General Surgery1

Figure 1.1 A shows acute paronychia with visible pointing pus. Figure 1.1 B shows sloughed area after paronychia which is granulating.

Figure 1.2A shows typical abdominal wall abscess, which is well localized. An abscess is a localized collection of pus lined by granulation tissue covered by pyogenic membrane [containing pus in loculi]. All abscesses should be confirmed 4by aspiration before drainage (Figure 1.2B). Abscess should be drained under general anesthesia. After skin incision abscess cavity is entered using sinus forceps and all loculi are broken to drain the pus (Hilton's method). Wound is not closed but drain is kept in the cavity. Antibiotics should be continued.

A callous ulcer is an ulcer without any signs of healing and without any granulation tissue. It is due to callous attitude of the patient. It may be due to nutritional deficiency, ischemia, venous hypertension, diabetes or immunosuppression. It lasts for many months. Floor contains pale unhealthy granulation tissue without any tendency to heal Pseudomonas infection is commonly a hospital acquired infection.6

Green color is due to pseudocyanin. Proper antibiotics should be started after doing culture and sensitivity of discharge from the ulcer bed. Slough should be excised from the ulcer bed. Split skin graft is used to cover the raw area. An ulcer can be spreading, healing or callous. It can be specific, nonspecific or malignant. Edge of an ulcer can be sloping, punched out, undermined, raised and beaded or everted7

Figures 1.5 and 1.6 shows necrotizing fasciitis of foot, leg and thigh. It is spreading inflammation of the skin, deep fascia and soft tissues with extensive destruction due to Streptococcus pyogenes infection commonly but often due to mixed infections. Muscle is not involved. It is common in limbs, lower abdomen, groin and perineum. Type I is due to 8mixed infection and Type II is due to Streptococcus pyogenes infection which begins as a minor injury. Sudden severe pain, skin changes, necrosis and discoloration, foul smelling discharge, oliguria, jaundice and toxemia are the features. Often patient deteriorates fast and death can ensue. Antibiotics, critical care management, fresh blood transfusions, radical wound excision and later split skin grafting are required.9

Cellulitis is spreading inflammation of the subcutaneous tissues and fascial planes. It is commonly due to Streptococcus pyogenes organism but can occur due to other organisms like gram negative organisms etc. Diffuse swelling with redness, shiny, stretched warm area with pain and tenderness are the features. It can cause abscess, bacteremia, septicemia, pyemia or local gangrene. Orbital cellulitis, Ludwig's angina are special types of cellulitis. It is more common in diabetics. Elevation of the limb, glycerine dressing, and antibiotics like penicillins or cephalosporins are the treatment. During active phase of the disease skin may get necrosed leaving a raw area which when granulates well needs split skin graft to cover.10

Ischemic ulcers are common in lower limb but can occur in upper limb in finger tips. It is due to poor blood supply. It is observed in TAO, atherosclerosis, diabetic patients. Limb can become gangrenous eventually. Healing is poorly observed due to poor blood supply. There is unhealthy and pale granulation tissue on the floor with slough. Doppler study confirms the diagnosis. Patient commonly needs amputation. Level of amputation is decided by skin temperature and Doppler study. Diabetes should be controlled using insulin.11

It is the inflammation of lymphatics causing redness, with often red streaks which blanches on pressure. It is warm and tender with signs of toxemia. Tender regional lymph nodes are palpable. It is commonly due to streptococcal organisms. Erysipelas is streptococcal induced cutaneous lymphangitis with cellulitis of the area. Erysipelas can occur in ear lobule but cellulitis cannot occur because skin of ear lobule is adherent to subcutaneous tissue. Treatment of cellulitis is antibiotics, elevation of the limb. Lymphangitis is common in filariasis and in lymphedematous limb/part. Recurrent lymphangitis aggravates the lymphedema.12

It is a large bedsore over the sacrum in a bedridden patient. Size of the bedsore is extensive and slough over the floor is typical. Bedsore is also called as decubitus ulcer or pressure sores. It is a trophic ulcer with bone as its base. It is nonmobile, deep and punched out. It is common in old age, diabetic, paraplegic, bedridden patient, tetanus, head injury patients. It is common over sacrum, occiput, heel, scapula and ischium. Management is by regular change of positions, using water bed, ripple bed, proper excreta disposal, avoidance of moisture, good nutrition, good nursing care, regular excision of slough and covering the defect using rotation flaps.13

Photo shows ear infection in a HIV patient. Note the extensive involvement of the ear. Cartilage infection is common here which is difficult to manage as cartilage has got poor blood supply. Anaerobic infection is common in ear. It should be treated with antibiotics [metronidazole], proper cleaning and wash/irrigation of the ear to prevent further destruction. When there is extensive cartilage loss it can be reconstructed using flaps, prosthesis etc. Ear infection is very difficult to manage and is cosmetically challenging.14

Tuberculous ulcer over the medial malleolus. Undermined edge is obvious. As disease progresses in the deeper plane faster than in the skin, ulcer edge is undermined. Ankle joint should be examined for the possibility of having joint tuberculosis. Inguinal lymph nodes should be examined. Chest should also be examined for tuberculous focus. Investigations are chest X-ray, X-ray ankle joint, ESR, discharge study for AFB and often edge biopsy for epithelioid cells. Treatment is by anti-tuberculous drugs.15

Gas gangrene is an infective gangrene of the skin, subcutaneous tissue and muscles caused by Clostridium welchii, Clostridium oedematiens, Clostridium septicum, Clostridium histolyticum organisms which are exotoxin releasing gram positive, spore bearing organisms. Toxemia, extensive necrosis of muscles, foaming liver and liver failure, renal failure, crepitus over the skin, khaki colored skin are the typical features of gas gangrene (malignant edema). Treatment includes liberal debridement, penicillins as antibiotics, fresh blood transfusion, anti gas gangrene polyvalent serum, supportive measures and often amputation as life saving procedure.16

Ingrowing toe nail is due to curling of toe nail inwards causing irritation, infection and formation of unhealthy granulation tissue at the fold. Great toe is commonly involved. Both medial and lateral margins of the nail can cause ingrowing. Often it is bilateral. Treatment is excision of outer part of the nail with its root so as to prevent its recurrence.17

It is a chronic granulomatous condition caused by Nocardia madurae, Nocardia brasiliensis, Nocardia asteroides. Organism enters the foot when walked with bare foot and evokes granulomatous inflammation which eventually leads into multiple discharging sinuses. Limb significantly becomes disabled. Condition mimics tuberculous osteomyelitis, chronic osteomyelitis. It needs long term therapy with penicillins, dapsone, iodides, antifungals.18

It shows sequestrum, new bone formation and radiolucent zone around the sequestrum. Sequestrum should be formed before surgical intervention. Sequestrum can be feathery {tuberculous}, ivory {syphilis}, granular {typhoid}, ring {stump} or black. Discharging sinus with bone pieces coming out are the features. Treatment is sequestrectomy and saucerization.19

It is scalp infection, scalp edema and subperiosteal pus formation, commonly observed in frontal region. It can be due to trauma or due to frontal sinusitis. Pain, warm, tender swelling with toxicity are the features. It may cause frontal bone osteomyelitis or can spread intracranially.20

Pyogenic granuloma is common in face, scalp and fingers. Minor trauma causes infection followed by formation and protrusion of unhealthy granulation tissue as a friable, tender red swelling which bleeds on touch. Treatment is excision.21

Extensive scalp injury causing slough formation over the center which is adherent to the periosteum. Slough is adherent to the periosteum and often outer table will be nonviable. In such occasion, after excising slough, multiple small drill holes are made over the outer table to allow blood supply to come from the diploë which will eventually lead to the formation of healthy granulation tissue. Later skin graft or flap is used to cover the defect.22

Fecal fistula commonly occurs after ileal/colonic surgeries for acute abdomen like lower GI perforations, malignancy, intestinal obstruction, volvulus, tuberculous intestine. It is usually treated conservatively by good nutrition {enteral/ total parenteral}, care of wound, antibiotics, electrolyte management. Usually fistula closes in few weeks provided there is no distal obstruction or residual disease or sepsis.23

Thromboangiitis obliterans is seen in male smokers as a hypersensitive reaction to carbon monoxide and nicotine. It causes vasospasm, hyperplasia, thrombosis and blockage of the medium sized vessels. Claudication, rest pain, ulceration, gangrene of toes and foot/leg and absence of distal pulsations are the typical presentations. Condition occurs in young individuals and is confirmed by duplex scan, angiogram or arterial biopsy. Treatment is complete cessation of smoking, vasodilators, antiplatelet drugs, lumbar sympathectomy, omentoplasty, profundaplasty or often amputation.24

Figure 1.23 A shows diabetic gangrene of the lateral four toes with distal part of the foot. Note the blackish discoloration. Great toe is spared. It needs amputation after control of diabetes. Figure 1.23 B shows gangrene of great and little toes. Arterial Doppler is required to find out the block, its site, extent and severity.25

On table use of synthetic arterial dacron graft as aorto-femoral bypass for aortoiliac block. Arterial grafts are synthetic or natural. Natural internal mammary graft is ideal one. Long saphenous vein and umbilical vein are also used. Synthetic grafts are woven/knitted graft or PTFE (polytetrafluoroethylene) graft. Graft can cause leak, thrombosis, re-block as complications.26

Figure shows aortic aneurysm from the arch of aorta which has eroded into the sternum presenting as pulsatile swelling. It is an aortic aneurysm with impending rupture. It has got poor prognosis. Emergency surgery is needed to save the life of the patient. It has got high operative mortality also.27

Note the extensive involvement of thoracic aorta which is extending into the abdominal aorta. Such cases are difficult to operate. U/S, Doppler and CT angiogram confirms the diagnosis as well as give the detail about the aneurysm. This patient had a massive rupture in a month and died.28

Persistent entire right developmental dorsal aorta and involuted distal part of left dorsal aorta. {Normally right dorsal aorta involutes}. Right arch aorta arising from ascending aorta passes backwards to the right of trachea and oesophagus to join upper descending aorta. Aneurysm has developed in this anomalous right arch aorta with thrombus in the aneurysm.29

It is creation of arteriovenous fistula to achieve hyperdynamic circulation so that hemodialysis at regular intervals becomes easier in chronic renal failure. It is commonly done in wrist but often done in brachial (elbow) region and femoral region. This A-V fistula can get infected, can get blocked or often can cause torrential bleeding. Creation of AV fistula is done under local anaesthesia.30

Figure shows aneurysm in an A-V fistula which is pulsatile, warm, and tender with continuous thrill on palpation and bruit on auscultation. Skin changes over the summit signify sepsis/thrombosis/impending rupture.31

Haemangioma in two children involving face. Haemangioma can be capillary or cavernous. Capillary can be salmon patch or strawberry type, both of which shows spontaneous regression. But third type, port-wine stain does not show any spontaneous regression. It needs laser therapy or excision or sclerotherapy32

Congenital arterio-venous malformation of the middle finger showing local gigantism. Typical increase in length and girth of the part with continuous thrill and bruit, warmness and often with bone erosion are the features. Even minor trauma causes torrential bleeding. It may cause hyperdynamic circulation and cardiac failure especially when it is extensive. X-ray of the part, Doppler and angiogram are needed.33

Figure shows congenital AV malformation in cerebral cortex. It may cause bleeding and CVA. It is treated by therapeutic embolization or by clipping.34

Figure shows Horner's syndrome which consists of ptosis, miosis, anhydrosis, enophthalmos and loss of spino-ciliary reflex. It can be due to Pancoast tumor, mediastinal tumor or neck secondaries infiltrating the cervical sympathetic chain, after cervical sympathectomy35

Dermal flares are small veins around the ankle {thread veins (0.5–1 mm)} which gets dilated with red/purple network of veins. These flares around ankle eventually lead into complications like dermatitis, ulceration, lipodermatosclerosis due to chronic venous hypertension. Reticular veins are 1-3 mm sized, small varicose veins are < 3 mm in size and large varicose veins are > 3 mm in size.36

Varicose veins are dilated, tortuous and elongated veins in the leg due to reversal of blood flow leading to chronic venous hypertension which itself causes dermatitis, ulceration and other complications. Deep vein thrombosis is contraindication for surgery for varicose veins. Flush ligation of varicose vein with stripping of the vein is the usual treatment.37

Typical site of venous ulcer is over the medial malleolus. It can lead into Marjolin's ulcer, talipes equinovarus, hemorrhage, joint ankylosis, periostitis and lipodermatosclerosis. It is treated by rest, elevation of limb, exercise, massaging and later skin grafting. Definitive therapy for varicose veins should be undertaken.38

It is severe lymphedema due to filariasis caused by a parasite, Wuchereria bancrofti, larva (microfilaria) of which is transmitted by Culex mosquitoes. Recurrent cellulitis and lymphangiitis are common. It causes severe psychological and physical morbidity. It is treated by Charle's excision, Swiss-roll {Thompson's} operation, Sistrunk operation. Recurrence is common.39

Figure shows severe lymphedema of penis which causes urinary problem and sexual dysfunction. It needs reduction and reconstruction.40

Figure shows bilateral axillary lymph node enlargement with sternal swelling. Patient has also got neck nodes on the left side. Biopsy proved Non-Hodgkin's lymphoma (NHL). Tonsils, mediastinum, epitrochlear nodes, abdominal nodes, liver and spleen, popliteal nodes and spine should be examined in this patient.41

Tuberculosis is more common in HIV infected person. Tuberculous lymphadenitis can be caseating or hyperplastic. Infection, periadenitis (matting), cold abscess, collar-stud abscess and sinus formation are the stages of tuberculous lymphadenitis. Antituberculous drugs, aspiration or drainage through non-dependent incision are the treatment strategies.42

Figure shows advanced secondaries in neck lymph nodes. Secondaries are well localized, hard, and initially mobile but later fixed to adjacent structures. Eventually fungation, ulceration can occur over the summit.43

Bursa is sac like cavity containing fluid within, which prevents friction. Inflammation and localized collection of fluid in this lead into bursitis. Student's elbow (Olecranon bursa) (Figure 1.38A), prepatellar bursa, infrapatellar bursa are examples of anatomical types of bursae. Adventitious bursa develops due to friction over a site which otherwise is normal, like over malleolus (Figure 1.38B), first metatarsal (Bunion) etc. It forms a localized swelling which is smooth and fluctuant. Excision is the treatment.44

It is a type of dystrophic calcification in and under the skin, usually presents as a circumscribed lesion in the skin. It is hard, with nodules and skin is adherent. It is common in females and common in waist but can occur anywhere. Often it is bilateral. Excision is the treatment.45

Callosity is protective thickened skin that protrudes outwards from the skin. It is limited to epidermis only. A corn is localized area of thickening over a bony projection. It shows severe keratoses which extends deep into the dermis showing central core of degenerated cells and cholesterol. Corn causes severe pain and tenderness.46

Sequestration dermoid occurs at the line of fusion. Common sites are forehead, external angular region, sublingual region. Dermoid is usually deep, often extends into the cavity in deeper plane like cranium/thorax. Skin is free but shows restricted mobility. Dermoid ear develops at line of fusion of one of the six ear tubercles. External angular dermoid occurs at fronto-zygomatic suture line. X-ray or CT scan of the part is often required to see the extension.47

Minor prick makes epidermis to get buried into the deeper plane which eventually forms implantation dermoid. It is common in finger but can occur anywhere. It is tensely cystic, smooth and often adherent to skin. Treatment is excision.48

Dermoid cyst ovary is derived from all germinal layers—ecto, meso and endoderms. It can be benign or malignant. It contains hair, teeth, cartilage and muscle. It can get twisted or can cause haemorrhage or occasionally can rupture.49

Figure shows papilloma right waist. It is warty swelling from skin or mucous membrane with central axis of vessel and lymphatics. It can occur in skin, oral cavity, urinary bladder, rectum, larynx or gall bladder. Occasionally papilloma can turn into squamous cell carcinoma.50

It is a cystic swelling occurring in relation to tendon sheath or synovial sheath or joint capsule. It contains clear gel like fluid. It is well localized smooth, soft, tensely cystic, nontender and transilluminant swelling. Its mobility restricts while contracting the muscle/ tendon in relation to the ganglion. Treatment is excision. It has got high recurrence rate—30%.51

Lymph cyst is an acquired distension cyst wherein lymphatics form a localized swelling with a capsule around it. It is common in neck and limbs. It is smooth, soft, fluctuant and transilluminant.52

Neurofibroma is a tumor arising from connective tissue of the nerve. It can be nodular, plexiform, pachydermatocele, elephantiatic type or generalized neurofibromatosis with von Recklinghausen's disease and café au lait spots. These are coffee coloured spots in the skin over back, thigh or abdomen. More than 5 in number with each 1.5 cm or more in size is significant. It can be associated with pheochromocytoma, MEN type IIb syndrome or scoliosis. Complications like erosion, neurological deficit, sarcomatous changes, and cystic degeneration can occur. Treatment is excision.54

Sebaceous cyst is very common swelling, It is a retention cyst due to blockage of the duct of sebaceous gland causing cystic swelling. It is common in scalp, face and scrotum. It does not occur in palm and sole. Punctum is a depressed black coloured spot present over the summit in 70% cases. Complications are infection, abscess, sebaceous horn, Cock's peculiar tumor. It is mobile, cystic, non-transilluminant swelling with adherent skin over the summit. Treatment is excision.56

Figure show different degrees of burns. Burns may be mild, moderate or severe. It can be first, second, third or fourth degree burns. First degree burns are superficial, epidermal which is red, painful and heals by epithelialization. Second degree burns are red, mottled, painful with blisters. It heals by scarring. Third degree burns are deep, full thickness, painless and insensitive, charred burns. It needs wound excision and later skin grafting or reconstruction. Involvement of muscles or bones is called as fourth degree burns.58

Figure shows destruction of the nasal cartilage and eyelids, exposure keratitis of the left eye {patient has got already poor vision on left eye due to burns}, and destruction of the part of cartilage of left ear. It needs coverage to skin, nasal reconstruction, treatment of keratitis, reconstruction of eyelid and also of left ear. Procedure will be multi-staged and challenging.59

Electric burn is always a deep and major burn. There is wound of entry and wound of exit. It can cause ventricular fibrillation and instant death. Patient can develop major internal organ injuries, convulsions, renal failure or gas gangrene. Wound excision and later reconstruction is needed. All patients with electric burns should be admitted for observation.60

Contracture due to burns is eventual sequelae of burn injury. Release of contracture is done 6 months after the burns. Release needs proper planning, staged procedures, long hospital stay. Skin grafting and or flaps of different types are used. Contracture can cause deformity, cosmetic problem, scar breakdown, ulcer formation, pain and scar tenderness and Marjolin's ulcer.62

Split skin graft is usually taken from thigh. It is epidermis with part of dermis. It is harvested using Humby's knife or using electric dermatome. Donor area dressing is kept for 10 days without opening in between. It epithelialises eventually. Graft in recipient bed is examined in 4-5 days for take up.63

Lipoma is a benign tumor arising from yellow fat. It is commonest benign tumor. It can occur anywhere in the body except brain. It is mobile, soft, smooth and slips between the fingers. It can turn into liposarcoma. It can undergo saponification, calcification. Submucous lipoma in intestine can cause intussusception and intestinal obstruction. Figure 1.55B shows lipoma under gastrocnemius muscle. Note the yellow coloured encapsulated tumor.64

Syndactyly is webbing or fusion of fingers which may be due to congenital, burns or trauma. It can be cutaneous, fibrous or bony. Release and Z plasty is the treatment.65

Dupuytren's contracture is localized thickening of the palmar aponeurosis and later formation of nodules which eventually leads into permanent joint changes in the hand. It usually starts in ring and little finger. It can be bilateral and familial. It is associated with plantar fasciitis and mediastinal fibrosis. Z plasty is the commonly done procedure.66

Keratoacanthoma also called as Molluscum sebaceum is an overgrowth and subsequent spontaneous regression of hair follicle. During regression central area separates leaving a deeply seated scar. It is not a malignant or pre-malignant condition but it mimics squamous cell carcinoma.67

Rhinophyma also called as ‘potato nose’ is glandular form of acne rosacea causing thickening of distal part of nose. There is hypertrophy and adenomatous changes in sebaceous glands. Nose is mildly red with visible capillaries over the surface.68

It is a benign overgrowth of the basal layer of epidermis with darkly stained excess basal cells. Common sites are face, back and neck. It is black {pigmented}. It is not a pre-malignant condition. ‘Stuck on’ appearance is characteristic. It does not occur in palms and soles.69

It is a hamartomata of melanocytes due to excessive stimulation. It may present during birth or in later life. It can be junctional, compound, dermal or blue naevus. Junctional naevus is potentially malignant. Change in colour, ulceration, crusting, satellite nodules are the features of malignant transformation. Naevus more than 20 cm size or more than 1% body surface area is called as giant naevus.70

Sebaceous epidermal naevus is common in females, begins in childhood. It has got 10% chances of turning into BCC. It needs surgical excision and skin grafting.71

Skin adnexal tumor is a tumor arising from adnexa of skin like hair follicle or sebaceous gland. It can be benign or malignant. It presents as protruding well localized swelling. Malignant tumor is nodular, hard with ulceration. It mimics squamous cell carcinoma. Regional lymph nodes can get involved. Treatment is wide excision.72

Xeroderma pigmentosa is due to defective DNA excision repair mechanism. Skin is dry, deeply pigmented with excoriations all over. It is more prone for skin malignancies like melanoma or BCC.73

Basal cell carcinoma is the commonest cutaneous malignancy. It can occur in muco-cutaneous junction but does not perse arise from mucosa. It is common in whites and common in Australia. It is only locally malignant. It does not spread through lymphatics or blood. It can be nodular, cystic, ulcerative, multiple, pigmented or geographic (field-fire). It erodes into deeper tissues like cartilage and bone. Treatment is radiotherapy/ wide excision / laser therapy / cryosurgery / MOHS (Microscopically Oriented Histographic Surgery). It has got a good prognosis.75

Melanoma is the most aggressive cutaneous malignancy. It spreads through lymph nodes as well as through blood. It can cause large liver secondaries. Satellite nodule in melanoma occurs within 2 cm of primary. ‘In-transit’ nodules are deposits in the skin between primary site to drainage nodes. Amelanotic melanoma is a type without melanin pigmentation. It is most aggressive type of melanoma. Clinically pigmented lesion which bleeds, itches, rapidly grows, ulcerates or forms halo around the lesion should be considered as melanoma. Induration is absent in melanoma. Incision biopsy is not used commonly in melanoma. Excision biopsy and later wide excision / amputation with nodal block dissection is the main treatment. Chemotherapy / isolated limb perfusion are the adjuvant modalities.77

Squamous cell carcinoma, also called as epithelioma is commonly ulcerative or ulcero-proliferative lesion. It is raised and everted with induration in edge and base. Regional lymph nodes often can get involved. Histologically it shows ‘keratin pearls’ with dispersed malignant cells. Edge biopsy and FNAC from the node are the investigations. Radiotherapy/wide excision/amputation of the part/nodal block dissection are the treatment modalities. Verrucous carcinoma is well differentiated squamous cell carcinoma with dry, exophytic, warty look. Nodal or blood spread is not known. Wide surgical excision is the treatment. It is curable.79

Soft tissue sarcomas are aggressive, warm, attain large size, vascular with dilated veins. They spread to lungs by blood. Open biopsy, CT scan of part to see local extension and chest CT to see secondaries are the main investigations. Wide excision/amputation/chemotherapy/radiotherapy are the modalities of therapy. Note the scar of old surgery in recurrent soft tissue sarcoma.80

Osteosarcoma is commonest primary malignant bone tumor which arises from the medulla of metaphysis. It is common in adolescents. It spreads through blood into lungs. Commonest site is around the knee joint. Painful swelling which is warm, hard and localized is typical. Often pathological fracture may develop. X-ray is diagnostic. Chest X-ray, CT of the primary, chest CT and open biopsy are essential investigations.

X-ray of lower end of femur showing ‘Codman's triangle’, ‘Sun-ray’ spicules, erosion of cortex with tumor, new bone formation. Opacity may be seen even in surrounding soft tissue also. Pathological fracture when occurs can be obvious in X-ray.82

Soft tissue sarcoma over plantar aspect of the foot. It is very vascular and well localized. It could be fibrosarcoma, rhabdomyosarcoma, haemangiosarcoma. Often melanoma may present like this. Treatment is below-knee amputation after confirming the tissue diagnosis. Chest X-ray / CT chest are must. GTNM staging is used for soft tissue sarcoma.83

Patient with typical malignant cachexia with loss of subcutaneous fat and muscle mass, thinned skin, and visible skeletal system. It is commonly observed in GIT malignancies like carcinoma stomach, pancreas etc.84

Malignant dermatofibrosarcoma protuberance is a low grade fibrosarcoma which grows slowly and persistently. It is nodular, multiple, hard often ulcerated extensive lesion. Regional nodes can get involved. It has got a good prognosis but recurrence is common. In many occasions patient undergoes many repeated surgical resections.85

Trauma to different part of the body is a major surgical problem. Figure 1.73A shows avulsion scalp injury exposing the outer table of skull. It needs drilling, revascularization and later reconstruction. It needs long hospital stay with many surgical procedures. Figure 1.73B is a crushed hand injury. Here management is to retain as much viable tissue as possible, initial debridement, marker stitch to nerves, management of metacarpals and later reconstructive procedures as needed like tendon transfer, flaps etc. Figure 1.73C is a severe penetrating injury. The woman fell over a tree which had its tip cut and sharpened. Top of the tree has passed through and through across abdomen, chest and neck. Patient was brought with part of the tree {cut from bottom later} to the hospital. Such injuries need adequate blood transfusion, laparotomy and management of liver and diaphragmatic injuries, thoracotomy and management of lung injury and proper exploration in the neck. This patient survived after surgery.