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Gateway to Success in Surgery
MD Ray
LONG CASES
CASE 1:
Abdominal Lumps (General Guidelines)
CHARACTERISTICS OF DIFFERENT MASS
Right Hypochondrial Mass
Liver Mass
Gallbladder Mass
MASS IN EPIGASTRIUM
Transverse Colon Mass (Carcinoma Transverse Colon)
LEFT HYPOCHONDRIAL MASS
Mass in Right and Left Lumbar Region
Mass in Umbilical Region
Right Iliac Fossa Mass
Mass in Hypogastrium
Left Iliac Fossa Mass
Unascending Kidney
Undescended Testicular Mass
Another Differentiating Point
CASE 2:
Surgical Obstructive Jaundice
HISTORY OF PRESENT ILLNESS
PAST HISTORY
PERSONAL HISTORY
Family History
On General Examination
Systemic Examination
Abdomen
Summary
On Examination
USG ABDOMEN
CECT ABDOMEN
UPPER GI ENDOSCOPY
COURSE OF THORACIC DUCT
SHORT NOTE ON SURGICAL OBSTRUCTIVE JAUNDICE
BILIRUBIN METABOLISM
CLASSIFICATION
CONSEQUENCES OF BILIARY OBSTRUCTION
PATHOLOGICAL EFFECTS OF BILIARY OBSTRUCTION
Liver
Kidney
Wound Healing
Endotoxemia
Coagulation Defects
Hemodynamic Changes
CLINICAL MANIFESTATIONS
INVESTIGATION PROTOCOL FOR A JAUNDICE PATIENT
Biochemical Parameters
Serum Bilirubin (0.2–1.2 mg%)
Alkaline Phosphate (60–170 IU/L; 3–13 KAU/mL)
Transminases (3–48 IU/L)
Serum Albumin (TP 6–8 g/dL; Alb: 3.8–5 g/dL; Glb: 1.8–3.5 g/dL)
Coagulation Profile
Urinary Bilirubin and Urobilinogen
Radiological Investigations
Hypotonic Duodenography
Abdominal USG
Endoscopic USG
CECT Scan
PTC Pictures in Various Diseases
Advantages
TREATMENT
Amelioration of Symptoms
Pruritis
RADIOLOGICAL AND PERCUTANEOUS DRAINAGE TECHNIQUE
PTC
ROLE OF PREOPERATIVE PERCUTANEOUS BILIARY DRAINAGE
Complications of Transhepatic Intubation
Endoscopic Technique
SURGERY
Curative Surgery
Palliative Surgery
Surgery for Benign Lesions
NOTES ON CONGENITAL NONHEMOLYTIC ANEMIA
Types
Unconjugated Hyperbilirubinemia
Conjugated Hyperbilirubinemia
Mirizzi Syndrome
CASE 3:
Cystic Lump Abdomen
HISTORY OF PRESENT ILLNESS
PAST HISTORY
PERSONAL HISTORY
FAMILY HISTORY
GENERAL SURVEY
On Examination
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS OF EPIGASTRIC INTRA-ABDOMINAL SOFT MASS
DIFFERENTIAL DIAGNOSIS OF RETROPERITONEAL CYSTIC LUMP
REASONS BEHIND INVESTIGATIONS
Open Surgery or Laparoscopic Surgery
For Chylolymphatic Cyst
Enterogenous Cyst
CASE 4:
Left Iliac Fossa Lump
HISTORY
EXAMINATION
General Examination
LOCAL EXAMINATION
Inspection
Palpation
Percussion
Auscultation
INVESTIGATIONS
Diagnostic Investigations
IMPORTANT DIFFERENTIAL DIAGNOSES
Parietal Swellings
Unascended Left Kidney
Undescended Testes
Lymph Nodes
Retroperitoneal Tumors
Ovarian Cysts/Tumors
Left Sided Bowel Malignancy
Diagnostic Evaluation
Staging Evaluation
Staging of Colorectal Cancer
Lymphoma (see Case 20—Cervical Lymphadenopathy)
Signs and Symptoms
Investigations
Definition of an Adequate Staging Laparotomy
Staging
COTSWOLD STAGING CLASSIFICATION OF LYMPHOMA
Classification Description
CASE 5:
Right Iliac Fossa Mass
A PATIENT OF ILEOCECAL TUBERCULOSIS
Past History
Personal History
Family History
General Survey
Systemic Examination
On Palpation
Other Systemic Exams
Summary of the Case
On Examination
Ileocecal Tuberculosis
Clinical Features
Investigations
Colonoscopy
Treatment
Appendicular Lump (Appendicular Phlegmon)
Investigations
Conservative
Surgery Laparoscopic Open
Investigations
Treatment
Crohn's Diseases or Regional Ileitis
Investigations
Treatment
Surgery
Mesenteric Tuberculous Lymphadenitis
RETROPERITONEAL TUMORS
Treatment of Retroperitoneal Tumors
CASE 6:
Epigastric Lump
LOCAL EXAMINATION
Abdomen
On Inspection
On Palpation
On Percussion
Other Systemic Examination
Summary of the Case
Cystadenoma or Cystadenocarcinoma of Pancreas
Simple Cyst of Pancreas
Aortic Aneurysm
Mesenteric Cyst
PSEUDOCYST
Characteristics of Pseudocyst
Causes of Pseudocyst
Mechanism
Clinical Presentations
Diagnosis
Treatment
INTRA-ABDOMINAL SOLID SWELLINGS IN THE EPIGASTRIUM—DIFFERENTIAL DIAGNOSIS
IMPORTANT SHORT NOTE ON PANCREAS
Blood Supply
On Examination
Investigations
CT severity Index (CTSI) of Acute Pancreatitis
CT Grading
Degree of Necrosis
Glassgo Scale
Principles of Surgery
Prognosis of Acute Pancreatitis
Few Important Things in Pancreatitis
CHRONIC PANCREATITIS
Pathology
Classification of Chronic Pancreatitis
Clinical Features
Complications of Chronic Pancreatitis
Investigations
Treatment
Advice
Medicine
Surgery
SHORT HISTORY OF INITIAL OPERATIONS
CARCINOMA HEAD OF PANCREAS
Clinical Features
Investigations
Treatment
Inoperable Cases
CASE 7:
Hepatic Mass
CASE 8:
Carcinoma Gallbladder
DIFFERENTIAL DIAGNOSIS
PATHOLOGY
DIAGNOSTIC EVALUATION
COMPUTED TOMOGRAPHY (CT) SCAN
OTHER DIAGNOSTIC TOOLS
SURGICAL MANAGEMENT
GUIDELINES BY TUMOR STAGE
Lymph Node Involvement
Palliative Treatment of Advanced Disease
Follow-up
CASE 9:
Renal Lump
STRUCTURES OF KIDNEY
INTRODUCTION
Epidemiology
Etiology
Pathology
DIAGNOSIS
Clinical
Other Presentations
Radiological
STAGING
TNM Classification: (AJCC, 2002)
Disseminated Mets
Immunotherapy
Prognosis
CASE 10:
Hydronephrosis
SYSTEMIC EXAMINATION
Abdomen
Summary of the Case
PROVOSIONAL DIAGNOSIS
Differential Diagnoses
Bilateral Hydronephrosis
PYELOPLASTY FOR SYMPTOMATIC PUJ OBSTRUCTIONS
Types
Dismembered Pyeloplasty
Flap Procedure
CASE 11:
Carcinoma Colon
SUMMARY OF THE CASE
SHORT NOTE ON CARCINOMA COLON
CASE 12:
Carcinoma Stomach—The Captain of Men's Death
SUMMARY OF THE CASE
CARCINOMA STOMACH—SHORT NOTE
Common Sites of Gastric Cancer
Gastric Lymphoma
Treatment
CASE 13:
Retroperitoneal Lump (Soft Tissue Sarcoma)
SUMMARY
Points in Favor
Other Possibilities
QUESTIONS AND ANSWERS
Tru Cut Biopsy
Incisional Biopsy
Excision Biopsy
Tumor Grades
SHORT NOTE ON LIMB SALVAGE SURGERY
Isolated Regional Perfusion
Gastrointestinal Stromal Tumor (GIST)
HIGHLIGHT ON RETROPERITONEAL SPACE AND ITS DISEASES
Anatomy
Abnormalities in Retroperitoneal Space
Characteristics of Retroperitoneal Mass
Features of Soft Tissue Sarcoma
Investigations
Treatment of STS
CASE 14:
Portal Hypertension
CLINICAL PRESENTATION OF PHT
Mechanism of Variceal Bleeding
PHARMACOTHERAPY IN PHT
VARICEAL LIGATION
Disadvantages
COMMONLY USED PORTA SYSTEMIC SURGERIES
NONSHUNT SURGERY
LIVER TRANSPLANTATION
ELECTIVE LONG-TERM MANAGEMENT OF PHT
CASE 15:
Pelvic Mass
SUMMARY
Gynecological causes of pelvic mass by approx. frequency and age group
Non-Gynecological Causes of Pelvic Mass
CASE 16:
Carcinoma Oral Cavity
LOCAL EXAMINATION
Externally
Internally
Inspection
Palpation
Systemic Examination
SUMMARY
Questions
INTRODUCTION
RISK FACTORS
Clinical Presentation
Diagnosis as Described Earlier
Choice of Treatment
Tumor Factors
Patient Factors
Surgery for Oral Cancers in Different Subsets
Ca Buccal Mucosa
Retromolar Trigone (RMT)
SURGICAL ANATOMY
ONCOLOGIC RELEVANCE OF LYMPH NODE LEVELS
EVOLUTION OF NECK DISSECTION
STANDARDIZING NECK DISSECTION TERMINOLOGY
Comprehensive Neck Dissection
Selective Neck Dissection
EVALUATION OF THE NECK
STAGING OF CERVICAL NODAL METASTASES
MANAGEMENT OF THE N0 NECK
SELECTION OF SURGICAL PROCEDURE
ROLE OF RADIOTHERAPY
CASE 17:
Peripheral Artery Occlusive Disease—Buerger's Disease
SHORT NOTES ON PAOD (BUERGER'S DISEASE)
Etiology
Pathogenesis
Stages
Clinical Features
CHRONIC AND CRITICAL LIMB ISCHEMIA
Diagnostic Criteria
Investigations
Management of Chronic Limb Ischemia
Infrainguinal Occlusive Disease
CASE 18:
Varicose Vein
MEDICAL MANAGEMENT OF CHRONIC VENOUS DISEASE (CVI)
DEEP VEIN THROMBOSIS (DVT)
Pathophysiology
General
Medical
Hematologic
Travelers Thrombosis
Sites
Investigations
Clinical Features
On Examination
Palma Operation
Lab Studies
Treatment
PREVENTION OF DVT
Complication of DVT
SHORT CASES
CASE 19:
Carcinoma Breast
CASE 20:
A Case of Solitary Nodule Thyroid (SNT)
HISTORY OF PRESENT ILLNESS
MULTINODULAR GOITER (MNG)
CASE HISTORY IN CARCINOMA THYROID
PAST HISTORY
FAMILY HISTORY
LOCAL EXAMINATION
SYSTEMIC EXAMINATION
Summary
On Examination
Other common questions - on thyrotoxicosis
MNG
IMPORTANT SHORT NOTE ON THYROID:
THYROID
a) Anatomy:
b) Physiology of thyroid gland:
Classification of Goiter
1. Simple Nontoxic Goiter
Colloid Goiter
MNG
SNT
DIFFERENTIAL DIAGNOSIS
Treatment
Carcinoma:
Follicular Carcinoma
Clinical features:
Investigations
Treatment
Follow up
Hurthle cell carcinoma
CASE 21:
Cervical Lymphadenopathy
CERVICAL LYMPHDENOPATHY
II NEoplastic
Primary
Secondary
III Autoimmune disorders
CAUSE OF GENERALIZED LYMPHADENOPATHY
1. TUBERCULOUS LYMPHADENITIS
2. LYMPH NODE'S PATHOLOGY
3. INVESTIGATIONS
TREATMENT
4. Side effects of antitubercular drugs
Management of cold Abscess
SECONDARIES IN NECK LYMPH NODES
Types of Secondaries in the neck
Hodgkin's disease
Symptoms and signs
Non Hodgkin's lymphoma
1. Clinical feature—slowly progressive
2. Investigations
Treatment
CASE 22:
Parotid Swelling
CASE 23:
Cystic Swelling in the Neck-Cystic Hygroma
BRANCHIAL CYST
SOLITARY SIMPLE CYST
COLD ABSCESS IN THE NECK
SHORT NOTE ON CYSTIC HYGROMA
SHORT NOTE ON SWELLING IN THE NECK
Neck swelling
Surgical Anatomy of Neck
Triangles of Neck
Cervical Dermoid
Thyroid Cyst
The fate of the duct
Sites of thyroglossal cyst
SITE OF BRANCHIAL CYST
Carotid Body Tumour: Chemodectoma / potato tumour
Sites of other chemoreceptor
Site of carotid body tumour
How to diagnose
CASE 24:
Inguinal Hernia
SHORT NOTES ON INGUINAL HERNIA
Aetiology
INGUINAL CANAL
Surgical anatomy:
BOUNDARIES OF INGUINAL CANAL
Anterior wall
Posterior wall
Coverings of Inguinal Hernia
Indirect Inguinal Hernia
Clinical Features
Different other Type of Hernias
Hernia En Glissade
Pantaloon Hernia
Remember the terms
LAPAROSCOPIC HERNIA REPAIR
Anatomy
Procedure
SHORT NOTE IN LAPAROSCOPIC SURGERY
Laparoscopy Instruments
CASE 25:
Femoral Hernia
ANATOMY FEMORAL HERNIA
Aetiology of Femoral Hernia
Course of Femoral Hernia
Clinical Features
Different forms of femoral hernia
CASE 26:
Paraumbilical Hernia (Supra- or Infraumbilical Hernia)
CASE 27:
Epigastric Hernia
CASE 28:
Incisional Hernia
CASE 29:
Testicular Tumor
ETIOLOGY
Congenital
Acquired
TESTICULAR Tumor Classification
CLINICAL PRESENTATION
Symptoms
Signs
Locally
Per abdomen
Chest examination
Lab findings
TREATMENT
Seminoma
Nonseminoma
SIDE EFFECTS OF PLATINUM-BASED CHEMOTHERAPY AND OTHERS
Recurrent Testicular Cancer
(i) Salvage Regimens
FOLLOW UP
PROGNOSIS
CONCLUSION
CASE 30:
Hydrocele
DEFINITION
Primary Hydrocele
Types
Vaginal Hydrocele
Congenital Hydrocele
Funicular Hydrocele
Infantile Hydrocele
Encysted Hydrocele of the Cord.
CASE 31:
Varicocele
CASE 32:
Carcinoma Penis
INTRODUCTION
Epidemiology
Causes and Risk Factors
Clinical presentation
Diagnosis
Differential diagnosis
The Jackson Classification
UICC-TNM Classification 2002 (11)
Primary Tumor
Regional Lymph Nodes
Metastasis
Treatment
Management of Inguinal Lymphadenopathy
Extent of lymphadenectomy
Chemotherapy
Prevention
CASE 33:
Basal Cell Carcinoma (Rodent Ulcer)
MODE OF SEQUESTRATION DERMOID FORMATION
Implantation Dermoid
Clinical Features
Treatment
Tubulodermoid
Teratodermoid
Different Diagnosis
SEBACEOUS CYST (WEN, EPIDERMOID CYST)
What it is
How to Diagnose
Complications
Treatment
LIPOMA
Classification
How to Diagnose
Features
LIPOSARCOMA
Treatment
Cavernous (Venous) Hemangioma
Arterial or Plexiform Hemangioma
Neurofibroma
Treatment of Neurofibromatosis
Treatment of keloid—Controversial still
CASE 34:
Squamous Cell Carcinoma (Epithelioma, Epidermoid Carcinoma)
CASE 35:
Melanoma
MELANOMA
Types of Naevus
MALIGNANT MELANOMA
Classifications
REMEMBER
CASE 36:
Upper Limb Ischemia
SUBCLAVIAN STEAL
Embolism and Thrombosis
Causes
Paradoxical Embolism
Peripheral arterial thrombosis
Cardinal Features
Treatment
THORACIC OUTLET SYNDROME (TOS)
Anatomy
Etiology
A. Congenital
B. Acquired
SYMPTOMATOLOGY
Symptoms
Investigations
Treatment
CONSERVATIVE MANAGEMENT
SURGICAL MANAGEMENT
Transaxillary Excision of First Rib
Advantages
Disadvantages
Supraclavicular Scalenectomy
Advantages
Combined Approach
ARTERIAL TOS
Investigations
Treatment
III VENOUS TOS
Investigations
Treatment
Conservative
Surgery
Raynaud's Syndrome
Etiology
Clinical Features
Pathophysiology of COLOR Changes
Diagnostic Test
Treatment
CASE 37:
Diabetic Foot
DESCRIPTION OF ULCERS
Examination of the Patients
Vascular Examination to Exclude Vasculopathy
Neurologic Exmination-to Exclude Neuropathy
Musculo skeletal Examination-to Exclude Osteoarthopathy
Ulcer Classification
POINTS TO REMEMBER
CASE 38:
Trophic Ulcer
CASE 39:
Amputated Stump
CASE 40:
Peripheral Nerve Injury
HIGH MEDIAN NERVE INJURY
Lower Median Nerve Injury
BRACHIAL PLEXUS INJURY
Anatomy
Nerves Arise from Different Cords
III. Important causes of brachial plexus injury
Types of brachial plexus injury
Common Peroneal Nerve Injury
Few important things about nerve and nerve injury
CASE 41:
Post Burns Contracture and Marjolin Ulcer
I. WALLACE'S RULE OF ‘9’
II. DEGREES OF BURNS
Pathophysiology
Management of Burns
First Aid
Primary Survey and Resuscitation
Resuscitation in Children
Secondary Survey
Local Management
Management of Eschar
Medicolegal and Ethical aspect in burns
CASE 42:
Popliteal Fossa Swellings
PEDIATRICS CASES
CASE 43:
Cleft Lip and Cleft Palate
DEVELOPMENT OF FACE, LIP AND PALATE
Frontonasal Process
The Maxillary Process
The mandibular Process
Incidence
Etiology
Classification
Cleft lip
CLEFT PALATE
Classification
I. Incomplete
II. Complete
Principles of Surgery
Secondary management for:
Secondary Surgery for Cleft Lipand Cleft Palate
CASE 44:
Hypospadius
DEVELOPMENT OF URETHRA
Know about Epispadias
Treatment
DENIS BROWNE'S TECHNIQUE:
CASE 45:
Undescended Testis
LOCKWOOD THEORY REGARDING ECTOPIC TESTIS
Etiology
Clinical Features
Clinical Examination
Differential Diagnosis
CASE 46:
Hydrocephalus
DEFINITION
CEREBROSPINAL FLUID
PATHWAY OF CST
TYPES OF HYDROCEPHALUS
CASE 47:
Wilms' Tumor (Nephroblastoma)
WILMS' TUMOR (SYNONYM NEPHROBLASTOMA)
NEUROBLASTOMA
Investigations
Treatment
(ii) Hydronephrosis
(iii) Cystic disease
STAGES OF NEUROBLASTOMA
CASE 48:
Congenital Hernia
NOTES ON CONGENITAL HERNIA AND HYDROCELE
Differential Diagnosis
SHORT NOTES ON CONGENITAL HYDROCELE
CASE 49:
Meningocele
Notes on Stapler, GI Stapler and Sutures
PRIMARY GOALS OF THE SURGICAL TECHNIQUES
HUTL'S STAPLING PRINCIPLES
HISTORY OF SURGICAL STAPLING
Russian Contributions
USA Contributions
Ethicon Contributions
ADVANTAGES OF SURGICAL STAPLING
ANASTOMOSIS
Side-to-side Gastrojejunostomy
ANASTOMOSIS: END-TO-END FUNCTIONAL
ANASTOMOSIS
End-to-side Ileocolostomy
GASTRIC SURGERY
Antrectomy with a Billroth Type I
Gastroduodenal Reconstruction
TOTAL GASTRECTOMY WITH ROUX-EN-Y ANASTOMOSIS
COLORECTAL SURGERY
Right Hemicolectomy
Side-to-side Ileocolostomy
LOW ANTERIOR RESECTION WITH END-TO-END ANASTOMOSIS
COLOPROCTECTOMY WITH ILEAL “J”
Pouch and Ileoproctostomy
GI STAPLING
INTRODUCTION
HISTORICAL PRINCIPLES
DIVISION OF THE DUODENUM
Division of the Duodenum
Formation of a Roux-en-Y Loop
Esophagojejunal Anastomosis
Jejuno-Jejunostomy
Key Points
KNOW FEW IMPORTANT THINGS ABOUT SUTURE MATERIALS
Ideal Suture Material-Criteria
Classification
Uses of Absorbable Suture
Monofilament and Polyfilament Suture
Monofilament
Numbering of Suture Materials
Mechanism of Absorption of Suture
Absorbable Suture
Example of Tensile Strenghth
Atraumatic Suture
THE CARE WORLD
INDEX
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