Unilateral Lower Limb Edema
437
• The draining lymph nodes are enlarged
• Fever and chills
• Painful swelling of the affected limb (initial
stages the swelling of the limb will subside after
an ADLA episode).
Q 19. What is the pathogenesis of filarial
lymphedema?
• The adult parasites living in the lymph vessels
initiate the damage
• Earliest pathology isthe dilatation of the lymph
vessel (Lymphangiectasia)
• Thislymphangiectasia is irreversible even after
treatment
• This will result in stagnation of the lymph and
incompetence of the unidirectional valves
• Lymph stasis encourages the growth of
invading bacteria as a result of trivial trauma
• The entry of organisms are through the so-called
entry lesions namely:
– Fissuring of skin
– Paronychia
– Eczema
• Secondary infection by microorganisms
especially streptococci resulting in ADLA
• Each attack worsensthe lymphedema as a result
of obstructive changes in the lymphatics
• Finallydermatosclerosis with nodular and warty
excrescences develops.
Q 20. What are the clinical features of filarial
lymphedema?
• In the early stages the swelling is reversible on
elevation of the limb and will pit on pressure
• The skin will be smooth without thickening
• Repeated attacks of ADLA (fever, chills and pain)
• Later the swelling will become persistent, does
not reverse on elevation of the limb
• Skin becomesthickened and itis no more pitting
• Formationofskinfolds,nodulesandwartychanges
• The limb will attain enormous size interfering
with mobility—elephantiasis
Q 21. What are the organisms responsible for
filariasis?
1. Wuchereria bancrofti
2. Brugia malayi.
Q 22. Which organism will cause hydrocele more
often?
The Wuchereria bancrofti.
Q 23. What are the sites of lymphdema?
Sites of lymphedema
• Lower limbs (commonest)—Unilateral or bilateral
• Upper limbs
• Male genitalia
• Breast in females.
Q 24. What are the differences between bancrofti
and malayi lymphedema?
Bancrofti Malayi
Involve the entire affected
limb
Swelling is confined to
the legs below the knee
or upper limb below the
elbow
Genitalia and breast are
involved
N o i n v o l v e m e n t o f
genitalia and breast
Hydrocele is common Hydrocele is rare
Q 25. What is the clinical difference between
lymphedema and venous edema?
The lymphedema will affect the toes much more
than other forms of edema. Later the toes get
squashed together and become squared-off.
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Clinical Surgery Pearls
Venous edema Lymphedema
• The edema is around the ankle, if
thrombosis is confined to the calf. It
may extend to the groin, if the iliac vein
is thrombosed
• The lymphedema affects the foot. The contour of the ankle is lost
and there is infilling of the submalleolar depression. The dorsum of
the foot will appear as a buffalo hump. The toes appear square. The
skin on the dorsum of the toes cannot be pinched because of the
subcutaneous fibrosis—Stemmer’s sign
• The lymphedema usually spreads upto the knee level but can involve
the whole limb
• Edema will pit • Early stages pits, later on nonpitting
• The skin—lipodermatosclerosis if long
standing (early stage skin is normal)
• Skin is hyperkeratotic later on nodules and folds of skin are found.
Fissuring, verrucae, warts (papillae) are also seen. Fungal infections of
the skin and nails and chronic eczema are also seen. Dilated dermal
lymphatics form blisters and are called lymphangiomas
• The muscles are thick and woody • Muscles are normal
• Regional lymph nodes—not enlarged • Lymph nodes are enlarged in secondary lymphedema.
Q 26. What is the dangerous complication of
lymphedema?
Lymphangiosarcoma (very rare)—This condition
is rapidly fatal. Lymphangiosarcoma was originally
described for post mastectomy upper limb edema
(Stewart-Treves’ syndrome). It is suggested that
the lymphedema leads to impairment of immune
surveillance and therefore predisposes to other
types of malignancy.
Q 27. What is phlegmasia alba dolens? (PG)
This results from venous thrombosis of the iliofemoral segment. The patients present with
swelling which commences below the knee and
spreads to the thigh reaching upto the inguinal
fold. The edema pits on pressure. The limb is pale.
There is tenderness along the course of the femoral
vein. The foot feels colder. The acute phase will last
for 2 to 4 weeks.
Q 28. What is phlegmasia cerulea dolens? (PG)
This is due to deep vein thrombosis affecting the
iliofemoral vein and it blocks all the main veins in
the skin. The skin is deeply cyanotic and blue. The
limb is greatly swollen and it feels tense. It is difficult
to feel the arterial pulsations in the affected limb
because the tissues overlying the vessels are bloated
and stiff. Finally venous gangrene will appear.
Q 29. What is cellulitis?
Cellulitis is a spreading inflammation of the cellular
tissue caused by Streptococcus pyogenes. This may
be superficial or deep. The superficial is again
classified into cutaneous and subcutaneous. The
clinical features are:
• The affected parts are swollen, tense and tender.
• Later it becomes red, boggy and shiny.
Note: The classical description is:
“Swelling with no edge, no limit, no fluctuation
and no pus”
Unilateral Lower Limb Edema
439
Q 30. What are the investigations?
1. Night examination of the peripheral smear for
microfilaria
2. Elisa test for circulating filarial antigen (CFA)—In
the early stage CFA may be positive
3. Lymphoscintigraphy—is useful to differentiate
primary and secondary type of lymphedema (it is
performed by injecting radio labelled albumin or
dextran in the web space of the toes and scanning
the lymphatics using a gamma camera)—not
routinely done
4. USG—will demonstrate thickening of the
subcutaneous tissue in lymphatic filariasis in
contrast to increase in size of the muscle compartment seen in varicose veins
5. Doppler—helps to confirm venous problems
6. CT/MRI—rarely required – reveal thickening of skin
and subcutaneous tissue and honey comb pattern
in cases of lymphedema
7. MR Angiogram—useful to establish the diagnosis
of arteriovenous malformation.
Q 31. What are the surgical complications of
filariasis?
Surgical complications of filariasis
1. Chronic lymphadenitis
2. Chronic epididymo-orchitis
3. Hydrocele—the most common feature of filariasis
(40% of the hydroceles are filarial)
4. Chyluria
5. Elephantiasis:
– Scrotum
– Upper and lower limbs
– Breast
– Vulva
6. Chylous ascites
7. Chylothorax
8. Chylous diarrhea.
Q 32. What is the management of lymphedema?
The management consists of:
• Conservative management of the edema
• Drug therapy
• Surgery.
Q 33. What is the conservative management of
lymphedema?
1. Prevention of infection
– General cleanliness
– Avoiding bare foot walking
2. Massage
3. Limb elevation
4. Exercise
5. Compression garments
6. Intermittent pneumatic external compression—
the limb is enclosed in an inflatable encasing
which is inflated upto 150 mm of Hg
7. Use of custom built stocking
8. Decongestive lymphedema therapy (DLT)
– Intensive period of therapist led care and
maintenance phase of self care
Intensive phase: by therapist:
– Skin care
– MLD (Manual Lymphatic Drainage) –
performed daily
– MLLB (Multi Layer Lymphedema Bandaging)—nonelastic MLLB for severe and
compression type for mild
– Simple Lymphatic Drainage (SLD)
– Exercise
Maintenance phase:
– Simple Lymphatic Drainage (SLD)—daily.
Note: The pressure exerted by the lymphedema
bandaging may be graduated—100% for ankle
and foot, 70% for knee, 50% for mid thigh and 40%
for growing.
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Clinical Surgery Pearls
Q 34. What is the drug therapy of lymphedema?
1. DEC (Diethyl Carbamazine)—DECkillsthe adult
worms and has no effect on microfilaria.
Dose—6 mg/kg/day over 3 divided doses
after meals for five days.
Repeated courses may be required.
2. Combination therapy with Albendazole plus
Ivermectin
or
Albendazole plus DEC
3. Antibiotics – long term benzathine penicillin
has been prescribed
4. Anti-inflammatory, antihistamines and
antipyretics.
Q 35. What are the surgical options for the
lymphedema of limb? (PG)
Can be classified into two groups:
Drainage procedures
1. Lymphonodovenous shunt procedures
2. Direct lymphaticovenous anastomosis (technically more difficult and operating microscope is
required)
3. Monofilament nylon netting—a subcutaneous
web of nylon fiber is created
4. Omental transposition—a subcutaneous tunnel
is made in the limb and a long mobilized length
of omentum is placed for lymphatic drainage.
Excisional procedures—(debulking procedures).
Q 36. What is lymphonodovenous shunt? (PG)
• Localize the draining nodes by injecting patent
blue in the web space
• Vertical or horizontal skin incision is made
centering on the saphenofemoral junction
• Mobilize the saphenous vein for 6 to 8 cm and
ligate the distal end
(Rule out saphenofemoral incompetence)
• Identify a suitable moderate sized lymph node
and make a transverse section of the node
without mobilization. Discard the superficial
portion of the lymph node
• Rotate the proximal end of the vein and tailor it
close to the node. Now section the saphenous
vein at a suitable point for anastamosis
• Anastomose the vessel wall to the lymph node
capsule with six zero prolene sutures, burying
the node to the vessel.
Q 37. What are the excisional procedures?
The essence of this form of treatment is to excise
all or part of the involved skin and subcutaneous
tissue. The cover is given by skin graft or raising
flaps:
Charles procedure: The entire skin is excised
and the area grafted, this is followed by pressure
bandage. It is not recommended for the dorsum
of the foot as it has too many tendons and very
minimal deep fascia.
Thompson procedure (Swiss roll operation):
He implanted the de-epithelialized dermal flaps
behind the deep fascia in attempts to promote
direct drainage. Necrosis of the buried portion is
frequent and when it occurs the discharge almost
never stops.
43 Hydrocele of tunica Vaginalis Sac
(Epididymal Cyst, Spermatocele, Varicocele, Hematocele, Chylocele, etc)
Case
Case Capsule
A 35-year-old male patient presents with increase
in size of the right side of the scrotum of two years
duration. He gives history of frequency of urine and
painful micturition. On examination, the right side
of the scrotum shows a swelling of 15 × 10 cm size
which is confined to the scrotum (can get above the
swelling). The surface of the swelling is smooth and it
is well-defined. There is no local rise of temperature.
Upper posterior part of the swelling is tender.
The swelling is fluctuant and translucent. It is not
reducible. On percussion it is dull. The right testis is
not separately felt. The skin of the scrotum over the
swelling is freely mobile. The spermatic cord is felt
above the swelling and is tender. The contralateral
testis and genitalia are normal. There is no evidence
of any mass or lymph nodes in the abdomen. There
are no supraclavicular lymph nodes.
Checklist for history
1. History of painful micturition and frequency of
urine
2. History of trauma
3. History of pain and discomfort in the testis
4. History of malaise and weight loss (tumor)
5. History of filariasis
6. History of tuberculosis and family history of
tuberculosis.
Checklist for clinical examination
1. Elicit fluctuation
2. Get above the swelling or not (Flow chart 43.1)
3. Palpation of testes
4. Palpation of cord
5. Palpation of vas deferens
6. Look for translucency
7. Examination of abdomen for lymph nodes (Paraaortic nodes)
8. Look for supraclavicular nodes
9. Always do ultrasound abdomen to rule out tumor
and other pathology.
Contd...
Contd...
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Clinical Surgery Pearls
Hydrocele of Tunica Vaginalis Sac (Epididymal Cyst, Spermatocele, Varicocele, Hematocele)
443
Q 3. Why this is hydrocele?
The points in favor of hydrocele are:
1. Can get above the swelling (purely scrotal)
2. Cystic in consistency
3. Fluctuation
4. Transillumination positive
5. Testis cannot be felt separately
6. It is not reducible usually
7. No impulse on coughing.
Q 1. What is the diagnosis in this case?
Hydrocele of tunica vaginalis sac (right side).
Q 2. What is the order of palpation of testis?
The order of palpation is from below upwards (fig.
43.1):
1. Testis
2. Tunica vaginalis
3. Epididymis
4. Cord structures
5. External inguinal ring.
Flow chart 43.1: Scrotal and inguinoscrotal swellings
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Clinical Surgery Pearls
Q 4.Hydrocele of what?
Hydrocele of tunica vaginalis sac [TV sac].
Q 5. What is hydrocele?
Hydrocele is an abnormal collection of serous fluid
in some part of the processus vaginalis, usually
the tunica.
Q 6. Can you get a hydrocele which is not
transilluminant?
Yes.
The criteria for transillumination in hydrocele are:
a. Sac must be thin
b. The fluid must be clear.
When the sac is thick or the fluid is not clear,
then it won’t be transilluminant.
Q 7. What are the conditions in which it is not
transilluminant?
a. Infected hydrocele (Pyocele)
b. Hematocele
c. Chylocele
d. Thickened and calcified sac.
Q 8. Can you get hydroceles which are
inguinoscrotal?
Yes. In the following situations, it may be
inguinoscrotal.
a. Infantile hydrocele: When the fluid collection
extends from scrotum up to the deep inguinal
ring.
b. Congenital hydrocele: Where the sac and the
fluid are communicating with the peritoneal
cavity.
c. Hydrocele en bissac [bilocular hydrocele]: Here
the sac communicates with extension of the
sac underneath the anterior abdominal wall
and we can elicit cross fluctuation between the
abdominal swelling and scrotal swelling.
d. Funicular hydrocele: Where the fluid collection
is communicating with peritoneal cavity and
it is coming down up to the testes without
involvement of the vaginal part. The funicular
process is closed just above the tunica
vaginalis. The fluid collection is confined to the
funicular region.
e. Encysted hydrocele: Where the fluid collection is
confined to the cord region and the traction test
will be positive.
f. Hydrocele of hernial sac: Where the neck of the
hernial sac is occluded at the deep ring region by
omentum and fluid accumulates distal to the sac.
Fig. 43.1: Order of palpation of the testis
(from below upwards)
Hydrocele of Tunica Vaginalis Sac (Epididymal Cyst, Spermatocele, Varicocele, Hematocele)
445
Features of hydroceles presenting as inguinoscrotal swellings
Type Age Communicationwith
peritoneal cavity?
Cause
a. Vaginal hydrocele All No May be primary or secondary to tumor,
trauma or infection
b. Congenital hydrocele Children < 3
years
Yes The communicating orifice is too small
for the development of hernia
c. Infantile hydrocele All age groups No The processus vaginalis is closed at the
deep ring and as a result of incomplete
absorption of fluid from the tunica
vaginalis
d. Funicular hydrocele All age groups Yes Processus vaginalis is closed just
above the tunica vaginalis. It does not
produce a proper scrotal swelling
e. Encysted hydrocele of the cord All No May occur anywhere along the cord.
May present as inguinal or scrotal
swelling. Traction test positive
f. Hydrocele of the hernial sac Older age No Neck of the hernial sac closed by
adhesions or plug of omentum. The
distal sac is filled with serous fluid
secreted by the peritoneum
• Fibrinogen
• Cholesterol crystals
• Crystals of tyrosine.
Note: Because of the presence of fibrinogen it will
clot the blood.
Q 12. What is acute hydrocele?
Sudden appearance of hydrocele in young men
is associated with a testicular tumor and it is a
dangerous situation.
Q 13. What is hydrocele of canal of Nuck?
It occurs in females in the inguinal region and
the cyst lies in relation to the round ligament.
It is similar to hydrocele of the cord [encysted
hydrocele]. But, hydrocele of the canal of Nuck is
always at least partially within the inguinal canal.
Q 9. What is the etiology of hydrocele?
It is produced by:
a. Defective absorption of fluid: This is the
explanation for primary hydrocele
b. Excessive production of fluid: Secondar y
hydrocele
c. Interference with lymphatic drainage of scrotal
structures: Filariasis
d. By connection with peritoneal cavity: As in
congenital variety.
Q 10. What is the color of the hydrocele fluid?
Hydrocele fluid is amber-colored [color of urine].
Q 11. What are the constituents of hydrocele fluid?
It contains:
• Albumin
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Clinical Surgery Pearls
Q 14. What is hydrocele of Nuck?
It is nothing but lymph cyst of the neck.
Q 15. What are the types of hydrocele?
The hydrocele is classified into congenital and
acquired types.
Four types of congenital hydroceles
a. Vaginal hydrocele
b. Infantile hydrocele
c. Congenital hydrocele
d. Hydrocele of the cord.
The acquired variety is further classified into
primary and secondary.
Differences between primary and secondary
Primary [Idiopathic] Secondary
• Most common in middle
and later life
Same
• Big size Small size
• Defective absorption
of fluid
Excessive production of
fluid
• Palpation of testis
difficult
Testis easily palpable
• Tense cyst Loose cyst
• Transillumination
positive
May be negative
Q 16. What are the causes for secondary hydrocele?
The important causes for secondary hydrocele are:
a. Tumor
b. Tuberculosis
c. Filariasis.
Q 17. How will you rule out a tumor in a case of
hydrocele?
a. By palpation of testis:
• Testis will be separately palpable in case of
tumor
• The testis becomes relatively heavy in
neoplasm (comparatively the testis is light
in gumma of the testis)
• The testicular sensation will be absent or
peculiar sickening sensation will be felt
• The testis will be nodular, indurated and
irregular.
b. By ultrasound examination—one can rule out a
mass lesion in the testis
c. By tumor markers—b hCG and a fetoprotein.
Q 18. How will you rule out tuberculosis?
Clinical features of tuberculosis of epididymis
i. Tuberculosis attacks epididymis (syphilis attacks
testis, filariasis attacks both)
ii. Tuberculosis affects the globus minor first
iii. In tuberculosis, the epididymis is craggy and the
vas is beaded
iv. A posteriorly placed ulcer that is fixed to the
epididymis is a tuberculous ulcer (anteriorly
placed ulcer that is fixed to the testis is gummatous
ulcer).
Q 19. How will you rule out filariasis?
The cord will be tender and thickened in filariasis.
Q 20. What are the features of filarial hydrocele
and chylocele?
• It accountsfor 80% of the hydrocelesin tropical
countries
• Chylocele is because of rupture of lymphatic
varix with discharge of chyle into the hydrocele
• Wuchereria bancrofti is the organism responsible
• The fluid may contain liquid fat and cholesterol
• Adult worms are demonstrated in epididymis
removed at operation.
Q 21. What is post-herniorrhaphy hydrocele?
It is because of interruption of the lymphatic
drainage of the scrotal contents as a result of
inguinal hernia repair.
Hydrocele of Tunica Vaginalis Sac (Epididymal Cyst, Spermatocele, Varicocele, Hematocele)
447
Q 22. What is hydrocele of hernial sac?
When the neck of the hernial sac is plugged with
omentum, fluid accumulates in the distal hernial
sac.
Q 23. What are the other differential diagnoses of
a cystic swelling in this region?
Other differential diagnoses are epididymal cyst
and spermatocele.
Q 24. How will you differentiate epididymal cyst
from spermatocele?
Epididymal cyst Spermatocele
• Itis a cystic degeneration
of the epididymis
• Itis a retention cyst from
some part of the sperm
conducting mechanism
• Usually above and
behind the body of the
testes
• Situated in the head of
the epididymis
• Multilocular • Unilocular
• Usually multiple and
often bilateral
• Single
• Brilliantly transilluminant
[Chinese lantern appearance]
• Negative
• Fluid is crystal clear • Barley water color (contains spermatozoa)
• Treatment is excision
(excision mayinterfere
with transport of sperms)
• Large ones are aspirated
or excised
Q 25. What is the treatment of hydrocele of TV sac
(Tunica vaginalis sac)?
It is mainly treated by surgery.
Q 26. What are the surgical options?
1. Jaboulay’s procedure (Eversion of the TV sac)
2. Lord’s operation (when the sac is thin-walled)
the sac is opened and it is plicated around
the testis. In this operation, there is minimal
dissection, the chance for hematoma is reduced
and there is no need for a drain.
Q 27. Can you drain the hydrocele fluid?
Drainage of hydrocele fluid is usually not done
because of the fear of complications like infection
and hematocele.
Q 28. What are the complications of hydrocele?
Complications of hydrocele:
a. Hematocele
b. Infection and pyocele
c. Hernia of hydrocele
d. Calcification of the sac
e. Rupture as a result of trauma or spontaneous
f. Atrophy of the testis.
Q 29. What are the causes for hematocele?
Causes for hematocele
• Tapping of hydrocele (damage to small vessels
during tapping)
• Testicular trauma
• Postoperative
• Tumor.
Q 30. What is clotted hematocele?
• Itisbecauseof a spontaneousslowoozeofblood
into the tunica vaginalis
• Usually it is painless
• A tumor may present as clotted hematocele.
Q 31. What is the treatment of clotted hematocele?
• Orchidectomy (It is very difficult to differentiate
tumor from a benign condition like this).
Q 32. What is the most important complication of
hydrocele operation?
Hematocele.
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Clinical Surgery Pearls
Q 33. What is varicocele?
It is a varicose dilatation of the veins draining the
testis (pampiniform plexus).
Q 34. What are the signs demonstrable in
varicocele?
Signs of varicocele
1. It feels like a ‘bag of worms’
2. It can only be felt with the patient standing. If the
patient is asked to lie down, the veins of the plexus
will empty
3. A thrill is felt while the patient is coughing
4. The ‘bow’ sign: lightly hold the varicocele between
the fingers and thumb. Now the patient is
instructed to bow. Tension within the veins become
appreciably less by this procedure
5. The scrotum on the affected side hangs lower than
normal
6. The testis below a large varicocele may be smaller
and softer than the normal side
7. After emptying the varicocele in supine position,
obstruct the external ring and make the patient
stand up. The varicocele will slowly fill up from
below upwards.
Q 35. What is the incidence of varicocele?
It is seen in up to 15% of the male population.
Q 36. Which age group is affected by varicocele?
• Seen in adolescence and early adulthood
• Seen in tall thin men with pendulous scrotum
(short, fat individuals are seldom affected).
Q 37. What are the symptoms of varicocele?
• Chronic dull ache in the scrotum, worse on
standing for prolonged periods
• May be associated with oligospermia (the
association remains unclear).
Q 38. On which side varicocele is more common
and why?
• Varicocele is more common on leftside because
the left testicular vein enters the left renal vein
at right angles (95%)
• Attimesthe lefttesticular artery arches overthe
left renal vein to compress it
• The loaded left colon may press on the left
testicular vein.
Q 39. What is the significance of recent onset of
left sided varicocele?
It is associated with left renal cell carcinoma
because of obstruction of the renal vein by a tumor
thrombus growing through the left renal vein.
Q 40. What is the venous drainage of testis and
epididymis?
The draining veins form a plexus called pampiniform
plexus in the scrotal region. The veins become fewer
as they traverse the inguinal canal. At or near the
deep inguinal ring, they join to form one or two
testicular veins. They pass upwards behind the
peritoneum and join the renal vein on left side and
inferior vena cava on right side.
Q 41. What is the peculiarity of the testicular vein?
They are having valves only at the termination
which may be absent (valve less system).
Q 42. Is there an alternative venous drainage for
the testis?
Yes. The collateral venous return from the testis is
through the cremasteric veins which drain into the
inferior epigastric vein.
Q 43. What is the relationship between varicocele
and spermatogenesis?
• Normally the scrotal temperature is 2.5°C less
than the rectal temperature
Hydrocele of Tunica Vaginalis Sac (Epididymal Cyst, Spermatocele, Varicocele, Hematocele)
449
• The presence of unilateral varicocele interferes
with the normal temperature control of
the scrotum that reduces the temperature
differential to (scrotum/rectum) about 0.1°C
below the rectal temperature
• Since varicocele is relatively common, those
who are having oligospermia with varicocele, it
is tempting to blame the varicocele as the cause
for infertility (not yet clinically proved).
Q 44. What are the muscles responsible for
supporting the testis?
Dartos and cremaster.
Q 45. What are the actions of dartos and cremaster?
• Dartos bearsthe weight of the testis and acts as
a kind of thermostat
• The cremasterisresponsible forreflex retraction
of the testis during threat of trauma and during
fight.
Q 46. What is the grading of varicocele?
• Grade I: Impulse felt in the scrotum on Valsalva
maneuver
• Grade II: Tortuous and dilated veins palpated
without Valsalva maneuver
• Grade III:Varicocele is visible through the scrotal
skin.
Note: Sonologically: More than two to three
veins of 3 mm or greater in size are found with
enlargement on standing and reflux on Valsalva
maneuver.
Q 47. What is subclinical varicocele?
Those which are impalpable on physical examination
are called subclinical varicocele.
Q 48. What are the indications for surgery?
3 ‘S’
• Symptoms
• Subfertility
• Service recruitment.
Q 49. What are the procedures available?
• Palomos operation
• Laparoscopic ligation of testicular veins
• Embolization of the testicular vein under
radiographic control.
Q 50. What is Palomos operation?
• It is a ligation of the testicular veins above the
inguinal ligament where the pampiniform
plexus coalesce to form one or two veins.
• An incision is made 3 cm above the deep
inguinal ring. The external oblique, internal
oblique and transversus muscles are split and
the testicular veins are ligated extraperitoneally
(the alternative venous pathway for the testis is
described above).
• Thisoperationcanbedone laparoscopically also.
Q 51. What is “triangle of doom”?
It is a laparoscopic finding seen in hernia surgery
and varicocele surgery. The triangle is formed
medially by the vas deferens, laterally by the
testicular vessel and an imaginary line joining these
two structures. Inside this triangle the iliac artery
and vein are seen which are likely to be injured and
hence called triangle of doom.
Q 52. Will varicocele recur after surgery?
Yes. Recurrence is common after all types of
varicocele surgery.
44 Inguinal Hernia/Femoral Hernia
Case
Case Capsule
A 60-year-old male patient presents with a
swelling in the right inguinoscrotal region of 2
years duration. He also complains of dragging
and aching sensation in the groin. He is a chronic
smoker with bronchitis. For the last 2 years, he
has difficulty in passing water. He has to get up
3–4 times every night for this purpose. There is no
history of chronic constipation, abdominal pain
or vomiting. He says the swelling is present only
during standing position and it will disappear as
soon as he lies down. On examination, there is a
large pear-shaped swelling seen above the crease
of the groin and medial to the pubic tubercle of
8 × 4 cm size. The swelling is not extending to
the scrotum, but confined to the inguinal region.
There is a visible expansile cough impulse, which
is demonstrated in palpation also. One “cannot
get above the swelling”: The swelling is reducible.
By applying pressure over the internal ring (Deep
ring occlusion test), the swelling cannot be held
reduced. A defect is felt in the abdominal wall
above the pubic tubercle. The swelling is dull to
percussion. The contralateral side is normal, so also
the external genitalia. Malgaigne’s bulging is noted
on the left sided while performing head raising test.
The abdominal examination revealed no scars and
no mass lesions. Perrectal examination is normal.
Checklist for history
• History of chronic cough, asthma, bronchitis
• History of heavy weight lifting
• History of constipation (straining to pass motion)
• History of urinary complaints: night frequency,
hesitancy-difficulty to initiate the act of micturition
and urgency, etc.
• History of pain in the groin
• History of epigastric pain (dragging on the
mesentery)
• History of appendicectomy (damage to ilioinguinal nerve)
• History of abdominal pain and vomiting.
Checklist for clinical examination
1. Always examine the patient in standing position,
while the examiner sits.
2. Always examine both inguinal regions (20%
hernias are bilateral)
3. Look for visible expansile impulse on coughing
4. Look for palpable expansile impulse on coughing
Contd...
Inguinal Hernia/Femoral Hernia
451
5. Assess whether you can get above the swelling
or not
6. Swelling is reducible or not
7. Assess the percussion note: Resonant if the
content is gut, dull if the content is omentum
8. Always examine the genitalia (there may be dual
pathology)
9. Feel the testis (testis will be separate from the
swelling)
10. Locate epididymis above and posterior to the testis
11. Feel along the spermatic cord
12. Always look for abdominal scars especially
appendicectomy scar which will injure the
ilioinguinal nerve
13. Assessment of the abdominal muscle tone—
head raising test. [Malgaigne’s bulgings—minor
bulging of both inguinal canal region in head
raising test. This is normal and seen when the
muscles are weak]
14. Examine the abdomen for visceral malignancy
15. Examine the chest for respiratory problems
16. Per rectal examination to rule out benign
hypertrophy of prostate.
Contd... Finally before presenting the case, determine
whether the hernia is
1. Inguinal/femoral
2. If inguinal, direct/indirect
3. Complete/incomplete
4. Determine the content—intestine/omentum
• Soft and resonant—intestine
• Firm, rubbery and dull—omentum
5. Complicated/uncomplicated
• Irreducibility, obstruction, strangulation,
incarceration and inflammation.
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Clinical Surgery Pearls
of the hernia varies depending on whether it is
indirect, direct or femoral [Read Anatomy]. The
contents are omentum [omentocele], intestine
[enterocele] or other organs, e.g. if Meckel’s
diverticulum is forming the content, it is called
Littre’s hernia. Appendix will form a content on right
side and sigmoid will form a content on left side.
Urinary bladder will form content on both sides.
Q 4. What is the name of the hernia where part
of the circumference of the viscus is forming the
content?
Richter’s hernia.
Q 5. What is the test to differentiate between
direct and indirect inguinal hernia?
Deep ring occlusion test is the test of choice to
differentiate these two. Before doing this, the
patient should be in supine position and the hernia
should be reduced. Reducibility is tested in the
recumbent position. If this is not possible, flex the
thigh in order to keep the pillars of the external
ring relaxed.
Q 1. Why this is hernia?
The points in favor of hernia are:
1. Inguinoscrotal swelling
2. Visible and palpable impulse on coughing [an
impulse is often better seen than felt].
3. Cannot get above the swelling [inguinoscrotal]
4. Reducibility [absent in case of complication]
5. Ring occlusion test
a. Positive in case of indirect hernia [swelling
will not come out]
b. Negative in case of direct hernia [swelling will
come out].
Q 2. What is the definition of hernia?
Hernia is defined as the protrusion of a viscus in
part or in whole through a normal or abnormal
opening in relation to the abdomen. Exceptions
are rare. For example, lung hernia, muscle hernia,
internal hernia, etc.
Q 3. What are the parts of hernia?
The hernia has got a sac, coverings and content. The
sac has got a neck, body and fundus. The coverings
Inguinal Hernia/Femoral Hernia
453
Q 6. What is Zieman’s test?
This is done in the standing position. The clinician
stands behind and somewhat to the right for the
right side and behind and somewhat to the left for
the left side. The hand of the corresponding side is
used for examination [Right hand for right side and
left hand for left side]. He places his index finger
over the indirect hernial site, the middle finger
over the direct hernial site, and ring finger over the
femoral hernial site. The patient is requested to hold
the nose and blow. A peculiar gliding motion of the
walls of the sac will be felt beneath the relevant
finger corresponding to the type of hernia.
Q 7. What are the clinical differences between
direct and indirect inguinal hernia?
Clinical differences between direct and indirect inguinal hernia
No Direct Indirect
1. Extend to scrotum Does not go down to the scrotum Can descend into the scrotum
2. Direction of reduction Reduce upwards and then straight
backwards
Reduce upwards, then laterally and
backwards
3. Controlled by pressure over the
internal ring
Not controlled after reduction, by
pressure over the internal inguinal
ring
Controlled, after reduction by
pressure over the internal inguinal
ring
4. Direction of reappearance after
reduction
The bulge reappears outwards to
original position
The bulge reappears in the middle of
the inguinal region and then flows
medially before turning down to the
neck of the scrotum
5. Palpable defect Defect may be felt in the abdominal
wall above the
No palpable defect as it is behind the
fibers of the external oblique pubic
tubercle muscle
6. Relationship of cord to sac Sac appears medial to the inferior
epigastric artery and is outside
the spermatic cord (posterior to
the cord)
The sac is inside the spermatic cord
Q 8. What are the peculiarities of direct inguinal
hernia?
Peculiarities of direct inguinal hernia
• Appear later in life
• Do not occur in children
• Rare in women
• Rarely strangulate
• Direct hernia is always acquired
• Usually seen in males
• They do not often attain large size or descend into
the scrotum
• The protruding mass mainly consists of extraperitoneal fat
• The neck of the sac is wide.
Contd...
Contd...
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Clinical Surgery Pearls
Q 9. How will you assess the content of the sac?
If it is omentum:
• It will give a doughy feel
• The first part of the hernialsac isreduced easily
and the last part is difficult to reduce.
If it is intestine
• The first part is difficult to reduce and the last
part is reduced easily
• It has got a characteristic gurgling sound during
reduction.
Q 10. What is sliding hernia [Hernia-en-glissade]?
Sliding hernia is a condition where portion of cecum
and appendix on right side, sigmoid on left side
and urinary bladder on both sides will slide down
behind the sac. Even though it is not inside the sac,
it forms the posterior wall of the sac. If the wall of
the sac is unusually thick peroperatively, one should
carefully rule out a sliding hernia.
Q 11. What is Maydl’s Hernia?
This is the so-called W loop hernia where the small
intestine forms a W loop within the hernial sac.
The importance of this type of hernia is in case of
obstruction, even if the visible intestine inside the sac
is viable if one is not pulling out the rest of the intestine,
you are likely to miss gangrene for the rest of the bowel.
Q 12. How will you differentiate inguinal hernia
from femoral hernia?
Inguinal Femoral
• Above and medial to the
pubic tubercle
• Below and lateral to the
pubic tubercle
• Above the crease of the
groin
• Below the crease of the
groin
•Canbereducedcompletely • Cannot be reduced
completely
• Cough impulse usually
present
• Many do not have cough
impulse
Q 13. Why femoral hernia is usually irreducible?
The femoral hernias are having:
a. Narrow neck of the sac
b. The contents are adherent to the peritoneal sac.
Q 14. What is the direction of enlargement of
femoral hernia?
It is usually downwards, forwards and upwards.
Q 15. What is the name of the triangle in which
you get the direct hernia?
The direct hernia comes out through Hesselbach’s triangle. It is bounded medially by the
lateral border of rectus abdominis, laterally by the
inferior epigastric artery and below by the inguinal
ligament.
Q16. What are the differential diagnoses of
inguinal hernia?
Differential diagnoses of inguinal hernia
a. Femoral hernia
b. Vaginal hydrocele
c. Undescended testis in superficial inguinal pouch
d. Hydrocele of the cord
e. Lipoma of the cord
f. Infantile hydrocele
g. Ectopic testis
h. Lipoma of the cord
i. Hydrocele of canal of Nuck
j. Psoas abscess
k. Psoas bursae
l. Sapheno-varix
m. Enlarged lymph nodes
n. Femoral aneurysm.
Note: There are two lumps which occur in the line
of the spermatic cord which can pop in and out
of the external ring, viz. undescended testes and
hydrocele of the cord.
Inguinal Hernia/Femoral Hernia
455
Q 17. What are the three types of inguinal hernia?
a. Bubonocele: When the hernia is limited to the
inguinal canal.
b. Funicular: When the processus vaginalis is closed
just above the epididymis. Here the contents of
the sac can be felt separately from the testis.
c. Complete: [scrotal] In complete hernia, the testis
appears to lie within the lower part of the hernia.
Q 18. What is the situation of testis in a complete
(scrotal) hernia?
It is sited posteroinferior to the hernia.
Q 19. What are the etiological factors for hernia?
Etiology of hernia
a. Congenital: Preformed sac where the processus is
patent
b. Acquired:
i. Increased intra-abdominal pressure [chronic
cough, straining, whooping cough, etc.]
ii. Smokers [collagen deficiency due to smoking]
iii. Intra-abdominal malignancy [acute onset of hernia]
iv. Obesity [muscles are weak, fat separate muscle
bundles and weakens aponeurosis]
v. Multiparity [for femoral hernia—stretching of
pelvic ligaments]
vi. TA/TF deficiency—transverses abdominis,
transversalis fascia deficiency
vii. After peritoneal dialysis—previous weakness or
enlargement of patent processus
c. Hereditary
d. The evolutionary factors are:
i. Absence of posterior rectus sheath below the
arcuate line
ii. Adoption of upright position
iii. Change from quadrapedal to bipedal locomotion
[In animals, the weight of the abdominal content
is directed away from the inguinal region].
Q 20. What is the definition of inguinal canal?
Inguinal canal is an intermuscular slit situated
between the superficial and deep inguinal rings
(Fig. 44.1).
Fig. 44.1: Anatomy of inguinal canal and related structures from inside the abdomen
Contd...
Contd...
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Clinical Surgery Pearls
Q 21. What is external inguinal ring?
• Itisanopeningintheexternalobliqueaponeurosis
• This is formed by the two crurae of the external
oblique aponeurosis
• Itliesjust above and medialto the pubic tubercle.
Q 22. What is internal ring?
• It is an opening in the fascia transversalis
• This is a ‘U’ shaped condensation of the fascia
transversalis
• It is situated ½ inch (1.25 cm) above the mid
inguinal point [between the pubic symphysis
and the anterior superior iliac spine]
• The inferior epigastric artery runs medially.
Q 23. What is mid point of the inguinal ligament?
• Itissituated between the pubic tubercle and the
anterior superior iliac spine
• It is 1–1.5 cm lateral to the mid inguinal point.
Q 24. What is Myopectineal orifice of Fruchaud?
The opening in the lower abdominal wall bounded
above by the myoaponeurotic arch of the lower
edge of the internal oblique and transversus
abdominis muscle (conjoint tendon), below by
the pectineal line of the superior pubic ramus,
laterally by the iliopsoas muscle and medially by
the lateral border of the rectus muscle. This serves
as the passage for blood vessels, nerves, lymphatics,
muscles and tendons between the abdomen and
the lower limb. The space is arbitrarily divided
into upper and lower halves by the lower free
aponeurotic edge, viz., inguinal ligament. This
space is closed off posteriorly by the transversalis
fascia. This is the site for direct, indirect and femoral
hernias. All the three can be repaired by a single
piece of mesh by covering this orifice (Fig. 44.2).
Fig. 44.2: Fruchaud’s myopectineal orifice
Inguinal Hernia/Femoral Hernia
457
Q 25. What is space of Bogros?
It is located in front of the peritoneum just beneath
the posterior lamina of the transversalis fascia. For
all practical purposes it is a lateral extension of the
retropubic space of Retzius. The space of Bogros is
used for the location of prosthesis during the repair
of inguinal hernia in laparoscopic surgery.
Q 26. What is conjoined tendon?
By definition, this is the fusion of fibers of the
internal oblique aponeurosis with similar fibers
from the aponeurosis of the transversus abdominis
muscle just as they are inserted on the pubic
tubercle, pectineal ligament, and the superior
ramus of the pubis. In reality conjoined tendon is
present only in 5% of individuals and therefore it is
considered as a myth and a better terminology is
conjoined area.
Q 27. What is transversalis fascia?
The term may be restricted to the internal fascia
lining the transversus abdominis muscle. In the
inguinal area the transversalis fascia is bilaminar
enveloping the inferior epigastric vessels.
Q 28. What is the frequency of various types of
hernia?
Frequency of types of Hernia
• Inguinal—75% (indirect 65% – 55% are rightsided
and direct 35%)
• Femoral—20% in women and 5% in men
• Umbilical—15%
• Rarer forms—1.5%
• Bilateral—12%
Q 29. What is the frequency of direct hernia?
• About 35%ofinguinalhernias aredirectinmales
(65% indirect)
• 12% will have contralateral hernia
• About four-fold increased risk for future
development on contralateral side.
Q 30. Inguinal hernia is more commonly seen on
which side?
About 55% seen on right side.
Q 31. What is the frequency of direct hernia in
females?
Women practically never develop a direct inguinal
hernia.
Q 32. What is the sex-wise incidence of hernia?
The male to female ratio for inguinal hernia is 20:1.
Q 33. What is funicular direct inguinal hernia
[prevesical hernia]?
This is a narrow necked hernia with prevesical
fat and sometimes a portion of the bladder that
protrudes through a small oval defect in the medial
part of conjoint muscle, just above the pubic
tubercle. It occurs in elderly males and occasionally
becomes strangulated.
Q 34. What is dual hernia [Pantaloon, “saddlebag”]?
This is a type of hernia where two sacs straddle the
inferior epigastric artery, one sac being medial and
other lateral to the artery. This is one of the causes
for recurrence, if one is overlooked during surgery.
Q 35. What will be the course of action, if a patient
develops sudden asymptomatic hernia?
One must search for occult intra-abdominal
malignancy and ascites. Do the following tests.
• Digital rectal examination
• Fecal study for occult blood
• Sigmoidoscopy/colonoscopy
• Double contrast barium enema.
Q 36. Why must a hernia be repaired?
Because of the potential dangerous complications.
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Clinical Surgery Pearls
Q 37. What are the complications of hernia?
Complications of hernia
• Irreducibility
• Obstruction
• Strangulation
• Incarceration
• Inflammation.
Q 38. What is the cause for inflammation in hernia?
Inflammation will occur when the sac contain the
following structures:
• Appendix
• Meckel’s diverticulum
• Salpinx.
Q 39. Is it possible to get strangulation without
obstruction?
Yes—in Richter’s hernia.
Q 40. What is obstructed hernia?
It is a condition where constriction of the neck of the
sac leads to obstruction of the loops of small bowel
within it. This will produce symptoms of intestinal
obstruction.
Q 41. What is strangulated hernia?
Strangulation is a condition where constriction of
the venous return of the bowel occurs initially, which
leads to congestion, arterial occlusion and gangrene
of the bowel. When a loop of gut is strangulated
there will also be intestinal obstruction.
Q 42. What is incarcerated hernia?
Here the contents are fixed in the sac because of
their size or adhesions. The hernia is irreducible,
but the bowel is not strangulated.
Q 43. What is the classification for hernia? (PG)
Many classifications are available. The Gilbert’s
classification with addition by—Rutkow and
Robbins remains the most practical classification.
Type I, II and III are indirect, IV and V are direct.
Type VI, both indirect and direct and Type VII femoral
hernia.
Rutkow and Robbins modification of Gilbert’s
classification
Type I – Tight internal ring
Type II – Moderately enlarged internal ring
Type III – Patulous internal ring more than 4 cm with
sliding component or scrotal component
which will also impinge on direct space
Type IV – Entire floor of the canal is defective
Type V – Direct diverticular defect of no more than
1 or 2 cm in diameter
Type VI – Both direct and indirect
Type VII – Femoral hernia
Q 44. What is Bendavid classification? (PG)
Bendavid classification of hernia
He proposed the Type, Staging and Dimension (TSD)
classification.
There are five types of groin hernias as per this
classification.
Type I: Anterolateral (indirect)
Type II: Anteromedial (direct)
Type III: Posteromedial (femoral)
Type IV: Posterolateral (prevascular)
Type V: Anteroposterior (inguinofemoral). The three
stages are:
Stage I: Extends from the deep inguinal ring to the
superficial inguinal ring
Stage II: Goes beyond the superficial inguinal ring,
but not into the scrotum
Stage III: Reaches into the scrotum
In the TSD classification the ‘D’refers to the diameter
of the hernial defect at the level of the abdominal wall.
The widest anterolateral measurement is recorded in
centimeters.
Inguinal Hernia/Femoral Hernia
459
Q 45. What is Nyhus classification? (PG)
Nyhus classification of hernia
Type I: Indirect inguinal hernia in which the
internal ring is of normal size. The area of
Hesselbach’s triangle remains normal
Type II: Indirect inguinal hernia in which the internal
ring is attenuated but does not impinge
on the floor of the canal. The Hesselbach’s
triangle is pathophysiologically intact
Type III: Consist of three subtypes:
Type IIIA: Direct inguinal hernia
Type IIIB:
• Indirect inguinal hernia with a large
dilated ring that has expanded medially
and encroaches on the inguinal floor
• The hernialsac frequently reachesto the
scrotum
• The sliding and pantaloon hernias are
included in this group
Type IIIC: Femoral hernia
Type IV: Recurrent hernia
– Recurrent direct – IV A
– Recurrent indirect – IV B
– Recurrent femoral – IV C
– Combination – IV D
Q 46. What are the preoperative investigations in
a case of inguinal hernia?
a. Chest examination and chest X-ray PA view
b. Perrectal examination to rule out prostatic
hypertrophy
c. Urodynamic study in male patients above 50
years
d. Cardiac assessment [ECG]
e. Rule out diabetes—blood sugar
f. Complete blood cell count including Hb
estimation.
Q 47. What is the anesthesia of choice for hernia
surgery?
It can be done under local anesthesia, spinal or
general anesthesia. In Shouldice Hospital in Toronto,
they routinely do all hernia operations under
local anesthesia. This hospital is solely dedicated
for hernia surgery and the recurrence rate in this
hospital is less than 1%.
Q 48. What are the advantages of local anesthesia?
Advantages of local anesthesia
a. Peroperative assessment of the hernia is possible
[Peroperative cough test]
b. The repair is not done under tension
c. Postoperative pain is less
d. Postoperative retention of urine is less frequent
e. The patient can leave the hospital in the same day
evening or next day [Day case surgery].
Q 49. What are the surgical procedures available
(Flow chart 44.1) ?
The procedures are:
a. Herniotomy
b. Herniorrhaphy
c. Hernioplasty.
The basic procedure for any hernia repair is
herniotomy. Herniotomy may be done alone or
combined with either herniorraphy or hernioplasty.
Q 50. What is herniotomy?
Herniotomy is the process of identification of the
sac, separation of the sac from the cord, opening the
sac, reducing the content, transfixion and ligature of
the neck of the sac followed by excision of the sac.
Q 51. Why herniotomy alone is done in children?
Because of the following reasons herniotomy alone
is sufficient in children:
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Clinical Surgery Pearls
a. The obliquity of the canal is less
b. For all practical purposes the superficial and
deep inguinal rings are almost superimposed
and therefore there is no need for repair
c. The muscles are very strong in children.
Q 52. What is the difference between herniorraphy
and hernioplasty?
In herniorrhaphy, a simple repair of the posterior
wall alone is done. Examples are:
a. Shouldice’s repair [Gold standard herniorrhaphy
previously]
b. Bassini’s repair [Time tested technique, nowadays
not recommended].
In hernioplasty, some form of synthetic material
is used to strengthen the posterior wall and cover
the defect [polypropylene mesh].
Note: a and b are tissue repairs.
Q 53. What is Shouldice’s repair?
This surgery was devised by E.E. Shouldice (1890–1965)
of Toronto. This is also called Canadian Repair. The
Shouldice hospital surgeons are true hernia specialists
and they restrict their surgery to hernia patients.
This is a four layer repair using non-absorbable
monofilament (polypropelene) suture material.
The basic principle of Shouldice’s technique is the
division of transversalis fascia obliquely, suturing
of the lower leaf of transversalis fascia to the under
surface of the upper leaf (first layer) followed by
the suturing of the lower border of transversalis
fascia to the inguinal ligament (second layer). This is
called imbrication of a double layer of transversalis
fascia to the inguinal ligament. This is followed by a
double layer of conjoint tendon—internal oblique
muscle suturing to the inguinal ligament (third and
fourth layers).
• In short, it is a 4 layer repair. In first layer, the
lower leaf of the divided transversalis fascia is
sutured first to the under surface of the upper
leaf by continuous 30 polypropylene suture.
• Thefirstlayeriscontinuedasthesecondlayerwhere
the lower border of the upper leaf is sutured to
the inguinal ligament by the same suture material
continuously. The first layer is started medially from
the pubic tubercle region and goes laterally and
then comes medially as the second layer.
• The third layer is started laterally at the deep
inguinal ring region and comes medially and then
it is continued again laterally as the fourth layer.
Flow chart 44.1: Management of inguinal hernia
Inguinal Hernia/Femoral Hernia
461
• The third and fourth layers are suturing of
the conjoint tendon and under surface of the
external oblique/inguinal ligament.
Q 54. What is Bassini’s herniorrhaphy?
This is the oldest technique of hernia repair
where after herniotomy the conjoint tendon is
approximated to the inguinal ligament using No.1
size interrupted polypropylene sutures (synthetic
nonabsorbable).
Q 55. What is the current gold standard surgery
for hernia repair [hernioplasty]?
The gold standard current hernia surgery is the
Lichtenstein Tension-free Hernioplasty. Here
approximately 16 × 8 cm size mesh (polypropylene) is placed anterior to the posterior wall
after herniotomy and overlapping it generously
in all directions including medially over the pubic
tubercle.
Q 56. What are the essential steps of inguinal
herniorrhaphy?
• Local anesthesia/regional anesthesia/general
anesthesia.
• An oblique inguinal skin crease incision
approximately 1.5–2 cm above the medial twothirds of the inguinal ligament.
• Incise the fatty and membranous layers of the
superficial fascia (fascia of Camper and fascia of
Scarpa).
• Ligate the superficial circumflex iliac,superficial
epigastric and superficial external pudendal
vessels (external pudendal may be retracted to
avoid edema scrotum).
• Identify the external oblique aponeurosis
and external ring. Divide the external oblique
aponeurosis along the line of its fibers and turn
back the edges.
• Identify the internal oblique and conjoined
tendon above and the inguinal ligament below.
The cord is in between.
• In indirect inguinal hernia, the sac is inside the
spermatic cord and the cremaster muscle has
to be divided in the line of the spermatic cord
for identifying the sac. In direct hernia the sac is
posterior to the cord.
• Safeguard the ilioinguinal nerve, vas deferens
and spermatic artery.
• Identification of the sac and isolation of the sac
from the cord (the sac is seen as pearly white
structure).
Indirect inguinal hernial sac
• If the sac issmall, it can be freed in toto. If it is of
long and scrotal type, the fundus of the sac must
not be sought (the blood supply to the testis
may be compromised by such a procedure).
The sac is isolated upto the neck of the sac until
the parietal peritoneum can be seen on all sides
and extraperitoneal fat is visualized. The inferior
epigastric vessels are seen on the medial side.
• Open the sac, reduce the contents (omentum
and intestines are returned to the peritoneal
cavity).
• Herniotomy: The neck of the sac is transfixed
as high as possible and the rest of the sac is
removed.
Direct hernial sac
• In this situation there is no need to incise the
cremaster muscle to identify the sac (the hernial
sac is seen posterior to the cord).
• Push the direct hernial sac inwards (no need
to open the sac and reduce the contents.
Transfixion and ligation and herniotomy are not
required).
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Clinical Surgery Pearls
• Interrupted polypropylene sutures are put so
that the sac will remain invaginated.
Repair of both direct and indirect hernia
• The best tissue repair is the four layer repair of
Shouldice (read the steps above).
• For Lichtenstein tension-free repair, the
polypropylene mesh is used to reinforce the
posterior wall. The mesh is sutured below to the
inguinal ligament, above to the internal oblique
and conjoined tendon. The mesh should overlap
beyond the pubic tubercle medially. Laterally
the mesh is incised to accommodate for the
spermatic cord. Finally, the spermatic cord will
be lying over the mesh.
Closure
• Approximate the external oblique aponeurosis
• Subcutaneous sutures are put with interrupted
absorbable sutures
• Skin is closed, ideally by skin tapes.
Q 57. Can you do hernia repair by laparoscopy?
Yes.
Q 58. What are the methods of laparoscopic hernia
repair? (PG)
TEP and TAPP.
TAPP: Transabdominal preperitoneal repair—Here
after entering the peritoneal cavity, the peritoneum
is incised cephalad to the inguinal floor and the
hernia defects are dissected. Moderate sized
indirect sacs are dissected and reduced. Large sacs
are occasionally transected and the distal sac left
in situ leading to a possible hydrocele formation
avoiding hematoma. Mesh is secured to Cooper’s
ligament and the underside to the conjoined
tendon with no staples being placed lateral to
epigastric vessels.
TEP: Total extraperitoneal repair—Here the peritoneal
cavity is not entered. With the help of an infraumbilical
trocar, the preperitoneal space is entered using a
combination of carbon dioxide and blunt dissection to
expose the entire myopectineal orifice. Polypropylene
mesh is then placed between the underside of the
abdominal wall and the peritoneum fixing the mesh
to Cooper’s ligament and the aponeurotic sling.
Q 59. What are the indications for laparoscopic
hernia repair? (PG)
Indications for laparoscopic hernia repair
• Bilateral inguinal hernia
• Recurrent hernia
• Femoral hernia.
Q 60. What is Stoppa groin hernia repair? (PG)
It is also called giant prosthetic reinforcement of
visceral sac [GPRVS].
• This is a revolutionary and innovative bilateral
properitoneal prosthetic hernioplasty. The
procedure is although useful for repair of all
hernias of the groin, it is mainly used to manage
complex hernias at high risk for recurrence and
for recurrent groin hernias.
• TheessentialfeatureofGPRVSisthereplacement
of the transversalis fascia in the groin by a
large prosthesis that extends beyond the
myopectineal orifice (MPO).
• The prosthesis envelops the visceral sac held in
place by intra-abdominal pressure and later by
connective tissue ingrowth.
• The mesh adheres to the peritoneum and
renders it inextensible so that it cannot protrude
through the parietal defect. Here the parietal
defects are not closed and should not be closed.
GPRVS is a suture less and tension-free repair.
Inguinal Hernia/Femoral Hernia
463
Bilateral GPRVS
• Bilateral GPRVS may be achieved through a
subumbilical midline or Pfannenstiel incision.
• The preperitoneal space is cleaved in all
directions, exposing the space of Bogros and
the space of Retzius, the superior ramus of the
pubis, the obturator foramen, iliac vessels and
the iliopsoas muscle.
• The elements of the spermatic cord are
parietalized.
• The chevron-shaped mesh is tailored to the
patient and should measure transversely 2 cm
less than the distance between the anterior
superior iliac spines and vertically should
measure the distance between the umbilicus
and the symphysis pubis.
• In obese patients, the mesh should be several
centimeters wider than the interspinous
dimensions.
• The repair also can be done unilaterally and
the mesh implanted through a lower quadrant
transverse abdominal incision or through an
anterior groin incision.
Q 61. What is the management of dual hernia?
The sac should be delivered to the lateral side of the
deep epigastric vessel and dealt with.
Q 62. What are the vessels likely to be injured in
hernia surgery?
Vessels likely to be injured in hernia surgery
1. Pubic branch of the obturator artery
2. Aberrant obturator artery originating from the deep
inferior epigastric artery—‘Artery of death’
3. Inferior deep epigastric artery
4. Deep circumflex iliac vessel
5. Cremasteric artery
6. External iliac vessel.
Q 63. What is the course of action if a deep bite is
taken through external iliac vessel?
• Remove the suture (do not tie the suture), If not
the artery will blow out within 2–3 days
• Apply pressure.
Q 64. What are the nerves inside the inguinal canal?
1. Ilioinguinal nerve (T12 - L1)
• It is in close relationship to spermatic cord
• It isseen in the usual position only in 60% of
cases
• It may be absent
• Innervation—base of the penis at the
scrotum and adjacent side.
2. Iliohypogastric nerve (T12 - L1)
• Seen 1 to 2 cm above the inguinal canal
• Supplies suprapubic area
• Injured while a relaxing incision is put over
the rectus sheath.
3. Genitofemoral nerve (L1,2,3)
Genital branch
• Prone to injury at the internal ring
• Penetrate the internal oblique at the origin
of the cremaster
• Motor innervation—cremaster muscle
• Sensory innervation—to the penis and
scrotum.
Femoral branch
• Innervation—upper thigh (less likely to be
injured).
Q 65. If a nerve is cut what is the course of
action? (PG)
• It may be ligated or clipped to allow closure of
the neurilemmal sheath
• Repair is impossible.
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Clinical Surgery Pearls
Q 66. What is the blood supply to the testis?
Blood supply to the testis
a. Testicular artery (major supply)—from aorta
b. External spermatic artery—from inferior epigastric
artery—also supply cremaster muscle
c. Artery to vas deferens—from superior vesical artery.
Note: There is a rich collateral existing between
these three vessels. In addition the vesical and
prostatic branches communicate with the above.
The scrotal vessels from internal and external
pudendal vessels, freely communicate with vessels
in the spermatic cord external to the superficial
inguinal ring.
Q 67. What will happen if testicular artery is
ligated? (PG)
Ligation of testicular artery alone at the deep
ring may not lead to testicular atrophy provided
collateral circulation is undisturbed.
Q 68. What are the steps in surgery which will
jeopardize the collateral supply to the testis?(PG)
• Removal of testis from scrotum
• Dissection of sac distal to the external ring.
Q 69. What are the complications of hernia surgery?
Complications of hernia surgery
i. Hematoma
ii. Seroma
iii. Wound infection
- Superficial incisional surgical site infection
- Deep incisional surgical site infection
iv. Infection of mesh
v. Scrotal edema
vi. Postherniorrhaphy hydrocele
vii. Recurrent hernia
viii. Ischemic orchitis
ix. Testicular atrophy
x. Chronic residual neuralgia (sensory nerve):
• Ilioinguinal neuralgia
• Genitofemoral neuralgia
xi. Obstruction of vas deferens
xii. Dysejaculation.
Q 70. What is the incidence of recurrent hernia?
1. For inguinal hernia: 2.3 to 20%
2. Femoral hernia: 11.8 to 75%
Q 71. What is the most common site of recurrence?
(PG)
• Medially: The transversus abdominis tendon is
inserted to the rectus sheath as much as 2 cm
above the pubic tubercle. If the mesh is not
reaching beyond the pubic tubercle for 1cm,
there is chance for recurrence
• The second most common site is at the internal
ring.
Q 72. What are the causes for hematoma after
herniorrhaphy? (PG)
• Bleeding from superficial vessels (external
pudendal, circumflex iliac and superficial
epigastric vessels).
• On a deeper plane, during resection of the
cremaster, careless ligature of the external
spermatic artery can result in tense hematoma
and ecchymosis that extend to the scrotum.
• Injury to the deep inferior epigastric vessel (one
artery and two veins) during division of the
transversalis fascia.
• Bleeding from venous circulation within the
space of Bogros.
Contd... • Bleeding from iliopubic artery.
Contd...
Inguinal Hernia/Femoral Hernia
465
• Injury to aberrant obturator artery from the
deep inferior epigastric artery when sutures are
inserted to Cooper’s ligament (artery of death).
• Injury to femoral vein and artery.
Q 73. How to avoid scrotal edema? (PG)
• Do not divide external pudendal vessels at the
medial limit during incision
• Bilateralsimultaneous herniorrhaphy will cause
edema of penis and scrotum.
Q 74. What is the cause for post herniorrhaphy
hydrocele? (PG)
• Overzealous skeletonization of the spermatic
cord
• Severance of the lymphatic drainage.
Q 75. What is ischemic orchitis? (PG)
• Ischemic orchitis will produce swollen, painful,
hard and tender spermatic cord, epididymis and
testicles
• It is seen within 24–72 hours of hernia surgery
• May be associated with fever
• The pain and tenderness will last for 6 weeks
• Swelling will last for up to 5 months
• The processissterile and there is no suppuration
• It is as a result of intense venous congestion
secondary to massive thrombosis of the veins
of the cord.
Q 76. What is the natural course of ischemic
orchitis? (PG)
• Subsides completely
or
• Testicular atrophy aslate as 12 months(no pain
or tenderness).
Q 77. What are the causes for chronic residual
neuralgia? (PG)
It may be due to the following reasons:
• Primary damage to the nerve—stretching,
contusion, crushing and suture— compression
• Secondarydamage—cicatrical compressionand
suture granuloma.
Q 78. What are the manifestations of chronic
residual neuralgia? (PG)
• It may be a neuroma pain, referred pain or
projected pain
• The pain will be out of proportion to the
pathology
• Patient may be unable to return to work.
Q 79. What is the treatment of chronic residual
neuralgia? (PG)
• Nerve block
• Neurectomy (division of three nerves)
• TENS
• Drugs.
Q 80. What are the causes for dysejaculation? (PG)
• It may be due to adhesion of the vas deferens
• Painful and burning sensation in the groin
preceding, during and after ejaculation.
Q 81. What is the management of infected mesh?
(PG)
• Infection does not necessarily imply removal
of a mesh unless the mesh is sequestrated and
bathed in purulent exudates.
• Usually will subside with culture and sensitivity
and appropriate antibiotics and irrigation. Partial
resection may be required.
Q 82. What is “metastatic emphysema of READ”?
(PG)
Acquired herniation is considered as the end result
of a collagen deficiency which is mentioned as
metastatic emphysema of Read.
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Clinical Surgery Pearls
Femoral Hernia
Q 83. What are the diagnostic points in favor of
femoral hernia?
• The femoral hernia is below and lateral to the
pubic tubercle (inguinal hernia is above and
medial to the pubic tubercle)
• The swelling is placed more laterally than the
inguinal hernia
• Irreducibility is encountered ten times more
frequently with a femoral hernia
• The visible impulse on coughing may be absent
in the supine position.
Q 84. What are the three stages of femoral hernia?
Stage I: There is a rounded reducible swelling
below the medial end of the inguinal
ligament.
Stage II: The hernia after passing through the
femoral canal bulges into the femoral
triangle (Scarpa’s triangle). Usually this
variety is irreducible.
Stage III: Further expansion downward is prevented
by blending of fascia, the fundus mounts
upwards in front of the inguinal ligament
and overlies the inguinal canal. By this
time it is always irreducible. Finally, the
femoral hernia takes the shape of a retort.
Q 85. Femoral hernia is more common in which sex?
• In female patients(commonest hernia in female
is inguinal hernia)
• Female to male ratio is 2:1
• Elderly group is involved in female (after
repeated pregnancies)
• The commonest age group in male is 30-45.
Q 86. What are the boundaries of femoral canal?
It is bounded medially by the lacunar ligament,
laterally by the femoral vein, superoanteriorly by
the inguinal ligament and inferoposteriorly by the
Astley Cooper’s ligament (pectineal).
Q 87. What are the most important problems of
femoral hernia?
• It has got a very narrow neck and therefore the
hernia is more prone for strangulation
• Itis more likely to obstruct and strangulate than
inguinal hernia
• Strangulation without obstruction is possible in
femoral hernia (Richter’s hernia).
Q 88. How to differentiate femoral hernia from
saphenavarix?
• Saphenavarix is softer than the femoral hernia.
• Cruveilhier’s sign: In the erect position when
the patient coughs or blows his nose, there is
a tremor imparted to the palpating fingers as
though a jet of water entering and filling the
pouch.
• Saphenavarix isusually associatedwithvaricosity
of the long saphenous vein.
• There will be blue discoloration of the skin over
the saphenavarix.
Q 89. How to differentiate irreducible femoral
hernia from enlarged lymph node (Cloquet’s node)?
It is a perplexing problem. When you suspect
Cloquet’s node, search for a focus of infection in
the following areas:
• Lower limb
• Buttocks
• Perineum
• Anus
• Genitals.
Note: Pressure by the hernial sac on the superficial
epigastric or circumflex iliac vein causes distension
of the superficial epigastric vein on the anterior
abdominal wall (Gaur’s sign).
Inguinal Hernia/Femoral Hernia
467
Q 90. How to differentiate reducible femoral
hernia and psoas abscess pointing beneath the
inguinal ligament?
Cold abscess arising from tuberculous disease of the
body of the lumbar vertebrae will track along the
psoas sheath to the insertion of psoas major muscle
• A psoas abscess will point lateral to the femoral
artery (it will be reducible and painless)
• Examination of the back will reveal evidence of
tuberculosis of the spine
• Therewillbe a swelling inthe iliac fossa andcross
fluctuation can be elicited between the swelling
in the femoral region and iliac fossa.
Q 91. What is Laugier’s femoral hernia?
This is a hernia through a gap in the lacunar
(Gimbernat’s) ligament. When there is unusual
medial position of the femoral hernial sac, one should
suspect Laugier’s femoral hernia. The hernia is nearly
always strangulated at the time of diagnosis.
Q 92. What is Narath’s femoral hernia?
This occurs only in patients with congenital
dislocation of the hip and is due to the lateral
displacement of the psoas muscle. The hernia lies
behind the femoral vessels.
Q 93. What is Cloquet’s hernia?
This is one in which the sac lies under the fascia
covering the pectineus muscle. It may coexist with
usual type of femoral hernia.
Q 94. What is the ideal timing for femoral hernia
surgery?
As early as possible (early surgery).
Q 95. What is the principle of repair of femoral
hernia?
Suture of the inguinal ligament to the pectineal
ligament after dealing with the sac.
Q 96. What are the operations available for
femoral hernia?
a. “Low” operation of Lockwood: Here an incision
is made 1cm below and parallel to the inguinal
ligament. After dealing with the sac and contents
(freeing the omentum, etc.), the neck of the sac is
pulled down and ligated as high as possible. The
femoral canal is closed by three nonabsorbable
interrupted sutures by suturing the inguinal
ligament to the iliopectineal line. Alternatively
a role of polypropylene mesh may be kept and
anchored with nonabsorbable sutures placed
medially, superiorly and inferiorly.
b. The Lotheissen’s operation: This is an inguinal
approach. The transversalis fascia is divided in
the line of incision avoiding injury to the inferior
epigastric vessel. The sac is withdrawn upwards
after releasing the adhesions and its contents are
dealt with. The femoral ring is now obliterated
by suturing the conjoined tendon to the
iliopectineal line to form a shutter by protecting
the femoral vein. Alternatively a polypropylene
mesh is inserted into the preperitoneal space
and anchored inferiorly to the iliopectineal line,
superiorly to the Cooper’s and superomedially
to the rectus sheath.
c. McEvedy’s approach: This operation may be
carried out by three incisions
i. Vertical incision (an incision extending
from the femoral canal region in the thigh
upwards to above the inguinal ligament)
ii. Oblique incision
iii. Unilateral Pfannenstiel incision: It can be
made a complete Pfannenstiel if laparotomy
is required.
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Clinical Surgery Pearls
Through the lower part of the incision the sac
is dissected out and through the upper part of the
incision which is going above the inguinal ligament,
the upper part of the procedure is carried out.
• An vertical incision is put parallel to the outer
border of the rectus muscle 2.5 cm above
the superficial inguinal ring until the extraperitoneal space is identified
• ByGuaze dissection the hernialsac entering the
femoral canal is identified
• If the sac is small and empty it may be drawn
upwards, if large the fundus of the sac is opened
below and dealt with before delivering the sac
upwards.
• After freeing the sac, the neck is ligated
• The conjoined tendon is sutured to the
iliopectineal ligament with nonabsorbable
sutures
• Alternatively a polypropylene mesh may be
kept and sutured inferiorly to the iliopectineal
ligament and medially to the rectus sheath
• Advantage ofthistechnique isthatifresection of
the intestine is required, it can be easily carried
out.
45 Incisional Hernia (Ventral
Hernia, Postoperative Hernia)
Case
Case Capsule
A 45-year-old obese female patient presents
with diffuse bulging of the surgical scar of the
lower abdomen (12 × 5 cm size). Patient gives
history of cesarean section 10 years back. On
examination there is a lower midline scar in the
anterior abdominal wall. After the surgery she
noticed a swelling which was increasing steadily
and reached the present size. Initially most of the
swelling used to get reduced in the supine position.
Of late the swelling is only partially reducible. The
skin overlying the swelling is thinned out and
atrophic. Expansile impulse on coughing is seen at
the swelling. Palpation of the abdomen revealed a
defect in the abdominal wall of about (10 × 4 cm
size). Normal peristalsis can be seen through the
skin overlying the bulge. She gets attacks of colic
for the last 3 months.
Read the checklist of abdominal examination.
Checklist for history
• Verify previous operation note
• History of drainage tube through the wound
• Historyofwound infection—Deep wound infection
is notorious for causing incisional hernia
• Reason for initial operation
• History of postoperative coughing, vomiting and
abdominal distension
• History of COPD
• History of steroid intake
• History of jaundice in the postoperative period.
Q 1. What is the diagnosis in this case?
Incisional hernia.
Q 2. What are the diagnostic points in favor of
incisional hernia?
• History of lower abdominalsurgery with a lower
midline scar
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Clinical Surgery Pearls
• The swelling is seen at the site of the scar in the
abdominal wall
• The swelling is partially reducible in the supine
position
• The swelling is more in the standing position
• Expansile impulse on coughing present
• Palpable defect in the lower abdomen.
Q 3. What is the most important clinical sign for
incisional hernia?
• The swelling will become more prominent in
head raising test
• Reducibility and cough impulse.
Q 4. If the lump does not reduce and does not
have a cough impulse, what are the differential
diagnoses?
Then it may not be a hernia. The following
differential diagnoses are to be considered:
Differential diagnoses if it is not reducible
• Deposit of tumor—Desmoid tumor
• Hematoma
• Foreign-body granuloma
• Old abscess
• Lipoma.
Q 5. What is incisional hernia?
• It is a hernia through an acquired scar in the
abdominal wall.
• An incisional hernia usually starts as a symptomless partial disruption of the deeper layersof
a laparotomy wound during the immediate
or early postoperative period, the event being
unnoticed if the skin wound remains intact.
Q 6. What are the causes for incisional hernia?
Causes for incisional hernia
1. Technique of wound closure (technical failure is
the most important cause for incisional hernia):
• Selection of suture material for closure of
the fascial layer (nonabsorbable synthetic,
monofilament, No 1 size suture material is
preferred for closing the fascia, e.g. Polypropylene)
• Method of closure: Single layer mass closurewith
interrupted ‘far and near’ sutures
• Length ofsuture material mustbe atleast 4 times
the length of incision but < 5 times if continuous
suture is used
• Use Jenkin’sformula for closure ofthe fascia:The
bites must be taken at least 1 cm away from the
fascial edge and 1 cm apart (the reason for this is
the fact that the collagenolysis will extend upto
1 cm from the fascial edge during healing)
2. Drainage tube:
• Keeping drainage tubes through the wound
– higher tendency to burst and later produce
incisional hernia
3. Type of incision:
• Midline and vertical incisions have greater
tendency than horizontal wounds—more
tendency to produce burst abdomen
4. Wound infection:
• Following operations for peritonitis—more
chance for wound infection and wound
dehiscence
• Operations onpancreas and subsequentleakage
5. Postoperative events—leading to wound disruption
• Postoperative vomiting
• Persistent postoperative cough
• Postoperative abdominal distension—due to
ileus
• Postoperative ventilation
Contd...
Incisional Hernia (Ventral Hernia, Postoperative Hernia)
471
6. Creation of stoma (colostomy, ileostomy, etc.)
7. Collagen deficiency—Decreased ratio of collagen
I/III (increase in collagen III)
8. Failure to close the fascia of laparoscopic trocar
sites over 10 mm size
9. General condition of the patient
• Obesity—There is increased intra-abdominal
pressure in obesity—Increased incidence of
seroma and hematoma in wounds
• Jaundice
• Cirrhosis
• Malignant disease
• Hypoproteinemia
• Anemia
• Malnutrition
• COPD
• Abdominal wounds in pregnancy
• Steroids.
Note: These are the causes for wound dehiscence
(Burst abdomen) also.
Q 7. Since incisional hernia is a symptomless partial
disruption of the deeper layers of the laparotomy
wound, it is better to know something about
wound dehiscence. What is the timing of wound
dehiscence and what are the manifestations?
• Between 6th and 8th day of surgery
• The initial manifestations is serosanguinous
(pink) discharge from the wound which is the
pathognomonic sign of wound disruption. It
signifies intraperitoneal contents lying extraperitoneally
• Patient may volunteerthe information thatthey
‘felt something give way’
• In revealed dehiscence the omentum and coils
of intestines may be found lying outside.
Contd... Q 8. What are the three most important etiological
factors?
Three most important causes for incisional hernia
• Technical failure in wound closure
• Wound infection
• Subclinical wound dehiscence in the postoperative
period.
Q 9. What is ventral hernia?
The term ventral hernia should be restricted to
incisional hernia arising in abdominal midline
operative wounds.
Q 10. What is the management?
The most important investigations are:
•X-ray chest – To rule out COPD
and other pulmonary
diseases
• Ultrasound abdomen – To demonstrate the size
of the defect
– To rule out other intraabdominal pathology
• Hematological
examination
– To rule out anemia
•Biochemicalinvestigation – To rule out
hypoproteinemia
• Nutritional assessment
• Evaluation of cardiac
status and renal
status. After proper
evaluation, surgery is
recommended
Q 11. Is there any conservative management? If
so what is the indication?
• Abdominal belt is sometimes recommended
especially in upper abdominal incisional hernias
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Clinical Surgery Pearls
• Belt is also recommended until the patient is fit
for surgery.
Q 12. What are the preoperative preparations
required?
• Weight reduction by dieting and exercise
• Patient is asked to stop smoking
• Treat the respiratory problems.
Q 13. What are the complications of incisional
hernia?
Complications of incisional hernia
• Irreducibility
• Obstruction
• Strangulation (Rarely)
• Ulceration of the overlying skin.
Q 14. What is large hernia?
A hernia can be considered large when the fascial
edges cannot be approximated without tension
(more than 4 cm).
Q 15. Which hernia is more dangerous, small or
large?
Small hernias may cause bowel obstruction early
and therefore more dangerous.
Q 16. In a very large hernia of long duration
in which most of the intestines are in the sac,
what additional precaution is taken to prevent
postoperative embarrassment?
There are three important problems in this situation:
• Increased risk of paralytic ileus from visceral
compression
• Pulmonary complications as a result of elevation
of the diaphragm when the contents are reduced.
• Risk of failure of hernioplasty.
This may be managed by enlarging the
abdominal cavity preoperatively by prolonged
pneumoperitoneum. This is achieved by increasing
the intra-abdominal pressure to 15–18 cm of water
with the help of a pneumoperitoneum apparatus
for several weeks preoperatively.
Q 17. What are the surgical procedures available
for repair of incisional hernia?
1. Anatomical repair (primary fascial repair)—
Useful only forsmall hernias < 4 cm size because
of the high incidence of recurrence
2. Mesh repair (tension free repair)—The gold
standard treatment
3. Autogenous repair by vascularized innervated
muscle flaps—Reserved for large and recurrent
hernias
4. Complex apposition (considered obsolete and
is of historical importance only. Examples are:
Keel’s operation, Cattel’s operation).
Q 18. What are the most important steps of fascial
repair?
• The hernial sac is dissected
• The adherent omentum and bowel are released
from the sac
• The contents are reduced
• The mouth of the sac is defined
• The layers are repaired with nonabsorbable
sutures—No 1 polypropylene, first the
peritoneum and then the fascial layer.
Q 19. What is mesh repair and what is the ideal
plane for keeping the mesh? (PG)
• The mesh repair can be done either by Open
method or Laparoscopic method
• The initial steps are same as the fascial repair
• For incisional hernias above the umbilicus,
a sheet of polypropylene mesh is inserted
between the posterior rectus sheath and muscle
fibers and anchored in place (Inlay repair)
• For hernias below the umbilicus the mesh is
placed in the preperitoneal space (Inlay repair)
Incisional Hernia (Ventral Hernia, Postoperative Hernia)
473
• The mesh may also be placed as on lay in front
of the fascia (Inlay is superior)
(Here the deficiency can be bridged by sewing
the mesh to the fascia on either side of the defect
ensuring at least a 4 cm overlap of the fascial edges)
• Tension-free mesh repair can be undertaken
laparoscopically apparently with good results.
Q 20. What is autogenous repair by vascularized
innervated muscle flaps? (PG)
• This method is reserved for massive midline
defects and recurrent hernias
• Itis also done afterremoval of infected synthetic
mesh
• The autogenous tissue reconstruction was
introduced by Ramirez et al
• The technique utilizes bilateral, innervated,
bipedicle, rectus abdominis—transverse
abdominis—internal oblique muscle flaps,
that are transposed medially to reconstruct the
central defect.
Q 21. What are the complications of incisional
hernia repair?
Complications of incisional hernia repair
• Wound infection
• Seroma formation
• Wound sinus
• Enterocutaneous fistula
• Recurrence
• Infection of the mesh.
46 Epigastric Hernia
(Fatty Hernia of the Linea Alba)
Case
Case Capsule
A 40-year-old strong muscular laborer male
patient presents with a mid line firm swelling in the
epigastrium of 2.5 cm size, which is associated with
epigastric pain after a large meal, (postprandial
epigastric discomfort) which is relieved by lying
down. He has in addition abdominal bloating
and occasional nausea and vomiting. There is no
impulse on coughing. The swelling is not reducible.
The swelling clinically appears to be parietal in
nature. The hernial orifices are normal. There is
no organomegaly and no other masses felt per
abdomen.
Read the checklist for history and examination of
abdomen.
Q 1. What is the most probable diagnosis in this
case?
Epigastric hernia.
Q 2. What is the cause for postprandial epigastric
discomfort in this case?
It may be because of the epigastric distension after
full meal.
Q 3. What are the differential diagnoses?
a. Parietal swellings b. Intra-abdominal conditions
• Subcutaneous lipoma • Peptic ulcer
• Neurofibroma • Gallbladder diseases
• Fibroma • Hiatal hernia
• Divarication of rectus
abdominis (Diastasis)
• Pancreatitis
• Small intestinal obstruction
Q 4. What is epigastric hernia?
• Hernia through the linea alba between the
umbilicus and the xiphisternum
• They develop through the opening of paramidline nerves and vessels
• 80% occur just off the midline.
Q 5. Which sex is affected more?
More common in men than women
Q. 6. What is the incidence and age group
affected?
• 3 to 5% of the population.
• Age group is 20–50 years.
Epigastric Hernia (Fatty Hernia of the Linea Alba)
475
Q 7. What are the peculiarities of epigastric
hernia?
• They are better felt than seen
• Impulse on coughing may not be there
• Reducibility is not there even in uncomplicated
hernias
• Usually no peritoneal sac and no bowel content.
Q 8. What is the usual content in epigastric hernia?
Preperitoneal fat which will come out through the
openings in the linea alba for vessels. Usually there
is no peritoneal sac.
Q 9. What are the stages of the hernia formation?
• First stage it is sac less (Only preperitoneal fat
protrusion)
• Second stage—A small pouch of peritoneum is
drawn after it
• Last stage—Small tag of omentum gets into the
sac and adherent to it.
Q 10. What are the usual symptoms and signs?
Symptoms and signs
• May be identified by routine clinical examination
• Present as painless swellings
• Mass in the epigastrium (difficult to feel in obese
patients)
• Mildepigastric pain/Burning epigastric pain
• Abdominal bloating, nausea or vomiting (these
symptoms may be also due to concomitant other
visceral pathology)
• Symptoms may occur after a large meal followed
by relief in lying down position.
Q 11. What are the complications of epigastric
hernia?
• Incarceration
• Strangulation.
Q 12. What are the investigations for confirming
the diagnosis?
• Ultrasound abdomen/CT to demonstrate the
defect in the linea alba especially in obese
patients (ultrasound will also rule out biliary
pathology and other visceral causes for pain)
• Upper GI endoscopy to rule out peptic ulcer and
other gastroesophageal diseases
• Assessment of the cardiac status, renal status
and respiratory status before surgery
• Hemogram and biochemical investigations.
Q 13. What is the surgical management of
epigastric hernia?
It is managed by epigastric hernia repair.
Q 14. What are the essential steps of epigastric
hernia repair?
• Anesthesia—GA/Local (for small cases)
• Position of the patient—supine
• Drapes are arranged so that the whole of
epigastric area from costal margin to just below
the umbilicus is exposed for surgery
• Incision—Vertical/horizontal. Vertical incision
has the advantage for ruling out more than one
defects in the linea alba so that, hernia is not
missed. Another advantage is that the abdomen
can be opened if required
• The herniated fat is dissected out from the
surrounding abdominal fat
• The opening in the linea alba which is usually
tiny is identified and enlarged transversally
• The hernia is incised at the neck to determine
whether peritoneal sac is present or not
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Clinical Surgery Pearls
• If sac is there, open the sac and reduce the
contents, transfix the neck. If sac is not there,
reduce the protruding extraperitoneal fat
• The opening in the linea alba is closed by
overlapping its edges (double breasting) with
two rows of interrupted polypropylene/nylon
sutures. (First row of mattress sutures, and
second row of simple sutures)
• Subcutaneous sutures are put with interrupted
cat gut
• Skin is closed preferably with skin tapes.
Summary of epigastric hernia
• Usually no impulse on coughing
• Usually not reducible
• Smaller the hernia, greater the symptoms
• Symptoms mimic peptic ulcers
• Rule out gastrointestinal pathology like peptic ulcer
by investigations before surgery
• Rule out epigastric hernia in all cases of dyspeptic
symptoms
• Rule out multiple hernias which is there in 20% of
patients.
47 Paraumbilical Hernia, Umbilical Hernia
in Adults and Children
Case
Case Capsule
A 50-year-old obese multiparous female patient
presents with a swelling on one side of the
umbilicus with pain and discomfort of one year
duration. She also complains of recurrent attacks
of colicky abdominal pain. On examination,
there is a swelling of about 3 cm size which is
firm in consistency having expansile impulse on
coughing. The swelling is reducible and according
to the patient at times it is not going in. Once the
hernia is reduced, a firm fibrous edge of the defect
of about 2 cm size is felt at the periphery of the
umbilical cicatrix. The umbilicus is stretched into a
crescent shape. There is no other hernia.
Read the checklist for history and examination of
abdomen.
Q 1. What is the most probable diagnosis in this
case?
Paraumbilical hernia.
Q 2. What is paraumbilical hernia?
It is a herniation through the linea alba just above
or sometimes just below the umbilicus, sometimes
on the sides (supraumbilical hernia/infraumbilical
hernia).
Q 3. What are the differences between umbilical
hernia and paraumbilical hernia?
In umbilical hernia the herniation occurs through
the umbilical scar and the umbilical scar is weak.
The abdominal contents bulge through the weak
spot everting the umbilicus.
Differences between umbilical hernia and paraumbilical hernia
Umbilical hernia Paraumbilical hernia
1. The abdominal contents bulge through the weak
umbilical scar
Herniation through the linea alba just above or below
the umbilicus
2. Umbilicus is everted The hernia is beside the umbilicus and push it to one
side taking a crescent shape
3. The entire fundus of the sac is covered by the umbilicus Half of the fundus of the sac is covered by umbilicus
and the remainder by the adjacent abdominal skin
Contd...
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Clinical Surgery Pearls
4. More common in girls than boys 5 times more seen in females
5. May be congenital or acquired Always acquired
6. Ascites (cirrhosis) and malignant peritoneal effusion
are predisposing factors for acquired umbilical hernia.
The congenital variety is due to incomplete closure of
umbilical ring at birth
Obesity, repeated pregnancies and flabby abdominal
muscles are responsible for paraumbilical hernia
7. Neck of the sac is wide Neck of the sac is narrow and complications can occur
early
8. Congenital type can wait up to 4 years because
spontaneous closure can occur
Always needs surgery
Q 4. What are the etiological factors for paraumbilical hernia?
• Obesity
• Flabby abdominal muscles
• Repeated pregnancy.
Q. 5 What is the content in paraumbilical hernia?
Greater omentum, small intestine and transverse
colon.
Q 6. What are the clinical manifestations of
paraumbilical hernia?
• Swelling/lump
• Dragging pain
• Gastrointestinal symptoms—traction on
stomach and transverse colon
• IntestinalColicandsignsofintestinalobstruction.
Q 7. What are the complications of paraumbilical
hernia?
• Dragging pain
• Irreducibility (omental adhesions)
• Obstruction—colic
• Strangulation—due to the narrow neck and the
fibrous edge of the linea alba
Contd...
– Presence of loculi may also result in
strangulation of the bowel.
• Ulceration
• Intertrigo in longstanding cases.
Q 8. What are the differential diagnoses of
paraumbilical hernia?
• Lipoma
• Neurofibroma
• Desmoid tumor
• Hematoma
• Sister Joseph nodule (umbilical metastasis)
• Caput medusa.
Q 9. What are the indications for surgery in
paraumbilical hernia?
Surgery is indicated in all cases.
Q 10. What are the investigations required?
• Ultrasound abdomen
– To identify the defect
– To rule out other pathologies
• Plain X-ray abdomen—when obstruction is
suspected
• X-ray chest
Paraumbilical Hernia, Umbilical Hernia in Adults and Children
479
• Assessment of the cardiac status
• Assessment of the renal status
• Complete hemogram.
Q 11. Any preparation required before surgery?
• If the hernia is symptomless and the patient is
obese—weight reduction.
• In symptomatic patientssurgery is donewithout
weight reduction.
Q 12. What is the surgical management of
paraumbilical hernia?
• Paraumbilical hernioplasty, without excision of
the umbilicus (modified Mayo’s repair)
• In Mayo’s repair the umbilicus is excised.
Q 13. What are the indications for prosthetic mesh
in paraumbilical hernia surgery?
• Very large paraumbilical hernia (fascial defect
more than 4 cm size)
• Recurrent paraumbilical hernia.
Q 14. What are the essential steps of paraumbilical
hernioplasty?
• A curved incision is put over the hernia
depending on the situation of the hernia in
relation to the umbilicus
• The hernial sac is identified and dissected all
around
• After opening the neck of the sac, the contents
are released and reduced
• The sac is excised
• The defect in the linea alba is closed by nonabsorbable polypropylene sutures
• Forlarger hernias prosthetic mesh repair may be
required if the surgery is elective.
Q 15. What are the causes for congenital umbilical
hernia?
• It is due to incomplete closure of the umbilical
ring at birth
• Failure of complete obliteration at the site
where the fetal umbilical vessels (umbilical
vein and two umbilical arteries) are joined to
the placenta during gestation.
Q 16. What is the incidence of Congenital umbilical
hernia?
• About 20% of the full-term neonates may have
incomplete closure and umbilical hernia
• 75–85% of the premature infants (weight
between 1 and 1.5 kg) show evidence of
umbilical hernia at birth.
Q 17. Is there any sex/race predilection for
congenital umbilical hernia?
• It is more common in girls than boys
• The incidence is higher in black children than
white children.
Q 18. What is the natural course of congenital
umbilical hernia?
• About 80% will decrease in size and close spontaneously by five years of age
• Congenital umbilical hernia of more than 2 cm
size rarely close spontaneously.
Q 19. What are the complications of congenital
umbilical hernia?
• Incarceration
• Small bowel obstruction (1 in 1500 umbilicus
hernias)
• Spontaneous rupture (very rare in first year of
life due to excessive crying) results in partial
evisceration requiring urgent intervention.
Q 20. What are the indications for surgery in
congenital umbilical hernia?
• Ring size of more than 2 cm
• Failure of closure of the umbilical ring above 4
years.
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Clinical Surgery Pearls
Q 21. What are the steps for umbilical hernia
repair?
• A curved (‘smile’) incision in the natural skin
crease immediately below the umbilicus. The
curved incision should not extend beyond
180°. It is considered important to preserve the
umbilical cicatrix after excising the sac.
• The skin cicatrix is dissected upwards and the
neck of the sac is isolated.
• After ensuring that the sac is empty, the defect
is repaired with polypropylene sutures.
Q 22. What are the causes for adult umbilical
hernia?
Adult umbilical hernia may be a manifestation of:
• Cirrhosis
• Malignant peritoneal effusion.
Q 23. What is the most important complication of
adult umbilical hernia?
• Incarceration—I t is a well-documented
complication of effective relief of ascites
following diuresis, paracentesis, peritoneovenous shunt and TIPS (Transjugular Intrahepatic Portosystemic Shunt).
Q 24. What are the important problems in the
surgical management of adult umbilical hernia?
• Cirrhoticpatientmayhave caputmedusaewhich
may interfere with repair.
• Repair may be difficult requiring a prosthetic
mesh.
• Asubcutaneoussuctiondrainshouldbe avoided
because of the increased risk of infection of the
ascitic fluid.
Q 25. What is omphalocele (exomphalos)?
• It is due to failure of all or part of the mid gut
to return to the celom during early fetal life
• There is a midline abdominal defect
• Liver and bowel are seen contained within a sac
composed of inner layer of peritoneum and
outer layer of amnion from which the umbilical
cord arises at the apex and center.
Q 26. What are the types of omphalocele?
• Omphalocele major—more than 4 cm size
• Omphalocele minor—less than 4 cm size
(herniation of the umbilical cord).
Note: A single loop of intestine in omphalocele
minor may not be obvious and ligation of the
umbilical cord without recognizing this fact will
result in transection of the intestine. This will leave
an umbilico enteric fistula.
Q 27. What are the structures seen in omphalocele
major?
Structures seen in omphalocele
• Liver—Evidence of adhesions to the sac
• Spleen
• Stomach
• Pancreas
• Colon
• Bladder
• Intestine—Lies freely mobile.
Q 28. What is the incidence of omphalocele?
Occurs once in every 6000 births.
Q 29. What are the associated anomalies in
omphalocele?
Associated anomalies are seen in 30–70% of infants
and the following anomalies are seen:
• Trisomy 13, 18, 21
• Tetralogy of Fallot
• Atrial septal defect
• Beckwith—Wiedemann syndrome (large for
gestational-age baby).
Paraumbilical Hernia, Umbilical Hernia in Adults and Children
481
Hyperinsulinism
Visceromegaly
Hepatorenal tumors
Cloacal extrophy.
Q 30. What is the management of omphalocele?
• Work up for associated anomalies
• Orogastric tube to prevent distension of
abdomen
• Since there is a sac covering the viscera,
emergency operation is not necessary
• Various surgical options are there for the
management.
Q 31. What are the surgical options?
1. Nonoperative therapy—This is recommended
for premature infants with a gigantic intact sac
with associated anomalies where survival of a
major operation is questionable.
The intact sac is painted daily with desiccated
antiseptic solutions (Mercurochrome) and
this will allow to form an eschar over the sac.
Granulation tissue grows from the periphery
over the eschar. This will ultimately form a ventral
hernia, which can be repaired later.
2. Skin flap closure:
• The sac is gently trimmed
• The skin is freed from the fascial edges and
undermined laterally
• The umbilical vessels are ligated
• The skin flaps are approximated in the
midline with simple sutures
• The ventral hernia is repaired at a later date
(months to years later).
3. Staged closure:
• The sac is trimmed
• The skin is further freed from the fascial
attachment
• Prosthetic material like PTFE (Polytetrafluoroethylene) is sutured with interrupted
nonabsorbable sutures circumferentially
to the full thickness of the musculofascial
abdominal wall to form a silo
• The top of the silo is gathered and tied with
umbilical tape
• Daily the silo is opened under strict aseptic
conditions and the contents examined for
infection
• The viscera are pushed gently back into the
abdominal cavity and the child is observed
for signs of raised intra-abdominal pressure
• The silo istied atreduced level daily untilthe
sac is flush with abdominal wall
• The fascia may be closed with interrupted
sutures at this stage
• Skin is closed over the top.
4. Primary closure:
• The sac is gently dissectedaway from the skin
edge and underlying fascia
• The intestine is evacuated completely of
meconium and fluid distally and proximally
with the help of a nasogastric tube
• The abdominal wall is stretched gradually
and repeatedly in all quadrants achieving a
doubling of volume
• The viscera are then replaced
• The fascial layer is closed primarily under
moderate tension.
Q 32. What is gastroschisis?
• It is a defect in the abdominal wall to the
right of the normal insertion of the umbilical
cord, without any investing sac (compare with
omphalocele)
• It is seen at the site of involution of the right
umbilical vein.
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Clinical Surgery Pearls
Q 33. What is the incidence of gastroschisis?
Twice as common as omphalocele.
Q 34. What is the cause for gastroschisis?
There is a controversy as to whether gastroschisis
represents a ruptured omphalocele sac in utero or
simply a separate entity.
Q 35. What are the differences between
omphalocele and gastroschisis?
Sl. No Omphalocele Gastroschisis
1. The midline abdominal defect as a result of failure of
return of the mid gut to the celom
Defect to the right of the normal insertion of the
umbilical cord (at the site of involution of the right
umbilical vein)
2. The bowels are contained within a sac composed of
peritoneum and amnion
There is no sac covering the intestine
3. The umbilical cord arises at the apex ofthe sac There is normal insertion of the umbilical cord
4. Liver may be seen as a content inside
the sac
Liver is not seen
5. The bowel is not edematous Bowel is edematous and intestines are matted
together and appears to be short
6. Urgent repair is not required because of
the covering sac
Urgent repair is required
Q 36. What are the associated anomalies in
gastroschisis?
• Non-rotation of the mid gut
• Intestinal atresia.
Q 37. What is the surgical management?
Urgent primary closure.
48 Desmoid Tumor, Interparietal Hernia
(Interstitial), Spigelian Hernia
Case
Case Capsule
A 30-year-old female patient presents with a
painless parietal swelling below the level of
umbilicus of 1 year duration. There is history of
cesarean operation during her first pregnancy.
She noticed the swelling within one year of the
child birth. She also gives history of using oral
contraceptives. There is no history of trauma. On
examination the swelling is hard in consistency
of about 6 × 4 cm size overlying the upper part of
the cesarean scar. The inguinal lymph node are not
enlarged. The rest of the abdomen is normal. There
is no organomegaly. The X-ray chest is normal.
Read the checklist for history and examination of
abdomen.
Q 1. What is the most probable diagnosis?
Desmoid tumor (aggressive fibromatosis).
Q 2. What are the points in favor of a diagnosis of
desmoid tumor?
• Onset of the swelling within a year of childbirth
• Use of oral contraceptives
• History of cesarean operations
• Presenceofpainlesshardparietalswellingbelow
the umbilicus.
Q 3. What are the types of desmoid tumor?
Contd...
Classification of desmoid tumors
• Sporadic type
• Part of inherited syndrome
– FAP (Mesenteric Desmoids)
– Risk increased 1000 fold in patients with FAP
It may also be classified as:
1. Superficial (fascial)—Dupuytren’s fibromatosis (they are having slow growth)
2. Deep (musculoaponeurotic)
– Relatively rapid growth and attains large size
– It has high rate of local recurrence
– Involves musculature of trunk and extremities
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Clinical Surgery Pearls
Depending on the location it is classified as:
• Extra-abdominal—shoulder girdle
• Abdominal wall
• Intra-abdominal (mesenteric and pelvic desmoid).
Q 4. What is the significance of oral contraceptives
and cesarean?
• There is association between the development
of this neoplasm and abdominal trauma like
operations
• Oral contraceptive use also has been associated
with the occurrence of these tumor.
Q 5. What is the incidence of desmoid tumors?
About 2.4 to 4.3 cases/million people.
Q 6. What are the differential diagnoses?
Differential diagnoses
• Interparietal hernia
• Spigelian hernia
• Lipoma
• Neurofibroma
• Foreign body granuloma
• Suture granuloma
• Incisional hernia
• Abdominal wall sarcoma.
Q 7. What are the investigations required for
further management?
• MRI—Providesinformationregardingthe extent
of the disease and its relationship to intraabdominal organs
– Homogeneous and isointense to muscle on
T1 weighted images
– Greater heterogeneity with signal less than
fat in T2 weighted images.
Contd...
• Core biopsy/incisional biopsy—Tumor
composed of spindle cells with variable
amounts of collagen. The fibroblasts are highly
differentiated and lack mitotic activity
• Estrogen receptor may be positive in the tumor.
Q 8. What is the most important problem of
desmoid tumor after resection?
• Local recurrence even after complete resection
(40%).
• Multiple local recurrences are common.
Q 9. What is the surgical management of desmoid
tumors?
Complete resection with a tumor-free margin.
Q 10. After complete resection with tumor free
margin, there will be a big defect in the anterior
abdominal wall. How to tackle the defect?
Prosthetic mesh repair is necessary after excision
of the desmoid when the size of the swelling is big.
Q 11. What is the chance for systemic metastasis?
Systemic metastases are extremely rare.
Q 12. Is there any role for radiation therapy in the
management of desmoid tumor?
The combination of surgery and radiation therapy
improves the local failure rate.
Q 13. Is there any role for radiation alone in the
management of desmoid tumor?
Radiation alone is reserved for those patients with
unresectable tumors.
Desmoid Tumor, Interparietal Hernia (Interstitial), Spigelian Hernia
485
Q 14. Is there any role for drugs in the management
of desmoid tumor?
Yes:
• NSAIDs
• Antiestrogens.
Note: The response rate for each of these agent is 50%.
Q 15. Is there any role for chemotherapy in the
management of desmoid tumor?
• They are reserved for unresectable clinically
aggressive disease
• Partial response is seen with doxorubicin,
dacarbazine or carboplatin.
Q 16. What is interstitial hernia?
• Here the hernialsac passes between the layers
of the anterior abdominal wall.
• The sac may be associated with, or communicate with, the sac of a concomitant
inguinal or femoral hernia.
Q 17. What are the varieties of interstitial hernia?
1. Preperitoneal (20%)—Usually itisadiverticulum
from the femoral or inguinal hernial sac (no
swelling is likely to be apparent in this condition).
2. Intermuscular (60%)—It passes between the muscular layers of the anterior abdominal wall (between
external oblique and internal oblique muscles). It is
usually associated with inguinal hernia.
3. Inguinosuperficial (20%)—The sac expands
beneath the superficial fascia of the abdominal
wall or thigh. It is usually associated with
incompletely descended testis.
Q 18. What are the complications of interstitial
hernia?
• Intestinal obstruction
• Strangulation.
Q 19. What is the treatment of interstitial hernia?
Surgical repair depending on the type of hernia.
Q 20. What is Spigelian hernia?
• This is a rare variety of interparietal hernia
occurring at the level of arcuate line.
• The fundus of the sac clothed by the extraperitoneal fat may lie beneath the internal
oblique muscle, and then spreads like a
mushroom between the internal and external
oblique muscles.
• The patient is usually above 50 years of age.
Q 21. What is the clinical presentation of Spigelian
hernia?
It will present as a soft reducible mass lateral to the
rectus muscle and below the umbilicus.
Q 22. How to confirm the diagnosis of Spigelian
hernia?
• Ultrasound scanning—can be performed in the
standing position if no defect is visible in supine
position
• CT scan.
Q 23. What is the most important complication of
Spigelian hernia?
Strangulation.
Q 24. What is the treatment of Spigelian hernia?
• A muscle splitting incision is put overthe swelling
• Isolate the sac, reduce the contents and transfix
the sac
• Transversus muscle, internal oblique and external
oblique muscles are repaired by direct apposition
• Laparoscopic approach may also be used.
49 Gynecomastia/Male
Breast Carcinoma
Case
Case Capsule
A 20-year-old male patient presents with bilateral
breast enlargement that is more on right side.
Right breast is 9 × 6 cm size and left breast
7 × 6 cm size. His external genitalia are normal.
Testicular size is normal and secondary sexual
characteristics are normal. No other abnormality
detected clinically.
Checklist for history
• History of trauma
• Duration of breast enlargement
• Unilateral/bilateral
• History of breast pain
• History of drug intake
• History of sexual function
• Symptoms of hypogonadism
• Loss of libido, impotence, decreased strength
• Changes in weight
• Changes in virilization
• Symptoms of hyperthyroidism
• Symptoms of renal disease
• History of alcoholism—cirrhosis.
Checklist for examination
General
• Look for masculine features, body hair, voice,
muscles, secondary sexual development
• Look for signs of hyperthyroidism
Abdominal
• Look for liver
• Abdominal mass (adrenal)
Genitalia
• Cryptorchidism
• Testicular atrophy
• Testicular tumor
Breast
• Size
• Presence of lumps
• Features of malignancy
• Nipple changes
• Ulceration
• Axillary nodes
• Unilateral/bilateral.
Gynecomastia/Male Breast Carcinoma
487
Q 1. What is your diagnosis?
Bilateral gynecomastia.
Q 2. What is gynecomastia?
It is an enlargement of the male breast, secondary
to proliferation of both epithelial and stromal
components.
Q 3. What is the word meaning of gynecomastia?
It is a Greek word meaning:
Gyne = female
Mastos = breast
Q 4. What is the clinical presentation?
It presents as palpable or visible, unilateral or
bilateral, breast enlargement; that may or may not
be tender.
Q 5. What are the causes for gynecomastia?
It is an imbalance between the stimulatory effects
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Clinical Surgery Pearls
of estrogens and inhibitory effects of androgens
on the growth of breast tissue.
Causes for gynecomastia
• Idiopathic gynecomastia – 25%
• Pubertal gynecomastia – 25%
• Drug-induced gynecomastia - 25%
• Cirrhosis/malnutrition – 8%
• Primary hypogonadism – 8%
• Testicular tumors – 3%
• Secondary hypogonadism – 2%
• Hyperthyroidism – 1.5%
• Renal disease – 1%
• Dialysis associated gynecomastia
• Hyperprolactinemia
• Klinefelter’s syndrome
Q 6. What is the incidence of gynecomastia?
• Young adults – 36%
• Older men – 57%
• Hospitalized elderly – 70%
• Autopsy – 55%
Q 7. What are the peak periods for physiological
gynecomastia?
There are three peak periods of physiological
gynecomastia.
1. In neonates—transplacentaltransfer of maternal
estrogen (regresses completely by the end of 1st
year)
2. Puberty—transient gynecomastia occurin up to
60% of boys (regresses after 2 years)
3. Late in life—progressive testicular dysfunction
and reduction of serum testosterone level and
elevated luteinizing hormone level (LH).
Q 8. What are the causes of drug-induced
gynecomastia?
Drugs causing gynecomastia with their
mechanism of action
Mechanism of action Drugs
Direct breast stimulation
by binding to estrogen
receptor
INH
Digoxin
Estrogens
Cannabis
Stimulation of testicular
leydig cell estrogen
Human chorionic
gonadotropins
Peripheral aromatization
of androgens to estrogen
Testosterone
Suppression of
the endogenous
testosterone
Anabolic steroids
Decreased estrogen
metabolism
Cimetidine
Estrogen displacement
from serum human
binding globulin
Spironolactone
Ketoconazole
Inhibition of testosterone
biosynthesis
Vincristine
Methotrexate
Ketoconazole
Metronidazole
Alcohol
Androgen receptor
antagonism
Cimetidine
Cyproterone acetate
Cannabis
Elevated serum prolactin Phenothiazines
Unknown mechanism Calcium channel blockers
Angiotensin-converting
enzyme inhibitors
Diazepam
Haloperidol
Phenytoin
Contd...
Gynecomastia/Male Breast Carcinoma
489
Antihypertensive:
– Amlodipine
– Methyldopa
– Reserpine
Amiodarone
Metoclopramide
Theophylline
Ranitidine
Omeprazole
Q 9. What are the causes for gynecomastia in
cirrhosis?
a. Alcohol inhibit the hypothalamic – pituitary –
testicular axis leading to low serum testosterone
b. Peripheral aromatization of androgens to
estrogen increases in liver disease
c. Serum human binding globulin (SHBG) levels
are elevated causing a further decrease in free
testosterone levels
d. Some alcoholic beverages contain phytoestrogens.
Q 10. What is refeeding gynecomastia?
Significant weight loss and malnutrition are often
accompanied by hypogonadism as a result of
decreased gonadotropin secretion. With weight
gain, gonadal function return to normal resulting
in a second puberty.
Q 11. Hypogonadism is a cause for gynecomastia.
What are the causes for hypogonadism?
A. Primary hypogonadism (congenital)
• Anorchia
• Klinefelter’s syndrome
• Hermaphroditism
• Hereditary defects in testosterone synthesis
B. Acquired hypogonadism
• Mumps orchitis
• Trauma
• Castration
• Granulomatous disease (leprosy)
• Cytotoxic chemotherapy
C. Secondary hypogonadism
• Partial hypopituitarism will lead on to androgen
deficiency.
Q 12. What is the cause for gynecomastia in
hyperthyroidism?
There are two reasons:
a. The serum human binding globulin (SHBG) is
increased in hyperthyroidism that attaches more
testosterone to it with resultant decreased free
testosterone available
b. The peripheral conversion of androgens to
estrogens is enhanced in hyperthyroidism by
aromatization.
Q 13. What are the estrogen producing tumors?
a. Leydig cell tumors—secrete estradiol (90%
benign)
b. Estrogen producing adrenal tumors (usually
malignant).
Q 14. What are the causes for gynecomastia in
renal failure?
• Low levels of serum testosterone
• Raised estradiol
• Raised LH levels
• Increase in serum prolactin
Contd...
Contd...
Contd...
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Clinical Surgery Pearls
Q 15. What is Simon’s classification of gynecomastia?
Simon’s classification of gynecomastia
• Group 1—Minor but visible breast enlargement
without skin redundancy
• Group 2A—Moderate breast enlargementwithout
skin redundancy
• Group 2B—Moderate breast enlargement with
minor skin redundancy
• Group 3—Gross breast enlargement with skin
redundancy that lookssuch as a pendulousfemale
breast.
Q 16. What are the differential diagnoses?
• Breast carcinoma
• Pseudogynecomastia
• Lipoma
• Neurofibroma
• Lymphangioma
• Dermoid cyst
• Hematoma.
Q 17. What is pseudogynecomastia?
Enlargement of the breast because of fat
deposition rather than to glandular proliferation
that is seen in obese men. There will be generalized
obesity. There will not be any history of breast
pain or tenderness.
Q 18. What are the investigations required in this
patient?
a. The investigations for asymptomatic group
must be kept to a minimum.
Biochemical assessment of liver, kidney and
thyroid function should be performed.
1. LFT
2. RFT
3. TFT.
If normal re-evaluation is done after 6 months.
b. Men with recent breast enlargement with breast
pain and tenderness (symptomatic) do the
following:
1. Serum total and free testosterone level
2. Luteinizing hormone
3. FSH
4. Estradiol
5. Prolactin
6. Human chorionic gonadotropins (b hCG)
7. Urinary 17—Ketosteroids—for feminizing
adrenal tumors
8. Sex chromatin study—if Klinefelter’s
syndrome is suspected.
c. Imaging studies should not be ordered, unless
indicated clinically or by blood results.
1. USG/mammogram of breast
2. FNAC/core biopsy breast
3. Open biopsy of the breast
4. Testicular ultrasound scan
5. CT scan of the adrenal
6. MRI scan of pituitary.
Q 19. What is the cause for discrepancy in size of
the breast in bilateral gynecomastia?
Discrepancy in size is explained by:
a. Asynchronous growth of the two breasts
b. Differences in the amount of breast glandular
and stromal proliferation.
Q 20. Mention one situation where gynecomastia
predisposes to the development of carcinoma?
• Klinefelter’s syndrome—phenotypic male with
karyotype XXY
• Gynecomastia is seen in 80% of cases
• The increased risk for carcinoma breast is 10–20
fold greater than normal
• Patient develops lobular structure in this
gynecomastia.
Gynecomastia/Male Breast Carcinoma
491
Q 21. What is the incidence of breast cancer in
men?
About 0.2% of all malignancies in men.
Q 22. What are the histological stages in gynecomastia?
Two histological stages are seen:
a. Proliferative stage/florid (early stage) less than a
year:
• Ductal proliferation and ductal hyperplasia
• Stroma is loose and edematous
• Clinically breast pain and tenderness
• Acinar development not seen in males
because it needs progesterone
b. Quiescent stage or inactive or asymptomatic cover
12 months (late stage):
• Reduction in proliferation
• Dilatation of ducts
• Fibrosis of stroma.
Q 23. What is the management of gynecomastia
after the investigations?
It can be managed by:
a. Medical treatment
b. Surgery.
Principles of management of gynecomastia
1. Spontaneousimprovement isseen in 85% without
treatment
2. When gynecomastia has been presentfor > 2 years,
medical therapy is unlikely to be effective
3. Medicaltherapy should be limited to only 6 months
4. Stop the drugs causing gynecomastia
5. Gynecomastia following chemotherapywillresolve
spontaneously
6. Treat the hyperthyroidism
7. Surgical removal of testicular/adrenal tumors
8. Hypogonadism is treated with testosterone.
Q 24. What are the drugs used for medical
management?
Drugs used for medical management
of gynecomastia
I. Androgens
i. Dihydrotestosterone—injectionorpercutaneous
administration (Testosterone is aromatized to
estradiol that will exacerbate the gynecomastia
and therefore dihydrotestosterone is used that
is nonaromatizable androgen)
• ↓in Breast volume in 75%
• Complete resolution in 25%
ii. Danazol (weak androgen)—400 mg daily
• The only licensed drug for the treatment of
gynecomastia in UK
• Complete resolution in 23%
• Inhibits pituitary secretion of LH and FSH
• Course of therapy is for 6 months
II. Antiestrogens
i. Clomiphen citrate—response rate 36 – 95%
ii. Tamoxifen 10 mg twice daily
• Complete regression in 78%
• 10 mg/day for 3 months—safe for painful
idiopathic or physiological gynecomastia
iii. Aromatase inhibitors
Testolactone—an aromatase inhibitor is tried with
good result in pubertal gynecomastia.
Q 25. What are the indications for surgery?
Indications for surgery in gynecomastia
• Social embarrassment
• Psychological trauma
• When there is no underlying treatable condition
• When trial of hormone treatment have failed.
Q 26. What are the surgical options?
1. Open subcutaneous mastectomy by a circum
areolar incision extending from 3 to 9 O'clock
position
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Clinical Surgery Pearls
2. Endoscopic—assistedsubcutaneousmastectomy
(very small distant incision)
3. Liposuction—assisted mastectomy (for
pseudogynecomastia)
4. Ultrasound—assisted liposuction.
Note: In Simon’s grade I, IIA and IIB the nipple is left
in its normal position. Grade III cases require skin
resection and repositioning of the nipple areolar
complex. Otherwise there will be redundant skin
folds and the nipple/areolar complex will be at a
lower position than normal.
Q 27. What are the complications of surgery?
Complications of surgery for gynecomastia
1. Nipple/areolar ischemia
2. Nipple distortion
3. Risk of saucer deformity
4. Hematoma
5. Seroma
6. Infection
7. Skin redundancy
8. Skin necrosis
9. Breast asymmetry.
Q 28. Can you prevent iatrogenic gynecomastia?
Yes.
1. Select a drug with lowest association for
gynecomastia
Calcium channel blocker
• Nifedipine—highest frequency
• Verapamil—lower
• Diltiazem—lowest association
H2 Receptor / Proton pump inhibitor
• Cimetidine—highest
• Ranitidine—lower
• Omeprazole—lowest
2. Prophylactic breast irradiation (low dose of
900 rads)is effective inpreventinggynecomastia
and mastodynia in patients receiving estrogen
therapy for prostate cancer.
Carcinoma Male Breast
(Read female breast cancer).
Q 29. What are the suspicious clinical findings for
carcinoma?
Suspicious clinical findings for carcinoma
of male breast
• Unilateral hard mass
• Eccentric mass rather than subareolar
• Nipple retraction
• Skin dimpling
• Nipple discharge
• Axillary lymphadenopathy.
Q 30. Is there any increased incidence of male breast
cancer in patients with benign gynecomastia?
No.
Q 31. What is the incidence of male breast cancer
and the mean age at diagnosis?
• < 1% (0.7%)
• Mean age at diagnosis – 65 years (5 – 10 years
older than in females).
Q 32. What are risk factors for male breast cancer?
Risk factors for male breast cancer
• Radiation exposure
• Estrogen administration
• Cirrhosis of liver
• Klinefelter’s syndrome
• Hepatic schistosomiasis
• Positive family history
• BRCA 2 gene.
Gynecomastia/Male Breast Carcinoma
493
Q 33. Why male breast cancers present as
advanced malignancies?
• There is only small amount of soft tissue in the
male breast and therefore, the carcinoma will
infiltrate the skin and nipple early
• Early involvement of pectoral fascia and muscle
because of the above reason
• Lack of awareness of male breast cancer.
Q 34. What is the prognosis of male breast cancer?
Similar to that of the female breast cancer when
compared stage for stage.
Q 35. What are the prognostic factors in male
breast cancer?
• Nodal status
• Tumor size
• Receptor status.
Q 36. What is the surgical management of male
breast cancer?
• Modified radical mastectomy (MRM)
• Breast conservation may not be possible in most
of the instances
• Radiotherapy is given because of the narrower
margin of excision and locally advanced nature
of the disease.
Q 37. Is there any role for tamoxifen in male breast
cancer?
• Yes. It is given for ER positive patientsfor 5 years
(20 mg daily)
• Many male breast cancers are ER positive
• Itisusedforthe firstlinehormonalmanipulation.
Q 38. What is the role of adjuvant systemic
chemotherapy in male breast cancer?
• Same indication as in female breast cancer.
Q 39. Is there any role for orchiectomy in male
breast cancer?
• No. Orchiectomy is obsolete
• LHRH(Luteinizing hormone releasing hormone)
analog is a better option
• Orchiectomy is used as a 2nd line hormonal
manipulation in metastatic male breast cancer
occasionally in some centers.
50 Fibroadenoma/Cystosarcoma/Breast
Cyst/Fibroadenosis/Fibrocystic Disease/
Mastalgia/Mastopathy/Chronic Mastitis
Case
Case Capsule
A 20-year-old female patient presents with two
painless lumps in her right breast of 6 months
duration. There is no history of any nipple discharge.
There is no family history of any breast diseases.
Her menstrual history is normal. There is no history
suggestive of cyclical mastalgia. On examination,
two very freely mobile rubbery hard lumps are felt
(which are disappearing from the palpating fingers)
in the upper outer quadrant of the right breast each
about 2 cm in diameter. The nipple areolar complex
is normal. There is no skin involvement or fixity. There
are no palpable axillary lymph nodes.
Read the checklist for history and examination of
breast in long case section.
Q 1. What is the probable diagnosis in this case?
Fibroadenoma.
Q 2. What are the clinical points in favor of
fibroadenoma?
Clinical points in favor of
fibroadenoma of the breast
• Painless, freely mobile, rubbery hard swellings in
the breast (Breast mouse)
• The age group (15 to 25 years)
• No fixity to skin or deeper structures
• No axillary lymph node involvement
• Multiplicity.
Q 3. What are the causes for painless lump in the
breast?
Causes for painless lump in the breast
• Fibroadenoma
• Carcinoma
• Fibroadenosis
• Traumatic fat necrosis.
Fibroadenoma/Cystosarcoma/Breast/Cyst/Fibroadenosis/Fibrocystic Disease/Mastalgia
495
Q 4. What are the causes for painful lump in the
breast?
Causes for painful lump in the breast
• Mastitis
• Breast abscess
• Fibroadenosis
• Fat necrosis.
Q 5. What are the causes for massive enlargement
of the breast?
Causes for massive enlargement of the breast
• Giant fibroadenoma
• Cystosarcoma phyllodes
• Sarcoma of the breast
• Benign hypertrophy of the breast (Diffuse hypertrophy)
• Filarial elephantiasis of the breast
• Colloid carcinoma of the breast.
Q 6. What are the causes for cystic swellings in
the breast?
Causes for cystic swellings in the breast
• Fibroadenosis
• Galactocele
• Abscess
• Lymph cyst
• Hematoma
• Parasitic cyst.
Q 7. What is fibroadenoma?
• It is hyperplasia of a single lobule where as
neoplasms arise from a single cell
• It is not a benign neoplasm, but are best
considered as aberrations of normal development and involution (ANDI)
• They arise in the fully developed breast during
the 15 to 25 year period (after 40 years they are
less common)
• They show the same hormonal dependence as
the remainder of the breast, e.g. they lactate
during pregnancy and involute during the perimenopausal period.
Q 8. What is the incidence of fibroadenoma?
• Theyaccountfor12%ofallpalpablesymptomatic
breast masses
• They are more frequently seen in Negro
population (black races).
Q 9. How will you classify fibroadenoma?
There are four separate entities of fibroadenomas.
They are:
Four types of fibroadenoma
1. Common fibroadenoma
2. Giant fibroadenoma
3. Juvenile fibroadenoma
4. Phyllodes tumor.
Q 10. What is intracanalicular and pericanalicular
fibroadenoma?
• This is a conventional classification by the
pathologists
• This histological distinction has no clinical
relevance
• This terminology can therefore be abandoned.
Q 11. What is giant fibroadenoma?
• A fibroadenoma must measure over 5 cm in size
to qualify for this definition
• They may or may not have different behavior to
an ordinary fibroadenoma
• Treatment is enucleation through a submammary incision.
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Clinical Surgery Pearls
Q 12. What is phyllodes tumor (serocystic disease
of brodie/cystosarcoma phyllodes)?
• There isstromal over growth and they are highly
cellular and heterogenous
• Mitosis is seen in sarcoma
• Mammoglobin is positive
• It is a distinct pathological entity and better
classified separately from fibroadenoma
• They occur in women more than 40 years
• Clinically they present as large massive tumor
with an unevenly bosselated surface
• Pressure necrosis of the overlying skin will result
in ulceration
• They are mobile despite the size
• Some ofthe tumors are purely benign,some are
malignant with higher mitotic index
• Cystosarcoma phyllodes are a misnomer:
usually neither cystic nor sarcomatous
(sarcomatous change can occur)
• If mammogram negative—MRI may be useful
and positive—70% pick up is there for MRI
• The malignant variety recur locally
• Malignant tumors may metastasize via the
bloodstream
• Treatment for benign variety-wide local
excision, malignant need simple mastectomy.
Note: Phyllus means—“leaf-like”—branching
projections of tumor tissue into the cystic cavities
of this neoplasm histologically.
Q 13. What are the indications for mastectomy in
phyllodes tumor?
• Malignant tumor
• Massive tumor
• Recurrent tumor.
Note: Mastectomy is followed by radiotherapy.
Axillary dissection is recommended.
Q 14. What are the differences between Phyllodes
tumor and carcinoma breast?
Sl
No.
Phyllodes tumor Carcinoma
1. No nipple retraction Nipple retraction may
be there
2. Absence of skin
involvement, tethering and skin fixity
Tethering, fixity and
skin involvement may
be there
3. Bosselated surface Not bosselated
4. Warm to touch Need not be warm
5. No axillary node
involvement
Axillary nodes present
6. Ulceration of the
overlying skin
may occur due to
pressure necrosis
Skin ulceration is
due to direct skin
involvement
7. There will be a gap
between the skin
and the tumor when
there is ulceration
The ulcer is fixed to the
tumor
8. For malignant
phyllodes, simple
mastectomy alone
without axillary
dissection
Breast conservation
and axillary dissection
and radiotherapy
or modified radical
mastectomy
Q 15. What is the natural course of fibroadenoma?
• One-third getsmaller or disappear overtwo year
period
• Less than 5% increase in size
• The reminder stay the same size, but becomes
clinically less distinct with time
• There is no need for excision in below 30 years
age group.
Q 16. Can fibroadenoma turn malignant?
No. Breast cancer is no more likely to develop in
fibroadenoma than in any other part of the breast.
Fibroadenoma/Cystosarcoma/Breast/Cyst/Fibroadenosis/Fibrocystic Disease/Mastalgia
497
Q 17. Can fibroadenoma occur after the menopause?
No. Does not normally occur after menopause, but
may occasionally develop after administration of
hormone.
Q 18. What are the investigations for suspected
fibroadenoma?
The triple assessment consisting of:
• Clinical examination
• Imaging—USG
• FNAC/core biopsy.
Q 19. What are the indications for surgery in
fibroadenoma?
Indications for surgery in fibroadenoma
• Lump more than 3 to 4 cm in size
• Above 30 years
• Suspicious cytology
• Patient desire.
Note: If access to good quality cytology and USG is
not available, it is wise to excise all fibroadenomas
to be certain in that no malignancy is missed.
Q 20. What is the incision for excision of
fibroadenoma?
• The lines of tension in the skin of breast (the
Langer’s lines) are generally concentric and
parallel with the nipple areolar complex.
Therefore, a curved incision that parallels the
areola is cosmetically acceptable.
• Radial incisions are not recommended in the
breast (except in 3 and 9 O’ clock position).
Q 21. What is complex fibroadenoma?
This is a relatively uncommon pathological
lesion and appear to be associated with a slightly
increased risk of breast cancer (1.5 to 2 times).
Q 22. What is juvenile fibroadenoma?
They occur in adolescent girls and is rare.
Q 23. What is diffuse hypertrophy of the breast
(benign hypertrophy)?
• It is due to alteration in the normal sensitivity
of the breast to estrogenic hormones
• They occur in healthy girls at puberty
• At times they also develop during pregnancy
• The breasts attain enormous dimensions
• The treatment is reduction mammoplasty/
antiestrogen.
Q 24. What is breast cyst?
• They are due to nonintegrated involution of
stroma and epithelium.
• Most commonly occur in the last decade of
reproductive life
• Often multiple, may be bilateral
• Confirmed by USG and aspiration
• Can mimic malignancy.
Q 25. What is the management of breast cyst?
Management of breast cyst
• More than 35 years do mammogram priorto needle
aspiration (1 to 3 % of patients with cysts have an
incidental carcinoma)
• Aspirate the cyst to dryness with 21 gauge needle
• No need for fluid cytology unless evenly blood
stained
• After aspiration examine the patient for residual
mass
• If there is a residual lump do FNAC from that
• 30% of the cysts will recur and require reaspiration
• Reviewthe patient 3 to 6weeks after cyst aspiration
to check for refilling.
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Clinical Surgery Pearls
Q 26. What are the indications for excision of the
breast cyst?
Indications for excision of the breast cyst
• If the cysts refill more than twice
• If the fluid is blood stained
• If there is residual lump.
Q 27. What is the risk of carcinoma in breast cyst?
• The relative risk for carcinoma is 1.5 to 4 times
• The risk is greatest in young patients less than
45 years (risk may be as high as 6 times that of
the general population).
Q 28.What is the management of multiple
asymptomatic cyst?
• Generally no treatment isindicated for multiple
cysts
• RegularUSGandmammogramevery 1 to2 years
• Only symptomatic cysts are aspirated.
Q 29. What is galactocele?
• Galactocelepresents as a solitary subareolar cyst
and always dates from lactation
• It contains milk and in long-standing cases the
walls tend to calcify
• It may reach enormous sizes.
Q 30. What are the benign diseases associated
with increased risk for invasive breast cancer?
• ADH(AtypicalDuctalHyperplasia)/Lobularhyperplasia
• Gross cysts
• Moderate and florid hyperplasia
• Papilloma with fibrovascular core
• Sclerosing adenosis
• Complex fibroadenoma.
Q 31. What is fibroadenosis and what is the
pathogenesis (fibrocystic disease/chronic mastitis/
mastopathy)?
• Seen in women of reproductive age group (35
to 45 years)
• The nomenclature of benign breast disease is
confusing and various synonyms are used as
mentioned above
• A new system has been developed and described
by the Cardiff Breast Clinic terming it as ANDI
(AberrationinNormalDevelopmentandInvolution)
• Thebreastis adynamic structure that undergoes
changes throughout reproductive life in
addition to the cyclical changes throughout the
menstrual cycles
• ANDI involves disturbancesin breast physiology
extending from an extreme of normality to welldefined disease process.
Q 32. What are the pathological changes in ANDI?
Pathological changes in ANDI:
• Fibrosis—fat and elastic tissue replaced
• Adenosis
• Cyst formation
• Papillomatosis
• Epitheliosis
• Hyperplasia of epithelium lining ducts and acini.
Q 33. What are the clinical features of ANDI?
• Cyclical breast pain (mastalgia) may or may not
be there
• The lump may be solid or cystic
• Multiple lumps or generalized nodularity may
be there
• Increase in lumpiness and tenderness before
menstrual period
• It may affect one or both breasts
• Associated nipple discharge may be there: clear,
green or serous.
Q 34. What is the Bloodgood’s blue domed cyst?
It is nothing but large cyst associated with ANDI.
Q 35. What is Schimmelbusch’s disease?
Presence of multiple cysts in both breast seen in
ANDI is called Schimmelbusch’s disease.
Fibroadenoma/Cystosarcoma/Breast/Cyst/Fibroadenosis/Fibrocystic Disease/Mastalgia
499
Q 36. What is the management of fibroadenosis?
Triple assessment—(The imaging of choice less
than 35 years is USG and more than 35 years
mammogram) and rule out malignancy.
Q 37. What is the treatment of lumpy breast of
ANDI?
Treatment of lumpy breast of ANDI
• Exclude malignancy
• Reassurance for lumpy breast
• Adequate support for the breast:
Appropriately fitting and supporting bra should be
worn throughout the day and soft bra (sports bra)
worn at night
• Avoid caffeine drinks
• Pain chart—chart the pattern of pain throughout
the month (to note the exacerbation of pain in the
premenstrual period and the cyclical nature)
• Medications.
Q 38. What are the drugs used for the manage -
ment of ANDI?
Drugs used for the management of ANDI
• Evening primrose oil, (GLA) gamma linolenic acid—
dose is 6 to 8 capsules per day
• More effective for > 40 years group
• It is given for a period of 3 months (will help 50%)
• For intractable symptoms Antigonadotrophin -
Danazol 100 mg tds.
• Prolactin inhibitor—Bromocriptine—2.5 mg twice
daily, increasing the dose over 1–2 weeks(A newer
antiprolactin agent, cabergoline, is now available)
• Tamoxifen 20 mg daily—Antiestrogen will deprive
the breast epithelium of estrogenic drive
• LHRH agonist—not recommended for routine use.
Note: All these drugs are not given simultaneously.
A planned escalation of treatment from the simple
evening primrose oil to the other drugs downwards
is given.
Q 39. What is the management of noncyclical
mastalgia?
• Exclude extramammary causes for pain
• Biopsy on localized tender area may be required
• Identify the trigger spot
• Inject the trigger spot with local anesthetic/
nonsteroidal analgesic.
Q 40. What is Tietze syndrome?
It is nothing but Tender costochondral junction
(commonest cause for noncyclical mastalgia).
Q 41. What are the clinical differences between the
benign lumps of the breast and malignant mass?
Comparison of clinical features of commonly seen
breast lumps:
Disease Age group Presence of pain No swellings Consistency Surface node Axillary
Fibroadenoma 15–25 No 1 or more Rubbery Smooth/ No
30–40 bosselated
Fibroadenosis ANDI 35–50 Yes 1 or more ordiffuse Variable Indistinct No
Breast cyst 30–50 Occasional 1 or more Tense and hard Smooth Normal
Carcinoma 25 + No 1 Stony hard Irregular Yes
Contd...
Contd...
S e c t i o n
4
Radiology
and Imaging
Radiology Questions
and Answers
1 – Small Intestinal Obstruction
Instructions for viewing the skiagram of the
abdomen:
1. The entire abdomen should be visualized from the
top of the diaphragm to the hernial orifices in the
groin
2. Always take both supine and erect films especially
when you are suspecting intestinal obstruction
3. Remember the five basic densities.
a. Gas – Black
b. Fat – Dark grey
c. Soft tissue/fluid – Light grey
d. Bone/calcification – White
e. Metal intense white – intense white
4. Look for bones – Spine, pelvis, chest cage and
the sacroiliac joints (presence or absence of
scoliosis and abnormality in bones)
5. Look for soft tissue shadows: The liver, spleen,
kidneys, bladder and psoas muscles (liver on
the right side, the left kidney higher than the
right, stomach, spleen and cardiac shadow on
the left side)
6. Gas shadow in the body of the stomach
7. Gas in the descending colon and inside pelvis
8. Look for radiopaque shadows
9. Look for any abnormal soft tissue shadows
10. Check for the ‘R’ marked low down on the right
side (always check left and right on every film)
Q 1. What is your observation?
Supine abdominal film (AP view) demonstrating
jejunal loopswith Valvulae conniventes suggestive
of distal ileal obstruction (Intestinal obstruction).
Intestinal obstruction
504
Clinical Surgery Pearls
Q 2. Why fluid levels are not demonstrated in
this film?
Fluid levels do not appear on supine AP films (the
characteristic radiological feature of intestinal
obstruction is demonstration of multiple fluid levels
which is possible only in erect film or decubitus
film). The supine film is taken for demonstration of
the intestinal loops so that the level of obstruction
can be ascertained.
Q 3. Why this is AP film?
Virtually every abdominal X-ray is an AP film, i.e.
the beam passes from front to back with the film
behind the patient who is lying down with the X-ray
machine overhead.
Q 4. What are the characteristic intestinal patterns
identified in intestinal obstruction?
1. Jejunum—Valvulae conniventes – coiled spring
shaped folds crossing the entire lumen is seen in
the jejunum when it is distended (caliber of the
bowel should not exceed 2.5–3 cms, increasing
distally. The folds completely pass across the
width of the bowel, they are regularly spaced
and gives a concertina or ladder effect.
2. Ileum—Feature less described by Wangensteen
(Structure less pattern)
3. Colon—Haustrations: Folds of mucosa
visualized across the bowel only partially. The
colonic mucosal folds do not completely cross
the lumen and they are placed irregularly and
do not have indentations placed opposite one
another.
Note: That the colon is peripheral and contains
feces and the small bowel is central and contains
fluid and gas).
Q 5. What is the essence of treatment of intestinal
obstruction?
The three essential principles are: Drip, suction and
relief of obstruction.
• Drip and suction (IV fluids: fluid and electrolyte
replacement and nasogastric decompression)
• Relief of obstruction by surgical interference at
the appropriate time
• Surgicaltreatmentis delayed untilresuscitation
is complete provided there is no strangulation
or closed loop obstruction
• Remember the aphorism: “The sun should
not both rise and set on a case of unrelieved
intestinal obstruction.”
Q 6. What are the clinical features of the
strangulation (which is an absolute indication
for surgical relief of obstruction)?
• Continuous pain
• Tenderness with rigidity/rebound tenderness of
the abdomen
• Shock
Note: Persistent pain even in the absence of
tenderness and rigidity in spite of conservative
management is also an indication for surgery.
2 – Intestinal Obstruction
Q 1. What is this skiagram and what is your
observation?
Erect abdominal film with multiple fluid levels
suggestive of intestinal obstruction.
Q 2. Why do you say that this is an erect film?
The gas in the gastric fundus is suggestive of
typical erect film.
Q 3. Upto how many fluid levels are normal?
In the normal adult erect film, usually upto 3 fluid
levels are normal. They are:
Radiology Questions and Answers
505
1. One at the fundus of the stomach
2. One at the duodenal cap
3. One in the terminal ileum.
Note: In infants < 1 year old a few fluid levels in the
small bowel may be physiological.
Q 4. What is the cause for fluid level?
For fluid level you need fluid, gas and horizontal
beam. Without gas you won’t see the fluid.
The fluid levels appear later in the course of the
intestinal obstruction. It takes some time for the
gas and fluid to separate.
Q 6. Which is the commonest nature of gas seen
in intestinal obstruction?
• Majority is made up of nitrogen (90%) and the
remaining hydrogen sulphide (oxygen and
carbon dioxide are reabsorbed)
• Overgrowth of aerobic and anaerobic organisms
produce gas.
Q 7. What is the cause for fluid inside the intestine
in obstruction?
It is constituted by 3 factors:
1. Various digestive juices
2. Absorption from the gut is retarded
3. Fluid secreted from the bowel wall.
Q 8. What is the importance of the number of
fluid levels?
• When the fluid levels are more the obstruction
is advanced
• The number of fluid levels are directly
proportional to the degree of obstruction
• The more distal the site of the obstruction, the
number of fluid level increases.
Q 9. Can you get fluid levels in non obstructing
conditions?
Yes; It may be seen in the following conditions:
1. Acute pancreatitis
2. Inflammatory bowel diseases
3. Intra-abdominal sepsis.
Q 10. What is the most important differential
diagnosis of small bowel obstruction?
Paralytic ileus. It is hard to differentiate between
paralytic ileus and obstruction radiologically.
Combined small and large bowel dilatation may
form the classic radiological sign of paralytic ileus.
Plain radiograph—abdomen
Q 5. What is the cause for distension of abdomen
in intestinal obstruction?
The distension proximal to the obstruction is
produced by gas and fluid.
506
Clinical Surgery Pearls
Q 11. What are the common causes of intestinal
obstruction?
• Postoperative adhesions (upto 40% of cases)
• Internalstrangulation of bowel (band orinternal
hernia)
• External hernia (e.g. inguinal 12%)
• Tumors (15%)
• Fecal impaction (8%)
• Pseudoobstruction (5%)
• Inflammatory bowel disease—Crohn’s disease
• Intussusception – usually children; in adults
often associated with a tumor. Tends to begin
in the ileum
• Congenital atresias – newborns
• Gallstone ileus.
Q 12. How will you classify intestinal obstruction?
Can be classified as:
1. Depending on the mechanism: Dynamic
(mechanical obstruction) and Adynamic
2. Depending on the site: Small bowel (high and
low) and large bowel.
3. Depending on the intactness or compromise of
the blood supply:
Simple obstruction and strangulating
obstruction (compromised blood supply
affecting the viability of the intestine)
4. Depending on the cause: Intraluminal, intra
mural and extramural.
Intraluminal Intramural Extramural
• Impaction • Malignancy • Adhesions/
bands
• Bezoars • Stricture • Hernia
• Foreign bodies • Volvulus
• Gallstones • Intussusception
5. Depending on whether it is acute or chronic
• Acute obstruction (usually small intestinal)
• Chronic obstruction (large intestinal)
• Acute on chronic
• Subacute – incomplete obstruction
6. Depending on whether it is complete or
incomplete.
Q 13. What are the clinical features of intestinal
obstruction?
Quartet of symptoms
• Pain
• Distension
• Vomiting
• Absolute constipation
Q 14. What is closed loop obstruction?
• When bowel is obstructed at both the proximal
and distal point closed loop obstruction will
occur (carcinomatous stricture of the colon with
a competent ileocecal valve).
• There is no early distension of the proximal
intestine
• When gangrene of the strangulated segment
occurs, retrograde thrombosis of the mesenteric
vessel will occur.
Q 15. What is absolute constipation?
Failure to pass neither feces nor flatus is called
absolute constipation which is suggestive of
complete intestinal obstruction.
Q 16. Mention a few situations where constipation
may not be present in spite of intestinal
obstruction?
Intestinal obstruction without constipation
• Richter’s hernia
• Mesenteric vascular obstruction
• Gallstone ileus
• Partial intestinal obstruction
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3 – Volvulus of the Sigmoid
Q 1. What is your observation?
a. Plain skiagram of abdomen - supine film with
pneumatic tyre appearance: grossly distended
loop of sigmoid colon extending from the pelvis
to the undersurface of the diaphragm. The loop
running diagonally from right to left with two
fluid levels. Compression together of the two
medial walls produce the ‘coffee bean sign’.
b. Barium enema picture showing the ‘bird beak’
appearance: Retrograde running of contrast
per rectum will show this appearance (point of
convergence of the distended loops appearing
as the birds beak or ‘bird of pray’.
Q 2. What is the diagnosis in this case?
Sigmoid volvulus
Q 3. What is volvulus?
Axial rotation of the bowel about its mesentery is
called volvulus.
Q 4. How will you classify volvulus?
May be classified as:
• Primary – Sigmoid volvulus (the commonest
spontaneous type in adults), cecal volvulus and
volvulus neonatorum
• Secondary– Rotation of bowel around an
acquired adhesion or stoma.
Q 5. What are the other radiological signs of
volvulus sigmoid?
a. Lack of haustration: This as a result of enormous
distension of the colon
b. Liver overlap sign: Indicative of the degree of
distension of the colon, i.e. the colonic loop will
reach the height of the liver or above it on the
right side.
c. Left flank overlap sign: The left limb of the
coffee bean overlies the descending colon.
Q 6. What are the likely symptoms?
Intermittent abdominal pain and distension along
with constipation usually occurring in elderly
patients. During acute presentation the patient
will be severely ill with severe abdominal pain,
obstipation and distension of the abdomen. Digital
rectal examination will reveal an empty rectum.
Q 7. What is the direction of twist of volvulus of
sigmoid?
Anticlockwise.
Q 8. What is cecal volvulus and what is the
direction of twist?
The cecum folds in a cephalad direction anteriorly
over the fixed ascending colon. The direction is
clockwise.
Q 9. What are the predisposing factors for sigmoid
volvulus?
• High residue diet and overloaded colon
• Chronic constipation
• Long pelvic mesocolon
• Narrow attachment of pelvic mesocolon
• Band/adhesions of the sigmoid to the parities
as a result of peridiverticulitis
Volvulus sigmoid—plain film and barium enema
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Q 10. What are the clinical features of sigmoid
volvulus?
• Chronic type (Elderly): Intermittent large bowel
obstruction followed by passage of large
quantities of flatus and feces
• Acute type (Young individuals): Abdominal
distension, hiccough, wretching and absolute
constipation.
Q 11. What is the emergency treatment of volvulus
of the sigmoid?
• Endoscopic detorsion initially with flexible
sigmoidoscope (most will recover)
• Insertion of flatus tube if the above one is not
available
• Resuscitation of the patient
• Definitive surgery in the form of resection of
the sigmoid and restoration of the continuity
of the bowel (sigmoidectomy) with or without
a proximal defunctioning colostomy
• Hartmann’s procedure (aftersigmoidectomy the
distal end is closed and left and the proximal end
is brought out. This is a procedure recommended
for emergency surgery when the surgeon is not
experienced)
• Paul-Mikulicz procedure (not done nowadays).
Q 12. What is compound volvulus?
It is a rare condition known as ileosigmoid knotting
where the long pelvic mesocolon allows the ileum
to twist around the sigmoid colon resulting in
gangrene of either or both segments of the bowel.
4 – Pneumoperitoneum (Gas under the
Diaphragm)
Q 1. What is your observation?
Skiagram chest showing dark crescentic area of
gas under the hemidiaphragm.
Q 2. What is the ideal skiagram for demonstration
of pneumoperitoneum?
Erect Plain X-ray abdomen or erect chest film
demonstrating the diaphragm.
Q 3. In seriously ill patients the use of erect
films may not be possible. What is the
recommended method for demonstration of
pneumoperitoneum?
Decubitus films with the left side down (left
decubitus) centered on the right upper flank should
be taken (this is the method used for confirmation
of a small amount of free gas and to demonstrate
fluid levels in a sick patient who is too ill to sit up).
A horizontal cross table beam is used rather than
the vertical beam from overhead for supine films.
5 to 10 minutes are spent with the patient in this
position to allow the free gas to track up before the
exposure is made.
Skiagram chest
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Q 4. What is the origin of the word decubitus?
The word originated from the Latin word –
Decumbere meaning to lie down, like a Roman
patrician lying on his side eating at a banquet.
Q 5. What are the other signs of pneumoperitoneum?
1. Double wall sign – Both sides of the wall of a
loop of bowel become visible because air on the
inside and air on the outside are demonstrated
2. Silver’s sign – Visualization of falciform ligament
3. Football or Dome sign – with a large
pneumoperitoneum the unde surface of the
diaphragm may be surrounded by air giving
a dark dome-like appearance in the upper
abdomen (may be there even in supine film).
Q 6. What are the differential diagnoses of gas
under the diaphragm?
1. Chilaiditi’s syndrome – (Colonic inter- position):
The incidental finding of pockets of gas beneath
the right hemidiaphragm with multiple bands of
mucosal folds. It may be seen with Shrunken livers
(Cirrhosis), in COPD and postoperatively where the
surgeon has pushed the gut out of the way.
2. Linear atelectasis:
3. Subphrenic abscess with fluid level under the
diaphragm
4. Meteorism due to excessive air swallowing
associated with crying in children
Q 7. What are the causes for pneumoperitoneum?
With peritonitis – hollow viscera perforation
• Perforated peptic ulcer (gastric, duodenal)
• Malignant ulcer perforation
• Appendix perforation
• Intestinal obstruction with perforation
• Ruptured diverticular disease
• Inflammatory bowel disease – Crohn’s disease,
ulcerative colitis
• Steroid induced perforation
• NSAIDs induced perforation
• Stress ulcers – burns, sepsis, multisystem trauma
etc.
• Chemotherapy and radiotherapy
Without peritonitis
• Postlaparotomy
• Postlaparoscopy
• Peritoneal dialysis
• Tube testing for sterility
• Pneumatosis coli
• Huge pneumothorax (tracking from chest)
• Escape of air from the tracheobronchial tree in
obstructive airway disease
Q 8. What are the stages of peritonitis?
1. Stage of chemical peritonitis
2. Stage of illusion
3. Stage of frank general peritonitis.
Q 9. What are the clinical findings of perforation
with peritonitis?
1. Generalized tenderness
2. Generalized guarding
3. Board-like rigidity of the abdomen
4. Obliteration of liver dullness
5. Absent bowel sounds
6. Free fluid may or may not be demonstrated.
Q 10. What is the management of duodenal ulcer
perforation with peritonitis?
1. Resuscitation of the patient—Nasogastric
decompression, IV fluids, correction of
electrolytes, and make the patient fit for surgery
2. Exploratory laparotomy
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3. Identify the site of perforation, suck out the pus
4. Closure of the perforation with 3 interrupted
absorbable sutures and reinforce with a patch
of pedicled omentum
5. Thorough peritoneal toilet and peritoneal lavage
6. Flank drainage
7. Closure of the abdomen.
5 – Cannon Ball Lesion, Pulmonary Metastasis,
Primary Malignancy of Lung
Q 1. What is your observation?
Skiagram chest showing two types of coin shadows
in the left lung (solitary pulmonary nodule).
Q 2. What are the differential diagnosis?
1. Primary malignancy of lung (18%)
2. Metastasis lung (64%)
3. Tuberculosis
4. Fungi: Histoplasmosis, coccidiomycosis
5. Benign neoplasms: (18%) Hamartoma,
hemangioma
6. Granulomatosis
Q 3. Can you differentiate benign from malignant
radiologically?
It may be difficult to differentiate. The differences
between benign and malignant lesions are given
below:
Benign Malignant
• Lesions are small (< 1cm) • Lesions are larger
• Stable for more than • Grows rapidly
2 years
• Calcified • Lack calcium
• Target or popcorn • Appear speculated
distribution (surface
umbilication
ornotching) Eccentric
or excavated
• Hounsfield unit > • < 175 units
175 unit
Q 4. What are the causes for pulmonary metastasis?
1. Head and neck malignancies
2. Carcinoma breast
3. GI malignancies (Colon, stomach and pancreas
commonest)
4. Renal cell carcinoma and other genitourinary
tumors)
5. Sarcomas: Osteogenic sarcoma, soft tissue
sarcoma, retroperitoneal sarcoma, etc.
6. Malignant melanoma.
Q 5. What is the incidence of metastasis in the
lung?
• 30% of all patients with malignancies develop
pulmonary metastasis
• 1.2% have solitary lung metastasis.
Skiagram chest showing two types of coin
shadows in left lung— pulmonary metastasis
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Q 6. What is the classification of primary neoplasms
of the lung?
• It is classified into:
1. Small cell carcinoma (Oat cell cancer) 20%
2. Non-small cell Lung cancer (NSCLC)
– Adenoma carcinoma (commonest)
– Squamous carcinoma (cavitating tumors)
– Large cell undifferentiated (included with
neuroendocrine tumors)
– Bronchioalveolar carcinoma (Ground glass
appearance on radiograph).
Q 7. What are the symptoms of metastasis in the
lung?
• Cough
• Hemoptysis
• Fever
• Dyspnoea
• Pain.
Q 8. How will you proceed to investigate such a
case?
1. CT of the lung: To assess the lungs for other
nodules (CT can identify nodules as small as
3mm).
2. Sputum cytology
3. FNAC from the peripheral lesions
4. Bronchoscopy for central lesions
5. PET to differentiate malignancy.
Q 9. If the report is coming as adenocarcinoma
metastasis, what next?
Do bone scan and CT of the head to rule out
metastasis in the bone and brain.
Q 10. If the report is coming as squamous cell
carcinoma and there is history of head and neck
squamous cell carcinoma, what will be your
inference?
Still, one should address it as a new primary.
Q 11. What is the treatment of the primary in the
lung?
Lobectomy + mediastinal lymph node dissection.
Q 12. What is the surgical approach for lung
resection?
• Posterolateral thoracotomy
• Anterolateral thoracotomy
• Median sternotomy.
Q 13. What are the adverse prognostic factors in
metastasis?
1. Multiple or bilateral lesions
2. More than four lesions on CT
3. Tumor doubling time < 40 days
4. Short disease- free interval
5. Advanced age.
Q 14. What are the indications for resection of
metastasis?
Medically fit patient with resectable disease with the
following criteria
a. Primary must be controlled or controllable
b. No other sites of disease may exist
c. No other therapy can offer comparable results
d. The operative risk must be low
Q 15. What are the surgical options for resection
of metastasis?
• Can be done as open procedure by thoracotomy
• Video assisted thoracoscopy (VAT)for metastatic
disease.
Q 16. What is the success rate with surgical
removal of pulmonary metastasis?
a. Testicular tumor - 51% 5-year-survival
b. Head and neck - 47% 5-year-survival
c. Colon cancer, renal cell carcinoma and
osteogenic sarcomas – prolonged survival
d. Melanoma - 10 – 15% survival.
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6 – Goiter
Q 1. What is your observation?
Skiagram of the neck lateral view showing soft
tissue shadow suggestive of goiter and the trachea
showing luminal narrowing.
Q 2. What is the purpose of skiagram of the neck
in thyroid swellings?
Skiagram neck AP and lateral views are obtained
preoperatively because of the following reasons:
• To assess the position of the trachea (this will
help the anesthesiologist for intubation).
• The AP view will reveal displacement of trachea
(displacement of the trachea is suggestive of
retrosternal extension of the goiter).
• The lateral view will reveal luminal narrowing
(chance for scabbard trachea is there)
• It will also reveal calcifications in thyroid.
Q 4. When do you suspect retrosternal extension
radiologically?
If the soft tissue shadow is coming down below the
clavicles one should suspect retrosternal extension.
Q 5. What is the investigation of choice for ruling
out retrosternal extension?
CT scan.
7 – Chronic Calcific Pancreatitis, Tropical
Chronic Pancreatitis
Q 1. What is your observation?
Plain skiagram of abdomen AP view showing
multiple radiopaque shadows in the region of the
head, body and tail of pancreas.
Q 2. What are the causes for radiopaque shadows
in plain X-ray abdomen?
1. Normal calcified structures
• Costal cartilage (mistaken for biliary, renal
and splenic calcification)
• Pelvic phleboliths –Vein stones(mistaken for
ureteric and bladder calculi)
• Mesenteric lymphnodes(calcified):They tend
to be mobile and show changes in position
from film-to-film.
• Iliac arteries (calcified)
• Aorta (calcified)
• Splenic artery (the Chinese dragon sign):
Serpiginous parallel - walled calcification
• Curving osteophytes in osteoarthritic spine
• Fecolith (seen in 14% of patients with acute
appendicitis)
Skiagram neck—lateral view
Q 3. What type of calcification you get in longstanding goiters?
Dystrophic calcification (the types of calcifications
in general are: metastatic, dystrophic, heterotopic
and calcinosis).
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2. Abnormal calcification
• Renal stones (85% are radiopaque)
• Ureteric stones
• Urinary bladder stones
• Gallstones (only 15% are radiopaque)
• Pancreatic stones
• Fracture transverse process of the vertebrae.
Q 3. Why do you suspect pancreatic stones?
The stones are located at the upper lumbar spine
passing upwards obliquely to the left towards the
splenic hilum.
Q 4. How will you differentiate renal stones from
gallstones?
This can be confirmed by taking a lateral view of
the abdomen. If the stone is superimposed on the
vertebrae it may be a renal stone. If it is in front of
the vertebrae it may be gallstones.
Q 5. What are the conditions which will produce
calcification of the pancreas?
1. Tropical chronic pancreatitis (seen in Kerala State
of South India)
2. Chronic pancreatitis
3. Cystic fibrosis.
Q 6. What is the etiology of tropical chronic
pancreatitis?
Etiology is unknown (alcohol ingestion do not play
a part): The following factors are attributed
• Malnutrition
• Dietary
• Familial
• Genetic
• Cassava ingestion (high content of cyanide).
Q 7. What are the pathological changes?
1. Dilatation of pancreatic duct with large
intraductal stones along the pancreatic duct
2. Fibrosis of the pancreas
3. High incidence of pancreatic cancer is seen.
Q 8. What are the diagnostic points of tropical
pancreatitis?
1. Young patient below the age of 40 with type
I diabetes having symptoms of diabetes,
abdominal pain, steatorrhea and malnutrition
2. The patient looks ill and emaciated
3. Serum amylase is normal
4. Plain X-ray abdomen will show pancreatic
calcification.
Q 9. What is the treatment of tropical chronic
pancreatitis?
Medical treatment:
• Pancreatic enzymes
• Insulin therapy for diabetes
• Management of pain as per analgesic ladder.
Endoscopic management:
1. Small head stones can be managed by
endoscopic extraction at ERCP
2. If pancreatic duct stricture is predominant with
upstream dilatation, a stent can be inserted.
Plain skiagram abdomen
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Surgical treatment: Done only for intractable pain
• The operations are:
1. Extraction of pancreatic duct stones followed
by longitudinal pancreatojejunostomy (Frey
procedure)
2. Beger procedure (Head coring): Duodenum
preserving resection of the pancreatic head
3. If mass lesion is there at the head of pancreas,
a pancreaticoduodenectomy is done
4. If the disease is limited to the tail of the
pancreas, a distal pancreatectomy is done
5. Intractable pain with diffuse disease: Total
pancreatectomy.
8 – Gallstone
Q 1. What is your observation?
Plain radiograph of abdomen showing a radiopaque
stone in the region of the gallbladder, suggestive
of gallstone.
The second picture is a barium enema taken to
rule out diverticulosis of the colon because of the
patient’s left lower abdominal complaints. There is
no evidence of diverticulosisin the picture (Normal
study).
Q 2. What is Saint’s triad?
The association of gallstones, hiatus hernia and
diverticulosis.
Q 3. How it is differentiated from renal stones?
Answer given skiagram No:7.
Q 4. How many percentage of the gallstones are
radiopaque?
10% (90% are nonradiopaque in contrast to renal
stones (85% radiopaque).
Q 5. What are the types of gallstones?
1. Cholesterol stones
2. Pigment stones (brown or black): contain <30%
cholesterol.
• Black stones are composed of insoluble
bilirubin pigment mixed with calcium
phosphate and calcium bicarbonate. The
incidence rises with age. They are also seen
in hemolytic conditions like hereditary
spherocytosis and sickle cell disease.
Therefore it is important to do a peripheral
smear examination and fragility test if
pigment stone is suspected. In hereditary
spherocytosis in addition to cholecystectomy
a splenectomy has to be done.
• Brown pigment stones: Contain cholesterol
and calcium bilirubinate, calcium palmitate
and calcium stearate. They are usually seen in
bile duct and related to infected bile as a result
of deconjugation of bilirubin diglucuronide by
bacterial beta glucuronidase. It is also associated
with presence of foreign bodies and parasites.
3. Mixed stones (pure cholesterol + a mixture
of calcium salts, bile acids, bile pigments and
phospholipids
Note: In the West 80% are cholesterol and mixed
stones.
In Asia 80% are pigment stones.
Gallstone in plain radiograph and barium enema
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Q 6. What is Mercedes – Benz or Seagull sign?
The center of a stone may contain radiolucent gas in
a triradiate or biradiate fissure giving characteristic
dark shapes in radiograph. This is called Mercedes
Benz sign.
Q 7. What is “porcelain” gallbladder, what is the
importance of it?
Calcification of the gallbladder in plain X-ray is
called porcelain gallbladder. The importance of this
appearance is an association of carcinoma in up to
25% of patients.
Q 8. What are the complications of gall-stones?
Complications of gallstones
• Biliary colic
• Acute cholecystitis:
Empyema of gallbladder
Gangrene of gallbladder
Perforation of gallbladder with peritonitis
Mucocele of gallbladder
• Chronic cholecystitis
• Bile duct stone – obstructive jaundice
• Cholangitis – secondary to bile duct obstruction
(Charcot’s triad consisting of intermittent fever,
intermittent pain and intermittent jaundice).
• Acute toxic cholangitis (Reynold’s pentad
consisting of Charcot’s triad + mental obtundation
+ hypotension)
• Acute pancreatitis (Gallstone pancreatitis)
• Gallstone ileus(stone obstructing thebowel usually
the terminal ileum)
• Gallbladder carcinoma (0.08% of symptomatic
patients)
Q 9. What are the etiological factors for gall stone
formation?
1. Supersaturation of bile by cholesterol or
decrease in bile acid concentration and unstable
unilamelar phospholipid vesicles
2. Nucleating factors: Infection (klebsiella,
E-coli, Enterococci, Bacteroides and typhoid
organism), mucus and glycoprotein
3. Stasis (Impaired gallbladder function): Repeated
pregnancy
4. Enterohepatic circulation is not taking place. For
example, Ileal resection, Cholestyramine.
Q 10. What is Moynihan’s aphorism?
“Gallstone is the tomb stone erected to the
memory of the organism within it” This statement
was given with respect to gallstones having
salmonella organism inside leading to typhoid
gallbladder. Salmonella typhimurium can infect
the gallbladder and produce chronic cholecystitis
or acute cholecystitis and the patient will remain
a typhoid carrier by excreting bacteria in the bile
(“Typhoid Mary”, a cook general who passed
salmonella typhi in her feces and urine and was
responsible for nearly twenty epidemics of typhoid
in and around New York city in USA). Surgeons
should not give patients their stones after surgery
if there is any suspicion of typhoid.
Q 11. What is the incidence of gallstone?
10-15% of the adult population.
Q 12. What is the incidence of asymptomatic
gallstone developing future symptoms?
1-2% will develop symptoms per year.
Q 13. What is the treatment of symptomatic
gallstones?
Laparoscopic cholecystectomy.
Q 14. Why stone dissolution is not recommended
in gallstones?
It is not recommended because of two reasons:
1. Dissolution by ESWL will result in fragmentation
of the stones. They come down and produce
obstructive jaundice.
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2. Removing gallstones without removal of the
gallbladder will lead to gallstone recurrence.
Q 15. What is the treatment of asymptomatic
gallstones?
• Observation is enough
• Cholecystectomy is indicated in the following
situations:
1. Diabetic patients – chance for infection and
complication
2. Hemolytic anemias
3. Patients undergoing Bariatric surgery for
morbid obesity
4. Calcified gallbladder wall (Porcelain
gallbladder).
Q 16. What is the timing of surgery for acute
cholecystitis?
1. Early laparoscopic cholecystectomy (preferred)
during the golden period (72hours): The open
conversion rate of laparoscopic cholecystectomy
is five times higher than in the elective setting
2. Elective surgery after a period of conservative
treatment for 6 weeks.
9 – Fracture of Ribs, Flail Chest
Q 1. What is your observation?
Skiagram chest showing multiple fracture ribs
shown with arrows.
Q 2. What are the clinical signs of fracture rib?
• Crepitus
• Deformity
• Limitation of chest wall movement.
Q 3. What are the consequences of fracture rib?
• Atelectasis
• Sputum retention
• Hypoxia
• Hypercapnia.
Q 4. What are the complications of fracture ribs?
1. Intractable pain
2. Pneumothorax, tension pneumothorax
3. Hemothorax
4. Hemopneumothorax
5. Flail chest and stove in chest.
Q 5. What is flail chest?
When three or more ribs are fractured in two or
more places, flail chest will occur. The diagnosis
is made clinically not radiologically by observing
Skiagram chest
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paradoxical movement of the chest wall at the
fractured area. The affected segment of chest wall
is displaced inwards on inspiration and outwards
on expiration and less air therefore moves into
the lung.
Q 6. What is stove in chest?
When there is a local indentation without any
paradoxical movement as a result of multiple
fractures, it is called stove in chest.
Q 7. What is the consequence of flail chest?
As a result of impaired chest wall movements, less
air is entering the lung. In addition there may be
voluntary splinting of the chest wall due to pain.
The patient may go into hypoxia (in addition there
may be associated lung contusion).
Q 8. What is the first aid treatment of flail chest?
Turn the patient to the side of the paradoxical
movement so that this movement is prevented.
Q 9. What is the treatment of flail chest?
The treatment consists of the following:
1. Oxygen administration
2. Analgesia
3. Tube thoracostomy if required
4. Mechanical ventilation in selected cases (PEEP)
developing respiratory failure
5. Physiotherapy.
Q 10. What is the mechanism of action of
mechanical ventilation?
It is nothing but internal splinting of the chest until
fibrous union of the broken ribs occur.
Q 11. Is there any role for operative fixation of
the segment?
May be used in selected cases.
Q 12. Is there any role for strapping of fractured
ribs?
No. Any sort of the splinting the chest wall will
result in impaired chest wall movement and less
of oxygenation.
Q 13. What is the treatment of pain of fracture
ribs?
1. Analgesic (NSAIDs)
2. Intercostal nerve block by injection of local
anesthetics
3. Intrapleural local analgesia if chest tube is there
4. Epidural analgesia for multiple fracture ribs with
intractable pain.
Q 14. What is the significance of fracture of the
first rib?
10% of fracture of the first rib are associated with
major vascular and brachial plexus injury.
10 – Pneumothorax
Q 1. What is your observation?
Skiagram chest showing pneumothorax right side
with collapsed lung border.
Q 2. What are the clinical features of pneumothorax?
• Decreased air entry on the affected sides
• Hyperresonanceonpercussionoverthe affected
chest.
Q 3. What is the skiagram of choice in chest
trauma?
A standard erect chest X-ray PA view and lateral
view.
Q 4. What is the problem of AP supine film?
It causes apparent mediastinal widening and
obscure hemothorax.
Q 5. What is the skiagram of choice in
pneumothorax?
Erect expiratory chest X-ray.
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Q 6. Is there any role for repeat X-ray if the initial
chest X-ray appears normal?
In 10% of casesthe initial chest X-ray appears normal
and the pneumothorax becomes apparent over the
first 8 hours and there after it should be repeated.
Skiagram chest
Q 7. What is the difference between simple
pneumothorax and tension pneumothorax?
A pneumothorax with mediastinal displacement to
the opposite side is called tension pneumothorax.
This is manifested by tracheal shift to the opposite
side and shift of the apex beat. The air is forced into
the thoracic cavity without any means of escape by
a one way valve either from the lung or through the
chest wall. As a result of tension, the lung will be
completely collapsed and the opposite lung will be
compressed because of the mediastinal shift. This
will result in decrease in the venous return.
Simple Tension
pneumothorax pneumothorax
Tracheal position Normal Displaced
Percussion note Normal Increased
(hyperresonant)
Jugular pressure Normal Elevated
(unless
hypovolemic)
Breath sounds Normal (unless large) Decreased
Respiratory distress Variable Severe
Q 8. What are the causes for tension pneumothorax?
1. Penetrating chest injury
2. Blunt chest injury with lung injury
3. Primary spontaneous pneumothorax
4. Secondary pneumothorax – diseases of lung
(tuberculosis, cavitating lung disease)
– necrosing tumors
– diseases of plurae
5. Iatrogenic lung injury due to central venous
cannulation
6. Mechanical ventilation.
Q 9. What are the clinical features of tension
pneumothorax?
Clinical features of tension pneumothorax
• Acute dyspnea
• Distended neck veins
• Weak pulse
• Low blood pressure
• Tracheal shift
• Shifting of the apex beat
• Hyperresonance on the affected hemithorax
• Absent breath sounds on the same side
Q 10. Mention another condition where there is
elevated JVP as a result of chest trauma?
Cardiac tamponade: Cardiac injury resulting in
hemopericardium which may seal temporarily the
bleeding from the cardiac injury.
Q 11. What is the diagnostic triad for cardiac
tamponade?
Beck’s triad: Elevated JVP, diminished heart sounds
(Muffled) and pulse paradox (15mm of Hg fall on
inspiration).
Q 12. How to confirm tension pneumothorax?
It is a clinical diagnosis and treatment must be
instituted urgently without wasting time for radiology.
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Q 13. What are the radiological findings of tension
pneumothorax?
Radiological findings of tension pneumothorax
• The lung is completely collapsed (the collapsed
lung margin can be seen, the rest of the chest cavity
showing only air without any lung markings)
• The mediastinum is pushed to the opposite side
• The diaphragm is flattened and pushed down
• The spaces between the ribs are widened on the
affected side (spreading of the ribs)
Q 14. What is the treatment of tension
pneumothorax?
• Urgent needle thoracostomyby inserting a large
bore needle into the second intercostal space
in the midclavicular line
• Thisisfollowed by tube thoracostomy in the safe
triangle which is connected to an underwater
seal.
Q 15. Is there any role for conser vative
management of small traumatic pneumothorax?
• All traumatic pneumothoraces are drained to
prevent tension pneumothorax
• This will encourage early lung expansion and
evacuate any hemothorax
• Without drainage half of all pneumothoraces
will increase over the first 24 hours.
Q 16. What is sucking wound?
It is nothing but open pneumothorax as a result
of open defect in the chest of more than 3cm. This
will lead on to hypoventilation or hypoxia.
Q 17. What is the treatment of sucking wound?
1. Closing the defect with sterile occlusive
dressing sealed on three sides so that the air
will escape but preventing the air entry
2. Tube thoracostomy
3. Formal closure of the defect may be required.
Q 18. If there is failure to expand the lung with
effective drainage, how one should proceed?
This is an indication for bronchoscopy (and often
thoracotomy).
11 – Surgical Emphysema
Q 1. What is your observation?
Skiagram chest showing air spaces in the
subcutaneous tissue suggestive of surgical
emphysema (Subcutaneous emphysema).
Q 2. What is surgical emphysema?
• It is the presence of air in the tissues
• Itrequires abreachof air containingviscuswhich
is in communication with soft tissues and the
generation of positive pressure to push the air
along tissue planes.
Q 3. What is the physical sign of surgical
emphysema?
Crepitus (a peculiar crackling sensation imparted to
the examining fingers when one places the fingers fan
wise on the affected area and exerts light pressure).
Skiagram chest
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Q 4. What is the cause for crepitus?
Presence of gas in the subcutaneous tissue
Q 5. What are the causes for surgical emphysema?
Causes for subcutaneous emphysema
1. Traumatic: Fracture of the ribs – emphysema may
extend from the ankle of the jaw to the scrotum
Lung injury
Bronchial injury
Fracture of the nasal fossa
Laryngeal injury
Tracheostomy
Fracture skull involving the frontal sinus
2. Infective: Gas gangrene
3. Extraneous: A poorly managed chest drain with
build up of pressure
Extravasation of fluids
Effusion of blood
Entrapped air during closure of surgical wound
4. Subcutaneous emphysema complicating rupture
of the esophagus (most serious). It will also produce
mediastinal surgical emphysema
Q 6. What is the probable cause in this case?
Lung injury, secondary to fracture ribs.
Q 7. What is the treatment of surgical emphysema?
a. If there is no respiratory distress and no
pneumothorax then no treatment is required
b. If there is respiratory distress tube thoracostomy
is done
c. If there is no improvement, suspect bronchial
injury for which thoracotomy and closure of the
bronchial injury may be required.
12 – Hemopneumothorax, Tube Thoracostomy,
Safe Triangle
Q 1. What is your observation?
Skiagram chest showing hemopneumothorax with
tube thoracostomy in position.
Q 2. What are the causes for hemopneumothorax?
1. Blunt chest trauma
2. Penetrating chest injury
3. Fracture ribs
4. Aspiration of hemothorax.
Q 3. What are the radiological signs of
hemopneumothorax?
1. Obliteration of costophrenic angle
2. Fluid level with air shadow above
3. Collapsed lung border.
Q 4. What are the clinical features of hemothorax?
Tracheal position – Displaced
Percussion note – Decreased (dull)
Breath sounds – Decreased
Respiratory distress – Variable
Q 5. What is the minimum blood required for
blunting of the costophrenic angle?
• 250-400 ml in erect film (in supine film it is not
apparent with < 1000 ml)
• In lateral decubitus film opacification is more
obvious.
Q 6. What is the source of bleeding in hemothorax?
It may be from the following sites:
1. Bleeding from intercostal vessel
Skiagram chest
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521
2. Bleeding from internal mammary artery
3. Bleeding from the lung.
Q 7. What is massive hemothorax?
If the initial drainage from the chest is more than
1500 ml of blood or ongoing hemorrhage of more
than 200 ml/hr over 3-4 hours.
Q 8. What are the indications for thoracotomy?
Thoracotomy is required only in 10% of major
injuries. The important indications are:
Indications for thoracotomy in chest trauma
1. If the initial drainage from the chest is more than
1500 ml of blood or ongoing hemorrhage of more
than 200 ml/hr over 3-4 hours
2. Great vessel injury
3. Tracheobronchial rupture
4. Persistent air leak
5. Cardiac injury
6. Esophageal injury
7. Diaphragmatic injury
Q 9. What is the management of hemothorax and
hemopneumothorax?
Tube thoracostomy.
Q 10. What is the safest site for insertion of chest
tube?
Safe triangle.
Q 11. What are the boundaries of safe triangle?
The safe triangle bounded by:
• 5th rib below
• Posteriorly by the midaxillary line
• Anterior axillary line anteriorly (lateral to the
pectoralis major muscle).
Q 12. What is the importance of this triangle?
Why safe triangle is selected
• It is important to remember that the abdominal
cavity is extending upto the nipple level
• Any insertion of tube below the 5th rib is likely to
enter the abdominal cavity and consequent injury
to the viscera
• The thickness of the chest wall in this triangle is
thin and constituted only by the intercostal muscles
(inner and outer) and no other muscle is coming in
the triangle. Therefore it is easier to insert the chest
tube here
• The interspace is large here
• No impairment of accessory respiratory muscles
• Away from mediastinal structures and internal
mammary artery
• Since the position of the tube is anterior, in the
supine position the tube will not kink.
Q 13. What is the ideal direction of the chest tube
for the purpose of draining hemopneumothorax?
• The tube should go posteriorly and upwards
towards the apex of the lung (apex for air,
posteriorly for blood)
• Adrainforpleural effusionandempyema should
be nearer the base.
Q 14. How will you prevent neurovascular injury
during chest tube insertion?
The tube should pass over the upper edge of the
rib to avoid neurovascular bundle.
Q 15. What are the important steps of tube
thoracostomy?
1. Take sterile precautions and paint the selected
area of the chest wall with antiseptics (centering
the safe triangle).
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2. Infiltrate local anesthesia at the site including
the pleura
3. Make and skin incision in the intercostal space
for about 2.5 cms
4. Blunt dissection is carried out through the
intercostal muscles
5. An oblique tract is made (the skin incision is
made one interspace lower) so as to enter the
pleural cavity
6. The gloved finger is introduced into the pleural
cavity and the pleural adhesions are separated
7. Sterile chest tube is introduced with the help
of an artery forces in an upward and medial
direction
8. See that all the side holes are inside the chest
cavity
9. The tube is fixed in position with a retaining
stitch and see that the retaining stitch is not
obliterating the tube
10. The tube is connected to under water seal of
the chest drain bottle
11. The wound is sealed
12. Take chest radiograph and see that the chest
tube is in position.
Q 16. What is the daily postoperative care of the
tube?
• See that the air column in the tube is moving
(means, the tube is in the chest cavity. If the
column is not moving, the tube is occluded or
it is not in the chest cavity).
• Look for air bubbling-suggestive of air escape
from the pleural cavity if there is pneumothorax.
• See thatthe lower end ofthe chesttube is below
the under water seal of the draining bottle.
• Measure the total drainage of blood in the
draining bottle (whenever the bottle is full, it
should be emptied after clamping the chest
tube).
• See that all the side holes of the chest tube are
inside the chest cavity- (there should not be any
air leak at the tube chest wall junction).
• Check for air entry on the side by auscultation
• Take check X-ray of the chest to look for
expansion of the lungs and clearance of the
costophrenic angle.
Q 17. Is there any role for applying suction to the
chest drain?
No:
Q 18. When to remove the chest tube?
Indications for removal of the chest tube
• Remove the drain when it is no longer draining
• The drain should be removed when there has been
no air leak for 24 hours with a fully expanded lung
• If the patient is ventilated the drain should be left
until after extubation or there has been no air leak
for five days
Q 19. What are the causes for failure to expand
the lung?
1. Inadequate drain size
2. Position of the drain not reaching the apex
3. Kinking of the tube
4. Excessive air leak
Q 20. What are the complications of tube
thoracostomy?
1. Infection – empyema
2. Danger of disconnection of the tube and
siphoning of air.
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Q 21. What are the radiological findings of rupture
of the diaphragm?
Traumatic rupture is commonly seen on left side.
The radiological findings are:
1. Stomach containing fluid level within the
left hemithorax (the fluid level in stomach will
not be completely across the hemithorax unlike
hemopneumothirax)
2. Compressed lung lying above and medial to the
top of the intrathoracic stomach
3. Gas shadows of intrathoracic colon if the
escaping viscera is colon
4. Lateral view showing double fluid level if there
is intrathoracic gastric volvulus.
13 – Cervical Rib, Thoracic Outlet Syndrome
Q 1. What is your observation?
Skiagram neck showing incomplete cervical rib
on right side.
Q 2. What is cervical rib?
It is an extension of costal element of transverse
process of C7 vertebra.
Q 3. What are the types of cervical rib?
1. Complete fibrous band (commonest type)
from the transverse process and reaching
anteriorly over the first rib or manubrium. It is
not demonstrated radiologically
2. Complete bony type (radiopaque)
3. Partly bony and partly fibrous
4. Partly bony: With free end of the rib expanding
as a bony mass.
Q 4. What are the various clinical syndromes
associated with cervical rib?
• Cervical rib syndrome
• Thoracic outlet syndrome
• Thoracic inlet syndrome
• Scalenus anticus syndrome.
Q 5. What are the clinical features of cervical rib?
It can be classified as:
1. Neurological symptoms: As a result of
compression of the lower trunk of the brachial
plexus (C8 and T1) mainly T1 resulting in wasting
of the interossei and numbness and tingling of
the little finger and medial side of the hand and
forearm.
Skiagram neck
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2. Vascular manifestations: The cervical rib causes
angulation of the subclavian artery producing
constriction at the level of the rib followed by a
poststenotic dilatation, which may also produce
a thrombus inside and embolus formation. It
will finally produce features of ischemia in the
hand and forearm and digital gangrene. It will
also produce wasting of thenar, hypothenar and
forearm muscles.
3. Local manifestations:
Bony mass in the supraclavicular fossa Palpable
thrill over the subclavian artery Bruit over the
subclavian artery.
Q 6. What are the differential diagnoses of the
above symptoms?
1. Carpal tunnel syndrome
2. Cervical disk disease.
Q 7. What is scalene triangle and what is the
pathology of cervical rib?
This scalene triangle is bounded by:
Scalenus anterior – anteriorly
Scalenus medius – posteriorly
First rib – below
Etiopathology of cervical rib
• The subclavian artery and lower trunk of the
brachial plexus crosses the first rib in the scalene
triangle.
• The presence of cervical rib compress the
subclavian artery and lower trunk of brachial
plexus more on T1 area.
• As a resultof constrictionatthesiteofthecervical
rib, the artery distally dilates (poststenotic
dilatation) which may contain thrombus which
leads to embolus. The vascular manifestations
are as a result of the pressure from the cervical
rib.
• The neurological manifestations are as a result
of pressure on the lower trunk.
Q 8. What are the upper limb positions which will
precipitate the symptoms of cervical rib?
1. Prolonged hyperabduction of the upper limb.
For example Painters, hair dressers and truck
drivers
2. Carrying heavy weight in the shoulder can also
precipitate the symptoms.
Q 9. How to radiologically differentiate first rib
from cervical rib?
The transverse process of the first thoracic vertebra
has obliquity upwards whereas the transverse
process of C7 vertebra has obliquity downwards.
If a radiologically demonstrable rib arises from
the latter (transverse process with obliquity
downwards), then it is cervical rib.
Q 10. What are the other investigations required
other than skiagram of neck and chest?
• Nerve conduction studies
• Color Doppler for vascular assessment
• Arteriogram ifrequired (Ifthere is apost-stenotic
dilatation it is suggestive of cervical rib).
Q 11. What are the clinical tests for cervical rib?
1. Adson’s test
2. Elevated Arm Stress Test (EAST)
3. Roos test
4. Tinel test.
Q 12. How Adson’s test is carried out?
The patient sits and the examiner feels the radial
pulse of the patient. Now the patient is instructed
to take a deep breath. He holds it and turns his
chin up and to the affected side. A diminution
or obliteration of the radial pulse indicates the
presence of scalenus anticus syndrome.
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525
Q 13. What is Elevated Arm Stress Test?
Arm is elevated above the shoulder with the elbow
stretched fully. Now ask the patient to move the
fingers rapidly. Patient will feel fatigue on the
affected side if cervical rib is present.
Q 14. What is Roos test?
Ask the patient to raise the arm above the shoulder.
On the affected side the patient cannot hold the
arm in that position and drops the hand down.
Q 15. What is Tinel test?
Light percussion over the brachial plexus in
the supraclavicular fossa produces peripheral
sensations and reproduces the symptoms of
neurological impingement.
Q 16. What is the treatment of cervical rib?
The cervical rib may be symptomatic or asymptomatic (may be unilateral or bilateral). Asymptomatic
cases are left alone. Symptomatic cases can be
managed conservatively or surgically.
A. Conservative treatment for a period of
3-6months consisting of:
Physiotherapy
Postural correction.
B. Surgery ifthere is no response with conservative
treatment:
• Resection of the first rib which may be done
either by a supraclavicular approach or by
a transaxillary approach. It will widen the
thoracoaxillary channel.
• Anterior scalene muscle must be divided in
all the procedures
• Excise the associated fibrous band
• A r te rial stenosis may need arterial
reconstruction in some cases
• Ifthere is associatedthrombosisofsubclavian
vein manifested in the form of unilateral arm
swelling, catheter— directed thrombolysis is
carried out.
14 – Intravenous urogram, Renal and Ureteric
Stones, Nonvisualization of Kidney
Q 1. What is your observation?
Intravenous Urogram (IVU or IVP – IVU is a better
terminology than pyelogram) showing ureteric
stone on left side with hydroureter.
Q 2. How intravenous urogram is carried out?
It is carried out by intravenous injection into a vein
in the antecubital fossa of iodine containing dye
like sodium diatrizoate (urografin) or meglumide
(about 20 ml of the dye). It is filtered from the blood
by the glomeruli and does not undergo tubular
absorption and rapidly passes through the urine.
Q 3. What is the preparation for IVU?
1. Bowel preparation in the form of laxatives on
each of the two preceding nights and charcoal
tablets for 48hours for absorption of gas
2. Nothing to drink for 8 hours before the
examination (fluid restriction is contra
indicated in patients who are in renal failure
or myelomatosis and in infants. Dehydration is
dangerous).
3. The investigation is done with an empty stomach
in the morning
4. The patient is asked to void immediately before
the examination
5. Diuretics are not given prior to the examination
(the dye as such has got diuretic effect).
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Q 4. What are the contraindications for IVU?
The contraindications are:
1. Those who are allergic to iodine, patients with
atopy and eczema
2. If the blood urea is more than 60 ml/100 ml
3. Impaired renal function
4. Anuria
5. Infants
6. Pregnant women.
Q 5. What are the types of urogram?
1. Intravenous urogram
2. Retrograde pyelography (the contrast is injected
through ureteric catheter after cystoscopy
3. Antegrade pyelography (the contrast is injected
to the pelvis).
Q 6. How many films are taken?
1. Scout film (the plain X-ray abdomen taken
before injection of the dye).
2. Nephrogram picture at 2 minutes, when the
dye is being filtered by the glomerulus – shows
the renal parenchyma opacified by contrast
medium. A delayed nephrogram on one side
indicates functional impairment.
3. Serial films thereafter at 5, 10, 15, 20 and 30
minutes after the injection of the dye (the
contrast is excreted into the collecting system
opacifying the renal pelvis and calyces).
4. Another film at 1 hour followed by another at 2
hours.
5. The patient is asked to void urine and a post
micturition film is taken to show the details of
the bladder area.
6. If there is poor functioning of kidney, films are
taken after 8-hours.
Q 7. What are the indications for IVU?
With the introduction of CT scan the indications are
becoming less and less.
The indications are:
1. To demonstrate stones within the urinary tract
which are not visualized in ultrasonography.
2. To demonstrate tumors which will distort the
pelvicalyceal system.
3. Hydronephrosis.
4. To show details of abnormal anatomy (horse -
shoe kidney, bifid pelvis, bifid ureter and ectopic
kidney).
5. In cases for trauma for extravasation of the dye
and nonvisualization of the kidney.
6. To demonstrate tumor infiltration from elsewhere
of the kidney, ureter and bladder areas.
Q 8. If pelvicalyceal system on one side is not
visualized what is the inference?
• That side the kidney is not functioning.
Intravenous urogram
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• Ifthere is delay of appearance ofthe dye on one
side the inference is there is poor functioning on
that side.
Q 9. What are the causes for nonvisualization of
the kidney?
When 90-95% of the parenchymal function is
lost the kidneys are nonvisualized. In such cases
radioisotope study using DTPA labelled with
technetium 99m can be used.
1. Gross hydronephrosis with no function
2. Tumors
3. Trauma
4. Tuberculosis
5. Congenital absence of one kidney.
Q 10. Can you visualize the entire length of ureter
in a single film?
No. Because of the ureteric peristalsis, the entire
ureter may not be visualized (The entire ureter is
visualized only when the ureter is diseased as in
the case of tuberculosis).
Q 11. What are the changes of hydronephrosis
in IVU?
Calyceal changes: Normally the calyces are cupshaped. In hydronephrosis the following changes
are seen.
• Loss of cupping
• Flattening and
• Clubbing of the calyces.
Q 12. What is the appearance of the pelvi- calyceal
system in tumor?
Spider leg deformity of the pelvicalyceal system
(distortion).
Q 13. What is double dose IVU?
When 2 ampoules (40ml) of the dye is used for
delineation of the nonfunctioning side, it is called
double dose IVU.
Q 14. What is infusion pyelogram?
When six ampoules (120ml) are put in a bottle and
given as infusion, it is called infusion pyelogram.
Q 15. How many percentage of the renal stones
are radiopaque?
85-90%. Owing to the calcium content.
Q 16. What is staghorn calculus?
It is a calculus filling the entire pelvicalyceal system
consisting of triple phosphate or struvite (calcium,
ammonium and magnesium phosphate). It is
smooth and dirty white in color, seen to grow in
alkaline urine in the presence of urea splitting
proteus organism. They are radiopaque.
Q 17. What are the types of renal stones?
1. Oxalate calculus
2. Phosphate (triple phosphate)
3. Uric acid and urate calculi
4. Cystine calculus
5. Xanthine calculus.
Q 18. What is the treatment of staghorn calculus?
1. PCNL (Percutaneous Nephrolithotomy)
2. ESWL (Extracorporeal Shock Wave Lithotripsy)
3. Silent Staghorn Calculus in the elderly is treated
conservatively.
Q 19. Which side is operated first in cases of
bilateral renal stones?
Kidney with better function is treated first unless the
other kidney is more painful or infected.
Q 20. What is the treatment of ureteric stones?
1. Conservative: Calculi smaller than 0.5 cm pass
spontaneously (larger stones, impacted stones
and infection in the upper urinary tract are
indications for intervention)
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2. Ureteroscopic stoneremoval(URS):Ureteroscope
is a long, thin endoscope passed transurethrally
across the bladder into the ureter for removal of
the impacted stones.
3. Push bang: Stone in the middle or upper part of
the ureter is flushed back into the kidney using
a ureteric catheter and treated with ESWL later.
4. Open surgery: Ureterolithotomy.
15 – Hydronephrosis
Q 1. What is your observation?
Intravenous urogram showing dilatation of the
calyces and delayed excretion of dye on right side
suggestive of hydronephrosis.
Q 2. What are the changes suggestive of
hydronephrosis?
See Question 11 of Skiagram No:14.
Q 3. What is hydronephrosis?
Aseptic dilatation of pelvicalyceal system due to
partial or intermittent obstruction. When there
is infection it is called pyonephrosis. Complete
and continuous obstruction may not produce
hydronephrosis.
Q 4. What is Dietl’s crisis?
It is nothing but intermittent hydronephrosis.
The patient will present with loin mass and renal
pain. After a few hours the pain is relieved and the
swelling disappears following the passage of large
volume of urine.
Q 5. What are the causes for hydronephrosis?
Hydronephrosis may be unilateral or bilateral.
Th e m o s t co m m o n c a u s e fo r u n i l ate ra l
hydronephrosis are idiopathic pelvi – ureteric
junction obstruction and calculus.
Causes for hydronephrosis
Causes for unilateral hydronephrosis Causes for bilateral hydronephrosis
Causes inside the lumen Congenital
• Stones • Posterior urethral valve
• Sloughed papillae • Urethral atresia
Causes in the wall Physiological
• Idiopathic pelviureteric junction obstruction • Pregnancy
• Ureterocele Acquired
• Stricture of the ureter • Benign prostatic enlargement
• Tumors of the ureter • Carcinoma of the prostate
• Bladder cancer involving ureteric orifice • Bladder neck obstruction
Causes outside the wall • Urethral stricture
• Carcinoma of the colon, cecum, rectum, uterus, • Phimosis
prostate, etc.
• Retroperitoneal sarcomas
• Retroperitoneal fibrosis
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Q 6. What happens to the renal parenchyma in
hydronephrosis?
The renal parenchyma is destroyed by pressure from
the dilated calyceal system.
Q 7. What is Whitaker test?
Percutaneous puncture of the kidney through
the loin and fluid infusion at constant rate with
monitoring of intrapelvic pressure is the basis of
this test. Abnormal rise in pressure is suggestive
of obstruction.
Q 8. What are the indications for surgery?
• Increasing hydronephrosis
• Infection
• Pain
• Parenchymal damage.
Q 9. What is the surgical treatment of idiopathic
pelvi – ureteric junction obstruction?
Anderson-Hynes pyeloplasty (provided reasonable
functioning parenchyma remains). A ‘V’ segment is
excised from the stenotic area and repair is done
so that the narrowed area is widened. Another
operation is V-Y plasty.
Q10. Is there any endoscopic procedure available?
Yes: Endoscopic pyelolysis by passing a balloon up
the ureter and disrupting the pelvi ureteric junction.
Q 12. What is the role for nephrectomy?
The basic aim of the treatment is to conserve the
kidney. Nephrectomy is done only when the renal
parenchyma is grossly destroyed.
16 – Barium Swallow, Achalasia Cardia
Q 1. What is your observation?
a. Skiagram chest showing mediastinal widening
b. Barium swallow showing ‘smooth pencilshaped’ narrowing at the lower end of
esophagus (“bird’s beak” appearance).
• Widening of the mediastinum is as a result
of large fluid-filled esophagus (soft tissue
shadow with air fluid level just to the right
of the atrium).
• The barium swallow shows smooth pencilshaped narrowing distally with proximal
dilatation of the esophagus. Being a benign
condition of long duration there is enough time
for proximal dilatation to occur in the esophagus
in achalasia. The narrowing in carcinoma is
irregular and described as ‘rat tail appearance’.
In carcinoma of the esophagus, the patient may
not be alive in majority of cases by the time the
esophagus dilates proximally.
The probable diagnosis in this case is achalasia
cardia.
Q 2. What is achalasia?
The word meaning is ‘a chalasia’ (Greek): Failure
to relax:
Intravenous urogram (IVV)
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It is due to the loss of ganglion cells in the
myenteric plexus (Auerbach’s plexus).
Q 3. What are the etiological factors for achalasia?
• Chagas’ disease: Destroys parasympathetic
ganglion cells
• Infection: Herpes zoster of neurons
• Degenerative disease of the neurons.
Q 6. What are the clinical features of achalasia
cardia?
• Pain (early stages)
• Dysphagia (more for liquid than for solid in
contrast to carcinoma)
• Regurgitation of food (Recurrent pneumonia is
seen)
• Aspiration at night.
Q 7. What is the endoscopic finding in achalasia
cardia?
• Dilated tortuous esophagus
• Food residue and fluid in the esophagus
• Tight cardia
• Evidence of esophagitis.
Q 8. What is the confirmatory test for achalasia
cardia?
Esophageal manometry: Raised resting pressure in
the esophagus.
Q 9. What is pseudoachalasia?
• Thisisproducedby adenocarcinoma andbenign
tumors of the esophagus
• Cancers outside ofthe esophagus, e.g. bronchus
can also produce pseudoachalasia.
Q 10. What are the treatment options in achalasia
cardia?
• Pneumatic dilatation
• Heller’s myotomy
• Injection of botulinum toxin into the lower
esophageal sphincter with temporary effect for
a few months (has to be repeated)
• Drugs will give only transient relief
Sublingual Nifedipine
Calcium Channel Antagonists.
Q 11. What is pneumatic dilatation?
• The dilatation of the cardia was originally
described by Plummer using Plummer’s
hydrostatic bag.
Skiagram chest and barium swallow
Q 4. How it differs from Hirschsprung’s disease?
InHirschsprung’s disease the dilated colon contains
normal ganglion cells, whereas in achalasia there
are no ganglion cells in the dilated segments.
Q 5. What are the physiological abnormalities in
achalasia cardia?
They are:
• Loss of peristalsis in the body of the esophagus
• Nonrelaxationofthe lower esophagealsphincter
• Dilatation and tortuosity ofthe lower esophagus
– mega esophagus and sigmoid appearance
• Stasis of food and fluid – retention esophagitis
• The emptying of esophagus takes place by
hydrostatic pressure of the content
• Absent fundal gas in the stomach.
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• This is now replaced by pneumatic dilatation
using plastic balloons of sizes 30-40 mm
diameter which are introduced over a guide wire.
• Progressive dilatations are carried out over a
period of weeks.
• Perforation isthe mostimportant complications.
Q 12. What is Heller’s myotomy?
This can be carried out either by open method
or laparoscopic method. In this procedure a
longitudinal incision is made in the anterior aspect
of the lower esophagus and cardia to divide the
muscles of the narrow segment without injuring
the mucosa so that the mucosa will pout.
Q 13. What is the most important complication of
Heller’s myotomy?
Gastroesophageal Reflux.
Most surgeons therefore perform a partial
anterior fundoplication. This is called Heller – Dor’s
operation .
17 – Barium Swallow, Carcinoma of the
Esophagus
Q 1. What is your observation?
Barium swallow picture showing narrowing at the
lower end of the esophagus having the typical ‘rat
tail appearance’ suggestive of ‘carcinoma of the
lower end of esophagus’.
Q 2. What are the pathological types of carcinoma
of the esophagus?
• Squamous cell carcinoma – affects the upper
two – thirds (most common type)
• Adenocarcinoma – affects the lower third.
Q 3. What are the etiological factors for carcinoma
of the esophagus?
Etiological factors for carcinoma of the esophagus
• Tobacco
• Alcohol
• Fungal contamination of the food
• Nutritional deficiencies
• Barrett’s esophagus
• GERD (Gastroesophageal reflux disease)
• Hot liquids
• Poor oral hygiene
• Achalasia
• Plummer-Vinson syndrome
Barium swallow
Q 4. What are the clinical features of carcinoma
of the esophagus?
Clinical features of carcinoma of the esophagus
• Dysphagia
• Regurgitation
• Vomiting
• Odynophagia
• Weight loss
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Q 5. What are the clinical features suggestive of
advanced malignancy?
Clinical features suggestive of advanced malignancy
• Enlarged supraclavicular lymph nodes
• Horner’s syndrome
• Recurrent laryngeal nerve palsy (Hoarseness —
Incurable disease)
• Diaphragmatic paralysis
Q 6. In which country you get the highest
incidence of carcinoma of the esophagus?
Linxian in Henan Province in China.
Q 7. What are methods of spread of carcinoma of
the esophagus?
• Longitudinal spread (via the submucosal
lymphatics)
• Horizontal spread (laterally through the layers
of esophagus)
• Lymphatic spread (commonest—predominantly
caudal spread) Any node from superior
mediastinum to the celiac axis may be involved
• Blood stream spread (liver, lungs, brain, bones)
• Transperitoneal – forthe intraabdominal part of
the esophagus.
Q 8. What is the significance of supraclavicular
lymph nodes in carcinoma of the esophagus?
Supraclavicular lymph nodes are suggestive of
metastasis (M1). So also celiac node involvement
in distal esophageal tumor.
Q 9. What are the most important investigations
in carcinoma of the esophagus?
1. Endoscopy and biopsy for confirmation of the
diagnosis.
Staging investigations
2. Endoscopic ultrasound is the most important
staging investigations—for depth of tumor,
invasion of the adjacent organs and for
metastasis to lymph nodes
3. Chest radiography for pulmonary metastasis
4. Liver function tests (LFTs)—Abnormal LFTs are
suggestive ofliver metastasis.Normal LFT does
not rule out liver metastasis.
5. Ultrasound abdomen—to rule out liver
metastasis.
6. Bronchoscopy (for middle and upper thirds).
7. Laparoscopy—for carcinoma arising from the
abdominal esophagus-abdominal and hepatic
metastasis
8. Spiral CT—for local spread and lymph node
assessment (also for assessment of metastasis).
9. MRI – Magnetic Resonance Imaging
10. PET (Positron Emission Tomography) –
combined with CT.
Q 10. What are the most important bad prognostic
factors in carcinoma of the esophagus?
• Depth of tumor penetration
• Regional lymph node involvement.
Q 11. What is the management of carcinoma of
the esophagus?
1. If the patient is unfit for surgery or metastasis
or adjacent organ invasion or peritoneal
spread—palliation for dysphagia, e.g. chemo
radiotherapy and endoscopic palliation.
2. If fit for surgery and there is no lymph
node metastasis – surgery alone (radical
oesophagectomy).
3. If lymph node metastasis is present multimodal
therapy – neoadjuvant treatment, chemo
radiotherapy.
• Radical esophagectomy for curative
treatment with 10 cm clearance above the
macroscopic tumor and 5 cm distally.
Radiology Questions and Answers
533
• Adenocarcinoma involving gastric cardia
need some degree of gastric resection.
Q 12. How many percentage of the carcinoma of
the esophagus are operable?
Above two-thirds of the tumors at the time of
diagnosis are inoperable and only one-third is
operable.
Q 13. What are the most important factors to be
considered before deciding surgical option if it
is operable?
1. General condition of the patient
2. Tumor location
3. Endoscopic appearance
4. Nodal status.
Q 14. What is the incision of choice for radical
surgery?
• For lower third growth: Left thoracoabdominal
incision for carcinoma of the lower end of
the esophagus below the aor tic arch
(esophagogastrectomy – part of the upper
stomach is removed followed by esophago
gastric anastomosis).
• For middle third growth: If the tumour is
above the level of aortic arch, the two phase
Ivor Lewis operation along with two field
lymphadenectomy (abdominal and mediastinal
nodes) by an initial laparotomy for construction
of a gastric tube followed by a right thoracotomy
for resection of the tumor and esophagogastric
anastomosis.
• For upper third growth: McKeown operation
for carcinoma of the upper thoracic esophagus:
It is a three phase operation with three field
lymphadenectomy: Here a third incision is put
in the neck for removal of the nodes there and
creating the cervical anastomosis.
Q 15. What are the viscera used for inter- position
as a substitute for esophagus?
They are placed in the substernal space and the
following viscera are used.
• Stomach (commonly used)
• Jejunum
• Colon.
Q 16. What is the blood supply of the transposed
stomach into the chest cavity?
Right gastroepiploic and right gastric vessels.
Q 17. What are the complications of surgical
treatment?
Complications of surgical treatment
• Anastomotic leakage
• Respiratory complications
• Recurrent laryngeal nerve injury
• Chylothorax
• Reflux:Itcanbeavoidedbysubtotalesophagectomy
and making the esophagogastric anastomosis high
up in the chest
Q 18. What is transhiatal esophagectomy?
• This was devised by Orringer for the removal of
Chagasic mega esophagus
• This is a useful procedure for the lesions of
the lower esophagus, but dangerous for the
middle third lesion
• The stomach is mobilized through an abdominal
incision
• The cervical esophagus is mobilized through a
cervical incision
• The diaphragm is opened from the abdomen
and the posterior mediastinum entered
• The tumor and lower esophagus are mobilized
under vision
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Clinical Surgery Pearls
• The upper esophagus is mobilized by blunt
dissection
• Total esophagectomy is done and esophagojejunostomy is carried out in the neck.
Q 19. What is the role of neoadjuvant treatments?
Neoadjuvanttherapy for adenocarcinoma is using
platinum is based is chemotherapy.
Q 20. What is the role of chemoradiation?
It is indicated for squamous cell carcinoma of the
esophagus in patients who are unfit for surgery.
Q 21. What is photodynamic therapy?
This is an endoscopic technique for treating early
esophageal cancer and dysplasia of Barrett’s
esophagus for patients who are unfit or unwilling
for surgery. Here a photozensitizer is administered
which is taken up preferentially by dysplastic and
malignant cells which is followed by exposure
to laser light. The main disadvantages is skin
photosensitization.
Q 22. What are the palliative procedures?
1. Intubation - Self-expanding metal stents
(SEMS): They are inserted under radiographic
or endoscopic control. This will produce wider
lumen for swallowing than the old conventional
rigid plastic and rubber tubes. The risk for injury
to the esophagus is also less in this case.
2. Intubation with plastic and rubber tubes
(Mousseau—Barbin tube—this requires
laparotomy).
3. Endoscopic laser—It is useful for recanalization
of the obstructed growth and also for canalizing
occluded stent. It has to be repeated.
4. Bipolar diathermy endoscopically.
5. Argon - beam plasma coagulation.
6. Alcohol injection.
7. Brachytherapy: Intraluminal radiation is given
by an introduction system.
Q 23. What are the terminal events of carcinoma
esophagus?
• Tracheo-esophageal fistula
• Severe respiratory infection and sepsis
• Cancer cachexia
• Immunosuppression.
18 – Barium Meal, Carcinoma of the Stomach
Q 1. What is your observation?
This is a barium meal picture showing a persistent
(for a lesion to be designated as persistent, the
observer needs more than one film or watch
the fluoroscopy) irregular filling defect in the
antral region towards the greater curvature side
suggestive of carcinoma of the stomach.
Q 2. What is the difference between barium meal
and barium swallow?
• Both investigations are done by using barium
sulphate
• Both are done under fluoroscopy
• Both are done on empty stomach
• In barium swallow a thick solution of barium
sulphate is given to the patient for swallowing.
This is mainly done for the study of esophagus
and pharynx
• For barium meal a dilute solution of barium
sulphate is used (about 500 ml is given orally)
• Microcrystallized barium sulphate solutions are
available which gives better images
• When you take a sequential films of the small
intestine after barium meal, it is called barium
meal follow-through.
Radiology Questions and Answers
535
Q 3. Why barium sulphate is used?
• Barium is radiopaque and in sulphate form it is
not absorbed
• Barium is stable in acidic medium
• Barium phosphate is a poison and therefore
cannot be used.
• Foridentification of leaks and perforation water
soluble contrast materials like gastrograffin may
be used
Q 4. For delineation of the mucosa what technique
is used?
Double contrast barium meal is done—by giving
effervescent tablets along with barium. This will
give the double contrast picture.
Q 6. What is the difference between benign and
malignant ulcer in barium meal?
• In benign ulcer, the ulcer protrudes outside
beyond the stomach margin and is seen in the
lesser curvature usually.
• In benign ulcer radiating mucosal folds will be
demonstrated towards the border of the ulcer.
• In benign ulcer, the ulcer is demonstrated as a
niche in the lesser curvature and a notch in the
greater curvature.
• The malignant ulcer will appear as though it
is sitting inside the stomach and the mucosa
surrounding the ulcer will not show mucosal
folds.
Q 7. What are the disadvantages of barium meal
examination?
• In barium meal examination we see the shadow
of the lesion
• We are not directly visualizing the lesion
• Biopsy cannot be taken from the lesion
• It cannot be used in perforation since it can
cause peritonitis.
Note: With the introduction of fiberoptic
endoscopes, now-adays upper GI endoscopy and
biopsy is the preferred investigation for carcinoma
of the stomach.
Q 8. When such a lesion is identified in Barium
meal what is the investigation of choice?
Upper GI endoscopy and biopsy.
Q 9. Is it an early lesion or an advanced lesion?
Advanced gastric carcinoma.
Q 10. What is the likely clinical presentation in
this case?
Features of carcinoma stomach like:
• Loss of appetite
Barium meal
Q 5. What are the radiological signs of carcinoma
stomach in barium meal?
• Persistent mucosal irregularity (early stages)
• Persistent loss of peristalsis in a particular
segment
• Persistent irregular filling defect.
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Clinical Surgery Pearls
• Loss of weight
• Epigastric pain
• Epigastric mass
Since it is a big tumor occupying the antrum
it is likely to produce features of gastric outlet
obstruction like:
• Vomiting
• Visible gastric peristalsis
• Succussion splash
• Electrolyte abnormalities: Hypochloremic
alkalosis (The acid - base disturbance is less
pronounced in malignancy than benign and
there is relative hypochlorhydria found in gastric
cancer).
Q 11. Is it likely to be operable? Is there any role
for surgery in this case?
• Unlikely to be operable
• Since it is obstructing the pylorus, palliative
intubation or a palliative gastrojejunostomy
(Anterior, antecolic, long loop, gastrojejunostomy
and jejunojejunostomy– not a good operation)
may be required for this patient. Another option
is a palliative gastrectomy
• Laser recanalization is a better option.
Q 12. What is the normal capacity of the stomach
and what is the length of the stomach?
• 40 ounces (40 × 30 = 1200 cc)
• 12 inch long (30 cm).
Q 13. What is linitisplastica and what is the
capacity of the stomach in linitisplastica?
Linitisplastica or leather—bottle stomach
• Linitis means woven linen
• It is diffuse type of carcinoma involving the entire
stomach
• There isthickening ofthe entire wall ofthe stomach
with great contraction of the lumen
• It is also called leather - bottle stomach
• The capacity of stomach is reduced 4 ounces
(120 cc) and the length of the stomach may be as
small as 4 inches (10 cm)
• Endoscopy and ordinary biopsy may be normal and
deep punch biopsy is required
Read for Details of Carcinoma Stomach, Refer
Section 2, Long Case No:7
19 – Barium Meal, Gastric Outlet Obstruction
Q 1. What is your observation?
Barium meal picture showing the following findings:
1. Gastric outlet obstruction
2. Dilatation of the stomach
3. The barium is not going to the duodenum and
duodenum is not demonstrated
4. The stomach has got mottled appearance which
is due to the retained food particles inside.
Q 2. What are the causes for gastric outlet
obstruction?
Causes for gastric outlet obstruction
1. Duodenal ulcer with pyloric stenosis (common)
2. Antral gastric carcinoma (common)
3. Congenital hypertrophic pyloric stenosis
(Ramstedt’s pyloromyotomy is the treatment)
4. Adult type of pyloric stenosis (Pyloroplasty is the
treatment)
5. Pyloric mucosal diaphragm (Excision of the
diaphragm)
6. Gastric Bezoar (Vegetable matter taking the shape
of the stomach called phytobezoar and if it is hair
it is called trichobazoar)
7. Lymphoma
8. Gastritis
9. Crohn’s disease
10. Tuberculosis
Radiology Questions and Answers
537
Note: Gastric outlet obstruction should be
considered malignant until proven otherwise.
Q 3. Is pyloric stenosis a correct terminology?
It is a misnomer. The stenosis is found in the first part
of the duodenum if it is due to duodenal ulcer. True
pyloric stenosis is seen only in a pyloric channel ulcer.
Q 4. Is barium meal indicated if you suspect gastric
outlet obstruction?
Should not be performed until the stomach is emptied.
Q 5. What are the clinical features of benign gastric
outlet obstruction?
Clinical features of benign gastric outlet obstruction
• Peptic ulcer pain of long duration
• Vomitus lacking bile and containing food material
taken several days previously
• Loss of weight
• Dehydration
• Distended stomach
• Visible gastric peristalsis
• Succussion splash
Q 6. What are the metabolic abnormalities of
benign gastric outlet obstruction?
Metabolic abnormalities of benign gastric
outlet obstruction
• Hypochloremic alkalosis (Sodium and potassium
are normal initially)
• Urine initiallyhaslowchloride andhighbicarbonate
(Alkaline urine)
• Bicarbonate is excretedalongwithsodiumresulting
in hyponatremia
• Dehydration leads to sodium retention and
potassium and hydrogen ions are excreted in urine
in turn producing paradoxical aciduria
• Hypokalemia
• Alkalosis leads to hypocalcemia and tetany
Q 7. What is the normal emptying time of the
stomach?
3 to 4 hours.
Q 8. What is Saline Load Test?
It is an objective test for assessing the degree of
pyloric obstruction.
Through a nasogastric tube, 700 ml of normal
saline (at room temperature) is infused over 3 to 5
minutes and the tube is clamped. Thirty minutes
later, the stomach is aspirated and the residual
volume of saline is recorded. Recovery of more than
350ml indicates obstruction.
Q 9. How to proceed in such a case?
Upper GI endoscopy is indicated to rule out an
obstructing neoplasm.
Q 10. What is the preoperative preparation?
1. Nasogastric decompression
Barium meal
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Clinical Surgery Pearls
2. Gastric lavage with saline until the effluent is
clear. This will allow the pyloric edema and
spasm to subside
3. Repeat the saline load test after 72 hours and
check whether there is improvement
4. If there is improvement and if malignancy can
be ruled out patient can be managed medically,
slowly starting liquid diet followed by solid diet
5. If there is no improvement, patient needs surgery
depending on the pathology on endoscopy.
Q 11. What is the surgical treatment of severe
gastric outlet obstruction secondary to duodenal
ulcer?
• Gastrojejunostomy and truncal vagotomy
• Endoscopic balloon dilatation in early cases.
20 – Barium Meal, Duodenal Deformity
Q 1. What is your observation?
Barium meal picture showing duodenal deformity
(trefoil deformity) suggestive of cicatrizing
duodenal ulcer.
Q 2. What is duodenal cap?
The first 2.5 cm of the first part of the normal
duodenum which is radiologically demonstrated
is called duodenal cap (it is roughly triangular in
shape).
Q 3. What are the radiological findings of
duodenal ulcer?
1. Deformed duodenal cap
2. Nonvisualization of the duodenal cap
3. Trefoil deformity (also called trifoliate deformity).
Q 4. What is the cause for trefoil deformity?
It is due to secondary diverticulum formation at the
duodenal cap region.
Q 5. What is the cause for non visualization of the
duodenal cap?
It is due to the spasm of the first part of the
duodenum.
Q 6. What are the complications of duodenal
ulcer?
• Acute Perforation (anterior
complications ulcers)
Hemorrhage
(posterior ulcers)
• Subacute Residual abscess
complications formation
• Chronic Pyloric stenosis
complications Penetration to
pancreas Intractability
Barium meal
Q 7. What is kissing ulcer?
When there is both posterior and anterior duodenal
ulcers it is called kissing ulcers.
Radiology Questions and Answers
539
Q 8. Erosion of which artery is responsible for
hemorrhage?
Gastroduodenal artery.
Q 9. Can duodenal ulcer turn malignant?
No.
Q 10. What are the common sites of peptic ulcers?
• First part of the duodenum
• Stomach (lesser curvature)
• Lower end of the esophagus
• Meckel’s diverticulum having ectopic gastric
epithelium
• Gastro jejunalstoma (Stomal ulcer) – on jejunal
side
Q 11. What are the etiological factors for peptic
ulcers?
Etiological factors for peptic ulcers
• It is an imbalance between the aggressive factors
(acid) and defensive factors (mucosal protective
factors – including the mucus)
• “No acid no ulcer”is still true (Normal or low level
of acid in gastric ulcer)
• Infection with H. pylori (most important)
• Genetic factors
• Blood group - common in O group patients
• Cigarette smoking
• Alcohol
• Drugs - NSAIDS, Steroids
• Hyperparathyroidism
Q 12. What is the treatment of duodenal ulcer?
Duodenal ulcer is a medical problem and is treated
by:
• H2 – receptor antagonists and proton pump
inhibitors
• Eradication ofHelicobacter pylori (Proton pump
inhibitor + Metronidazole and Amoxycillin).
Q 13. What are the indications for surgery?
Indications are complications:
• Perforation
• Stenosis.
Q 14. What is the surgical procedure of choice
for stenosis?
• Truncal vagotomy and gastrojejunostomy isthe
operation of choice
• Pyloroplasty is contraindicated when there is
cicatrization of the duodenum
• HSV (Highly Selective Vagotomy) alone is
contraindicated since there is duodenal
obstruction. It can be done in early cases of
stenosis provided dilatation of the duodenum
can be successfully carried out.
21 – Double Contrast Barium Enema, Carcinoma
Cecum
Q 1. What is your observation?
Double contrast barium enema showing irregularity
of the mucosa of the cecum suggestive of
carcinoma.
Q 2. What is double contrast barium enema?
In addition to the barium sulphate solution given
as enema, air is injected so that the mucosa will be
delineated.
Q 3. What is the preparation for barium enema?
• Low residue diet for 3 days before the
examination
• Patientis given laxatives atbedtime fortwo days
• Liquid diet for 24 hours
• The colon must be empty. This can be achieved
by enema and colon washout
• The patient must be undressed completely
(wearing an open - backed gown).
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Clinical Surgery Pearls
Q 4. What is the position of the patient for barium
enema?
The patient is initially in the left lateral position and
followed by prone position.
Q 5. What is the procedure?
1. About 1 liter of barium sulphate is introduced
per anally using an enema tube from the enema
can
2. A Foley’s catheter with inflated bulb is used in
children
3. The procedure is done under fluoroscopy
4. X-ray is taken after completely filling the colon
5. Air is insufflated to delineate the mucosa
(Double contrast)
6. Finally a post evacuation film is taken (Patient is
asked to evacuate the barium).
3. Foley’s catheter is not used to avoid false
negative study.
Q 7. What further investigations are carried out
in this case?
1. Colonoscopy and biopsy
2. CEA level for getting the baseline value
3. X-ray chest to rule out metastasis in the lung
4. Ultrasound abdomen to rule out free fluid and
metastasis liver
5. CT of the abdomen to find local invasion.
Q 8. What are the possible radiological findings
in carcinoma of the colon?
• Apple core deformity with shouldering on both
sides
• Irregular filling defect
• Irregularity in the mucosa
• Annular lesions and strictures on left side
• Synchronouspolypsandmultiplecarcinomas(5%).
Q 9. What are the likely clinical presentations in
carcinoma of the cecum?
1. Mass in the right iliac fossa
2. Anemia
3. Symptoms of intermittent obstruction when
the growth forms the apex of the intussusception.
Q 10. What is the treatment of carcinoma of the
cecum?
Right hemicolectomy.
(Read section on long cases no:10).
22 – Barium Enema, Apple Core Deformity of
the Ascending Colon
Q 1. What is your observation?
Barium enema showing the typical apple core
deformity with shouldering on either side in the
ascending colon suggestive of carcinoma.
Barium enema—double contrast shows
mucosal pattern
Q 6. What are the precautions to be taken when it
is carried out for Hirschsprung’s disease?
1. Saline is used instead of water for diluting the
barium
2. Prior enemas may deflate the mega colon and
distend the aganglionic segment
Radiology Questions and Answers
541
5. Sterlin sign – Fibrotic terminal ileum opening
into contracted cecum.
All these findings are suggestive of ileocecal
tuberculosis.
Barium enema
• Read skiagram No: 21
• Read section on long cases No:10.
23 – Barium Enema, Ileocecal Tuberculosis
Q 1. What is your observation?
1. The cecum is pulled up and is seen in the
subhepatic region. Normally the cecum should
be at the level of iliac bone.
2. Obtuse ileocecal angle.Normally the ileumjoins
the cecum at right angles.
3. The terminal ileum is narrow–napkin lesion.
4. Narrow terminal ileum with wide open ileocecal
valve is called Fleischner sign.
Q 2. What are the likely clinical features?
• General symptoms like: weight loss, malaise,
evening rise of temperature, etc.
• Alternating constipation and diarrhea
• Mass in the right iliac fossa
• Features of distal small bowel obstruction –
abdominal pain, distension and vomiting.
Q 3. What are types of small intestinal tuberculosis?
Ulcerative type and hyperplastic type.
Q 4. What are the differences between ulcerative
type and hyperplastic type?
No Ulcerative Hyperplastic
1. Secondary to pulmonary tuberculosis Primary
2. Primary tuberculosis in the chest No primary in the chest
3. The virulence of the organism outstrips The host resistance is stronger than the virulence
the resistance of the host of the organism
4. Patient is very ill Not very ill
Barium enema showing cecum
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Clinical Surgery Pearls
5. Multiple transverse ulcers in the ileum, the Thickening of the intestinal wall and narrowing
overlying serosa studded with tubercles of the lumen
6. Clinical presentation is diarrhoea and bleeding Mass right iliac fossa
per rectum
7. Gross caseation is seen Absence of gross caseation
Read section on long cases No: 9 for management
Q 5. What is the most important clinical feature of
left sided colonic malignancy ?
Alternating constipation and diarrhea and colicky
abdominal pain.
Q 6. What is the cause for alternating constipation
and diarrhea?
The left sided growths are of the stenotic variety
which leads to constipation. This in turn will
produce stercoral enteritis. Enteritis leads on to
diarrhea. This is again followed by constipation
forming a vicious cycle.
Q 7. What are the most important complications
of descending colon growth?
• Large bowel obstruction (commonest)
• Perforation.
Q 8. What is the site of perforation in such a case?
It can perforate in 3 situations:
a. At the site of the growth
b. Proximal to the growth at the site of stercoral
ulcer.
c. Perforation of the cecum if the ileocecal valve is
competent.
Q 9. What is the surgical procedure of choice for
this lesion?
• Left hemicolectomy (mid transverse colon to
upper sigmoid is removed)
• In this procedure the left colic artery is ligated
preserving the inferior mesenteric artery
• Subtotal colectomy andileosigmoidorileorectal
anastomosis is another option.
24 – Barium Enema, Carcinoma of the
Descending Colon
Q 1. What is your observation?
It is a barium enema picture showing filling defect
in the descending colon suggestive of carcinoma
of the descending colon.
Q 2. What is your differential diagnosis?
The filling defect may also be due to a pericolic
abscess.
Q 3. How to confirm your diagnosis?
Colonoscopy and biopsy.
Q 4. How many percentage of carcinomas are seen
in descending colon?
4%.
Barium enema
Radiology Questions and Answers
543
25 – Barium Enema, Intussusception
Q 1. What is your observation?
1. Barium enema picture showing nonfilling of the
colon beyond the hepatic flexure
2. The typical “claw sign” of intussusception is
demonstrated. The barium is seen as a claw
around a negative shadow of intussusception.
It is also called pincer shaped filling defect (Coil
spring appearance).
Q 2. What is the definition of intussusception?
Telescoping of proximal into the distal intestine
is called intussusception.
Q 3. What is the age group commonly affected?
Infancy (5-10 months).
Q 4. What are the causes for intussusception?
Causes for intussusception
1. Idiopathic (hyperplasia of the Peyer’s patches in the
ileum during weaning period) Upper respiratory
tract infection and gastroenteritis may precede the
intussusception
2. Meckel’s diverticulum acting as a lead point
3. Polyps
4. Submucosal lipoma
5. Carcinoma
6. Henoch - Schönlein purpura
7. Appendix – acting as a lead point
8. Peutz - Jeghers syndrome
Q 5. What are the common causes in adults?
The adult causes for lead point are:
• Tumor (carcinoma)
• Polyp
• Submucosal lipoma.
Q 6. What are the parts of intussusception?
• Inner tube or entering layer
• Middle tube or returning layer
• Outer tube or the sheath (intussuscepiens).
Note: The inner tube and the middle tube together
are called intussusceptum).
The part that advances is called apex
The neck is the junction of the entering layer
with the mass.
Q 7. What are the types of intussusception
depending on the location?
Anatomical types of intussusception
1. Ileocolic (commonest variety)
2. Ileocecal – ileocecal valve forming the apex
3. Ileo Ileocolic
4. Ileoileal
5. Colocolic
6. Multiple
7. Jejunogastric
Barium enema—Intussusception
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Q 8. What is retrograde intussusception?
Telescoping of the distal intestine into the proximal
is called retrograde intussusception. The typical
example is a jejunogastric intussusception seen
after a gastrojejunostomy.
Q 9. What type of intestinal obstruction is
produced in intussusception?
Strangulating obstruction (the blood supply of the
inner layer is usually affected).
Q 10. What are the diagnostic clinical features and
important diagnostic signs?
Clinical features of intussusception
• Colicky abdominal pain (screaming and drawing up
of the legs in infants)
• “Redcurrant jelly” stool (initially the stool may be
normal)
• Vomiting is a later event (Milk followed by bile)
• Dehydration
• Abdominal distension
• Sausage – shaped mass with concavity towards
the umbilicus which harden on palpation
(Disappearing mass)
• Sign de-dance (Emptiness of right iliac fossa)
• Blood - stained mucus on rectal examination
• Palpable mass per rectum (apex of the
intussusception)
• The finger canbe introducedbetween themass and
anal verge in intussusception which is not possible
in prolapse rectum
Q 11. What is the ultrasound finding in
intussusception?
Doughnut appearance of concentric rings in
transverse section.
Q 12. What is the nonoperative management?
Nonoperative management consists of:
• Resuscitation – IV fluids (fluid and electrolyte
correction)
• Nasogastric decompression
• Hydrostatic reduction – Using barium enema
or air (pneumatic reduction).
Q 13. What is successful hydrostatic reduction?
• Free reflux of barium or air into the small bowel
is suggestive of successful reduction
• Resolution of symptoms and signs.
Q 14. What are the contraindications for non
operative management?
Contraindications for nonoperative management
• Signs of peritonitis
• Perforation
• Shock
Q 15. What is the recurrence rate of non operative
management?
10%.
Q 16. What are the indications for surgery?
Indications for surgery
• Contraindications for nonoperative reduction
• Failure of pneumatic or hydrostatic reduction
• Suspected pathological lead point
• Gangrene
Q 17. What is the operative method of reduction?
• Laparotomy is done initially (transverse right
sided incision for children)
• Manual reduction – gently compress the most
distal part of the intussusception towards its
origin (don’t pull)
• After reduction check for viability of the bowel
• If irreducible or gangrenous do resection and
anastomosis.
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26 – T-Tube Cholangiogram
Q 1. What is your observation?
It is a T-tube cholangiogram showing the normal
CBD (Common Bile Duct) with the horizontal limb
of the T-tube inside the CBD and the vertical limb
coming outside the body. The dye is coming down
the CBD and filling the duodenum. There is no
evidence of any obstruction or residual stone in
the CBD. This is a normal study.
Q 2. What is the purpose of T-tube?
• The T-tube is put inside the bile duct after
exploration of the bile duct (choledochotomy)
for removal of stones (choledocholithotomy).
• After clearing the stones there will be some
papillary edema and spasm and therefore the
dye may not come to the duodenum after
the peroperative cholangiogram. Therefore a
T-tube is put for drainage of the infected bile.
This tube is later utilized for T-tube cholangiogram after 7 to 10 days.
• The T-tube is then connected to a drainage
bottle and the 24 hour measurements are taken
daily. As the edema and spasm of the papilla
disappear, the quantity of bile coming to the
bottle will decrease gradually over a period of
one week. It allows time for relief of the papillary
spasm.
• This tube can also be used for T-tube cholangiogram postoperatively for demonstration of
residual stones.
Q 3. What is the incision in the CBD for
choledochotomy?
• A longitudinal incision in the supraduodenal
part of the CBD
• Afterremoval ofthe stonestheT-tube isinserted
and the duct closed around it.
Q 4. What is the timing of T–tube cholangiogram?
• Usually 7-10 days after surgery. by that time the
papillary edema and spasm will disappear and
the bile will become clear.
• The quantity of bile draining to the bottle
will come down as the natural passage to the
duodenum becomes patent.
Q 5. What is the purpose of T–tube cholangiogram?
1. To look for residual and retained stones in
the CBD - identified as negative shadows
(radiolucent) inside CBD
2. To look for free flow of the bile into the
duodenum.
Q 6. How will you differentiate air and radiolucent
shadow of residual stone?
If it is air, change of position of patient will result in
change of position of the shadow.
Q 7. How can you avoid air?
The T – tube is initially flushed with 20 ml of normal
saline so that the air bubble is removed before
T injecting the dye. -tube cholangiogram
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Q 8. What dye is used and how much quantity?
Iodine containing dye usually urograffin 3 ml is
injected into the T-tube.
Q 9. Is there any role for clamping the T-tube
before removal?
• T – tube is clampedforincreasingperiodsoftime
for 2-3 days before removal (8hours, 12hours,
and 24 hours).
• If there isresidualstone and obstruction to the
flow of bile to the duodenum, it will produce
pain, jaundice and leak along the side of the
T-tube.
Q 10. When is the T – tube removed?
If there are no residual stones and there is free
flow of bile into the duodenum then the T tube is
removed usually around 10 days.
Q 11. What is the technique of removal of T- tube?
It is removed by gentle traction.
Q 12. If residual stones are found, what is the
management?
• The T-tube is left in place for 6 weeks, so that a
mature tract is formed. There is a chance that the
stone may pass to the duodenum mean while.
• The stone can be laterremoved percutaneously
by an interventional radiologist (Burhenne
technique).
Q 13. What are the indications for choledochotomy?
Indications for choledochotomy
1. Radiologically demonstrated stone (In peroperative cholangiogram)
2. Sonologically demonstrated stone in the CBD
3. Palpable stone in the CBD
4. CBD diameter more than 1cm (More than 6mm
sonologically)
5. History of obstructive jaundice
6. Abnormal LFT (Raised bilirubin and alkaline
phosphatase)
7. Multiple faceted stones in the gallbladder
Q 14. What is the alternative for choledocholithotomy?
• Endoscopic sphincterotomy and stone
extraction using Dormia basket (Open
choledochotomy is used less nowadays which
is replaced by minimally invasive techniques).
27 – Percutaneous Transhepatic Cholangiogram
(PTC) for Obstructive Jaundice
Q 1. What is your observation?
It is a picture of Percutaneous transhepatic
cholangiography (PTC) showing;
1. Dilatation of intrahepatic biliary radicle
2. Obstruction to the passage of dye beyond the
Common Hepatic Duct (CHD).
The findings are suggestive of obstructive
jaundice probably cholangiocarcinoma at the
junction.
Q 2. What are the indications for PTC?
1. It is usually done in cases of obstructive jaundice
when the level of obstruction is at the level of
confluence and CHDregion. It will delineate the
proximal limit of the lesion and the nature of
the lesion.
2. For external biliary drainage in obstructive
jaundice with cholangitis as a preoperative
measure.
3. For insertion of indwelling stents to bypass the
obstruction in inoperable cases of obstructive
jaundice.
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4. The drainage catheter can be left in place for
a number of days and then the tract can be
dilated so that a flexible choledochoscope can
be introduced for the diagnosis of stricture of
biliary duct. A biopsy also can be taken with
choledochoscope.
Q 3. What are the precautions to be taken before
PTC?
1. Check the coagulation profile and correct the
prothrombin time before doing this invasive
procedure by administering vitamin K1 10 mg
IV daily for 3 days
2. Give prophylactic antibiotics
3. The injection needle is introduced under
fluoroscopic control or ultrasound or CT
guidance
4. If surgery is contemplated, it is preferable to do
it in the morning of the day of surgery.
Q 4. What is the procedure?
1. After giving local anesthesia the Chiba or Okuda
needle is introduced into the liver through the
8th intercostal space in mid- axillary line.
2. Needle is placed in a dilated biliary radicle under
sonological guidance or fluoroscopy.
3. The bile is under tension and it is aspirated and
sent for culture and cytology.
4. Water-soluble contrast medium is then injected
into the biliary system and multiple images
are taken to visualize the area and nature of
obstruction.
5. A catheter is introduced into the biliary system
if external biliary drainage is required.
Q 5. What are the complications of PTC?
1. The bile is under tension and it will leak into the
peritoneal cavity producing biliary peritonitis
2. Bleeding
3. Infection
4. Septicemia.
28 - Ultrasound Abdomen – Intussusception,
B-mode and Real Time Ultrasonography
Q 1. What is your observation in the ultrasound
picture of the abdomen?
The ultrasound showing the typical doughnut
appearance of concentric rings is suggestive of
intussusception.
Q 2. What is ultrasonography?
• Ultrasound is energy in the form of mechanical
vibrations, the frequency of which is in excess
of that to which the human ear is sensitive, i.e.
greater than 20,000 Hz.
Percutaneous transhepatic cholangiogram
(PTC)— for obstructive jaundice
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• Ultrasound makes use of high frequency sound
waves generated by a transducer containing the
piezoelectric material.
• The sound waves are reflected by tissue
interfaces (as the sound energy passes through
various tissues of the body, it interacts by
reflection, refraction, defraction, scattering
and absorption.
• The echoes vary depending on the tissue type.
• The frequencies in the range of 3 to 20 MHz are
used (1 MHz being equal to 1000,000 Hz).
• For abdomen 3 to 7 MHz transducer is used
• Low frequency waves have greater penetrating
powers than high frequency waves, but produce
less definition. (For superficial structures higher
frequency transducers are used).
• Quartz
• Lithium sulphate
• Synthetic ceramic lead zurconate tinanate (PTZ):
most commonly used
Q 5. What is B- mode ultrasound?
This is the primary display mode introduced in 1972.
It is called B-mode or brightness mode display
which gives two dimensional cross- sectional
representation of the tissues under examination on
horizontal and vertical axes while encoding echo
amplitude information in gray levels of 1 and 14.
Q 6. What is real time ultrasonography?
This is the universally accepted method which
produces about 40 B - scan images per second. This
is above the flicker rate of the eye (16-18 images/
second) and the examiner perceives a continuum
of motion like the systolic dilatation and diastolic
diminution of the diameter of the aorta.
Q 7. What are the uses of ultrasonography?
Use of ultrasound in surgery
1. It can differentiate solid and cystic lesions
2. Vascular system can be assessed (by Doppler study)
3. Guided biopsies are possible
4. Can differentiate benign and malignant lesions
5. First - line investigation of choice of the liver: For
hepatic tumors, metastasis, abscess formation,
cystic diseases, etc.
6. First-line investigation of choice of the biliary
system: Intrahepatic biliary radicle dilatation,
assessment of the CBD size, identification of the
stones, assessment of the wall thickness of gall
bladder, etc.
7. First-line investigation of choice of the renal tract.
8. Fluid collection in the peritoneal cavity, pleural
cavity and pericardial cavity can be identified
9. Can identify lesions in other solid organs like
spleen
USG—abdomen
Q 3. What is piezoelectric effect?
It is the process of conversion of electrical to
mechanical energy.
Q 4. What are the examples of piezoelectric
materials?
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10. Pancreatic diseases: Difficult to visualize distal
body and tail. Head and proximal body can be
visualized by making use of the acoustic window
of the liver
11. Lesions of thyroid can be assessed
12. Breast lesions can be ascertained in young patients
< 35 years
13. Testicular lesions.
14. Imaging method of choice in obstetrics and
gynecology
15. Endocavitary ultrasound is possible.
Q 8. What are the advantages of ultrasound?
1. It is noninvasive
2. No radiation hazard
3. Inexpensive
4. Interaction with patient is possible.
Q 9. What are the disadvantages of ultrasound?
• It is operator dependent
• Little information is gained in tissues beyond
bone and air-filled structures like viscera
• Pulmonary and skeletal system cannot be
assessed.
Read the management of intussusception skiagram
No:25
29 - Ultrasound Abdomen, Gallstone
Q 1. What is your observation?
Ultrasound examination of the gallbladder area
showing a gallstone casting an acoustic shadow
at the neck of the gallbladder (posterior acoustic
shadows are suggestive of stones).
Q 2. What further sonological assessment of the
biliary system is required when stone is identified?
1. Gall-bladder thickness (If thick it is suggestive of
previous inflammation).
2. Pericholecystic collection.
3. Size of cystic duct – if wide possibility of stone
slipping to the CBD is there.
4. Intra hepatic biliary radicle dilatation suggestive
of obstruction to the flow of bile
5. Size of the CBD (Upper limit 6mm sonologically.
More than 6mm suggestive of obstruction of the
bile duct).
6. Look for stones in the CBD.
Read Skiagram No:8 for gallstones and cholecystitis
30 – CT Brain, Extradural and Subdural
Hematoma
Q 1. What is your observation?
Axial Computerized Tomography (CT scan) of the
brain showing right sided hyperdense lesion
suggestive of subdural hematoma (Concave
USG—abdomen
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appearance in contrast to the biconvex appearance
of the extradural hematoma) with mass effect with
midline shift to the opposite side.
Q 2. What is CT scan?
• I t was introduced by Godfrey Newbold
Hounsfield in 1963 (British Engineer - Awarded
Nobel prize in 1979).
Q 3. What is Hounsfield unit?
The attenuation value of tissues obtained in the
gray - scale image is related to that of water,
which is given a CT number of zero Hounsfield
Unit (HUs). The Hounsfield units of various tissues
are given below:
Hounsfield units of various tissues
• + 1000 HUs – Bone
• Zero HUs – Water
• Minus 100 HUs – Fat
• Minus 1000 HUs – Air
Other tissues come in between bone and air.
Q 4. What is the difference between conventional
CT and Helical/Spiral CT and multislice CT?
• In conventional CT the individual scans are
acquired during suspended respiration.
• In spiral CT because of the continuous rotation
of the X-ray tube with the beam tracing a spiral
path around the patient, during a single breath
hold for 30seconds, 3cm or more of tissues can
be covered.
• Rapid acquisition of image istherefore possible
in spiral CT.
• Imaging arterial and venous phase is possible in
spiral CT.
• Three dimensional analysis is possible in spiral
CT.
Q 5. What are the advantages of CT scan?
Advantages of CT scan
• Highest resolution than plain radiograph
• 1 to 2mm sections are possible
• Radiation exposure is less
Ct— Brain
• It consists of a gantry containing the X-ray tube
where the patient is placed, filters and detectors
which revolve around the patient, acquiring the
information at different angles and projections
which is mathematically reconstructed to
produce a 2 dimensional gray scale image by a
computer.
• It can pass through air and bone.
• The entire body can be studied in a series of
cross sections and therefore called tomogram
• Resolution is very high and can be increased by
using contrast medium.
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• Images ofthe chest, abdomen and pelvisis possible
under 20seconds in new generation machines
(Multislice CT Scanner)
• High resolution CT (HRCT) is used to for lung
diseases
• The natural contrast ofthe tissues can be enhanced
with the use intravenous contrast medium
• Scanning during arterial phase and venous phase is
possible which may aid in characterization of lesions
• CT guided biopsies are possible
• Improved spatial resolution has resulted in
the development of CT angiography, virtual
colonoscopy and virtual bronchoscopy
• Three dimensional images can be reconstructed
Q 6. What are the disadvantages of CT scan?
• High dose of ionizing radiation
• Increased cost
• Availability of the equipment
• Radiologicalexpertiserequiredforinterpretation.
Q 7. What is the reason for concave appearance
in the given CT?
In subdural hematoma the blood spreads across the
surface of the brain. Since there is less resistance
to blood moving through the subdural space than
through the extradural space, it takes the concave
shape (In extradural hematoma a lentiform or lensshaped or biconvex hyperdense lesion is seen).
Q 8. What are the types of hemorrhages in relation
to the brain?
1. Extradural (outside dura, associated with fracture
skull and more common in the young).
2. Subdural – acute subdural and chronic
subdural.
3. Subarachnoid hemorrhage.
4. Intracerebral hemorrhage.
5. Intraventricular hemorrhage.
Q 9. Which type of hematoma is more common
— extradural or subdural?
Subdural is more common (5:1).
Q 10. What are the differences between extradural
and acute subdural hematoma?
Differences between extradural and acute subdural hematoma
Acute subdural Extradural
Cause Need not be associated with fracture Always associated with skull fracture
of the skull
Cause Injury to the cerebral veins Arterial injury (major dural venous sinus
possible)
Age group Any age Younger age
Location Space between dura and arachnoid. Space between bone and dura Usually
Depends on the area of bleeding temporal region.
Mass effect and Less common and late since it is More common and early since it is
midline shift venous arterial
Conscious level Impaired conscious level from the Conscious level normal initially
time of injury
Lucid interval Not present Present
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Brain damage Extensive damage (laceration) may No primary damage or minimal
be seen
March of paralysis May occur on both sides Typical paralysis on the opposite side
CT appearance Hyperdense diffuse and concave Lentiform or biconvex hyperdense
appearance lesion with or without mass effect or
midline shift
Treatment Evacuation via craniotomy. Immediate surgical evacuation via
Small hematomas may be managed craniotomy
conservatively
Mortality rate 40% 2 to 18%
Q 14. What is lucid interval?
It is the period following head injury when the
patient complains of headache, is fully alert and
oriented with no focal deficits. This is followed after
minutes or hours by rapid deterioration in conscious
level, contralateral hemiparesis and the classical
Hutchinson’s pupil.
31- CT Scan Abdomen, HCC, Metastasis,
Focal Nodular Hyperplasia, Hepatic Adenoma,
Hemangioma
Q 1. What is your observation?
CT scan section of abdomen showing a wellencapsulated lesion in the right lobe of liver with
lack of enhancement in the central part of the lesion.
Q 2. What are the possible differential diagnoses?
Differential diagnoses are:
1. Focal nodular hyperplasia
2. Hepatic adenoma
3. Metastasis
4. Hepatocellular carcinoma.
Q 11. Which artery is involved in extradural?
Tearing of meningeal artery: The largest meningeal
artery is the middle meningeal artery which is
involved in trauma to the temporal region (Pterion
is the thinnest part of the skull overlying the
meningeal artery).
Q 12. What is the nature of paralysis on the
contralateral side in extradural hemorrhage?
The paralysis is seen in descending manner starting
from face, arms, body, legs, etc.
Q 13. What is Hutchinson’s pupil?
This is a clinical finding in extradural hemorrhage.
1. Initially the pupil on the side of injury contracts
due to irritation of the oculomotor nerve and the
contralateral pupil remains normal
2. The pupil on the injured side becomes dilated
due to paralysis of the oculomotor nerve while
the contralateral pupil contracts as a result of
irritation by mass effect and shift of midline
3. Finally the pupils of both sides become dilated
and fixed which is a grave sign.
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553
Q 3. What are the characteristics of focal nodular
hyperplasia (FNH)?
The contrast CT in FNH may show central scarring
and well-vascularized lesion. A sulphur colloid liver
scan can differentiate from other lesions. The FNH
contain both hepatocytes and Kupffer cells. The
Kupffer cells take up the sulphur colloid, whereas
Kupffer cells are absent in adenomas, primary and
metastatic tumors.
Q 4. What are the features of hepatic adenoma?
• They are well-circumscribed vascular solid
tumors.
• Angiography will show well-developed
peripheral arterialization
• They have got malignant potential
• They are associated with sex hormones and oral
contraceptives
• Withdrawal of hormones is associated with
regression of the lesion
• Resection is recommended.
Q 5. What are the features of hepatocellular
carcinoma (HCC)?
• ContrastenhancinglesionintheCT(Early arterial
phase enhancement is suggestive of HCC
whereas delayed contrast enhancement or slow
contrast enhancement is seen in hemangioma).
• Lipiodol uptake is seen in HCC after
administering poppy seed oil (Lipiodol) into the
hepatic artery at selective mesenteric angiogram
and doing CT scan of the liver after 2 weeks.
Q 6. What are the features of metastatic lesion?
Lack of enhancement of the mass lesion in the liver
after IV contrast is suggestive of metastasis.
Note: In summary early arterial enhancement
and Lipiodol uptake are suggestive of HCC,
non enhancement of the lesion is suggestive of
metastasis, sulphur colloid uptake is suggestive
of focal nodular hyperplasia and slow and late
enhancement is suggestive of hemangioma of liver.
Read section on Liver malignancy - Long case no:8
32 – Mammogram, Carcinoma Breast and
Benign Lesions
Q 1. What is your observation?
1. Oblique view of mammogram showing irregular
calcified lesion in the breast
2. Four axillary lymph nodes of different sizes.
Q 2. What is mammography?
It is nothing but plain X-ray of the breast using low
voltage and high amperage X-rays.
Q 3. What are the views recommended for
mammography?
1. Craniocaudal view: This will be marked in the
film as CC for craniocaudal
2. Oblique view.
CT-scan— Abdomen
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Q 4. What is the radiation dose of mammography?
Less than 0.1cGY is standard (each chest X-ray
delivers 1/4th of this radiation volume).
Q 5. Can you image the breast by mammography
in all age groups?
Mammography is rarely of value in women aged
under 35years because breasts are relatively
radiodense and low sensitivity for the procedure
in this age group. Therefore ultrasound is used for
imaging in this age group.
Q 6. What are the indications for mammography?
Indications for mammography
1. For screening women above 50 years
2. Screening asymptomatic women above 35 years
who have a high risk of cancer
3. Women with previously diagnosed atypical ductal
hyperplasia.
4. To differentiate benign from malignant lesions
5. To identify multicentricity when carcinoma is
diagnosed.
6. For assessment of the size of the lesion before
chemotherapy so that the response of the lesion
can be assessed.
7. For assessment of the axilla for nodal enlargement.
8. For assessment of the contralateral breast.
9. Surveillance of the breast following conservative
surgery.
10. Evaluation of the breast following augmentation
mammoplasty: To diagnose disease in the breast
surrounding the prosthesis and complications
related to prosthesis.
11. Investigation of suspicious breast lump in males.
Q 7. What are the guidelines for evaluation of
mammography?
The following criteria should be looked for:
1. Mass lesion: Margin and density
2. Architectural distortion
3. Asymmetric density
4. Calcification.
Mammogram—carcinoma breast and bengin
lesions
Malignant Benign
Margin of mass Spiculated mass lesion with ill - Well circumscribed mass lesion
lesion defined margin (commonest finding of
invasive carcinoma)
Density High density increases the probability Relatively low density
of malignancy
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Architectural Stellate lesion: Numerous straight lines No architectural distortion
distortion radiating towards the central area
Asymmetric With associated microcalcification, Can occur in normal involution of
density spiculation and architectural distortion glandular tissue, hormone replacement
therapy and trauma
Calcification Clustered microcalcification with Scattered and rounded calcification
variable shape and size: Granular, with relatively uniform size and density
branching, rod-shaped, bizarre micro- • Popcorn calcification –
calcifications are suspicious (tight fibroadenoma
clusters >1 cm2 area is highly suggestive) • Teacup calcification – fibrocystic disease
• Needle-like calcification – duct ectasia
Q 8. What are the secondary signs of malignancy?
• Skin changes – thickening, retraction and
dimpling
• Nipple retraction, flattening of the nipple
• Focally dilated duct
• Increased vascularity
• Axillary lymphadenopathy.
Q 9. What are the disadvantages of mammography?
1. It is painful.
2. It is expensive.
3. Requires high technology machinery.
4. Requires special film and processing.
5. Requires highly trained radiologists.
Q 10. What is the reason for recommending
screening the breast between the age group of
50 to 70 years by mammography?
• Current availabledata indicate thatthereduction
in mortality is maximal between the age of 50 to
70years (25 to 30% reduction in mortality).
• In age group of 40 to 49years the reduction in
mortality is only 7 to 8%.
• Howeve r screening mammography i s
recommended starting from 35 years who have
a high risk of developing breast cancers.
Q 11. What is the frequency of screening
mammography?
• The optimum frequency for screening is
probably 2 years
• Annual screening is certainly too frequent.
Q 12. What are the mammographic views
recommended?
• Two views at the first screen (craniocaudal and
oblique)
• Only one view subsequently (oblique).
Q 13. What is the false-negative rate of
mammography?
6 to 8%.
Q 14. Can you miss the presence of carcinoma in
mammogram?
• Yes. About 5% of breast cancers are missed in
mammographic screening programmes
• A normal mammogram does not exclude the
presence of carcinoma.
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Q 15. What is BI-RADS?
Breast Imaging Reporting And Data System
is a quality assurance tool devised for the
standardization of mammographic reporting.
BI-RADS classification of mammographic
abnormalities
Category Assessment
1. Negative
2. Benign finding
3. Probably benign finding
4. Suspicious abnormality
5. Highly suggestive of malignancy
Q 16. What is digital mammography?
Here the images are obtained in computer which
are then magnified so that computer aided
diagnosis is possible.
Q 17. What are the currently recommended
methods of screening?
1. Clinical breast examination (CBE).
2. Mammographic screening.
3. Breast self-examination (BSE).
Note:A combination of CBE and mammography
is better.
Q 18. Which is the imaging of choice for recurrence
in breast?
MRI.
Q 19. What are the advantages of MRI?
1. It can differentiate scar from recurrence
2. It is the imaging of choice in breasts with
implants
3. Abnormal enhancement is seen af ter
radiotherapy and therefore it is not used within
9 months of radiotherapy.
Trauma
18: Triage – ICRC Guidelines
• French“Triager”to sort
• Principle of“Best for Most”
• Categorization into three groups
• Marked in the forehead in Roman numerals
I - Urgent surgery
II – No surgery – (minor + very severe with little chance of survival)
III – Nonurgent surgery
19: Prevention of Trauma
• Primary Prevention – Antidrink driving, speed limit
• Secondary – Active – Helmet, Seat belts – Passive – ABS, air bags
• Tertiary – Minimize the effects of injury by improving health care delivery
20: Three Most Important X-Rays in Multisystem Trauma
• Lateral cervical spine
• Upright chest
• Pelvis
21: Trimodal Distribution of Death by Donald Trunkey
• Immediate death – 50% (within first few minutes)
• Early death (GOLDEN HOUR and preventable death) – 30% (within first few hours)
• Late death – 20% (days or weeks after)
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22: Dangerous Injuries
• Fall from height of 20 ft or more
• Crash greater than 20 miles/hr
• 20 inch impingement on the passenger compartment
• Ejection of the patient
• Roll over
• Death of another person
23: Advanced Trauma Life Support (ATLS) System
(American College of Surgeons Committee on Trauma)
A Advanced
T Trauma
L Life
S Support
James Styner (1970) – Orthopedic Surgeon
24: Four Stage Approach ( ATLS )
• Primary survey
• Resuscitation
• Secondary survey
• Definitive care
• It is a continuous process
25: Primary Survey (60 Sec Exam)
• A — AIRWAY
• B — BREATHING
• C — CIRCULATION
• D — DISABILITY
• E — EXPOSE, ENTRY
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26: A– Airway Control
1. Basic airway techniques
— Modified jaw thrust maneuver
— Oral/nasopharyngeal airway
2. Advanced Airway Techniques
— Oral or nasal intubation
— Surgical/needle (13G) cricothyroidotomy
27: Indications for Ventilation in Chest Injury
• Tachypnea above 40
• PaO2below 60mm of Hg or less
• PaCO2 above 45mm of Hg
• Progressive fall in PaO2
• Extensive pulmonary contusion or diffuse infiltrative change on X-ray
• Severe flail chest — >8 Unilateral fractures of rib
• More than 4 bilateral — rib fractures
28: Life-threatening Chest Injuries
• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Massive hemothorax — >1500 ml blood
• Flail chest
• Cardiac tamponade
29: C – Circulation
• Radial pulse is palpable with BP of 80mm of Hg
• Femoral pulse is palpable with BP of 70mm of Hg
• Carotid pulse is palpable with BP of 60 mm of Hg
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30: The Tennis Score Classification of Hemorrhage
Hemorrhage % blood loss Vol. of blood Pulse rate BP Pulse Respiratory
loss (mL) pressure rate
Class 1 Upto 15 Upto 750 < 100 Normal Normal or 14-20
increased
Class 2 15-30 750-1500 > 100 Normal Decreased 20-30
Class 3 30-40 1500-2200 > 120 Decreased Decreased 30-40
Class 4 > 40 > 2000 > 140 Decreased Decreased > 35
31: Five Places where Patient can Lose Large Volume Blood
(Blood on the floor and four more)
• Externally
• The chest
• The abdomen
• The retroperitoneum
• Into muscle compartment
32: D—Disability (Glasgow Coma Scale)
Response Details Score
Eye opening Spontaneous 4
Speech 3
Pain 2
None 1
Verbal response Orientated 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Best motor response Obeys commands 6
Localizes pain 5
Withdrawal from pain 4
Flexion to pain 3
Extension to pain 2
None 1
Trauma
571
34: Poiseuille’s Law
• Flow is proportional to the fourth power of the radius of the cannula and inversely related to it’s length
• 14G two peripheral IV lines are better than the central cannula
• 14G 2 ¼“ length – flow of 200cc/min
• 16G 8”length – central cannula;flow rate – 150cc/min
33: Resuscitation Phase
• Secure large bore IV access
• Shock therapy
• Continuous EKG monitoring
• Blood samples – CBC, electrolytes, glucose, coagulation studies, ABG, cross matching
• NG tube (Nasogastric)
• Foley’s catheter
35: Contraindications for Nasogastric Tube and Foley’s Catheter
Contraindications for NG Tube in Trauma
• Fracture of the cribriform plate
Contraindications for Foley’s
• Rupture urethra—Blood at the meatus
If urethral trauma is suspected—Urethrogram
36: Avoid Hypothermia in Trauma
• All IV fluids stored at 39°C
• PRC reconstituted by warm saline
• Fluid warmer
• Warm blankets
• Warm irrigating fluids
Hypothermia Produces
• Cardiac irritability
• Coagulopathy
• Enzyme impairment
Clinical Surgery Pearls
572
37: Bloody Vicious Cycle in Trauma
• Metabolic acidosis
• Profound hypothermia
• Coagulopathy
38: Autotransfusion—Not Recommended
• Consumptive coagulopathy
• Platelet dysfunction
• These risks may outweigh the benefits of autotransfusion
39: Secondary Survey
• Head to toe examination
• Look, listen and feel
• High yield X-rays
– Cervical lateral
– Upright chest
– Pelvis
• Rule out intra-abdominal bleeding in all cases of multisystem trauma
40: Secondary Survey AMPLE History
• A — Allergy
• M — Medication
• P — Past medical history
• L — Last meal
• E — Events of the incident
41: Rule Out Intra-abdominal Bleeding in Every Patient
• CT scan/USG
• Physical examination
• Serial hematocrit
• FAST – Focused assessment with sonography for trauma
• DPL (diagnostic peritoneal lavage)
Trauma
573
42: Tertiary Survey
• 15% incidence of clinically significant injuries diagnosed after initial resuscitation
• Tertiary survey – Physical examination
• Review of results
• Early detection of all clinically significant injuries
43: Damage Control in Surgery (Three Phase Surgical Approach)
Phase 1 - Control hemorrhage, contain contamination
Phase 2 - ICU – Restore normal physiology
Phase 3 - Definitive surgery
44: Monson’s Zones for Penetrating Neck Injuries
• Zone 1 – Structures at the thoracic outlet (below a horizontal line inferior to the cricoid cartilage)
• Zone 2 – Between zone 1 and the angle of the mandible (between the angle of the mandible and above the
horizontal line inferior to the cricoid cartilage)
• Zone 3 – From the angle of the mandible to the base of the skull (between the angle of the mandible and the
base of the skull)
45: Classification of Retroperitoneal Hematoma
Zone 1 Central medial – extends from All penetrating injuries and all Zone 1 hematomas
the diaphragmatic hiatus to the are explored
sacral promontory
Zone 2 Flank retroperitoneal hematoma • All penetrating injuries explored
• Blunt injury with hematomas contained in Gerota’s fascia
and not expanding are managed conservatively
• Blunt injury with expanding hematomas are explored
Zone 3 Pelvic retroperitoneal hematoma • Not explored
• Therapeutic embolization is the treatment of choice
Note: Zone 1 – Are liberally explored
Zone 2 and 3 – With clinical evidence of vascular and visceral injuries–exploration
Without clinical evidence of vascular and visceral injuries – four vessel angiogram, esophagogram and
esophagoscopy are done and depending on the finding operative exploration is done.
Burns
46: Classification of Burns
Degree of burns Involvement of skin Characters Resolution
First degree Epidermis alone Erythema Resolves in 48 – 72 hrs
Heals uneventfully
No scarring
Second degree Epidermis plus some
(partial thickness) part of dermis
two types: super- • Superficial second
ficial and deep degree: injury to the
epidermis and
superficial dermis
• Deep second degree:
deep dermal involvement
Third degree Full thickness involving • White, waxy appearance No potential for reepithelia-
(full thickness) the subcutaneous fat • Lack of sensation lization
• Leathery texture Need skin grafting
• Lack of capillary refill
Fourth degree Underlying muscles,
tendons, bone and brain
are involved
• Blister for superficial, • Superficial heal with minimal
weepy and painful scarring in 10 – 14 days
• Reddish for deep, • Deep takes 25-35 days for
decreased sensation healing, produces hyper-
trophic scar and skin grafting
may be required
Burns
575
47: Rule of Nine of Wallace
Each upper limb – 9% of TBSA (Total Body Surface Area)
Each lower limb – 18% of TBSA (9% for anterior half and 9% for posterior half)
Head and neck – 9% of TBSA
Front and back of trunk – 18% each
Genitalia – 1%
48: Parkland Formula for Resuscitation of Burns
4ml/kg per percentage TBSA burn (TBSA × weight in Kg × 4 = volume in ml)
49: Types of Burns
1. Flame burns – Damage from super heated oxidized air (mixed deep dermal and full thickness)
2. Scald – Damage from hot liquids (superficial, with deep dermal patches – may be deep in young infant)
3. Fat burns – Damage from hot oil (Deep dermal)
4. Chemical – Contact with alkali and acids and other chemicals (weak concentration of chemical produces
superficial dermal and strong concentration produces deep dermal)
5. Electric burns – Conduction of electrical current through tissues (Full thickness burns)
6. Contact burns – Contact withhot solid material
Note: The patients whole hand (digit and palm) represents 1% of TBSA
In children the area of head and neck is amended to 18% and the lower limb to 12%
Note:
• This calculates the fluid to be replaced in the first 24 hours
• Half of this volume is given in the first eight hours and the second half is given in the subsequent 16 hours
• The fluid is given as Ringer’s lactate
• IV resuscitation is required for children with a burn greater than 10% of TBSA
• IV resuscitation is required for adults with a burn greater than 15% of TBSA
• If oral fluids are used, salt must be added
Clinical Surgery Pearls
576
50: Complications of Burns
1. Immediate complications
a. Infection
- Clostridium tetani
- Streptococcal infection
- Pseudomonas
b. Duodenal and gastric ulceration
- Curling’s ulcer
- Erosions in stomach and duodenum
c. Renal failure
d. Liver necrosis
e. Pulmonary complications
– pulmonary edema and atelectasis
f. Burn encephalopathy in children (Cerebral edema)
2. Intermediate complications
a. Pseudomonas septicemia
b. Pneumonia
c. Decubitus ulcers
d. Constricting eschar
e. Embolic lung phenomena
3. Late complications
a. Contractures
b. Hypertrophic scar
c. Pruritus
51: Differences between Hypertrophic Scar and Keloid
Hypertrophic scar Keloid
Relationship with Rises above the skin level Rises above the skin level, extends beyond the
the original wound but stays within the confines border of the original wound
of the original wound
Regression Regress over time Rarely regress spontaneously
Familial Not familial May be familial, autosomal dominant
Race Not race related More in black than the white (15 times)
Sex Men and women equally Women > men
affected
Contd...
Burns
577
Age group Children 10 – 30 years
Site Areas of tension and flexor Sternum, shoulder, face, skin of ear lobe, deltoid
surfaces which tend to be at and upper back regions
right angles to joints/skin
creases
Cause Related to tension Unknown: can result from surgery, burns, skin
inflammation, acne, chicken pox, zoster, folliculitis,
lacerations, abrasions, tattoos, vaccinations,
injections, ear piercing, etc. or spontaneously
Histology Collagen bundles are flatter, Collagen bundles are virtually nonexistent and
more random and in a wavy fibers arranged haphazardly and are larger and
pattern thicker
Immune system Higher T lymphocyte and Antinuclear antibody (ANA) against fibroblast,
Langerhans cell content epithelial cells and endothelial cells present
Hypertrophic scar Keloid
Contd...
Note: Clinically keloid is itching, spreading, tender and vascular.
Neck
52: WHO Grading (1994) of Goiter
Grade 0 : No palpable / visible goiter
Grade 1 : A thyroid that is palpable but not visible
when the neck is in normal position
Grade 2 : An enlarged thyroid that is visible with the
neck in normal position
53: Surgical Causes for Horner’s Syndrome
1. Extracapsular invasion of cervical node
2. Extralaryngeal involvement of laryngeal cancer
3. Cervical sympathetic involvement in lung cancer
4. Cervical sympathetic involvement in carcinoma
thyroid
54: Half-life of Radio Isotopes Used in Thyroid
Isotopes Half life Route of
administration
Rays Comment
I
123 13 hrs Oral g rays Will not detect nodules < 1 cm size
I
131 8 days Oral g and b rays Too much irradiation for diagnostic scanning
I
132 2.3 hrs Oral “”
TC99 6 hrs IV “”
Breast
55: Reporting of Fine Needle Aspiration Cytology (FNAC) Results
Grade Result
AC0 No epithelial cells present
AC1 Scanty benign cells
AC2 Benign cells
AC3 Atypical cells present—may need a biopsy if clinically or radiologically suspicious
AC4 Highly suspicious of malignancy
AC5 Definitely malignant
56: Reporting of Core Biopsy Results
Grade Result
B1 Normal breast tissue
B2 Benign lesion
B3 Hyperplastic lesion present
B4 Severe atypia or carcinoma or carcinoma in situ requiring excision
B5 Malignant lesion
Clinical Surgery Pearls
580
57A: Bloom Richardson Grading of Carcinoma Breast
1. Tumor tubule formation
• > 75% of tumor cells arranged in tubules
• > 10% and < 75%
• < 10%
- score 1
- score 2
- score 3
2. Number of mitoses
• < 10% mitoses in 10HPF (high power field)
• > 10% mitoses and < 20 mitoses
• > 20 mitoses per HPF
- score 1
- score 2
- score 3
3. Nuclear pleomorphism
• Cells nuclei are uniform in size and shape,
relatively small, without prominent nucleoli
• Cell nuclei are somewhat pleomorphic,
have nucleoli and are intermediate in size
• Cell nuclei are relatively large, have
prominent nucleoli / multiple nucleoli, coarse
chromatin pattern and vary in size and shape
- score 1
- score 2
- score 3
57B: Bloom Richardson Combined Scores: (BR Grade)
BR grade 3, 4, 5 - Well-differentiated (low grade)
BR grade 6. 7 - Moderately differentiated (intermediate grade)
BR grade 8, 9 - Poorly differentiated (high grade)
58: Nottingham Prognostic Index (NPI)
Nottingham Prognostic Index (NPI)
NPI = (0.2 x size in cm) + grade + stage
Good < 3.4, Moderate 3.4 – 5.4, Poor > 5.4
Breast
581
59: WHO Definition of Objective Response to Anterior Chemotherapy
Complete clinical response Disappearance of palpable disease
Partial response Decrease of > 50% in total size of tumor
No change Decrease of < 50% or increase of < 25% in total size of tumor at 6 months
Progressive disease Increase of > 25% in total size of palpable lesion
60: Van Nuys Prognostic Index for DCIS (Ductal Carcinoma in Situ)
The factors responsible for local recurrence after wide local excision in DCIS are:
• Disease extent
• Excision margin
• Histological type
By scoring three major predictors for recurrence, a prognostic index has been developed.
Van Nuys prognostic index for DCIS (Ductal carcinoma in situ)
Score
Disease extent
• 15 mm 1
• 15 – 40 mm 2
• > 40 mm 3
Margin
• < 10 mm 1
• 1 – 9 mm 2
• 1 mm 3
Histological type
• Nonhigh grade 1
• High grade, no necrosis 2
• High grade + necrosis 3
• It is suggested that patients with score of 3, 4 and 5 be treated by wide local excision
• 6 and 7 by wide local excision and radiotherapy
• 8 and 9 by mastectomy.
Clinical Surgery Pearls
582
61: Indications for Radiotherapy after Mastectomy in Carcinoma Breast
1. Large tumors (> 4 cm)
2. High grade tumors (Bloom Richardson grade 3)
3. Node positive tumors (4 or more nodes positive) and extranodal disease
4. Node negative tumors with widespread vascular/lymphatic invasion
62: Complications after Mastectomy
1. Seroma
2. Infection
3. Flap necrosis
4. Injury to neurovascular structures
5. Pneumothorax
6. Lymphedema
7. Frozen shoulder
8. Lymphangiosarcoma (late)
63: Causes for Nipple Retraction
1. Congenital
2. Acquired (Slit-like appearance)
• Carcinoma
• Duct ectasia
• Periductal mastitis
• Tuberculosis
Abdomen
64: Causes for Dysphagia
Lesions in the wall of the esophagus
1. Stricture
A. Posttraumatic
B. Corrosives
2. Benign tumors
3. Malignant neoplasms (carcinoma)
4. Acute and chronic esophagitis
5. Crohn’s disease
6. Esophageal diverticulum – congenital, pulsion, traction or pseudodiverticula
7. Scleroderma
8. Abnormalities of esophageal contraction
A. Achalasia
B. Diffuse esophageal spasm
C. Cricopharyngeal spasm
9. Medical conditions
A. Bulbar paralysis
B. Cerebrovascular accidents
C. Tetanus
D. Myasthenia gravis
10. Postvagotomy
11. Globus hystericus (Dysphagia occurring in moments of tension)
Lesions outside the wall of the esophagus
• Thyroid swellings
• Retrosternal goiter
• Pharyngeal pouch
Contd...
Clinical Surgery Pearls
584
• Aortic aneurysm
• Abnormal aortic arch
• Mediastinal tumors and lymph nodes
• Paraesophageal hiatus hernia
• Dysphagia Lusoria (Vascular ring): Anomalous aortic arch leaving a vascular ring containing the trachea and
esophagus
• Tight repair of hiatus hernia
Lesions in the lumen of the esophagus
• Foreign bodies: Fish bones, coins, pins, and dentures
• Webs
• Schatzki’srings – CircumferentialWeb-likeObstruction at the lower esophagusin association with hiatus hernia
• Sideropenic dysphagia (Plummer - Vinson syndrome): The web is situated in the postcricoid region (Tongue
devoid of papillae, koilonychia and angular stomatitis or cheilosis)
65: Endoscopic Grading of Esophageal Varices
Grade 1 – visible, nontortuous
Grade 2 – tortuous, nonprotruding
Grade 3 – protruding (normal mucosa in between the columns)
Grade 4 – like grade 3, no normal mucosa in between
66: Difference Between Duodenal and Gastric Ulcer
Duodenal ulcer Gastric ulcer
Age group 25 – 50 Late middle age and elderly (55 – 65)
Sex Male preponderance Sex incidence equal
Socioeconomic status Higher socioeconomic group Lower socioeconomic group
Location Duodenopyloric junction Anywhere along the lesser curvature. Near
incisura angularis
Location of pain Epigastrium Epigastrium
Hunger pain Present, and relief with food Absent, food aggravates pain and afraid to eat
Contd...
Contd...
Abdomen
585
Duodenal ulcer Gastric ulcer
Weight gain/loss Likely to be overweight Weight loss
Nausea, vomiting Not usually a feature unless More commonly seen
obstructed
Periodicity Remitting disease characterized Periodicity not observed
by: Periodicity of activity and
quiescence
Malignant change Never May turn malignant (0.5%)
Helicobacter pylori 90% of duodenal ulcer cases 75% infected
infection
Parietal cell mass Increased Not increased
67: Classification of Gastric Ulcers
Type I Ulcer in the antrum (antral ulcers)
Type II Combined gastric and duodenal ulcer
Type III Prepyloric ulcer (In the pyloric canal)
68: Causes of Gastric Outlet Obstruction
• Peptic ulcer disease in distal stomach/duodenum with scarring
• Gastric carcinoma in antrum
• Congenital hypertrophic pyloric stenosis
• Annular pancreas
• Bezoar (furball, vegetable matter)
• Lymphoma
• Gastritis
• Crohn’s disease (stomach or duodenum)
• TB
• Impacted foreign bodies
• Metastases
Contd...
Clinical Surgery Pearls
586
69: Forrest’s Classification for Activity of Bleed in Upper GI Endoscopy
Grade Ia: Spurting vessel at base of lesion
Grade Ib: Ooze of blood from lesion
Grade 2a: Nonbleeding visible vessel at base of lesion
Grade 2b: Stigmata of Recent Hemorrhage (SRH): adherent clot, black spot
Grade 3: Lesion seen but no evidence of recent bleed
70A: Child - Turcote - Pugh Classification of Functional Status in Liver Disease
Parameter Numerical score
1 2 3
Class - A Class - B Class - C
Risk – Low Risk – Moderate Risk – High
Ascites Absent Slight to Moderate Tense
Encephalopathy None Grade I – II Grade III – IV
Serum Albumin (g/dL) > 3.5 2.8 to 3.5 < 2.8
Serum Bilirubin mg/dL < 2 2.0 – 3.0 > 3.0
Prothrombin time (Seconds above control) < 4.0 4.0 – 6.0 > 6.0
70B:
Total score Child – Turcote – Risk
Pugh classification
5 – 6 A Low risk
7 – 9 B Moderate risk
10 – 15 C High risk
71: UICC Staging of Gallbladder Cancer
Stage I Confined to the mucosa/submucosa
Stage II Involvement of the muscle layer
Stage III Serosal involvement
Stage IV Spread to the cystic node
Stage V (advanced carcinoma) Invasion of the liver and adjacent organs
Abdomen
587
72: Bismuth Classification of Bile Duct Strictures
Type I Low common hepatic duct stricture – hepatic duct stump > 2 cm
Type II Mid common hepatic duct stricture – hepatic duct stump < 2 cm
Type III Hilar stricture with no residual common hepatic duct – hilar confluence intact
Type IV Destruction of hilar confluence – right and left hepatic ducts separated
Type V Involvement of the aberrant right sectoral duct alone or along with the common hepatic duct
73: Bismuth Classification of Perihilar cholangiocarcinoma
Type I Confined to the common hepatic duct
Type II Involves bifurcation without involvement of secondary intrahepatic ducts
Type IIIa and b Extend into either the right or left secondary intrahepatic ducts respectively
Type IV Involve the secondary intrahepatic ducts on both sides
74: Todani Classification of Choledochal Cyst
Type I (50%) Fusiform or cystic dilatation of the extrahepatic biliary tract
Type II Saccular diverticulum of extrahepatic bile duct
Type III Bile duct dilatation within the duodenal wall (choledochocele)
Type IV (35%) Cystic dilatation of both intrahepatic and extrahepatic biliary tract
Type V Intrahepatic cysts (Caroli’s disease)
75a: Ranson’s Prognostic Signs for Gallstone Pancreatitis
Admission Initial 48 hours
Age > 70 years Hct fall > 10
WBC > 18,000/mm3 BUN elevation > 2 mg/100 ml
Glucose > 220 mg/100 ml Ca2+ < 8 mg/100 mL
LDH > 40 IU/l Base deficit > 5 mEq/L
AST > 250 U/100 ml Fluid sequestration > 4L
Clinical Surgery Pearls
588
75b: Ranson’s Prognostic Signs for Nongallstone Pancreatitis
Admission Initial 48 hours
Age > 55 years Hct fall > 10
WBC > 16,000/mm3 BUN elevation > 5mg/100ml
Glucose > 200 mg/100 ml Ca2+ < 8mg/100ml
LDH > 350 IU/l Pao2 < 55 mm Hg
AST > 250 U/100 ml Base deficit > 4 mEq/l
Fluid sequestration > 6l
Note:
• Patients with fewer than 3 of the prognostic criteria can be expected to have a mild attack
• 3 or more criteria suggest bad prognosis
• 5 or 6 signs require ICU care
76: Glasgow Scoring System (Prognostic Score) for Acute Pancreatitis
On admission Within 48 hours
Age > 55 years Serum albumin < 3.2 gm
WBC > 15,000/mm3 Ca2+ < 8 mg/100 ml
Glucose > 200 mg/100 ml LDH > 600 IU/l
Serum urea > 5 mg% (no response to IV fluids) AST/ALT > 600 U/100 ml
Arterial oxygen saturation < 60 Mm Hg
77: Anatomical Difference Between Jejunum and Ileum
Sl. No: Jejunum Ileum
1. Large circumference Smaller circumference
2. 1 – 2 vascular arcades in the mesentery 4-5 vascular arcades
3. Long vasa recta from the arcade Shorter vasa recta
4. Thick wall Thin wall
Abdomen
589
78: Positions of Appendix
Retrocecal (65%) 12 O’ clock position
Splenic 2 O’ clock position
Promontoric 3 O’ clock position
Pelvic (30%) 4 O’ clock position
Mid inguinal 6 O’ clock position
Paracolic 11 O’ clock position
79: Alvarado Score (Mantrels)
Score
Symptoms
• Migratory RIF pain 1
• Anorexia 1
• Nausea and vomiting 1
Signs
• Tenderness (RIF) 2
• Rebound tenderness 1
• Elevated temperature 1
Laboratory
• Leukocytosis 2
• Shift to left (increase in the number of immature neutrophils) 1
or banded forms
Total score 10
Note: A score of 7 or more is strongly predictive of acute appendicitis.
80: Classification of Acute Diverticulitis (Hinchey)
Stage 1 Pericolic abscess or phlegmon
Stage 2 Pelvic or intra-abdominal abscess
Stage 3 Nonfeculent peritonitis
Stage 4 Feculent peritonitis
Clinical Surgery Pearls
590
81: Grading of Severity of Ulcerative Colitis
1. Mild Rectal bleeding or diarrhea with four or fewer motions without systemic signs
2. Moderate > 4 motions per day. No systemic signs of illness
3. Severe > 4 motions per day with 1 or more signs of systemic illness
82: Signs of Systemic Illness of Ulcerative Colitis
• Fever over 37.5oC
• Tachycardia > 90/min
• Hypoalbuminemia < 3 gm/liter
• Weight loss > 3 kg
83: Comparison of Ulcerative Colitis and Crohn’s Disease
Symptoms, signs, Ulcerative colitis Crohn’s disease
radiology, pathology,
natural history and
treatment
Diarrhea Marked Less severe
Gross bleeding Characteristic Infrequent
Perianal lesions Infrequent and mild Frequent and complex
Toxic dilatation Present in 3 – 10% Present in 2 – 5%
Perforation Free Localized
Systemic manifestations Common Common
Radiology Confluent, diffuse Skip areas
Loss of haustration and lead pipe Cobble-stone appearance
appearance
Coarse mucosa Longitudinal ulcers and
transverseridges
Concentric involvement Eccentric involvement
Internal fistula rare Internal fistula common
Contd...
Abdomen
591
Symptoms, signs, Ulcerative colitis Crohn’s disease
radiology, pathology,
natural history and
treatment
Only colonic involvement, except back Any portion of the intestine
wash ileitis involved
Gross morphology Confluent involvement Segmental, with skip areas
Rectum usually involved Rectum often not involved
Mesocolon not involved Thickened mesocolon
No thickening of bowel wall Thickened bowel wall due to
transmural inflammation
No mesenteric fat advancement Mesenteric fat advancement
towards antimesentericborder
Widespread superficial ulcers Longitudinal ulcers and
transverse fissures
Inflammatory polyps common Not prominent
(pseudo polyps)
Microscopic Inflammation limited to mucosa and Chronic inflammation of all layers
submucosa (crypt abscess) of bowel wall
Muscle coat involved in severe cases Muscle coat damaged usually
only
Granulomas rare Granulomas frequent
Natural history Exacerbations and remissions, may Indolent and recurrent
be explosive and lethal
Response to medical Good response in 85% Difficult to evaluate, less welltreatment controlled
Type of surgical treatment Proctocolectomy with ileoanal Segmental colectomy, total
anastomosis colectomy + ileorectal
anastomosis
Recurrence common
Contd...
Clinical Surgery Pearls
592
84: Differences between Ulcerative and Hyperplastic Type of Intestinal Tuberculosis
Sl.No. Features Ulcerative Hyperplastic
1. Primary/Secondary Secondary to pulmonary Primary (ingestion of milk)
tuberculosis
2. Virulence of the organism Virulence outstrips the resistance Resistanceofthepatientishigh
of the patient and virulence of the organism
is low
3. Associated pulmonary Primary in the chest demons- No primary in the chest
tuberculosis trated (PT)
4. Clinical presentation Patient is very ill Not very ill
5. “” Diarrhea/bleeding Mass right iliac fossa
6. Gross pathology Multiple transverse ulcers in Thickeningoftheintestinalwall,
the ileum narrowing of the lumen
7. Pathology Caseation present Absence of gross caseation
85: Risk Stratification of Gastrointestinal Stromal Tumor (GIST) NIH Consensus
Risk Size No. of mitoses/50 HPF
Very low < 2 cm < 5
Low 2 – 5 cm 5 – 10
Intermediate 5 – 10 cm 10
High risk > 10 cm -
86: Radiographic or Endoscopic Features Suggesting Malignancy in GIST
1. Invasion to surrounding structures
2. Evidence of dissemination
3. Size > 5 cm
4. Lobulated border
5. Heterogeneous enhancement
6. Mesenteric fat infiltration
7. Ulceration
8. Presence of regional adenopathy
9. Exophytic growth pattern
10.Hemorrhage
11. Necrosis
12.Cyst formation
Abdomen
593
87: Bad Prognostic Factors in GIST
• Male gender
• Incomplete resection
• Nongastric tumor
• High tumor cellularity
• High Ki-67 count
88: Staging of Desmoid Tumors of Abdomen with its Management (SCNA June 2008)
Stage I Asymptomatic not growing • Simple observation
• Nontoxic Therapy (NSAIDs)
• Resection if found incidentally during
surgery
Stage II Symptomatic, < 10 cm in maximum diameter • Resection
Not growing • Tamoxifen + NSAIDS if unresectable
Stage III Symptomatic, 10-20 cm in maximum diameter • Active treatment
Asymptomatic and slowly growing • NSAIDs
• Tamoxifen/relaxifen
• Vinblastine/Methotrexate
• Adriamycin/dacarbazine
Stage IV Symptomatic, > 20cm • Urgent therapy – major surgery
or +·
Rapid growing • Antisarcoma chemotherapy
or +·
Complicated • Radiation
SCNA – Surgical Clinics of North America.
Vascular
89: ABI (Ankle Brachial Index) and symptoms of vascular disease
ABI Symptoms
> 0.9 None
0.5 to 0.8 Claudication
0.3 to 0.5 Rest pain
< 0.3 Gangrene
90: Differences between Acute Thrombosis and Embolism
Feature Embolism Thrombosis
• Source • Cardiac source (60-70%) • Atherosclerotic stenosis (no distant
• Noncardiac source (15-20%): e.g. source)
aneurysms, poststenotic dilatation • Hypercoagulable states
• Iatrogenic (angiography and cathete-
rization)
• Trauma
• History of None Usually present
claudication
• Onset Sudden Usually gradual, unless traumatic
• Contralateral Normal May be absent
pulse
• Loss of function Rapid Gradual (because of the presence of
collaterals)
Vascular
595
91: Wagner’s classification of Diabetic foot
Grade 0 High risk and no ulceration
Grade I Superficial ulcer
Grade II Deep ulcer (Cellulitis)
Grade III Osteomyelitis with ulceration and abscess
Grade IV Gangrenous patches/partial foot gangrene (fore foot)
Grade V Gangrene of the entire foot
92: Staging of Pressure sores (American National Pressure Ulcer Advisory Panel)
Stage 1 Nonblanchable erythema without a breach in the epidermis
• Color - red/blue/purple
• Consistency - firm/boggy
Stage 2 Partial thickness skin loss involving the epidermis and dermis
Stage 3 Full thickness skin loss extending into the subcutaneous tissue but not through the underlying
fascia
Stage 4 Fullthicknessskin lossthrough fascia with extensive tissue destruction, may be involving muscle,
bone, tendon or joint
93: Shamblin Classification of carotid body tumor
Group I: The tumor can be easily removed from the carotids
Group II: Subadventitial dissection of the vessel is required
Group III: Arterial excision and grafting are required
Clinical Surgery Pearls
596
94: Deep Vein Thrombosis (DVT) Abnormalities of thrombosis and fibrinolysis responsible for DVT
Congenital
• Antithrombin III deficiency
• Protein C deficiency
• Protein S deficiency
• Resistance to activated Protein C (due to factor V Leiden)
• Increased factor VIII
• Factor VII deficiency
• Factor XII deficiency
• Disorders of the fibrinolytic system
• Mutation in prothrombin
Acquired
• Antiphospholipid syndrome
• Lupus anticoagulant
• Hyperhomocysteinemia
• Secondary causes of hypercoagulability
• Hyperviscosity syndrome
• Nephrotic syndrome
• Malignancy
• Diabetes
• Sepsis
• Stroke
• Pregnancy
95: Virchow’s Triad for development of venous thrombosis
• Endothelial damage
• Stasis of blood flow
• Hypercoagulability (Thrombophilia)
Vascular
597
96: Risk assessment protocol from the THRIFT (Thromboembolic Risk Factors) Consensus Group
Risk Level Group Suggested Prophylaxis
Low Minor surgery Leg elevation and early mobilization
Major surgery < 40 years
Minor trauma
Minor medical illness
Moderate Major surgery > 40 years As low risk +
Major trauma or burns Antiembolism hosiery or
Major medical illness Subcutaneous heparin
Minor surgery and risks Mechanical calf compression
Inflammatory bowel disease
High Hip, pelvis, knee fracture Both antiembolism hosiery and
Major cancer surgery subcutaneous heparin
Surgery and thrombophilia Mechanical calf compression
Surgery and previous thrombosis
Acute lower limb paralysis
Illness and thrombophilia
Illness and previous thrombosis
97: Risk factors for venous thromboembolism
Patient factor Disease or surgical procedure
Age > 60 years Trauma or surgery, especially of pelvis, hip, lower limb
Obesity Malignancy, especially pelvis, abdominal metastatic
Immobilization Recent myocardial infarction
Varicose veins Heart failure
Pregnancy Paralysis of lower limb (s)
Puerperium Inflammatory bowel disease
High dose oestrogen therapy Nephrotic syndrome
Previous deep vein thrombosis or Polycythemia
pulmonary embolism
Thrombophilia [see previous chart] Paraproteinemia
Behçet’s disease
Infection
Clinical Surgery Pearls
598
98: Diagnosis, management and complications of DVT
1. Diagnosis of DVT
a. D-dimer assay
b. Compression ultrasonography (Duplex ultrasonography of the deep veins)
c. Ascending venography (rarely required)
2. Treatment of established DVT – Low Molecular Weight Heparin (LMWH) for 5 days and Warfarin for
6 months.
3. Complications – Pulmonary embolism
– Triad of tender calves, pleural pain and hemoptysis
– Sudden collapse followed by death in 20%
– Other symptoms are central chest pain, tachypnea, cough, cyanosis
– CT scanning of the pulmonary arteries show filling defect
Limbs
99: Causes of unilateral lower limb edema
1. Cellulitis
2. Lower limb edema from lymphatic causes
• Primary Lymphedema a) lymphedema congenita – onset < 2 years (more common in males
Sporadic and Familial (Milroy’s Disease)
b) lymphedema praecox – 2 to 35 years, more common in females
(sporadic or familial). The familial is called Meige’s disease.
c) lymphedema tarda – after 35 years (associated with obesity – the
nodes are replaced with fibrofatty tissue)
• Secondary Lymphedema - Lymphatic filariasis
- Other infections – Tuberculosis, lympho-granuloma inguinale
- Tumors of the pelvic floor (prostate cancer)
- Surgical dissection of lymph nodes (block dissection)
- Orthopedic surgery
Radiation therapy for malignant tumors
- Advanced intrapelvic and intraabdominal tumors
- Recurrent soft tissue infections
- Podoconiosis (cutaneous absorption of mineral particles)
3. Lower limb edema due to venous causes
• Chronic venous insufficiency
• Postthrombotic syndrome
• Deep vein thrombosis
• Phlegmasia alba dolens (white leg or milk leg)
• Phlegmasia cerulea dolens
• Varicose vein stripping
• Vein harvesting
Contd...
Clinical Surgery Pearls
600
4. Arterial causes: Arteriovenous malformation
Aneurysm
Ischemia - reperfusion (following lower limb revascularization)
5. Edema secondary to congenital vascular anomalies
- Lymphatic angiodysplasia syndrome
- Klippel – Trenaunay’s syndrome
- Hyperstomy syndrome
6. Posttraumatic: Sympathetic dystrophy
7. Obesity: Lipodystrophy. Lipoidosis
8. Gigantism
9. Retroperitoneal fibrosis: Causes arterial, venous and lymphatic abnormalities
10. Hansen’s disease
11. Dermal leishmaniasis
12. Mycetoma
13. Allergic disorders – Angioedema
100a: Grading of Lymphoedema (Brunner)
Subclinical Excess interstitial fluid is present with histological abnormalities in lymphatics and lymph nodes.
No clinically apparent lymphedema
Grade I Edema pits on pressure-Swelling largely/completely disappears on elevation/bed rest
Grade II Nonpitting edema. Does not significantly reduce upon elevation
Grade III Nonpitting edema associated with irreversible skin changes, i.e. fibrosis, papillae, etc.
100b: Another grading of lymphoedema
Mild < 20% excess limb volume
Moderate 20 – 40 % excess limb volume
Severe > 40% excess limb volume
Contd...
Limbs
601
101: Lymphangiographic patterns of lymphedema
• Congenital hyperplasia (Congenital) • Lymphatics are increased in number, although
– Males more affected functionally defective
Unilateral/bilateral • Increased number of the lymph nodes are seen
Involving the whole leg • May have chylous ascites, chylothorax and protein-losing
Progressive enteropathy
• Distal obliteration • Absent or reduced distal superficial lymphatics
(Puberty) – Females more affected • Also termed aplasia or hypoplasia
Often bilateral
Ankle and calf
• Proximal obliteration with distal • There is obstruction at the level of aortoiliac or inguinal
hyperplasia nodes
Any age, equal sex incidence, • The patient may benefit from lymphatic bypass
whole leg affected, usually unilateral operation because of the hyperplasia
• Proximal obliteration without distal • Cannot do lymphatic bypass operation
hyperplasia
102: Zones of hand (Verdan’s)
Zone I Distal to the insertion of flexor digitorum superficialis
Zone II From distal palmar crease to flexor digitorum superficialis insertion
Zone III Distal to transverse carpal ligament to distal palmar crease
Zone IV Area of transverse carpal ligament
Zone V Proximal to transverse carpal ligament
103: Seddon’s classification (1942) - Types of nerve injury
Neurapraxia : Axons are intact. Spontaneous recovery is complete
Axonotmesis : Axons divided. Connective tissue intact. Wallerian degeneration occurs. Axons then
regenerate slowly
Neurotmesis : Whole nerve severed. Recovery may occur if cut ends are apposed
Clinical Surgery Pearls
602
104: Sunderland’s Classification
Sunderland grade Axon Endoneurial Perineurium Epineurium Comparison
tube With Seddon’s
First degree + + + + Neurapraxia
Second degree – + + + Axonotmesis
Third degree – – + +
Fourth degree – – – + Neurotmesis
Fifth degree – – – – Neurotmesis
+ Intact, – severed.
105: Complications of amputations
Skin complications
1. Delayed healing
2. Wound infection (Staphylococcal)
3. Ulceration
4. Sinus formation
Bone complications
1. Spur formation
2. Osteomyelitis with sequestrum formation and sinus
3. Bone end may perforate in growing child
4. Cross union between two bones
Muscle complications
1. Contracture and deformity
2. Fixed flexion and abduction deformity in above knee amputation
3. Fixed flexion deformity in below knee amputation
Nerve complication
1. Painful neuroma
Idiopathic complications
1. Phantom limb
2. Painful phantom
3. Causalgia
Limbs
603
106: Site of election for above knee and below knee amputation
Above knee – 10 – 12 inches (25-30 cm) below the greater trochanter
Below knee – 5½ inch (14 cm) below the tibial plateau
Anorectal
107: Degree of Hemorrhoids
• First degree • Bleed
• Second degree • Bleed and prolapse (Reduce spontaneously)
• Third degree • Bleed and prolapse (Require manual reduction)
• Fourth degree • Prolapsed, cannot be reduced
• Permanently outside anus
• May strangulate
108: Park’s classification of Anal fistula
Intersphincteric fistula (45%) • Do not cross the external sphincter except the most distal
subcutaneous fibers
• Run directly from the internal to the external opening
Transsphincteric fistula (40%) • Primary track crosses both internal and externalsphincters,the
latter at variouslevels and crossthe ischiorectal fossa to reach
the skin of the buttock
• May have secondary tracks,rarely passing through the levators
to the pelvis
Suprasphincteric (Very rare) Thought to be iatrogenic and difficult to distinguish from high
transsphincteric
Extrasphincteric Usually as a result of pelvic diseases or trauma
Anorectal
605
109: Sites of Pilonidal Sinus
1. Natal cleft (commonest)
2. Axilla
3. Umbilicus
4. Between fingers
5. Genitalia
6. Amputation stump
110: Causes for constipation
A. GI causes
1. Dietary – lack of fiber and or fluid intake
2. Structural causes
– Colonic carcinoma
– Hirschsprung’s disease
– Diverticular disease
3. Obstructed defecation (Painful conditions)
– Anal fissures
– Hemorrhoids
– Crohn’s disease
4. Motility disorders
– Irritable bowel syndrome
– Slow transit constipation
– Drugs – Analgesics, opiates, antidepressants, iron, anticholinergic, antacids, etc.
– Pseudoobstruction
5. Immobility – Elderly
6. Social – Irregular work pattern, hospitalization, travel (long flights)
7. Psychological – Institutionalized individuals/depression
8. Postoperative – Child birth, Pelvic floor repair
Contd...
Clinical Surgery Pearls
606
B. Nongastrointestinal disorders
1. Neurological
- Paraplegia (Autonomic dysfunction)
- Cerebrovascular accidents
- Parkinsonism
- Multiple sclerosis
2. Metabolic/endocrine
- Hypothyroidism
- Diabetes mellitus
- Pregnancy
- Hypercalcemia
3. Chagas’s disease
– Trypanosomiasis with megacolon
Contd...
INDEX
A
Abdomen 505, 583
Abdominal tuberculosis
types of 131
Alvarado score 150
Ancillary procedures 216
Anomalies in branchial cyst 352
Anorectal 604
Antituberculous regime 133
Apathetic hyperthyroidism 30
Appendicitis, indications for 148
Appendicular abscess
complications of 149
Appendicular mass 146
Apple core deformity of ascending
colon 540
Arteriovenous fistula 430
Ascites
complications of 276
signs of 263
Ascites and ovarian cyst
differences 264
ASO and Buerger’s disease
differences 190
Athyreosis 347
B
Bad prognostic factors in gist 593
Balanoposthitis, causes for 416
Barium enema 540-42
Barium meal 534, 538
Barium swallow 531
Basal cell carcinoma 402
Basal cell carcinoma
important types of 403
Bayley’s symptom complex of
thyroid storm 42
Beck’s triad 518
Bendavid classification of
hernia 458
Benign tumors
classical sites of 243
Bilateral hydronephrosis
causes for 227
Biopsy, precautions for 357
Bird beak 507
Bird of pray 507
Bismuth classification of perihilar
cholangiocarcinoma 587
Bloom richardson combined
scores 580
Bloom richardson grading of
carcinoma breast 580
B-mode and real time
ultrasonography 547
Boyd’s grading of
claudication 192
Branchial cyst 349
clinical features of 350
Breast 579
Breast cancer
advanced 95
concepts in 76
early 74
Breast conservation
contraindication for 85
Breast cyst 185
management of 497
Burns 574
Bypass operations depending on
the level of occlusion 203
C
Callous ulcer
characteristics of 380
Cannon ball lesion 510
Carbimazole
side effects of 31
Carcinoembryonic antigen 143
Carcinoma
benign lesions 553
breast 80
bad prognostic factors
for 90
important steps of wide
excision for 85
cecum 539
descendingcolon 542
Carcinoma of esophagus 531
608
Clinical Surgery Pearls
Carcinoma of stomach 534
epithelioma 407
gingivobuccal 319
tongue
clinical features of 308, 315
differential diagnoses of 309
penis 414
treatment options for 419
stomach
role of laparoscopy 110
Causes for
constipation 605
dysphagia 583
nipple retraction 582
unilateral lower limb edema
599
Cecum 134
Cell cycle 563
Central abdominal cystic swelling
differential diagnoses of 278
Cervical metastatic lymph node 296
Cervical rib 523
Chemotherapy
indications for 323
Child-pugh classification of
functional status of
liver 125, 268
Cholangiocarcinoma
risk factors for 166
Cholangitis 165
Choledochal cyst 159
types of 158
Chronic calcific
mastitis 494
pancreatitis 512
Chronology of descent of
testis 250
Chylolymphatic cyst and
enterogenous cysts
differences 280
Clark’s levels for depth of
invasion 395
Classification of
acute diverticulitis 589
burns 574
dermoids 565
gastric ulcers 585
Coffee bean sign 507
Cold nodule
differential diagnoses of 48
Colorectal cancer
in various sites 137
predisposing causes for 137
Completion thyroidectomy
indications for 61
Complications of
amputations 602
burns 576
gallstones 515
xylocaine 564
Congenital arteriovenous
fistula 422
Congenital hydroceles
four types of 446
Courvoisier’s law 158
Cryptorchidism 251
Cyst
benign cyst 51
biliary 159
bone 135
branchial 286, 287, 345, 350,
351
Choledochal 155, 158, 159,
166, 233
Chylolymphatic 280
Classic 159
Complex 47
Congenital 159, 232
dermoid 341, 342, 342
duct 347
epidermal 135
extrahepatic 159
false 210
hydatid 210, 278, 120
intrahepatic 158
mesenteric 278, 279, 280, 281
mucous 341
nonparasitic 210
omental 280, 281
ovarian 129, 147, 151, 225,
263, 264, 278, 279, 345,
169, 171
papillary 329, 247
parathyroid 51
polycystic 226, 229, 230, 232,
233
pseudocyst 14, 165, 234, 235,
236, 237, 238, 239, 240,
279
pseudomesenteric 281
retroperitoneal 279
salivary gland c330
sebaceous 134, 286, 287
serosanguinous 279
Index
609
Stafne bone 339
thyroglossal 22, 286, 287, 342,
345, 346, 347, 348
thyroid 49
traumatic 345
true 210
white cyst 342
Cystic hygroma
sites for 353
Cystic lesions of the
retroperitoneum 247
Cystic swellings in the breast
causes for 495
Cystic swellings on the side of the
neck 352
Cystosarcoma 185
Cysts, complications of 345
D
Death in carcinoma tongue,
causes for 318
Dermoid cyst 373
diagnostic features of 377
interparietal hernia
(interstitial), spigelian
hernia 483
classical sites of 483
Desmoid tumors of abdomen 593
Diagnostic algorithm for a neck
swelling 285
Diagnostic algorithm for a
swelling anywhere 369
Diseases
abdominal 259
acute alcoholic liver 268
aggressive 485
alcoholic liver 124, 157, 268,
275
aortoiliac 192
arterial 169, 179, 184, 190, 196
atherosclerotic 205
autoimmune 43, 220, 326
Bazin’s 384
benign 143, 498
blood 210, 381
bone 161
Bowen’s 408, 409
breast 78, 494, 495, 498
Buerger’s 184, 190, 192, 198,
199, 201, 204
bulky 214, 218, 219, 259
cardiac 268, 432
Caroli’s 155, 159, 166
celiac 220
chronic liver 428
chronic occlusive 201
chronic respiratory 276
circulatory 210
collagen 324
collagen vascular 85, 89
congenital cystic 159
Crigler-Najjar and Gilbert’s
155
Crohn’s 129
Dercum’s 371
diabetic vascular 197
diffuse 205
distinct 210
endocrine 434
extrahepatic 126
familial 64
fibrocystic 494, 498
gallbladder 474
gastroesophageal 475
Gaucher’s 210
Gilbert’s 155
granulomatous 489
Graves’ 25, 26, 27, 33
Hansen’s 378, 382, 383, 432, 434
Hashimoto’s 220
heart 268
hepatocellular 162
Hirschsprung’s 65
Hodgkin’s 78, 211, 212, 214,
215, 217, 218, 219, 221
inflammatory bowel 25, 137
infradiaphragmatic 214
intra-abdominal malignant 169
intrahepatic biliary cystic 159
ischemic heart 276
jaundice and infiltrative liver
157
life-threatening 59
lipid storage 210
liver 262, 267, 270, 277, 489
malignant 436, 471
Marion’s 17
Meige’s 434
metastatic 400
microscopic 115
Milroy’s 434
minimal 205
moderately advanced 331
610
Clinical Surgery Pearls
nervous 378
nodal/extra nodal 214
non-Hodgkin’s 211
oligometastatic 105
Paget’s 378, 380, 408
pelvic inflammatory 129
peripheral vascular 202
Plummer’s 26
polycystic 233
Pott’s 151
proliferative breast 78
pulmonary 471
queyrat 416
Raynaud’s 380
renal 233
renal 486, 488
residual 105
rheumatoid 184
Schimmelbusch’s 498
serocystic 496
serosal 118
severe cardiopulmonary 162
sexually transmitted 417
sickle cell 153
spectrum of 59
splenic 270
stigmata of liver 262
Still’s 210
systemic 324, 358
Takayasu’s 201
tuberculous 467
valvular 205
valvular heart 261
varicose vein 187
vascular 188
veno-occlusive 268
venous and arterial 169
venous 432
von Hippel-Lindau 230
von Recklinghausen’s 365,
366, 367, 368
Weil’s 210
Wilson’s 268
Distant metastases 82
Dose of radioiodine (131I) in
differentiated carcinoma
thyroid 64
Double contrast barium enema
539
Duodenal deformity 538
E
Ectopic testis
common positions of 250
Ectopic thyroid subhyoid bursa
and carcinoma arising in
thyroglossal cyst 343
Epidermoid cyst 373
Epigastric hernia 474, 476
Epigastric lump 106
Excision biopsy
indications for 79
Excision of the breast cyst
indications for 498
Extradural and subdural
hematoma 549
Eye signs 26
F
Fast track surgery 145
Fatty hernia of the linea alba 474
Fearon-Vogelstein adenomacarcinoma multistep model of
carcinogenesis 138
Femoral hernia 450
Fever in jaundice, causes for 162
Fibroadenoma 185
Fibroadenoma of the breast,
clinical points in favor
of 494
Fibroadenoma
indications for 497
types of 495
Fibroadenosis 185
Fibrocystic disease mastalgia 185
Filariasis
surgical complications of 439
Fine needle aspiration cytology of
thyroid, classification of 47
Fistula, cystic hygroma 349
Five modes of spread of
carcinoma stomach 113
Flail chest 516
Focal nodular hyperplasia 552
Fontaine classification of limb
ischemia 192
Fracture of ribs 516
Functional neck dissection
indications for 62
G
Gallbladder (enlarged)
physical findings 153
Gallstone 514, 549
Gangrene, causes for 199
Index
611
Gastric outlet obstruction
causes for 108
Gastric ulcer 584
Glasgow seven point
checklist 392
Glasgow coma scale 570
Glasgow scoring system 588
Glossitis, causes for 314
Goiter 512
Grading of trismus 321
Gynecomastia
causes for 488
indications for surgery 491
principles of management
of 491
H
Hamburg classification of
congenital vascular
defects 426
Hansen’s disease
stigmata of 382
Hard thyroid nodule
causes for 49
Healing ulcer, characteristics of 380
Hemangioma 552
complications of 426
sites for 425
treatment of 430
Hemangioma and vascular
malformations,
differences 425
Hematocele, causes for 447
Hematuria, causes for 228
Hemobilia, causes for 159
Hemolytic jaundice
investigations for 157
Hemopneumothorax 520
Hepatic adenoma 122, 552
Hepatic causes 268
Hepatocellular carcinoma,
macroscopic types of 124
Hernia
complications of 458
etiology of 455
frequency of types of 457
postoperative hernia 469
Hidden areas for primary 287
Hodgkin’s lymphoma 214
Hollow viscera perforation 509
Hydrocele of
tunica vaginalis sac 441
Hydroceles presenting as
inguinoscrotal swellings
features of 445
Hydronephrosis 528
Hypoparathyroidism, clinical
manifestations of 39
I
Ileocecal tuberculosis 541
Incisional hernia repair
complications of 469, 472,
473
Incisional hernia, causes for 470
Inflammatory carcinoma
features of 86
Inguinal block dissection
complications of 420
Inguinal hernia 450
clinical differences between
direct and indirect 453
differential diagnoses of 454
Inoperability in carcinoma
stomach, signs of 108
Intestinal obstruction 504
Intravenous urogram 525
Intussusception 547
Ischemic ulcer 192
Ischemic ulcers, causes for 192
J
Jaundice (various types of)
clinical features of 154
Jejunal loops with valvulae
conniventes 503
K
Karnofsky performance status 12
Kasabach-Merritt syndrome 426
Kidney (enlarged)
physical signs of 225
Klippel-Trenaunay syndrome 431
L
Lack of haustration 507
Laparoscopic hernia repair
indications for 462
Laparoscopic signs of
inoperability 110
Left flank overlap sign 507
Leg ulcers, causes for 184
612
Clinical Surgery Pearls
Lesions prone for Marjolin’s 410
Leukoplakia
pathological changes in 312
Limbs 599
Lingual thyroid 343
differential diagnoses of 347
symptoms of 347
Lipoma (universal tumor) 370
Liposarcoma
symptoms and signs of 242
Liver disease, stigmata of 122
Liver enlargement without
jaundice, causes for 120
Liver overlap sign 507
Liver transplantation
contraindication for 276
Local anesthesia, advantages of 459
Lump without jaundice 119
Lumpectomy, essential steps of 89
Lumpy breast of andi
treatment of 499
Lymph node
examination 207
metastases 52, 288
Lymphangioma
classical sites of 428
Lymphatic drainage of the
tongue 315
Lymphedema, sites of 437
Lymphoma 207
M
Maffucci syndrome 431
Male breast cancer
risk factors for 492
Malignancies involving the
retropharyngeal nodes 300
Malignancy in a goiter signs of 25
Malignancy in leukoplakia
clinical features of 313
incidence of 313
Malignancy in submandibular
salivary gland
signs of 338
Malignant melanoma 388, 389
differential diagnoses for 389
types of 391
Malignant tumors of thyroid
incidence of 57
Mammographic findings in
metastatic cancer of the
breast 93
Mandatory procedure 216
Marginal mandibulectomy,
contraindication for 322
Marjolin’s ulcer
characteristics of 410
Mass right iliac fossa
important causes for 129
Massive enlargement of the breast
causes for 495
Mastopathy 494
Medullary thyroid carcinoma 65
Melanoma of the eye 398
Mesenteric cyst 278
complication of 280
Metabolic and endocrine
abnormalities in
hepatocellular
carcinoma 121
Metastases in breast cancer
sites of 104
Metastasis, histological type of 299
Metastatic cervical lymph nodes
checklist for evaluation of 297
Midline swellings of the neck 287
Modes of spread of malignant
melanoma 389
Monson’s zones for penetrating
neck injuries 573
Mucosal melanoma, sites of 398
Multinodular goiter 68
Multiple endocrine neoplasia 65
Mumps (caused by
paramyxovirus) 326
N
Neck 578
Neck dissection complications of
296, 307
Neurofibroma 364
diagnostic features of 366
Neurological complications of
von Recklinghausen’s
disease 368
Neurotrophic ulcer, causes for 383
Nipple discharge, causes for 91
Nodes involved in carcinoma
nasopharynx 300
Nodular goiter
complications of 71
Non-thyroid neck swelling 285
Non visualization of kidney 525
Nyhus classification of hernia 459
Index
613
O
Obstructive jaundice 152
checklist for examination of a
case of 153
Omphalocele
structures seen in 480
Oral cancer
etiological factors for 311
indications for surgery 322
investigations for 310
macroscopic types of 310
Oral cavity 320
Oral melanoma
characteristic features
of 398
Oral submucous fibrosis
features of 313
Ovarian cyst 147
P
Paget’s disease
eczema of the nipple 91
Painful lump in the breast
causes for 495
Painless lump in the breast
causes for 494
Palliative procedures for
carcinoma stomach 116
Panendoscopy 298
Papillary carcinoma thyroid
with 52
Paraganglioma, features of 243
Paralytic ileus 505
Park’s classification of anal fistula
604
Parotid swelling 324
Peculiarities of direct inguinal
hernia 453
Percutaneous transhepatic
cholangiogram 546
Peripheral occlusive 188
Peripheral occlusive vascular
disease 190
Pleomorphic adenoma
features of 330
Pneumatic tyre 507
Pneumoperitoneum 508
Pneumothorax 517
Poiseuille’s law 571
Polycystic disease of kidney
manifestations of 233
Polyp, classification of 15
Portal hypertension 261
common causes for 268
Post-thyroidectomy stridor
causes for 41
Preauricular node
drainage area for 327
Precancerous lesions of the
skin 408
Prediction for bleeding
endoscopic signs of 265
Pregnancy and carcinoma
breast 91
Prehepatic causes 268
Prehepatic
hepatic and posthepatic
jaundice causes for 155
Prevention of trauma 567
Primary malignancy of lung 510
Propranolol
contraindication for 32
Pseudocyst examination
checklist for history in the
case of 235
Pseudocyst of pancreas 235
indications for
intervention 237
physical features of 235
Pulmonary metastasis 510
R
Radical neck dissection 323
Radioiodine therapy
contraindication for 33
problems of 33
Radiopaque shadow in plain
X-ray abdomen, causes
for 281
Radiotherapy
in advanced gingivobuccal
complex 322
complications of 318
indications for 318, 332, 419
Ranson’s prognostic signs for
gallstone pancreatitis 587
Ranula 340
Read for details of carcinoma
stomach 536
Recklinghausen’s disease 364
Regional nodes 81
Renal and ureteric stones 525
Renal cell carcinoma 231
Renal mass other than colon
differential diagnoses of 226
614
Clinical Surgery Pearls
Renal swelling 224
checklist for examination of
suspected 225
Retroperitoneal cystic lesions 247
Retroperitoneal sarcoma
etiological factors for 244
Retroperitoneal tumor 241
clinical points in favor of 242
investigations for 245
Right hypochondrial 119
Right iliac fossa mass
checklist for 128
Rodent ulcer 402
Rule of nine of wallace 575
S
Safe triangle 520
Saint’s triad 514
Salivary glands 342
Sarcoma with lymph node
metastasis 245
SCC with bilateral metastasis 300
SCC, predisposing causes for 409
Sclerosants 272
Sclerotherapy
complications of 182
Sebaceous cyst 373
classical sites for 374
complications of 375
Severity of ulcerative colitis 590
Shamblin classification of carotid
body tumor 595
Signs of systemic illness of
ulcerative colitis 590
Simon’s classification of
gynecomastia 490
Simple pneumothorax and tension
pneumothorax
differences 18
Skiagram chest 508
Soft tissue sarcoma 355, 358
Solid swelling in the testis 251
Solid swellings on the side of the
neck 352
Solitary thyroid 45
Spleen (enlarged)
physical signs of 209
Splenomegaly 210
Spreading ulcer
characteristics of 380
Squamous cell carcinoma
types of 310, 407
Sublingual dermoid and mucous
cyst 340
Submandibular lymph node 308
Submandibular sialadenectomy,
complications of 335, 338
Sunderland’s classification 602
Surgical emphysema 519
Superficial thrombophlebitis
causes for 184
Surgery for carcinoma
stomach 118
Surgery for gynecomastia,
complications of 492
Suspected ileocecal
tuberculosis 128
Syndromes
anticus 195
Banti’s 268, 270
Beckwith-Wiedemann 480
Blowout 173
Budd-Chiari 121, 262, 268,
269, 275
cancer family 135
carcinoid 122
Cezary 221
clinical 211, 436
Costello 242, 243
Cowden 58
Crigler-Najjar 155
Cruveilhier-Baumgarten 262
Cushing’s 121
Dubin Johnson 155
dysplastic nevus 393
economy class 169
Felty’s 210, 381
Frey’s 334
Gardner’s 135, 241, 244, 357, 375
genetic skin cancer 402
Gorlin’s 402, 405
hepatorenal 277
hereditary 402
Horner’s 25, 39, 296, 285
Hungry bone 39, 40
hyperstomy 434
inherited 483
Kasabach Merritt’s 425, 426
Klinefelter ’s 490, 436, 251,
254, 488, 489, 492
Klippel-Trenaunay 176, 431
Leriche’s 192
leukemic ileocecal 151
Li-Fraumeni 241, 244, 357
lymphatic angiodysplasia 434
Lynch 135
Maffucci 431
Mallory-Weiss 265
Index
615
Meig’s 262
Mikulicz’s 326
multiple endocrine neoplasia
(men) 64, 65
myelodysplastic 368
nephrotic 228
Noonan 436
paraneoplastic 66, 223, 228,
245
Parkes-Weber 431
Paterson-Kelly 341
platelet trapping 430
Plummer-Vinson 311, 341
popliteal artery
entrapment 204
postphlebitic 171, 176
post-thrombotic 434
primary glandular sicca 327
Prune Belly 251
Raynaud’s 200
Rendu-Osler-Weber 265
Sezary 213
Sjogren’s 220, 326, 327, 327, 329
Stauffer’s 228
Stewart-Treves’ 438
superior vena cava 72, 211
thoracic outlet 195, 201
Tietze 499
Turcot’s 135
Turner 436
Wadsworth 238
Wiskott-Aldrich 220
Yellow nail 436
Syphilitic stigmata 382
T
Tamoxifen
actions of 87
side effects of 87
Tennis score classification of
hemorrhage 570
Tension pneumothorax 518
Testicular
malignancy 248
manifestations 255
panel classification of
teratoma 253
tumor 256
etiological factors for 254
Testis, blood supply of 464
Tests for varicose veins 176, 178
Thrombosis and embolism,
differences 205
Thoracic outlet syndrome 523
Thyroglossal cyst 343
differential diagnoses of 344
features of malignancy in 346
Thyroid
carcinoma 65
storm
treatment of 42
checklist for examination
of 22
final checklist for clinical
examination of 22
Thyroidectomy
complications of 39
Thyrotoxicosis
clinical types of 26
drugs available for the
treatment of 31
TNM staging 245
Toxic goiter 21
Toxicity
signs of 25
symptoms of 25
Transudate and exudate
differences 263
Trauma 567
Triad of renal cell carcinoma 226
Trismus, causes for 320
Tropical chronic pancreatitis 512
T-tube cholangiogram 545
Tube thoracostomy 520
Tuberculosis
characteristic features 129
diagnosis 130
drugs 133
types of tuberculosis 132
Tuberculous ulcer
features of 383
Tumors producing hypoglycemia
566
Tumors
benign 13, 46
cystic degeneration 7
granuloma 11
hamartoma 11
hepatoma 3
human malignant 57
Hurthle cell 11, 59
Krukenberg’s tumor 76, 80
Lethal 66
Lindsay 59
616
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malignant 46, 57
monoclonal thyroid 30
multifocal 62
papillary 62
primary 59, 81,
small intrathyroid 60
solid 12
spleen 3
trophoblastic 26, 27
universal 13
Types of burns 575
U
Ulcer 378
checklist for examination
of 378
Ulcerative and hyperplastic type
of intestinal tuberculosis
592
Ultrasound abdomen 547, 549
Umbilical hernia and
paraumbilical hernia
differences 477
Unilateral hydronephrosis
causes for 227
Unilateral lower limb edema 432
Upper GI bleeding
causes for 265
V
Varicose ulcer and venous ulcer
differences 184
Varicose veins, checklist for
examination of 169
Varicose veins
complications of 183
investigations for 179
surgery
complications of 168, 183
treatment of 180
Vascular cases, clinical tests 193
Vascular disease 188
Vasopressin
complications of 273
Venous insufficiency
symptoms of 175
Venous malformation 430
Venous ulcer
features of 185
Vessels likely to be injured in
hernia surgery 463
Virchow’s triad for development
of venous thrombosis 596
Volvulus sigmoid-plain film and
barium enema 507
von Recklinghausen’s disease,
diagnostic criteria for 367
von Tecklinghausen’s disease
bony abnormalities 368
W
Wadsworth syndrome 238
Wagner’s classification of diabetic
foot 595
Warthin’s tumor
clinical features of 329
Weil’s disease 210
WHO grading (1994) of goiter 24
WHO grading of lymphedema of
the limbs (1992) 435
Wilson’s disease 268
Wiskott-Aldrich syndrome 220
Y
Yellow nail syndrome 436
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