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SURGERY TACTIC

CONTENTS
SURFACE ANATOMY OF ABDOMEN
UPPER GI BLEEDING
Peptic Ulcer
Oesophageal varices
Acute erosive gastritis
CA Stomach
LOWER GI BLEEDING
Diverticulitis
Angiodysplasia
Colorectal polyps
Colon cancer
Ulcerative colitis
CA Rectum
Haemorrhoids
MASS IN ABDOMEN
Liver mass Gallbladder mass
Spleen mass Kidney mass
Hepatomegaly
ACUTE ABDOMEN
Acute appendicitis
Acute cholecystitis
Acute pancreatitis
OBSTRUCTIVE JAUNDICE
Choledocholithiasis
Gastro-oesophageal reflux disease
CA Oesophagus
Achalasia
INTESTINAL OBSTRUCTION
Adynamic bowel obstruction
Pseudo-obstruction
Strangulation
HEMATURIA
Urinary canaliculi
Bladder CA
BLADDER OUTFLOW OBSTRUCTION
Benign prostate hyperplasia
Prostate Ca
BREAST DISORDER
Breast cancer
Fibroadenoma
Phyllodes tumor (Brodies disease)
Fat necrosis
Acute breast abscess
Duct papilloma
Mammary duct ectasia
Mondor disease
Mastalgia

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NECK SWELLING
Thyroid swelling
Specific goiters
INGUINOSCROTAL SWELLING
Inguinal hernia
Other inguinal swelling
Other scrotal swelling
LEG ULCER
Varicose vein
Deep vein thrombosis
Lower limb ischemia
DISORDER OF THE SKIN
Sebaceous cyst
Lipoma
Ganglion
Dermoid cyst
Basal cell CA
Squamous cell CA
Malignant melanoma
METABOLIC RESPONSE TO INJURY
TRAUMA/ALTS
SHOCK
Hypovolemic shock
Septic shock
FLUID & ELECTROLYTES BALANCE
INTRAVENOUS SOLUTION
ASEPSIS & ANTISEPSIS IN SURGERY
BLOOD TRANSFUSION
BLOOD PRODUCTS
AUTOLOGOUS TRANSFUSION
SURGICAL NUTRITION
WOUND HEALING
SURGICAL COMPLICATION
INSTRUMENTS
CLINICAL EXAMINATION
Examination of a lump
Examination of abdomen
Examination of breast
Examination of thyroid
Examination of ulcer
Examination of hernia
Examination of varicose vein

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1. SURFACE ANATOMY OF ABDOMEN

Surgery Tactic

UNIMAS

The Layers of Abdominal Wall


o Skin
o Superficial fascia
Campers fascia fatty (superficial) layer of superficial fascia
Scarpas fascia membranous (deep) layer of superficial fascia
o Deep fascia
o External oblique muscle
o Internal oblique muscle
o Transverse abdominal muscle
o Transversalis fascia
o Extraperitoneal (endoabdominal) fat
o Peritoneum
Location of Abdominal Structures by Quadrants
Right Upper Quadrant
o Liver: right lobe
o Gall bladder
o Stomach: pylorus
o Duodenum: part 1-3
o Pancreas: head
o Right suprarenal
gland
o Right kidney
o Hepatic flexure
(right colic flexure)
o Ascending colon:
superior part
o Transverse colon:
right half

Right Lower Quadrant


o Cecum
o Vermiform
appendix
o Most of ileum
o Ascending colon:
inferior part
o Right ovary
o Right fallopian
tube
o Right ureter:
abdominal part
o Right spermatic
cord
o Uterus (if enlarged)
o Bladder (if full)

o
o
o
o
o
o
o
o
o
o

Left Upper Quadrant


Liver: left lobe
Spleen
Stomach
Jejunum & proximal ileum
Pancreas: body & tail
Left suprarenal gland
Left kidney
Splenic flexure (left colic
flexure)
Descending colon: superior
part
Transverse colon: left half

Left Lower Quadrant


o Sigmoid
o Descending colon:
inferior part
o Left ovary
o Left fallopian tube
o Left ureter:
abdominal part
o Left spermatic cord:
abdominal part
o Uterus (if enlarged)
o Bladder (if full)

Gen05

Surgery Tactic

2. ANATOMY OF OESOPHAGUS

UNIMAS

Muscular tube extends from termination of pharynx (C6) to oesophagogastric junction portions
Length: 25cm, diameter: 2cm
Distance from incisor teeth to gastro-oesophageal junction about 40 cm
4 constrictions:o 15cm from incisor teeth - caused by cricopharyngeus muscle (C6)
o 22.5cm from incisor teeth - cross by arch of aorta (T4)
o 27.5cm from incisor teeth - cross by left main bronchus (T5-6)
o 40cm from incisor teeth - at the level of oesophageal hiatus of the diaphragm - referred as clinically as
lower oesophageal sphincter (T10)
Clinically important when passing instruments through the oesophagus and stomach (i.e. OGDS)
Most foreign bodies & caustic burn occur proximity to these constrictions

*caustic def:
capable of burning, corroding, or
destroying living tissue

Anatomical weak point: above and below cricopharyngeus muscle posteriorly pulsion diverticula (Diverticula formed by
pressure from within a hollow organ, often causing herniation of the mucous membrane through the
muscular layer)
Left lateral wall of lower oesophagus spontaneous rupture
Short abdominal part of oesophagus = 2.5cm

Artery supply

Venous
drainage
Lymphatic
drainage

Cervical region
Inferior thyroid
artery

Thoracic region
Branches of descending
thoracic aorta:
-bronchial artery
-oesophageal artery

Inferior thyroid vein

Azygous and hemiazygous vein Left gastric vein (portal)


(systemic)

Deep cervical LN

Posterior mediastinal lymph n.

Abdominal region
Oesophageal branches of left
gastric artery
Inferior phrenic artery

Coeliac nodes & left gastric


lymph n.

Gen05

Surgery Tactic

UNIMAS

Connection of azygous & hemiazygous vein (systemic) & left gastric vein (portal) ----oesophageal varices---- in
portal hypertension
Nerves supply
- Sympathetic
Preganglionic fibres from spinal cord segment T5 & T6 postganglionic fibres from cervical
vertebral & celiac ganglia.
- Parasympathetic
From glossopharyngeal, recurrent laryngeal & vagus nerves.
Superior third
Middle third
Lower third

: skeletal muscle
: skeletal & smooth muscle
: smooth muscle

What is the significance of knowing the stratified squamous epithelium of oesophagus?


In malignancy, SCC (squamous cell carcinoma) response well to radiotherapy compared to
adenocarcinoma

Gen05

3. ANATOMY OF STOMACH
1)
2)
3)
4)
5)
6)

Surgery Tactic

UNIMAS

Stomach part of upper gastrointestinal tract


Upper gastrointestinal tract from oral cavity Ligament of Treitz (4th part of duodenum)
J-shaped ; capacity aproximately 1500ml
10 inches long = 25cm
Extending from beneath the left costal margin to epigastric, umbilical & left hypochondriac region
External features
2 openings (cardiac and pyloric orifices)
*classification of sphincter:
2 curvatures (greater and lesser curvature)
- Anatomical sphincter:
2 surfaces (anterior and posterior surface)
- Physiological sphincter:

7) Cardiac orifices
behind left 7th costal cartilage
1 inch lateral to sternum
at level T 11
physiological sphincter (no anatomic)
8) Pyloric orifices
opens into duodenum
lies at transpyloric plane 0.5 inch to the right or median plane
at level L 1
indicated by circular groove called pyloric constriction produced by pyloric sphincter (physiological
and anatomical sphincter)
marked by prepyloric vein, which lies in front of the constriction
9) Transpyloric Plane
lies midway between xiphisternum and umbilicus
corresponds with the lower border of L1, tips of the 9 th costal cartilages
10) Trans-tubercular plane
passes through the tubercles of the iliac crest
corresponds with the center of L5
5cm behind the anterior superior iliac spine (ASIS)
11) Part of the stomach
Cardiac
Fundus
Body
Pyloric part pyloric antrum, pylorus
12) Incisura angularis & anastomosis right and left gastroepiploic artery divides between antrum and body
(refer picture before)
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Gen05

Surgery Tactic

UNIMAS

13) Anterior surface: anterior abdominal


left costal margin
left pleura & lung
diaphragm
left lobe of liver
14) Posterior surface: Lesser sac
Diaphragm
Spleen
Left suprarenal gland
Upper part of left kidney
Splenic artery
Pancreas
Transverse colon
Mesocolon
15) Blood supply of the stomach
Artery supply
o Left gastric celiac artery
o Right gastric hepatic artery
o Short gastric splenic artery
o Left gastro-epiploic splenic artery
o Right gastro-epiploic gastroduodenal artery
Venous drainage
o Left and right gastric veins portal vein
o Short gastric vein & left gastro-epiploic vein splenic vein
o Splenic vein joins superior mesenteric vein to form portal vein
o Right gastro-epiploic vein superior mesenteric vein
o Prepyloric vein ascends over the pylorus to the right gastric vein because this vein is obvious in
living persons, surgeons use it for identifying the pylorus
16) Lymphatic drainage
left gastric artery to celiac nodes
right gastric artery to hepatic nodes
short gastric and left gastro-epiploic artery to splenic nodes
right gastro-epiploic artery to gastro-duodenal nodes
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Surgery Tactic

UNIMAS

Gastric carcinoma metastasize to Virchows node palpable left supraclavicular lymph nodes
Presence of Virchows node Troisiers sign
17) Nerves supply
Sympathetic
o Segment T6-T10 via greater splanchnic nerve & celiac n hepatic plexus
o Vasomotor, motor to sphincter, inhibitory to muscle, chief pain pathway
Parasympathetic
o Vagus nerve
o Anterior vagal trunk from left vagus nerve gives off hepatic and duodenal branches supply anterior
wall of stomach
o Posterior vagal trunk from right vagus nerve gives off celiac branches supply posterior wall of
stomach

Gen05

4. ANATOMY OF HEPATOBILIARY TRACT

Surgery Tactic

UNIMAS

Anatomy of Liver
1.
2.
3.
4.
5.
6.

Largest abdominal organ 1500g


Extends from 5th intercostal space to the right costal margin
Triangular in shape
Apex - reaches the left midclavicular line in the 5th intercostal space
External surface of the liver is covered by fibrous Glissons capsule
Bile passes from liver right and left hepatic ducts common hepatic duct (CHD) CHD unites with the
cystic duct common bile duct
7. Liver has 2 surfaces:A) Diaphragmatic surface
Anterior, superior & some posterior
Smooth & dome-shaped
Separated from the diaphragm by subphrenic recesses
Hepatorenal recess (hepatorenal pouch / Morisons pouch) deep recess of the peritoneal
cavity on the right side extends superiorly between the liver anteriorly and the kidney &
suprarenal gland posteriorly
Covered with visceral peritoneum except posteriorly in the bare area of the liver, where it lies in
contact with the diaphragm
B) Visceral surface
Postero-inferior
Covered with peritoneum except the bed of gall bladder and porta hepatis
Portal triad
P
8. Porta hepatis gives passage to the:- portal vein
- hepatic artery
- hepatic ducts
- hepatic nerves plexus
- lymphatic vessels

The portal triad of the liver


is contained within the
hepatoduodenal ligament.

9. Liver is divided by falciform ligament into right and left lobes.


(Anatomical lobe caudate & quadrate belong to the right)
10. Also divisible into right & left hemi-livers (each with 4segments) by a line running from gall bladder to the
IVC (functional / physiological / surgical lobe)
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Surgery Tactic

UNIMAS

11. Segmental anatomy of liver:o Segment 1 caudate lobe (left hemiliver)


o Segment II & III left lobe
o Segment IV quadrate lobe
o Segment V VIII right hemiliver
12. The hepatocytes are arranged in the lobules, each of which has: a central branch of the hepatic vein
peripheral portal tracts (containing a branch of
the hepatic artery, portal vein & bile duct)
13. Blood supply
receives 1500ml blood/minute
has a dual blood supply
65% from portal vein & 35% from hepatic artery celiac trunk
portal vein poorly oxygenated but nutrient-rich blood from GIT
hepatic artery
o divide into common hepatic artery & hepatic artery proper
o supplies 50% of the oxygen requirement because of better oxygenation carry well oxygenated
blood from aorta
venous drainage
- hepatic vein
- formed by union of central veins of liver
- drains into IVC inferior to diaphragm
14. Right and left hepatic arteries, ducts & portal vein DO NOT communicate so hepatic lobectomies (removal
of right / left part of liver) can be done without excessive bleeding

Gen05

15. Lymphatic drainage

Surgery Tactic

UNIMAS

thoracic duct

Bare area diaphragmatic area posterior mediastinal nodes


parasternal nodes

thoracic duct & right lymphatic duct

Other part of liver hepatic nodes celiac nodes cisterna chili thoracic duct
*Liver is common site of metastasis of malignancy, esp lung, colon & breast carcinoma because half of
the total body lymph are in liver.

16. Nerve supply


- Sympathetic celiac plexus
- Parasympathetic vagus nerve
ANATOMY OF GALLBLADDER
7-10cm long
Lies in the gallbladder fossa on the visceral surface of the liver
Pear-shaped
Capacity = 50ml of bile
Peritoneum completely surrounds the fundus of the gallbladder & binds its body & neck to the liver
Has 3 parts:- Fundus
wide end
projects from the inferior border of the liver
located at the tip of right 9th costal cartilage in the midclavicular line
- Body
contacts the visceral surface of the liver, the transverse colon & the superior part of the
duodenum
- Neck
narrow, tapered & directed towards the porta hepatis
mucosa spirals into the fold spiral valve
spiral valve
keeps the cystic duct open so that bile can easily divert into the gallbladder
bile can pass to the duodenum as the gallbladder contracts
makes an S-shaped bend & joins the cystic duct
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Surgery Tactic

Cystic duct
4cm long
connects the neck of the gallbladder to common hepatic duct

UNIMAS

Blood supply of the gallbladder & cystic duct


- cystic atery right hepatic artery
- cystic veins (drains the biliary duct & neck of gallbladder) liver (directly) / portal vein
- veins ( from fundus & body) directly into the visceral surface of the liver hepatic sinusoids
Lymphatic drainage
- cystic nodes celiac nodes cisterna chili thoracic duct
Nerves supply
- celiac plexus (sympathetic)
- vagus nerve (parasympathetic)
- right phrenic nerve (sensory)
Valve of Heister
= spiral valve in cystic duct
Sphincter of Lutkins = muscular coat of the neck of GB
Hartmanns pouch = infundibulum of GB (between neck and cystic duct) where stone
usually impacted
Porcelain GB
= calcified GB in abdominal X-ray (rare)

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ANATOMY OF BILE DUCT

Surgery Tactic

UNIMAS

cystic duct common hepatic duct common bile duct


5-15cm length; diameter = 8mm
descends posterior to the 1st part of duodenum
lies in the groove on the posterior surface of the head of pancreas
on the left side of 2nd part of the duodenum, the bile duct come into contact with the main pancreatic duct
unite to form hepatopancreatic ampulla (ampulla of Vater) the dilatation within the major duodenal
papilla
o the circular muscle around the distal end of the bile duct is thickened to form the sphincter of the bile duct
(choledochal sphincter)
o
o
o
o
o

Choledochal sphincter
- Synonym for sphincter of common bile duct.
- Smooth muscle sphincter of the common bile duct immediately proximal to the
hepatopancreatic ampulla. It is this sphincter that controls the flow of bile in the
duodenum.

Blood supply

Arterial supply
o cystic artery proximal part of the duct
o right hepatic artery middle part of the duct
o posterior superior pancreaticoduodenal artery & gastroduodenal artery retroduodenal part of the duct

Venous drainage
o veins from proximal part of bile duct & hepatic ducts liver (directly)
o distal part of bile duct - posterior superior pancreaticoduodenal vein portal vein

Lymphatic drainage
o cystic nodes
o node of the omental foramen
o hepatic lymph nodes
o efferent lymphatic vessels celiac lymph nodes

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Pain

Surgery Tactic

Biliary pain
- due to spasm of smooth
muscle
sympathetic through celiac
plexus
thoracic segment

Right hypochondrium & epigastrium


by thoracic segment T7,8 & 9

Central part of diaphragm


supplied by phrenic nerve
(C3,4,5)

Shoulder supply by supraclavicular


nerve
(C3 & C4)

UNIMAS

Referred pain
Pain at the right hypochondrium &
epigastrium
Tip of scapula

Parietal peritoneum of
peripheral part of diaphragm
& anterior abdominal wall

Irritation of diaphragm by inflamed


liver or GB may refer to tip of
shoulder
Irritation of parietal peritoneum by
inflamed liver or GB may refer to
inferior angle of scapula

ANATOMY OF PANCREAS
Retroperitoneum
Lies in the epigastrium & left hypochondrium
Secretes 1-2 litres of the alkaline per day; pH 7.5-8.8
Posterior to stomach ; between duodenum (right) & spleen (left)
Divided into 4 parts:o Head / neck / body / tail
Head
- lies within C-shaped curve of duodenum
- at the right of superior mesenteric vessels
- uncinate process projection from inferior part of the head, extends medially to the left, posterior
to the superior mesenteric plexus
- Overlying: IVC
Right renal artery & vein
Left renal vein
Neck
-

posteriorly & near its upper border superior mesenteric veins join splenic veins portal vein
anteriorly: adjacent to pylorus of stomach

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Body
-

Surgery Tactic

UNIMAS

passing over aorta & L2


anterior : covered by peritoneum
posterior : not covered by peritoneum
in contact with aorta, superior mesenteric artery, left suprarenal gland, left kidney & renal vessels

Tail
-

anterior to left kidney


closely related to the hilum of the spleen & left colic flexure

Main Pancreatic Duct (Duct of Wirsung)


- begins from tail of pancreas
- runs through parenchyma of gland to head
- at head, turns inferiorly & closely related to the bile duct
- Main Pancreatic Duct + bile duct hepatopancreatic ampulla (short & dilated) opens into
descending part of duodenum at major duodenal papilla (Ampulla of Vater)
Accessory Pancreatic Duct (Duct of Santorini)
- drains the upper part of the head
- opens into 2nd part of duodenum 2.5cm above the ampulla of Vater at minor duodenal papilla
Smooth muscle sphincters that control the flow of bile & pancreatic juice into the duodenum:- sphincter of pancreatic duct
- sphincter of bile duct
- hepatopancreatic sphincter (sphincter of Oddi)
Blood supply
Arterial supply
- splenic artery greater pancreatic artery, dorsal pancreatic artery & inferior pancreatic artery
- superior pancreatico-duodenal artery hepatic artery
- inferior pancreatico-duodenal artery superior mesenteric artery

Venous drainage
- pancreatic veins splenic vein

Lymphatic drainage
- celiac & superior mesenteric lymph nodes

Nerves supply
- sympathetic celiac & superior mesenteric plexus
- parasympathetic vagus nerve
13

Gen05

Surgery Tactic

UNIMAS

Pancreas produces: Exocrine secretion


- Pancreatic juice trypsin (trypsinogen), lipase & amylase
- From acinar cells main & accessory pancreatic ducts duodenum

Endocrine secretion
- 4 types of islet cells:o A cells glucagons
o B cells insulin
o D cells somatostatin
o PP cells pancreatic polypeptide
- Gastrin producing (G) cells abnormal Zollinger-Ellison syndrome

5. ANATOMY OF SMALL & LARGE INTESTINE


Anatomy of Small Intestine
Small Intestine
Length

Duodenum

Jejunum

Ileum

25cm

2.5m

3.6m

Diameter

How many parts?

2.5cm
4 parts
1st superior : 2 inches
2nd descendng: 3 inches
3rd horizontal : 4 inches
4th ascending : 1 inch
(4th part is held by peritoneal fold:
Ligament of Treitz to right crus of
diaphragm)

Any peritoneum?

Only 1st part covered by peritoneum.


The rest are retroperitoneum.
14

Suspended by mesentery: mobile

Gen05

Surgery Tactic

Anterior:
Liver, gallbladder, stomach, transverse
colon, small intestine

Relation to
surrounding
structures

Posterior:
Lesser sac, gastroduodenal artery, bile
duct, portal vein, inferior vena cava,
right kidney, ureter, aorta
Medial:
Pancreas, bile duct
Lateral:
Hepatic flexure

15

UNIMAS

Gen05

Features

Blood supply

Lymphatic
drainage

Nerves supply

Duodenum
Bile & pancreatic duct unite to
form ampulla & enter into 2nd
part of duodenum thru major
papilla of Vater

Surgery Tactic

Duodenal arteries celiac trunk


& SMA
Celiac trunk-gastroduodenal
artery- suppancreaticoduodenal
a. supplies duodenum
proximal to the entry of bile
duct.
SMA inf. Pancreaticoduodenal
a supplies duodenum distal to
entry of bile duct.
Duodenal veins portal v
Anterior lymphatic vessels
pancreaticoduodenal LN- pyloric
LN.
Posterior lymphatic vessel.
Efferent lymphatic vessels fr
duodenal LN celiac LN
Vagus & sympathetic thru celiac
& sup mesenteric plexus

UNIMAS

Jejunum
Ileum
Thick & > vascular
Thin & less vascular wall
wall
Narrow &loaded lumen
Wide empty lumen
No window
Window
More fat
Less fat
3-6 arterial arcades
1-2 arterial arcades
Shorter & > vasa recta
Longer & < vasa recta
Sup. Mesenteric a. sends 15-18 branches to jejunum and
ileum.
Arteries unite to form arterial arcades- give rise to
straight arteries- the vasa recta
Sup mesenteric vein

Specialised lymphatic vessel that absorb fat LACTFALS


Mesenteric LN (MLN)
Ileocolic LN(ICLN)
MLN &ICLN sup mesenteric nodes.

Sympathetic T5-9
Parasympathetic- post. Vagal trunk

16

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ANATOMY OF LARGE INTESTINE

Length
Diameter
Any peritoneum?

Relation to
surrounding
structures

CECUM/APPENDIX
7.5 cm/ 6-10 cm
Completed covered by
peritoneum/
mesiappendix
Anterior:
Coils of SI
Posterior:
Psoas, iliacus muscles

Features

Medial:
Appendix
Ileocecal valve
Variable postion but
usually retrocecal

Surgery Tactic

LARGE INTESTINE
ASCENDING COLON
13 cm
5 cm
Covered by peritoneum
ant.
Retroperitoneum
Anterior:
Coils of SI, greater
omentum
Posterior:
Iliacus muscles,
Lower pole of kidney, iliac
crest
Forms hepatic flexure

Blood supply

Ileocolic artey /
Appendicular artery
Ileocolic v.

Ileocolic & rt colic a. SMA


Ileocolic and rt. Colic vein

Lymphatic drainage

Iliecolic LN
Sup mesenteric LN

Nerves supply

Sup mesenteric plexus

Epicolic & paracolic LN


ileocolic & rt colic LN
sup.mesenteric LN
Sup mesenteric plexus

17

UNIMAS

TRANVERSE COLON
45 cm
Attached by mesocolon
Most mobile part of LI
Anterior:
Greater omentum,
anterior abd. Wall
Posterior:
2nd part of duodenum,
head of pancreas, coils of
jejunum & ileum
Splenic flexure is higher
than hepatic flexure
Splenic flexure attaches
to thye diaphragm
through the phrenicocolic
ligament
Middle colic a SMA
Also supplied by right &
left colic artery
Venous drain- SMV
Middle colic LN
Sup. Mesenteric LN
Sup & inf mesenteric
plexus

Gen05

Length
Diameter
Any peritoneum

Relation to surrounding
structures

Features
Blood supply
Lymphatic drainage
Nerves supply

Surgery Tactic

UNIMAS

LARGE INTESTINE
DESCENDING COLON
SIGMOID COLON
25cm
40cm
5cm
Covered by peritoneum anteriorly.
Attached by fan-shaped
Retroperitoneum
mesocolon.
Mobile
Anterior:
Anterior:
Coils of SI, greater omentum, ant. Abd. Male- urinary bladder
Wall
Female- uterus, upper part of
vagina
Posterior:
Lateral border of left kidney, iliac crest, Posterior:
iliacus muscles, femoral nerve
Rectum & sacrum

Forms splenic flexure

Continuous with descending colon


in front of pelvic brim
Left colic & superior sigmoid a. Inf. Mes.v
Inf. M.V
Epicolic & paracolic l.n intermediate colic l.n inf. M. l.n
Lymph from splenic flexure may also drain to the sup. Mes. l,n
Sympathetic- lumbar part of sympathetic trunk & sup. Hypogastric plexus.
Parasympathetic- pelvic splanchnic nerves

18

Gen05

6. ANATOMY OF RECTUM

Surgery Tactic

UNIMAS

1. rectum 10cm(5in)
Anal canal 4cm long
2. Consists of 2 muscular tubes:
-inner tube- continuation of the smooth muscles of the gut
-outer tube- sheath of striated muscles
3. Extends from the anal verge (hair-bearing skin with sebaceous glands) to the anorectal junction(columnar
epithelium)
4. Pecten
-part of the external canal
-exposed by traction on the rim of the anus
-hairless
-anoderm pecten + anal verge
5. Pectinate / dentate line
-line of the anal valves
-marks the junction between the pectin & large bowel mucosa (rectum)
-corresponds to the line of fusion between endoderm of the embryonic hindgut & ectoderm of anal pit
6. Anal valves
-Crescentic mucosal folds
-forms pectinate line around the lumen some 2cm from the anal verge
7. Canal above pectinate line
-lined by mucosa columnar cell
-innervated by autonomic nervous system
8. Canal below pectinate line
-lined by modified skin squamous cell
-innnervated by peripheral nervous system sensitive to pain
9. Submucosa of the anal canal
-forms 3 pads of vascular connective tissue-anal cushions
-left lateral, right anterior & right posterior- Y shaped (3,7,11 clock)

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10. Blood supply of the rectum

Surgery Tactic

UNIMAS

Arterial supply
Superior rectal a. IMA
o forms 3 branches - 2 right, 1 left
o supplies proximal part of rectum
Middle rectal a. I. Vesical a.
o supply middle & inferior partsof the rectum
Inferior rectal a. Internal pudendal a.
o supply the anorectal junction & anal canal
Venous supply
Superior rectal vein inferior mesenteric vein (portal)
Middle and inferior rectal veins inferior vena cava (systemic)
*portal-systemic anastomoses
11. Lymphatic drainage
o Superior half of the rectum pararectal LN Inf. Mes. LN of sigmoid colon inf. Mes. LN and lumbar LN
o Inferior half of the rectum : internal iliac LN
12. Nerve supply
o Autonomic innervation
Sympathetic
1. lumbar part of the sympathetic trunk
2. superior hypogastric plexus
Parasympathetic
1. pelvic splanchnic nerves
o Somatic innervations
1. Pudendal nerves S2,3 & 4 nerves

20

Gen05

7. ANATOMY OF URINARY TRACT & PROSTATE

Surgery Tactic

UNIMAS

Anatomy of the kidneys


o Retroperitoneum
o T12- L3
o Right kidney - lower large size of the right lobe of liver
o Reddish brown bean shaped
o 10 x 5 x 2.5 cm
o Right kidney is separated from the liver by hepatorenal recess
o Receive 20-25% blood of cardiac output
o Upper end: suprarenal glands
o Lower end: 2.5cm above iliac crest
o Covering: kidney capsule perirenal fat renal fascia Gerotas fascia) pararenal fat
o Renal hilum (VAP)
Renal vein (anteriorly)
Renal artery (middle)
Renal pelvis (posterior) L1- leave the renal sinus
o Renal hilum- entrance to a space within the kidney the renal sinus
o Relationship of the kidney to surrounding structures

Rt. Kidney

Lt. Kidney

ANTERIOR
1. Rt. Suprarenal gland
2. Liver
3. Duodenum
4. Hepatic flexure
1. Lt. suprarenal gland
2. Spleen
3. Stomach
4. Pancreas
5. Splenic vessels
6. Splenic flexure
7. Jejunum

21

POSTERIOR
1. Diaphragm
2. Psoas major
3. Quadratus lumborum
4. Transverse
abdominalis
5. Subcostal vessels
6. Iliohypogastric nerves
7. Ilioinguinal nerves

Gen05

Surgery Tactic

Blood Supply
Arterial blood supply
Rena artery abd. Aorta --- lies posterior to renal vein at L1-2
Left renal artery --- shorter
Divided into 5 segmented artery enter hilum go to segment of kidney
A) 4 anterior segmented arteries
I. Apical segmental artery apical segment
II. Anterosuperior segmental artery anterosuperior segment
III. Anteroinferior segmental artery anteroinferior segment
IV. Inferior segmental artery inferior segment

UNIMAS

B) 1 posterior segmented artery


posterior segmental artery inferior segmental artery

Vein drainage
veins follow artery , emerged from hilum in front of the renal artery IVC

Lymphatic drainage
lymph follow renal vein lumbar ( aor c ) LN
Nerves supply
derived from celiac plexus
afferent fiber travel through renal plexus enters spinal cord at 10 th , 11th and 12th thoracic nerves

Anatomy of Ureter
fibromuscular tube
25-30 cm long
retroperitoneum
lumen ---- transitional epithelium
urine pass through the ureter to the bladder by 2 ways
I. peristaltic contraction
II. filtration pressure produce by glomeruli

Journey of the ureter to reach the bladder


Emerge from the hilum of the kidneys
Runs downwards , medially & infront of psoas muscle behind the parietal peritoneum
Enters the pelvic cavity by crossing the bifurcation of common iliac artery in front of the sacral iliac
joint
22

Gen05

Surgery Tactic

Runs down the lateral wall of pelvis to the region of ischial spine
Turns forward to enter lateral angle of the bladder ( in front of upper end of seminal vesicle )
Obliquely penetrate the bladder wall about 2cm at the lateral angles of the trigone ( acts as a valve
--- prevent regurgitation )
Ductus deferences crosses to its medial

Relation of right ureter


Anterior
- duodenum
- right colic &ileocolic vessels
- lower part of mesentery
- terminal part of ileum
- right testicular or ovarian vessels

- IVC

Posterior
- left psoas muscle
- bifurcation of the
left iliac artery

Posteromedial
- inferior
mesenteric vein

Blood supply
Arterial supply
- renal artery upper end
- testicular / ovarian artery
- superior vesicle artery
- hypogastric lower part

Medial

Relation of left ureter


Anterior
- left colic vessels
- sigmoid colon &its mesentery
- left testicular / ovarian vessels

UNIMAS

Venous drainage
- venous drain into IVC thru the vein
corresponds to the arteries

Nerves supply
Sympathetic
T 11 - L1

Parasympathetic
S2-4

23

Gen05

Constricting areas of the ureters

Surgery Tactic

UNIMAS

1. Junction of pelvic & abdominal parts.


2. Junction of abdominal & pelvic part at the brim of pelvis.
3. In the bladder wall.
These are the potential sites of obstruction by ureteric stone, which causes referred pain at
o Scrotum/ Labium majus/ Thigh
ANATOMY OF URINARY BLADDER
- Lies in the pelvic cavity.
- Size & position vary, depending on the amount of urine it contains.
- Structures associated with the bladder:
In female:

Anterior
Posterior
Superior
Inferior

: symphysis pubis
: uterus & upper part of vagina.
: small intestine
: urethra & the muscles forming the pelvic floor

In male:

Anterior
Posterior
Superior
Inferior

: symphysis pubis
: the rectum & seminal vesicles
: the small intestine
: the urethra & prostate gland

-Bladder wall is composed of 3 layers


o Outer layer
Loose connective tissue
Containing blood & lymphatic vessels and nerves
Covers on the upper surfaces by the peritoneum.
o Middle layer
Consists of mass of interlacing smooth muscle fibres & elastic tissue loosely arranged in 3 layers.
o Inner layer
Transitional epithelium.
-Blood supply
Sup & inferior vesical a. anterior trunk of internal iliac artery
Venous plexus internal iliac vein
-Lymphatic drainage
Mostly external iliac nodes.
Few internal iliac, lateral aortic nodes
24

Gen05

Surgery Tactic

- Nerves supply
Parasympathetic S2-4motor to detrusor muscle & inhibitory to sphincter vesicae.
Sympathetic- T11-12 inhibitory to detrusor & motor to sphincter
Both carry pain fibers.
Somatic pudendal nerve supplies sphincter urethra & is voluntary
Pain sensation is transmitted through lateral spinothalamic tract.
Distension sensation through posterior column.

UNIMAS

ANATOMY OF PROSTATE
-3 cam long/ 2cm thick/ 8g.
-Largest accessory gland of the male reproductive system.
-Walnut-sized
-Lobes of prostate
o Anterior lobe

lies anterior to the urethra.


fibromuscular

o Posterior lobe

posterior to the urethra.


inferior to the ejaculatory duct.
palpable by digital examination.

o Lateral lobe
(right & left)

on either side of the urethra


major part of prostate.

o Middle lobe

between the urethra & ejaculatory ducts


closely related to the neck of bladder.

-Blood supply
o Arteries : inferior vesical arteries, internal pudenda &middle rectal arteries internal iliac artery.
o Venous
: prostatic venous plexus internal iliac veins.
-Lymphatic drainage
o Internal iliac & sacral LN
-Nerves supply
o Parasympathetic : pelvis splanchnic nerves ---S2-4
o Sympathetic
: inferior hypogastric plexus.

25

Gen05

ANATOMY OF MALE URETHRA


o Muscular tube
o 18-20 cm long
o Divided into 4 parts
Pre-prostatic u
Prostatic u
Membranous u
Spongy u
o Blood supply
- Arteries
- Veins

Surgery Tactic

1-1.5cm Urethra in the bladder neck.


4 cm.
1-2 cm intermediate part of the urethra.
15-16 cm.

: prostatic branches of infra-vesical& middle rectal a.


: follow the arteries n have similar names.

o Lymphatic drainage
- Main internal iliac LN
- Few external iliac LN
o Nerves supply
- Pudendal nerves
- Prostatic plexus

26

UNIMAS

Gen05

8. ANATOMY OF BREAST
1.
2.
3.
4.
5.
6.

7.
8.
9.
10.

11.

12.

Surgery Tactic

UNIMAS

Mammary gland in the subcutaneous tissue overlying the pectoral muscles (pectoral major &
minor).
Breasts size determined by amount of fat surrounding glandular tissue.
Transversely: lateral border of the sternum mid-axillary line.
Vertically: 2nd 6th ribs.
The axillary tail (of Spence) runs upwards between the pectoral muscles and latissimus dorsi to
blend with the axillary fat.
Retromammary space (bursa)
Loose connective tissue / potential space
Between the breast & deep pectoral fascia.
Containing a small amount of fat allows the breasts some degree of movement of pectoral
fascia.
Mammary glands firmly attached to the dermis of the overlying skin by skin ligaments
(retinacula cutis) the suspensory ligaments (of Cooper) of the breast.
Saccular alveoli (lobules) lac ferous duct lac ferous sinus segmental ducts ductules.
Lactiferous duct 15-20 lobules of glandular tissue.
Blood supply
Arterial supply
- Internal thoracic artery subclavian artery
- Lateral thoracic & thoraco-acromial axillary artery
- Post. Intercostal a thoracic aorta (2nd -4thintercostals space)
Venous drainage
- Mainly to axillary vein
- Some to internal thoracic vein
Lymphatic drainage
- > 75 % axillary LN
- 20% internal mammary (thoracic) chain.
- Small amount of lymph intercostal vessels diaphragm liver
Axillary LN
- Apical LN
- Central LN
- Humeral (brachial/ lateral) LN
- Pectoral (anterior) LN
- Subscapular (posterior) LN

27

Gen05

13.
Affected LN
LN below the pectoralis minor
LN at the level of pectoralis minor
LN above the pectoralis minor

Surgery Tactic

Staging of breast ca
Stage 1
Stage 2
Stage 3

14.
Nerve supply
- Ant. & lateral cutaneous branches of the 4th thru 6th intercostal nerves.
15.

Breast layers (p. 74) Keith L. Moore


Nipple
Areola
Skin
Fat lobule
Mammary gland lobule
Suspensory ligaments
Subcutaneous ligaments
Retromammary space
Pectoral fascia
Pectoralis major
Pectoralis minor
Ribs (2nd6th )

28

UNIMAS

Gen05

Surgery Tactic

9. ANATOMY OF NECK
1.

Sternomastoid muscles divide neck into


a) Anterior triangle
b) Posterior triangle

a)

Anterior triangle

Borders:

4 small

Anterior
Posterior
Superior
Apex
Roof
Floor

: median line of neck


: anterior border of SCM
: inferior border of mandible
: jugular (suprasternal) notch in the manubrim.
: subcutaneous tissue containing in the platysma
: pharynx, larynx and thyroid gland

divided by ant. & post. belly of digastric & sup. belly of omohyoid m.

1. Submental triangle
contents :
submental LN
small veins (unite to form anterior jugular vein)
2. Submandibular (digastric) triangle
contents :
submandibular gland
submandibular LN
accessory nerve
3. Carotid triangle
contents :

carotid sheath (CCA, UV, Vagus nerve )


external carotid artery
accessory nerve
hypoglossal nerve
deep cervical LN

4. Muscular (omotracheal) triangle


contents :
sternothyroid muscles
sternohyoid muscle
thyroid& parathyroid glands

29

UNIMAS

Gen05

Surgery Tactic

b)

Posterior triangle

borders :

2 small triangles divide by inferior belly of omohyoid muscle :-

1. Occipital triangle
contents :

anterior
posterior
inferior
apex
roof
floor

: posterior border of SCM


: anterior border of trapezius
: middle third of clavicle
: superior nuchal line of occipital bone
: investing layer of deep cervical fascia
: prevertebral layer of deep cervical fascia

part of external jugular vein


accessory nerve
trunk of brachial plexus
cervical LN

2. Supraclavicular (omoclavicular/subclavian) triangle


contents :
subclavian artery (3rd part)
part of subclavian vein
supraclavicular artery
supraclavicular LN
Neck Layers
1. Skin
2. Superficial fascia
3. Platysma muscle
4. Cervical fascia
5. Strap muscle (sternohyoid, sternothyroid, omohyoid )
6. Pretracheal fascia
7. Carotid fascia (cca/ijv/cnx formed by condensation of pretracheal f
8. Thyroid gland
9. Trachea

30

UNIMAS

Gen05

10. ANATOMY OF THYROID GLAND

Surgery Tactic

UNIMAS

1. Adult thyroid gland 15-30g.


2. 2 lobes right larger & higher than left
3. Lie on the front (front of it have: sternohyoid + sternothyroid m)& side of trachea & larynx C5-7
4. 2 lobes connected by isthmus 2nd, 3rd, & 4th tracheal rings.
5. invested by the pretracheal fascia which binds it the larynx, cricoid cartilage & upper tracheal (ligament
of Berry because of this ligament the thyroid elevates with the larynx on swallowing.
6. Relations of the lobes :
Anterolaterally:
Sternothyroid
Superior belly of omohyoid
Sternohyoid
Anterior border of SCM
Posterolaterally:
Carotid sheath ( CCA, IJV, vagus nerve )
Medially:
Larynx
Trachea
Pharynx
Oesophagus
Cricothyroid muscle
External laryngeal nerve
Recurrent laryngeal nerve.
7. Relations of the isthmus
Anteriorly
:
Sternothyroid
Sternohyoid
Anterior jugular vein
Fascia
Skin
Posteriorly
:
2nd, 3rd& 4th tracheal rings.

31

Gen05

8. Blood Supply / lymphatics / nerve

Surgery Tactic

UNIMAS

Arterial supply
* Superior thyroid artery external carotid artery
related to external laryngeal nerve superior laryngeal branch of the vagus nerve
* Inferior thyroid artery thyrocervical trunk - 1st part of subclavian artery
inferior thyroid artery 70% blood supply
related to the recurrent laryngeal nerve
* Thyroidea ima artery aorta / brachiocephalic artery
runs into isthmus ( in ~10% people )

Venous drainage
* Superior thyroid vein internal jugular vein ( accompany by superior thyroid artery )
* Middle laryngeal vein internal jugular vein ( accompany by inferior thyroid artery )
* Inferior thyroid vein brachiocephalic vein ( independent )

Lymphatic drainage
* Drains mainly lateral into deep cervical lymph nodes
* Prelaryngeal, pre-isthmus & pretracheal LN are also present

Related anatomically
* Sympathetic ganglia (vasomotor )
* Parasympathetic nerve vagus nerve laryngeal nerve
left
right
recurrent
superior

internal
external

Injury:
* recurrent laryngeal nerve ( unilateral ) hoarseness of voice
if bilateral ? Vocal cord paralysed
* external superior laryngeal nerve weakness of voice ( decrease high pitch of voice /
monotonous voice )
Q : Why thyroglossal cyst moves up with protrusion of tongue ?
A : Thyroglossal cyst is remnants from thyroglossal duct from foramen caecum ( tongue )

32

Gen05

11. ANATOMY OF INGUINAL CANAL

Surgery Tactic

1. Inguinal canal
- an oblique intermuscular split
- about 4cm long
- lying above the medial half of the inguinal ligament
- starts at deep inguinal ring & ends at superficial inguinal ring
- transmit :* spermatic cord & inguinal nerve ( male )
* round ligament of uterus & ilioinguinal nerve ( female )
2. Deep / Internal inguinal ring
- lies about 1.5 cm above the midpoint of inguinal ligament
- an opening of fascia transversalis
- oval in shape
- its margin give attachment to the internal spermatic fascia
3. Superficial / external inguinal ring
- lies 1 cm above & medial to the pubic tubercle
- V split in external oblique aponeurosis
- Triangular in shape
- Its margin give attachment to the external spermatic fascia
Related to the surrounding structures
Low :Anterior wall
Posterior wall
Floor
Roof

Medial
Lateral
External oblique aponeurosis
Internal oblique muscles
Strong conjoint tendon
Fascia transversalis
Lacunar ligament ( Gimbernat's
Inguinal ligament
ligament )
Arching fibres of internal oblique &transverse muscles

33

UNIMAS

Gen05

Hesselbach's Triangle

Surgery Tactic

A weak spot on anterior abdominal wall


through which DIRECT inguinal hernia comes out
Bounded :* Medially
: lateral border of rectus abdominis muscles
* Laterally
: inferior epigastric artery
* Below
: Inguinal ligament

What is mid-inguinal point ?


* midpoint between the ASIS & symphysis pubis
* femoral artery pulse found here

What is midpoint of inguinal ligament ?


midpoint between ASIS & pubic tubercle
= 1.5 cm ABOVE mid-inguinal point ??
Deep ring found here

Femoral Canal

Supero-anteriorly inguinal ligament


Infero-anteriorly pubic ramus + pectineus muscle
Medially Gimbernat's ligament + pubic bone
Laterally femoral vein anatomy of lower limbs

34

UNIMAS

Gen05

13. ANATOMY OF LOWER LIMBS

Surgery Tactic

UNIMAS

Venous drainage of lower limb


Superficial venous system
Deep venous system
Perforator system
A) Superficial venous system
System of veins in subcutaneous tissue superficial to deep fascia
Includes long & short saphenous veins
Long saphenous vein

Short saphenous vein

Longest vein
from dorsal venous arch of the medial aspect
of foot
passes 1 cm in front of the medial malleolus
runs up to medial aspect of leg &thigh
passes thru cribriform fascia covering the
saphenous opening lies 3 cm below
&lateral to pubic tubercle
joins femoral vein
contains >12 valves ( up to 20 ),
most which are BELOW the knee
just before joining , it usually receives
4 tributaries :1. Superficial circumflex iliac
2. Superficial epigastric
3. Superficial external pudendal
4. Deep external pudendal veins

B) Deep venous system


includes : femoral vein
popliteal vein
venae comitantes
valveless venous lakes in the calf muscles

BENEATH the deep fascia


35

From dorsal arch on the lateral aspect of


foot
passes BEHIND the lateral malleolus
runs up in the midline of calf
pierces the deep fascia before entering
popliteal vein

Gen05

Surgery Tactic

UNIMAS

C) Perforator system
connect superficial & deep venous system
usually have valves to allow blood flow from superficial to deep veins

** the main sites of deep-superficial venous communication : sapheno-femoral junction


sapheno-popliteal junction
mid-thigh perforations in Hunter's canal
medial calf perforators- just below , 5cm, 10cm, 15cm above medila malleolus & just
below the knee
Adductor's canal / Hunter's / Subsartorial Canal
a gutter-shape groove between the vastus medialis & the front of adductor muscles, below the apex of
femoral triangle
contains :- femoral artery & vein
- saphenous nerve
- nerve to vastus medialis ( in upper part )
Roof : sartorius lying on fascial roof
Floor : adductor longus ( above ) & adductor magnus ( below )
Muscles of the lower limbs :-

Anterior thigh
Sartorius
Rectus femoris
Vastus lateralis
Adductor (pectineus,
adductor longus,
gracilis)
Vastus medialis

Posterior thigh
Semitendinosus
Semimembranosus
Biceps femoris

Anterior &Lateral leg


Tibialis anterior
Ext. digitorum longus
Ext. hallucis longus
Fibularis tertius
Fibularis longus
Fibularis brovis

36

Posterior leg
Gastronemius
Soleus
Tibialis posterior

Gen05

Surgery Tactic

SURGICAL PROBLEM

Upper GI Bleeding
Lower GI Bleeding
Mass in Abdomen
Obstructive Jaundice
Dysphagia
Intestinal Obstruction
Hematuria
Bladder Outflow Obstruction
Breast Lump
Neck Swelling
Inguinal Scrotal Swelling
Leg Ulcer
Skin

1. Upper GI Bleeding ( Hematemesis + Melena )


DD :1. Peptic Ulcer
2. Oesophageal Varices
3. Acute erosive gastritis
4. Ca stomach
5. Mallory-Weiss Syndrome
6. Bleeding Disorder
7. Oesophagitis
UGIB : Peptic Ulcer
Symptoms and History
Hematemesis & melena
Duodenal ulcer more in MAN & < 40
Epigastric pain / discomfort
Gastric : increase by food , relieved by alkali/ vomiting
Duodenal : increase by fasting , relieved by food
Acid / water brash and heartburn
Pain radiate to the back indicate posterior penetration

37

UNIMAS

Gen05

Signs

Surgery Tactic

UNIMAS

Few signs, may have tenderness in the epigastrium


Peritonitis signs : Board-like rigidity, rebound tenderness, tacycardia, absent bowel sound
Succussion splash in pyloric stenosis
Anemia signs

Causes
H. pylori
Occupation with greater stress
Zollinger-Ellison syndrome
Smoking & alcohol
Familial
NSAIDs
Complications
Haemorrhage
- duodenal ulcer ( posterior wall ) may erode gastroduodenal artery
Penetration
- pain radiate to the back ( pancreas, liver, post abd wall )
Perforations
- abscess in lesser sac; peritonitis; pain starts fr epigastric then to RIF ( paracolic gutter ) then genralize
diffuse pain
Obstruction
- Pyloric stenosis; Hour-glass 's stomach ( AXR )
Investigations
Endoscopy shows ulcer
- Biopsy, inject sclerosing agent, laser / thermo-coagulation, H. pylori screening
H. pylori
- C13/14 breath test / CLO test ( fr biopsy sample )
Radiology ( AXR / Ba meal )
Principle of Management
H. pylori eradication
- triple therapy
Omeprazole ( Proton pump inhibitor )
Antibiotics ( Metronidazole, Amoxicillin )
Bismuth
38

Gen05

Surgery Tactic

UNIMAS

Decrease acid secretion


- H2 antagonist ( Cimetidine )
- Proton pump inhibitor
Surgical
- partial gastrectomy
- vagotomy ( high selective / truncal )
Others
- neutralize acid ( NaHCO3 / CaCCO3 )
- mucosa protective agent ( sucralfate )
- control agravating causes ( alcohol / NSAIDs )

Treatment of Shock
Strict bad rest
IV line for volume replacement, Open central venous line to measure CVP
Blood for GXM, FBC, BUSE
IV opiate ( morphine and pethidine )
NG tube to empty stomach and provide early warning if any further bleeding
Repeated monitoring PR, BP, RR. Record any blood loss
NPO
If ulcer bleeding is suspected, give IV histamine H2 Blockade with Cimetidine / Ranitidine
Discussion

Tables :-

Peptic Ulcer
Pathogenesis
Site
Pain
Periodicity
Body weight

Gastric
Decrease mucosa resistant
Antrum along lesser sac
Aggravated by food soon after eating
2-3 months cycle/ few weeks duration
Decrease

Duodenal
Increase acid secretion
1stpart mostly anterior wall
Releived by food ...few hurs after eating
4-6 months cycle/ 1-2 months duration
Increase

Transpyloric plane, transtubercular plane


- Refer surgical anatomy

3 types of gastric ulcer


a) at lesser curvature, assoc with gastritis, junction btw acid and non-acid mucosa
b) gastric ulcer secondary to duodenal ulcer
c) pyoric channel / prepyloric area, assoc with N or Increased gastric secretion
39

Gen05

Surgery Tactic

Vomited blood appeared bcoz of hematin ( Hcl act on haemaglobin )

Stomach fluid
- Colorless, 1.5-2L, pH 1-3

Peritonitis
- 1st 6hours is due to ACID IRRITATION :- clinical peritonitis
- Later is due to BACTERIA :- bacteria peritonitis

20% blood loss starts to cause orthostatic hypotension

What kind of patient prone to re-bleed after treatment?


- old age, ulcer on top of a vessel

What r the signs of continued / re- bleed ?


- Falling CVP
- Rising PR & RR, Falling BP
- Restless, sweating, pallor
- Failure of BP during transfusion
- Repeated / persist aspiration of blood from NG tube
- Hematochesia ( defecate bloody feces ) indicating fast continued bleeding

40

UNIMAS

Gen05

Surgery Tactic

UNIMAS

Pyloric stenosis
- vomiting lost Hcl ( Hypochloremic alkalosis ) compensation (kidney take up H+, K+ and loss Na+)
hyponatremia
- Can't vomiting dehydration compensation ( kidney retain H20, Na+, K+, H+ ) hypokalemia +
paradoxical acidic urine

Clinical significance of venous drainage of stomach


- Portal hypertension

UGIB may present with hematochesia if profuse

IV omeprazole proved to reduce rebleed, surgery and mortality

UGIB : Oesophageal Varices


Symptoms and History
Hematemesis & melena
Alcoholic
Liver disease (hepatitis, cirrhosis)
Signs
Liver sign : Ascites, Spider naevi, flapping tremor, splenomegaly, palmar erythema, jaundice
Anemia's sign : Dizziness, fatigue, pallor
Causes
Portal hypertension
Schistosomiasis portal HPT
Portal Vein Thrombosis
Complications
Bronchial aspiration
Hepatic encephalopathy
Investigations
Endoscopy can see varices
LFT reveal underlying liver disease
Coagulation profile shows if there is defect

41

Gen05

Surgery Tactic

Principle of Management
Resus as mentioned in treatment of shock
Prevention of protein breakdown ( prevent encephalopathy )
bowel washout from below
give cathartic agent like MgSO4
give neomycin to reduce bowel bacteria number
give lactulose to change the faecal flora
Securing Haemostatis ( to stop bleeding )
Vit K admin
Sengstaken-Blakemore tube ( 4 opening )
Gastric balloon inflation orifice
Gastric aspiration orifice
Oesophageal balloon inflation orifice
Oesophageal aspiration orifice
Direct attack on bleeding source ( sclerosant injection, stapler )

UNIMAS

Discussion
What other varices assoc with portal HPT ?
Oesopahageal varices
- left gastric vein anastomoses with azygous vein
Retroperitoneal varices
- branches of colic vein ( portal ) anastomoses with retroperitoneal vein ( systemic )
Periumbilical ( caput medusae )
- paraumbilical veins ( portal ) anastomoses with samll gastric vein of anterior abdominal wall (
systemic )
Anorectal
- superior recta vein ( systemic ) anastomoses with middle & inferior rectal vein ( portal )

Child's grading
to assess severity of liver disease & operative risk for portal HPT
5 factors to be considered :1. Ascites
2. Serum albumin
3. Serum bilirubin
4. Prothrombin
5. Encephalopathy

42

Gen05

SCORE
Encephalopathy
Bilirubin
Albumin
Ascites
Operative mortality risk

A
X
<2
>3.5
x
2%

Surgery Tactic

B
Minimal
23
3 3.5
Decrease control
10 %

UGIB : Acute Erosive Gastritis


( Also called as acute peptic ulcer / acute gastritis etc. )
Symptoms and History
Haematemesis & melena
Arthritis with ingestion of NSAIDs
Symptoms like chronic peptic ulcer
Causes
NSAIDs ( more to exacerbate )
Stress ( trauma, shock, burn, sepsis, CNS injury, multisystem failure )
Complications, Signs, Investigations, Principle of Management
Basically same as Peptic Ulcer
UGIB : Ca Stomach
Symptoms and History
Asymptomatic till last stage
Epigastric pain
Epigastric mass
Dyspepsia indigestion
LOA + LOW
Anemia, Anorexia, Asthenia insidious onset
Dysphagia , vomiting, early satiety due to obstruction
Hematemesis & melaena bleeding & ulceration

43

C
Severe
>3
<3
Refractory
30 %

UNIMAS

Gen05

Signs

Surgery Tactic

Succussion splash in pyloric stenosis


Virchow's node
Migratory thrombophlebitis ( Trousseau sign )
Sister- Joseph's Nodule ( Periumbilical nodule )

Risk factors
Smoking
Old age
Smoke fish
Food containing nitrosamine
H. Pylori
Complications

Obstruction
Haemorrhage
Perforations acute abdomen
Fistula formation
Varicose vein due to stomach cancer mass compressing IVC

Investigations
Diagnostic
Endoscopy ( OGDS ) with biopsy ( multiple deep punch )
Ba meal ( if no other device )
Staging
U/S abdomen ( liver, peritoneal seedling, Krukenberg tumor, etc )
Endoscopic U/S
CT
CXR
Bone sean skeletal survey ( if bone pain )
For operation ( baseline treatment applied for all surgery )
Blood ( FBC / BUSE / Coagulation profile PT, PTT / GXM )
Urine ( analysis / FEME )
CXR
ECG if old age

44

UNIMAS

Gen05

Surgery Tactic

Principle of Management
Curative surgery ( remove cancer ) : total - proximal lesion / subtotal distal lesion
Palliative surgery
Pass thru cardial obstruction with endoscopy intubation
Bypass GOC ( Gastric outlet obstruction ) with gastro-jejunostomy
Supportive therapy ( relieve pain )

UNIMAS

Discussion
Macro feature / types of gastric Ca
Ulcerative
Proliferative fungating
Infiltrative diffuse ( total infiltration of stomach, linitis plastic - fibrous reaction produced
leather bottle stomach )
( superficial spreading )
Spreading
Direct / Local
- stomach bed adjacent structures ( liver, pancreas, transverse colon, diaphragm, CBD, greater
& lesser omentum )
Lymphatics
- Coeliac node, portal hepatic node, virchow's node
Hematogenous
- BBLL ( Bone Brain Lung Liver )
Peritoneal / transcoelomic
- Ovary Krukenberg tumor
- Pouch of Douglas Blumer's shelf
- Umbilicus Sister joseph's nodule
Characteristics of biopsy taken ( from endoscope )
Multiple ( up to 6 or more )
Deep
Punch
Micro features
Adenocarcinoma thus very resistance to radio & chemotherapy
If associated with jaundice , what to expect ?
Severe liver involvement
Portal hepatic node enlarge blocking CBD

45

Gen05

Surgery Tactic

2. Lower GI Bleeding
DD : SI
Meckel's diverticulum ( children )
Intussucception ( esp. ileo-caecal )
Tumor
Colon
Diverticular disease ( esp sigmoid )
Angiodysplasia
Polyps
Tumor ( colon ca )
IBD ( ulcerative colitis / Chron's ds )
Rectum
Polyps
Tumor ( rectal ca )
Anal perianal
Hemorrhoid
Perianal hematoma
Anal fissure ( fissure-in-ano )

Ix ( investigations ): FBC + GXM ( Group cross match )


BUSE
PT, PTT
Proctoscope / sigmoidoscope / colonoscope
Scintilation scan ( T-99 or 99m-Technetium-sulphur colloid )
Ba enema
LGIB : Diverticulitis
Other symptoms and History

Diverticulosis
Asymptomatic
Symptoms of distension, flatulence, sense of heaviness in lower abdomen

Diverticulitis
Persistent lower abdominal pain, usually LIF
Loose stool or constipated
Pneumaturia, faeces in urine ( vericocolic fistula )
46

UNIMAS

Gen05

Signs

Surgery Tactic

UNIMAS
Risk factors
- low fiber diet
- age>70

Peritonitis
Fever, malaise
Tenderness ( Esp LIF )
Sigmoid colon palpable, tender, thickened

Causes
Recurrent intraluminal pressure as in straining of constipation
Segmental contraction
Complications
Recurrent periodic inflammation & pain
Intestinal obstruction
sigmoid : due to progressive fibrosis and stenosis
SI
: adherent loops of SI to pericolic abscess
Haemorrhage
Massive bleeding which often requiring transfusion
Perforation
general peritonitis or pericolic abscess formation
Fistula formation
vesicocolic ( most common )
Investigation
Leucocytosis
Ba enema
- saw-tooth appearance
- to differetiate diverticula from Ca colon and also assess the extent of the disease
Colonoscopy exclude Ca
Principle of Management
Diverticulosis : high-fibres diet, bowel rest, anti-spasmodic
Diverticulitis : bowel rest (NBM), IV antibiotic
Operation
- Hartmann's procedure is the safest option
- for those recurrent / complicated case
- removal of the affected segment, end-to-end anastomosis

47

Gen05

Surgery Tactic

Discussions
MASSIVE bleeding in lower GI
- Diverticular disease
- Angiodysplasia
- Meckel's diverticular

UNIMAS

LGIB : Angiodysplasia
Vascular malformation associate with aging
In ascending colon and caecum, NOT associated with cutaneous lesion
Malformation consists of dilated tortious submucosal veins
Reddish raised area at endoscopy
Associated with aortic stenosis
Ba enema NOT helpful
Investigations
Colonoscopy, Selective superior and inferior mesenteric angiography, radioactive test (technetium99m-labelled red cells)
can be demo by translumination thru caecum ( colonoscopy )
Some can treat by colonoscopic diathemy or open surgery
LGIB : Colorectal polyps
Adenomatous polyps

Symptomless / prolapse thru


anus / intussusception
intes nal obstruction
Ix :- colonoscopy, ba enema
Can be removed by
colonoscopically by using
diathermy snare
Premalignant condition, pt
follow-up with regular
colonoscopy
90% of polyps is this type

Villous polyps

Most often rectum and


sigmoid
Excessive mucus discharge
thru anus, may lead to
HYPOKALEMIA, weakness,
oliguria, alkalosis
Pre-malignant, invasive ca
found in 1/3 of cases
PR palpable, seen in
sigmoidoscopy
Excision in all cases

Familial Adenomatous polyposis

Autosomal dominant, Ch5


Onset 10-15 yo
Diarrhea + mucous discharge
Malignnacy inevitable
risk of adenomatous polyps
in duodenum & periampullary
cancer
Resect all affected part and
screen for all family members

Gardner's syndrome = Multiple adenoma + sebaceous cyst + dermoid cyst + bony exostoses + connective
tissue tumors

48

Gen05

LGIB : Colon Cancer

Surgery Tactic

UNIMAS

Clinical features

Right colon
Anemia symptoms ( due to chronic
occult blood loss )
RIF pain
Altered bowel habit / obstruction is
LATE symptom
LGIB
Palpable mass

Left colon
Obstruction and altered bowel habit
Abdominal distension
( relieved by pass n flatus )
Pain ( refer to suprapubic )
LGIB
Palpable lump
Sigmoid ca has extra :- Tenesmus + bladder
symptoms (d/t vesicocolic fistula formation )
Colicky pain

Hepatomegaly & ascites in advance case

Risk factor
Dietary ( high-fat, low-fruit, low vege fibre ) slow transit prolonged exposure to carcinogen in
faeces ( such as bile salt )
Family history
Polyps and FAP
UC, Chron's
Complication
Bleeding
Obstruction
Perforation
Fistula
Investigation
AXR
Endoscope ( Sigmoidoscope / colonoscope )
Ba enema ( apple core appearance short stenosis with sharp shoulder at each end )
LFT / CXR / Liver scan ( USG / CT ) exclude metastases
Principle of Management
Laparotomy ( assess resectability, see Liver, Peritoneum, LN, Tumor )
Hemicolectomy
49

Gen05

Discussions:

Surgery Tactic

UNIMAS

1. 4 types:
Annular (obstruction)
Tubular
Ulcer
Cauliflower/ polypoidal (most malignant)
2. Dukes classification (colorectal CA)5 years survival
A. Confined to bowel wall 90-95%
B. Spread through bowel wall (to serosa)65-75%
C. LN40-50%
D. Distant metastases (particularly liver)
Original Dukes doesnt have D
3. More common in left colon and rectum
4. Spreading is by local, lymphatic, haematology
5. Overall 5 years survival rate= 40%
6. Synchronise lesions= both Lt & Rt side affected (10%)
LGIB: Ulcerative Colitis
Other symptoms and history
1.
2.
3.
4.
5.

Watery/bloody diarrhoea
Mucus discharge
Pain (rare)
Chronic, remission
If in rectum (25%)- tenesmus and urgency
95% starts in the rectum, spread proximally when ileocecal valve is incompetent, ileitis is
likely to occur

Signs
1.
2.
3.
4.
5.
6.

Anaemia
Hypoproteinemia
Dehydration
Fever
Tachycardia
Weight loss

50

Gen05

Surgery Tactic

Causes
1.
2.
3.
4.
5.

Unknown
1st degree relative ha 15x risk
Some allergic to milk protein
Smoking seems to have protective effect
3 hypothesis, none proven:
a. Mucosal immunological reaction
b. Weakened mucosal barrier
c. Defective mucosal metabolism of butyrates

Complications
1.
2.
3.
4.

Fulminating colitis and toxic dilatation (megacolon) AXR shows colon diameter > 6cm
Perforation
Severe haemorrhage (uncommon)
Carcinomatous changes

Investigation
1. Ba enema
Loss of haustration (tubular) esp in distal colon (no loss of haustration in ileus of
obstruction)
Mucosal changes caused by granularity
Pseudopolyps
Narrow contracted colon in chronic case
2. Sigmoidoscopy (better in early case which will not show up in Ba enema)
3. Colonoscopy and biopsy
See extent of inflammation
Distinguish UC and Crohns
Monitor response to Rx
Assess malignant changes
NOT used in acute case prevent aggravating and perforation
Principle of management
1. Medical treatment
Corticosteroids (Sulphasalazine, other %-ASA derivative)
2. Operation
Severe/fulminating
Chronic w anemia, frequent stool, tenesmus, urgency
Steroid dependent, remission cant be maintained w/o substantial dose
Risk of neoplastic
Extraintestinal manifestation
Severe haemorrhage/stenosis causing obstruction
51

UNIMAS

Gen05

Discussions

Surgery Tactic

UNIMAS

1. Bad prognosis
Severe initial attack
Involving whole colon
Old age>60
2. Grading
Mild- rectal bleeding or diarrhea in <4 times motions a day, absence of systemic signs
Moderate- >4 times a day, but no systemic sign (fever, tachy, hypoalbuminemia, LOW)
3. 95% starts in rectum spread proximally
4. Extra-intestinal manifestations
Skin lesions
Iritis
Liver ds
Bile duct CA
LGIH: CA rectum
Other symptoms and history
1.
2.
3.
4.

Mucus per rectum


Low rectal ca- little constipation + early morning diarrhoea
High rectal ca-alternating constipation & diarrhoea
Tenesmus
Definition: persistent, ineffectual spasm of the rectum, accompanied by strong desire to
defecate
If lower rectal ca large enough to irritate the rectal mucosa

5. General debility and malaise


6. Pain (late symptoms)
Colicky- intestinal obstruction d/t advanced growth in retro-sigmoid
Severe- deep ulcer erodes prostate or bladder
Back/sciatica- invasion of sacral plexus
7. LOA + LOW
Causes and risk factor
1. UC
2. Adenoma
3. Polyposis coli

52

Gen05

Surgery Tactic

Signs

1.
2.
3.
4.
5.
6.

UNIMAS

90% can be felt in PR


Pappilliferous tumor fell soft and frond-like
Ca ulcer- hard, buldges into lumen, everted edge, base irregular
Palpable liver in advanced case
Ascites in peritoneal involvement
Sign of intestinal obstruction if advanced annular growth

Investigations
1. Proctosigmoidoscopy + biopsy
2. Colonoscopy or Ba enema if former is not available
Principle of management
1. Radical excision
Of rectum, mesorectum and assoc LN. even in widespread case, this is the best palliative
treatment
2. Pre-op radiotheraphy
Reduce tumour size and make it more amenable to radical to radical excision
3. Transanal excision/laser destruction/ interstitial radiation
Unfit pt
Sphincter-saving op (anterior resection) is usually possible for upper 2/3 rectal ca
For lower 1/3 ca, remove rectum w permanent colostomy (abdominoperineal excision)
At least 2cm margin of normal bowel from edge of tumour
Discussions
1. 75% in lower part of rectal ampulla tend to papillarous OR a simple ulcer with everted edge
2. 25% in upper part often annular shape (cotton-reel)
3. Liver usually the 1st organ for distant metastases
LGIH: haemorrhoids
Other symptoms and history
1.
2.
3.
4.
5.
6.

Bright red painless bleeding


Mucus discharge
Pruritus ani (d/t mucus)
Prolapse
Painless (unless complicated)
Anemia (rare)

53

Gen05

Surgery Tactic

Causes
1.
2.
3.
4.

UNIMAS

Hereditary
Chronic constipation
Rectal ca
Pregnancy

Complications
1.
2.
3.
4.
5.
6.
7.
8.

Profuse haemorrhage
Strangulation
Thrombosed
Ulceration
Gangrene
Fibrosis (white colour)
Suppuration/infection
Pylephlebitis/portal pyemia (rare)

Signs
1. Haemorrhoids classically sited at 3, 7, 11 oclock in anus (in lithotomy position)
2. Internal haemorrhoiscant be felt by PR unless thrombosed
Investigation
1. Protoscope- just below the anorectal ring, internal haemorrhoids will budge into lumen of
protoscope when insert & withdraw it slowly.
Principle of management
1. Symptomatic
When haemorrhoids are symptoms of other conditions i.e. pregnancy. Regulate bowel w
hydrophilic colloids, or apply cream at night or b4 defecation
2. Injection of sclerosant (phenol in oil)
1st degree
3. Banding (banrons tech)
2nd degree
4. Haemorrhoidectomy
3rd and 4th degree or
Failure of non-op Tx for 2nd degree
Fibrosed piles
Intero-external piles when the external is well-defined

54

Gen05

Discussions

Surgery Tactic

1. Classifications of haemorrhoids
1st degree: bleed but not prolapse
2nd degree: prolapse and reduced spontaneously
3rd degree: prolapse and reduced digitally
4th degree: permanent prolapsed
2. Bleeding w/o pain
If blood mixed w stool = ca colon
If blood streaked on stool = ca rectum
If blood after defecation = haemorrhoids
If blood and mucus = colitis
If blood alone = diverticular ds
3. How to differentiate prolapse piles from perianal hematoma
Prolapse pile cover by mucosa but perianal hematoma by skin
Perianal hematoma irreducible
4. Internal haemorrhoid above pectinate line
External haemorrhoid below pectinate line

55

UNIMAS

Gen05

3. MASS IN ABDOMEN

Surgery Tactic

UNIMAS

Overall:
Parietal swelling Sebaceous cyst, lipoma, fibroma, neurofibroma, angioma, rhabdomyoma, cold abscess
(fr ribs) etc.
RHC
Epigastrium
LHC
1. Liver (hepatomegaly)
1. Liver (L lobe megaly)
1. Splenomegaly
2. GB (mucocele/abscess)
2. Gastric (Ca/ p. stenosis)
2. Gastric (Ca/ p.stenosis)
3. Gastric (Ca/ p.stenosis)
3. Pancreas (Ca/ pseudocyst)
3. Pancreas (Ca/ pseudocyst)
4. Colon: hepatic flexure
4. Aorta (AAA)
4. Colon: spleenic flexure
(Intussuception/
5. Transverse colon
(Intussuception/ diverticulitis/
diverticulitis/ Ca)
(Intussuception/ Ca)
Ca)
5. Kidney (hydronephrosis/
6. Retroperitoneal (sarcoma/
5. Kidney (hydronephrosis/
polycystic/RCC)
teratoma)
polycystic/RCC)
6. Subphrenic abscess
7. Subphrenic abscess
6. Subphrenic abscess
RL
1. Liver/GB/Kidney/ Ascending
colon
RIF
1. Liver/GB
2. Appendicular (mass/
abscess)
3. Ileocaecal (TB/Crohns/ Ca
caecum)
4. Ascending colon
5. Iliac artery (aneurysm)
6. Iliac LN
7. Kidney (unascended k/
dropped k)
8. Bladder (full)
9. Psoas abscess
10. Pelvic abscess
11. Testis (un descended)
12. Uterine fibroid & ovarian
cyst

PU
1. Gastric/Pancreas/Aorta/
Colon/Retroperitoneal
2. SI (tumor)
SP
1. Bladder (full)
2. Pelvic abscess
3. Uterine fibroid & ovarian cyst

56

LL
1. Spleen/Kidney/ Descending
colon
LIF
1. Descending colon
2. Sigmoid colon (diverticulitis/
Ca)
3. Iliac artery (aneurysm)
4. Iliac LN
5. Kidney (unascended k/
dropped k)
6. Bladder (full)
7. Psoas abscess
8. Pelvic abscess
9. Testis (un descended)
10. Uterine fibroid & ovarian cyst

Gen05

Surgery Tactic

Disscussion
1.
Liver mass
Cant get above
Below R coastal margin& angle
Move with respiration
Sharp or rounded edge
Ca be smooth or irregular

Gallbladder mass
Cant get above
Below tip of 9th rib
Doesnt move much with respiration
Hemiovoid shape
Smooth

Spleen mass
Extend inferomedially
Move > freely with respiration
Medial notch
Palpated > easily from anterior
Not ballotable
Hand not able to get btw swelling &
coastal margin
Dull

Kidney mass
Extended inferiorly
< freely
No
Can be felt bimanually
Ballotable
Hand easily get btw swelling & coastal
margin
Resonant (d/t bowel)

2.

3. Hepatomegaly
Congestion (d/t heart failure)
Biliary tract obstruction (gallstone/ pancreas ca)
Carcinoma (1o/2o)
Cirrhosis
Liver abscess
Polycystic
Infective hepatitis
Infection (amoebic/TB/syphilis)
Riedals lobe
Hydatid cyst

57

UNIMAS

Gen05

Surgery Tactic

4. ACUTE ABDOMEN
Pathological Process

Inflammation

Obstruction

Organ
Appendix
Gallbladder
Colon
Fallopian tube
Pancreas
Intestine
Gallbladder
Ureter
Urethra
Intestine

Ischaemia

Perforation

Rupture

1. Gallbladder
2. Colon
1.
2.
3.
1.
2.
3.
4.
5.

Kidney
Ureter
Colon
Appendix
Caecum
Colon
Ovary
Fallopian tube

Ovary
Duodenum
Stomach
Colon
Gallbladder
Fallopian tube
Abdominal aorta
1.
2.
3.
1.
2.

Gastric
Duodenum
colon
SI
Aorta

UNIMAS

Disease
Acute appendicitis
Acute cholecystitis
Diverticulitis
Salpingitis
Acute pancreatitis
Intestinal obstruction
Biliary colic
Ureteric colic
Acute urine retention
Strangulation hernia
Volvulus (sigmoid)
Mesenteric ischaemia
Torsion ovarian cyst
Perforated peptic ulcer
Perforated ulcer/cancer
Perforated diverticulitis
Perforated cancer
Biliary peritonitis
Ruptured ectopic pregnancy
Ruptured aneurysm
1. Pancreas
2. Colon
1.
2.
3.
1.
2.
3.
4.

1. Bladder
2. Uterus

58

Kidney
Ureter
Colon
Colon
sigmoid
Ovary
Fallopian tube

Gen05

ACUTE APPENDICITIS

Surgery Tactic

History
1.
2.
3.
4.

Pain (periumbilical shifted to right iliac fossa)


Anorexia
Nausea and vomiting
Constipation or diarrhea (i.e case of pelvic appendix, irritating the rectum

Signs
1. Fever + tachy (not early sign)
2. Foetor (not specific)
3. Tenderness and guarding over Mc Burneys point
4. PR may elicit tenderness and detect abscess
5. Mass in RIF
6. Specific test & sign
Rovsings sign
- pressure in LIF, pain in RIF
Blumberg sign
- crossed rebound tenderness: press & release in LIF, pain in RIF
Psoas sign
- hyperextend of right hip causing pain
Obturator/ cope sign
- flexion w internal rotation of rt hip cz pain
Straight leg raising sign
- raising of rt leg cz pain while finger press on abdo. render spot
Causes
1. Lymphoid hyperplasia
2. Faecolith
3. Fibrosis
4. Adhesion
5. Neoplasm
6. Worm
7. Seeds
Complication
1. Appendix abscess and appendix mass
2. Perforation (>12hrs after onset)
3. Peritonitis
4. Pylethrombophlebitis / Portal pyremia (extremely rare)
Shaking chills, fever, jaundice
AXR: air in portal system
59

UNIMAS

Gen05

Investigation

Surgery Tactic

UNIMAS

1. Polymorphonuclear leucocytosis
2. Urinalysis (rule out uro problem and DM)
3. AXR (late)
Faecolith/ fluid level in RIF (inflamed appendix cz ileus to nearby bowel)/ altered Rt psoas shadow
Principle of Management
1. Appendicectomy
2. If abscess diagnosed pre-op, drainage then elective appendicectomy
3. Antibiotics: metronidazole OR clindamycin + aminoglycoside
Disscussions
1. Periumbilical pain is visceral pain due to appendiceal obstruction, transmitted by sympathetic nerve.
RIF pain is parietal pain due to local inflamm of peritoneum, by somatic nerve T5-L2.
2. Diabetic ketoacidosis and basal pneumonia can produce abdominal pain and laparotomy is positively
contraindicated, so they must be excluded.
3. Fever usually low grade (38-38oC), if 40 oC complicated (peritonitis, abscess)
4. Before appendicular abscess is formed, appendicular mass have to be formed. So if appendicitis
perforated too early (24-36hrs), generalize peritonitis developed.
5. Vomiting is caused by visceral inflamm/ distension and impulse send to vomiting centre. So it can
happen in any visceral inflammation.
6. Appendicular mass/ abscess is formed by 3 components:
Perforated appendix
Omentum
Surrounding (Caecum + Small bowel)
7. Common site for appendix:
Retrocaecal (63%)/ Pelvic (33%)/ Subcaecal/ Pre-ileal/ Post-ileal

60

Gen05

ACUTE CHOLECYSTITIS

Surgery Tactic

UNIMAS

History
1.
2.
3.
4.

Biliary colic (continuous, wax & wane in intensity over several hrs)
Severe RHC pain radiating to subscapular, rt shoulder.
Fever
Nausea, vomiting

Signs
1. Tachycardia
2. Murphys sign
catching of breath during inspiration while the GB area (tip of 9 th rib) is pressed by examiners finger
3. Abdo. tenderness & rigidity
may be generalized but more mark over GB
4. RHC mass
due to omentum wrapped around inflamm GB
5. Jaundice
Stones in CBD, or compression of CBD by enlarged GB
6. Boas sign
Pain radiates through tip of scapula, there may be an area of skin below the scapula which is
hyperaesthetic.
Risk factors (cholelithiasis & cholecystitis)
1. Fat
2. Fair
3. Fertile
4. Forty
5. Female
Causes
1. Calculous cholecystitis (commonest; d/t obstruction of GB outflow)
2. Acalculous cholecystitis
a. Anatomical obstruction of cystic duct
b. Ischaemia of GB
c. Spasm of sphincter of Oddi
d. Systemic ds or infection
Complications
1. Empyema (dev of tender mass assoc w rigors and marked pyrexia)
2. Gangrene perforation
3. Perforation biliary peritonitis
Investigation Leucocytosis
61

Gen05
Surgery Tactic
Principle of management
1. Conservative mx (90% settle)
NPO, IV fluid, antibiotics, NG suction if appropriate
2. Cholecystectomy if
GB is permanently diseased
Cx may supervene

UNIMAS

Discussions
1. Chronic cholecystitis
Recurrent flatulence, fatty food intolerance, RUQ pain
Pain worsen by meal, associated w/ feeling of distension and heartburn
DD : Duodenal ulcer, hiatus hernia, MI, chronic pancreatitis, GI neoplasia
2. Murphys area at transpyloric plane (tip of 9 th intercostal cartilage) + mid-clavicular
3. Transpyloric plane
Pylorus
GB
Murphys point
Cauda equina
Splenic vein
Head of pancreas
Lt kidney hilum just above
Rt kidney hilum just below

Acute pancreatitis
History
Severe constant pain in epigastrium/ radiate to the back/ relieved by leaning forward
Nausea, vomiting, retching (reverse movement (peristalsis) of the stomach and esophagus without
vomiting)
Signs

Tenderness, guarding, rigidity (usually less than expected)


Shock (severe)
Obstructive jaundice (usually transient)
Pleural effusion (effect of inflammation tracking retroperitoneally to involve pleura)
Abdominal mass pseudocyst / abscess / palpable omentum
Paralytic ileus abdomen distension/ absent bowel sound
Cullens sign (bruising around umbilicus)
Grey-turner syndrome (brawny discolouration of the flanks)
62

Gen05
Causes

Surgery Tactic

1. Idiopathic
2. Obstruction
Gallstone
Ampullary/pancreatic tumor
Congenital accessory duct obstruction
Ascaris
3. Toxin
Alcohol/drug (e.g salicylate/ tetracycline/
metronidazole)
4. Trauma
Iatrogenic (e.g ERCP/road accident, massage)
5. Infection virus : AIDS, mumps, chickenpox
6. Metabolic

G gallstones
E ethanol
T trauma
S steroid
M Mumps
A autoimmune
S- scorpion venom
H hyperlipidaemia, hypothermia,
hypercalcemia
E - Endoscopic retrograde
cholangiopancreatography (ERCP)
D drugs

Complications
1. Pancreas swollen & edematous (conservative mx)
2. Fat necrosis/ saponification hypoglycemia
3. Pancreatic necrosis
4. Infected necrotizing pancreatitis (surgery, death)
5. Pseudocyst
6. Pancreatic abscess
7. Acute haemorrhagic pancreatitis
8. Systemic
Respiratory distress
ARF
Shock
Hypergylcemia
Investigation
1. Serum amylase concentration
N = 100-300 iu/l
1000 iu/l strongly suggest acute pancreatits
(due to rupture of acinar cells + ductal system releasing amylase)
2. serum lipase also rise but slower than amylase
3. X-ray
CXR
Left-sided pleural effusion in 20%
AXR
Sentinel loop dilated adynamic SI in the centre
Ground grass appearance if peritoneal exudates present
62

GET SMASHED

UNIMAS

Gen05

Colon cut-off sign


Gall stone may be seen in some pt

Surgery Tactic

4. USG
Swelling w/ peripancreatic fluid collection & oedema, gallstone
5. ERCP

Glascow score and Ranson criteria


Access severity
3 factors present indicate severe pancreatitis
1. Glascow/ Imrie score (PANCREAS)
P : P02
A : Age
N : Neutrophil
C : Calcium
R : raised serum urea
E : Enzymes
A : albumin
S : sugar

: <60 mmHg/ <8kPa


: > 55 yrs
: 15 x 109
: < 2.0 mmol/l (hypocalcemia)
: > 16 mmol
: LDH > 600 iu/l, AST > 100 u/l
: < 32 g/l
: > 10 mmol/l

2. Ranson criteria
On admission :SEAN
Sugar > 10 mmol/l
Enzyme (ldh > 600 u/i), (ast > 120 u/i)
Age > 55 yrs
Neutrophil > 16 000
Within 48 hrs
Calcium < 2 mmol
PO2< 60 mmHg
Raised serum urea > 0.9 mmol/l
Haematocrit fall > 10%
Fluid sequestration > 6 L
Metabolic acidosis

63

UNIMAS

Gen05
Principle of management

Surgery Tactic

UNIMAS

1. Conservative
Pain relief
Treatment of shock
Suppress pancreatic function (NPO)
2. Endoscopic
Remove gallstone if have
3. Surgical treatment
Diagnosis uncertain
Pt fails to improve on conservative mx or deteriorates
When gallstone present
When complication develop
Discussions
1. Mild and edematous usually settles w/ conservative mx. Necrotizing pancreatitis is frequently severe,
often lead to complication, need for surgery and death
2. Non-pancreatic cause of hyperamylasemia
Acute cholecystitis
Bowel strangulation
High intestinal obstruction
Mesenteric vascular occlusion
Perforated duodenal ulcer
Rupture AAA
Rupture ectopic pregnancy
3. Pancreatic pseudocyst
2-3 weeks after attack
Fibrous walled peri-pancreatic fluid collection
No epithelial lining. Fluid has high amylase content
Persistent/ intermittent abdominal discomfort, vomiting, jaundice
Classification
type 1 normal duct/ no fistula between duct and cyst
type 2 abnormal duct/ no fistula
type 3 abnormal duct/ fistula
Ix : USG/ CT/ ERCP
Treatment
50% resolve spontaneously over 3 months
Drainage (percutaneous/ endoscope/ surgical)
Indication for op : enlarging, avoid infection, hemorrhage, rupture
64

Gen05
4. OBSTRUCTIVE JAUNDICE

Surgery Tactic

DD :
Choledocholithiasis
Ca head of pancreas
Periampullary/ major bile duct cancer
Iatrogenic biliary stricture (surgical damage)
Metastatic tumor compressing bile duct
Choledochal cyst
Parasite infestation in CBD
Hepatitis
Ix :
1. Serum
Bilirubin (deconjugated/ conjugated)
Alkaline phosphatase (ALP)
Transaminase
Lactic dehydrogenase (LDH)
Hepatitis B surface antigen
2. FBC + coagulation (unable to absorb fat soluble vit-K)
3. USG
4. AXR (limited use as gallstone rarely radio-opaque)
5. ERCP (Endoscopic retrograde cholangiopancreatography)
6. Cholangiography
PTC (Percutaneous transhepatic cholangiography)
Pre-operative/ operative
T-tube
7. CT scan

CHOLEDOCHOLITHIASIS
History
Pale stool
Dark urine
Intermittent fever/ pain/ jaundice (charcots triad A.cholangitis) + Rigors
Itchiness
Signs
Jaundice
Scratch mark
Tenderness in RUQ
65

UNIMAS

Gen05
Surgery Tactic
Risk factors for gallstone
1. Metabolic
High cholesterol (OCP, obesity, old age)
Low bile salt (oestrogen reduce bile salt concentration)

UNIMAS

2. Infective
Unclear (maybe in the core of gallstone)
3. Bile stasis
GB contractility reduced by estrogen, pregnancy, truneal, vagotomy, long term parental nutrition
4. 5 F (fat, fair, fertile, forty, female)
Effect and complication of gallstone
In the GB
Silent/asymptomatic
Biliary colic
Cholecystitis (acute/chronic)
Obstruction
Mucocele
Empyema
Ischemic gangrene
Perforation
Carcinoma
In the bile duct
Obstructive jaundice
Ascending cholangitis
Acute pancreatitis
In the intestine
Adhesion& cholecysto-duodenal fistula
Acute obstruction (gallstone ileus)
Principle of Management
1. Removal of stone
ERCP (Dormia basket)
Laparoscopic
Open surgery

66

Gen05

Surgery Tactic

Discussions
1. Courvoisiers law
Jaundice w/ palpable GB is not due to gallstone because
Stone inflammation fibrosis not distensible
Stone obstruction wall thickening not distensible
Exceptions of Courvoisiers law
Converse (if not palpable doesnt mean it is due to stone)
Double pathology (stone in cystic duct + stone in CBD)
Stone in cystic duct (while other thing compress CBD)
Stone in CBD but normal distensible GB

UNIMAS

2. Calot triangle
Bound by lower border of liver/ cystic duct/ common hepatic duct
Essential in laparoscopic cholecystectomy
3. Differentiate
Biliary colic
Colicky pain (usually resolve)
No fever
Normal WBC
No murphys sign
USG : normal wall

Acute cholecystitis
Colicky pain (persistent)
Fever
WBC
Murphys sign, Boas sign
USG : thicken wall

4. Gallstone
Composition : Mix/ cholesterol/ bile pigment/ CaCO3
Characteristic : Multiple/ small/ faceted/laminated
5. S. bilirubin
Normal : 5-17 mol/L
Clinically detectable : 40 mol/L
Jaundice 1st appear at sclera as ut has higher affinity to bilirubin
6. ERCP (Endoscopic retrograde cholangio-pancreatography)
Endoscope reach 2nd part of duodenum, cannula passed into duodenal papilla (ampulla of vater) &
contrast injected.
Use in biliary and pancreatic disease
Indication
Diagnostic (visualise biliary tract e.g. causes of obstruction : stone or tumour)
Therapeutic (stone removal)
Complication
Perforation/ bleeding/ infection
7. Hemolytic anemic is the main cause for gallstone in children pigmented stone
67

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5. DYSPHAGIA

Surgery Tactic

UNIMAS

DD :
1. Mouth
Tonsillitis/ peritonsillar abscess/ tongue Ca/ paralysis soft palate
2. Pharynx
In the lumen
Impaction foreign body (coin, tooth..)
In the wall
Acute pharyngitis/ malignant growth
Outside the wall
Retropharyngeal abscess/ enlarged cervical LN/ malignant thyroid
3. Esophagus
In the lumen
Impaction of foreign body
In the wall
Atresia of esophagus
Benign stricture
o Reflux esophagitis
o Swallowed corrosive
o Tuberculosis
o Sclerodermal
o Radiotherapy
Spasm
o Paterson-Kelly syndrome
o Achalasia
o Webs & rings
Diverticulum
Neoplasm (esophagus Ca)
Neuromuscular disorder
o Bulbar paralysis
o Post-vagotomy
Outside the wall
Malignant or large thyroid swelling
Retrosternal goiter
Pharyngeal diverticulum
Aneurysm of aorta
Mediastinal growth
Dysphagia lusoria
Tylosis : focal keratosis of palm/sole. Occur at early life and mutasomal dominant a/w esophagus cancer
68

Gen05
Surgery Tactic
Ix
CXR
To exclude bronchial carcinoma
May see esophageal fluid level
Barium swallow
High dysphagia
shouldering in esophageal Ca
rat-tail in achalasia
cock-screw in diffuse oesophageal spasm
OGDS
Lower dysphagia
Berstein test passing fine-bore NG tube and infuse 100 mmol/l
Manometry measure the pressure
GASTRO-OESOPHAGEAL REFLUX DISEASE
Reflux oesophagitis is a complication of gastro-oesophageal Reflux Disease
Happen when vertical linear erosions merge together
Clinical features
Heartburn
Bitter-tasting regurgitation
Symptoms worse
o When lying flat
o When bending forward
Angina-like pain
o Caused by esophageal spasm
o Relieved by glyceryl trinitrite (angina drug)
o Confusing with angina and MI
Dysphagia when stricture formed
Causes
Anatomical (hiatus hernia)
Raised intra-abdominal pressure (pregnancy, fibroid)
Incompetent cardiac sphincter (Transient Lower Oesophageal Sphincter Relaxation, TLOSR)
Complication
Stricture
o Worsen dysphagia
Barrets esophagus
o Squamous epithelium replaced by metaplastic columnar
o Specialized intestinal metaplasia
o Severe dysphagia
o Leads to malignant change (pre-malignant)
69

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Gen05
Surgery Tactic
Ix
Barium swallow
Endoscopy withb biopsy
Others
o Physiological pressure
o pH studies
Mx
Most cases (mild) reducing reflux
o Weight reduction
o Diet changes (reduce alcohol, coffee, tea, chocolate)
o Use many pillows when sleeping
o Stop smoking
o Antacid
2nd line therapy
o H2 receptor antagonist
o Sucralfate
o Prokinetic drugs (Dopamine antagonist)
Metoclopramide
Cisapride
nd
If 2 failed proton-pump inihibitor
o Heal 96% in 8 weeks
Management of stricture
o Dilate stricture using gastroscope
Surgery
o Indications
Medical Rx failed
Complication (Barretts stricture)
o Nissen fundoplication

UNIMAS

Discussion
In endoscopic, differentiate sliding hernia from Barrets esophagus by looking at the longitudinal
mucosa fold of gastric

70

Gen05
CA ESOPHAGUS

Surgery Tactic

Clinical features
Progressive dysphagia (solid semisolid fluid)
LOA + LOW
Excessive salivation (water-brash)
Aspiration pneumonitis
Anemia + metastases
o Hepatomegaly
o Virchows node
o Hoarseness of voice
Risk factor
Chronic irritation (achalasia, reflux, leukoplakia)
Alcohol, smoking, hot spicy food
Environmental carcinogen
o Nitrosamine
o Mould (aspergillus flavus) ingestion
Pre-malignant : Barrets esophagus, achalasia, scleroderma, web
Pathology
>90% squamous Ca, middle & upper
adenocarcinoma from stomach/lower esophagus (barrets)
spreading
o longitudinally in submucosa plane
o direct spread : bronchi, lung, aorta
o lymphatic :
upper supraclavicular LN
lower subdiaphragmatic + coeliac LN
Complications
Obstruction use feeding tube (ryles tube/PGE) direct to stomach / TPN
Bleeding blackish stool
Spread
o Recurrent laryngeal & phrenic nerve paralysis
o Tracheo-esophageal fistula (shown in Ba swallow)
o Empyema, lung abscess, pneumonia
o Pericarditis
o SVC obstruction

71

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Gen05
Surgery Tactic
Ix
Ba swallow (irregular luminal filling defect) shouldering effect
Endoscopy OGDS
Staging laparoscopy
Staging thoracoscopy
Endoscopic USG
o Delineate tumour
o Show involved lymph nodes

UNIMAS

Mx
Curable patient
o Radiotherapy
o Chemotherapy
o Oesophagectomy

Incurable (palliative tx)


o Radiotherapy
o chemotherapy
o Stenting
o Laser recanalisation

Discussion
Contraindication to surgery
o Mets to N2 nodes (i.e. celiac, cervical or supraclavicular lymph nodes) or solid organs (e.g. liver,
lungs)
o Invasion of adjacent structure (e.g. recurrent laryngeal nerve, tracheobronchial tree, aorta,
pericardium)
o Severe associated with comorbid conditions (e.g. CVS ds/ respiration ds)

ACHALASIA
Clinical features
Dysphagia
Fluid solid (gravity helps to pass the food)
Aggravated by anxiety/ fatigue
Easier when standing
Food regurgitation
Aspiration pneumonitis, pulmonary fibrosis
Retrosternal pain (25%)
Predispose to Ca if long term
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Gen05
Ix
Chest x-ray
o Dilated esophagus shadow
o Fluid level (sometimes)
Barium swallow
o rat tail appearance
o dilated esophagus
o site of constriction
o uncoordinated peristaltic wave
o tertiary contraction
esophageal manometry
o esophageal sphincter pressure

Surgery Tactic

UNIMAS

Mx
Hellers cardiomyotomy
o Longitudinal incision of lower esophageal and upper gastric muscle wall until the mucosa bulge
through
o Maybe combined with partial Nissen fundoplication
Hydrostatic balloon dilation (relief 80% of cases)
Risk of perforation
Discussion
Pathogenesis : failure of lower oesophageal sphincter to relax due to defect in Auerbachs plexus
Dysphagia 1st solid then liquid mechanical obstruction (e.g. Ca oesophagus)
Dysphagia 1st liquid then solid achalasia (d/t the weight of solid food helps overcoming spasm by
gravity)
Paterson-kelly syndrome : triad dysphagia/ anemia/ glossitis

7. INTESTINAL OBSTRUCTION
Classification
Level of obstruction (high or low si, colonic)
Rate (acute, chronic, acute on chronic)
Location of pathological process (intraluminal, mural, extramural)
Nature of obstruction (dynamic simple mechanical, strangulation, adynamic paralytic ileus)
Causes
Adhesion or bands (25%)
o Previous surgery
o Intraperitoneal infection (peritonitis, pancreatitis)
o Congenital band (rare)
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Gen05
Surgery Tactic
UNIMAS
Obstructed or strangulated external hernia (35%)
o Femoral hernia
o Inguinal hernia
Tumor (30%)
o Colonic carcinoma (especially left-sided)
o Gastric carcinoma (near pylorus)
o Tumor of small bowel (rare)
Volvulus of small/large bowel
o Mobile or distended loop bowel rotates causing obstruction at its neck. Common site : sigmoid/
caecum
Inflammatory stricture
o Diverticular disease
o Chrohns disease
Bolus
o Impacted faeces
o Foreign bodies
o Solitary gallstone
o Phylobezoar (impacted vege)
o Trichobezoar (eating hair, psychological problem)
Internal hernia
Intussusception
o Telescoped into distal segment
o Usually initiated by a mass in the bowel which is dragged along during peristalsis
o Enlargement of lymphatic tissue or tumour
Symptoms
Vomiting
o Onset (early in small bowel, late in large bowel)
o Nature of vomitus
Abdominal pain
o Colicky (peristalsis)
o Mild in uncomplicated obstruction
o Severe in strangulation
Absolute constipation/ obstipation
o No flatus
o No faeces

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Gen05
Surgery Tactic
Signs
Abdominal distention
o Gas
o More distal obstruction, more distention
Dehydration (usually more in SI)
o Vomiting
o Sequestration of fluid in small bowel
o Lack of fluid intake & absorption
o >proximal obstruction, >severe dehyration
Visible peristalsis
o Chronic distal incomplete small bowel obstruction
Abdominal tenderness
o Tender for strangulation
o Non-tender for uncomplicated obstruction
Central resonance
o Gas rise to uppermost point
Abnormal bowel sound
o Exaggerated (during attack of colic)
o Lapping
o Sloshing
o High-pitched, tinkling (when distended with gas)
o Absent bowel sound (adynamic obstruction)
Femoral hernia
o Maybe found
o Causes bowel obstruction

UNIMAS

Ix
Plain AXR
o Supine + erected
o Small bowel obstruction show centrally located, Valvulae Conniventes, distention less mark
o Large bowel obstruction show peripheral located, Haustral indentation, grossly distended
o Bowel gas absent beyond the obstruction
o Caecum reaches radiological diameter 12 cm imminent danger of rupture
o Contrast radiology
Use diluted barium or water-soluble contrast (Gastrografin)
Undiluted barium may compound obstruction and never use barium if perforation suspected

75

Gen05
Surgery Tactic
Mx
Resuscitation (rest the bowel)
o NPO
o IV fluid
o NG tube
Reduce distenstion
Reduce vomiting
Reduce nausea
Reduce risk of inhalation of gastric contents
Drugs
o Neostigmine for adynamic bowel obstruction
Operation
o Diagnostic
o Therapeutic
ADYNAMIC BOWEL OBSTRUCTION
Occurs after abdominal surgery or being handled
For small bowel, called ileus/ paralytic ileus
Post-operative ileus should not be more than 4 days
Other causes
o Hypokalaemia
o Anti-parkinsonianns drugs
PSEUDO-OBSTRUCTION
Involves large bowel
Causes
Retroperitonial inflammation/ haemorrhage
Neurological illness
Drugs
o Anticholinergic
Pregnancy (progesterone coz relax of smooth ms)
Orthopaedic injuries/ surgery
Prolonged recumbency
Signs are similar to the mechanical obstruction but
o Bowel sound normal or inaudible
Confirmed by unprepared barium enema

76

UNIMAS

Gen05
Surgery Tactic
STRANGULATION
Pathophysiology
Partial obstruction due to
o External pressure
o Twisting
Edema of the wall
o Aggravates obstruction
o Venous return obstructed
Closed loop dilated by gas due to fermentation
Arterial inflow inhibition
o Ischaemia
o Infarction
Discussion
How to describe stool of intussusception
o Redcurrant jelly stool
Intussusception
o Most common in ileocolic junction
o Common in children when solid food is started
Sign of bowel viability (during operation)
o Shiny appearance
o Pink colour
o Arterial pulses present
o Peristalsis present
8. HEMATURIA
DD :
1. Kidney
o Stone/ tumour (RCC)/ inflammtion (pyelonephritis)
o Polycystic/ ruptured
2. Ureter
o Stone/ tumour/ inflammation (ureteritis)
3. Bladder
o Stone/ tumour (Ca)/ inflammation (cystitis)
4. Urethra
o Stone/ tumour (TCC)/ inflammtion (urethritis)
o Ruptured
5. Prostate
o PBH/ tumour (Ca)/ inflammation (prostatitis)

77

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Gen05
URINARY CALCULI

Surgery Tactic

UNIMAS

History
1. Pain (fixed renal/urinary colic) unilateral
2. Hematuria
3. Frequency/difficulty in micturition
4. Fever/pyuria in infection
Causes & risk factors
1. Idiopathic (most common)
2. Urine stasis
3. Hypersecretion of stone forming substances in urine
o Hypercalciuria (hyperparathyroid, immobilization, absorptive)
o Hyperuricemia (meat)
o Hyperoxaluria (nuts, berries, chocolate)
4. Hyposecretion of anti-stone forming substances in urine
o (PyroPO4/ Mg/ citrate)
5. UTI (proteus/ klebsilla produce urease convert ura to ammonium alkaline condition favor
stone formation)
6. Diarrhea & dehydration
7. Excess vit C intake
8. Foreign body (schistosome ova)
9. Diet high in meat, fat, sodium & low in fibre
Complications
Obstruction/ hydronephrosis/ kidney failure
Investigations
1. Urinalysis
2. Renal function test
3. KUB (10-15% radio-lucent)
4. IVU
5. USG
6. Cystoscopy
Principle of management
1. Kidney PNCL/ ESWL/ open surgery
2. Ureterics ESWL (proximal part)/ ureterorenoscope (dormia basket)/ open surgery
3. Bladder lithotrite (crush th stone)/ open surgery
Stone < 0.5 cm can pass out in th urine spontaneously
PNCL = percutaneous nephrolithotomy
ESWL = extra-corporal shock wave lithotripsy
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Gen05
Surgery Tactic
Discussions
1. ESWL
Indication
o Kidney stone/ prox. Ureteric stone
o Used together with ESWL if stone is big
Complication
o Infection (bacteria released from broken stone)
o Haemorrhage (kidney injured)
o steinstrasse (ureter obstructed by stone fragment)
contraindication
o pregnancy
o coagulation defect (get worse if bleeding)
o febrile UTI (kidney can have risk infection if injured)
o big stone (use PNCL)
o hard stone (e.g. cystein stone)
o bladder stone (because stone is floating inside, cant be fixed)

UNIMAS

2. Nephrectomy usually done on the side bcause rt kidney vein shorter, hard to clamp, may injure IVC
3. Uric acid containing food : fast food growing things e.g. mushroom; bamboo shoot, fish & prawn egg,
fruits with lots of seeds (strawberry), beer and wine (yis), internal organs
4. Terminology : pyelolithotomy/ nephrolithotomy/ pyelonephrolithotomy
*pyelolithotomy : insicion and renal pelvis + removal of calculi
**nephrolithotomy : insicion and kidney + removal of calculi
BLADDER CA
History
1. painless hematuria
2. urinary symptoms : frequency, urgency, dysuria
3. systemic symptoms : bone pain, acute renal failure
Causes & risk factors
Smoking (40%)
Occupational exposure (dye/ rubber/ petrol/ lead)
Radiotherapy cervical ca
Infection schistosomes
Drug cyclophosphamide (breast ca)
Chromosome p53

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Surgery Tactic
Complications
1. Clot retention
2. Hydronephrosis
3. Uraemia
4. Secondary infection
5. Incontinence (if tumor invade bladder neck)
Investigation
1. Baseline blood test
2. Urine cytology (look for malignant cells, not for initial evaluation or haematuria)
3. KUB & IVU
4. USG
5. Cystoscopy/ cystourethroscopy
6. CT/ MRI for staging
Principle of management
1. Non-muscle invasive
Transurethral resection = intravesical chemotherapy
2. Muscle invasive
Organ confined radical cystectomy/ radiotherapy
Locally advanced non-adjuvant chemo radical resect/ radio
3. Muscle invasive metastases palliative care
Discussions
1. Types of malignant cell
TCC (most)
SCC
Adenocarcinoma
Mix
Undefined
2. BCG has been shown to be effective c against CIS (carcinoma in situ)
3. Intravesical therapy mitomycin C, thiotep
4. Staging
<pT2 : non-muscle invasive/ superficial (confine to lamina propia)
pT2 : muscle invasive
5. CIS carcinoma in situ high malignant potential, 50% will die of bladder Ca
*pTa: mucosa, does not invade lamina propria
**pT2 : invade lamina propria
80

UNIMAS

Gen05
9. BLADDER OUTFLOW OBSTRUCTION

Surgery Tactic

Definition : low flow rate/ high voiding pressure


1. Bladder (neck)
o Stenosis (dyssynergia)
o Hypertrophy
o Fibrosis (d/t scarring after TURP)
o Occlusion (stone/ blood clot)
2. Prostate (enlargement)
o BPH
o Prostate Ca
o Prostatitis
3. Urethral
o Stricture (trauma/ inflammation/ post-op)
o Stone (prostatic calculi)
o Tumour
BENIGN PROSTATE HYPERPLASIA
Symptoms (prostatism)
Frequency
Urgency
Nocturia
Straining to micturate
Hesitancy (have to wait few seconds to start micturition)
Poor stream
Intermittent flow
Terminal dribbling
Incomplete bladder emptying
Complications
Overflow incontinence history
Hematuria (d/t straining) history
Urine stasis
o Stone
o Infection history (fever)
o Hydronephrosis
o Renal failure hx (uraemic sx : headache/ drwosy/ itchy)
Bladder diverticulum
Atonic bladdder (d/t hypertrophy)
Inguinal hernia
81

UNIMAS

Gen05
Surgery Tactic
Investigation
UFEME
Urine culture exclude infec on
Serum PSA (prostate specific antigen) exclude Ca
Renal fx test exclude renal failure
KUB/ IVU exclude stone
Urine flow rate judge severity
PVR (post void residual)
Cystometrography measure bladder volume & pressure
USG
Abdominal/ transrectal
Cystoscope
Needle biopsy
Treatment
1. Medical
5-reductase inhibitor
Block testosterone dihydrotestosterone
Reduce/ stop prostate enlarging
Eg Finasteride
Alpha blocker
Relax smooth muscle of prostate
Produce slight increase in flow rate
Eg Prazosin
2. Surgical
TURP (transurethral resection of prostate)
Prostatectomy
Long term catheterization/ stenting
Discussion
I-PSS (International Prostate Symptom Score)
Assess severity
7 components (each max 5 points)
I increase frequency
increase urgency
intermi ent ow
incomplete emptying
P poor stream
S straining
S sleep (nocturia)

82

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Gen05
PROSTATE CA

Surgery Tactic

UNIMAS

Clinical features
Asymptomatic
Prostatism
Malignancy (LOA/ LOW/ malaise)
Bone pain/ backache (metastasis)
Investigation
As in BPH & plus below:
Enzyme
PSA
Acid & alkaline phosphatase (bone mets)
X-ray bone
Radionucleotide bone scan
USG
CT
Treatment
TURP
Prostatectomy
Hormonal therapy ( testosterone)
Bilateral orchidectomy
Gonadorelin (LHRH agonist)
Anti-androgen drug (eg flutamide)
Radiotherapy
Discussion
1. PR examination
BPH
Rubbery firm
Smooth
Symmetry enlarge
Regular shape
Median sulcus palpable
Rectal mucosa can move over prostate

Prostate Ca
Hard
Nodular
Asymmetry
Irregular
Not palpable
Cant move over

2. Common site
BPH transi onal zone
Ca peripheral zone

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Gen05
10. BREAST DISORDER

Surgery Tactic

UNIMAS

1. Pain
Cyclical
Premenstrual syndrome
Fibroadenosis ( cyclical nodularity )

Non-cyclical
Inflammatory ( infection )
Pregnancy masititis

2. Lump
Painful

Cyclical nodularity
Breast cyst
Breast abscess
Periductal mastitis
Carcinoma ( rare )

Painless

Carcinoma
Breast cyst
Fibroadenoma
Nodularity ( Fibroadenosis )
Fat necrosis ( mimic ca )
Mammary duct ectasia

3. Skin changes
Dimpling
o Cancer ( skin pulled in by underlying neoplasm )
Visible Lump
o Cyst
o Carcinoma
o Phylloides
Peau d'orange
o Carcinoma
o Infection
o Tumor lympha c blockage edema deepens mouth of sweat glands & hair follicles
Redness
o Infection
Ulceration
o Neglected carcinoma

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Gen05
Surgery Tactic
4. Nipple disorder
Inversion
o Carcinoma
o Mammary gland ectasia ( dilatation )
Red, Encrusted, Oozy
o Paget's disease
o Eczema
Discharge
o Clear
Physiological
o Milky
Lactation
Hyperprolactinemia ( pituitary tumor )
Drugs ( Chlorpromazine )
o Pus
Abscess
o Green, Brown
Perimenopausal
Duct ectasia
Fibroadenosis
o Bloody
Papilloma ( single duct )
Carcinoma
BREAST CANCER
Risk factor
1. Female ( F:M = 100:1 )
2. Early menarche
3. Late menopause
4. Nulliparious
5. 1st pregnancy after age 30
6. Family history
7. Previous hx of breast ca
8. Ionising radiation
9. HRT & OCP ( controversial )
10. Obesity ( BMI> 35 increase 2 times )
11. Benign breast ds
High risk ( 8-10 times )
Ductal carcinoma in situ
Lobular carcinoma in situ

85

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Gen05
Clinical Features

Surgery Tactic

1. Breast lump
Painless , progressive, NO fluctuation in size
Irregular, hard, diffuse, limited mobility
Early case can be smooth and mobile
Dimpling / tethering of skin
Peau d' orange ( dermal lymphatic involvement cz edema )
Fixation to skin and underlying structure
Ulcer, bleeding
Inflammatory carcinoma : Erythema usually involve whole breast
No tender , no fever
2. Change in size and contour
3. Bloody nipple discharge ( Ductal ca in situ / infiltrating ductal ca )
4. Nipple eczema
Paget's disease, always assoc with Ductal Ca in situ , Infiltrating Ductal Ca
5. Nipple retraction
DD : Congenital, duct ectasia, fat necrosis
6. Breast pain
Unless in advance case ( ulcer + infection )
7. Symptoms of metastases
Unilateral axillary LN
Bone pain
Pleural effusion
Investigation
1. Mammography
> 35 yo ( not helpful if younger bcoz breast tissue is dense )
95% diagnostic accuracy
Routinely 2 views ( craniocaudal, oblique )
Signs of malignancy
Microcalcification
Stellate mass
Skin thickening
Irregular soft tissue
Distorted architexture
2. USG
Useful in young women ( dense breast )
Distinguish cystic from solid

86

UNIMAS

Gen05

Surgery Tactic

UNIMAS

3. Biopsy
FNAC
- Gauge 20-22 needle
- Estrogen receptor status can be obtained
- Sensitivity 80-90%
Core-cutting needle biopsy ( tru-cut )
Excisional biopsy
- Complete removal of lump
- If malignant, definitive operation still required
Incisional biopsy
-Remove portion of the lump ( rare now )

4. MRI
No limited by breast density
Mainly for diagnosis of residual or recurrent tumor in patient with breast cancer who have
undergone conversation surgery
Staging
1. TNM ( Tumor, Node, Metastasize )
T
T0
T1
T2

N
No tumor
< 2cm
2-5cm

M
N0
N1
N2

T3

> 5cm

N3

T4

> 10cm /
ulceration

No nodes
Mobile nodes
Fixed nodes
Ipsilateral /
supraclavicular LN

Stage I : T1-T2 / N0
Stage II: T1-T2 / N1
Stage III
: T3-T4 / M0
Stage IV
: T3-T4 / M1
2. Manchester
I
mobile lump , no LN
II
mobile lump, LN
III
fixed lump = LN
IV
Distant metastases

87

M0
M1
Mx

No mets
Mets
Not confirmed

Gen05
Treatment

Surgery Tactic

1. Lumpectomy
Remove lump & 1 cm normal surrounding tissue
Must accompanied by radiotherapy, with or without chemo & hormonal therapy
Contraindication
- Wish to avoid radiotherapy
- Multifoci ca
- Large tumor in small breast
- Widespread DCIS
- Patient's choice
2. Mastectomy
Simple : breast but no other structure
Modified radical : breast / axillary LN / no underlying chest wall muscles
Radical : breast / axillary LN / underlying chest wall muscles
3. Radiotherapy
4. Chemotherapy
CMF ( cyclophosphamide / methotrexate / fluorouracil )
FAC ( fluorouracil / andriamycin / cyclophosphamide )
5. Hormonal therapy

especially those with estrogen or progesterone receptor positive

eg: Tamoxifen
Prognostic factor
1. TNM
2. Histological type and grade
3. Age at diagnosis
4. Estrogen receptor +ve ( responsive to therapy )
5. Other genetic factor
** First prognostic index = Noltingham prognostic index
Which take Tumor size, LN staging, Histological grade
Discussion
1. What is triple assessment?
- Clinical , imaging, biopsy
2. Indications for breast reconstructive surgery ?
- Big breast
- Small tumor
- Tumor not under nipple

88

UNIMAS

Gen05
3. Mammogram coding
0 Unable to tell any mass
1 Normal
2 Benign
3 Propable benign
4 Propable malignant
5 Highly suspicious malignant

Surgery Tactic

4. Most affected site : Upper quarter quadrant


5.
Paget's disease
Unilateral
Menopause women
Not itchy
No vesicle
Destroy nipple
May have lump

Eczema
Bilateral
Lactating women
Itchy
Vesicle
Nipple intact
No lump

Other breast disorder


1. Fibroadenosis
also called as nodularity, chronic mastitis
histo features : epitheliosis + fibrosis + adenosis
35-55yo
Aberrations of Normal Development of Involution ( ANDI )
may originate from duct, lobule, fibrous tissue
features :- single or multiple lump
- cystic
- cyclical breast pain
- generalized nodularity
- nipple discharge ( clear to green )
Fibroadenoma
1. Benign
2. 15-30 years old
3. Arise from aberrant development of a lobule
4. Has condensed connective tissue capsule
5. No recurrence

89

UNIMAS

Gen05

Surgery Tactic

- Fibrous component (fibrosis)


- AbN multiplication of ducts and acini (adenoma)
6. Features
- Highly mobile (breast mouse)/ well defined/ painless/ smooth/ firm
- No axillary LN
7. If untreated, may undergo hyalinization and merge w surrounding to form a hard calcified mass.
8. Giant fibroadenomata (>5cm) = Phyllodes tumor
Phyllodes tumor (Brodies disease)
1.
2.
3.
4.
5.
6.
7.

Cystosarcoma phylloides
Giant fibroadenoma
Cut section : Slit-like cleft arranged in botanical manner
Usually benign but can be malignant (25%)
If malignant features of sarcoma
Mimicking malignant
Tend to recur (differentiate it from fibroadenoma which does not recur)

Fat necrosis
1.
2.
3.
4.
5.

Long after trauma


Macrophages take up lipid material
Hard, irregular
May cause skin dimpling
Excisional biopsy

Acute Breast Abscess


1. Common by local staphylococcal infection
2. During pregnancy & lactation (trauma crack)
3. Features
- Pain, progressively severe, continuous throbbing pain, very tender
- Lump/ diffuse swelling and redness over skin
- Feels malaise/ hot/ night sweat/ flushes/ fever/ tachy/ rigors
4. Treat by Flucloxacillin and Drainage for abscess
5. Prevent by good hygiene

90

UNIMAS

Gen05

Surgery Tactic

Duct papilloma
1.
2.
3.
4.
5.

Epithelial proliferation in lactiferous duct


Bloody discharge
Swelling deep to, or just lateral to areola
As filling defect in mammography/ ductography
Microdochectomy (excision of affected duct)

Mammary duct ectasia


1.
2.
3.
4.
5.

Dilatation of mammary ducts, full of inpissated material


containing macrophages & chronic inflammatory debris

Benign
Common perimenopausal
Dilatation of larger duct
Cause: plasma cell mastitis
Clinical feature:
- Nipple discharge - purulent
- Tender beneath or close to areola
- Nipple retraction or inversion
6. Fibrotic thickening of duct wall
7. Atrophy of lining epithelial
8. Lymphocytic infiltration around the duct
9. Often bilateral
10. May progress to frank abscess formation
11. Treated by excising the affected duct
Mondor disease

1. Spontaneous thrombophlebitis of superficial vein over thorax/ breast


2. Guttering over the surface of breast
3. Mimic ca
Mastalgia
1. Ca
2. Pregnancy
3. Menstruation cyclical mastalgia bilateral
4. Onset of puberty
5. Lactation
6. Cracked nipple
7. Inflammation of nipple
8. Cyst of the breast
9. Galactocele
10. Abscess & submammary abscess
91

UNIMAS

Gen05

11. Mastitis
12. TB breast
13. Angina
14. Cervical spondylor
15. Herpes Zoster

Surgery Tactic

UNIMAS

11. NECK SWELLING


DD:
Thyroid

Midline

Thyroglossal cyst
LN (submental)
Dermoid cyst
Lipoma
Laryngocele
Pharyngeal pouch
Ranula

Anterior triangle
Gland (parotid/
submandibular)
LN
Carotid aneurysm
Carotid body tumor
Branchial cyst
Sternomastoid tumor
Lipoma

Posterior triangle
Pharyngeal pouch
LN
Subclavian aneurysm
Cystic hygroma
Cervical rib
Lipoma

THYROID SWELLING
a. Simple
Diffuse
Physio (puberty/ pregnancy/ menopause)
Patho (iodine def/ goitrogen eg diet & drug/ genetic)
Multinodular
Iodine def (initially diffuse, later become multinodular)
Solitary
Thyroid cyst
Prominent nodule of a multinodular goiter
Haemorrhage into a nodule
Malignancy (papillary/ follicular)

92

Gen05

Surgery Tactic

b. Toxic
Diffuse
1 thyrotoxicosis (graves disease)
Multinodular
2 throtoxicosis (high TSH)
Solitary
Toxic adenoma
SPECIFIC GOITERS
Inflammatory

Hashimotos thyroiditis
De Quervains acute thyroiditis
Riedles thyroiditis

** Hyper hypothyroid
** Hard & tender
** Diffuse swelling
Neoplastic

Benign adenoma
Papillary ca
Differentiated ca
Follicular ca
Medullary ca Undifferentiated
Anaplastic ca ca

Clinical presentations
1. Swelling
Present since birth thyroglossal cyst
Sudden increase in size with pain haemorrhage
Fast growing anaplas c (other goiter slow growing)
2. Pain
Pain inammatory/ Anaplas c
Painless most goiters
3. Pressure effect
Trachea dyspnoea/ stridor
Recurrent laryngeal nerve hoarseness of voice
Esophagus dysphagia
93

UNIMAS

Gen05

Surgery Tactic

UNIMAS

4. Thyrotoxicosis & hypothyroidism (myxoedema)


1
2
3
4
5
6
7
8
9

Throtoxicosis

LOW without LOA


Heat intolerance
Excessive sweating & moist
Nervous excitability
Insomnia
Diarrhea
Amenorrhea
Hand tremor
Eye signs (lid lag/ lid retraction/ exophthalmus/
ophtalmoplegia/ chemosis)
10 CVS (tachycardia/ palpitation/ dyspnea on exertion)

Hypothyroidism

Wt gain
Cold intolerance
Dry skin
Slow thought & speech
Falling memory
Constipation
Menorrhagia
Muscle fatigue
Puffy face
Loss of hair/ eyebrow

5. Other signs for thyroid swelling


Pembertons sign Raise the hand and plethora/ cyanosis in the face
Kochers test push on the lateral lobes will produce stridor
Laheys method push the affected lobe from the other side to make it prominent for palpation
Berry sign lost of carotid pulse/ decrease/ displace
Investigation
1. Thyroid fx test
T3 & T4 level
TSH level (low in hyper & high in hypothyroidism)
2. Scintillation/ radioisotope scan
Hot nodule ac vely func oning
Cool nodule normal func oning
Cold nodule non-functioning
3. USG
Differentiate cystic, solid nodule
4. Plain X-ray
On chest & thoracic inlet
Trachea deviation, compression, retrosternal goiter, thyroid calcification
5. Thyroid needle biopsy
FNAC (fine needle aspiration cytology)
Needle core biopsy

94

Gen05

Management

Surgery Tactic

UNIMAS

1. Antithyroid drug
Carbimazole, propylthiouracil (PTU)
2. Radioactive iodine
Contraindication in pregnancy & pt who wants to have children
3. Surgical
Thyroidectomy (subtotal/ total/ partial)
Discussion
1. Simple hyperplastic goiter
Due to excessive stimulation by TSH as result of low thyroid hormone level
Causes: puberty, pregnancy, iodine def (eg endemic goiter), goitrogen (eg cabbage)
Colloid goitre is to describe the late stage of hyperplasia when all the acini are distended with colloid
which has not been released because the stimulation by TSH has dropped off.
2. Thyroglossal cyst
Can be formed anywhere along the midline of thyroglossal tract, which marks the line of embryological
descend of the thyroid from the foramen caecum to its normal position in the neck
Usually in children & young adult
Move on tongue protrution
3. Grave disease
Diffuse thyroid hyperplasia due to action of LATS (long acting thyroid stimulator) which mimics effect
of TSH
Autoimmune ds
Causing thyrotoxicosis
Bruit
4. Hashimotos thyroiditis
Middle age female
Smooth firm goiter
Lymphocytes infiltrate thyroid gland causing progressive destruction of thyroid follicles & leads to
atrophy & fibrosis
Various antithyroid antibody usually present in plasma in high titre (TPO-thyroid peroxidase, TRCAtanned red cell agglutination)
Hurthle cell change
Initially hyper later hypothyroidism
Complicate to lymphoma
95

Gen05

Surgery Tactic

5. Solitary nodule
Multinodular (50% cases)
Thyroid cyst
Haemorrhage into a hyperplastic nodule
Adenoma
Ca (papillary, follicular, medullary)
Enlargement of the whole of one lobe (usually Hashimoto)
6. Papillary Ca
Most common thyroid ca in both adult & children
Slow growing/ painless/ firm/ thyroid lump or cervical LN or both
Lymphatic spread
Hard, dull, not fluctuated, no bruit, euthyroid
Distant metastasis are rare
Psammoma bodies
Orphan annie eye nucleus
Multifocal
Total thyroidectomy
Best prognosis among other thyroid
7. Follicular Ca
Similar presentation with papillary ca but rarely involve cervical LN
Hard, dull, not fluctuated, no bruit, euthyroid
Hurthle cell
Distant metastasis eg bone, lung, liver
Hematological spread
Cant be distinguished cytologically (eg FNAC) from benign follicular
8. Medullary Ca
Arise from parafollicular or C cell
Calcitonin as tumor marker
Often associated with MEN II
Hard, dull, not fluctuated, no bruit, euthyroid
Does not take up radioiodine thus is resistant to radiotherapy

96

UNIMAS

Gen05

Surgery Tactic

UNIMAS

9. Anaplastic Ca
Poorly differentiated & spread rapidly
Dyspnea, hoarseness, ear pain (infiltrate vagus nerve), bone pain & fracture, malaise, LOW, resp
distress
Hard, dull, not fluctuated, no bruit, euthyroid
Poor response to radio & chemotherapy. Palliative tx
Worst prognosis
Common in old age, female

10. Eye signs


Exophthalmus (sclera visible below cornea as eyeball pushed forward by edema of retro-orbital
muscle)
Chemosis (oedema of conjunctiva)
Lid retraction (sclera visible above the cornea due to over activity of smooth muscle of levator
palpabrae superioris muscle)
Lid lag (eyelid cant keep pace with eyeball when looking down)
Ophthalmoplegia (difficulty looking upward & outward due to weakness of sup rectus, lateral rectus &
inf oblique)
Diplopia
11. Causes of cervical lymphadenopathy
a. Infection (non-specific, TB)
b. Metastatic tumor (head, neck, chest, abdomen)
c. Primary reticuloses (lymphoma, lymphosarcoma, reticulosarcoma)
d. Sarcoidosis
12. Complications of thyroidectomy
i. Injury to nearby structure
a) Trachea, esophagus
b) Recurrent laryngeal n, external laryngeal n (hoarseness of voice)
c) Parathyroid (hypoparathyroidism)
ii.
Endocrine complications
a) Recurrence
b) Hypothyroidism
c) Thyroid storm
iii.
General complications of operation
a) Hematoma
b) Infection

97

Gen05

Surgery Tactic

13. By doing aspiration, Ca is excluded & cyst is confirmed if


Swelling disappear
No blood stained
Not recurrent after 6 months

UNIMAS

12. Inguinoscrotal swelling


Groin swelling

Scrotal swelling

1.
2.
3.
4.
5.
6.
7.
8.
9.

1.
2.
3.
4.
5.
6.
7.
8.
9.

Inguinal hernia
Femoral hernia
LN enlargement
Sapheno varix
Femoral a aneurysm
Undescended testes
Ectopic testis
Psoas abscess
Lipoma

Indirect inguinal hernia


Spermatocele & epididymal cyst
Hydrocele
Hematocele
Varicocele
Testicular tumor
Testic torsion
Epididymitis
Epididymo-orchitis

INGUINAL HERNIA
History

Inguinoscrotal swelling reduce/ irreducible


Discomfort & with or without pain
Sx of intestinal obstruction (abdominal pain & distension, vomiting & constipation)
Hx straining of abdominal muscle (heavy lifting/ chronic coughing/ constipation/ difficulty in micturition)

Complication

Obstructed (no cough impulse, irreducible, intestinal obstruction)


Strangulated h (obstructed hernia + arrest of blood supply)
Venous return blocked + arterial obstruction infarction
Tense, tender & pain
Inflamed ( due to external abrasion OR internal inflamed content)
Not tense, no obstruction

98

Gen05

Diagnosis of hernia
1.
2.
3.
4.
5.
6.
7.

Surgery Tactic

UNIMAS

Right/ left
Inguinal/ femoral
(if inguinal) direct/ indirect
Enterocele/ omentocele
Simple/ obstructed/ strangulated
Complete/ incomplete
Reducible/ irreducible

Inguinal hernia
Above ing lig & medial to pubic tubercle
Ziemans t: impulse on index/ middle f.
Little f. invagination: impulse on tip/ pulp
Indirect ing hernia
Any age but common in young
Via deep ing ring & along the ing canal
Patent or reopen processus vaginalis
Unilateral in 2/3 case (rt more common
because rt testis descend later than lt)
Enter scrotum (complete)
Reduced by pt/ doctor (manually)
Narrow neck more liable to strangulate
Ziemans technique impulse on index f.
Deep ring occlusion t not bulge out
Little f. invagination impulse on nger p
Enterocele

Visible peristalsis
Elastic in consistency
Gurgling sound on reduction
Difficult to reduce 1st part/ easy last part
Resonant on percussion
Bowel sound

Femoral hernia
Below ing lig & lateral to pubic tubercle
Impulse on ring finger
No impulse felt
Direct ing hernia

Elderly
Via transversalis fascia (Hessalbachs triangle)
Weak abdominal wall/ muscle
Bilateral in > case
Not enter scrotum
Reduced on lying down (automatically)
Broad neck less liable to strangulate
Impulse on middle f.
Bulge out
Impulse on pulp
Omentocele

No peristalsis
Doughy & granular
No
Easy 1st part/ difficult last part
Dull
No

99

Gen05

Treatment

Surgery Tactic

UNIMAS

Herniotomy reduce & single s tch


Only for children/ congenital indirect hernia
Herniorraphy close with local ssue
Femoral hernia
Hernioplasty using mesh (non-tension technique)

Discussion
1. Hernia definition: a protrusion of a viscus or part of viscus through an abnormal opening in the wall of its
containing cavity
2. Hernia = mouth, neck, body, fundus
3. Sac is a peritoneal pouch that comes out
4. Primary hernia = hernia which no operation has been performed
5. Recurrent hernia = after a previous hernia repair
6. Richters hernia = contains part of bowel wall, can strangulate without causing obstruction
7. Littres hernia = contain Meckels diverticulum
8. Maydls hernia = contain 2 adjacent loops of bowel (W)
9. Classification of INDIRECT HERNIA
a) Bubonocele = hernia limited within inguinal canal
b) Funicular = into scrotum, testis below hernia, still can be felt separately. (processus vaginalis closed just
above epididymis)
c) complete = testis felt behind hernia with great difficulty (patent processus vaginalis)
10. Coverings of indirect inguinal hernia
a) Peritoneum
b) Extraperitoneal fat
c) Internal spermatic fascia
d) Cremasteric muscle and fascia
e) External spermatic fascia
f) Superficial fascia
g) Skin
11. What are the contents of inguinal canal?
a) Spermatic cord and its covering (male)
b) Round ligament of uterus & ilioinguinal nerve (female)
12. What are the contents of spermatic cord?
a) 3 arteries: testicular/ cremasteric/ vas deferens
b) 3 nerves: genital branch of genitofemoral/ ilioinguinal/ sympathetic
c) 3 structures: vas deferens/ pampiniform plexus/ lymph
d) 3 coverings: cremasteric/ internal spermatic/ external spermatic
100

Gen05

OTHER INGUINAL SWELLING

Surgery Tactic

UNIMAS

1. Femoral hernia
Protrusion of peritoneum through femoral canal
May contain bowel or omentum
Since femoral canal is narrow:
Usually irreducible
Rare to have cough impulse
Easily obstructed & strangulated
2. Enlarged inguinal LN
2 groups: horizontal/ upper (medial & lateral) & vertical/ lower
Enlarge due to foot infection/ skin ds/ STD/ tumor/ lymphadenopathy
Multiple small hard nodes are commonly found esp in men which are accepted as normal as a result of
minor infection of lower limbs. The nodes easily palpated in male as they have < subcutaneous fat.
3. Sapheno varix
Dilatation of long saphenous vein proximal to its junction with the femoral vein
Result from valvular incompetence
Usually there are varicose vein elsewhere in long saphenous syst.
Empty with minimal pressure & refill on release
Tx: high saphenous ligation
4. Femoral artery aneurysm
Below the midpoint of ing ligament
Expansile pulsation
5. Undescended testis
Arrested at any point along its normal path of descent
Usually noticed in early life
Enlargement, irregularity or immobility suspect malignancy
Assoc with indirect ing hernia
6. Ectopic testis
Deviated from its usual path of descent
Types
Inguinal (superficial ing pouch)
Femoral (femoral triangle)
Pubic (root of penis)
Perineum
101

Gen05

OTHER SCROTAL SWELLING

Surgery Tactic

UNIMAS

1. Spermatocele & epididymal cyst


Cant be distinguished clinical. Only by aspiration
Spermatocele: slightly grey, opaque fluid containing spermatozoa
Epididymal cyst: clear fluid
Testis are palpable
2. Hydrocele (vaginal)
Excessive collection of fluid within tunica vaginalis
Divided into: congenital & acquired (further divided into primary & secondary)
Congenital
Patent connection with peritoneal cavity via patent processus vaginalis
Acquired
Primary
o Idiopathic
o Can reach very large size with no pain
Secondary
o Trauma/ infection/ tumor
o Small size. Tender if underlying testis tender
Translucent/ usually bilateral/ testis impalpable
Complication
Rupture (trauma or spontaneous)
Hematocele (injury to hydrocele)
Infection
Hernia of hydrocele sac
Sac wall calcification
Testis atrophic
3. Hematocele
Collection of blood within tunica vaginalis
Due to trauma or underlying malignant disease
Not translucent
4. Varicocele
Dilated, tortuous & elongated veins of pampiniform plexus of spermatic vein (varicose vein in
spermatic cord)
90% on the left because left testicular vein drain into high pressure renal vein whereas the right
testicular vein drains directly into IVC.
Usually asymptomatic but pt usually infertile as it increases scrotal temperature which affect normal
sperm function
102

Gen05

Surgery Tactic

5. Testicular tumor
>90% are derived from germ cells
Spread to para-aortic LN thoracic duct supraclavicular LN
Inguinal LN are not involved unless spread to scrotal skin
20-40 years old
Most common
Seminomas: derived from spermatocyte
Teratoma: derived from 3 germ cells layer ectoderm/ mesoderm/ endoderm
Presentation
Solid testicular lumo
Painless
May cause secondary hydrocele
Investigation
USG for scrotal content
Chest X-ray for lung secondaries
Tumor marker
o BHCG (human chorionic gonadotrophin)
o AFP (alpha fetoprotein)
o LDH (lactate dehydrogenase)
CT for staging
o I: confined to testis
o II: retroperitoneal LN
o III: metastasis above diaphragm confined to LN
o IV: extralymphatic metastasis (lung/ liver)
Treatment
Orchidectomy
Radiotherapy
Chemotherapy
LN dissection
6. Testicular torsion
Presentation & finding
Acute severe testicular pain
Poorly localized central abdo pain
Vomiting (sometimes)
Testis is tender, swollen & hang higher up
Scrotal skin becomes red, hot & edematous in later stage
Palpation may feel the twisted cord
Pain is increased or no improvement by raising the testis
103

UNIMAS

Gen05

Treatment

Surgery Tactic

UNIMAS

Untwist without operation (if detect early)


Untwist during operation. Untwisted testis is then sutured to tunica vaginalis or placed into a dartos pouch
to prevent recurrence

7. Acute epididymo-orchitis
Primarily an infection of the epididymis but then spread into testis
Organism: Chlamydia/ gonococcus/ E coli
May be asoc with UTI
Presentation (similar to testicular torsion)
Acute severe testicular pain
Scrotal skin red, hot & edematous
Pain is decreased by raising the testis

104

Gen05

13. Leg ulcer

Surgery Tactic

1. Venous ulcer (70%) STASIS


Varicose vein
Deep vein thrombosis
2. Arterial ulcer (20%) ISCHEMIC
Large artery (atherosclerosis/ embolism)
Small artery (burgers ds/ Raynauds ds/ scleroderma/ embolism/ physical agent)
3. Neuropathic u.
Peripheral neuropathy (diabetic foot/ alcoholic peripheral neuritis/ leprosy)
Spinal cord lesion (spina bifida/ tabes dorsalis/ syringomyelia)
4. Traumatic u.
Where skin is closely applied to bony prominence eg Malleoti, back of heel
Plaster sores & bedsores may be included
5. Primary infective u.
Pyogenic u/ syphilis u/ Bainsdale u (Mycobacterium ulceran)
6. Neoplastic u.
Malignant melanoma
Epithelioma
Scc (marjolin ulcer)
7. Ulcer due to physical/ chemical agents
Cold injury/ radiation/ insect bite
8. Self inflicted u.
Injury to skin by scratching or cutting most often in those who are psychologically abnormal
9. Tropical u.
Seen in travelers returning from tropical areas
Fungal infection/ cutaneous Leishmaniasis

105

UNIMAS

Gen05

Surgery Tactic

Differentiating ulcer types


Ulcer
Site
Base
Margin
Skin

Discharge

Venous
Gaiter area
- lower medial 1/3

Beefy red
Shallow
Irregular

Red & warm


Edematous
Pigmentation
May have v. vein
Copious

Arterial
Pressure area
- Tip of toe
- Heel
Gray or yellow
Deep
Regular
punched-out
Pale/ gray/ black & cold
No edema

Minimal

UNIMAS

Diabetic
Pressure area
- Toes

Necrotic
Deep
Undefined
punched-out
Dry, thin
Normal blood supply

Infected
- Purulent
Others
- No drainage
Painless

Present

Pain

Pulses

Mild aching
Relieved by elevation

Present (may be difficult


to palpate if edema)

Severe
Aggravated by elevation
Relieved by dependency
Absent

Investigation

Urine routine exam (eg glucose)


Blood (FBC/ glucose)
Culture & sensitivity
Biopsy
Vascular ix (any vascular condition: eg VV/ DVT/ leg ischemia)
Doppler USG ABPI (ankle-brachial pressure index)
Colour duplex can produce image compared to Doppler
Angiography

106

Gen05

Treatment

Surgery Tactic

UNIMAS

1. Venous ulcer
Proper dressing (keep moist)
Compression bandaging
Leg elevation
Operation
Skin grafting
Perforator ligation
Long & short saphenous ligation (superficial incompetence)
Local antibiotic should be avoided due to danger of resistant organism growth. Systemic antibiotic only
required if there is cellulitis, lymphadenitis
2. Arterial ulcer
Treat the cause
Stop smoking
Arterial reconstruction (bypass) surgery
Lumbar symphatectomy (dilate skin vessel)
Treat the ulcer & limb
Wound dressing/ drainage/ debridement
Analgesic
Antibiotic
Amputation to save life
3. Diabetic ulcer
Control glucose
Proper foot wearing
Control infection
Minor infection: early oral antibiotic
Spreading infection: admitted (parenteral antibiotic/ excision of necrotic tissue)
Surgery
Simple desloughing
Major amputation

107

Gen05

VARICOSE VEIN

Surgery Tactic

Definition

Dilated, tortuous & elongated superficial veins in the lower limb


Due to damaged & incompetent of the venous valves
Woman > man

Causes
1. Primary: idiopathic
2. Secondary
Venous return obstruction
Pregnancy
Fibroid
Ovarian cyst
Pelvic tumor (ovary/ uterus/ cervix/ rectum)
Ascites
Abdominal lymphadenopathy
Iliac vein thrombosis
Valve destruction
DVT
High pressure flow
Arteriovenous fistula
Signs & symptoms

Aching leg after standing


Relieved by elevation
Poor cosmetic appearance
Leg ulcer
Venous eczema
Ankle edema
Recurrent superficial thrombophlebitis

Treatment

Bandage
Sclerotherapy
Operation
Ligation of the incompetent perforator site
Removal of varicosities
108

UNIMAS

Gen05

DVT (DEEP VEIN THROMBOSIS)

Surgery Tactic

Pathophysiology
1. Stasis
2. Vein wall abnormalities (trauma/ inflammation)
3. Blood disorder (hypercoagulability/ increase viscosity)
Predisposing factors

Previous venous thromboembolism


Trauma & surgery
Immobility (post-op)
General or regional anaesthesia (cause venous stasis)
Cardiac failure
Venous return obstruction (pregnancy/ pelvic mass)
Lower limb fracture
Increasing age
Dehydration
Blood disorder (hypercoagulability)
High-estrogen OCP

Presentation

Pain & tender


Swelling
Warm
Homans sign (calf pain on passive dorsiflexion of the foot)
Phlegmasia alba dolens (painful white leg)
Phlegmasia caerulea dolens (painful blue leg due to venous infection)

Treatment
1. Prophylaxis
Reduce weight (if over-wt)
Compression stocking during pre-op & post-op for major surgery patient
Leg elevation after operation
Encourage exercise

109

UNIMAS

Gen05

Surgery Tactic

2. Conservative
Elastic stocking
Leg elevation
Anticoagulant (heparin)
Fibrinolitic agent (streptokinase, t-PA tissue plasminogen activator)
3. Operation
Thrombectomy (clot sucked out or pulled out with balloon catheter)
Inferior vena caval placation
Caval umbrella filters

110

UNIMAS

Gen05

LOWER LIMB ISCHEMIA

Surgery Tactic

Classification
Acute (<14 days)
Acute on chronic (worsening ischemic features <14 days)
Chronic (>14 days)
1. Acute limb ischemia (d/t EMBOLISM/THROMBUS)
Features (6P)
Pain
Paraesthesia
Perishing cold
Pallor
Pulseless
Paralysis
Treatment

Anti-coagulant (e.g. IV heparin)


Thrombolytic agent (Streptokinase /tPA: tissue plasminogen activator)
Embolectomy
Arterial reconstruction (e.g. femoral-popliteal or femoral-tibia bypass)

2. Chronic limb ischemia(d/t ATHEROSCLEROSIS)


4 stages (Fontaine classification)
I : asymptomatic
II: intermittent claudication (noncritical)
III: rest pain (subcritical)
IV: ulcer or gangrene or both (critical)
Treatment

Advice : exercise, stop smoking, reduce weight


Balloon angioplasty
Reconstructive arterial surgery (bypass)
Amputation
Others
pain relief
vasodilator
lumbar sympathectomy
111

UNIMAS

Gen05

Surgery Tactic

Discussion

UNIMAS

1)
Pain from limb ischemia
> severe
Pallor
Cold
No swelling
Pulselss (periphery)

Pain from DVT


< severe
Red
Warm
Swelling / edema
Peripheral pulse present

Intermittent claudication
Pain at calf
During walking

Rest pain
Pain at foot or toe
Worse at night which wakes patient from
sleep
Relieved by hang the leg over side of bed

2)

Relieved by rest

3) ABPI ( ankle brachial pressure index)


o Measured by using handled Doppler
o ABPI= ankle brachial/pressure index
o Index
> 0.95
= normal
O.4-0.9
= intermittent claudication
0.15-0.4
= rest pain
<0.15
= critical
4) Site of arterial pulsation of lower limb
Femoral
Mid-inguinal point
Popliteal
Knee flex, hell on couch, thumbs on tibial tuberosity, finger on popliteal fossa
Anterior tibial
Midway between 2 malleoli, above ankle joint
Posterior tibial
Midway between medial malleoli &archilis tendon
Dorsalispedis
Proximal end of the groove between 1st and 2nd toe, just lateral to tendon of extensor
hallucislongus

112

Gen05

14. Disorder of the skin

Surgery Tactic

UNIMAS

Sebaceous cyst= Epidermoid cyst = Dermoid cyst


1. Dermal swelling covered by epidermis
2. Contain cheesy white epithelial debris, NOT sebum
3. Common in hair bearing area
4. Arise from blockage of hair follicle
5. SOFT, SMOOTH hemisphere swelling, skin cant be moved
6. Small surface punctum often seen
7. Infection hot, red, painful
8. Sebaceous horn formation
9. Calcification
10. Ulceration Cocks peculiar tumor
Lipoma
1.
2.
3.
4.
5.
6.

Slow growing benign tumor of fat tissue


Lobulated soft mass
Enclosed by thin fibrous capsule
Mostly in fatty tissue between skin and deep fascia
Can occur in dermis
Can occur in fat of intermuscular septa, more firm and diffuse which become prominent when muscle
contract
7. Free mobility of overlying skin
8. Painless, if repeated trauma fat necrosis hard + painful
9. Radiolucent
10. Soft tissue X-ray can be diagnostic
11. Should be removed
12. Indication of removal : causing trouble on account of its site, size, appearance, pain
13. Dercums disease ( adiposis dolorosa ) tender deposit of fat esp in trunk
14. Sarcomatous changes esp in large lipoma of thigh, shoulder, retroperitoneum
15. Cx (long duration) : Myxomatous degeneration, saponification, calcification
16. Slipping sign +ve
17. Fluctuation test +ve (due to softness not fluid)
18. Transluminate only when large enough

113

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DD of lipoma
1.
2.
3.
4.
5.
6.
7.
8.
9.

Surgery Tactic

UNIMAS

Liposarcoma
Fibrosarcoma
Rhabdomyosarcoma
Neurofibroma
Neurilemmoma
Sebaceous cyst
Hemangioma
Dermoid cyst
Ganglion

Ganglion
1.
2.
3.
4.
5.
6.

Cyst lined by compressed fibrous tissue


Contain gelatinous fluid
Communicate with synovial membrane or tendon sheath
Mostly on the dorsum of wrist or foot
High recurrent rate
Theories of pathogenesis
a. Myxomatous degeneration of connective tissue
b. Leakage of synovial fluid with 2ndary fibrous encapsulation
c. Extrasynovial benign synovioma

Dermoid cyst
1. Congenital (inclusion dermoid cyst) common at sites of closure of embryonal fissure: End angle of orbit
(external angular dermoid), midline of neck, abdomen, scalp
2. Implantation dermoid common in hand
3. Lined by squamous epithelium
4. Contain sebum
5. Congenital type may contain hair, sweat glands etc
6. External angular dermoid is the commonest congenital dermoid
Basal cell Ca
1.
2.
3.
4.
5.
6.

Also known as rodent ulcer


Spread slowly by field fire pattern
Locally malignant can go deep
Rarely metastasize
Middle third face area
Hard pearly nodule central ulcer with raised rolled edge
114

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7. Biopsy
8. Radiotherapy cure over 90%
9. Surgical excision + skin grafting in
a. Recurrent
b. Involve muscle, cartilage, bone
c. Closure to cartilage or eyes

Surgery Tactic

Squamous Cell Ca
1.
2.
3.
4.
5.
6.
7.
8.

Affect any area esp exposed part ( ear, cheek, lower lip)
Common in area of epithelial hyperplasia or keratosis
Analogous to leukoplakia in mucosa (lips)
Hard erythematous nodule which proliferate to form cauliflower like excrescence
Ulcerate to form malignant ulcer
Raised fixed hard edge
Keratin pearl/nest on histology
Early lymphatic involvement

Malignant melanoma
1. Predominantly disease of fair skinned individual
2. Expose to sunlight
3. Common in female
4. Lower leg
5. 50% arise in pre-existing naevus
6. Essential feature: invasion of dermis by proliferating melanocytes
7. Spread rapidly by blood
8. Lymphatic spread also
9. In-transit phenomena. (form painless nodules in subcutaneous along the track of lymphatic)
10. 3 types:
a. Melanotic freckle (lentigomaligna)
b. Superficial spreading melanoma
c. Nodular melanoma
11. Superficial spreading is the commonest
12. Nodular melanoma has a worst prognosis

115

UNIMAS

Gen05

Surgery Tactic

Cardinal symptoms of malignant change in a mole


1.
2.
3.
4.
5.
6.

Change in skin surface ( loss crease, rough, scaly)


Itching
Increase in size, shape, thickness
Change in color
Bleeding
Evidence of local, distant spread

C. Surgical care

Metabolic response to injury


Trauma/ ATLS
Shock
Fluid & electrolytes balance
Asepsis & antisepsis in surgery
Blood transfusion
Surgical nutrition
Wound healing
Surgical complications
Instruments

116

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Gen05

1. METABOLIC RESPONSE TO INJURY

Surgery Tactic

UNIMAS

Injury = includes trauma, hemorrhage, major sepsis, burns


Summary of main event occurs within 48 hours of major injury:
Neuroendocrine response
1.
2.
3.
4.
5.

Cytokine response

Cortisol
Adrenaline
Glucagon
ADH
Aldosterone

1. IL-1
2. IL-6
3. TNF

Metabolic response
1.
2.
3.
4.
5.
6.
7.
8.

Tachycardia and pyrexia for 24-48 hours


Elevated energy expenditure
Increase substrate cycling
Muscle catabolism (breakdown) and nitrogen loss
Adipose tissue breakdown
Sodium and water retention
Leukocytosis, acute phase response
Hypercoagulablehypocoagulable

117

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Factors that initiate the metabolic response

Surgery Tactic

UNIMAS

Fluid loss
Afferent nerve stimuli (pain)
Bacteria and endotoxin
Pro-inflammatory cytokine response
Activated neutrophils and monocytes

Factors that modify the metabolic response

Severity of injury
Co-existing ds ( cancer, renal failure)
Infection
Nutritional status
Ambient temperature
Anaesthesia and drugs
Miscellaneous ( complications, metabolic demand)

2. TRAUMA /ATLS
ATLS: advanced trauma life support
Trauma team: 4 doctors, 5 nurses, 1 radiographer
Primary survey
Airway and cervical spine control
Breathing
Circulation and hemorrhage control
Dysfunction of the CNS
Exposure and environmental control
Treatment of shock / other emergency ( tension pneumothorax, cardiac tamponade, flail chest)
Secondary survey
History
Exam
Ix
Dressing
Refer to appropriate specialist team

118

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Surgery Tactic

3. SHOCK

UNIMAS

Definition: regardless of the underlying cause, shock is characterized by an acute alteration of the circulation
in which inadequate perfusion leads to cellular damage and dysfunction of major organ system.
Causes
a.
b.
c.
d.
e.
f.

Hypovolemia
Sepsis
Pump failure
Anaphylaxis
Neurogenic
Endocrine

A. Hypovolemic shock

1.
2.
3.
4.
5.

Causes
Hemorrhage
Loss of GI fluid ( vomiting, diarrhea, fistula, intestinal obstruction, fluid sequestration)
Trauma and infection (inflammationedema)
Burns
Renal loss (nephritis, diabetic ketosis, Addisonian crisis)

1.
2.
3.
4.
5.

Clinical features
Results from loss of circulating volume tissue hypoxia and excessive sympathetic stimulation,
Pale, restless, confused
Peripheral; rapid thready pulse, cold extremities, collapsed veins, prolong capillary filling time
Respiratory rate increased early as result of chemoreceptor activity
Low urine output

119

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B. Septic shock

Surgery Tactic

UNIMAS

Pathophysio:
1. Most frequently gram ve (but can be due to gram +ve and fungi)
2. Endotoxin from bact cell wall most important. Derived from:
o Organism at site of function
o Gut organism following ischemic damage to the mucosal barrier
3. Haemodynamic response : loss of tone and vasodilation fall in systemic vascular resistant
4. Reflex increase in cardiac output produce a hyperdynamic circulation (early stage)pt appear well with
pink perfused extremities
Clinical features
Early
Restlessness & slight confusion
Tachypnea
Tachycardia
Low systemic vascular resistant (SVR)
High CO
BP normal or slight decrease
Oliguria
Blood lactate increase
Warm dry suffused extremities

Late
Decreased conscious level
Tachypnea
Tachycardia
High SVR
Low CO
BP lower than 80
Oliguria
Blood lactate increase
Cold extremities

120

Gen05

4. FLUID& ELECTROLYTES BALANCE

Surgery Tactic

Normal value
135 145
3.5 5.3

Na
K
H2O

UNIMAS

Daily requirement
2 mmol/kg
1 mmol/kg
38.5 mmol/kg

To calculate how much a pt need:


For Na:
{Deficit x Wt x 0.6 } + Daily requirement
2

For K:
{Deficit x Wt x 0.3} + Daily requirement
2
Example:
50kg male with Na 130, K 3.0
Na: {135-130} x 50 x 0.6 + (50 x 2)
2

121

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INTRAVENOUS SOLUTION
Characteristics

Normal saline
Isotonic crystalloid

Content

Na 150 mmol/L
Cl 150 mmol/L
Water for injection

Indication

Isotonic dehydration
NaCl depletion
Hypochleromic

Contraindicating Hyperhydration
Hypertension
Hypertonic
dehydration
Hypotonic
dehydration
Acidosis
Hypernatremia
Hypokalemia

Surgery Tactic

Hartmanns/ Ringers lactate


Isotonic crystalloid. Contain lactate
thus having a slightly alkalinizing
effect
Na lactate
NaCl
KCl
CaCl
Isotonic dehydration
Na depletion
Loght metabolic acidosis
Hyperhydration
Hypertension
Hypertonic dehydration
Hypotonic dehydration
Alkalosis
Renal insufficiency
Hyperlactemia

122

UNIMAS

Dextrose 5%
Hypotonic crystalloid

Dextrose anhydrase
(caloric value 200 kcal/L)

Energy supply
Hypertonic
Dehydration
Hypoglycemia
Hyperhydration
DM
Glucose intolerance
Hypokalemia

Gen05

Surgery Tactic

5. ASEPSIS & ANTISEPSIS IN SURGERY

UNIMAS

Methods of sterilization
1.
2.
3.
4.
5.

Autoclave- steam under pressure (132oC at 2.2 atmosphere for 3 min)


Ethylene oxide gas (effective but rarely used because of explosive)
Ionizing radiation (for disposable instrument and sutures)
Glutaraldehyde (disinfect endoscope)
Other agents
a) Scrub: Chlorhexidine, Povidone-iodine
b) Skin preparation: Chlorhexidine, Povidone-iodine, Alcohols, Hexachlorophene
c) Instrument: Cetrimide, Hypochlorites
d) Hand washing: Cetrimide, Hexachlorophene

6. BLOOD TRANSFUSION
** All blood product need ABO
compatibility except albumin &
immunoglobulin

Donor
Whole Blood

Packed Cell

Plasma

Platelet

Fresh frozen plasma

Cryoprecipitate

123

Albumin/
Immunoglobulin

Gen05

Blood products:

Surgery Tactic

UNIMAS

1. Whole blood
a) + Citrate anticoagulant
b) + Phosphate, Dextrose, Adenine nutrient
c) Max 30 days at 4 +/- 2oC
d) Hemostatic properties decline, platelet dysfunction
e) When large volume replacement needed (Major trauma)
f) Not in chronic anemia pt
g) Not sterile, carry risk of infection that are not detected by donor screening.
h) Need ABO and Rh(D) compatibility
2. Packed cell
a) Remove plasma until 65%-75% hematocrit
b) Final volume 300ml
c) Ideal for chronic anemia pt
d) Risk of infection, storage, safeguard all same with whole blood
e) 1 pine of packed cell increase
3. Platelet concentrate
a) 50-60ml of platelet from one whole blood (centrifugation)
b) Store on an agitator for 5 days 2-24oC
c) Greater risk of infection bcz 1 pint is a combination of 6 donors platelet concentrate
d) Bacteria contamination more likely since its not refrigerated
e) Need ABO and Rh compatibility bcz contain some RBC
f) Indication:
Thrombocytopenia, defective platelet function, microvascular bleeding in pt receive massive
blood transfusion (Oozing from mucous membrane, needle puncture site and wounds)
4. Fresh frozen plasma
a) 200-300ml plasma removed from donation within 6 hours
b) Frozen at -30oC, can store up to a year
c) Thaw to 37oC when use
d) Contain Albumin, immunoglobulin, all coagulation factors
e) Must be ABP compatible. Average adult dose: 3-4units
f) Indication:
Multiple coagulation defects (DIC)
Single factor replacement when heat-treated product not available
Overdose of anticoagulant warfarin

124

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Surgery Tactic

5. Cryoprecipitate
a) 1 unit of cryo can be removed from FFP after control thawing
b) Contain fibrinogen, factor VII, fibronectin
c) Adult dose 1C units, 10 donors exposure
d) Indication:
Fibrinogen level low, bleeding assoc w uraemia, some vWD
6. Factor VIII and IX concentrate
a) Treat VIII and IX deficiency
7. Human immunoglobulin

Autologous Transfusion
Use patient own blood, 4 ways:
1. Pre-operative donation
a) Blood withdrawn before elective surgery can store up to 35 days
b) Up to 5 unit can be made available
c) Contraindication: sepsis & severe myocardial ds
2. Isovolemic haemodilution
a) Up to 1.5L of blood withdraw just before anesthesia
b) Replace with saline
c) Reinfuse during/after surgery
3. Cell salvage
a) Blood collect from operation site and processed by a cell salvage machine
b) Contraindication: malignancy & sepsis
4. Long-term storage
a) For rare blood group patient

125

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Gen05

Adverse effect of blood transfusion

Surgery Tactic

UNIMAS

1. Acute haemolytic transfusion reaction (ABO)


a) 1 in 2000
b) Very shortly after transfusion and few ml can be fatal
c) Distress, pain at infusion site, flushing, abdominal pain, loin pain, breathlessness
d) Hypotension, DIC, oliguria ARF
e) Stop transfusion immediately
2. Delayed haemolytic transfusion reaction
a) After 5-10 days
b) Fever, haemoglobinuria, fall Hb level
c) 1 in 500
d) Kidd, Duffy, Rhesus antibodies are implicated
3. Febrile non-haemolytic transfusion reaction
a) Fever and rigors
b) Esp in those with multiple transfusion
c) Recipient white cell antibody act against donors leucocyte
d) Usually mild, can be treated with Paracetamol
4. Alloimmunization
5. Allergic reaction (due to plasma reaction)
6. Cardiac failure (volume overload)
7. Iron overload
a) Each unit of blood contain 200mg, only 1mg excreted daily
b) Iron accumulates in liver, heart and endocrine organ
c) Treat with chelation therapy
8. Graft vs Host Reaction
a) Rare, happen in immunocompromised patient
b) Due to viable lymphocytes from donor
c) 1-4 weeks later with fever, desquamating rash, abN liver function, neutropenia, mortality rate
80%
d) Prevent by irradiating cellular blood components before transfusion

126

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Surgery Tactic

UNIMAS

9. Transfusion-associated lung injury


a) Very occasionally, donors antibodies react with recipient leucocyte
b) Acute breathlessness, fever, chills, CXR shows nodular infiltration of the hilum and lower lung
field
c) Assisted ventilation may be needed
10. Infections
a) Hepatitis B
b) Hepatitis C
c) HIV
d) CMV

127

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7. SURGICAL NUTRITION

Surgery Tactic

UNIMAS

Nutritional Status
1. Nutrition in surgical pt may be adversely affected by
a) Starvation (effect of ds e.g. esophageal ca restrict intake)
b) Effect of inflammation (increase catabolism)
c) Effect of operation itself
2. Nutritional status is assessed by
a) Weight loss (> 10% loss)
b) Serum albumin
c) Lymphocyte count
d) Mid-arm muscle circumference
3. Four major surgical cause of intestinal failure are
a) Short bowel syndrome (result from massive small bowel resection)
b) Fistula formation
c) Motility disorder
d) Extensive SI disease (Crohns)
4. Nutritional status may be improved by eliminating the source of catabolism (e.g Sepsis) or inadequate
intake by
a) Encouraging oral intake in those who can eat
b) Enteral and Parenteral support in those who cannot eat
Enteral Feeds
1. 2 ways: NG tube/ Gastrostomy & Jejunostomy
2. Complications:
Gastric retention
Nausea, vomiting
Diarrhea
Dehydration
Hyperglycemia
Leakage around gastrostomy/jejunostomy
Aspiration
Abd cramps and distention
Gastroenteritis
Hyperosmolar coma
Tube displacement
128

Gen05

Parenteral

Surgery Tactic

UNIMAS

1. Indication: Cant be fed orally, enterally (Intestinal failure)


2. TPN need concentrated solution (irritant, thrombogenic) therefore infused through catheter in highflow veins (e.g SVC)
3. Complications
4. Catheter insertion (pneumothorax, air embolus, and bleeding)
5. Thrombophlebitis
6. Infection and septicaemia
7. Metabolic complications ( e.g Hyperosmolar syndrome, hyponatremia, hypokalemia, deficiency
syndrome, sensitivity reaction, abN liver fx)
8. WOUND HEALING
Definition: A wound is an interruption or break in the continuity of the external surface of body or of the
surface of an internal organ caused by surgery or other forms of injury and trauma.
Stage of Healing

Inflammatory phase (0-3 days)


Proliferative phase (3 days 3 weeks)
Remodeling phase (~ 6 months)

1. Inflammatory phase
Inflammatory response to injury
Increase capillary permeability and a protein rich exudates accumulates
Inflammatory cells migrate into it, dead tissue removed by macrophage and capillaries begin to
proliferate
2. Proliferative phase
Formation of granulation tissue and collagen (Fibroplasia)
Tensile strength increase rapidly
Suture can be removed at this phase (Face: 4-5days, Trunk/lower limb: 10-14 days)
3. Remodeling phase
Continuous reorientation and maturation of collagen fibres
Types of Wound Healing
1. Primary intension
Clean surgical incision
Minimal tissue loss
Minimal bacterial contamination
Edge reapproximated without tension
129

Gen05

Surgery Tactic

2. Secondary intension
More extensive defect between the edges
Tissue loss or injury (surgical excision/trauma)
OR heavy wound contamination kept edges apart
More fibrin exudation and more necrotic tissue
Prolong inflammatory phase w greater granulation tissue
Wound contracture reduce size of wound

UNIMAS

Factors affect wound healing


Local
Blood supply
Bacteria contamination
Foreign body
Presence of necrotic tissue
Tension and oedema
Excess mobility
Radiotherapy

Systemic
Old age
Nutritional def (Vit C, Protein)
Steroid therapy
DM
Malignancy
Smoking
Immunosuppression
Genetic ds (Ehlers-Danlos)

Complications

Infection
Dehiscence
Fibrosis
Hypertrophic scar/Keloid

Classification of wound
1. Clean: Non-traumatic, no break in surgical technique, no septic focus, no viscus opened (e.g hernia
repair)
2. Clean-contaminated: Non-traumatic, minor break in surgical technique, contaminated entry into a
viscus w minimal spillage (e.g elective cholecystectomy)
3. Contaminated: Traumatic wound or major break in surgical technique or significant spillage from an
open viscus, or acute inflammation encounter (e.g emergency appendicectomy)
4. Dirty: Traumatic wound from a dirty soure, or delayed treatment, or when significant bacterial
contamination or release of pus encountered (e.g emergency surgery for faecal peritonitis)

130

Gen05
9. SURGICAL COMPLICATION

Surgery Tactic

UNIMAS

1. Hemorrhage
- Primary H
:During operation
- Reactionary H
: within 24 hrs, usually 4-6 hrs.
- Secondary H
: 7-14 days
- How to control bleeding in operation?
o Direct compression
o Clamping
o Diathermy
o Suture
o Ligature
2. GIT
a.
b.
c.
d.

Paralytic ileus
Nausea & vomiting
Diarrhea
Constipation

3. Respiratory complications
a. Pulmonary collapse (Paralysis of silia by anaesthesia, impairment of diaphragm, over-sedation,
abdominal distension, wound pain)
b. Pulmonary infection (follow pulmonary collapse)
c. Treat by physiotherapy, oxygen and antibiotics
4. Renal failure/retention of urine (result from protracted inadequate perfusion of kidney)
5. DVT
10. INSTRUMENTS
1.
2.
3.
4.
5.
6.
7.
8.

Endotracheal tube
CBD (foleys catheter, cystofix)
T-tube
NG-tube
Chest tube
Colostomy
Scissors and forceps
Sutures
131

Gen05

Surgery Tactic

UNIMAS

1. Endotracheal intubation (ETT tube)


i. Indication
a. Apnoea or acute airway obstruction (eg. Asthmaticus)
b. Hypercapnoea/Respiratory failure
c. Unconscious (Coma, GA)
d. Severe head or facial injury
e. Surgical condition affecting chest (eg. Lung operation)
f. Tracheal and laryngeal trauma
g. Stridor
h. Pt prone to vomiting
ii. Criteria b4 doing
a. Suction
b. Airway
c. Laryngoscope
d. Endotracheal tube
e. + Pre-oxygenate the patient
f. + Check balloon competent or not
g. + Check laryngoscope light
iii. Procedure
a. Hold laryngoscope with left hand.
b. Open pt mouth, insert laryngoscope fr right side of the mouth.
c. Push tongue to the left, base of tongue lifted.
d. Go interior to the epiglottis, epiglottis lifted & will see vocal c.
e. Push the tube in, once the balloon pass the vocal cord, inflate the balloon to fix it.
f. Fix it around the mouth.
g. How to access if theres air coming out? Look for fogging.
h. Tips: Once take up laryngoscope, take a deep breath and start insert the laryngoscope without
changing breath. When u need a breath, stop trying and oxygenate the patient.
iv. How to make sure its in place?
a. Inspect chest wall for equal movement
b. Auscultate for presence & equal breath sound bilaterally
c. Detector of CO2 CO2callorymeter device
d. CXR

132

Gen05
Surgery Tactic
v. Complications
a. Esophageal intubationHypoxiaDeath
b. Local trauma (eg. larynx)
c. Perforation
d. Pneumothorax
e. Gp into Rt bronchus and cz the Lt side collapse
f. Aspiration pneumonia

UNIMAS

vi. Other method (for O2 giving)


Tracheostomy tube
Laryngeal mask

2.1 Foleys catheter


i. Use for CBD (continuous bladder drainage)
ii. Made from latex
iii. 2 or 3 openings
Urine output
Balloon dilatation (use water for injection to inflate the balloon but not NS as it will react with latex)
Drip (if 3 opening)
iv. Indications
a. Perioperative monitoring of urinary output
b. Acute/Chronic urinary retention
c. Aid to abdominal or pelvic surgery
d. Incontinence
v. Equipment
a. Foley catheter (size 12-20G)
b. Dressing/catheter pack containing drapes
c. Cleansing solution
d. Gloves
e. Lignocaine gel
f. Gauze swabs
g. Drainage bag
h. 50ml bladder syringe
i. Specimen pot
133

Gen05
Surgery Tactic
vi. Procedure (male)
a. Wash hand and open the set.
b. Wear glove, hold the penis with gauze and retract prepuce.
c. Clean the penis (povidone-iodine/alcohol).
d. Drape the pt.
e. Prepare syringe with 8ml of water.
f. Catheter assessed by injecting some water, then withdraw it.
g. Connect urine bag to catheter.
h. Catheter put on lubricant and lignocaine.
i. Slowly put into urethra for whole length.
j. Inject water into the balloon.
k. Pull until feel resistance.
l. Replace the prepuce.

vii. Contraindications
a. Urethral injury/ruptured
b. Urethral stricture
c. Use suprapubic catheter instead
viii. Complication
a. Trauma
b. Infection
2.2 Cystofix
1. As suprapubic catheter
2. Indication urethral
Injury
Obstruction
Rupture
3. Complication
Infection
Trauma

134

UNIMAS

Gen05
Surgery Tactic
3. T-tube
1. 3 opening-CBD, Common hepatic duct, Skin
2. Purpose & indication

a. CBD exploration
b. Any injury to CBD
3. Complication
a. Infection
b. Blockage of CBD
c. Fistula formation
4. Conditions where fistula wont close after removal of T-tube
a. Foreign body
b. Radiation
c. Infection
d. Epitheliasation
e. Neoplasm
f. Distal obstruction
5. Usually 7 days after insertion of T-tube, do cholangiogram through T-tube to exclude stone etc.
4. NG-tube/Ryles Tube
1. Size: 16=large, 12=medium, 10=small
2. Purpose & indication
Feeding
o Dysphagia (eg. esoca)
Gastric aspiration
o Intestinal obstruction
o Unconscious pt (prevent aspiration pneumonia)
3. Complications
a. Perforation of stomach
b. Aspiration pneumonia (insect & feed into bronchus)
c. Trauma
d. Pain
e. Loss of electrolytes
f. Oesophagitis
g. Necrosis: retro- or nasopharyngeal
135

UNIMAS

Gen05
4. To confirm position
Inject air & auscultate for air entry
X-ray

Surgery Tactic

5. Chest tube

6. Colostomy

Type
Indication
Appearance
Position
Effluent
Complication

Ileostomy
Permanent only
UC/Crohns
FAP
Spout of mucosa
RLF

Colostomy
Temporary/permanent
Colorectal ca
Diverticular ds
Mucosa sutured to skin
Permanent: RLF
Temporary: RHC
Intermittent

Continuous
Fluid and electrolytes
imbalance

Ischemia
Obstruction
Skin erosion
Recurrent ds at stoma site
Bowel prolapse
Parasternal hernia

136

UNIMAS

Gen05
Two types: Loop colostomy/End colostomy
7.1 Artery forcep (curved/straight)

Surgery Tactic

Clamp the artery to prevent bleeding


Methods of control bleeding
Direct compression
Clamping
Diathermy
Suture
Ligation
7.2 Tooth dissecting forcep

To pick up tissue (eg. skin/fibrous tissue) during


operation
Contraindication pickup
Vessels
Eye tissue
Nerve
Small bowel

Organ (liver/GB)

8. Sutures
Absorbable
Catgut
Vicryl
Dexon
Maxon
PDS

Non-absorbable
Silk
Linen
Stainless steel wire
Nylon
Ticron
Prolene
Goretex

137

UNIMAS

Gen05
D. Clinical Examination
1.
2.
3.
4.
5.
6.
7.

Surgery Tactic

Examination of lump
Examination of abdomen
Examination of breast
Examination of thyroid
Examination of ulcer
Examination of hernia
Examination of varicose veins

138

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Gen05
1. EXAMINATION OF A LUMP

Surgery Tactic

Applied for any lumps


Inspection (7S)
Single multiple (number)
Site (neck/shoulder/leg)
Side (left/right)
Size (vertical x horizontal cm)
Shape (round/oval/irregular)
Surface (smooth/nodular)
Skin (redness/ulcer/pigmentation)
Palpation (ST MRCP F)
State again: single multiple/site/side/size/shape/surface/skin
Temperature (cold/warm)
Tenderness
Transilumination
Margin (well or poorly defined)
Reducibility
Consistency (soft/firm/hard)
Pulsation (transmitted/expansile)
Fluctuation
Fixity (mobile/fix)
Percussion
Less important. Only in certain swelling eg. Hernia
Auscultation
Bruit (esp. in pulsatile swelling)
Other relevant
Regional LN

139

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Gen05
Surgery Tactic
2. EXAMINATION OF ABDOMEN
Exposure
Nipple line to mid-tigh
General exam (May not be necessary)
Hand
o Nail (cyanosis/clubbing/koilonychias/leuconychia)
o Palm (palmar erythema/Dupuytrens contracture)
o Pulse (rate/rhythm/volume/delay)
Face
o Eye (anemia/jaundice)
o Mouth (anemia/hygiene)

UNIMAS

Inspection
Shape: flat/distended (fat, fetus, fluid, feces)/scaphoid/symmetry
Respiratory movementnot move: peritonitis
Umbilicus: displace (upward by pelvic mass/downward by ascites)/inverted (obesity) or everted
(ascites)
Scar
Dilated vein (site & direction)
Pulsationthinpt/AAA/tumor in front of aorta
PeristalsisLt to Rt (SI obstruction)/Rt to Lt (LI obstruction)
Cough impulsehernia(umbilical/inguinal/femoral)
Palpation
Superficial
o Rigidity (soft, guarding)/tender/rebound tenderness/temp/mass
Deep
o Massdescribe as mentioned in Exam of lump
o Liver/Spleen/Kidney
Supraclavicular LNpalpable (Troisiers: gastric ca)
Percussion
Shifting dullness/fluid thrill (gross ascites)
Auscultation
Bowel soundabsent (paralytic ileus/peritonitis), increase (bowel obstruction)
Bruit: liver/spleen/kidney
Other relevant
External genitalia/PR

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Gen05

Guideline

Surgery Tactic

UNIMAS

Specific signs & exam


1. Acute abdomen
Grey turner sign (Lt flank discoloration) & Cullens sign (bluish around umbilicus) a. hemorrhagic
pancreatitis
Boass s (hyperesthesia at tip of scapula) a. cholecystitis
Bed-shaking test peritoni s
A. appendicitis Rovsings s/ Blumbergs/ Psoas s/ cope s/ Straight leg raising s
(pls refer surgical problem acute abdo a. appendicitis)
Murphys sign (catching of the breath during inspiration while the GB area (tip of9th rib) is pressed
by examiners finger) a. cholecys s
Pointing test (ask pt to point out where)
Mc-Burneys point a. appendici s
Tip of 9th Rt costal cartilage a. cholecys s
2. Chronic abdomen
Succession splash (hold pts hip & shake side to side) pyloric stenosis if gurgling sound is heard
3. Abdominal mass
Ask pt to contract abdominal muscle by raise up shoulder & hold the position. Palpate the mass
o > prominent mass arise fr the wall
o Disappear or smaller intra-abdominal mass
Refer surgical problems Mass in abdomen for:
Differentiate liver & GB mass
Differentiate spleen and kidney mass
Causes of hepatomegaly

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Gen05

EXAMINATION OF BREAST

Surgery Tactic

Exposure
Whole of upper half
Position
Inspection (sitting)
Palpation (45/ lying with shoulder supported by pillow)
LN (sitting)
Inspection
Breast (symmetry: position/ size/ shape)
Skin (colour/ prominent veins/ dimpling/ peau dorange/ nodule/ ulcer)
Nipple (presence/ position: compare both/ retraction/ ulcer/ discharge)
Areola (colour/ size/ eczema/ ulcer/ discharge)
Arm and thorax (cancer en cuirasse/ brawny edema/ edematous arm)
Axilla & supraclavicular fossa
Raise arms
Hands on & against hip
Bending forward
Palpation
Start with normal site. Palpate with palmer of finger by hand flat
4 quadrant + axillary tail + nipple
Lump
- Single multiple/ site/ side/ size/ shape/ surface
- Temp/ tenderness/ transilumination/ margin/ consistency/ fluctuation
- Fixity
Skin (pinch-up the skin or slide it over the lump)
Tissue (hold the breast & try to move the lump)
Muscle (compare mobility for relaxes & press on hip)
Chest wall (fixed irrespective contraction of any muscle)
Palpate nipple and press
- Discharge (blood/ pus/ serous/ greenish/ milky)
Examination of LN
Axillay
- From the front : pectoral/ central/ apical/ brachial
- From behind : subscapular
Supraclavicular

Associated examinations
Liver/ rectal/ vaginal
142

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Gen05

Guidelines
Skin
-

Surgery Tactic

UNIMAS

Red & edematous infec on/ mas s


Veins phylloides/ rapid growing sarcoma/ huge breast abscess
Dimpling Ca (pulled in by underlying neoplasm)
Peau dorange Ca (lympha c blockage causes edema which deepens the mouths of sweat glands
& hair follicles)
Ulcer advanced Ca

Nipple
- Destroyed Pagets disease
- Drawn upward Ca
- Retraction Ca
Areola
-

Pink in young girl/ darker in adult


Larger: huge swelling of soft fibroadenoma/ smaller: scirrhous. Ca
Eczema Pagets disease (if unilateral)
Mont. tubercle (enlarged Mon. gland) pregnancy/ lacta on

Arm & thorax


- Edema lympha c obstruc on (tumor inltra on/ a er mastectomy)
Palpation start fr normal breast: have to know the normal texture 1 st as it may vary fr woman to woman
Lump
-

Smooth (fibroadenoma/ irregular Ca)


Hot & tender inamma on
Well-define (cyst/ fibroadenoma)/ ill-define (Ca/ fibroadenosis)
Soft (cystic)/ firm (fibroadenoma/ fibroadenosis)/ hard (Ca)
Fluctuant cyst/ abscess/ lipoma
Mobile (fibroadenoma breast mouse)/ xed (Ca)

Discharge
- Blood Ca/ duct papilloma
- Pus breast abscess
- Serous (clear) physiological
- Greenish broadenosis/ ductal ectasia/ perimenopause
- Milk lacta on/ hyperprolac naemia
Palpable nodes Ca mets

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Gen05

EXAMINATION OF THYROID

Surgery Tactic

UNIMAS

General survey
A (alert & activity)/ B (breathing & behavior)/ C (color & condition)
Inspection (neck)
Swelling (goiter/ LN/ others)
Skin (scar/ ulcer/ fistula)
Dilated veins (face/ neck/ upper chest)
Goiter
Inspection
Describe swelling (single multiple/ site/ side/ size/ shape/ surface/ skin/ scar)
Swallowing
Tongue protrusion
Palpation
Size (from measuring) + transilumination test
Stand behind, neck flexed to relax the muscle, palpate lobe by lobe
- Surface (diffuse/ multinodular/ solitary nodule)
- Tenderness
- Consistency (soft/ firm/ hard)
- Fluctuant/ fixity (non mobile suggest malignancy)
- Swallow. Try to get below the gland to exclude retrosternal goiter
- Cervical LN (submental/ submandibular/ preauricular/ postauricular/ occipital/ jugular chain/
supraclavicular/ post. triangle)
Stand in front
- Tracheal position
- Korchers test (push lateral lobe produce stridor)
- Berrys sign (unable to feel the carotid pulse)
Percussion

Percuss manubrium

Auscultation
Bruit as sign of increased vascularity (hyperthyroidism)
Pembertons sign
Ask to raise both arms. Look for facial congestion & resp. distress (test for thoracic inlet
onstruction d/t retrosternal goiter)
144

Gen05

Thyroid status

Surgery Tactic

UNIMAS

Face

Excitement/ nervousness/ agitation/ uninterested/ puffy face

Eyes
Exophthalmus (sclera visible above lower lid/ anterior & superior orbital margin is visible
when look fr behind over pts forehead)
Chemosis (oedema of conjunctiva)
Lid retraction (sclera visible above the cornea)
Ask pt to follow examiners moving finger (H) to test for eyes movement
Lid lag (eyelid cant keep pace with eyeball when looking down)
Ophthalmoplegia (difficulty looking upward & outward)

Hands

Palm (warm/ sweaty/ palmer erythema)


Nails (thyroid acropathy: clubbing/ onycholysis: plummers nail)
Pulse (tachycardia/ atrial fibrillation/ collasing)
Tremor (stretch out arms & pace a sheet of paper)
(test for proximal myopathy by testing shoulder abduction)

Legs

Pretibial myxoedema
(test for proximal myopathy by testing hip flexion & squatting)

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Gen05

Guidelines

Surgery Tactic

UNIMAS

Nervous excibility, thin thyrotoxicosis


Obese, puffy face hypothyroidism
Pizzillos method pt asked to place hands behind head & push head backward to render inspection
(swelling) easier
Neck swelling:
Midline: goiter/ thyroglossal cyst/ LN (submental)/ dermoid cyst/ lipoma
Lateral (ant ): gland (parotid/ submandibular)/ LN/ carotid a. aneurysm/ carotid body tumor/ brachial
cyst/ sternomastoid tumor/ lipoma
Lateral (post ): LN/ subclavian a. aneurysm/ cystic hygroma/ pharyngeal pouch/ cervical rib/ lipoma
Move up w swallowing goiter/ thyroglossal cyst
Move up w tongue protrusion thyroglossal cyst
Diffuse simple (physio/ iodine def/ goitrogen)/ toxic (1 thyrotoxicosis (graves disease))
Multinodular iodine def (simple)/ 2 thyrotoxicosis
Solitary nodule thyroid cyst/ mul nodular/ hemorrhage/ adenoma/ Ca/ one whole lobe enlarge eg
hashimoto
Tender thyroidi s/ late malignant
Consistency so (colloid g), rm (1 thyrotoxicosis/ hashimoto), hard (malignant/ calcica on of cyst/
Riedls t)
Fixed malignant/ chronic thyroidi s
Kochers test +ve obstructed trachea
Berry sign +ve malignant tumor engulf caro d sheath
Dull retrosternal goiter
Systolic bruit 1 thyrotoxicosis (graves disease)
Exophthalmos eyeball pushed forward d/t edema or increase fat
Lid retraction over ac vity of levator palpabrae superioris muscle
Ophthalmoplegia weakness of ocular muscle (sup & lateral rectus inf oblique) d/t edema cellular
infiltration

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Gen05

EXAMINATION OF ULCER

Surgery Tactic

Inspection
Single multiple/ site/ side/ size/ shape/ skin/ surrounding (hair/ nail/ muscle)
Discharge: smell/ quantity/ quality (serous/ sanguineous/ purulent...)
Edge
Slopping
: healing u/ venous u
Punched out : syphilitic/ trophic
Undermined : TB
Rolled
: basal cell ca
Everted
: SCC
Floor
Red : healing & healthy
Pale : slow healing
Black : malignant melanoma
Slough : gummatous u
Bone : trophic u
Palpation
Tenderness/ temperature
Base (feel the hardness)
Depth (record in mm)
Fixity (fix gummatous u/ malignant)
Surrounding
Sensation (present/ absent)
Peripheral pulses
Regional LN

147

UNIMAS

Gen05

EXAMINATION OF HERNIA

Surgery Tactic

Position
Start with pt standing & exposed fr umbilicus to mid-thigh
Inspection
Swelling
- Single multiple/ site/ side/ size/ surface/ shape/ skin
- Extension (groin/ scrotum)
- Peristalsis
- Coughing impulse
Palpation
State again: single multiple/ site/ side/ size/ surface/ shape/ skin
Temperature/ tenderness/ consistency
Testis & spermatid cord
Extension (relation to ing. lig & pubic tubercle)
Get above the swelling (esp scrotal swelling)
Patient lying down
- Reducibility
- (3 fingers test Ziemans technique)
- (invagination test)
Patient standing up
- Ring occlusion test (thumb on deep ing. ring & ask pt to cough)
Percussion
Dull/ resonant
Auscultation
Peristaltic sound
Assoc. Examination
Abdomen (intestinal ostruction)
Rectal (chronic constipation/ enlarged prostate)
Chest (chronic cough)

148

UNIMAS

Gen05

Surgery Tactic

UNIMAS

Guidelines
Groin inguinal h/ femoral h/ LN/ sapheno varix/ femoral artery aneurysm/ undescended testes/
ectopic testes/ psoas abscess/ lipoma
Scrotal indirect inguinal h/ spermatocele/ hydrocele/ hematocele/ varicocele/ testicular tumor/
testis torsion/ epididymitis/ epididymo-orchitis
Umbilicus umbilical hernia/ paraumbilical hernia
Shape pyriform (indirect)/ spherical (direct)
Skin red strangulated
Peristalsis enterocele (content bowel)
Coughing impulse evidence of hernia except obstructed
Warm & tender strangulated
Elastic (enterocele)/ doughy (omentocele)
Normal palpable testis & spermatid exclude tes s sperma d origin
Above ing. lig & medial to pubic tubercle inguinal h
Below ing. lig & lateral to pubic tubercle femoral h
Get above scrotal origin
Reduce spontaneously on lying down (direct)/ reduce manually (indirect)/ irreducible (obstructed h/
not a hernia)
Ziemans technique. Impulse on:
- Index finger (deep ring) indirect h
- Middle finger (superficial ring) direct
- Ring finger (saphenous opening) femoral h

Invagination test. Impulse on:


- Finger tip indirect
- Finger pulp direct

Ring occlusion test


No bulge out indirect

Dull (omentocele)/ resonant (enterocele)


Peristaltic sound omentocele

149

Gen05

Surgery Tactic

EXAMINATION OF VARICOSE VEIN (LOWER LIMB)

UNIMAS

Exposure
Uncovered from umbilicus downward
Position
Patient standing
Inspection
Varicosities
Site/ side/ size/ extent
Skin & surrounding (esp. gaiter area)
Colour/ eczema/ pigmentation/ ulcer/ scar/ ankle edema/ loss of hair/ increase brittleness of nails
Palpation
Mark the varicosities
Skin lipodermatosclerosis (pi ng edema/ thickening/ tenderness)
Cough impulse
Patient lying down & elevate the leg to empty the varicose vein
Fegans method
Tourniquet or Trendelenburg
(Perthes test)
Percussion
Patient in standing position
Tap teh vv & feel the wave by another finger at saphenous opening
OR finger tap on upper limit & other finger feel at lower limit of the varicose vein
Auscultation
Bruits (suggest arteriovenous fistula)
Other relevant
Examination of abdomen/ PR/ vagina (to look for cause for vv)

150