supportive Treatment: 1. Good antibiotics 2. Adequate fluid balanced 3. Control of IHD, DM Conclusion: Intense care is needed to prevent complications.

72. Surgical Complication of Typhoid Fever

Introduction: Typhoid fever is a common systemic illness caused by Salmonella typhi. It may turn into fatal complications if untreated (Though typhoid fever is medical disease but surgeons can encounter when complications arise). Complication: 1. Intestine: Paralytic ileus Perforation Haemorrhage 2. Hepatobiliary: Cholecystitis 3. Venous: Phlebitis 4. Genitourinary: Typhoid cystitis Pyelitis Epididymo-orchitis 5. Joint: Arthritis 6. Bone: Osteomyelitis Treatment of complication: 1. For perforation: Peritoneal toileting and ileostomy 2. For cholecystitis: Cholecystectomy 3. Other complication: Needs primarily medical treatment but may need surgical intervention. Prevention:

Conclusion: Early diagnosis and treatment of typhoid fever is vital to prevent complications.

55 73. Complications of Colostomy

Introduction: It is a life-saving procedure and (overall complication rate is 20%) most of the complications are due to poor technique and it is preventable. Complication: During operation: o General o Specific Post-operative: o Early o Late: Stenosis Metabolic complication e.g Gall stone, Skin irritation 1. Prolapse: More in loop colostomy 2. Retraction: Due to tension, infection or technical error 3. Necrosis: More in distal end 4. Stenosis: Due to ischaemia or recurrent Crohns disease 5. Colostomy hernia: Due to large hole in the abdominal wall 6. Bleeding: From granuloma around the margin 7. Colostomy diarrhea: Due to infective enteritis 8. Stomal obstruction: Due to faecal impaction stenosis 9. Fistula formation: Due to through and through suture 10. Skin irritation Treatment of complication: Majority of complications need refashioning and some improve with conservative treatment. Prevention: 1. Meticulous surgical technique 2. Avoid ischaemia to the gut 3. Skin incision should be disc shaped 4. Proper post-operative care e.g adequate hydration Conclusion: Meticulous surgical technique is needed to prevent complications.

74. Therapeutic ERCP

Introduction: ERCP is a modern and minimally invasive technique and its therapeutic use is either palliative or curative for (therapeutic and diagnostic purpose for the disease of) hepatobiliary and pancreatic duct system. Therapeutic Indication: Curative Palliative 1. Stone extraction from CBD and pancreatic duct by sphincterotomy with dormia.. busket or balloon extraction. 2. Endo prosthesis insertion Inoperable (Palliative): Cholangiocarcinoma Ca head of pancreas Periampullary carcinoma Benign stricture: When balloon dilatation fails of CBD and pancreatic duct 3. Balloon dilation of biliary stricture 4. Sphincterotomy for papillary stenosis

56
5. Transnasal biliary drainage Patient Preparation: 1. Investigation: Liver function test PT HBsAg USG 2. Counseling: About procedure About complications 3. NPO for at least 6 hours 4. Prophylactic antibiotic e.g. Cefuroxime, Aminoglycoside Complication: During procedure: o Bleeding o Perforation of duodenum Post procedure: o Cholangitis o Acute pancreatitis o Bacteraemia o Septicaemia Advantage: Minimally invasive procedure Less hospital stay No G/A Convenience to the patient Disadvantage: Costly Expertise needed Not available Post-operative follow up: For at least 8 hours. Conclusion: It is a costly procedure but its invention obviates the need for many open surgical procedures in HBS and pancreas (Its use is gradually expanding).

75. Pre-Operative Preparation for Obstructive Jaundice

Introduction: Surgery in a patient with obstructive jaundice may develop many complications, so adequate pre-operative preparation is vital to minimize the complication. Aim: To minimize the complications. Problem in surgery: 1. Infection: Cholangitis Septicaemia Wound infection 2. Bleeding: Due to abnormal clotting mechanism 3. Renal failure 4. Liver failure

57
5. Fluid and electrolyte abnormalities Pre-operative Preparation: 1. Correction of coagulation abnormality by Inj. Vit K(10mg) I.M or I.V for 3 days or FFP 2. Prevention of Liver failure: High CHO diet I.V 10% glucose infusion 3. Prevention of renal failure: Adequate pre-operative hydration I.V Manitol > If needed Frusemide > If needed 4. Correction of fluid and electrolyte imbalance 5. Prevention of infection: By prophylactic antibiotic at the time of induction 6. Correction of anaemia by BT and improvement of nutritional status 7. Pre-operative biliary drainage: Controversial Advantage: Less bleeding Less chance of renal failure Less infection Smooth recovery Conclusion: Proper pre-operative preparation is essential to prevent complications.

76. ITP and Splenectomy

Introduction: Splenectomy is one of the treatment options of ITP, many patients can be cured by splenectomy but proper selection is important. Indication of splenectomy in ITP: 1. In children: a) Severe cases which have relapsed b) Girls approaching menarche 2. In adult: a) Patient who do not respond to corticosteroid therapy for more than 6 9 months b) Relapse after initial response on steroid c) Steroid dependent patients Preparation of splenectomy in ITP: 1. Correction of coagulation abnormality by a) Fresh blood transfusion b) Platelet transfusion c) Immunoglobulin 2. Correction of anaemia by blood transfusion 3. Treatment of infection by antibiotic 4. Prophylactic vaccination with pneumovax Contraindication of splenectomy: Acute phase of ITP Results of splenectomy: Cured: 60% Improved: 20% No benifit:15% Conclusion: To get benefit from splenectomy in ITP proper selection of patient is important. This patient needs regular follow up.

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77. Treatment Options of Pancreatic Pseudocyst

Introduction: Treatment of pancreatic pseudocyst is needed to improve symptoms and to prevent complications. Treatment options: Depends upon Duration of cyst Size of cyst Symptoms of the patient A. Expectant treatment: For spontaneous resolution Indication: i. No symptom ii. Size of cyst < 5 cm iii. Duration < 6 12 weeks B. Drainage: i. External drainage: Indication: a) Critically ill patient b) Cyst wall not mature c) Symptomatic patient d) Percutaneous drainage under ultrasonoguided ii. Internal drainage: Indication: a) Symptomatic b) Mature cyst c) Cyst size < 5 cm Option: a) Roux-en-y cysto jejunostomy (best) b) Cystogastrostomy c) Cystoduedenostomy C. Excision of cyst: i. Cyst in the tail of pancreas ii. Occurs following trauma Conclusion: Prognosis is good after treatment but proper selection is important.

78. Indication of Hepatic Resection

Introduction: Wide knowledge of segmental anatomy of liver and with the invention of USG hepatic resection becomes easier, which may be the treatment of choice in many conditions. Indication: A. Traumatic: Severe shattering liver injury confined to one lobe. B. Neoplastic: i. Benign: Large haemangioma ii. Malignant: a) Primary: HCC High cholangiocarcinoma b) Secondary: Solitary lesion from colorectal, adrenal etc. C. Parasitic: Hydatid cyst D. Congenital: Carolis disease if confined to one lobe. Resectability: Non-cirrhotic liver 80% Cirrhotic liver: o Child A: major resection

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o Child B: limited resection o Child C: minor resection Contra-indication: 1. Involvement of IVC 2. Extrahepatic malignancy 3. Involvement of both lobe of liver 4. Involvement of portal vein Complication: Bleeding Infection Biliary fistula Metabolic consequences

Conclusion: With the invention of CUSA hepatic resection can be done more conveniently. Liver resection should be done in specialized hepatobiliary unit where all facilities of liver resection are available.

79. Clinical Feature & Outcome of Cerebral Concussion

Introduction: Cerebral concussion is a type of primary brain injury where there is transient loss of consciousness with quick recovery due to diffuse neuronal damage. It is diagnosed clinically. Clinical Feature: H/O trauma to the head followed by Transient loss of consciousness Sweating Amnesia Lethargy Irritability Memory dysfunction Bradycardia Hypotension Outcome: A. Spontaneous and quick recovery. B. Post-concussion syndrome: Due to early return to work i. Headache ii. Irritability iii. Depression iv. Vertigo v. Lassitude C. Secondary brain injury: i. Intracranial haematoma ii. Brain swelling iii. Hypoxic brain damage iv. Infection v. Meningitis vi. Cerebral abscess vii. Epilepsy viii. Psychiatric disturbance Conclusion: Every effort should be made to prevent secondary brain injury.

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80. Hydrocephalus
Introduction: Hydrocephalus is a disproportionate increase in the amount of CSF within the cranium usually associated with raised ICP. Aetiology: A. Congenital: Aqueduct stenosis B. Acquired: i. Obstruction in anywhere of CSF pathway: a) Neoplastic: Cerebral tumour b) Intracerebral or intra-parenchymal haemorrhage causes scarring c) Meningitis: Causes scarring aqueduct, basal cistern or over cerebral convexities. ii. Over production of CSF due to choroid papilloma Pathogenesis: Imbalance between normal physiological production of CSF and absorption. Clinical Feature: Depends upon the age of the patient Neonatal period: o Increasing head circumference o Tense frontanelle o Failure to thrive o Feeding problem o Sun-setting appearance Older children and adult: o Symptoms of ICP: Headache Nausea Vomiting Deterioration of level of consciousness o Visual disturbance o Symptoms of neoplasm itself Investigation: In neonates: 1. Measurement of head circumference 2. Crack pot on percussion Older children and adult: 1. X-ray skull: Widening suture line Copper beating appearance Erosion of pituitary fossa 2. USG: If anterior frontanelle patient To see ventricle 3. CT Scan of brain: For neoplasm Site of obstruction 4. MRI: For planning of surgery Treatment: Primarily surgical A. Medical: Reduce CSF production by i. Acetazolamide ii. Frusemide B. Surgical: i. Removal of tumour if present.

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ii. Shunt operation: a) VP shunt b) VA (Ventriculo-Right Atrial) c) VPL (V. Pleural cavity) Bypassing obstruction: a) Canulation of aqueduct b) Third ventriculo-cisternostomy Ablation of intraventricular choroid plexus

iii. iv.

Prognosis: If it is due to benign tumour: With treatment the prognosis is good. With other condition: Outcome is not satisfactory. Conclusion: Early diagnosis and proper treatment (improves outcome of treatment) is vital to prevent permanent cerebral damage.

81. Diagnostic Criteria of Hirschsprungs Disease

Introduction: It is a type of megacolon and the most common cause of constipation in infant and older children. Incidence: 1 in 4500. Pathology: Absence of ganglion cells in the neural plexus of the intestinal wall with hypertrophy of nerve trunks producing aganglionic segment and physiological obstruction. Aetiology: Failure of cephalocaudal migration of ganglion cells into the distal bowel. Type: 1. 2. 3. 4. Ultra short segment Short segment/ recto sigmoid Long segment Extensive aganglionosis

Clinical Feature: Male 4 times than female In neonates: o Delayed passage of meconium o Mild abdominal distension In children and adult: o Constipation o Progressive abdominal distension o Nutritional deficiency o No vomiting DRE: D/D: 1. 2. 3. 4. Finger grip like ladys hand shake No rectal dilatation Acquired megacolon Hypoganglionosis less functioning ganglion cells Oligoganglionosis less number of ganglion cells Meconium ileus

Investigation: 1. Plain X-ray abdomen: Distended bowel loop

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Small gut Large gut 2. Water soluble contrast enema Uniform area of narrow segment starts from anus Proximal dilatation Funnel shaped transitional segment 3. Full thickness rectal biopsy: Site, dilated, Less ganglionic cell Thickened nerve bundle 4. Anorectal monometry: Rectosphincteric inhibitory reflex absent Treatment: The principle is removal of disease segment and anastomoses of normal segments of gut with the anus. Procedure: A. Staged procedure: i. 1st stage Colostomy ii. 2nd stage Resection of aganglionic segment and pull through procedure B. Single stage procedure No colostomy Name of operation: Duhamel Swensons Coloanal anastomosis Restorative proctocolectomy Conclusion: Prognosis is good with operation.

82. Meconium Ileus

Introduction: This is the neonatal manifestation of cystic fibrosis (It is one of the important causes of neonatal intestinal obstruction and usually associated with cystic fibrosis). Incidence: 10 20% infant with cystic fibrosis. Aetiopathogenesis: Deficiency of pancreatic enzymes Meconium become thick and inspissated and filled in the terminal ileum Produce obstruction. Presentation: No passage of meconium Progressive abdominal distension Bilious vomiting O/E: Distended abdomen Rubbery swelling on abdomen

Investigation: 1. Plain X-ray abdomen: Distended small intestine with mottling (soap bubble) 2. USG of W/A: Echogenic shadow with distended bowel wall 3. Contrast X-ray: By gastrografin enema (Confirm the Dx) Microcolon with meconium flecks Pellets of inspissated mucus at terminal ileum Distended proximal bowel Complication:

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Volvulus neonatorum Gangrene, perforation and meconium peritonitis Atresia of ileum Complications associated with cystic fibrosis

D/D: Hirschsprungs disease. Treatment: A. Non-operative treatment: i. NG tube suction ii. I.V fluid iii. Gastrografin enema under fluoroscopic control B. Operative: If above measures fail then Laparotomy with options i. Bishop-Koop ii. Anti-Bishop-Koop iii. Resection with: a) Anastomosis b) Double barrel stoma with closure 3 months later Conclusion: All patients should be evaluated for cystic fibrosis. This patient should be managed in specialized paediatric unit.

83. Coronary Angioplasty

Introduction: It is one of the modern methods of coronary re. for the treatment of IHD. Indication: 1. Clinical: Short history of angina resistant to medical treatment 2. Anatomical: Patient with proximal lesion in one or two vessels Contraindication: 1. Triple vessels disease 2. Left main coronary artery disease 3. Diffuse of calcified stenosis 4. Previous coronary spasm Procedure: Passing a small balloon tipped catheter into the femoral or radial artery retrogradely into the aortic root Inject dye into coronary ostia to see the coronary anatomy Pass a catheter across the stenosis and inflated Crush the atheromatous plaque. Advantage: Minimally invasive Less hospital stay Patient convenient Disadvantage: Not all patient are suitable Restricture and occlusion is high Complication: Local trauma Coronary dissection Occlusion and rupture of coronary artery MI Restricture Conclusion: Many patients can avoid open operation but chance of restenosis is high.

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84. Treatment of Post-operative Hypoxia in an Old Patient

Introduction: An old patient has more chance of developing post-operative hypoxia due to decreased lung compliance and increased dead space. Post-operative hypoxia is a serious complication as it may lead to death of a patient more seriously in an old patient. So intense monitoring throughout the post-operative period is vital. Risk Factor: COPD. Causes of Post-operative Hypoxia: A. Pre-operative: Pre-existing lung disease i. COPD ii. Asthma B. Operative: Surgery in the neck, chest and upper abdomen i. Pulmonary aspiration ii. Injury to the larynx during intubation C. Post-operative: i. Inadequate reversal from anaesthesia ii. Excess opiates iii. Pain iv. Respiratory obstruction: a) Secretion b) Tongue fall back c) Foreign body d) Laryngeal oedema e) Pressure from outside: Paratracheal haematoma Tracheomalasia Prevention: Treatment of any pre-existing lung disease Pre-operative assessment of lung function Prevention of aspiration during induction Adequate recovery from anaesthesia Treatment: 1. Treatment of the cause 2. Adequate analgesia 3. Secretion: Frequent suction 4. Tongue fall back: Cheen lift Oropharyngeal tube Foreign body: Remove it Haematoma: Open the wound including deep fascia and take the patient to OT Tracheomalasia: Tracheostomy Laryngeal oedema: Inj. Hydrocortisone 5. 100% O2 inhalation by mask 6. Monitor: Blood gas analysis and chest X-ray as soon as possible Conclusion: Adequate pre-operative assessment and intense care during post-operative period is vital to prevent post-operative hypoxia.

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85. Presentation & Treatment of Paravertebral Abscess

Introduction: Paravertebral abscess is commonly due to spinal tuberculosis. Most common cause of paravertebral abscess in our country is due to spinal TB which may lead to cripple the patient. So early dx and Rx is vital. Cause: 1. TB of spine is most common. 2. Pyogenic infection of spine e.g: Staphylococcus Streptococcus Pneumococcus Site: Commonly 1. Thoracic spine 2. Lumbar spine Source: 1. Tubercular: Haematogenous spread from tubercular focus elsewhere in the body 2. Pyogenic: Haematogenous and lymphatic spread from septic focus Presentation: Constitutional symptoms Local symptoms Symptom of complications Tubercular: Young adult Pain and stiffness in the back Deformity and localized swelling in the back Involvement of spinal cord: o Weakness of legs o Visceral dysfunction Other features of TB Pyogenic: Acute onset Pyrexia Local pain and restriction of spinal movement Features of spinal cord compression O/E: Ill looking Angular kyphosis Local tenderness

Investigation: A. Blood count: i. ESR ii. Leukocytosis in pyogenic B. X-ray spine (B/V): i. In TB spine: a) Early: Narrowing of intervertebral space Local vertebral osteoporosis b) Late:

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Destruction of vertebral bodies Collapse and wedge-shaped deformity c) Abscess: Thoracic: Fusiform paraspinal shadow Lumbar: Lateral bulging at psoas outline ii. In pyogenic: a) Erosion of bone b) Disc space c) Abscess shadow may be found C. CT or MRI: To see the spinal cord compression Spread of pus: From thoracic: Over the chest wall or in the flank From lower thoracic and lumbar: o Iliac fossa (Psoas abscess) o Posteriorly o In the thigh D/D: 1. Ankylosing spondylitis 2. PLID 3. Spinal tumour Treatment: A. Conservative: i. Anti TB drugs: for 9 - 12 months ii. Drainage of abscess: With closure of skin a) Aspiration b) Incision iii. Spinal support: a) Plaster jacket b) Brace B. Surgery: i. All diseased bones are excised and gap is covered by bone graft and spinal stabilization. ii. Anti TB drugs C. Pyogenic: i. Antibiotic according to C/S ii. Drainage of pus iii. Spinal support Conclusion: Early diagnosis and treatment is vital to prevent dreadful complications.

86. Treatment of Discharge from Female Breast Nipple

Introduction: Nipple discharge is a common problem in female breast. It may be physical or pathological and the treatment is directed towards the cause. Causes of Discharge: A. Physiological: Nipple discharge in newborn B. Pathological: i. Duct ectasia ii. Duct papilloma iii. Malignancy

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iv. v. vi. Fibrocystic disease Infection From surface: a) Pagets disease b) Eczema c) Psoriasis

Treatment: Exclude carcinoma by Occult blood test of discharge Cytology of discharge 1. Reassurance: For benign disease 2. Surgery: a) Microdochectomy for single duct b) Cone excision of major duct c) Segmental mastectomy for multiple duct 3. Malignancy: Rx according to staging 4. Infection: Drainage and antibiotic 5. Pagets disease: Exclude malignancy 6. Eczema: a) Local treatment b) Biopsy - if persist 7. Psoriasis: Local treatment Conclusion: Proper evaluation to exclude malignancy is vital.

87. Pre-operative Counseling in a Patient with Carcinoma Colon

Introduction: Pre-operative counseling is an important part of management in surgery especially for malignant disease. Counselor: 1. Surgeon himself 2. Stoma therapist - if stoma is needed Place of counseling: Private and free of any disturbance or interruption. Counseling for Ca colon: 1. About the disease 2. Treatment options 3. Plan of treatment and outcome of surgery 4. About colostomy: Temporary or permanen 5. Post-operative complications: Impotence Incontinence of both bladder and bowel 6. Life-long follow up 7. Recurrence of malignancy 8. Adjuvant therapy Conclusion: Counseling should be written and undersigned by the patient himself or relatives when appropriate.

88. Oxygenation in a Critically ill Patient

Introduction: The patient who cant maintain vital function without mechanical means is a critically ill patient and this patient needs oxygenation to combat tissue hypoxia.

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Method of oxygenation: Controlled intermittent positive pressure ventilation. Procedure: 1. Established an artificial airway: Endotracheal tube Tracheostomy 2. Suppress the patients drive to spontaneous respiration by Opiates Benzodiazepine Muscle relaxant 3. Monitor the patient and machine Benefit of artificial ventilation: Elimination of CO2 Improved oxygenation Hazards: 1. Complications of artificial airway: Trauma Obstruction Displacement 2. Accidental displacement from ventilator 3. Pneumothorax, surgical emphysema 4. Acute dilation of stomach 5. RTI Weaning: Patient takes breath spontaneously for an indefinite period Ability to cough effectively Conclusion: Adequate oxygenation and proper care can save the patients life. This patient needs ICU management for proper care.

89. Treatment Options of Locally Advanced Malignant Tumour

Introduction: Locally advanced malignant tumour are those which has invaded the surrounding tissue and Rx is either curative or palliative depending upon surrounding tissue involvement and presence or absence of distal metastases. Aim: 1. Adequate control of local disease 2. Prevent distal metastases Plan of treatment: Curative: If no distant metastases Palliative: If distant metastases Treatment Modalities: Depends on Histological type Grading Site Sensitivity to chemotherapy, radiotherapy or hormone therapy The treatment modalities are 1. Surgery

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2. 3. 4. 5. 6. Chemotherapy Radiotherapy Hormone therapy Laser and intervention radiology Combination of above

Example: A. Surgery: i. Ca Breast: Toilet mastectomy ii. Ca Bladder: a) Radical cystectomy + Pelvic lymphadenectomy b) Salvage cystectomy iii. Colorectal carcinoma: a) APR b) Anterior resection c) Removal of growth + tissue from post abdominal wall iv. Ca Prostate: Channel TURP B. Chemotherapy: i. As neo adjuvant: a) Osteosarcoma b) Ewings sarcoma c) Ca Breast ii. Adjuvant: Ca Breast C. Radiotherapy: i. As neo adjuvant: a) Rectal carcinoma b) Oesophageal carcinoma ii. As adjuvant: SSC of skin iii. As curative: SSC, BCC iv. Hormone therapy: a) Ca Breast b) Ca Prostate v. LASER therapy: a) Ca Oesophagus b) Ca Prostate vi. Intervention radiologist: To relieve obstruction e.g. stenting in cholangiocarcinoma, Ca Oesophagus Conclusion: Proper planning and choice of appropriate modalities of treatment is vital for good outcome.

90. Adjuvant Therapy

Introduction: It is an extra remedy added to the treatment of malignant disease after surgery and/ or radiotherapy to increase its effectiveness. Indication: Patient at high risk of post-operative recurrence. Modalities of adjuvant therapy: 1. Chemotherapy 2. Radiotherapy 3. Hormone therapy 4. Immunotherapy 5. Combination of above Aim: 1. To prevent local recurrence 2. To improve survival

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3. To destroy the micro-metastases Example: Chemotherapy: o Ca Breast (stage l, ll) o Colorectal carcinoma (stage c) o Carcinoma stomach (early) o Ewings sarcoma o Teratoma Radiotherapy: o Ca Breast (after conservative breast surgery or to the axilla) o Colorectal carcinoma o Head and neck cancer o Testicular cancer (stage l, ll) Hormone therapy: o Early breast cancer o Ca prostate Immunotherapy: For early carcinoma of urinary bladder (superficial bladder cancer) Conclusion: Adjuvant therapy is an important modality of treatment of cancer patient which increases the patient survival rate significantly.

91. Neo-adjuvant Therapy/ Down Staging of Primary Tumour

Introduction: When an extra remedy is used prior to surgery or radio therapy in the treatment of malignant disease it is called neo adjuvant therapy. Sometimes Down staging of primary malignant tumour is helpful for better locoregional control. It is a modern concept to Down stage the locally advanced malignant disease prior to surgery by using extra remedy called neo adjuvant therapy. Indication: 1. Large 2. Unresectable primary tumour Modalities: 1. Chemotherapy 2. Radiotherapy 3. Hormone therapy 4. Combination Advantage: Facilitate surgical resection by shrinking the primary tumour Convert an resectable tumour into a resectable tumour Determine the sensitivity of primary tumour to a particular agent Disadvantage: Extra cyst Response is unpredictable Delay in surgery Example: 1. Chemotherapy: Ca Breast (locally advanced) Osteosarcoma Advanced bladder carcinoma

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Ca Oesophagus 2. Radiotherapy: Ca rectum (locally advanced) Sarcomas Lung cancer Ca Oesophagus 3. Hormone therapy: Large breast carcinoma Androgen deprivation (before external beam radio therapy) in locally advanced Ca prostate Conclusion: This modern approach has increase the quality of patient management in malignant disease.

92. SIRS
Introduction: Systemic Inflammatory Response Syndrome (SIRS) is defined as failure of localization of inflammation or an exaggerated host reaction result in progressive illness, organ dysfunction and may lead to death. Aetiological Factor: 1. Trauma 2. Burn 3. Pancreatitis 4. Infection: Gm negative bacteria E. coli Aggravating Factor: Hypoxia Hypovolaemia Nosocomial infection Bacteria and endotoxin result from GIT malnutrition: o Cytokine release o Arachidonic acid formation o Free radical formation Pathogenesis: Whatever the stimuli the common pathway is 1. Vasodilation 2. Increased endothelial permeability 3. Thrombosis 4. Leukocyte migration and activation Clinical Feature: Fever (>38.5o c) or hypothermia (<35.5 c) Tachycardia (>90 beats/min) Tachypnoea (>20/ min) WBC count (>12000/mm3) or (<4000/mm3) Urine output (<0.5ml/kg/hour) Hypoxia (<10Kpa) More than 2 criteria must be present. Effect: A. Local effects: Exude production and tissue necrosis B. Systemic: i. Hormonal: a) Catecholamine, cortisol, ACTH, aldosterone, ADH b) Insulin ii. Metabolic:

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a) Metabolic rate b) O2 consumption c) Gluconeogenesis and hyperglycaemia d) Protein and fat utilization Haemodynamic response: a) Tachycardia b) Vasodilation c) Hypotension Immunological: a) Leukocytosis b) Compliment system activation c) Antibody production d) Macrophage production

iii.

iv.

Treatment: The aim is to prevent organ damage: 1. Admission into ICU 2. Treatment of primary cause: a) Incision and drainage of abscess b) Antibiotics c) Wound care d) Rx of pancreatitis 3. Resuscitation and support of vital organ 4. Nutritional support 5. Drug treatment: a) Low dose corticosteroids b) Insulin c) Dopamine, dobutamine d) Antibiotic e) Recombinant activated protein: Anticoagulant Anti-inflammatory drug 6. Monitoring: a) Vital sign b) CVP 7. Dialysis if needed Conclusion: Once SIRS develops it is very difficult to reverse this process. So effective and vigorous initial treatment of the cause is vital to prevent SIRS.

93. MODS/ MSOF

Introduction: MODS is a delayed condition characterized by sequential failure of numerous organ systems. It is a clinical manifestation of SIRS. Organs involved: Lungs CVS Kidney Liver Gut Pancreas Aetiology: 1. Poly trauma 2. Major surgery 3. Infection

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4. Burn 5. Pancreatitis Stages of developing MODS: 1. Primary insult: Aetiology 2. Compounding insult: a) Hypoxia b) Hypovolaemia c) Nosocomial infection d) Malnutrition 3. SIRS: Cytokine production Activated complement system, PG, O2 free radical and DIC 4. MODS: a) Established micro vascular occlusion b) Tissue hypoxia c) Cellular dysfunction Risk factors for developing MODS: 1. Patient with septic shock, haemorrhagic shock or poly trauma 2. Surgical intervention with 24 hours of onset of aetiology 3. Admission to ICU within next 24 hours 4. ARDS requesting mechanical ventilation within 5 days of ICU admission 5. Patient requires ICU > 5 days Clinical Feature: Lungs: Hypoxia Brain: Delirium CVS: Shock and Oedema Kidney: Oliguria Intestine: Ileus Liver: Hyper bilirubinaemia Haematology: o Anaemia o Coagulopathies Immunologic: Immunosuppression Treatment: A. Admission into ICU B. Aggressive source control through active dx: i. Surgical drainage of pus ii. Second look laparotomy iii. Early stabilization of fracture iv. Use of antibiotic v. Proper management of burn C. Resuscitation and support of vital organs: i. Lungs: IPPV if required O2 adjustment ii. Heart ionotropic drugs: Dopamine Dobutamine iii. Kidney: Dialysis iv. Correction of coagulopathy: Cryoprecipitate v. O2 radical scavenger: Steroid Chlorpromazine vi. IL1 antagonist: Ibuprofen

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vii. Monoclonal antibody to endotoxin and IL2 viii. Immunotherapy D. Metabolic support: 30 35 KCal/kg/day i. Enteral ii. Parenteral Conclusion: Prevention of MODS by the prompt Dx and treatment of primary insult coupled with CVS resuscitation and supportive care is vital.

94. Prevention of Organ Failure

Introduction: Organ failure is a dreadful complication in surgical practice. There is no effective treatment of organ failure. So always prevention should be the aim. Aim: Prevention of organ failure by interfering in every steps of pathogenesis. Cause: 1. 2. 3. 4. Poly trauma Infection Burns Pancreatitis

Risk Patient: 1. Patient with septic shock, haemorrhagic shock or poly trauma 2. Surgical intervention with 24 hours of onset of aetiology 3. Admission to ICU within next 24 hours. 4. ARDS requising mechanical ventilation within 5 days of ICU admission. 5. Patient requires ICU > 5 days. Pathogenesis: Primary insult Compounding insult SIRS MODS Prevention: As the pathogenesis of MODS is well understood we can prevent MODS by interfere in every steps of pathogenesis 1. Correct diagnosis and proper treatment of primary insult 2. Avoiding tissue hypoxia by Resuscitation by I/V fluid Ionotropic drugs to improve cardiac function 3. Avoiding nosocomial infection by Good hand washing Avoidance of cross infection from staff 4. Treating endotoxaemia: Monoclonal antibody to endotoxin 5. IL1 antagonist: Ibuprofen 6. Monoclonal antibody against IL2 7. Cyclooxygenase inhibitor Ibuprofen, Indomethacin 8. SIRS: Resuscitation and support of vital organ Nutritional support

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Conclusion: Prompt dx and treatment of primary insult along with vigorous resuscitation and supportive care is vital to prevent organ failure.

95. Revised Trauma Score (RTS)

Introduction: It is a scoring system for the assessment of trauma patient. It measures the physiological derangement. Objective: 1. Assessment of severity 2. Estimation of prognosis 3. Comparison of treatment methods between trauma centres Component: Combination of 1. Glasgow Coma Scale score (3-15) 2. Systolic blood pressure 0(nill) 4 (>89) 3. Respiratory rate 0 (MI) 4(>19) Trauma score: GCS 13 15 9 12 68 45 3 Systolic BP (mm/Hg) > 89 76 89 50 75 1 49 0 RR/min > 19 10 19 69 15 0 Point 4 3 2 1 0

Conclusion: This RTS should be known to every doctor working in emergency department.

96. AIDS and Surgery

Introduction: AIDS is the pandemic disease of this century and the surgeon is continued to be at risk of transmission of HIV as they are regularly exposed to blood. Risk Factor: Personal risk factors: o Homosexual and bisexual male o I/V drug abuser o Sexual contact with HIV infected person o Received unscreened blood transfusion from HIV prevalence area Geographical: High prevalence of HIV infection Surgical factor: o Emergency o Elective Precaution in surgery: A. Pre-operative: i. Awareness of all the appropriate stuff ii. Should be at the last of OT list and infected OT B. Per-operative: i. Disposable ETT, anaesthetic . and laryngoscope ii. Full range of protective clothing: a) Double glove b) Eye protector

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c) Safety spectacles d) Face mark iii. Minimum assistant iv. Slow and methodical operation v. Sharp instrument should be passed via a kidney tray C. Post-operative: i. All disposable sheet, cloths, gloves must be discarded and incinerated ii. Instrument auto claving before washing iii. Table and floor cleaned with bleaching. Management: Of accidental needle prick 1. Wound: Encourage bleeding Wash with soap and running water 2. Post exposure prophylaxis (within 1 hour) by antiviral drug 3. Send the blood for HIV test for base line 4. If the patient is suspected sent the patients blood also for HIV test 5. Repeat HIV test after 12 weeks and after 6 months 6. Surgeon must be protected from HBV (prophylaxis for HBV) Prophylaxis: Zidovudine 25 mg 12 hourly Or Lamivudine 150 mg 12 hourly Or .. 800 mg 8 hourly Conclusion: Adoption of universal precautions and careful attention to the operative technique will reduce the risk of transmission of HIV.

97. Spread of Seminoma Testis

Introduction: Seminoma testis is a common malignant tumour of testis in middle age group and usually spread via lymphatics. Mode of spread: A. Lymphatics: i. In the retroperitoneal nodes a) On the right side: Primary to the inter-aortocaval region below the renal vessels. b) On the left side: Primary to the left para aortic region below the renal vessels. ii. Other groups of lymph node: a) Iliac b) Mediastinal c) Supraclavicular iii. From the medial side of the testis: Lymph node at the bifurcation of common iliac artery, along the artery to the vas deference. iv. Inguinal lymph node: If only when scrotal skin is involved B. Haematogenous: i. Uncommon ii. To the lungs C. Local spread: Very uncommon as tumour lies within the tight tunica albuginea. Importance: Treatment and prognosis depend upon the extent of spreading. Features of spreading: History:

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o Intra-abdominal lump o Chest pain o Cough o Haemoptysis Examination: o Retroperitoneal lump usually above the umbilicus o Left supra clavicular lymph node o Features of consolidation in lungs Investigation: o USG o Chest X-ray o CT Scan abdomen

Conclusion: In spite of distant spread, prognosis is good with appropriate treatment.

98. Recurrent Bladder Tumour

Introduction: It is a notorious disease and high chance of recurrence and it is a challenge for the surgeon and frustrating to the patient. Recurrent bladder tumour is a common problem in urological practice, both for the surgeon and for the patient. Incidence: 50 70% after Rx of primary tumour. Risk Factor: High grade PTI disease Concomitant CIS Multiple primary tumour Recurrent disease of the first check cystoscopy Type: 1. Same stage or grade as the primary tumour 50 70% 2. Advanced (muscle invasive) 15% Presentation: H/O operation (TURBT) followed by o Painless haematuria o Frequency o Suprapubic discomfort Incidental in check cystoscopy Features of metastases Investigation: 1. Urine: R/E C/S Cytology 2. USG of W/A: SOL in bladder 3. IVU - To detect other tumour, function of kidney 4. Chest X-ray P/A view: Metastases 5. CT Scan Abdomen: To see extension 6. Urethrocystoscopy: Final diagnosis and therapeutic Treatment: Depend upon the stage of the disease Options: TURBT Intravesical chemotherapy

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Radical cystectomy Diversion according to stage

Conclusion: Regular follow up is essential. Follow up: 3 monthly for 6 months 6 monthly for 1 year Yearly for 5 years 5 yearly for life long

99. Causes and Treatment of Perinephric Abscess

Introduction: Abscess between the renal capsule and the perinephric fascia is called perinephric abscess. It is a urological emergency which needs immediate attention to save the kidney function. Cause: 1. Extension of cortical abscess (Most common cause) 2. Haematogenous 3. Extension of: Appendix abscess Nearby tubercular vertebrae Tubercular pyenephrosis 4. Infection of peri-renal haematoma Organism: E. coli Mycobacterium tuberculosis Treatment: A. Preventive treatment: i. Early treatment of renal abscess, any primary foci in the body ii. Early treatment of vertebral TB B. Drainage of abscess: i. Percutaneous drainage under USG or CT guided ii. Open drainage: If percutaneous method fails C. Antibiotic: i. Broad spectrum systemic antibiotic with anaerobic coverage started very early of treatment ii. Pus is sent for C/S, if tubercular Anti TB chemotherapy for 9 12 months D. Rx of complication Nephro-urectrectomy: If kidney function <10% and opposite kidney normal. Conclusion: In spite of aggressive treatment mortality remains high: 20 50% with antibiotic and drainage 75 100% with only antibiotics

100. Diagnosis & Treatment of Epididymal Nodule

Introduction: Epididymal nodule is a distracting condition for the patient common in clinical practice and sometimes creates problem both in diagnosis and treatment. Cause: 1. Cyst connected with epididymis:

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Epididymal cyst Cyst of testicular appendage Spermatocele Chronic tubercular epididymoorchitis Chronic non tubercular epididymitis Filariasis of epididymis Late stage of .. orchitis

2. 3. 4. 5.

Presentation: According to cause Scrotal swelling Discomfort Lower urinary tract symptoms associated with renal TB O/E: Swelling is separated from testis Fluctuation and trans-illumination test positive Epididymis is firm and craggy in tubercular epididymitis Characteristic beading of vas in TB epididymitis Secondary hydrocele may present On DRE: Indurated and swollen seminal vesicle. Investigation: 1. Urine and semen: To exclude tuberculosis 2. CXR (P/A view): To see any TB focus 3. IVU: Features of renal TB 4. CFT for Filaria: To exclude filariasis 5. USG of scrotum: To exclude malignancy 6. Testicular biopsy: To confirm the Dx, when in doubt Treatment: 1. Epididymal cyst: Excision if symptomatic 2. Spermatocele: Aspiration or excision 3. Cyst of testicular appendage: Excision 4. If tubercular: Anti TB chemotherapy with or without Epididymectomy or orchidectomy if needed 5. If filarial origin: Rx of filariasis Conclusion: Proper counseling of patient about sterility is important before treatment.

101. Treatment of Gastrojejunocolic Fistula

Introduction: It is a devastating condition usually follows recurrent ulceration after peptic ulcer surgery. Cause: 1. Recurrent ulceration after peptic ulcer surgery 2. Ca stomach, Ca colon 3. Crohns disease and TB colon Prevention: Vagotomy during gastrojejunostomy Early diagnosis and prompt treatment of recurrent ulceration Early diagnosis and treatment of Malignancy Proper treatment of Crohns disease and TB Definitive treatment: Surgery

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A. Improvement of general well-being of patient: i. Correction of dehydration and electrolyte imbalance ii. Improved nutritional status by parenteral nutrition iii. Correction of anaemia by BT iv. Vitamin supplementation B. Local: Gut preparation C. Surgery: i. Excision of involved colon and ulcerated gastrojejunal segment and re-establish the colonic continuity ii. Vagotomy, partial gastrectomy or both to treat ulcer and prevent another recurrent ulcer D. Treatment of malignancy: According to staging Conclusion: Results are excellent for benign disease. Poor for malignant disease.

102. Angiodysplasia of Gut

Introduction: It is an acquired vascular malformation (associated with aging and important causes of GI bleeding of obscure origin. Site: 1. Caecum and proximal ascending colon old age. 2. Jejunum in young. Pathology: Focal submucosal vascular ectasia. Associated disease: Aortic stenosis Von Willebrands disease Presentation: Age: > 60 years Per-rectal bleeding: o Intermittent o Massive (rarely) H/O melaena Anaemia D/D: 1. Diverticulitis 2. VC 3. Ischaemic colitis Investigation: 1. Colonoscopy: Reddish, raised area of few mm size 2. Mesenteric artery angiography (SMA, IMA) Early filling vein Vascular TUFT and delayed emptying vein 3. Radioactive (99MTe) labeled red cell: Confirm and localize the source of bleeding Treatment: A. Colonoscopic diathermy: Elderly, risk patient B. Expectant treatment: i. Single episode of bleeding

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ii. Colonoscopy fails C. Surgery: i. Right hemi-colectomy: If the source is from right colon. ii. Total abdominal colectomy with ileo-rectal anastomosis if bleeding site cant be identified. iii. Resection and anastomosis if small gut. Conclusion: With the invention of modern technology diagnosis of angiodysplasia is now easier than previous.

103. Cause & Treatment of Per-rectal Bleeding in Children

Introduction: Per rectal bleeding in children is common and causes anxiety to the parents but in majority of cases it is benign in origin. Cause: 1. 2. 3. 4. 5. 6. 7. Rectal polyps Bleeding disorder Intussusception Rectal injury Infective diarrhea Rectal prolapse Anal fissure

Treatment: Resuscitation of patient followed by evaluation of causes and treatment of the cause A. If rectal polyps: i. Exclude other polyps by colonoscopy ii. Wait and follow up spontaneous resolution if single polyp iii. Endoscopic snared and excision if bleeding persists B. Bleeding disorder: Consult with haematologist C. Intussusception: i. Resuscitation ii. Contrast enema both diagnostic and therapeutic iii. Surgery: a) Unsuccessful conservative treatment b) Perforation c) Peritonitis D. Rectal injury: i. If it is intra-peritoneal: Laparotomy with closure of perforation with colostomy with peritoneal toileting ii. If extra-peritoneal: Only colostomy E. Infective diarrhea: i. Stool R/E and C/S ii. Antibiotic accordingly F. Rectal prolapse: i. Usually partial ii. Digital reposition for 6 months iii. Injection sclerotherapy iv. Operation: Thieres operation G. Anal fissure: Always conservative i. Conservative: a) Chemical sphincterotomy b) Laxative ii. Operative: Lateral anal sphincterotomy Conclusion: As majorities are benign, prognosis is good after treatment.

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104. Diagnosis of Zollinger Ellison Syndrome (Gastrinoma)

Introduction: ZES is manifested by gastric acid hyper secretion caused by gastrin producing tumour. It is a cause of intractable PUD caused by gastrin producing tumour, may be associated with MEN-I, so exclude it before Rx. Site of tumour: G-cell hyperplasia of pancreas (Non islets cell of pancreas) Duodenum: submucosa Gastric antrum Ovary Presentation: PUD at very young age Virulent PUD, PUD of unusual site: o Marginal ulcer o Post bulbar o Proximal jejunum Unexplained diarrhoea Present with complications: o Haemorrhage o Perforation o Obstruction Features of parathyroid disease Association: MEN- I (1/3 cases) Investigation: Diagnostic Localization A. Laboratory investigations: i. Serum gastrin level: hypergastrinaemia ( > 500 pgm/ml, diagnostic) ii. Gastric acid hyper secretion: BAO/ MAO: >0.6 iii. Secretin provocative test: I/V injection of Secretin Gastrin level (>150pgm/ml) within 15 minutes iv. Serum calcium level: To exclude hyper parathyroidism v. Serum level of -HCG, chromogra B. Imaging Studies: i. Upper GI series: a) Ulcer in the post duodenal bulb and upper jejunum (diagnostic) b) Stomach: Prominent rugal fold Secretion present in overnight fasting ii. CT or MRI: To see pancreatic tumour iii. Somatostatin receptor ..graphy: Detection of gastrinoma (highly sensitive) iv. Transhepatic portal vein blood sampling: Before and after injection of secretin into artery supplying the tumour Treatment: A. Medical treatment: i. H2 receptor inhibitor 300 600 mg 6 hourly ii. Proton pump inhibitor B. Surgical treatment:

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i. Resection of tumour: indication single localized tumour ii. Total gastrectomy: Failure of medical treatment C. If malignant: i. Resection of tumour if possible along with metastases to peri-pancreatic lymph node or liver ii. Advanced: Combined chemotherapy Conclusion: As it is often associated with MEN-1 , so before treatment of ZES must be excluded, other component of MEN-1 particularly parathyroid and pituitary.

105. Meckels Diverticulum

Introduction: It is a patent proximal remnant of vitello intestinal duct and represents a true congenital diverticulum. It contains some heterotrophic mucosa, so it has some surgical importance. Incidence: 1 to 3% of population. Gross anatomy: Site: 2 feet proximal to ileocaecal valve At antimesenteric border Length: 3 5 cm It has its own blood supply 20% has heterotrophic mucosa: o Gastric o Colonic o Pancreatic Surgical importance: Peptic ulceration Infection Obstruction Haemorrhage Presentation: Severe haemorrhage in the form of melaena Intussusception Meckels diverticulitis: Features of acute appendicitis Pain around umbilicus Features of Intestinal obstruction Silent Investigation: 1. Small bowel enema 2. 99MTC labeled pertechnetate. scan (T99M Scanning) Treatment: A. Symptomatic or complicated diverticulum: i. Wedge excision at its base or ii. Limited resection of diverticulum bearing edge of ileum and end to end anastomosis B. Incidental dx: i. Better to remove ii. Left:

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a) Poor general condition of patient b) Emergency operation c) Wide mouth and not inflammed Conclusion: Suspicion is important for diagnosis of symptomatic Meckels diverticulum.

106. Parathyroid Adenoma

Introduction: This is a benign tumour of parathyroid gland and the most common cause of primary hyperparathyroidism. It may be associated with MEN type l, ll. Incidence: 89% cause of primary hyperparathyroidism mostly single. Microscopic (Cell of origin): Consists of chief cell, water cell or oxyphil cell. Presentation: Female more than male. Asymptomatic: Dx by routine screening (hyper calcaemia) Features of hyperparathyroidism: o Bones, stones, abdominal organs and psychic moans. o Nonspecific symptoms: thirst, muscle weakness, polyuria, anorexia, weight loss. o Bone disease: Generalized decalcification of skeleton Bone cyst Pseudotumour o Renal stone o Psychiatric disorders May present with neck swelling: 2 to 3% O/E: Dehydration Corneal calcification Hypertension

D/D: Other causes of hypercalcaemia. Investigation: 1. Biochemical: Serum calcium: Serum phosphate: Urinary calcium: Serum alkaline phosphate: May Serum parathyroid hormone: May 2. Localization: Careful examination of neck USG of neck CT scan of neck: most valuable Thallium-Technetium isotope substraction imaging MRI neck Selective angiography Treatment: Surgical removal of adenoma and explore all rest of the gland as adenoma may be multiple. Prognosis: With treatment prognosis excellent.

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Follow up: Life-long follow up at regular interval.

107. BRCA1 and BRCA2

Introduction: These are two important breast cancer predisposition genes. Gene location: 1. BRCA1: Long arm chromosome 17 (17q) 2. BRCA2: Long arm chromosome 13 (13q) Association: 2 4% all breast cancer 1. BRCA1: Ca breast, colorectal and prostate cancer, ovarian and FT cancer. 2. BRCA2: Ca breast, male breast cancer, ovarian and FT cancer. Importance: Gene positive woman: 80% risk of developing Ca breast in premenopausal age 20 to 40% risk of developing ovarian cancer Gene positive woman: Advanced for prophylactic mastectomy. Conclusion: Genetic testing of these two genes can be included for screening of breast and ovarian cancer.

108. Treatment of Thymoma

Introduction: This is the most common primary mediastinal tumour. Incidence: 25% of total. Site: Anterior mediastinum Cell or origin: Thymic epithelial cells of Hassalls corpuscles. Behaviour: Completely benign to aggressively invasive (variable). Associated condition: Myasthenia Gravis Paraneoplastic syndrome: o Cytopenia o Red cell aplasia o Hypogamaglobulinaemia Type: According to predominant cell type 1. Lymphocytic 2. Epithelial 3. Lympho-epithelial Presentation: Asymptomatic: Dx by CXR (incidental) Symptomatic: o Chest pain o Dysphagia o Myasthenia Gravis o Dyspnoea o Superior vena caval syndrome Investigation: 1. CXR (P/A view and lateral view): Mediastinal mass

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2. CT scan Chest: To see extent of lesion 3. MRI: To see vascular invasion D/D: 1. Lymphoma 2. Germ cell tumour 3. Neurofibroma Treatment: A. Benign: Total thymectomy through median sternotomy B. Malignant thymoma: i. If resectable: Complete excision ii. For invasive: resection of tumour with pericardium, pleura or lung if possible followed by post-operative radiotherapy. iii. Large bulky tumour: Neoadjuvant chemotherapy shrinks the tumour complete resection. iv. If not resectable: Taken biopsy + Chemo-radiotherapy v. For metastatic disease: Combined chemotherapy C. Associated with Myasthenia: i. Anti-cholinesterase drugs e.g. Neostigmine Bromide ii. Early thymectomy Prognosis: For benign disease: Excellent Malignant disease: o Early: 10 years survival 100% o Late: 10 years survival 25 to 75%

109. Mx of Ulcer on a Post-burn Scar

Introduction: Scar tissue has less protective power than normal skin. So chance of ulceration is relatively common. Type of ulcer: A. Marjolins ulcer: i. Specific ii. Non specific B. Traumatic ulcer: i. Specific ii. Non specific Nature: Usually malignant (SSC) Presentation: H/O burn No healing Painless ulcer Slow growing O/E: An ulcer which has Irregular margin Raised and everted edge Surface covered by necrotic tissue-serum and blood Non tender, indurated base and draining LN usually not palpable Investigation: 1. Wound swab: for C/S 2. Biopsy for confirmation: Small: Excision biopsy

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Large: Incision biopsy

Treatment: A. Prevention: i. Avoid prolonged exposure to sunlight. ii. Use ultra-violate screening agent for wound in the face and hands iii. Use cream and lotion to prevent drying and cracking iv. Vitamin A and vitamin D ointment application B. For malignant ulcer: Surgery i. Wide excision with 1.5 2 cm normal skin all around and wound is covered according to wound and site a) Small wound: Direct closure b) Large wound: Skin graft Split thickness Full thickness ii. Amputation: Ulcer on a non-functioning limb C. For traumatic ulcer: i. Regular dressing to prevent infection and granulation tissue formation followed by wound ii. Closure: a) Direct b) Skin grafting Conclusion: Early dx.

110. Complications of Surgical Diathermy

Introduction: Diathermy is an important device for surgical practice but its use is not devoid of complications. Diathermy is an essential equipment in modern surgical practice but there is every chance of complications if precaution is not taken. Risk: Improper fitting of patients plate Patient touching earth, metal object like drip stand, metal component of operating table, monitoring electrode even via the surgeon Pacemakers or any metallic prosthesis Mono polar diathermy For laparoscopy: Insulation failure

Complication: A. Both for open and laparoscopic: i. Burn full thickness skin a) Site of surgery b) Site of patients plate (full thickness skin burn) c) Site of inadvertent contact d) Explosion e) Inflammation ii. Cardiac complication: a) Cardiac arrhythmia b) Ventricular fibrillation c) Cardiac arrest iii. Painful muscle contraction iv. Channel effect v. Personal and equipment hazards e.g. tear of gloves B. For laparoscopic: i. Insulation failure ii. Capacitative coupling contact with trochar

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Precaution: Proper fitting of patient plate: o Close to the operation o Avoid bony prominence of scar tissue o Good skin contact (At least 70cm2) o Away from pacemaker box (from 20 cm ) Check the dial setting before use Should not use mono polar diathermy to penis, testis and salphinx Consult with cardiologist if pace maker Treatment: 1. If arrhythmia: Stop use of diathermy 2. If skin burn: Require excision and skin graft Conclusion: Careful use of diathermy is vital to prevent its complications.

111. Pathogenesis of Chronic Pyogenic Osteomyelitis

Introduction: Chronic osteomyelitis is nearly always a sequel to acute haematogenous osteomyelitis and it is a troublesome condition for the patient and treatment is difficult. Causes: 1. Sequel to acute osteomyelitis 2. Associated with open fracture or operation Organism: Usually mixed organism Staphylococcus aureus Escherichia coli Streptococcus pyogens Proteus Pseudomonas In foreign implant: Staphylococcus epidermidis Predisposing Factor: Age: Infancy and childhood Sex: male > female Poor nutrition Unhygienic condition Focus of infection e.g. boils Growing end of long bone Mechanism: 1. Once osteomyelitis is established Pus lift the periosteum Rupture through periosteum Tracks into soft tissue Through the skin and form sinus 2. The bone dies and forms sequestrum 3. New boned is formed by the periosteum which has been lift called .. 4. Dead bone acts as a permanent source of infection. Presentation: Purulent discharge through sinus: o Continuous o Intermittent Pain, pyrexia on acute flare Comes with pathological fracture

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O/E:

Bone: Thickened Overlying: o Scars o Sinus Pyrexia, abscess on acute flare

Conclusion: It is very difficult to eradicate, so proper treatment of acute osteomyelitis is vital to prevent it.

112. Complications of Colles Fracture

Introduction: It is the most common fracture of post-menopausal women fall on out-stretched hand. There is an every chance of complications if not treated properly. Risk factors: Osteoporosis Delayed & improper reduction Early return to work Complication: A. Early: i. ii. iii. iv. B. Late: i. ii. iii. iv. v. vi.

Vascular compromise: a) Injury to radial artery b) Compression due to swelling Nerve injury: Median nerve due to carpal tunnel syndrome. Reflex sympathetic dystrophy: Due to sympathetic nervous system activity Rupture of extensor policis longus tendon Mal union Non union Sudecks atrophy: Late sequel of R. sympathetic dystrophy Shoulder hand syndrome Stiffness of joint Frozen shoulder

Complication: Most of the complications require conservative treatment Surgery: Vascular compromise If conservative treatment fails Rupture EPL tendon: Repair Non-union: ORIF, mal-union, corrective osteotomy Sudecks atrophy: Sympathectomy o Locally L/A o Cervical Conclusion: Early diagnosis and proper treatment and follow up is vital to prevent complications.

113. Presentation of TB of Lower Thoracic Spine

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Introduction: Tuberculosis is the most common disease that affects the spine in our country. Spinal TB is common in our country and most common only affects thoracic spine. There is wide spectrum of presentation. Symptom: Age: Children and adolescents Pain in the back which is dull ache is nature and may refer to chest, abdomen or sometimes girdle pain. Stiffness in the back (more on cervical and lumbar region) Visible deformities in the back: o Kyphosis o Gibbus General symptom: o Fever with evening rise of temperature o Anorexia o Weight loss Present with complication: A. Paraplegia/ weakness in the lower limb: Due to cord compression B. Abscess formation: i. Localized swelling ii. Pass may track down: a) Anterior and lateral thoracic region by IC vessels and nerves b) Psoas abscess: From posterior mediastinum beneath the medial arcuate ligament c) Lumbar abscess: From posterior mediastinum through lateral arcuate ligament via Petits triangle O/E: Ill looking, cachexic temperature Angular kyphosis Local tenderness Restricted movement at thoracic spine Abscess in the thoracic and flunk or iliac fossa or upper thigh Weakness of lower limb muscles Lower limb jerks may be exaggerated

Conclusion: Early diagnosis and proper treatment is vital to prevent complications.

114. Informed Consent

Introduction: It is the fundamental things on which the morality and the legality of good surgical practice depend. Component: 4 general components1. Proper descriptions of procedure with its prognosis. 2. Associated risks of compilations. 3. Complications associated with general anaesthesia, bed rest, i/v fluid and catheter. 4. Alternative medical and surgical treatment option or non-treatment along with merits and demerits. Good counseling practice: 1. Surgeon will take the consent 2. Maintain privacy

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3. In a simple language 4. Help of nurse 5. Two way communication Consent Form: Should be written. Signed by patient > 16 years (for general anaesthesia and some procedures under local anaesthesia) Consent in special situation: Children < 16 years: From parents or courts. Unconscious adults: Surgeon as a proxy. Mentally handicapped and psychiatric patient: Both surgeon + psychiatrist. Emergency situation: No need of informed consent to save life but keep a good record of the situation. Legal importance: To avoid allegation of Battery or negligence. Informed consent and confidentiality: 2 situations where confidence should be broken1. For public interest 2. Interest of the individual patient Conclusion: Every surgeon should practice legal aspect of medicine to protect himself and to respect human rights.

115. Consent for Below Knee Amputation

Introduction: It is the fundamental things on which the morality and the legality of good surgical practice depend. In routine surgery: i. Counseling abouta) Procedure and prognosis b) Risks or complications c) Artificial limb and rehabilitation ii. Allow time to take the decision between painful, useless limb and painless useful limb and patient will take the final decision. iii. In skip area at gangrene consent taken for above knee amputation. iv. It should be written and must be signed by patient himself > 16 years of age. If < 16 years then by parents. In special situation: a) Children b) Unconscious c) Emergency d) Psychiatric patient In emergency surgery: 1. If patient is conscious and capable then take informed consent. 2. If unconscious patient or life threatening condition no need informed consent but keep a good record of situation. In mentally handicapped or psychiatric patient decision taken both by surgeon and psychiatry. Importance: To avoid allegation of Battery or negligence.

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Conclusion: Every surgeon should practice legal aspect of medicine to protect himself and to respect human rights.

116. Treatment of Broncho-biliary Tree

Introduction: It is a type of internal biliary fistula where biliary tree is communicated with bronchial tree. Cause: 1. Ruptured right sub-phrenic abscess or liver abscess into lungs. 2. Ruptured hydatid cyst of liver into lungs. Prevention: Early diagnosis and treatment of sub-phrenic abscess, liver abscess or hydatid cyst. Treatment: 1. Adequate drainage of sub phrenic abscess or liver abscess. 2. Correction of biliary obstruction - if any 3. Improvement of the general condition of the patient: Diet Blood transfusion 4. Broad spectrum antibiotic. With these measures fistula invariably heels and no need of active interference. Conclusion: After treatment of primary cause, fistula invariably heels.

117. Unilateral RLN Palsy

Introduction: RLN is the most common cranial nerve which becomes injured in different clinical situation, left side is most commonly affected. Cause: A. Congenital: 2 3% B. Acquired: i. Traumatic: a) Surgery: Thyroid, parathyroid Any neck surgery b) Penetrating trauma to the neck ii. Neoplastic e.g: a) Ca lung b) Ca oesophagus c) Ca thyroid d) Laryngeal carcinoma iii. Inflammatory (virus) iv. Miscellaneous: Subclavian artery aneurysm Type: 1. Neurapraxia 2. Axontamesis 3. Neurotamesis

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Presentation: Asymptomatic: Incidental dx or IDL H/O operation in the neck Hoarseness of voice Recurrent chest infection Investigation: 1. CXR (P/A): to exclude Ca lung 2. CT scan of neck and chest: To see any malignant growth 3. IDL: To see vocal cord paralysis. 4. DL: To see any growth and take a biopsy if any 5. Upper GIT Endoscopy: To see Ca oesophagus Treatment: According to cause 1. Expectant with speech therapy: Due to neurapraxia after thyroid surgery 2. In malignancy: It is usually advanced, so treatment is palliative (Radiotherapy) 3. Symptomatic: Antibiotic for chest infection. Importance: If diagnosed pre-operatively, opposite RLN must be preserved during surgery by any cost. Conclusion: Careful neck surgery and early dx of causes are vital to prevent RLN palsy.

118. Insertion of Chest Drain in Pneumothorax

Introduction: Chest drain insertion is the vital part of management of pneumothorax. Insertion of chest drain in pneumothorax is a life saving measure and it should be inserted immediately when indicted. Indication: 1. Traumatic pneumothorax 2. Spontaneous rupture of bulla Procedure: 1. Site: Triangle of safety 2. Position of patient: Sitting and leaning forward 3. Antiseptic washing and draping under L/A. 4. A 3cm transverse incision is made along the intercostal line 5. Skin and subcutaneous tissue is cut along the line of incision 6. Intercostal muscles are separated by artery forceps and puncture the pleura by sudden thrush 7. Insertion of chest drain with straight artery forceps under finger guidance 8. Tip of the drain is directed posteriorly and superiorly towards the apex of the lungs 9. Drain is fixed with the chest wall by purse string suture and then connected with under water seal drainage 10. Wound is closed and covered with gauze Post-operative: 1. CXR (P/A view): To confirm position of tube 2. Drainage system kept at floor level 3. Quantity and quality of any efficient noted 4. Daily follow up to see lung expansion 5. General measure: Antibiotic Analgesic Chest physiotherapy Complication:

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o o o o During procedure: Wrongly placed tube Injury to the neurovascular bundle, lungs, liver, spleen Post-operative: Surgical emphysema due to tube block Accidental removal of tube infection

Removal of chest tube: When clinical and radiological evidence of lung expansion and no air bubble in the chest drain during coughing. Conclusion: It is a life-saving procedure. So every doctor should know it to save the patient.

119. Radial Nerve Palsy

Introduction: Radial nerve is the most commonly injured nerve in the upper limb. Cause: 1. 2. 3. 4. 5. Site: Fracture shaft of humerous Axillary crutch Slipping on a chair with arm suspended over the back of the chair Pressure from callus Iatrogenic during removal of neuro-fibroma Radial groove Axilla Supracondylar fracture H/O injury Operation Look: Wrist drop Muscle wasting Any scar marks Loss of sensation and dry hand over radial nerve distribution. Loss of muscle power: Brachioradialis Wrist extensor Extensor digitorum Triceps Movement: Loss of wrist and metacarpo-phallangeal joint extension.

Presentation: o o o Feel: o o

Investigation: 1. X-ray local part: If history of trauma to see Fracture Callus 2. Nerve conduction test:

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Site of injury Partial/ complete

Treatment: A. Conservative: i. Reduction and immobilization of fracture ii. Expectant treatment in crutch injury or Saturday night palsy iii. Splintage of hand by plaster cast B. Exploration and repair of nerve: i. Failure of conservative Rx for 6 months ii. Complete transaction of nerve C. Tendon transfer: If recovery is incomplete Complication: Pain: o Neuropathic o Casualgia Trophic skin change Joint contracture Muscle wasting Prognosis: Prognosis is not satisfactory even in early repair.

120. Chronic Subdural Haematoma

Introduction: It is the most common intracranial haematoma resulting from head injury occurs in two extremes of age, suspicious is important for early diagnosis. Age: Infant Older > 60 years due to large ventricles or dilated subarachnoid space.

Cause: Head injury with torn bridging veins draining blood from the cortex to dura. Pathogenesis: Initial small haemorrhage (or large ventricles or dilated subarachnoid space in elderly people) Formation of encapsulated haematoma remain clotted for 2 to 3 weeks Liquefies Presentation: H/O head injury 2 to 3 weeks back Features of raised ICP: o Headache o Vomiting o Visual disturbance Dementia: Forgotten initial head injury Progressive neurological deficits O/E: Bradycardia Dilated pupil : ICP Papillo-oedema: CSF pressure

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D/D: 1. Senile dementia 2. Brain tumour Investigation: CT scan of brain reveals Hyperdense area (white) in the subdural space due to clotted blood initially Black area due to liquefaction of blood Isodense area with midline shifting late findings Treatment: Surgery 1. Removal of collection by burr holes or craniotomy and washing out with warm saline and kept a drain at subdural space 2. Antibiotic Complication: Progressive neurological deficit Seizures Abscess formation Conclusion: Strong suspicious is important for early diagnosis and treatment.

121. Thyroglossal Cyst

Introduction: It is a common congenital midline swelling in the neck. It may be the only thyroid tissue, so proper evaluation is vital. It is a remnant of thyroglossal duct. Site: Any part of thyroglossal tract but common site 1. Subhyoid 2. Over the thyroid cartilage 3. Suprahyoid Presentation: Age: Anytime of life, common in early childhood Mid line neck swelling Present with abscess O/E: Swelling moves up with deglutition as well as with protrusion with tongue Examination of oral cavity: To see lingual thyroid

Investigation: 1. Serum T3, T4 & TSH: For base line infection. 2. Isotope thyroid scan: This may be the only thyroid tissue D/D: 1. Dermoid cyst 2. Subhyoid bursitis 3. Goitre in the thyroid isthmus Complication: Infection with abscess formation Fistula formation Malignancy (papillary carcinoma) Treatment:

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A. Sistrunk operation: Complete excision of thyroglossal tract with .. removal of body of hyoid bone along with care of lingual muscles around F. caecum. B. If abscess: Incision and drainage + antibiotic, followed by operation 6 weeks later. Conclusion: Sometime life-long thyroid replacement may be needed if it is the only thyroid tissue in the body after excision.

122. Complication & Treatment of Cellulitis Neck

Introduction: Cellulitis of neck is a life threatening complication and the most common form is Ludwigs angina, which is characterized by .. swelling of submandibular region with inflammatory oedema of mouth. Cause: Usually by mixed organism both aerobic and anaerobic 1. Virulent streptococci 2. Staphylococci 3. Clostridium perfringence 4. . 5. Predisposing Factor: 1. Dental sepsis 2. Carcinoma of floor of mouth Complication: Dysphagia: Oedema and inflammation of floor of the mouth with backward displacement of tongue Airway obstruction: o Backwards displacement of tongue o Glottic oedema o Tracheal congestion - airway obstruction Septicaemia Neck stiffness Prevention: Early treatment of dental sepsis and malignancy. Treatment: A. Conservative: i. Bed rest. ii. I/V broad spectrum antibiotic: Amoxicillin/ Cefuroxime + Metronidazole iii. Supportive measures e.g. analgesics, I/V fluid. B. Surgery: Incision and drainage, if no response occurs within 12 24 hours i. A curved submental incision to drain both sub mandibular triangles ii. Myelohyoid muscle may be incised to decompress the floor of the mouth iii. Corrugated drain is placed and wound is lightly sutured. C. Rx of complication: i. Tracheostomy may be necessary for respiratory obstruction ii. Septicaemia: Antibiotic according to C/S Conclusion: Early diagnosis and treatment is vital to prevent complications.

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123. Treatment of Acid Burn on Face

Introduction: Acid burn on face is a common problem in our country, which is a devastating condition and the usual victims are female and mostly due to assault. Cause: 1. Mostly due to assault 2. Accidental Treatment: A. Prevention: i. Social awareness ii. Implementation of chemical act iii. Punishment of criminal iv. Protective clothing in industry B. First Aid: i. Resuscitation by ABC management ii. Irrigation of the burn surface by Sterile isotonic saline Clean water or Any safe liquid available iii. Analgesic NSAID iv. Antibiotic Oral/ I.V/ topical v. Apply local anaesthetic gel C. Local management: Multidisciplinary approach which depends upon site of injury and extent of involvement: i. Eye: Consult with ophthalmologist Topical anaesthetic Topical antibiotic Eye is packed ii. Ear: Consult with otolaryngologist iii. For cosmetic region/ aesthetic region: Consult with plastic surgeon for some reconstructive procedure. Conclusion: First aid management is vital for better outcome.

124. Complication & Treatment Options of Cervical Rib

Introduction: Cervical rib is congenital over development of 7 th cervical vertebral costal process, more on right side. Cervical rib is the most common cause of thoracic outlet syndrome which is a disabling condition more on right side and may produce many complications. Complication: A. Vascular: When rib is complete, due to thrombosis and emboli within post stenotic dilatation in the forearm and hand i. Cyanosis ii. Ulceration iii. Gangrene B. Neurological: Due to pressure over the lower trunk of Brachial plexus i. Motor: a) Weakness of hand b) Difficulty in fine movement c) Wasting of intrinsic muscles of hand ii. Sensory: Pain, numbness or loss of sensation in the forearm and hand C. Hormonal: Loss of sweating & dryness of hand

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Treatment: Depends upon the severity of symptoms 1. Mild case: Physiotherapy Shrugging exercise 2. Moderate to severe: Extra periosteal excision of cervical rib (with periosteum) Conclusion: As many conditions stimulate with this manifestation, so proper evaluation before surgical treatment is vital.

125. Management of Oesophageal Atresia

Introduction: It is a common congenital anomaly of oesophagus usually associated with tracheooesophageal fistula. Incidence: 1 in 3000 live births. Associated anomalies: VACTERL V = Vertebral bodies segmental defect A = Anorectal Imperforated anus C = Cardiac o PDA o Septal defect TE = Tracheo-oesophageal R = Renal L: Limb anomalies. Type: 1. With tracheo-oesophageal fistula: a) Distal Tracheo-oesophageal (85%) b) Proximal fistula (2%) c) Proximal and distal fistula (1%) 2. Without fistula Presentation: Excessive salivation Regurgitation Repeated episodes of coughing and cyanosis O/E:

Associated anomalies Dehydration Cyanosis

Confirmation of dx: 1. Clinical: By N-G tube Tube will not go down the expected length of stomach Will coil in the oesophageal pouch 2. Radiological: X-ray chest (lateral view): Radiolucent proximal pouch Air in the stomach and bowel: if distal fistula 3. Bronchoscopy: Identify majority of fistula 4. Other investigations: Echocardiography To see position of aortic arch Exclude cardiac anomalies

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Treatment: Surgery A. Divide and ligate the fistula and repair the atresia in one stage if possible. B. Staged operation: i. Premature baby ii. Long gap between the oesophageal pouch a) 1st stage: Gastrostomy with stretching of upper end by bougi b) 2nd stage: Oesophageal anastomosis Complication: Chest infection Pneumonia Prognosis: Survival for a full term infant without associated anomalies is excellent.

126. Outcome of Coronary Artery bypass Graft/ CABG

Introduction: It is one of the procedures for revascularization of myocardium. Indication: 1. Angina unmanageable by medical treatment. 2. Stenosis of left main coronary artery (>70%) 3. 3 vessels disease 4. Unstable angina without infraction 5. Quality of life hampered by long term administration of drug Choice of graft: A. Natural: i. Vein: a) b) c) ii. Artery: a) b) c) B. Synthetic: i. Dacron ii. PTFE

Long saphenous Cephalic Short saphenous Internal mammary Gastro epiploic Inferior epigastric

Procedure: With cardiopulmonary bypass 1. Side to side anastomosis of graft with coronary artery distal to stenosis 2. Proximal end of graft anastomosis with ascending aorta 3. Distal end of internal mammary artery anastomose with left anterior descending coronary artery Complication: Peri-operative MI Graft occlusion: o Thrombosis o Fibrosis Recurrent angina Outcome: Depends upon some factors Smoking Obesity

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Diabetes HTN RTI Previous ventricular function 80% patients have completer relief of symptoms and require no further medication Graft patency is 70 90% after 12 months Graft occlusion: May occurs due to Thrombosis Fibrosis: Conduct atherosclerosis or progression of native disease Rate of occlusion is 2 3% per year Up to 30% patient develop recurrent angina over a 5 years period Many patients respond to medical treatment but some require redo surgery. Good quality of life is the rule in terms of Less medication Improved exercise Symptomatic relief Return to work.

1. 2. 3.

4. 5. 6. 7.

Conclusion: This is the most effective and reliable method of coronary revascularization.

127. Fracture of Lower Ribs

Introduction: Fracture lower rib needs special attention because many important organs underneath it become injured, so need careful assessment for better management. Cause: 1. RTA 2. Fall from height 3. Direct trauma: Blunt trauma Penetrating Importance of lower rib: Structures injured are Both side: o Neurovascular o Pleura o Lungs o Diaphragm Right side: Liver injury on right Left side: o Spleen injury on left o Diaphragm injury o Pneumothorax o Haemothorax Presentation: H/O trauma Severe chest pain Features of haemo-pneumothorax Features of shock due to liver/ spleen injury Investigation: After initial resuscitation send the patient for investigations 1. Chest X-ray (P/A view): To see fracture site

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Pneumothorax Haemothorax 2. Plain X-ray abdomen in erect posture: Features of liver and splenic injury Free gas shadow under diaphragm 3. Blood for grouping and cross matching Treatment: Resuscitation and assessment side by side A. ABC management. B. Haemo-pneumothorax: i. Chest drain ii. Analgesic + antibiotics + chest physiotherapy iii. Blood transfusion C. Associated liver injury: i. Conservative: If patient haemodynamically stable ii. Operative: Repair a) No improvement on resuscitation b) Facilities not available D. Associated splenic injury: i. Conservative: a) If patient is stable b) Angiography with selective embolization of bleeding vessels ii. Operative: a) Splenorrhaphy b) Splenectomy E. Diaphragm injury: Repair by non-absorbable suture. Conclusion: Strong suspicious of liver and splenic injury is very important in lower rib fracture. Proper assessment is needed to exclude intra-abdominal injuries.

128. Pulse Oxymeter

Introduction: It is an essential piece of equipment used for monitoring of critically ill patient (during operation, post-operative period and in the ICU). Indication: Monitoring of patient During operation In post-operative period In the ICU Monitors: Pulse rate Pulse volume O2 saturation M/A: Fingertip sensor contains 2 light sources 1. Red: Measure oxygenated Hb% 2. Infrared: Measure total amount of Hb% Disadvantage: Pulse oxymeter does not indicate adequate ventilation. Limitation: Severely vaso-constricted patient Carbon-monoxide poisoning Conclusion: This non-invasive equipment helps for easy monitoring of ill patient and we can take appropriate measures early.

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129. Secondary Lymphoedema

Introduction: This is the most common form of lymphedema due to defective lymphatic drainage in the presence of normal net capillary filtration. It is the most common form of lymphoedema and treatment is usually difficult, so proper counseling is vital. Cause: A. Infective: i. Parasitic ii. Bacterial iii. Fungal B. Traumatic: i. Degloving injury ii. Surgical excision of lymph nodes and lymphatics e.g. axillary surgery C. Neoplastic: i. Hodgkins and NHD ii. Secondary to lymph node D. Others: i. Radiotherapy to lymph node ii. Superficial thrombophlebitis Presentation: Slow, progressive and painless swelling which is pitting initially but non-pitting later on Difficulty in movement of limb Overlying skin change: o Ulceration o Eczema o Fissuring Investigation: According to cause 1. Midnight PBF 2. CFT for Filaria 3. Routine blood count for Filaria: Eosinophil 4. Lymph node biopsy for lymphoma 5. CT scan: To exclude pelvic or abdominal wall 6. MRI: To see lymphatic channel and Lymph node Treatment: A. Physical methods: i. Elevation of foot on the bed ii. Avoid prolonged standing iii. .. pneumatic compression. B. Drug: i. Antibiotics for cellulitis ii. Antifungal iii. Antifilarial iv. Chemo-radiotherapy for lymphoma C. Surgery: i. By pass: Lympho-venous anastomosis ii. Limb reduction procedure: a) Sistrunk b) Homan c) Thompson d) Charles

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D/D: 1. HF 2. Angioneurotic oedema 3. Lymphoedema tarda/ praecox.. Conclusion: Early treatment of the cause is vital for better outcome.

130. Recurrent Inguinal Hernia

Introduction: It is a distressful condition both for the surgeon and for the patient. So proper preoperative evaluation and appropriate measures are vital to prevent recurrence. Incidence: Indirect: 0.6 3% Direct: 1 28% as tissue is more attenuated in direct hernia After mesh repair: < 2% Type: 1. True: Same type of hernia occurs e.g. direct hernia after repair of direct 2. False: Another type of hernia occurs e.g. indirect after direct Cause: A. Within a few months or years: i. Persisting of predisposing factor: a) Chronic cough b) Prostatism c) Constipation ii. Technical errors: a) Overlooking an indirect sac in . b) Failure to repair of fascial defect securely c) Repair under tension B. After 2 years: i. Progressive weakening of patents fascia. ii. Repeated recurrence: Lax abdominal musculature due to defective collagen synthesis. Point of recurrence of direct hernia: Lateral to the pubic tubercle. Surgical importance: More chance of development of incarceration and strangulation because fascial defect is small, firm and unyielding. Presentation: H/O operation Swelling in inguino-scrotal region on same side Investigation: 1. CXR 2. USG of abdomen: To exclude predisposing factors. Treatment: 1. Treatment of predisposing factors if any. 2. Hernioplasty: If previous operation was herniotomy and herniorrhaphy. 3. Herniotomy: Indirect hernia after direct hernia. 4. Repair the defect by fascia lata/ Non-absorbable patch PTFE After repeated recurrence. Conclusion: Proper pre-operative evaluation and meticulous operative technique is vital to prevent recurrence of hernia.

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131. Cervical Rib

Introduction:

Type: 1. 2. 3. 4.

Complete rib Nodular ending Fibrous band Sharp ending with tapper

Clinical Feature: Local Neurological Vascular Investigation: Chest X-ray (P/A view)

Complication:

D/D:

Rx:

Conclusion:

132. Horse-shoe Kidney

Introduction: It is the most common congenital anomaly of kidney where lower pole of both kidneys become fused and arrested by IMA. Incidence: 1 : 1000 live birth. Anomalies: 1. Fused at the lower pole of both kidneys. So normal ascend is arrested by mid line structure usually by inferior mesenteric artery. 2. Usually lies at 4th lumbar vertebrae.

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Associated Anomalies: 1. VUR, PUJ obstruction 2. VACT.. Presentation: Common in male Asymptomatic: Incidental dx by IVU/ USG Infection and stone formation Features of PUJ obstruction: Pain in loin Fixed mass below the umbilicus Investigation: 1. Urine: Routine examination C/S 2. USG: Renal mass Hydronephrosis 3. IVU: Diagnostic Lower pole calyces are directed towards midline. Kidneys are vertical and medial border intersects and crosses the psoas muscle instead of parallel course. Complication: UTI Renal stone Treatment: A. No symptom: i. No treatment ii. Reassurance B. UTI: Antibiotics according to C/S C. PUJ obstruction: Pyeloplasty D. Surgery: i. Only indicated before operation of abdominal aortic aneurysm. ii. Division of isthmus. Conclusion: Only needs regular follow up after incidental dx, as liable to become diseased.

133. Filarial Hydrocele

Introduction: It is one of the common secondary hydroceles in tropical countries. Causative agent: Wucheria bancrofti. Pathogenesis: Follow repeated attacks of filarial epididymo-orchitis. Rupture of lymphatic varix with discharge of chyle into the hydrocele chylocele Presentation: 1. Periodic fever with attack of epididymo-orchitis 2. Scrotal swelling 3. Elephantiasis of scrotum and lymph varix - may be associated. O/E:

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Scrotal swelling Epididymis and testis may be palpable swollen, firm, nodular and slightly tender Fluctuation test: (+)ve Transillumination test: (-)ve Tubercular epididymo-orchitis Syphilitic orchitis

Investigation: 1. CBC: Eosinophilia, ESR 2. CFT: For filaria 3. Blood: For microfilaria 4. Aspiration of fluid: Microfilaria 5. Testicular biopsy: May be needed for confirmation Complication: Elephantiasis of scrotum Testicular atrophy Subfertility/ Infertility Treatment: 1. Rx of filariasis 2. Rx of hydrocele if required 3. Rest and aspiration of fluid 4. Rx of filariasis by diethylcarbamazine 5. Excision of sac if needed Conclusion: Early dx and treatment is vital to prevent complications.

134. Intractable Cystitis

Introduction: It is an uncommon condition of urinary bladder which causes significant distress to the patient which hampers the daily life. Aetiology: 1. Unknown 2. Autoimmune collagen disease may be associated Pathology: Pancystitis Fibrosis of vesical musculature Contracture of the bladder and avascular atrophy of epithelium Ulceration of bladder mucosa in the fundus of bladder. In severe cases bladder capacity is reduced to 30 to 40 ml. Presentation: Middle aged women Frequency at both day and night Pain relief by micturition Pain is increased by over-distension Haematuria D/D: 1. TB cystitis 2. Ca bladder Investigation: 1. Urine: R/E: RBC may be present No pus cell usually

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C/S 2. USG: To exclude bladder neoplasm 3. CBC: For TB 4. Cystoscopy: Linear bleeding ulcer in the fundus Urethra and trigon may be involved 5. Cystogram: Small bladder Treatment: Difficult and unsatisfactory, some options 1. Hydrostatic dilatation under G/A 2. Light diathermy fulguration of ulcer 3. Intravesical dimethylsulphoride 4. Bladder substitution if symptoms are severe 5. Cysto-urethrectomy and urinary diversion for complete relief Conclusion: As treatment is difficult and unsatisfactory, proper counseling is vital.

135. Partial Nephrectomy

Introduction: It is a type of nephrectomy done on special situation. Type: 1. 2. 3. 4. Congenital Traumatic Inflammatory Neoplastic

Indication: 1. RCC or TCC in kidney: a) Solitary kidney b) Bilateral disease c) Poor renal function of opposite kidney d) Small tumour < 4cm e) Low grade tumour 2. Renal injury 3. Stone in one pole of kidney with fibrosis or infected Pre-operative preparation: 1. See the functional status of same kidney and opposite kidney 2. Two unit of blood ready Anaesthesia: G/A with ETT. Position: For posterolateral approach. Skin preparation: Antiseptic washing and proper draping done. .: (Lumbar subcostal incision): Depends upon indication. Procedure: 1. Full mobilization of kidney 2. Elevation of anterior and posterior flap of renal capsule 3. Cooling of kidney by ice pack 4. Apply vascular clamp across the pedicle 5. Divide the kidney transversely at the level of flap 6. Capsule is closed over the raw surface 7. Remove the clamp and haemostasis is secured

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Post-operative: Proper post-operative care. Complication: During operation: Haemorrhage o Renal artery o IVC o Ureter Post-operative: o Bleeding o Infection o Recurrence of disease Conclusion: Regular follow up is essential.

136. Emphysematous Cholecystitis

Introduction: It is a rare & severe form of acute cholecystitis which needs immediate surgical intervention. Cause: Gas forming anaerobic infection 1. Clostridia species 2. E. coli 3. Anaerobic streptococci Risk factor: 1. Diabetes mellitus 2. Elderly people Pathogenesis: Anaerobic gas forming organism Produce gas in the lumen of Gall Bladder, in the wall, pericholecystic space and even in the bile duct. In many cases gall bladder contains no stone. Presentation: Sudden onset Progressive right upper quadrant pain Fever O/E: Patient toxic Mass in the right upper quadrant

D/D: Other forms of acute cholecystitis Investigation: 1. Plain X-ray abdomen: Tissue emphysema outlining the gall bladder Air fluid level in the lumen 2. CT scan abdomen: If X-ray is doubtful Treatment: Surgical emergency A. Initial resuscitation with high dose of antibiotic which acts against clostridia B. Operation: i. Emergency cholecystectomy ii. Cholecystostomy if ill patient Complication: Gangrene of gall bladder

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Perforation and biliary peritonitis Septicaemia

Conclusion: In spite of early and vigorous treatment death rate is higher.

137. Tumour Metastasis in Liver

Introduction: Metastatic cancer is 20 times more common than primary tumour in the liver. Liver is the site where any tumour can metastases specially from GIT. Common Primary Site: 1. Colorectal 2. Stomach 3. Gall bladder 4. Pancreas 5. Breast 6. Lungs 7. Kidney 8. Ovaries 9. Uterus Route: 1. Direct spread: a) Stomach b) Gall bladder c) Pancreas d) Hepatic flexure of colon 2. Vascular: Portal vein Hepatic artery a) Colorectal b) Stomach c) Pancreas d) Lungs e) Kidney 3. Lymphatics: a) Colorectal b) Breast Presentation: General: o Weight loss o Anorexia o Fatigue o Mass in the right hypochondrium o Pain Specific features of primary tumour: o P/R bleeding o Alteration of bowel habit Anaemia

O/E:

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Jaundice Hepatomegaly Ascites

Investigation: For primary tumour & liver metastases 1. Haematocrit: 2. LFT Serum bilirubin: , Alkaline phosphatase: 3. USG SOL in the liver 4. CT scan with I.V contrast: Hypodense area with no contrast enhancement 5. MRI: Superior than CT scan 6. CT Portography: More useful 7. 99Tc Liver scan: > 2cm diameter 8. Investigation for primary tumour: Colonoscopy Chest X-ray Upper GIT Endoscopy 9. Liver biopsy: USG / CT guided P/C FNAC Treatment: Treatment is palliative but in colorectal carcinoma curative resection can be done. A. Surgery: Partial hepatectomy i. Wedge resection ii. Lobectomy Indication: Colorectal carcinoma which is curable and no detectable extra hepatic metastases Solitary or < 4 in single lobe Amneable to curative: o Pancreatic islet cell tumour o RCC o Carcinoid tumour B. Radiotherapy: As a palliative C. Chemotherapy: As a palliative i. Local via hepatic artery canulation ii. Systemic D. Radio-chemotherapy E. Hepatic artery ligation F. Angiographic chemo-embolization Prognosis: Varies with extent 3 months to 2 to 3 years, according to extent and types of treatment. Conclusion: It is a stage IV disease, so prognosis poor.

138. Biliary Endoprosthesis

Introduction: With the invention of interventional radiology, placement of biliary endoprosthesis has made an essential contribution for patient management. It is a modern method of biliary drainage and mostly used as a palliative purpose. Indication: A. For palliation: For advanced malignancy i. Ca head of pancreas ii. Primary bile duct cancer iii. LN enlargement of porta hepatis by secondary iv. Involvement of major bile duct by secondary

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B. For curative: i. Bile duct leakage ii. Short segment biliary stricture C. For preparation of operation in biliary obstruction Advantage: No need of external drainage which is inconvenient Reduced the risk of infection Avoid major surgery in advanced malignancy Type: 1. Plastic 2. Self-expanding metallic Procedure: Percutaneous transhepatic Endoscopic A guide wire is placed through stricture under radiological control Endoprosthesis is inserted over the guide wire into distal normal CBD or into the duodenum Guide wire is withdrawn and prosthesis is kept in situ. Complication: Major: o o Minor: o o o

Haemorrhage Sepsis Pain Fever Catheter blockage or leakage

Conclusion: With the invention of endoprosthesis we can avoid major surgical procedure for palliation of jaundice patient.

139. Cholecystoduodenal Fistula

Introduction: It is the most common internal biliary fistula where gall bladder is communicated with duodenum. Cause: A. Inflammatory: Acute cholecystitis B. Neoplastic: i. Ca Gall bladder ii. Ca Duodenum C. Surgically made: Rarely done D. Traumatic Presentation: Elderly usually female patient Asymptomatic - incidental dx Features of cholangitis: o Pain

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o o Fever Jaundice Gall stone ileus (Intestinal obstruction)

Investigation: 1. Plain X-ray abdomen: Radio opaque gall stone may be seen IO Gas in the biliary tree 2. Upper GI series: Fistula may be seen 3. USG of W/A: Gall bladder mass 4. ERCP: Fistula can be seen Treatment: 1. No symptom: No treatment. 2. Cholecystectomy with closure of fistula: If symptomatic. 3. If gall stone ileus: Laparotomy Enterotomy and removal of stone Closure of gut. Cholecystectomy with closure of fistula if symptomatic later on. 4. If associated with malignancy: Rx according to staging of malignancy (usually advanced). Conclusion: High index of suspicious is important for dx.

140. Sliding inguinal Hernia

Introduction: It is a type of indirect inguinal hernia in which the wall of a viscus forms a portion of the wall of the hernial sac excessively in male and faces many difficulties during operation if not suspected pre-operatively. Involved viscus: Left side: Sigmoid colon and its mesentery Right side: Caecum Both side: Urinary bladder

Side: Five out of six on left side. Clinical Feature: Elderly, male patient A large hernia which is incompletely reducible No special pathogenic sign Investigation: 1. Barium enema: Segment of colon in the scrotum 2. Cystogram: Part of bladder in the hernial sac Treatment: Operation A. Open: i. Herniotomy ii. Herniorrhaphy B. Laparoscopic (best) Procedure: 1. Separation of hernia sac from the .. and abdominal wall. 2. It is replaced deep to repaired fascia transversalis

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Difficulties during operation: Separation of sac Unusual bleeding Ligation of neck Injury to caecum, sigmoid colon Special situation: Large hernia: May need laparotomy via separate incision and fixation of bowel into post abdominal wall. Orchidectomy: May be needed for secure repair. Complication: Strangulation and obstruction On operation: Faecal fistula due to o Injury to the gut o Impairment of vascularity o Injury to bladder and ureter Recurrence Conclusion: Strong suspicion and care during operation is vital to prevent complications.

141. Tongue Ulcer

Introduction: It is a common clinical problem which is very distressful for the patient and needs proper evaluation to exclude malignancy. Cause: 1. Non-specific: a) Aphthous ulcer b) Dental ulcer c) Post pertussis d) Chronic non-specific 2. Specific: a) Syphilitic b) Tubercular 3. Carcinomatous ulcer Presentation: Varies according to aetiology Pain: Specially in non-specific and tubercular Salivation: In carcinoma Dysphagia In malignant ulcer: o Disarticulation o Neck swelling Site: Tip:

o Aphthous ulcer o Tubercular Dorsum Margin Anterior 2/3rd: Non-specific ulcer Investigation: 1. CBC: For TB and non-specific ulcer

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2. Chest X-ray (P/A view) 3. VDRL: To exclude syphilitic ulcer 4. Open biopsy: a) Excision: Small ulcer b) Incision 5. FNAC from lymph node: +ve 6. Swab from ulcer: For C/S Treatment: According to cause1. Aphthous ulcer: Reassurance Analgesic 2. Dental ulcer: Tooth extraction 3. Tubercular: Anti TB drugs 4. Syphilitic ulcer: Penicillin 5. Non-specific: Antibiotic according to C/S 6. Malignant: a) Surgery b) Radiotherapy c) Combination according to the stage Conclusion: High index of suspicion of malignancy particularly in older people is vital.

142. Insulin Dependent DM Undergoing an Abdominal Operation

Introduction: Diabetes and surgery is a common problem especially in elderly patients and needs proper pre-operative evaluation and peri-operative measures to prevent complication. Problem in diabetic patient: 1. CVS: PVD IHD HTN 2. Nephropathy 3. Retinopathy 4. Hidden infection 5. Electrolyte disturbance 6. Uncontrolled glucose level Pre-operative work up: History: o Controlled or uncontrolled o Chest pain o Visual disturbance Thorough physical examination specially any infective foci Investigation: o Blood: CBC Glucose Ketone body o Urine: Sugar Ketone body o Serum electrolyte

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o o o o Lipid profile Serum creatinine: To see renal function Chest X-ray ECG

Types of surgery: 1. Elective 2. Emergency In elective surgery: 1. Pre-operative control of blood sugar by short acting insulin 2. Operation is scheduled at morning 3. Peri-operative control of glucose by sliding scale regimen 4. Blood sugar measurement 2 hourly 5. Maintain blood glucose within 6 12 mmol/L In emergency surgery: 1. Blood sugar level: Bed side Laboratory 2. Bed side urine test for sugar and ketone bodies 3. Send the blood for electrolyte, creatinine, urea 4. If ketoacidosis First treat ketoacidosis by i.v N/S + Insulin i.v bolus + KCl 5. When blood glucose level is < 14 mmol/L start sliding scale regimen and patient can be operated safely. Post-operative: Switch over into s/c insulin when patient can take orally as pre-operatively.

143. Subphrenic Abscess

Introduction: It is a common sequel of intra-peritoneal disease, which (usually after leakage of infected or infective fluid from viscus) causes great morbidity to the patient and need early Rx to prevent complications. Type: A. Intra-peritoneal: i. Right and left suprahepatic ii. Right and left subhepatic B. Extra-peritoneal: i. Right and left extra-peritoneal perinephritis ii. Midline (bare area of liver) Cause: 1. Perforated duodenum, stomach: Peritonitis due to any cause After laparotomy 2. Following biliary surgery 3. Any upper abdominal surgery 4. Perforation of biliary tree 5. Perforation of colon 6. Acute appendicitis 7. Acute pancreatitis 8. Following abdominal trauma

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Presentation: H/O acute abdomen/ any abdominal surgery, followed by Unexplained fever Hectic rise of temperature Toxic, irritated patient Weight loss Anorexia D/D: 1. Liver abscess 2. Pyelonephritis 3. Empyema thoracic O/E: Anaemia Temperature Restricted chest movement Slight bulging of right upper abdomen

Investigation: 1. CBC: Hb% ESR Leukocytes 2. USG of abdomen: Collection 3. Chest X-ray: Raised hemi-diaphragm Abscess cavity (gas fluid level) 4. Right pleural effusion 5. CT scan abdomen: 75% Sensitive 6. Radionuclide scan: Radio labeled autologous leukocyte Treatment: A. Drainage of abscess: i. Percutaneous under USG/ CT guided ii. Open drainage B. Supportive Measure: i. Improve nutritional status ii. Maintain fluid and electrolyte balance iii. Correction of anaemia by blood transfusion iv. Antibiotic according to C/S Conclusion: In spite of early dx and treatment mortality rate is high, so prevention is vital.

144. Chronic Bursitis

Introduction: It is a common problem in clinical practice especially in elderly patient, mostly initiative usually needs conservative treatment. Type: 1. Irritative 2. Infective Cause:

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1. Irritative: Due to excessive pressure or friction 2. Infective: Due to tuberculosis Common site: Pre patellar bursitis (housemaids knee) Infra patellar (.. knee) Olecranon bursitis (students elbow) Bunion. Trochanteric bursitis (specially for TB) Presentation: Pain Swelling Difficulty in movement of joint Features of TB may be present Investigation: 1. CBC: Lymphocytosis ESR Hb% 2. X-ray chest: TB 3. X-ray of local parts: Any joint pathology 4. Biopsy: In suspected TB Treatment: 1. Irritative bursitis: a) Avoidance of aggravating factors b) Anti-inflammatory drugs c) Aspiration and intra-lesional steroid d) Surgical excision: In resistance case 2. Infective bursitis: a) Excision of bursa b) Anti TB drug Conclusion: As mostly are irritative, so avoidance of aggravating factors is important.

145. ATLS
Introduction: ATLS is a structured trauma management training program. Philosophy: To treat lethal injury first, then reassess and treat again. Component: 1. Primary survey: Identify what is killing the patient 2. Resuscitation: Treat what is killing the patient 3. Secondary survey: Identify all other injuries 4. Definitive care: Develop a definitive management plan 5. Primary survey and resuscitation must be concurrent Relation with trimodal distribution of death: ATLS focuses on early death group where death is preventable by following ATLS guideline. Advantage: Prevent early death in trauma patient Reduces the number of late death in trauma

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Conclusion: This life support course should be taken by every doctors working in accident and emergency department.

146. Brodies Abscess

147. Painful Knee Joint

Introduction: It is a common problem in all age group particularly in adult and elderly people which may make the patient crippled, so need proper evaluation and early Rx. Cause: A. Inflammatory: i. Septic arthritis

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ii. Osteoarthritis iii. Rheumatoid arthritis iv. Tubercular arthritis B. Traumatic: Injury to i. Ligament e.g. cruciate ligament ii. Muscles iii. Bones iv. Meniscus C. Neoplastic: i. Osteosarcoma ii. GCT iii. Syno... D. Miscellaneous: i. Bursitis ii. Referred from hip Presentation: Pain Swelling Deformity Difficulty in working General feature: o Weight loss o Anorexia Investigation: 1. X-ray knee joint: Joint space Boney spars Bony lesion 2. CBC: ESR Hb% 3. Joint fluid analysis: C/S for AFB Malignant cells 4. CT Scan: Dx of osteoarthritis 5. MRI: Torn meniscus and ligament 6. Arthroscopy: Ligament and meniscus injury 7. Biopsy: In neoplastic condition Treatment: Depends upon the cause 1. Rest 2. Elevation 3. Analgesic 4. Splintage 5. Early mobilization 6. Rx of specific cause mostly needs surgical intervention. Conclusion: Proper evaluation and orthopaedic consultation is vital for treatment.

148. Pulmonary Embolism

Introduction: Pulmonary embolus is a major cause of morbidity and mortality in surgical patient especially in high risk patient. Source: 1. Thromboembolism (most common) from ileal and femoral vein 2. Air embolism CVC

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3. 4. 5. 6. 7. 8. Amniotic fluid Fat emboli Septic emboli Tumour emboli Parasitic emboli # Long bone

High risk group: Age > 40 years Obesity Type of surgery: o Orthopaedic o Urology OCP Previous H/O DVT Varicose vein Presentation: Small emboli: o Asymptomatic o Pleuritic chest pain o Pulmonary HTN o Right heart failure Larger emboli: Triad of o Dyspnoea o Chest pain o Haemoptysis Massive: o Haemodynamic collapse o Acute shortness of breath o Severe chest pain Investigation: 1. Chest X-ray: Normal Pleural cap 2. ECG: Atrial fibrillation Ischaemic change Non-specific ST and T wave change 3. Blood gas analysis: Hypoxia Respiratory alkalosis 4. Spiral CT scan: Diagnostic and most sensitive 5. MRA: Diagnostic and most sensitive 6. Pulmonary artery angiography most reliable 7. Ventilation: Perfusion scan Treatment: A. Acute minor embolus: i. No specific Rx ii. Prevention of further emboli iii. Heparinisation than oral anticoagulant iv. Inferior vena caval filter in recurrent cases B. Acute massive embolus: i. Lying flat ii. Heparin/ LMK. started as soon as possible

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iii. iv. v. Thrombolytic agent: TPA helps in resolution (within 24 hours) O2 inhalation Surgery: Haemodynamically unstable patient a) Percutaneous pulmonary embolectomy b) Open surgical pulmonary embolectomy

Conclusion: Prevention is vital.

149. Prevention of Breast Cancer

Introduction: It is a new concept and ongoing under trial. Aim: To reduce cancer incidence. Method of prevention: 1. Diet: Low fat diet Rich in soya diet 2. Chemoprevention: Tamoxifen Phyto-oestrogen 3. Prophylactic mastectomy: Gene positive women: BRCA1, BRCA2 and PS3 gene Family history Indication/ Eligible person: 1. Women with family history/ genetic predisposition of breast cancer 2. After surgery for carcinoma breast: Prevention for the same breast or opposite breast 3. Women > 50 years of age Advantage: Avoid expensive and toxic treatment of breast cancer. Disadvantage: Cost effectiveness Side effects of Tamoxifen e.g. Endometrial carcinoma Psychological upset due to loss of breast Conclusion: Participation in chemoprevention should be actively encouraged.

150. Chemoprevention
Ca Breast Head neck carcinoma: Vit A (Retinol) Retinoid Used in oral leukoplakia It is a premalignant condition.

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151. Pancoast Tumour

Introduction: Apical lung cancer. Type: Usually squamous cell type. Presentation: Persistent drug Dyspnoea Haemoptysis Pancoast syndrome: o Horners syndrome due to pressure over the sympathetic chain o Pain in the C8, T1 nerve distribution due to brachial plexus involvement o SVC obstruction Paraneoplastic syndrome O/E: Anaemia Clubbing Engorged neck vein Chest: Features of consolidation

D/D: 1. Pulmonary TB 2. Mediastinal tumour Investigation: 1. CXR (P/A view & lateral view): Site Collapse Pleural effusion Raised hemi-diaphragm Rib erosion 2. Sputum for cytology 3. CT scan of chest: Extension 4. Bronchoscopy and biopsy 5. Needle guided biopsy: Tissue dx Treatment: According to staging Surgery: i. Lobectomy ii. Segmentectomy iii. Wedge excision of tumour Radiotherapy Chemotherapy Prognosis: Depends on cell types, grading and general condition of the patient. But overall survival rate is poor.

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152. Traumatic Aneurysm

Introduction: It is a false aneurysm (not contained by vessels wall .) confined by fibrous capsule, communicating with the artery through the opening in its wall. Cause: 1. Direct trauma to the vessels 2. Anastomotic site between graft and vessels Site: Usually peripheral artery e.g. 1. Femoral artery 2. Popliteal artery 3. Radial artery Presentation: H/O trauma or surgery Pulsatile swelling Local symptoms depends upon tissue compression Thromboembolic manifestation O/E: Expansile pulsation Compressible, thrill present Bruit present

D/D: 1. A-V fistula 2. Pulsatile tumour: a) Bone sarcoma b) Osteoclastoma c) Metastatic RCC 3. Abscess in groin Investigation: 1. Duplex scan: Anatomy of vessels Blood flow and turbulence 2. Arteriograph: For plan of surgery Anatomy and associated pathology of vessels 3. X-ray local part Bony erosion Complication: Rupture Calcification Infection Thrombosis Embolism

Treatment: A. Conservative: Not expanding, no sign of vascular insufficiency. B. Surgery: i. Open: a) Excision and ligation of vessels if sufficient collateral e.g. radial artery b) Resection and arterial reconstruction by end to end anastomosis or interposition of graft tissue. ii. Endovascular repair through arteriotomy and placement of graft.

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Conclusion: Surgery of false aneurysm is a challenge to the vascular surgeon.

153. Myocutaneous Flap

Introduction: With the advancement of reconstructive surgery, myocutaneous flaps are used in a variety of reconstructive procedure. Composition: Skin and underlying muscles along with its blood vessels. Principle: Based on known vascular pedicle supplying the muscles and overlying skin. Type: 1. 2. Use: Arial flaps Free tissue transfer Breast reconstruction Open tibial fracture Pressure sore wound Wound caused by radiation or osteomyelitis Wound with high chance of infection Functional transfer with intact nerve e.g. o Brachial plexus injury o Facial nerve palsy

Commonly used flap: 1. Latissimus dorsi: Breast reconstruction 2. Rectus abdominis: Breast reconstruction 3. Pectoralis major: Defect over the sternum, neck and lower face 4. Trapezius: Defect in the neck, face, scalp 5. Temporalis: Orbital defect 6. Tensor fascia lata: Reconstruction of lower abdominal wall 7. Gastrocnemius: Exposed bone in the lower leg Advantage: Reliable Better cosmetic outcome Rapid wound healing Can be used in contaminated wound Disadvantage: Flap failure Too much and too less tissue transfer Complication of donor site Need experts Conclusion: Knowledge of the anatomy of muscles and their nerve and blood supply is necessary for successful design of myocutaneous flap.

154. Post-operative Analgesia

Introduction: Pain is a protective mechanism for the body but post-operative pain serves no useful purpose rather it aggravates post-operative complications.

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Aim: 1. Smooth post-operative recovery 2. Prevent post-operative complications Why should we treat post-operative pain? A. Humanitarian aspect B. Physiological purpose: i. Respiratory:: a) Reduce VC, FRC b) Reduce cough and deep breathing c) Secretion d) Atelectasis e) Pneumonia ii. Cardiovascular: a) Tachycardia b) HTN c) Bleeding d) Stroke iii. Neuro-endocrine: a) Metabolism b) O2 consumption iv. Mobilization: a) Delayed mobilization b) DVT Assessment of severity of pain: It is a subjective feeling Indirect evidence: o FEV1 and PFR o Pain score by analogue scale of pain Method: A. Non-pharmacological: i. Pre-operative counseling ii. TENS (transcutaneous Electrical Nerve Stimulation) B. Pharmacological: i. Narcotic: a) Morphine b) Codaine c) Pethidine ii. Non-narcotic: a) NSAID: Mefenamic acid 50mg 8 hourly Diclofenac Ketorolac 10 mg i/v or i/m 6 hourly b) Local anaesthetics Route of Administration: A. Parenteral: i. Intravenous: a) Continuous infusion b) PCA (Patient control analgesia) intravenous ii. Intramuscular B. Rectal C. Oral D. Inhalation N2O/ O2 (Entonox) E. Local infiltration i. Wound (Bupivacaine) ii. Nerve block: a) Intercostal block:

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Bupivacaine Lignocaine b) Paravertebral block c) Caudal block Epidural block Transdermal: Fentanyl Sublingual Subcutaneous Nebulizer: Morphine Diamorphine

iii. F. G. H. I.

i. ii. Advantage: Early recovery Reduce post-operative complications Disadvantage: Respiratory depression Spinal headache Pneumothorax in intercostal block Gastric erosion: NSAIDs

Monitoring of Analgesia: 1. Behaviour of patient 2. Pain score: Visual analogue score Visual rating score 3. Sedation score: 0 = Patient alert 1 = Mild sedation 2 = Moderate sedation 3 = Severe sedation 4. Respiratory monitoring Modern Concept: o o o No single analgesic Balanced analgesia used in combination: NSAIDs + Opioid or local anaesthesia Multidisciplinary APS AP Team:

Conclusion: Effective post-operative pain control improves the outcome of major operation.

155. Abdominal Wound Dehiscence

Introduction: It is a devastating complication of abdominal surgery, more common in emergency surgery. Incidence: 1% of all abdominal operation. Time: Between 6th and 8th POD. Predisposing Factor: A. Pre-operative (General causes): i. Chest infection

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ii. Systemic sepsis iii. Persistent cough iv. Jaundice v. Malignancy vi. Anaemia vii. DM viii. Steroid therapy ix. Obesity x. Immune deficiency B. Operative (Local): i. Septic surgery ii. Operation for peritonitis iii. Poor surgical techniques (too tight or too loose suturing) iv. Nerve injury v. Haematoma C. Post-operative: i. Persistence of per-operative problem ii. Post-operative distension: a) Gastric b) Paralytic ileus iii. Premature removal of deep tension suture iv. Wound infection and haematoma Type: 1. Superficial: Gaping of skin and subcutaneous tissue 2. Deep: Separation of all layer of anterior abdominal wall except skin 3. Complete (Burst abdomen): a) Gradually (Sero sanguineous fluid) b) .. Presentation: Sero-sanguineous discharge Patient feels something give way Omentum or coils of intestine protruding outside the wound Treatment: A. Prophylactic: i. Correction of predisposing factors before surgery e.g. a) Reduction of obesity b) Rx of chest infection or sepsis c) Stoppage of smoking, control of DM ii. Proper aseptic condition and meticulous surgical technique iii. Post-operative NG tube suction and timely removal of stitches are essential B. Superficial: i. Evacuation of clots ii. Rx of wound infection iii. Wound closure by secondary stitch C. Deep: i. Delay stitch removal ii. Apply abdominal corset iii. Rx of incisional hernia later on D. Burst abdomen: i. Reassure the patient ii. Apply sterile warm packs iii. Urgent repair under G/A through and through tension suture Conclusion: Prevention is vital.

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156. Intracranial Abscess

Introduction: It is an uncommon condition and mostly occurs secondary to infective foci elsewhere in the body. It is a surgical emergency and needs immediate drainage to prevent fatal complications. Type: 1. Brain abscess 2. Subdural abscess 3. Epidural abscess Predisposing factors: Congenital cyanotic HD Trauma Surgery Cause: 1. Direct extension from infected a) Para-nasal sinus b) Middle ear cavity c) Teeth 2. Haematogenous: a) Heart b) Lungs 3. Direct trauma Organism: Streptococcus Staphylococcus Enteric Gm (-)ve rods Anaerobic streptococcus Bacteroids Fungus, protozoal infection in immune-compromised person Presentation: Depends on Location of abscess Immune status of patient 1. H/O primary source 2. Features of focal neurological sign: ICP Seizure Meningeal irritation 3. Fever Investigation: 1. 2. 3. 4. 5. CBC: Leukocytosis ESR Hb% Blood culture Swab from primary site CT Scan with i/v contrast: Low density area enhancement Features of sinusitis MRI: Differentiate between brain tumours.

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Treatment: 1. 2. 3. 4. 5.

6.

Drainage of abscess Supportive measures Identification of organism I/V broad spectrum antibiotic coverage with Metronidazole + Anticonvulsant Drainage of abscess by Burr hole with or without Stercotaxis or Excision of abscess Treatment of primary cause

Complication: Burst into ventricle or subarachnoid space Obstruction of CSF pathway Transtentoreal herniation of brain substance Conclusion: Needs regular follow up as recurrence may occur.

157. Nerve Entrapment Syndrome

Introduction: It is a syndrome caused by entrapment of nerves in the natural pathways in facial planes or fibro-osseous tunnel especially during movement. It is a very distressful condition for the patient which hampers the daily life of the patient and makes them psychologically upset. Common nerve: 1. Median nerve 2. Ulnar nerve 3. Radial nerve 4. Common perineal nerve 5. Tibial nerve 6. Lower trunk of brachial plexus 7. Lateral cutaneous nerve of thigh 8. Spinal nerve root or trunk by PLID Causes: Prolapsed intervertebral disc Fibro-osseous tunnel Facial plane by callous Common site: 1. Carpal tunnel of wrist 2. Cubital vulgus: Tardy ulnar nerve palsy 3. Radial groove of humerous - Saturday night palsy 4. Supinator muscle 5. Facial nerve at facial canal 6. Around the fibular neck 7. Tarsal tunnel 8. Thoracic outlet 9. Inguinal ligament (meralgia paraesthetica) 10. Spine prolapsed disc Presentation: According to nerve involvement Sensory Motor Autonomic Pain along the distribution of nerve

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Paraesthesia, muscle weakness and atrophy Investigation: 1. Nerve conduction test Site of involvement 2. X-ray local part - To see associated fracture Treatment: A. Conservative B. Surgery: i. Splintage ii. Analgesia iii. Surgical decompression iv. Transposition of nerve

Complication: Atrophy of muscle Deformity of joint Complete loss of function of nerve Prognosis: Early: Good Late: o Endo-neural fibrosis o Axonal degeneration Conclusion: Early dx and treatment is important to improve quality of life.

158. Bells Palsy

Introduction: It is the most common form of facial nerve palsy and usually resolves within 6 12 weeks. Cause: Mostly Idiopathic but viral infection may be associated (Herpes Simplex virus). Site: Facial canal (Stylomastoid foramina). Pathogenesis: Vascular ischaemia and compressive oedema within the facial canal Neurapraxia and cessation of axoplasmic flow. Type of injury: 1. UMN lesion 2. LMN lesion Presentation: Bells sign + Eye falls to close Forehead doesnt wrinkle Angle of mouth drops D/D: 1. 2. 3. 4. Tumour of cerebello-pontine angle Acquastic neuroma Facial nerve neuroma Middle ear tumour

Investigation:

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CT scan of head To exclude D/D Gadolinium enhanced MRI Better soft tissue delineation and enhancement of facial nerve.

Treatment: A. Medical treatment: Usually resolves in 6 12 weeks: i. Prednisolone 60 80 mg/day for 7 10 days ii. Acyclovir 800 mg 5 times a day iii. Supportive care: a) Care of eye by b) Artificial Gold with eyelid + ear implant c) Facial muscle physiotherapy B. Surgery: If paralysis persists > 1 year i. Placement of gold weight eye lid implant to prevent exposure keratitis ii. Nerve cross over by hypoglossal nerve iii. Decompression of facial nerve iv. Neuro muscular transfer: a) Temporalis b) Masseter Conclusion: With early dx and treatment, most of the cases recover completely.

159. Neurofibroma
Introduction: It is a very common tumour of peripheral nerve. Cell of origin: Connective tissue of nerve sheath (Endoneurium). Behaviour: Benign. Type: 1. 2. 3. 4. Local Generalized Plexiform Elephantiasis and patchy dermatocele

Presentation: Swelling, pain, paraesthesia along the course of nerve. May present with paralysis If associated with spinal nerve (Dumble tumour). O/E: Tender, smooth swelling moves side to side but not above downwards. D/D: 1. Lipoma 2. Fibroma Investigation: 1. FNAC: Exclude malignancy 2. Nerve conduction test Treatment: 1. No symptoms no treatment requires, only reassures. 2. Excision and biopsy If symptomatic. Complication: Repeated trauma with ulceration

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Spinal cord compression (Dumble tumour) Cystic degeneration Sarcomatous change

Conclusion: During excision parent nerve injury is inevitable, so proper counseling is vital.

160. Tension Pneumothorax

Introduction: It is a surgical emergency and occurs mostly due to trauma and needs immediate attention to save the patient. Cause: A. Traumatic: i. Isolated chest: a) Unilateral b) Bilateral B. Rupture of emphysematous bulla Presentation: H/O trauma Severe respiratory distress: Hypoxia Severe pain Cyanosis O/E: 1. 2. 3. 4. 5. 6. Distended neck vein Breath sound: or absent On percussion: Hyper-resonance Trachea shifting to opposite site Hypotension Cyanosis may be present

Investigation: After insertion of chest drain X-ray of chest (P/A view): Fracture rib Pneumothorax Haemothorax Free gas under dome of diaphragm (Poly trauma) Treatment: This may be a part of poly trauma and need resuscitation and assessment side by side: Primary surgery Secondary surgery 1. Immediate insertion of side bore needle through 2 nd intercostal space in the midclavicular line to relieve pressure. 2. Chest drain tube insertion with water seal drainage at the triangle of safety 3. Treatment of other injury accordingly if present. 4. If haemorrhage or hypovolaemia I/V channel open Blood grouping & cross matching for blood transfusion

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Conclusion: Strong clinical suspicion is vital to save patients life.

161. Transluminal Angioplasty (PTA)

Introduction: It is a part of interventional radiology where balloon dilatation of arterial occlusion or stenosis is done to improve circulation. Aim: 1. To increase blood flow to the distal part 2. To tissue perfusion Indication: 1. PVD with short occlusion (10 15 cm) 2. IHD with CA stenosis 3. HTN of CRF due to renal artery stenosis 4. Mesenteric/ coeliac artery stenosis 5. Carotid artery stenosis Procedure: 1. Under L/A guide wire is passed through the stenosis. 2. Balloon catheter is inserted over the guide wire. 3. Balloon is positioned within the stenosis and confirmed by angiography. 4. Balloon is inflated for 1 minute and then deflated. 5. Repeat this procedure before withdrawal of catheter. Advantage: No need of G/A Early discharge from hospital Minor procedure Complication: Local haemorrhage, haematoma False aneurysm, subintimal dissection Arterial perforation Distal embolization Restenosis Stroke and death Success rate: 85 90% Conclusion: Avoid major surgical procedure/ demand increasing.

162. PDA (Persistent Ductus Arteriosus)

Introduction: It is one of the acyanotic congenital heart disease where there is failure to obliterate the ductus arteriosus. Incidence: 2 to 3% of live birth.

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Pathology: Ductus arteriosus remain patent which connects the main pulmonary artery to aorta distal to the origin of left subclavian artery. Aetiology: 1. Actual cause unknown 2. More in prematurity 3. Presence of high in circulation Presentation: Asymptomatic or Symptomatic: o Failure to thrive o Reluctant to food o Recurrent chest infection o Heart Failure (RHF) O/E: Bounding pulse Widened pulse pressure Continuous mechaniary Murmur

Complication: Chest infection Pulmonary HTN Heart failure . Investigation: 1. Echocardiography: Diagnostic 2. Chest X-ray (P/A view): To see infection Treatment: Depends upon the age of the patient A. Medical treatment: Premature infant i. Indomethacin ii. PG inhibitor B. Surgery: i. Failure of medical Rx ii. Term infant iii. Older children Option: Ligation, clipping or division through left thoracotomy Interventional radiology by umbrello occlusion per-cutaneously Conclusion: Early detection and treatment is vital to prevent complications.

163. Uretero Sigmoidestomy

Introduction: Permanent urinary diversion/ continent UD..

Indication: 1. After total cystectomy 2. Late case of ectopia vesica

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Type: 1. Colonic in continuity 2. Rectal bladder and colostomy Advantage:

Disadvantage

Contraindication: Upper urinary tract dilatation Faecal incontinence Pre-requisite: Gut perforation. Complication:

Conclusion: Proper selection of patient.

164. Indication & Technique of Circumcision in Adult

Introduction: Circumcision in our country is commonly done for religious purpose in children but in adult it is done due to some disease conditions. Indication: Operative surgery. Technique: 1. Pre-operative preparation: BT CT 2. Position 3. Anaesthesia 4. Washing and draping 5. Action dissection methods 6. Post-operative care Conclusion: Should be done carefully to avoid complications.

165. Ureterocele

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166. Urological Complications of # Pelvis

Introduction: Pelvic fracture is invariably associated with complications and urological complications are the most disabling condition (complications of pelvic fracture). Complication: A. Early: i. ii. iii. iv. v. B. Late: i. ii. iii.

Injury to posterior urethra usually at prostato-membranous junction Injury to urinary bladder: a) Extra-peritoneal (mostly) b) Intra-peritoneal Injury to sphincter urethra Injury to ureter Injury to sacral nerve Stricture urethra Urinary incontinence Impotence due to damage to nerve supply of penis

Treatment: 1. Urethral injury: If patient does not pass urine SPC

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If patient passes urine observation 2. Bladder injury: Extra-peritoneal: Repair + Retroperitoneal space drain + SPC/ Urinary catheter Intra-peritoneal: Laparotomy Repair Peritoneal toileting + Catheterization/ SPC 3. Ureter: Repair/ Reimplantation + Stenting/. 4. Urinary incontinence: Repair if possible or artificial sphincter Perineal exercise 5. Sacral nerve injury: Wait for 3 months then exploration and repair may be needed. 6. Impotence: If not recovery Medical Rx/ penile prosthesis Conclusion: Proper initial management of pelvic fracture is vital to prevent or minimize late complications.

167. Choice of Urethral Catheter & Technique of Urethral Catheterization

Introduction: Catheterization is a common urological procedure, so proper selection and aseptic technique is important. Choice of catheter: Depends upon Age Indication Duration of use Financial condition of patient A. Non ballooned catheter (Nelaton): i. Catheter to be removed after single use ii. Bladder empty or filled or fluid injected B. Ballooned catheter: Catheter to be left i. Bi-channel Foley: a) Urinary retension b) Urinary incontinence c) Per-operative or post-operative urine drain ii. Tri-channel Foley: a) After operation of bladder or prostate (Endoscopy or open) to prevent clot retension b) Irrigation of highly infected bladder iii. Latex with silicon coated: For long term catheterization iv. All silicone: For long term catheterization but it is expensive v. Haematuria: Foley Catheter a) Walls are reinforced with nylon b) Used after bladder operation for suction of clot vi. Hydrogel coated catheter: Used for self-dilation of urethral stricture Procedure: 1. Counseling, consent, privacy and attendance 2. Supine position 3. With all aseptic precaution (antiseptic wash + draping) introduce 2% Jesocaine jelly into urethra and hold it and wait for 2 3 minutes. 4. Foley catheter is gently introduced into the urethra until urine come out. 5. Introduce another few cm of catheter and then balloon is inflated with 20ml distilled water. 6. Catheter is connected with closed drain system and fix with medial side of thigh. 7. Urine colour and volume is noted. Conclusion: Technique of safe catheterization should be known by every doctor.

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168. Extra-urinary Indications of Foley Catheterization

Indication: 1. Monitoring of critically ill patient in ICU. 2. In gastrostomy, cholecystostomy, jejunostomy, caecostomy. 3. For recurrent small bowel obstruction, due to adhesion as a jones tube. 4. In rectal stump for easy identification prior to reconnection with colon in Hartmanns procedure. 5. For injection of contrast medium in Barium Enema or distal loopogram.

169. Selection of Patient for Day Case Surgery

Introduction: Day case surgery is a demanding concept but not all patents are suitable. Selection of patient for day case surgery is an important part of day case surgery for better outcome. Aim: To avoid predictable complications and morbidity. Place: At the time of out-patient consultation. Assessment: Selection criteria,3 factors A. Procedure to be undertaken: i. Minimal physiological stress ii. Not associated with excessive blood loss or fluid shift iii. Low risk of post-operative complication like bleeding, tracheal obstruction iv. Duration: Maximum 1 2 hours v. Pain must be controlled by oral analgesic vi. Ambulant afterwards B. Social circumstances: i. Ready access to hospital or GPS ii. Responsible adult for home care at least next morning iii. Home circumstances: a) Good toilet b) Few stairs c) Telephone iv. Live within 60 minutes travelling distance C. Patients health: i. Age: Not > 70 years ii. Obesity: BMI not > 35 iii. Respiratory: No H/O hospital admission for asthma or COPD iv. Cardiac disease: a) Poorly controlled HTN b) No angina, heart failure, myocardial infarction within previous 6 months v. Diabetes: IDDM and poorly controlled NIDDM vi. Drugs: Anticoagulant, , GTN, systemic steroid not be selected Conclusion: To achieve a good result proper selection is vital.

140 170. Day Case Surgery

Introduction: It is planned investigations or procedures and patients who are admitted and discharged home on the day of their surgery. Planned now resident basis Surgery performed on a day basis in dedicated day limit Type of Surgery: 1. It is a part of elective surgery 2. Minor procedure in OPD and A and E department are not included. Day surgery unit: 1. Part of general hospital 2. Own reception, operating and recovery area 3. Adjacent parking place 4. Same high standard as in general OT 5. Good record keeping 6. Trained experienced staff 7. Consultant, anaesthetist and surgeon Advantage: Reduced cost. in patient hospital stay Reduced waiting list for elective surgery. Reduced thromboembolism and hospital acquired infection. Minimal disruption of patients life. Early return to work and normal activities. Preferable to children. Disadvantage: Cost of setting of DSU. Good organization and management needed. Poor patient and procedure selection. Morbidity from anaesthesia and surgery. Patient selection: 1. Duration of surgery: 1 to 2 hours maximum 2. Home facilities: Responsible adult Telephone facilities Good bathroom facilities 3. Patient fitness: Age: Not > 70 years Obesity: BMI not > 30 No CVD and asthma or COPD Anaesthesia: 1. 2. Local or regional anaesthesia: Preferable General

Example: A. General surgery: i. Lumps and bumps: a) Sebaceous cyst b) Breast lump c) Lipoma ii. Varicose vein iii. Hernia repair, toe nail avulsion iv. Anal procedure: Abandoned now a) Anal stretch

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b) Sphincterotomy B. Urology: i. Cysto-urethroscopy ii. Circumcision iii. Varicocele surgery iv. Orchidectomy v. Orchidopexy C. Plastic surgery: i. Skin graft ii. Minor hand surgery iii. Tendon repair D. Orthopaedic: i. Manipulation under G/A ii. Arthroscopy iii. Carpal tunnel decompression E. Ophthalmic: Cataract surgery F. ENT: i. Tympanoplasty ii. Dx of Intraocular lens implantation G. Oral Surgery: Extraction deciduous and wisdom teeth H. Gynaecological: D& C Criticism: Many surgeons do not like it. Discharge: Patient must be seen by surgeon and anaesthetist before discharge. Conclusion: Day surgery should be encouraged in our country.

171. Tumour Marker

Introduction: These are the products of the metabolic activity of tumour and secreted into body fluid (in blood, urine or other fluid) or expressed on a cell surface in quantities larger than those in normal tissue. Measured by: 1. Radioimmunoassay 2. Detected on cell surface: Paraffin sections Smears Fresh biopsy tissue Use: Screening Diagnostic Prognostic indicators Monitoring therapy Early diagnosis of relapse

Type: 1. Hormone with their sub unit: a) ACTH b) ADH c) PTH d) Calcitonin: Medulla e) -HCG 2. Onco-foetal products and antigens: a) CEA b) PSA

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c) AEP 3. Enzymes and iso-enzymes: a) Acid phosphate: Ca Prostate b) Lactage dehydrogenase: Seminoma 4. Macromolecules: Paraprotein M.M 5. Hormone receptors: Estrogen receptors in Ca breast Clinically Useful Measures: 1. HCG (-HCG): Testicular tumour (mainly teratoma) Hydatidiform mole 2. AFP: Testicular tumour (teratoma) Hepatoma Ca GIT 3. CEA: Colorectal carcinoma Ca Pancreas, liver 4. PSA: Ca Prostate 5. Oestrogen receptor in Ca breast Conclusion: Clinically useful marker are not 100% sensitive or specific but mostly used as a prognostic indicators.

172. Acute Abdominal Compartment Syndrome

Introduction: Compartment syndrome mostly occurs in the limbs but it is not uncommon in the abdomen more due to trauma. It is a new problem or newly recognized old problem where IAP cause viability of abdominal organ is compromised. Cause: 1. Traumatic: Blunt trauma to abdomen with injury to liver, spleen, kidney, major vessels Bullet injury: Damage the major blood vessels 2. Tense ascites: Cirrhosis of liver Intra-abdominal malignancy Tubercular 3. Tension pneumoperitoneum: Traumatic rupture of large gut Large gastric ulcer perforation Site: 1. Intra-peritoneal 2. Retro-peritoneal 3. Abdominal wall: a) Burn b) Repair of large hernia Pathology: Intra-abdominal pressure Vascular compromise to the gut and other organ Ischaemia Gangrene IAP Venous return CO May lead to shock IAP Reduced chest movement Cyanosis

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.. Renal perforation GFR Oliguria

Presentation: H/O trauma with Abdominal distension and tense Respiratory distress, oliguria Feature of shock Clinical Feature: Pulse, BP, Cyanosis Tense and hugely distended abdomen Tympanic or dull on percussion Investigation: 1. Plain X-ray abdomen: Pneumoperitoneum Ground glass appearance Abdominal viscera collapse medially 2. X-ray chest: Elevated both domes of the diaphragm 3. USG of abdomen: Cirrhosis of liver Intra-abdominal malignancy 4. Blood grouping and cross matching 5. CT Scan 6. Measurement of IAP Treatment: Depends upon the cause: Rx of ACS according to grade Rx of primary cause 1. Traumatic complication: Resuscitation followed by laparotomy 2. Pneumoperitoneum: Decompression by wide bore needle and prepare the patient for laparotomy 3. Tense ascites: Paracentesis and I/V fluid + Human albumin and Rx of primary cause Conclusion: Early diagnosis and Rx is essential to save the patients life.

173. Ideal Stump for Below Knee Amputation

Introduction: It is a great demand of an amputee to regain their independent life. So for better function ideal stump is very important especially in below knee amputation. Characteristic of ideal stump: 1. Length: Should be 10 -12 cm from knee joint but at least 8 cm. 2. Shape should be conical. 3. Types of amputation: Should be cone bearing. 4. Adequate stump muscle should be left for better function. 5. Anterior surface of tibia should be beveled. 6. Fibula should be cut 2 cm proximal to tibial division to prevent skin 7. Long posterior flap to ensure blood supply. 8. Avoid bulky muscle of the stump end. Advantage: Proper function of knee joint Good fitting of prosthesis Prevent long term complications: o Painful scar

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o Ischaemia and skin necrosis

Disadvantage: Wound failure and may need higher amputation. Conclusion: Proper pre-operative evaluation and plan is vital to make an ideal stump.

174. Avulsion Fracture of Base of 5th Metatarsal Bone

Introduction: It is a common fracture of foot affects mostly in adolescent and young adult. Mechanism of injury: Rotational injury Forced inversion of foot. Presentation: H/O trauma followed by Pain Swelling Deformity and Loss of function Investigation: X-ray of foot including ankle (A/P and lateral view) Fracture line seen. Treatment: 1. Adhesive strapping or strip sole shoe If minimal displacement. 2. Walking boot If displacement > 3 to 4 mm. Complication: Non-union Osteoarthritis Conclusion: Usually heals well.

175. Complications of Supracondylar # of Humerous

Introduction: It is a common fracture in orthopaedic practice most commonly in children and adolescent and there is chance of developing complications. So need immediate attention to prevent complications. Complication: A. Local: i. Early: a) Injury to brachial artery b) Nerve injury: Radial Median c) Compartment syndrome d) VIC, soft tissue injury e) Infection: If open fracture f) Osteomyelitis: If open fracture g) Tetanus and gas gangrene ii. Late complication: a) Mal-union b) Non-union c) Elbow stiffness d) Myositis ossificans e) Tardy ulnar nerve palsy

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f) Chronic osteomyelitis g) Frozen shoulder h) Valgus deformity of elbow B. General: Hypovolaemic shock Treatment of complication: 1. Brachial artery injury: Exploration and repair 2. Nerve injury: Wait for 3 months for spontaneous recovery If no recovery exploration and repair 3. Compartment syndrome: Remove all external splint If no improvement Fasciotomy 4. Infection: Wound debridement and antibiotic according to C/S 5. Mal-union: Corrective osteotomy 6. Tardy ulnar nerve palsy: Anterior transposition Conclusion: Every effort should be made to prevent complications.

176. Dupuyterns Contracture/ Palmer Fasciitis

Introduction: It is an inflammatory condition of palmar fascia. Most commonly effects male over 50 years of age. Aetiology: 1. Unknown 2. Hereditary predisposition: Auto dormal dominant 3. Risk group: Smoking PTB Epilepsy AIDS Alcoholic cirrhosis DM Pathology: Thickening and shortening of palmar apponeurosis mostly at ring and little finger and flexion of metacarpo-phalangeal and proximal inter-phalangeal joint. Type: 1. Acute 2. Sub-acute 3. Chronic Associated disease: Peyronias disease Planter fasciitis (Ledderhoses disease) Associated Presentation: Age: > 50 years usually Sex: Male common Flexion deformity of the metacarpo phalangeal and proximal inter phalangeal joint, mostly at the ring and little finger. O/E: Nodular swelling of the palm

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Overlying skin pucked and cord like

D/D: 1. Rheumatoid arthritis 2. TB Tenosinovitis Investigation: X-ray hand To see any joint pathology. Treatment: A. Conservative: Reassurance, in case of i. In old age ii. Disease not progressing rapidly iii. No functional abnormalities B. Surgery: Excision of thickened part of palmar apponeurosis Conclusion: Recurrence is common after surgery, so counseling is important.

177. Femoral Embolectomy Indication & Technique

Introduction: Occlusion of femoral artery by emboli is an acute emergency and this patient needs emergency embolectomy. Indication: Acute occlusion of common femoral artery by emboli with features of acute ischaemia and the limb is still potentially viable Pain Pallor Paraesthesia Pulselessness Persistently cold and paralysis Technique: 1. Position: Supine 2. Anaesthesia: L/A or G/A 3. Washing and draping 4. Artery is exposed by vertical incision and held up by slings or by rubber catheter 5. Artery is opened by longitudinal/ transverse incision over the CF opposite the PF and clot is removed together with embolus. 6. Fogarty catheter is passed proximally and distally and remove all clots until bleeding occurs. 7. Irrigate the proximal and distal end of artery by heparin solution 8. Close the artery by 6/0 prolene 9. Completion angiography may be done 10. Post-operative i/v anticoagulant is continued. Conclusion: Every surgeon should know this procedure to save the patients limb.

178. Stab Wound to the Chest First Aid

Introduction: As the wound is visible and structures at risk can be quickly assessed, plan of management can be made accordingly.

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Structures at risk: Depends upon the site and depth of injury. In addition to structures in the chest On the right side: Diaphragm and liver On the left side: Spleen and diaphragm First Aid: Resuscitation and assessment side by side 1. If sucking chest wound Seal the wound by occlusive pad and arrange for chest drain 2. If any external bleeding Pressure bandage + wound close 3. If the patient is in shock: Start I/V infusion by wide bore canula Blood for grouping and cross matching and transfuse when available 4. If cardiac temponade: Aspiration If not successful - need for thoracotomy 5. If oesophagus and tracheal injury need for thoracotomy 6. Injury to the spleen, liver and diaphragm need laparotomy and repair 7. Aorta injury Thoracotomy Other Measure: 1. I/V broad spectrum antibiotic 2. Tetanus prophylaxis 3. Analgesics Conclusion: Quick assessment and vigorous resuscitation is vital to save the patients life.

179. Intussusception
Introduction: It is a common cause of intestinal obstruction in children, where one portion of gut becomes invaginated within an immediately adjacent segment. Aetiology: 1. Infant: Idiopathic 2. Children: a) Meckels diverticulu b) Polyp 3. Adult: a) Sub-mucosal lipoma b) Tumour c) Polyp Pathology: 3 parts 1. Inner tube 2. Middle tube 3. Outer tube Types: 1. 2. 3. 4. 5. Ileo-colic Ileo-ileocolic Ileo-ileal Colo-colic Multiple retrograde

Presentation: Classical presentation: Otherwise fit and well male child of 6 months, sudden onset of screaming with drawing up of legs. Attacks last for a few minutes and recur every 15 minutes with or without vomiting. In adult: Intestinal obstruction O/E: Emptiness of right iliac fossa Lump in the right iliac fossa

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DRE: Red current jelly stool. Investigation: 1. Plain X-ray abdomen: Features of intestinal obstruction 2. Ba-enema: Diagnostic + therapeutic D/D: 1. Acute enterocolitis 2. Rectal prolapse Treatment: A. Conservative: Hydrostatic reduction by Ba-enema B. Surgery: i. Failure of hydrostatic reduction ii. Presence of complications C. In adult: Resection and anastomosis of gut Complication: Gangrene Perforation Peritonitis Conclusion: Early dx and Rx is vital to prevent complications.

180. Recurrent Incision Hernia

Introduction: It is an embarrassing condition both for the patient and for the surgeon. Incidence: 2 to 50% depending on the site of previous hernia. Cause: 1. Pre-operative 2. Per-operative: Poor surgical technique a) Inadequate fascial bite b) Too tight closure 3. Post-operative: a) Post-operative wound infection b) Vigorous cough during recovery and immediate post-operative period c) Failure to reduce weight in obese patient d) Failure to improve general debility of the patient Investigation: 1. Hb% 2. RBS Treatment: Depends on Age General condition Symptoms Previous surgery 1. Elastic corset: Small hernia in poor risk patient 2. Anatomical repair: Small hernia 3. Repair by prolene mesh Large hernia Prevention: Operative principles 1. With all aseptic precaution 2. Prophylactic antibiotic must be given 3. Meticulous surgical technique Proper anatomical dissection

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Should not be haematoma 4. Use of monofilament Non absorbable suture material Conclusion: Proper pre-operative evaluation and correction of predisposing factors is vital to prevent recurrence.

181. Bile Duct Stricture

Introduction: It is one of the most common causes of obstructive jaundice and mostly due to iatrogenic which morbidity and mortality, so prevention is vital. Cause: A. Benign: i. Congenital: Biliary atresia ii. Traumatic: a) Operative b) Penetrating and blunt abdominal trauma iii. Inflammatory: Cholangitis iv. Others: a) Chronic DM b) Chronic pancreatitis B. Malignant: i. Cholangio carcinoma ii. Ca Head of pancreas iii. Periampullary carcinoma Presentation: H/O operation in and around of biliary tree H/O obstructive jaundice General feature of malignancy O/E: Icteric Anaemic Lymphadenopathy Gall bladder, liver may be palpable Ascites may be present

Investigation: 1. Liver function test: Serum bilirubin: Alkaline phosphatase: Prothrombin time: SGPT: 2. USG of W/A: Dilatation of biliary tree Detect cause of obstruction e.g. Ca head of pancreas 3. ERCP and PTC: Both may be needed for dx and planning of surgery 4. CT scan: For malignant case 5. Other investigations for staging and general assessment if needed. Treatment: Depends on causes 1. Benign: Biliary reconstruction by Roux-en-y jejunostomy. 2. Malignant According to staging but usually stenting.

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Conclusion: As mostly due to iatrogenic, every effort should be made to prevent bile duct injury. Proper evaluation is vital for management.

182. Percutaneous Nephroblastomy (PCNL)

Introduction: It is a modern and minimally invasive method of treating renal stone disease. Indication: Renal stone with obstruction of ureter Stone > 2 cm in size Lower calecial stone Procedure: 1. With all pre-operative preparation 2. Under G/A 3. Washing and draping 4. Prone position 5. a) A hole needle is inserted into renal pelvis under ultrasound control b) Guide wire is passed through the needle c) Needle is removed d) Dilators are passed over the guide wire to enlarge the tract e) Introduce nephroscope through the tract and remove stones under vision f) If large stone, remove it by piecemeal Contraindication: Bleeding Diathesis Anomalous kidney Complication: Haemorrhage Perforation of collecting system Extravasation of urine Perforation of colon Conclusion: Avoid major operative procedure/ demand increasing.

183. Testicular Biopsy

Introduction: It is not a common procedure and done in special situation (circumcision). Type: 1. 2. 3. 4. Incisional Excisional Frozen section FNAC

Indication: 1. Sub-fertile male: Incisional 2. Contralateral testis of patient with testicular tumour 3. Testicular malignancy: Excisional biopsy Complications: Chance of local spread to the scrotal skin if malignancy presence Scrotal haematoma

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Conclusion: T-biopsy was contraindicated in malignant disease but now it is done routinely with precaution to prevent spillage.

184. Urinary Incontinence

Introduction: Urinary incontinence is the most distressful disability in urological practice which hampers social, psychological and sexual life of a patient. Type: 1. 2. 3. 4. Stress Urge Overflow Continuous

Cause: A. Psychological B. Abnormality of urethral sphincter: i. Congenital: a) Ectopia vesicae b) Epispaedius ii. Genuine stress incontinence iii. Traumatic: a) Surgical b) Damage to nerve supply iv. Malignancy: Ca prostate involve the sphincter C. Abnormality of detrusor muscle: i. Idiopathic detrusor instability ii. Small capacity bladder iii. Out flow obstruction D. Drugs: i. Anticholinergic ii. TCA E. Fistula: i. Uretero-urethral fistula distal to sphincter ii. Uretero-vaginal fistula F. Neurogenic bladder Diagnosis: 1. Careful history: Symptoms with duration and severity Neurological symptoms Gynecological symptoms Medical and psychiatric disorder Drug therapy H/O operation 2. Physical examination: General Neurological, vaginal and rectal examination 3. Investigation: Urine R/E and C/S IVU Urodynamic study Treatment: Depends upon the cause, options of treatment

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1. Devices for collection or control: a) Penile condom indwelling catheter b) Penile clamps 2. Drugs: Anticholinergic 3. CISC 4. Surgery to decrease outlet resistance: Prostatectomy 5. Increasing outlet resistance: a) Pelvic floor resistance b) Colpos-suspension 6. Augmentation of bladder capacity 7. Urinary diversion: Ileal condu.. Conclusion: Proper evaluation of the cause and counseling of the patient is vital for management.

185. Venous Ulcer

Introduction: It is the most common cause of leg ulcer, but it is a very disabling condition and usually associated with varicose vein. Site: Lower part of leg usually above the medial malleolus. Cause: 1. Associated with varicose vein 2. Deep vein incompetence Pathophysiology: Ischaemic ulcer due to chronic ambulatory venous hypertension Hypothesis: Fibrin Hypothesis White cell trapping Presentation: H/O varicose vein or DVT Non healing ulcer on the leg O/E: Ulcer Varicose vein Colour Oedema Muscle wasting Abdominal examination: Any pelvic lump

Investigation: 1. Coagulation screening 2. Lipid profile 3. Blood sugar 4. Chest X-ray 5. ECG 6. Duplex scan: Deep vein incompetence/ patency Sources of varicose vein Complication:

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Treatment: A. If associated with varicose vein: i. Rx of varicose vein then ii. Rx of ulcer B. Deep vein incompetence: Difficult i. Local Rx of ulcer ii. Compression bandage: 4 layers a) Wool b) Crep c) Elesto crep d) Adhesive outer wrap Conclusion: Prevention of recurrence after successful treatment is vital.

186. Residual Biliary Stone

Introduction: It is a common complication after surgery of biliary stone disease occurs within 2 years of surgery and it is an embarrassing condition. Cause: A. Pre-operative: Multiple stone in CBD B. Per-operative: i. Failure to explore the CBD in suspected cases ii. Lack of facilities: a) Per-operative choledoscopy b) Per-operative cholangiography Presentation: H/O operation of biliary surgery Immediate post-operative detection by T-tube cholangiogram Patient may present with features of cholangitis and intermittent jaundice Investigation: 1. Liver function test: Serum bilirubin: Alkaline phosphatase: SGPT: 2. USG of Hepatobiliary system: Dilatation of CBD Echogenic structure 3. T-tube cholangiogram: In post-operative patient negative shadow in CBD 4. ERCP: Diagnostic and therapeutic Treatment: A. If T-tube present: i. Clamping ii. Flushing by N/S iii. Dissolution by cholate and MTBE iv. Percutaneous extraction via T-tube tract by choledoscope B. ERCP with stone extraction C. Re-exploration and stone extraction D. Definitive surgery: If indication Prevention:

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Per-operative choledoscopy Per-operative cholangiogram

Conclusion: Every effort should be made to prevent this devastating complication.

187. Gall Stone ileus

Introduction: It is an uncommon cause of small intestinal obstruction, particularly in an elderly patient. Pathology: Erosion of large gall stone through the gall bladder into the duodenum or upper jejunum. Site of impaction: 60 cm proximal to the ileocaecal valve Site of stone: 2.5 cm or more Clinical Feature: Features of small bowel obstruction, may be partial, may be complete. Investigation: Plain X-ray abdomen: Distended small bowel loop with gas fluid level Gas in the biliary tree Presence of radio-opaque gall stone Ba meal X-ray of upper GI: Cholecystoduodenal fistula Treatment: Resuscitation followed by laparotomy. Options after laparotomy 1. Crush the stone within the bowel lumen If it is soft 2. Enterotomy and removal of obstructed stone 3. Check for other enteric stone 4. Definitive Rx of fistula Later on if symptomatic Conclusion: Death rate is high even in early intervention as most of the patients are elderly poor general health.

188. Insulinoma
Introduction: It is the most common functioning islets cell tumour. It may be associated with MEN type I. Cell of origin: Pancreatic beta () cell. Behaviour: Mostly benign 10% malignant 15% unpredictable Incidence: 1% of all pancreatic tumour. Clinical Feature:

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Related to hypoglycaemia: o Bezarre behavior o Memory lapse o Unconsciousness, uncoordinated movement Profound sympathetic discharge: o Palpitation o Sweating Increasing obesity

Classical dx criteria: Whipples triad 1. Signs and symptoms of hypoglycaemia 2. Blood glucose level < 50mg/dl 3. Relief of symptoms by I/V glucose Investigation: 1. Blood glucose level (FBS): 2. Serum insulin level: > 6 unit/dl 3. C-peptide: For localization: 1. Spiral CT scan with I/V contrast: 40% pre-operative 2. MRI Scan of pancreas: 40% pre-operative 3. Endoscopic (gastroscopic) ultrasound 4. Per-operative ultrasound: Confirmatory D/D: Other tumour producing hypoglycaemia 1. Hepatoma, adrenocortical tumour 2. Fibrosarcoma Treatment: A. Surgery: i. Enucleation ii. Resection of tumour iii. Distal pancreatectomy B. Medical: i. In operative malignancy ii. Diazoride: Insulin secretion iii. Streptozoon: Chemotherapeutic Complication: 1. Permanent cerebral damage 2. Obesity Prognosis: Good after removal but unpredictable if associated with MEN I.

189. Splenorrhaphy
Introduction: Increasing knowledge is towards the effect of splenectomy. Now-a-days the approach is to conserve the spleen especially in children. Indication: 1. Lesser degree of splenic injury, especially in children. 2. Splenic injury in malarial endemic zone. Principle: Debride the devitalized tissue and then approximate the normal contour of the spleen.

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Method: 1. Repair by catgut with long atromatic needle and use of omentum or Taflon to prevent cutting of suture. 2. Wrap the organ with vicryl mesh. Advantage: Preserve immunological function, so prevent post splenectomy sepsis. Disadvantage: Needs experienced surgeon. Chance of post-operative bleeding and haematoma Conclusion: It is the better treatment option to prevent post splenectomy sepsis. Every effort should be made to preserve the spleen.

190. Retained Abdominal Gauze Swab

Introduction: It is a devastating condition both for the patient and surgeon. Cause: 1. Negligence of the surgeon and team: Not counting the gauze swab before closure of abdomen Use of excess number of gauze swab Not counting the gauze and swab before start OT 2. Negligence of stuff: No written document of number of gauze Presentation: H/O operation Persistent abdominal pain Wound infection Chronic discharging sinus Intra-abdominal lump May present with faecal fistula Sometimes swab may come out through abdominal wound May come out through vomiting or defecation Persistent fever malnutrition Investigation: 1. USG of W/A: Soft tissue mass within a cavity 2. CT scan abdomen: Confirmation of dx 3. Diagnostic laparotomy Treatment: 1. Surgery: Laparotomy and removal of retained gauze swab and peritoneal toileting. 2. Improvement of general condition. Prevention:

Conclusion: Every effort should be made to prevent this devastating complication.

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191. Gastric Volvulus

Introduction: It is an uncommon condition where stomach rotates usually in vertical axis. Type: 1. Acute 2. Chronic: Common Predisposing Factor: 1. Large diaphragmatic defect around the oesophagus with para-oesophageal hernia 2. Eventration of left hemi-diaphragm Pathology: Stomach rotates in two axes Vertical (Organo-axial): Common Mesentero-axial Presentation: Acute: o Abdominal pain o Vomiting o Epigastric distension o Failure to pass NG tube Chronic: o Difficulty in eating o Intermittent abdominal pain D/D: 1. Intestinal obstruction 2. Perforation of HV Investigation: 1. Plain X-ray abdomen: To exclude perforation and intestinal obstruction 2. Ba meal stomach and duodenum: Diagnostic in chronic cases Treatment: Resuscitation and immediate laparotomy A. If para-oesophageal hernia: Reduction of sac and its content and repair the diaphragmatic defect: i. Direct ii. Mesh then anterior gastropexy B. If D. eventration: Division of gastrocolic ligament take the stomach into its normal position and anterior gastropexy C. Rx of compilation: i. Perforation: repair ii. Gangrene: Gastrectomy Complication: Ischaemia Gangrene Perforation of stomach Conclusion: Good outcome if treat earlier.

192. Short Bowel Syndrome

Introduction: It is a devastating condition that develops after extensive resection of small intestine.

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Cause: A. Traumatic small gut injury B. Inflammatory: i. Crohns disease ii. Radiation enteropathy C. Neoplastic: Malignant small bowel tumour D. Others: i. Strangulated small bowel obstruction ii. Mesenteric vascular occlusion iii. Necrotising enterocolitis iv. Compound volvulus with gangrenous gut: a) 3 meter of less remaining b) 2 meter or less remaining c) 1 meter or less remaining Severity of symptoms: Depends upon Extent and site of resection Presence or absence if ileocaecal valve Adaptation of remaining bowel Underlying disease process Adaptation of gut:

Presentation: Diarrhoea Steatorrhoea, anaemia Stone in the urinary tract Features of lactic acidosis Gastric hypersection Investigation: 1. Hb%: 2. Electrolyte deficiency of all electrolyte 3. Serum creatinine Management: A. General Measure: i. Stage I: 1 to 3 months. a) TPN b) Electrolyte correction c) H2 blocker ii. Stage II: I/V + Oral feeding when diarrhea < 2.5 L/day a) PN b) ORS c) Liquid diet iii. Stage III: Oral feeding after several months a) Vit B supplement b) Low oxalate diet c) Other trace element supplement B. Adjunctive surgical procedure: Clinical trial Conclusion: Proper counseling and patience is vital to manage this patient.

193. DRE
Introduction: It is the most important clinical examination by which many intra-abdominal and anal canal diseases can be diagnosed.

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Prerequisite: 1. Counseling and consent 2. Privacy 3. Female attendant in case of female 4. Good illumination 5. High examining couch Position: 1. Left lateral (sinus): Most convenient 2. Lithotomy 3. Knee-elbow, dorsal, right lateral Procedure: 1. Protective gloves with good lubrication 2. Patient should be relax 3. Inspection of anus by opening the buttock 4. Lay the pulp of index finger flat upon the anal verge 5. Slowly introduce the tip of the digit into the anal canal with the palp facing posteriorly Diseases diagnosed: A. Inspection: i. Inflammatory skin change: skintage ii. Haemorrhoid iii. Fissure iv. Fistula B. Palpation: i. In the lumen: Polyp or carcinoma ii. Intramural: Carcinoma, leomyoma, rectal injury iii. Extramural: a) Prostatic pathology b) In female cervix, uterus & pouch of Douglas C. Bi manual palpation D. Palpating during strain down Contraindication: Acute anal fissure Any painful condition of anus Early pregnancy Conclusion: Omission of this examination often cause diagnostic delay, so the aphorism, If you do not put your finger in it, you put your foot in it.

194. Congenital Club Foot

Introduction: It is the most common congenital abnormality of foot, 50% bilateral and more common in boys. Incidence: 1 in 1000 live birth Boys twice than girls Aetiology: A. Idiopathic

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B. Some factors related: 1. Posture 2. Heredity 3. Neuromuscular: a) Arthrogryposis b) Spina bifido Deformity: The heel is equinus Hind foot is varus Mid and fore foot adducted and supinated Type: 1. Rigid variety 2. Flexible Patho-anatomy: Bones: o Navicular bone shifted medially o Neck of the talus pointed downward Tendons: o Tendo achilles o T. posterior o FHL o FDL Contracture of joint capsule and ligament Hypoplastic calf muscle Treatment: A. Conservative: i. Repeated manual stretching ii. Serial light plaster cast changed every weak B. Surgery: If conservative Rx fails i. Time: At 3 months of age ii. Option: a) Soft tissue release b) Corrective osteotomy: After 12 years of age c) Arthrodesis: After 12 years of age Conclusion: Outcome is good if treated earlier.

195. Rupture Tendo Achillis

Introduction: Tendo achillis is the commonest tendon which becomes liable to rupture, usually due to degeneration of tendon following trivial trauma. Predisposing Factor: Tendinosis which is the hyaline degeneration of tendon. Site of rupture: Musculo-tendinous junction. Type: 1. Complete 2. Incomplete Cause: 1. Mild trauma e.g. getting up from seated position

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2. Sports injury Clinical Feature: Middle aged male Sudden severe pain of lower leg Limping Patient cant stand on tip toe O/E: Calf muscle contracted Gap in the Tendo Achillis 5cm above the insertion Simmonds test positive

D/D: 1. DVT 2. Rupture of soleus Treatment: A. Conservative: By plaster cast Apposition of two ends by planter flexing the ankle and maintain it by cast for 6 to 8 weeks. B. Surgery: Failure of conservative treatment i. Repair of rupture tendon ii. Preserving its blood supply. Conclusion: Re-rupture can occur, so counseling is important.

196. Scaphoid Fracture

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197. TB Tenosynovitis
Introduction: It is an uncommon condition by which chronic inflammation of tendon sheath is caused by tubercular infection. Site: Common flexor tendon sheath of hand. Clinical Feature: Gradual onset Mild ache pain in the hand Function of finger and hand impaired General feature of TB O/E: Swelling: Palm and lower part of forearm Wasting of thenar and hypothenar muscles Cross fluctuation: + ve

D/D: RA Investigation: 1. CBC: Hb% ESR 2. Chest X-ray: Primary focus 3. Synovial biopsy: Confirmatory Treatment: A. Conservative: i. Immobilization of wrist and forearm ii. Anti TB B. Surgery: Synovectomy + Anti TB drug 1 year Complication: Muscle wasting Tendon rupture Joint stiffness Conclusion: Early dx and Rx is vital to prevent complications.

198. Flail Chest

Introduction: it is a major chest wall trauma, where several adjacent ribs are fractured in two places which need immediate attention to save the life of patient. Cause: Severe chest trauma 1. Poly trauma 2. Isolated chest injury Effect: Paradoxical movement (respiration) Reducing effective gas exchange Poor oxygenation Cyanosis. Presentation: H/O trauma Breathlessness Severe chest pain O/E:

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Cyanosis Paradoxical movement of chest Patient may be in shock

Investigation: After initial resuscitation 1. Chest X-ray (P/A view & Lateral oblique view): Fracture site Pneumothorax Haemothorax 2. Blood for grouping and cross matching Treatment: Resuscitation and assessment side by side A. If small and not embarrassing respiration: i. Admit into HDU ii. Analgesic + Antibiotic + Regular blood gas analysis until flail segment is stabilized B. In severe case: Embarrassing respiration i. Admit into ICU ii. Positive pressure ventilation via: a) Tracheostomy b) ETI iii. Strong analgesic + Antibiotic C. Rx of complications: i. Chest tube drain in pneumothorax and haemothorax ii. Thoracotomy if indicated + fixation of chest D. Blood transfusion Complication: Haemothorax Pneumothorax Underlying lung contusion Cardiac temponade Conclusion: Patients life can be saved in if resuscitation is started earlier.

199. Spontaneous Pneumothorax

Introduction: It is not an uncommon condition and may produce severe life threatening compilations. Cause: 1. 2. 3. 4. 5. Rupture of sub pleural emphysematous bulla Rupture of sub pleural tubercular focus Rupture of apical bulla (Patient with COPD) Metastatic cancer Rupture of oesophageal or lung abscess

Type: 1. Closed 2. Open 3. Tension Presentation: Middle aged male Smoking Symptom varies o Asymptomatic o Severe chest pain o Dyspnoea o Cardiovascular collapse.

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O/E:

Tachypnoea Tachycardia Cyanosis Hypotension Trachea deviated to opposite side

Investigation: 1. X-ray chest (A/P view & lateral view): Site and position of bulla Pneumothorax Effusion Features of TB 2. Specific investigations directed towards the cause Complication: Tension pneumothorax Cardiovascular collapse Treatment: Depends upon: Symptoms General condition Cause A. Small asymptomatic: Follow up B. Large symptomatic: Chest tube drainage C. Surgery: If there is i. Persistent air leak > 7 days ii. Lungs not fully expanded iii. High risk occupation: Prophylactic surgery a) Scuba divers b) Air pilot iv. Large bulla and poor lung function: Prophylactic surgery Options: a) Pleurodosis b) Bullectomy c) Complete parietal pleurectomy v. Specific Rx related to cause: a) Anti TB if TB b) Radiotherapy for cancers Conclusion: High chance of recurrence, so need prolonged follow up.

200. Endovascular Procedure

Introduction: This is a modern technique of vascular surgery which is a part of interventional radiology. Indication: 1. Diagnostic: a) Angiography b) Venography 2. Therapeutic: a) Percutaneous transluminal angioplasty (PTA): e.g. PVD, IHD with coronary artery stenosis, renal artery stenosis, mesenteric/coeliac artery stenosis

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b) Vascular stentic e.g. Renal stenosis, aortic artery aneurism, coronary artery disease, major peripheral artery c) TIPSS: In portal HTN d) Therapeutic embolization e) Endovascular repair of false aneurysm Method: 1. Seldenger technique 2. Direct technique Advantage: Avoid major surgery Avoid general anaesthesia Early recover Early discharge from hospital Disadvantage: Needs special training Costly Complication: Local & distal Distal embolization and ischaemia Stroke in carotid a procedure Restenosis Vascular injury with haematoma Conclusion: The scope of endovascular procedure is increasing day by day.

201. Kaposis Sarcoma

Introduction: It is a neoplasm of proliferating capillary vessels and perivascular connective tissue cell. It is multifocal in origin. Cell of origin: Connective tissue cells Fibroblast. Nature: Malignant but slowly progressive. Risk people: Immuno-compromised specially AIDS patients. Spread: 1. Local 2. Lymphatic 3. Vascular Presentation: Dark blue or purplish colour and macular lesion In elderly male patient: Indolent course In AIDS patient: Painful and rapid course Investigation: Biopsy Confirmatory. Treatment: 1. Radiotherapy 2. Immunotherapy Prognosis: Poor in AIDS patient. Follow up: At regular interval.

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202. Mediastinal Tumour

Introduction: The mediastinum is a common site of variety of tumour, both malignant and benign. Type: Benign: o Thymoma o Neurofibroma o Dermoid o Mesenchymal o Endocrine Malignant Primary: Thymoma Neurogenic tumour: a) Neuroblastoma b) Neurofibroma iii. Lymphoma iv. Rare tumour: a) Germ cell e.g. dermoid b) Mesenchymal c) Endocrine e.g. pheochromocytoma from sym. chain B. Secondary: Most common i. Direct infiltration from intra-thoracic primary e.g. a) Ca bronchus b) Ca oesophagus ii. Metastatic i. ii.

A.

Presentation: Asymptomatic: Dx by X-ray chest Chest pain Secondary to compression: o SVC obstruction o Oesophagus o Trachea Invasion: o Nerve: Phrenic Hoarseness of voice Horners syndrome o Pericardium: Features of pericardial effusion o Spinal cord: Paralysis Investigation: 1. X-ray Chest: Mediastinal widening Pleural effusion Rib destruction Hemi-diaphragm 2. CT scan of chest: More precisely delineate the site, size, extension of tumour 3. Mediastinoscopy: Direct visualization and taken biopsy Treatment: According to nature, tissue dx and extension of tumour

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1. Surgery 2. Radiotherapy 3. Chemotherapy Conclusion: Most of the tumours are malignant and overall prognosis is poor.

203. Arthroscopy
Introduction: It is a modern and minimally invasive procedure to evaluate the joint pathology, either diagnostic or therapeutic. Use: A. i. ii. iii. iv. B. i. ii. iii. iv. v. vi. vii. Diagnostic: Injury to cruciate ligament Meniscus, loose body, synovial thickening of joint cavity For degenerative disease Synovial biopsy Therapeutic: Removal of loose body Menisectomy Synovectomy Meniscal repair Cruciate substitution Articular cartilage shaving Debridement of osteophytes

Site: Common sites 1. Knee joint 2. Shoulder joint 3. Elbow joint 4. Wrist joint 5. Hip joint Procedure: 1. Under L/A a small incision is made over the joint 2. The trochar and cannula are passed 3. Trochar is removed and blunt probe is passed 4. Probe is removed and arthroscope is passed through the canula Advantage: Can be done as a day case surgery Less discomfort to the patient Early recovery Disadvantage: Needs expertise Costly Complication: Infection Haemarthrosis Joint stiffness Conclusion: It is a demanding technique and its use is gradually increasing.

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204. False Aneurysm

Introduction: Aneurysm which is not contained by the vessel wall layer but confined by a fibrous capsule and it is communicated with the vessel wall. Cause: 1. Traumatic injury to vessel wall: a) Direct trauma b) Surgical 2. Anastomotic site of vessels 3. Puncture of vessel wall during angiography 4. Infective e.g. aortitis by virulent organism Common Site: 1. Radial artery 2. Femoral artery 3. Brachial artery 4. Subclavian artery Presentation: H/O trauma or operation Pulsatile swelling Pain O/E: Expansile pulsatile swelling Features of distal ischaemia due to pressure effect Partially compressible

D/D: 1. A-V fistula 2. Any pulsatile swelling: a) Osteosarcoma b) Aneurysmal bone cyst 3. True aneurysm Investigation: 1. Duplex study: Vascular anatomy Site, flow, communication with vessels 2. Arteriography: If surgery is planned 3. X-ray local part: Calcification Bony erosion Treatment: A. Conservative: Reassurance Symptomatic In early stage Asymptomatic Surgery: i. Progressively enlarge ii. Distal circulatory failure due to pressure Options: Ligation and excision of sac Reconstructive procedure:

i. ii. iii. iv. B.

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o Graft o Anastomosis Endovascular placement of graft

C.

Complication: Infection Thrombosis Embolism Pressure effect on rupture Conclusion: Excellent outcome after surgery.

205. Prolectinoma
Introduction: It is the most common tumour of pituitary gland and Rx is usually medical. Cell of origin: Chromophobe cells of anterior pituitary. Behaviour: Benign. Type: 1. Secretory: Secrets prolactin 2. Non secretory According to size: 1. Microadenoma < 1 cm 2. Macroadenoma > 1 cm Presentation: Most commonly younger women Galactorrhoea Amenorrhoea Infertility and loss of libido Visual disturbance due to pressure effect Investigation: 1. Serum prolactin level: High > 200ng/ml, diagnostic 2. X-ray skull (lateral view): Widening of pituitary fossa 3. MRI: Confirm the intrasellar mass Treatment: Depends on Size Extent of tumour Serum prolactin level Patient desire A. Medical Rx: Bromocriptine (Dopamine agonist) i. Shrink of tumour ii. Prevent tumour growth B. Surgical: Excision of tumour, Indication i. Size > 1 cm compressing the optic chiasma ii. Failure to medical Rx iii. Side effects of drugs

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Conclusion: Most of the patients are treated conservatively.

206. Intra-operative Radiotherapy for Breast Cancer

Introduction: It is a new concept for treating early breast cancer as an adjunct to surgery to prevent local recurrence. Why this concept developed? Because the 6 weeks course of post-operative radiotherapy after breast conservative surgery has several disadvantages 1. Long duration of course 2. If patient lives far away from RT facilities 3. Fails to complete 6 weeks course 4. Delay in starting radiotherapy due to waiting list 5. Missed target volume of cancer cell 6. Costly Advantage: Cant missed target volume of cancer cells Single dose Economic Convenient to the patient Disadvantage: Needs specially equipped operating theatre. Conclusion: This concept is still under trial and optimum dose has not been stabilized as yet.

207. Aesthetic Surgery

Introduction: It is the integral part of plastic surgery where it increases the beauty of a person and improves the body image and psychological support. Aim: Increased body image and psychological support. Patient selection criteria: 1. Anatomic feasibility of the procedure (1st factor) 2. Age: Adult age group 3. General health: Good 4. Psychologically sound patient 5. Realistic expectation of the patient Ideal candidate: 1. Adult/ mature younger person 2. Person have a realistic idea about procedure 3. Person is not under pressure from others 4. Doesnt expect major change Goal of aesthetic surgery: Cosmetic purpose Correction of functional problem in some case Common aesthetic surgery: 1. Rhinoplasty 2. Facelift

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3. Blepharoplasty 4. Mammoplasty: a) Augmentation b) Reduction c) Mastopaxy 5. Abdominoplasty 6. Suction assisted lipectomy Conclusion: Not all patients are good candidate for aesthetic procedure, so patient selection is important.

208. Nerve Sparing Surgery

Introduction: It is the principles of surgery to save the nerve during operative procedure. Advantage: Preserve motor and sensory function of particular nerve. Example: Facial nerve in parotid surgery RLN in thyroid surgery Long thoracic and thoraco-dorsal in breast surgery Lower intercostal nerve in subcostal incision Ileo-inguinal nerve in appendisectomy and inguinal hernia operation Sacral plexus in APR and radical prostatectomy Lingual nerve, Hypoglossal nerve or Marginal mandibular nerve in submandibular gland excision. Spinal nerve in spinal surgery Prevention: 1. Incision should be made in proper site 2. Meticulous dissection and identification of nerve 3. Blood less field during operation 4. Judicious use of diathermy close to the nerve 5. Use of nerve stimulator pre-operatively Disadvantage: Sometimes adequate clearance of pathology cant be done (not passive) e.g. Parotid surgery During APR Removal neurofibroma. Conclusion: Always prefer nerve sparing surgery.

209. Thoracic Duct Injury

Introduction: Thoracic duct injury is a devastating condition and difficult to manage and it may lead to death of a patient. Site of injury: 1. Cervical 2. Thoracic 3. Upper abdominal

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Cause: 1. During operation: a) . dissection from left supraclavicular area b) Cystic hygroma operation c) Neck dissection d) Thoracic surgery e) Pancreatic surgery 2. Penetrating trauma to the neck, thorax and upper abdomen Presentation: Leakage of chyle through the wound Dyspnoea due to chylothorax Features of cardiac temponade: o Tachycardia o Low CO Investigation: 1. X-ray chest: a) Pleural effusion b) Pericardial effusion 2. Characteristic appearance of discharge Treatment: A. B. i. ii. Detection during operation: Ligation of proximal end. If detected after operation: Cervical part: a) Pressure bandage + supportive measures b) Re-exploration and ligation if conservative fails 3 5 days Thoracic part: a) Conservative: Fat free, high CHO and protein diet Chest drain if chylothorax Pericardiocentesis if pericardial effusion TPN if required Spontaneous heal within 3 to 4 days b) Surgery: Failure of conservative Rx Daily cut put > 1500ml for 5 days Right thoracotomy and ligation of proximal end

Conclusion: Prevention of injury is vital.

210. SOL in Liver on USG

Introduction: It is a common finding on USG of abdomen and needs proper evaluation to find out the cause. Cause: A. Congenital: i. Haemangioma ii. Polycystic liver disease B. Traumatic: Haematoma C. Inflammatory: Liver abscess i. Amoebic ii. Pyogenic D. Neoplastic: i. Benign e.g. a) Hepatic adenoma b) FNH

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Malignant: a) Primary: HCC b) Secondary: GIT Breast Kidney E. Parasitic: Hydatid cyst Presentation: According to cause Asymptomatic Discomfort in the right hypochondrium Hepatomegaly Anorexia Weight loss Pain Fever Investigation: According to cause 1. CBC: ESR, Leukocytosis Eosinophilia in Hydatid cyst 2. Liver function test: bilirubin 3. CFT for E. granulosus 4. CT scan with i/v contrast: Differentiate primary from secondary lesion 5. FNAC in selective cases: For tissue dx 6. MRI: In vascular lesion Treatment: According to cause 1. Conservative: In most of the cases 2. Surgery: a) In liver abscess b) Hydatid cyst c) Occasionally for malignancy Conclusion: Proper evaluation is important. ii.

211. Segmental Splenectomy

Introduction: Increasing knowledge about complications of splenectomy, recent trend is to conserve the spleen. Indication: 1. Lesser degree of splenic injury specially children 2. Splenic injury in malarial endemic zone 3. Splenic cyst Principle: Based on segmental vascular pattern of spleen. Advantage: Preserve immunological function so prevent post splenectomy infection Vaccination can be avoided Disadvantage: Needs experienced surgeon.

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Chance of post-operative bleeding and haematoma.

Complication:

Conclusion: It is better treatment of prevent post splenectomy sepsis. Always try to conserve the spleen whenever possible.

212. Abdominal TB
Introduction: It is a very common condition in our country but often causes difficulty in diagnosis. Organism: Mycobacterium tuberculosis with Human and Bovine type. Source: 1. Ingestion: a) Via milk b) Infected sputum 2. Haematogenous: Part of military TB Site: 1. Intestine: Mainly terminal part of ileum 2. Peritoneum 3. Solid organ e.g. a) Liver b) Spleen c) Kidney 4. Omentum 5. The mesentery Clinical Feature: General Features: o Fever: At night low grade pyrexia with night sweating o Anorexia o Wight loss Local sign: According to involvement o Intestine: Obstructive: Features of intestinal obstruction Ulcerative: Diarrhoea Pain Clinical features of perforation o Peritoneum: Ascites Encysted Fibrous Purulent form o Omentum: Abdominal lump Investigation: 1. CBC:

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ESR Hb% Lymphocytosis Chest X-ray: Primary focus Plain X-ray abdomen: Calcified lymph node Mantoux test: +ve Sputum for AFB: May be +ve Small bowel enema: Colonoscopy: History Micro Dx Laparoscopy: Ascitic fluid analysis: AFB staining Cell cytology Biochemical: Protein analysis, sugar Lymph node Biopsy from mesentery Dx Laparotomy: Diagnostic Therapeutic

2. 3. 4. 5. 6. 7.

8.

9.

Treatment: A. Medical: i. Anti TB drug for 12 months (with or without steroid) ii. General condition by: a) Protein diet b) Vitamin c) d) Minerals B. Surgery: i. Rx of complication: a) Intestinal obstruction b) Perforation c) Purulent peritonitis ii. Failure to medical Rx Options: Right hemicolectomy Ileocaecal resection Limited resection and anastomosis Stricteroplasty Conclusion: Early dx and Rx carries excellent prognosis.

213. Crash Induction/ Rapid Sequence Induction

Introduction: It is a method of induction of G/A consistent of rapid sequence i/v induction, cricoid pressure and tracheal intubation. Aim: To prevent regurgitation and aspiration of stomach contents. Advantage: Minimizes the time during which trachea is unprotected. Disadvantage: Hypotension in a patient with cardiovascular disease or less circulatory volume due to rapidly given depressant drugs. Indication: 1. All non-fasted patient

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2. 3. 4. 5. 6. Hiatus hernia Emergency trauma patient: Slow stomach emptying Intestinal obstruction, gastric stasis Pregnancy: Slow stomach emptying Intra-abdominal tumour: which slows gastric emptying

Procedure: 1. Pre-anaesthetic oxygenation 2. I.V Thiopentone (3 5 mg/kg) immediately followed by Suxamethonium (1.5 mg/kg) 3. Apply pressure over the cricoid cartilage and trachea is intubated with cuffed tracheal tube and cuff is inflated and attached with anaesthetic tube. Time required: Induction: 30 seconds Intubation: 60 90 seconds Conclusion: It is the most commonly used induction procedure.

214. Epidural Anaesthesia

Introduction: It is a type of regional anesthesia where local anaesthetic agents are injected into epidural space. Drug used: 1. Local anaesthesia: a) Bupivacaine b) Ropivicaine (newer) 2. Opioid: a) Diamorphine or b) Fentonyl Advantage: Multiple dose can be used via indwelling catheter Good pain relief even in the post-operative period Hypotension less likely and easier to control as slow onset Less blood loss Early recovery Early mobilization So less affected lung function Less headache Disadvantage: Slower in onset Needs sedation Use: 1. During labour and interventional delivery 2. Urological operation 3. Surgery in the lower half of the body Complication: Epidural haematoma Post-operative urinary retention Hypotension

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Conclusion: Recent trend towards regional anaesthesia and its use is gradually increasing.

215. Haemospermia
Introduction: It is an alarming condition where seminal fluid contains blood and makes the patient psychologically and sexually upset. Cause: 1. In younger age: a) Prostatitis b) Seminal vesiculitis c) Congestion of prostate and seminal vesicle 2. In old age: a) Ca prostate b) HTN Presentation: Red or brown colour semen Features of primary disease: o Perineal pain in prostatitis o LUTS in prostatitis, Ca prostate Investigation: 1. Urine: R/E: Pus cell, RBC C/S Malignant cell 2. Semen analysis: RBC Pus cell Malignant cell 3. Cystoscopy: If RBC in urine 4. USG: For Ca prostate 5. FNAC or true cut biopsy from prostate Treatment: According to cause 1. Antibiotics for infection 2. Treatment of other cause accordingly Conclusion: Proper evaluation is vital for management.

216. Hypovolaemic Shock

Introduction: It is common in our clinical practice and caused by inadequate circulating blood volume. Cause: It may be due to Blood loss Plasma loss Fluid loss 1. Haemorrhage: a) External b) Internal 2. Severe vomiting and diarrhea

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3. Loss through fistulous tract 4. Plasma loss in burn patient 5. Sequestration of fluid in the gut lumen in intestinal obstruction Cause of hypovolaemia in surgery: 1. Mechanical bowel preparation 2. Over-night fasting before surgery 3. Blood loss during surgery 4. Insensible loss: a) Respiration b) During laparotomy Pathophysiology: Inadequate blood volume of vascular volume Collapse of small venules and vein VR EDV Cardiac output. Body response to shock: Sympathetic discharge Release of vasoactive hormone e.g. Angiotensin II Release of metabolically active hormone e.g. Cortisol, Glucagon Release of volume conserving hormone e.g. ADH, Aldosterone Types of Shock: 1. Mild: < 20 40% volume loss 2. Moderate: 20 40% volume loss 3. Severe: > 40% volume loss Clinical Feature: H/O trauma Vomiting Bleeding Diarrhea Confusion Restless Pale Cold calmy skin Tachycardia BP Low urine output Empty neck vein Investigation: 1. Blood grouping and cross matching 2. Serum electrolyte, PCV 3. Blood urea, creatinine Treatment: It is a medical emergency and need resuscitation and assessment side by side. ABC management 1. Control any external haemorrhage by pressure 2. I.V channel by wide bore canula 3. Fluid preferably colloid and start blood when available 4. Monitoring: BP Pulse Urine output Temperature 5. Drug: Dopamine

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Dobutamine Steroid NaHCO3 for metabolic acidosis

Conclusion: Early and aggressive treatment is vital to prevent MODS and death.

217. Septic Shock

Introduction: It is a life threatening condition mostly associated with Gm (-)ve bacterial infection. Current concept: Sepsis with systolic BP < 90 mm of Hg or drop of systolic BP by > 30 mm of Hg Organism: A. Bacteria: i. Gm (-)ve rod: a) E. coli b) Proteus c) Klebsiellla d) Pseudomonas ii. Gm (+)ve: a) Staphylococcus aureus b) Streptococcus pneumonia B. Rickettsia C. Fungus D. Virus Cause/ Source: 1. Soft tissue infection 2. Strangulated intestine 3. Peritonitis 4. Anastomotic leakage: Oesophagus Gut 5. Suppurative biliary condition Predisposing Factor: Immunosuppression Corticosteroid DM Long term catheterization: Urinary sepsis Abdominal surgery Mediators: C3a Endotoxin TNF, NO, IL Bradykinin Histamine Activated Hae. Clinical Feature: A. Early: Hyperdynamic (warm) septic shock

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Warm, dry skin: a) CO b) Blood shunted to the. c) Anaerobic metabo..(Lactiacidosis) ii. Tachycardia iii. BP mained iv. CVP: .. low systemic vascular resistance B. Late: Hypovolaemic hypodynamic (cold) septic shock (S. sepsis or Endotoxin persist) i. Cold, calmy ii. Drowsy iii. C.O iv. Oedema v. Vasoconstriction vi. Tachypnoea vii. Low BP viii. Low CVP ix. High SVR Treatment: A. Eliminate the source of infection: i. Drainage of pus ii. Antibiotic B. O2 administration C. Adequate fluid therapy (colloidal solution) D. Drugs: i. Dopamine ii. Dobutamine iii. Anti-endotoxin (gamma globulin to ..) antibody iv. Anti TNF antibody Recent concept: Antibiotic polymixin E Absorb endotoxin Activated protein C Complication: SIRS MODS Conclusion: Prevention is vital as outcome of Rx is not satisfactory. i.

218. Thyroid Calcification

Introduction: Although thyroid calcification is uncommon but it is a significant finding and needs further evaluation to exclude malignancy. Cause: 1. Long standing MNG due to degeneration 2. Thyroid malignancy: a) Papillary carcinoma b) Follicular c) Medullary carcinoma Type: Dystrophic calcification

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Importance: Pattern of calcification can give idea about the diagnosis Lamilated calcification around bodies indicate papillary carcinoma Spotty calcification: Medullary carcinoma Focal calcification: o Follicular carcinoma o MNG Conclusion: Proper evaluation is vital to exclude malignancy, so need frozen section biopsy during OT.

219. Recurrent Perianal Fistula

Introduction: It is a difficult and embarrassing condition both for the patient and for the surgeon. Cause: 1. Inadequate excision of fistulous tract 2. Associated with specific disease: a) TB b) Crohns disease c) Malignancy d) Hydradermitis 3. High variety of fistula in Ano 4. Immune compromised patient Presentation: H/O operation for fistula Chronic mucopurulent discharge Itching of anus Features of specific disease Investigation: 1. Discharge for: C/S AFB 2. Fistulogram: To see the tract 3. Blood sugar 4. Chest X-ray 5. Specific investigations for Crohns and malignancy Treatment: A. Low variety: i. Fistulectomy and biopsy ii. Fistulotomy laying open B. High variety: i. Staged operation ii. Use of seton. C. Treatment of specific disease if present Complication: Anal incontinence Anal stenosis Malignancy in fistulous tract Conclusion: Prevention of recurrence should be the aim.

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220. Acid Burn

Introduction: It is a great problem in our society and mostly homicidal. Cause: 1. Accidental 2. Homicidal 3. Suicidal Mechanism of burn injury: Local coagulation of protein and necrosis of tissue. Common site: Face Eye Trauma Effect: Local: o Tissue damage o Infection o Nerve damage Regional: o Impairment of circulation o Compartment syndrome Systemic: o Fluid loss o Shock o MODS Type of burn: Deep and extensive but less than alkali. ABC management: 1. Immediate irrigation of local part with sterile isotonic saline solution or water 2. I.V fluid if required 3. Local anaesthetic agent 4. Analgesic 5. Antibiotic 6. Tetanus prophylaxis 7. Wound management: Dressing Escherotomy Skin grafting Complication: Disfigurement of part Blindness Contractive Conclusion: Social awareness, legislation is vital to prevent acid burn.

221. Gastroschisis
Introduction: Congenital abdominal wall defect immediately adjacent and usually to the right of the umbilicus. Incidence: 1 in 2500 live birth.

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Aetiology: 1. Idiopathic 2. At the site of involution of right umbilical vein 3. Rupture of an omphalocal sac in utero 4. More in premature baby Structure herniate: Midgut 1. Small gut 2. Part of large gut Associated Anomalies: 1. Malrotation of midgut 2. Intestinal atresia Presentation: Premature baby Protrusion of midgut which is oedematous, short and covered with fibrous exudate Complication: Failure to enlarge abdominal cavity Infarction of bowel Infection D/D: Omphalocele Covered by amniotic membrane Treatment: A. Immediate: Prevention of dehydration by covering of gut B. Definitive: i. Small size: Closed primarily after manual stretching of abdominal wall ii. Large size: Staged procedure (SIL procedure) Conclusion: Antenatal diagnosis can be done by USG and delivery should be at territory hospital for better management.

222. Helicobacter pylori

Introduction: Helicobacter pylori infection is the most important aetiological factor in peptic ulcer disease. Characteristic: Gm (-)ve Spiral Flagellated bacillus Site: 1. Mucus lining human gastric epithelium 2. Area of gastric metaplasia in duodenum Spread: Faeco-oral route. Disease produced: 1. Chronic gastritis 2. Peptic ulceration 3. Gastric cancer 4. Gastric lymphoma

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Pathogenesis: Production of enzyme Disruption of gastric mucosal barrier Production of cytotoxin Gastritis + . Detection of organism: 1. Invasive (Endoscopy): a) Rapid urease test (CLO) b) Histology: Stained gastric mucosa (ge) c) Culture 2. Non-invasive: a) Serology: IgG antibody b) Breath test Eradication: Triple therapy various combinations can be used, e.g. Omeprazole 20 mg 12 hourly Amoxicillin 1000 mg 12 hourly Clarithromycin 500 mg 12 hourly It should be continued for 12 weeks Conclusion: With the invention of Helicobacter pylori, PUD is now regarded as a curative disease.

223. Male Infertility

Introduction: It is a psychological and social embarrassment for a couple. Incidence: 10 to 15% of marriage, 1/3 due to male cause. Cause: A. Congenital: i. Bilateral anorchia ii. Bilateral cryptorchidism iii. Germ cell anaplasia iv. Immotile cilia syndrome B. Traumatic: i. Both testis with atrophy ii. Neurologic with erectile or ejaculatory dysfunction C. Infective: i. Systemic ii. Reproductive organ specific D. Others: i. Endocrine disorders e.g. Pituitary insufficiency ii. Varicocele iii. Vasectomy iv. Drugs e.g. Oestrogen Diagnosis: 1. History: Very important 2. Physical examination: Full urological examination Penile examination Testis Vas DRE Varicocele

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Investigation: 1. Semen analysis: Quantity: Oligospermia Azospermia Quality: Structure Motility 2. Hormone studies: FSH LH Prolactin Testosterone 3. Testicular biopsy: To detect obstructive versus parenchymal disease 4. Others: Antisperm antibody Chromosomal study Scrotal USG Colour Doppler: Varicocele TRUS: Ejaculatory duct cyst Treatment: A. Non-operative: i. Endocrine therapy in hypogonadism ii. Rx of infection by antibiotic iii. Treatment of retrograde ejaculation by -adrenergic drug iv. Steroid for antisperm antibody B. Operative: i. Varicocele: Ligation of varicocele ii. Vasal obstruction: Vasova.. iii. Epididymal obstruction: Epdidymovasostmy C. Assisted reproductive technique: i. AIH (Artificial insemination with husband sperm) ii. ICSI (Intracytoplasmic sperm infection) iii. In vitro fertilization (IVF) Conclusion: Proper evaluation of the patient is vital for management.

224. Post Urethral Valve Band

Introduction: Common congenital anomaly, Incidence:

Site: Distal to verumontanum but may present within the prostatic urethra. Presentation:

Investigation: Urine

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USG MCU

Complication:

Treatment: Endoscopic

Conclusion: Early dx.

225. Neurofibromatosis
Introduction: Common nerve sheath tumour and may be associated with MEN - II. Cell of origin: Connective tissue of nerve sheath containing both fibrous and neural element. Type: 1. 2. 3. 4. Type I (Van Rechlinghausens disease) Type II (Central neurofibromatosis) Plexiform neurofibromatosis Elephantiasis neurofibromatosis

Mood of inheritance: As autosomal dominant. Presentation: Multiple small swelling F/H Associated with hairing disturbance due to aquastic neuroma May present with features of other MEN Type II Features of cord compression O/E: Multiple small, mildly tender nodule Skin pigmentation (Caf..): Diagnostic o > 6 in number or o 1.5 cm across Exclude other MEN II Repeated trauma with ulceration Infection Haemorrhage Sarcomatous change (1 5%)

Complication:

Treatment: A. Counseling: Genetic B. No symptom: No treatment C. Surgery: Excision and biopsy Indication: Mechanical problem Cosmetic

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Malignancy

Conclusion: Always exclude other MEN II before operation and regular follow up is essential.

226. Birth Injury

Introduction: Common problem in paediatric practice. Incidence: 2% of all neonatal death. Predisposing factors: Large baby Difficult labour Instrumental delivery Abnormal lie Types of birth injury: 1. Haematoma: a) Cephal haematoma b) Subglial haemorrhage 2. Spinal cord injury : More in breach presentation 3. Peripheral nerve injury: a) Facial nerve b) Brachial plexus 4. Skeletal fracture: a) Clavicle b) Humerous 5. Pneumothorax 6. Haemothorax 7. Rib fracture 8. Internal visceral injury: a) Liver b) Spleen c) Adrenal gland Presentation: According to the type of injury Swelling over the scalp Refusal to take food Breathlessness Investigation: According to nature of injury 1. X-ray of local part 2. USG of abdomen for visceral injury 3. CT Scan if available for visceral injury Treatment: In most of the cases the treatment is conservative except in pneumothorax and visceral injury where surgery may be indicated. Conclusion: Every effort should be made to prevent birth injury.

227. Ectopic Anus

Introduction: It is one of the common and congenital anomalies of ano-rectum where anus is situated anteriorly.

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Incidence: 1 in 3000 birth. Pathogenesis: Results from incomplete migration of anus back across the perineum. Position of anus: Anteriorly 1. Boys: Perineum 2. Girls: Vulva, vagina Presentation: Passage of meconium through an abnormal opening Associated with other congenital anomalies O/E: Ectopic opening of anus Exclude other congenital anomalies

Treatment: Operation Plastic cut-back operation followed by regular anal dilatation for 6 8 months to prevent stricture. Conclusion: After operation outcome is good. Follow up is essential.

228. CSF Shunt

Introduction: It is a lifesaving procedure where CSF is diverted from subarachnoid space into various body cavities or exterior. It is an important Rx option for Hydrocephalous. Type: 1. External 2. Internal: a) Ventriculo peritoneal b) Ventriculo atrial c) Ventriculo pleural (rare) Indication: Hydrocephalous due to any cause 1. Congenital: Aqueduct obstruction 2. Acquired: a) Meningitis b) Intracranial tumour obstructing CSF c) Trauma due to haemorrhage into ventricle Method: 1. Proximal end of silicon catheter at the lateral ventricle 2. Distal end one of the surface 3. A flushing valve is connected between two tubes to regulate CSF Complication: Bleeding into ventricle Occlusion of shunt Infection Ulceration of scalp over valve Conclusion: Regular follow up is vital to detect complications and its treatment.

229. Surgery of Epilepsy

Introduction: Epilepsy is the commonest neurological condition where role of surgery is relatively small.

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Indication: 1. Failure to control seizures with anticonvulsant 2. Seizures with focal lesion e.g. Intracranial tumour Pre-operative evaluation: Careful history: o Onset and nature of seizures o Change with time o Anticonvulsant medication o Birth history: Antenatal Perinatal Physical examination: Otherwise normal Neuropsychology and neuropsychiatry assessment o IQ o Memory function o Psychiatric disorder Investigation: 1. MRI: To see the site and extent of lesion 2. EEG: To identify the lesion Localized Diffuse Contraindication of surgery: Epilepsy with established psychosis. Options of surgery: 1. Resection of temporal lobe: a) Amygdala b) Hippocampus 2. Hemi-spherectomy 3. Section of the corpus callosum 4. Vagal nerve stimulation Procedure: 1. Stereotactic 2. Minimally invasive technique: Intraoperative EEG Operating microscope Conclusion: With proper selection, seizure-free rate is 70 80%.

230. Desmoid Tumour

Introduction: It is a common tumour of anterior abdominal wall and slowly growing, may be associated with FAP, so exclude musculo-aponeurotic structure before operation. Site: 1. Anterior abdominal wall, below the umbilicus 2. The mesentery Behaviour: Benign but unencapsulated. Aetiology: 1. Women (80%) with born children 2. Scars of anterior abdominal wound 3. Trauma in anterior abdominal wall

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Association: FAP (Gardners syndrome) Meduloblastoma (10%) Upper GI malignancy Pathology: Composed of fibrous tissue containing multinucleated giant cells. Clinical Feature: Middle aged women H/O operation Lump in the scar tissue in the anterior abdominal wall O/E: Firm to hard lump. Investigation: 1. USG of W/A: Lump is extra or intra-abdominal Associated abdominal pathology 2. FNAC: For tissue dx Treatment: 1. Wide local excision: 2.5 cm of healthy margin followed by repair of defect with prolene mesh. 2. Prevention of recurrence: Tamoxifen Prednisolone Progesterone Combination of chemotherapy may role Conclusion: Exclude FAP and pre-operative counseling about high chance of recurrence is vital.

231. Electric Burn

Introduction: Electric injury occurs when body becomes a part of an electric circuit. Electric burn is a dangerous condition as it burns deep tissue more than superficial one. Type: Usually deep burn. Mechanism: Low voltage (<1000V): o Contact wound o Cardiac arrest o No deep tissue damage High voltage (>1000V): o Flush o Current transmission Pathology: Electric current passing through the tissue causes heating which results in cellular damage. Effects: Depends upon Type of current Duration of contact

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Part of the body involved 1. Local: Tissue damage Inflammation Infection 2. Regional: Impairment of circulation due to thrombosis and compartment syndrome 3. Systemic: Fluid loss MOF Inhalational injury Complication: Cardiac arrest Myoglobinurea and renal shut down Gangrene of affected part Treatment: Difficult and complex in every step 1. Initial resuscitation 2. Wound debridement (may be multiple) and wound covered by Skin graft Microvascular flap Xenograft (modern approach) 3. Amputation if needed Conclusion: Management should be in specialized centre.

232. Anterior Tibial Syndrome

Introduction: It is a compartment syndrome affecting the extensor compartment of the leg. It may be acute or chronic. Type: 1. Acute 2. Chronic Cause: 1. Acute: a) Trauma to the leg causing haematoma in the anterior compartment with or without fracture of tibia b) Reperfusion of blood supply after arterial injury 2. Chronic: Long distance runner Clinical Feature: Pain in the leg Unable to extend the big toe (Extensor Hallucis Longus is affected first) H/O trauma with or without fracture of tibia Investigation: Dx is mostly clinical. Compartment pressure can be measured in chronic cases. Treatment: According to cause A. Acute: i. Fasciotomy + internal fixation of fracture if required ii. If no arterial injury Evacuation of haematoma B. Chronic: i. Subcutaneous fasciotomy

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ii. Change the occupation

Complication: Muscle ischaemia Gangrene VIC Conclusion: Suspicious and early treatment particularly in acute cases is important.

233. Congenital Hypertrophic Pyloric Stenosis

Introduction: It is one of the causes of neonatal gastric outlet obstruction. It is the most common surgical disorder in infancy. Incidence: 3 per 1000 live birth. Pathology: Hypertrophy of the circular and longitudinal muscles of the pylorus and distal antrum of stomach with narrowing of pyloric canal. Clinical Feature: Male : Female = 4 : 1 1st born male child Positive family history more in maternal side At 4 weeks after birth with o Vomiting, projectile and non-bilious o Weight loss o Epigastric lump O/E: Dehydrated, emaciated Visible peristalsis may be seen

D/D: 1. G-O reflux 2. UTI 3. ICP Investigation: 1. USG of abdomen: Thickened muscle layer (>4 mm) Length of pylorus (>16 mm) 2. Ba-meal X-ray: Narrow pyloric channel Double tract sign due to fold of mucosa Complete obstruction Complication: Metabolic alkalosis Electrolyte imbalance (Hypokalaemia, hypochloremia) Aspiration and pneumonia Gastritis and reflux oesophagitis Treatment:

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1. Correction of metabolic abnormalities 2. Correction of dehydration by I/V fluid 3. Surgery: Definitive treatment Ramstedts pyloromyotomy Conclusion: Excellent outcome after surgery.

234. Hypophysectomy
Introduction: With the invention of modern medical endocrine manipulation, hypophysectomy is rarely done. Indication: 1. Advanced carcinoma breast where other endocrine manipulation fails or relapse. 2. Advanced carcinoma prostate 3. Pain relief for other advanced carcinoma 4. Rarely for primary pituitary tumour, in marked endocrine disturbance or pressure effect. Advantage: Regression of tumour Pain relief by interrupting the hypothalamic pituitary axis for encephalin Route: 1. Transphenoidal 2. Frontal craniotomy 3. Transnasally Complication: CSF rhinorrhoea Diabetes incipidus Conclusion: Hormone replacement is essential and this patient needs prolonged follow up.

235. Cardiogenic Shock

Introduction: It is not uncommon in surgical practice and it is a dreadful condition and in spite of intense therapy mortality rate is high. It is caused by failure of the heart pump action. Cause: A. Pump failure: i. Sudden MI ii. Arrhythmia iii. Severe CCF with low CO iv. Following open heart surgery v. Acute septal perforation B. Mechanical vascular obstruction: i. Massive pulmonary embolus ii. Tension pneumothorax iii. Cardiac temponade

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Pathophysiology: Pump failure Failure of the heart to pump out all the venous blood return to it Congestion of lungs and viscera Leak out of pulmonary capillary Pulmonary oedema and hypoxia. Presentation: H/O cardiovascular disease Features of shock O/E: Enlarged neck vein Bilateral basal crepitation Cyanosis Tachycardia

Investigation: 1. ECG change: MI, LVF 2. CVP 3. Cardiac enzymes: May be raised Treatment: 1. Complete bed rest 2. Opioids: Morphine/ Pethidine Pain relief Sedation Overflow Outflow 3. Diuretics: Right and left atrial pressure 4. Inotropic drug: Flow in CVS Dopamine Dobutamine 5. Vasodilators: Redistribution of fluid 6. -blocker: O2 demand of myocardium 7. Intra-aortic balloon pump in selected patient. Conclusion: Early dx and Rx reduced the mortality.

236. Ventricular Aneurysm

Introduction: It is a complication of myocardial infarction where fibrous ventricular wall balloons out during systole. Site: Left ventricular wall. Pathology: Partial thickness necrosis of vessel wall Replaced by non-contractile fibrous tissue Ventricular aneurysm Actual stroke volume. Presentation: H/O MI Features of LVF: o Tachycardia o Basal crepitus Features of embolism Features of congestive heart failure Investigation: 1. ECG MI: ST elevation 2. Chest X-ray: Localized LV bulging

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3. Echo: Diagnostic Treatment: 1. Resection and repair using cardiopulmonary bypass with or without CABG 2. Heart transplantation in refractory cardiac failure Conclusion: Significant increase in ventricular function after surgery but life-long follow up is necessary.

237. Burkitts Lymphoma/ Tumour

Introduction: Commonest tumour in paediatric age group. Aetiology: 1. Unknown 2. Linked with E-B virus infection 3. Common in malaria endemic area 4. Associated with AIDS Site: Multifocal 1. Abdominal viscera 2. Retroperitoneal 3. CNS 4. Jaw 5. Maxilla Presentation: Age: At any age Abdominal mass Jaw swelling Neurological manifestation: o Cranial nerve paralysis o Limb paralysis Investigation: 1. Histologically: Starry sky appearance 2. USG of W/A: Mass in the abdomen LN Treatment: Combination of surgery and chemotherapy. Conclusion: Early diagnosis and treatment is vital.

238. Prognosis of Malignant Melanoma

Introduction: Malignant melanoma is the most common skin cancer with variable prognosis, depending upon some factors. Prognostic Factor: 1. Tumour thickness: Most important - <0.75 mm, good prognosis. 2. Infiltration level: Involvement of reticular dermis bad prognosis. 3. Ulceration: Bad prognosis 4. Mitotic activity: High mitotic activity poor prognosis

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5. 6. 7. 8. Location: Limb good prognosis Number of lymph node involvement: More in number - bad prognosis Systemic metastases: Poor prognosis Clinical type: Am.: Bad prognosis Lentigo maligna: Good prognosis

Conclusion: Early diagnosis and Rx is vital for better prognosis.

239. Inhaled FB
Introduction: It is a dangerous condition and commonly occurs in small children. Site of Impact: Usually in the right main bronchus as it is wider and more vertical. Example: Children: o Coin o Safely pin o Pin o Tiny toys o Seeds o Marble Adult: o Denture o Meet o Fish bone Presentation: According to the site and size of FB Asymptomatic Wheezing with persistent cough Pyrexia with productive cough due to pulmonary infection Investigation: 1. Chest X-ray (A/P & lateral view): Can be seen 2. Bronchoscopy: Dx + therapeutic Treatment: 1. Bronchoscopic removal of FB 2. Thoracotomy and Bronchotomy with removal of FB if bronchoscopic facilities are not available 3. Lobectomy: If chronic lung damage Complication: Pneumonia Lung abscess Chronic lung damage Conclusion: Early management by an experienced hand is vital to prevent complications.

240. Cavernous Sinus Thrombosis

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Introduction: It is a serious condition which may lead to death occurring secondary to infection around the head region specially face. Source: Infective & neoplastic 1. Infection from face 2. Otitis media 3. Peritonsilar abscess 4. Orbital cellulitis 5. Open fracture of skull Predisposing Factor: 1. Dehydration 2. Pregnancy 3. OCP 4. Hypotension Clinical Feature: Severe headache Delirium Proptosis, Conjunctional chemosis Loss of pupillary reaction due to cranial nerve involvement Investigation: CT scan of brain cavernous sinus is seen. Treatment: A. Supportive RX: i. Broad spectrum I/V antibiotic ii. Maintenance of hydration B. Surgery: Decompression of brain To allow brain swelling by subtemporal craniotomy. C. Rx of cause. Complication: Blindness and death. Conclusion: Early treatment of infection around head region is vital to prevent cavernous sinus thrombosis.

241. Transplantation of Isolated Pancreatic Islets

Introduction:

Sources of Islets: 1. Human 2. Animals Site of transplantation: Liver Indication: DM receiving immunosuppression due to kidney transplantation. Methods of Connection of Islets Cell: Advantage:

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Problem: C mass of islets cell collection Graft resection Conclusion:

242. Patient Con. Analgesia

243. TENS

Treatment option: A. Surgical excision:

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i. Middle ear approach ii. Sub-occipital approach iii. Trans labyrinthin approach B. Radiosurgery: Old age

244. Acquastic Neuroma

CSD 919/ Rx 925

245. LUTS
Introduction: It is a manifestation of various lower urinary tract diseases, which is a very distressful condition and hampers the daily life of patient. Types of symptom: 1. Obstructive 2. Irritative Cause: 1. 2. 3. 4. 5. Congenital Traumatic Inflammatory Neoplastic Miscellaneous: Idiopathic detrusor instability Neuropathic bladder dysfunction e.g. Strokes Alzheimers disease Parkinsons disease

Investigation:

Treatment:

Conclusion: Proper evaluation of cause.

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246. ICU Syndrome

Introduction: It is a symptoms complex both physical and psychological developed in a patient who has been admitted in ICU. Symptom: Physical: o Body fatigue o Reluctance to move o Pain Psychological: o Mild psychosis: Confusion Anxiety o Severe psychosis: Hallucination Fear Panic Factors Contributing: 1. Pathophysiological disorders e.g. Hypoxia Renal dysfunction 2. ICU environment 3. Separation from family 4. Constant interventions by staff 5. Endotracheal intubation 6. Overhearing of staff conversation 7. Drugs and sedation 8. Use of invasive measures Prevention: Communication by paper and pen, keyword board Counseling before any procedure Clinical touch Conclusion: Proper counseling and appropriate measures to prevent ICU syndrome.

247. Mentation of a Debilitated Patient

Introduction: Mentation is a common reaction in a debilitated patient who needs tender loving care and psychological support to reduce the symptoms. Common symptoms: Anxiety Depression Denial (Refusal of necessary medication) Anger Restlessness Insomnia Feeling of guilt Suicidal ideas

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Lowering of interest in social activity

Aetiology: 1. Fear of unrelieved symptoms e.g. pain 2. Fear of death and process of dying 3. Fear of dying alone 4. Fear of incomplete testis 5. Fear of loss and separational dignity Treatment: Multidisciplinary approach 1. Counseling 2. Psychological support 3. Family support 4. Spiritual support 5. Drug treatment: Anxiolytic Antidepressant Conclusion: Proper counseling.

248. Hazards of Lap Electro-surgery

Introduction: Diathermy is an important device for surgical practice but its use is not devoid of complications. Diathermy is an essential equipment in modern surgical practice but there is every chance of complications if precaution is not taken. Risk Factor: Improper fitting of patents plate. Patient touching earth, metal object like drip stand, metal component of operating table, monitoring electrode even via the surgeon. Pacemakers or any metallic prosthesis Mono polar diathermy For laparoscopy: Insulation failure Complication: Burning wrong structure Conductive thermal gradient Insulation failure Instrument to instrument coupling (direct coupling) Retained heat in the tip of active electrode after diathermy use Channel effect Capacitative coupling Personal and equipment hazards: o Inadvertent activation of electrode by pressure on foot switch o Leakage of gloves Other complications: o Cardiac arrhythmia o VF o Cardiac arrest Prevention: A. General precaution B. Specific for lap ..: i. Check instrument before use ii. Avoid open circuit activation

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iii. iv. v. vi. Conclusion: Dont activate diathermy when instruments are not in view Dont active electrode .. not touch the tissue Should not use monopolar diathermy Use non-conducting trocars or metal trocars should good contact with abdominal wall.

249. Channel Effect

Introduction: It is a complication of diathermy due to high current density in pedicles and necrosis of tissue due to heating. Risk Factor: Use of diathermy near the pedicle structures Use of monopolar diathermy Use of high current Common Site: 1. Base of penis 2. Base of finger 3. Cystic duct and cystic artery in GB surgery 4. Testis and sulphinx Prevention: Use of bipolar diathermy in risk area Careful use of diathermy during GB surgery Conclusion: Monopolar diathermy should not be used on organs attached by small pedicle to important structures.

250. Iatrogenic Intra-abdominal Injuries

Introduction: Inadvertent injuries to intra-abdominal structures can occur during the performance of different diagnostic and therapeutic procedures performed in different branch of specialist. Caus: 1. During closed cardiac message with rib fracture 2. Different endoscopic procedure: GIT Hepatobiliary 3. Percutaneous diagnostic and therapeutic procedure 4. Radiological procedure 5. Laparoscopic procedure 6. Open surgical procedure Diagnosis: Detected at the time of procedure direct visualization Detected immediately after procedure depends upon type, site and nature of injuries Late presentation - depends upon type, site and nature of injuries Investigation: Depends upon site of injury, type, time and general condition of patient A. General investigations: i. CBC ii. USG iii. Plain X-ray abdomen B. Special investigations:

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i. ii. iii. iv. CT ERCP PTC IVU

Prevention: 1. Must have good knowledge of anatomy about the area 2. Should know the normal anatomical variation 3. Consideration of distortion of normal anatomy by disease process 4. Should help from senior person 5. Well trained surgeon 6. Have a clear idea about the complications 7. Follow standard step of procedure Treatment: A. During open surgery: i. Detected at the time of surgery: a) Repair b) Reconstruction ii. Detected post-operatively: supportive care + assessment + decide then Rx B. Laparoscopy + endoscopy: Converted into open procedure Conclusion: Every effort should be made to prevent iatrogenic intra-abdominal injuries.

251. Post-cholecystectomy Syndrome

Introduction: Heterogeneous group of disorders affecting patients who continue to complain of symptoms after cholecystectomy. Incidence: 15% of cholecystectomy. Cause: 1. 2. 3. 4. 5. 6. Choledo-cholithiasis Stone in cystic duct Operative damage to biliary tree Biliary dyskinesia Chronic pancreatitis Depression, psychological upset

Presentation: Pain in upper abdomen Dyspepsia Fatty food intolerance Jaundice cholangitis Investigation: 1. Liver function test: S. bilirubin Alkaline phosphatase 2. USG: Dilated biliary tree stone 3. ERCP/ PTC: Dx + therapeutic 4. Biliary monometry: Exclude biliary dyskinesia Treatment: According to cause 1. Stone: Removal 2. Stricture: Hepatic jejunostomy

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3. Pancreatitis: Rx of .. merits 4. Biliary dyskinesia: Sphincterotomy 5. Antidepressant drug Conclusion: Proper evaluation before cholecystectomy is vital.

252. Biliary Dyskinesia

Introduction: It is an important cause of post-cholecystectomy syndrome which is suspected when any abnormality is found in physical examination routine test. Pathology: Dysmotility of sphincter of . Clinical Feature: Pain in the upper abdomen Fatty food intolerance Investigation: 1. Liver function test: May be abnormal 2. USG: Dilated biliary tract 3. ERCP: .. biliary tree Hold contrast prolong period 4. Biliary monometry: Elevated resting pressure Retrograde contraction of Tachyarrhythmia Paradoxical response to cholecystectomy Grade: 1. Grade-I: Abnormal liver function test Prolonged (> 45 minute) emptying of CBD dilated > 12 mm 2. Grade-II: One or two findings positive 3. Grade-III: None of positive finding. Treatment: 1. Grade-I & II: Endoscopic sphincterotomy 2. Grade-III: Follow up Conclusion: Strong suspicious is important.

253. CICS
Introduction: It is a simple technique to evacuate the bladder by the patient himself. Indication: 1. Self-dilatation of stricture urethra after O/U or metallic dilatation 2. Neurogenic bladder dysfunction 3. Over flow incontinence 4. After bladder substitution Catheter:

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Nelaton catheter All silicon Folly catheter

Procedure: 1. Cleaning of catheter by boiling or povidone iodine solution 2. Urethra is well lubricated by 2% jesocaine jelly 3. Gently introduce the catheter by patient himself Advantage: Economic Self-procedure Patient can lead almost normal life Disadvantage: Infection Urethral injury Conclusion: Proper follow up in important.

254. PET
Introduction: It is a modern technology of radionuclide imaging which is more sensitive than conventional. Indication: 1. Staging of malignant disease 2. Detection of unsuspected regional and distal metastases Methods: Detection of annihilation protons, resulting from radionuclides that decay by positron emission by specially designed camera. Advantage: More sensitive than conventional radionuclide imaging Detect micro-metastases Disadvantage: Costly Need special setting in hospital Need expertise False negative in 10 20% Conclusion: Demanding technique but non-available everywhere.

255. Hepatectomy
Introduction: The liver has a tremendous (remarkable) power of regeneration and resection is therefore well tolerated, about 80 85% normal liver can be resected. Indication: A. Neoplastic: i. Benign (Adenoma) ii. Malignant: a) Primary (Hepatoma)

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b) Secondary (most common) B. Traumatic C. Inflammatory: i. Liver abscess ii. Hydatid cyst D. Congenital: Large hepatic haemangioma E. Miscellaneous: i. Liver cyst ii. High biliary stricture iii. Hepaticolithiasis Type of Liver Resection: A. Segmental: i. Right and left lobectomy ii. Right and left extended hepatectomy iii. Left lateral segmentectomy iv. Segmentectomy B. Non-segmental: i. Wedge resection ii. Local resection Methods: 1. CUSA aspiration, debridement in trauma 2. Finger dissection 3. Kellys forceps 4. Back of BP.. 5. Water jet Resectability: 1. Non cirrhotic: 80% 2. Cirrhotic: According to child grade Contraindication: Tumour involving IV. Extrahepatic metastases Both lobes of liver Both brancesh of portal vein Complication: Bleeding Infection Biliary fistula Metabolic Conclusion: Liver resection done in high specialized centre where all facilities are available.

256. Damage Control Laparotomy/ Staged or Abbreviated Laparotomy

Introduction: It is a staged operative procedure for severely injured patient who fails to respond to non-operative resuscitation methods. It is a part of primary survey and resuscitation. Aim: 1. To arrest haemorrhage 2. Limit cavity contamination Indication:

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1. Catastrophic intra-abdominal haemorrhage 2. Time consuming procedure in poorly resuscitated patient 3. Reassessment of compromised intestinal blood supply due to extensive mesenteric injury Procedure: 1. After damage control surgery ICU for: Monitoring Resuscitation Investigation 2. Second definitive surgery Time of second surgery: Usually within 24 hours of damage . Procedure Advantage: Life saving Definitive surgery can be done with adequate investigation and in stable patient Disadvantage: Second surgery is needed Need intense monitoring with ICU facilities Conclusion: It reduces the mortality rate in trauma patient.

257. Tenesmus
Introduction: It is a very distressful condition which is characterized by intense painful but fruitless desire to defecate. Cause: A. Neoplastic: i. Ca rectum ii. Ca anal canal iii. Large rectal polyp B. Inflammatory: i. Proctitis due to any cause ii. Tubercular or amoebic granuloma in the rectum iii. Pelvic variety of acute appendicitis C. Miscellaneous: i. Pelvic abscess ii. Any collection in the pouch of Douglas which irritate the rectum Presentation: Patient complaints I want to go to toilet but nothing happens Other features related to cause O/E: Rectal growth may be found. Investigation: 1. Proctoscopy and biopsy 2. USG of W/A: .. 3. Other investigation related to cause Treatment: According to cause 1. Ca rectum: According to site and staging 2. Ca anal canal: According to site and staging 3. Pelvic abscess: Per rectal/ per vaginal drainage 4. TB: Anti TB drugs Conclusion: Proper evaluation of cause.

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Short Notes: Block dissection

Introduction: This is a radical wide excision of the tympanic field including lymph nodes and intervening lymphatic tissue. Type: 1. Prophylactic block dissection: It is done when lymphatic field is adjacent to the primary tumour but not involved by primary tumour. Example: Axilla in Ca Breast Groin in back melanoma Neck in facial cancer No prophylactic block dissection When primary tumour is far away from lymphatic field e.g melanoma at sole of foot No need to block dissection in the groin. 2. Therapeutic block dissection: It is done when lymph nodes are involved by the curable operable primary tumour. Site and Indication: A. Cervical block dissection: i. Ca oral cavity e.g tongue, mouth floor, mandible tumour ii. Ca Larynx: glottis, supra glottis and infraglottic iii. Face: melanoma, squamous cell carcinoma of lip iv. Neck: Papillary Ca thyroid, malignant parotid and submandibular salivary tumour. B. Axillar block dissection: i. Ca breast ii. Melanoma of breast C. Groin block dissection: i. Melanoma of lower limb ii. Ca penis, scrotum or vulva D. Retroperitoneal block dissection: Testicular malignancy Contraindication: If the tumour is inoperable If the tumour is incurable Presence of distant metastases Conclusion: Though block dissection increase the morbidity of the patient but it increases survival of the patient and provide prolong cancer free period.

Cause of Exophthalmos (Proptosis)

Introduction: Forward protrusion of the eye from its normal position in the orbit. Clinical Feature: First sign of exophthalmos is the appearance of sclera .. the inferior limbus. The proptosis has to considerable . Scleral is visible along the superior limbus with retraction of upper .. will reveal sclera above the ..

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1. 2. 3. 4. Patient can look up without wrinkling forehead Convergence for every close vision is restricted Patient .. Patient may not be able to close his eyes ......................... corneal