xiv Surgery Essence

SECTION 7: NEUROSURGERY

Contents 33.
34.
Cerebrovascular Diseases
CNS Tumors
833
856

SECTION 8: HEAD AND NECK

Image Based Questions
Annexures i-xxvi 35. Oral Cavity 877
36. Salivary Glands 892
SECTION 1: ENDOCRINE SURGERY 37. Neck 908
38. Facial Injuries and Abnormalities 918
1. Breast 3
2. Thyroid 48 SECTION 9: ONCOLOGY
3. Parathyroid and Adrenal Glands 87
39. Oncology 929
SECTION 2: HEPATOBILIARY PANCREATIC SURGERY 40. Sarcoma 948

4. Liver 109 SECTION 10: OTHERS

5. Portal Hypertension 147
6. Gallbladder 168 41. Pediatric Surgery 957
7. Bile Duct 194 42. Trauma 960
8. Pancreas 226 43. Transplantation 988

PREVIEW
44. Anesthesia and Perioperative Complications 997
SECTION 3: GASTROINTESTINAL SURGERY 45. Robotics, Laparoscopy and Bariatric Surgery 1001
46. Sutures and Anastomoses 1008
9. Esophagus 273
47. Sterilization and Infection 1015
10. Stomach and Duodenum 309
48. Fluid, Electrolyte and Nutrition 1033
11. Peritoneum 361
49. Blood Transfusion 1045
12. Intestinal Obstruction 378
50. Shock 1052
13. Small Intestine 405
51. Miscellaneous 1058
14. Large Intestine 431
15. Ileostomy and Colostomy 465
16. Inflammatory Bowel Disease 470
17. Vermiform Appendix 482
18. Rectum and Anal Canal 495
19. Hernia and Abdominal Wall 519
20. Spleen 543

SECTION 4: UROLOGY
21. Kidney and Ureter 557
22. Urinary Bladder 610
23. Prostate and Seminal Vesicles 627
24. Urethra and Penis 644
25. Testis and Scrotum 664

SECTION 5: CARDIOTHORACIC VASCULAR SURGERY

26. Arterial Disorders 691
27. Venous Disorders 725
28. Lymphatic System 739
29. Thorax and Lung 747

SECTION 6: PLASTIC SURGERY

30. Burns 791
31. Plastic Surgery and Skin Lesions 804
32. Wound Healing, Tissue Repair and Scar 823
 COLOR PLATE

IMAGE-BASED QUESTIONS 143. What is the type of this shunt? 146. Which of the following statement is correct about gallstones?
a. 1-Cholesterol, 2-Black, 3-Brown
b. 1-Cholesterol, 2- Brown, 3- Black
c. 1- Brown, 2-Black, 3- Cholesterol
d. 1- Black, 2- Brown, 3- Cholesterol

MULTIPLE CHOICE QUESTIONS

5. What is the name of given instrument?
INSTRUMENTS a. Doyen’s towel clip
1. What is the name of given instrument? b. Mayo’s towel clip
a. Kocher’s thyroid dissector b. Doyen’s retractor c. Moynihan’s tetra towel clip
c. Joll’s thyroid retractor d. Deaver’s retractor d. Lanes tissue forceps

a. Non-selective shunt b. Selective shunt

c. Partial shunt d. None of the above
144. This shunt is used in which condition?
a. NCPF b. EHPVO

PREVIEW
c. Budd-Chiari syndrome d. Veno-occlusive disease

2. What is the name of given instrument?

a. Aneurysm needle b. Veress needle
c. Tracheal dilator d. Urethral dilator

6. What is the name of given instrument?

a. Doyen’s towel clip
b. Mayo’s towel clip
c. Moynihan’s tetra towel clip
d. Lanes tissue forceps

3. What is the name of given instrument?

a. Aneurysm needle b. Veress needle
c. Tracheal dilator d. Urethral dilator

145. What is the diagnosis based on the given HIDA-scan?

4. What is the name of given instrument?

a. Doyen’s towel clip b. Mayo’s towel clip
c. Moynihan’s tetra towel clip d. Lanes tissue forceps 7. What is the name of given instrument?
a. Doyen’s towel clip
b. Bonecurette
c. Aneurysm needle
d. Doyen’s coastal elevator

147. Whatisthenameofthisclassification?
a. Mirizzi’sclassification
b. Strasbergclassification
a. Chronic cholecystitis b. Mucocele c. Csendesclassification
c. Acute cholecystitis d. Normal scan d. Bismuthclassification
 COLOR PLATE

EXPLANATIONS 14. Ans.b.Mayo’sveinstripper

Mayo’s Vein Stripper:
(Ref: Jaypee Manual of Surgical Equipments/p 175)
Used in the stripping of varicose veins

15. Ans.a.Giglisaw (Ref: Jaypee Manual of Surgical Equipments/p 235)

INSTRUMENTS Gigli’s Saw: Used to cut bones in amputations

1. Ans.a.Kocher’sthyroiddissector (Ref: Jaypee Manual of Surgical Equipments/p 178) 16. Ans.c.Cuttingedgeneedle (Ref: Jaypee Manual of Surgical Equipments/p 58)
Kocher’s thyroid dissector Needle Point Symbol
l Used during thyroid surgeries, used to dissect the superior thyroid pedicle Point Type Symbol
2. Ans.a. Aneurysmneedle (Ref: Jaypee Manual of Surgical Equipments/p 135) Taper Point
Aneurysm needle
l Used during venesection to pass ligature around the vein Blunt Taper Point

3. Ans.b.Veressneedle (Ref: Jaypee Manual of Surgical Equipments/p 226) Cutting Edge

Veress needle
l Used for induction of pneumoperitoneum during laparoscopic surgeries Reverse Cutting Edge

4. Ans.b.Mayo’stowelclip (Ref: Jaypee Manual of Surgical Equipments/p 109) Taper cut

Mayo’s Towel Clip
Micro-Point Spatula curved
l Curved blades helps to hold entire thickness of drapes firmly

PREVIEW
l Used to fix drapes, suction tubes, laparoscopic cables and diathermy wires on OT table
Needle Shape
5. Ans.a.Doyen’stowelclip (Ref: Jaypee Manual of Surgical Equipments/p 109)
1/2 Circle 3/8 Circle 1/4 Circle 5/8 Circle Straight
Doyen’s Towel Clip
l Short instrument with curved blades, used to fix the towels during draping
6. Ans.c.Moynihan’stetratowelclip (Ref: Jaypee Manual of Surgical Equipments/p 110)
Moynihan’s Tetra Towel Clip
l Curved blades with four teeth (two teeth in each blade) Metric 1.5 2–2.5 3 3.5 4 5 6
l Used to hold the cut edges of skin incision to the four corners of draped tetra towels toisolate the operative field USP 5/0 4/0 3/0 2/0 0 1 2

7. Ans.d.Doyen’scoastalelevator (Ref: Jaypee Manual of Surgical Equipments/p 223) 17. Ans.b.Fistulaprobe (Ref: Jaypee Manual of Surgical Equipments/p 190)
Doyen Rib Raspatory (Doyen’s Coastal Elevator) Brodie’s Fistula probe
l Used to remove tissue and cartilage from the ribs l Winged blade, curved shaft gradually tapered to pointed tip with groove along the curvature longitudinally
8. Ans.d.Usedwithbladeforskinincision (Ref: Jaypee Manual of Surgical Equipments/p 127) l Used to probe and treat fistula in ano; as a guide and protector to release tongue tie

Bard Parker Handle (BP Handle): Blades are held in position by BP Handle to give incisions 18. Ans.a.Gallbladdertrocar (Ref: Scott-Conner & Dawson: Essential Operative Techniques and Anatomy/p 416)
9. Ans.c.Harvestingskingraft (Ref: Jaypee Manual of Surgical Equipments/p 247) Gallbladder trocar
Humby Knife l Gallbladder trocar is used to decompress the distended gallbladder during cholecystectomy
l A knife with a roller attached, used for cutting skin grafts of varying thickness
19. Ans.a.Needleholder,toothforcepsandscissors (Ref: Bailey 25/e p2137)
l The distance between the roller and blade of the knife can be varied by means of a calibration device.
Needle holder, tooth forceps and scissors are required for suturing a patient.
10. Ans.b.Needleholder (Ref: Jaypee Manual of Surgical Equipments/p 136)
Mayo Hegar Needle Holder FORCEPS
l Smaller distal blades with cross-serrations with a groove in middle
l Ratio of length of handle to blade is 4:1 20. Ans.b.Spongeholdingforceps (Ref: Jaypee Manual of Surgical Equipments/p 108)
l Needle is placed at junction of proximal 2/3 and distal 1/3 rd of the blade
rd Rampley’s Sponge Holding Forceps
l Used for suturing skin and other organs l Used for cleansing the skin with swab dipped in antiseptic solution during all operations
11. Ans.d.Ribshear (Ref: Jaypee Manual of Surgical Equipments/p 234) l Used for removing laminated membrane and the daughter cysts during operation of hydatid cyst
l Used to hold the fundus and Hartmann’s pouch of gallbladder during cholecystectomy
Rib Shear
l Used to swab an abscess cavity
l Same as bone cutter but it has one cutting blade l Used to cut the ribs
21. Ans. b. Kocher’s hemostatic forceps (Ref: Jaypee Manual of Surgical Equipments/p 154)
12. Ans.a.Hemorrhoids (Ref: Jaypee Manual of Surgical equipments/p189)
Kocher’s hemostatic forceps
13. Ans.c.Periostealelevator (Ref: Jaypee Manual of Surgical Equipments/p 233)
l Used during appendectomy to crush the base
Periosteal Elevator
l Used to hold perforating vessels during mastectomy
l Used to elevate and dissect bone, tissue, nerves , clean and scrape bone. l Used during subtotal thyroidectomy
l Used to expose fracture sites or bone in other procedures. l Used to hold bleeding vessels while operating on palm and sole
l Used to strip portions of the membrane (periosteum) covering the exterior surface of a bone.
 C HAPTER 4 Surgery Essence

1
CARCINOMA BREAST: RISK FACTORS
Risk Factors for Breast Cancer
1. Age : Incidence increases with age Q 6. Alcohol and high fat diet Q

Breast 2. Country of birth : More common in western countries

3. Family history and genetic risk factors
4. Hyperestrogenemia:
(BRCA) Q
Q
7. Personal history of malignancy:
– Contralateral breast cancer Q
– Ovarian and endometrial cancer Q

– Early menarche Q , late menopause Q 8. Previous benign breast disease Q

– Nulliparity Q 9. High socioeconomic status Q

– Obesity Q 10. Radiation exposure Q

5. Latefirst full term pregnancy Q 11. Hormone replacement therapy Q

NIPPLE DISCHARGE

Endocrine Surgery
l Combined (estrogen + progesterone) HRT is associated with increased risk of CA breast.Q
Nipple D ischarge l Only estrogen HRT is not associated with increased risk of CA breastQ.

l Unilateral, spontaneous, serous or serosanguinous discharge from a single duct is usually caused by an intraductal papillomaQ, l SmokingQ and OCPsQ does not appear to increase risk of breast cancer
or rarely by an intraductal cancer. l Longer duration of breast feeding has a protective effectQ
l Mostly the underlying cause is a duct papilloma or duct ectasia , but since the chances of malignancy are high, it must be
Q

investigated further. BRCA-1 BRCA-2

l Risk of malignancy increases if an underlying massQ is present.Q • Chromosome: 17 Q • Chromosome: 13 Q
• BRCA-1 associated breast cancers: • BRCA-2 associated cancers:

PREVIEW
Causes of Nipple Discharge
– Invasive ductal carcinomas – Invasive ductal carcinomas
Colour Cause – Poorly differentiated Q – Well differentiated Q
Q Q
Blood-stained • Duct papillomaQ – Hormone-receptor negative – Hormone-receptor positive .
• Intraductal carcinomaQ – Early age of onset – Early age of onset
• Duct ectasiaQ – Bilateral – Bilateral
Q
• Associated ovarian, colon and prostate cancers . • Associated ovarian, colon, prostate, pancreas, gall-
Serous • Fibrocystic diseaseQ bladder , stomach cancers and melanoma Q .
• Duct ectasiaQ
• CarcinomaQ
Black, green, paste like or • Duct ectasiaQ Carcinoma Breast Risk Assessment Models
grumous discharge

Investigations Gail Model Q

Claus Model Q

l Mammography: Can show underlying suspicious lesions • Most frequently used model • Based on assumptions about the prevalence of
l Cytological examination: (may identify malignant cells, but a negative finding does not rule out cancer) • Incorporates: high-penetrance breast cancer susceptibility genes.
1. Age at menarche • Incorporates more information about family
Ductography 2. Number of breast biopsies history but excludes other risk factors.
l Primary indication: Nipple dischargeQ (particularly when the 3. Age at firstlivebirth • Estimates of breast cancer risk according to:
fluid contains blood) 4. Number of first-degreerelatives with breast cancer decade of life based on presence of 1st and 2nd-
l Radiopaque contrast media is injected into one or more of the • Predicts the cumulative risk of breast cancer according to degree relatives with breast cancer and their age
major ducts and mammography is performed decade of life at diagnosis .
l Intraductal papillomas: Small filling defectsQ surrounded by l Risk factors that are less consistently associated with breast cancer (diet, use of OCPs, lactation) or are rare in the general population
contrast media
(radiation exposure) are not included in either the Gail or Claus risk assessment model
l Cancers: Irregular masses or as multiple intraluminal filling
l None of these models accounts for the risk associated with mutations in BRCA-1 & BRCA-2
defectsQ
l Duct ectasia: Dilated cystic structureQ
CARCINOMA IN SITU
l Ultrasound: May show presence of an underlying mass or duct ectasia

1
Final Diagnosis DCIS (Ductal carcinoma in situ)
l Final diagnosis is made by excising the involved duct (Microdochectomy)Q and any underlying mass if present and subjecting l Among the mammographically detected cancer, almost half are DCIS .
then for a histopathological diagnosis.

Section
l DCIS most frequently presents as mammographiccalcifications .
l Radical duct excision (removal of all lactiferous ducts) is not doneQ. Histological types of DCIS (five types) • Low Grade: Cribifrom, Papillary and Micropapillary
Treatment 1. Comedocarcinoma Q • High Grade: Solid and Comedocarcinoma
2. Cribiform Q
l Firstly exclude a carcinoma by occult blood test and cytology.
3. Micropaillary Q
l Simple reassurance may then be sufficient but, if the discharge is proving intolerable, an operation to remove the affected duct
4. Solid
or ducts can be performed (microdochectomy).
5. Papillary Q
 MULTIPLE CHOICE QUESTIONS EXPLANATIONS
NIPPLE DISCHARGE 10. Investigation of choice for high risk breast cancer in female NIPPLE DISCHARGE
is: (DNB 2014)
1. Blood stained nipple discharge is seen in: a. MRI b. CT-PET 1. Ans. c. Ductal papilloma (Ref: Schwartz 10/e p554, 9/e p467; Sabiston 20/e p824-826; 19/e p828; Bailey 27/e p863, 26/e p802)
(Recent Question 2017, DNB 2013, 2011, Orissa 2011, PGI June c. Mammography d. USG
2009, UPPG 2010, AIIMS Nov 2003, All India 2005) l MC cause of greenish discharge: Duct ectasiaQ
11. Gold standard investigation for screening of breast carcino- l MC cause of blood-stained discharge: Duct papillomaQ
a. Breast abscess b. Fibroadenoma ma in patients with breast implant: (Recent Question 2015)
c. Ductal papilloma d. Fat necrosis of breast
a. MRI b. USG
2. Green discharge is most commonly seen with: 2. Ans. b. Duct ectasia.
c. Mammography d. CT Scan
(Recent Question 2016, Kerala PG 2015, WBPG 2015, AIIMS Nov 98) 3. Ans. b. Microdochectomy (Ref: Bailey 27/e p863, 26/e p802; CSDT 12/e p299; Schwartz 10/e p526, 9/e p448)
12. A 60-year-old lady comes with blood stained discharge from
a. Duct papilloma b. Duct ectasia 4. Ans. a. Mammography, b. Cone excision done in single intraductal tumour, d. Red discharge indicate malignancy, e. Blue-black
the nipple with family history of breast cancer. Next best
c. Retention cyst d. Fibroadenosis discharge indicate duct ectasia
step for her will be: (AIIMS May 2015)
3. A 25-years old female complains of discharge of blood from a. Ductoscopy 5. Ans. b. Radical duct excision is the operation of choice.
a single duct in her breast. The most appropriate treatment b. Sono-mammogram
is: (All India 2008) c. Nipple discharge cytology CARCINOMA BREAST INVESTIGATIONS
a. Radical excision d. MRI 6. Ans. d. Clinical examination, Mammogram and FNAC (Ref: Schwartz 10/e p522-523, 9/e p444-446; Sabiston 20/e p826-828; 19/e p840-842;
b. Microdochectomy Bailey 27/e p863, 26/e p799-801)
13. Best investigationtodifferentiatescarfromrecurrenceafter
c. Radical mastectomy
mastectomy done for carcinoma breast: (Recent Question 2016)

PREVIEW
d. Biopsy to rule out carcinoma l Triple Assessment includes a combination of clinical assessment, radiological imaging (USG/ Mammography) and tissue
a. MRI b. CT
4. True statement (s) about nipple discharge is/are: sample analysis (FNAC/Biopsy)Q
c. PET scan d. Mammography
a. Mammography (PGI June 2004) l The positive predictive value of Triple Assessment should exceed 99.9%Q
14. All of the following are indications for MRI in breast
b. Cone excision done in single intraductal tumour
carcinoma except: (Recent Question 2017)
c. Mammography done when duct papilloma is <4.5cm 7. Ans. c. Biopsy (Ref: Schwartz 10/e p529-530, 9/e p450; Sabiston 20/e p826-828; 19/e p830-831; Bailey 27/e p862, 26/e p800)
a. Microcalcification b. High-riskcases
d. Red discharge indicate malignancy c. Breast-implant patients d. Lobular carcinoma in situ
e. Blue-black discharge indicate duct ectasia CA B reAst
15. What is the sensitivity of axillary ultrasound in identifying
5. A 25-years old lady presents with spontaneous nipple dis- axillary metastases in clinically node negative carcinoma l First investigation for tissue sampling: FNACQ l Best and diagnostic investigation: BiopsyQ
charge of 3-months duration. On examination the discharge breast? (AIIMS May 2017)
is bloody and from a single duct. The following statements a. 10–20% b. 20–30% 8. Ans. c. Mammography (Ref: Schwartz 10/e p523-529, 9/e p447-450; Sabiston 20/e p826-827; 19/e p830-832; Bailey 27/e p861, 26/e p799-801)
about management of this patient are true except: c. 30–40% d. 55–60%
a. Ultrasound can be a useful investigation (AIIMS Nov 2004) l First investigation: Mammography
b. Radical duct excision is the operation of choice l First investigation for tissue sampling: FNAC
c. Galactogram, though useful, is not essential
MAMMOGRAPHY
l Best and diagnostic investigation: BiopsyQ
d. Majority of blood stained nipple discharges are due to 16. Most sensitive imaging for ductal carcinoma in situ of breast
papillomas or other benign condition is: (AIIMS Nov 2010)
a. Mammography b. MRI Investigations in CA Breast
CARCINOMA BREAST INVESTIGATIONS c. PET d. USG l Initial investigation for symptomatic breast in women >35 years and for screening Q
Mammography
17. Dose of radiation per study in mammography: l IOC for microcalcification Q
6. Triple assessment for CA Breast includes: (Kerala PG 2015) a. 0.1cGy b. 0.2 (Recent Question 2016) l Initial investigation for palpable lesions in women <35 years Q

a. History, clinical examination and mammogram c. 0.3 d. 0.4 Ultrasound

l Not useful in screening
b. History, clinical examination and FNAC
18. True about screening mammography: l Indicated in scarred breast, implants and borderline lesions for breast conservation
c. USG, mammogram and FNAC (DNB 2010, All India 2009)
a. Indicated in 50–70 years of age (PGI June 2004) MRI l IOC for implant related complications Q
d. Clinical examination, mammogram and FNAC
b. Mortality reduced by 30% l Gold standard for imaging breast in females with implants Q
7. Best diagnostic method for breast lump is: (AIIMS June 95) c. Radiation due to mammography can cause carcinoma
a. USG b. Mammogram l IOC for detecting recurrences in scarred breast Q
d. MRIisbetterthanmammography PET scan
c. Biopsy d. FNAC l Useful in multifocal disease and in helping detect axillary involvement
e. USGisbetterthanmammography
8. A 45-years old woman presents with a hard and mobile lump 19. On mammogram all of the following are the features of a 9. Ans. b. Needle biopsy 10. Ans. a. MRI 11. Ans. a. MRI
in the breast. Next investigation is: (All India 2001) malignant tumor except: (AIIMS Nov 2003) 12. Ans. d. (MRI): (Ref: Schwartz 10/e p527, 9/e p447-450; Harrison 19/e p526; Sabiston 20/e 828; 19/e p830-832; Bailey 26/e p799-801)
a. FNAC b. USG a. Spiculation
c. Mammography d. Excision biopsy b. Microcalcification A 60-year-old lady comes with blood stained discharge from the nipple with family history of breast cancer. Next best step for
c. Macrocalcification her (high risk female) will be MRI for screening of breast cancer.
9. A female patient present with a hard mobile lump in her
right breast. Which investigation would be most helpful in d. Irregular mass
20. BIRADS stands for: (AIIMS Nov 2012) “There is current interest in the use of MRI to screen the breasts of high-risk women and of women with a newly diagnosed
making the diagnosis? (AIIMS Nov 2001)
a. Breast Imaging Reporting and Data System breast cancer. In the first case, women who have a strong family history of breast cancer or who carry known genetic
a. FNAC
b. Needle biopsy b. Best Imaging Reporting and Data System mutations require screening at an early age, but mammographic evaluation is limited because of the increased breast density
c. Excision biopsy c. Brain Imaging Reporting and Data System in younger women. In the second case, an MRI study of the contralateral breast in women with a known breast cancer has
d. Mammography d. Best Imaging Reporting and Data System shown a contralateral breast cancer in 5.7% of these women.”- Schwartz 10/e p527, 9/e p450
 PREVIEW
A4 size
27 cm

21.5 cm

Surgery Essence | 6th edition | YOP: 2018 | Pages: 1058

By Pritesh Singh | Color: 2 color | ISBN: 9789352704194

Available on EduLanche.com