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Long Cases in General Surgery
R Rajamahendran
CASE 1:
Inguinal Hernia
Definition
History
Presenting Complaints
About the Hernia
Complications
History of Precipitating Factors
Past History
Family History
Personal History
General Examination
Cardiovascular System
Abdomen
Local Examination
Inspection
Palpation
Discussion of Palpation
Complications of Taxis
To Demonstrate by Inspection
Inference
To Demonstrate by Palpation
On Testing the Reducibility
Procedure
Percussion
Auscultation
Others
Per-rectal Examination
Differential Diagnosis
Investigations
Treatment
Truss
ANATOMY OF INGUINAL HERNIA
Types of Hernia (Figs 1.5A to C)
Boundaries of Inguinal Canal (Fig. 1.6)
Inguinal Canal (House of Bassini)
Contents of Inguinal Canal
Hesselbach Triangle (Figs 1.8A and B)
COVERINGS OF INGUINAL HERNIA
Indirect Hernia
Direct Hernia
How does Ilioinguinal Nerve enter the Inguinal Canal?
Femoral Hernia: Anatomy (Figs 1.9 and 1.10)
Surgeries for Hernia
Herniotomy
HERNIORRHAPHY
Hernioplasty
Shouldice Technique
McVay's Repair
Lichtenstein Hernioplasty
Gilbert's Plug Repair
Stoppas Procedure
Darning
Laparoscopic Hernia Repair (Figs 1.13 and 1.14)
Author's Note
FEMORAL HERNIA SURGERY
Strangulated hernia (Fig. 1.15)
Management
If Bowel is not Viable; (Gangrenous, Lustureless, No Peristalsis)
Nonviable Bowel
Large Bowel
Strangulation in Maydl's Hernia
Sliding Hernia
Definition
Clinical Features
During Surgery
Scrotal Abdomen
Clinical Features
During Surgery
Spigelian Hernia (Fig. 1.17)
MISCELLANEOUS
Richter's Hernia
Littre's Hernia
Sacless Hernia
Dual Hernia
(Pantaloon/Saddle Bag)
OGILVIE HERNIA
CONSOLIDATION
CASE 2:
Thyroid Gland
Exam Cases
HISTORY
HISTORY OF PRESENT ILLNESS
History of Complaints
History of Pressure Effects
History of Thyrotoxicosis
History of Hypothyroidism
History of Malignancy
PAST HISTORY
PERSONAL HISTORY
Menstrual History
Family History
General Examination
LOCAL EXAMINATION
Inspection
Palpation
Percussion
Auscultation
Primary Thyrotoxicosis
Features of Primary Thyrotoxicosis
Eye Signs
Tachycardia
Tremors
Hot and Moist Palms
Thyroid Bruit
Features of secondary Thyrotoxicosis
Signs of Hypothyroidism
Signs of Malignancy
Examination of Other Systems
Discussion
INVESTIGATIONS
Indirect Laryngoscopy
Fine Needle Aspiration Cytology
Trucut Biopsy
Indications
Radioactive Iodine Uptake Study
Contraindication
Administration
Inference
Thyroid Scan (Figs 2.10 and 2.11)
Indications
Inference
Treatment Options
Preoperative Preparation of Thyrotoxicosis
Advantages of Propylthiouracil
SIDE EFFECTS
Mechanism of Action
Propranolol
Lugol's Iodine
Radio-Iodine
Adverse Effects
Surgery
Modalities of Surgery
Surgical Anatomy of Thyroid
Embryology
Anatomy (Fig. 2.12)
Coverings of Thyroid Gland
Blood Supply (Fig. 2.13)
Venous Drainage
Lymphatic Drainage
Vagus Nerve Branches
Nerve Relationship (Flow chart 2.2)
Subtotal Thyroidectomy
LOBECTOMY (HEMITHYROIDECTOMY)
POSTOPERATIVE COMPLICATIONS
Perioperative Complications
Early Postoperative
Late Postoperative
Carcinoma Thyroid
Dunhill's Classification of Malignant Thyroid
Etiology
MULTIPLE ENDOCRINE NEOPLASIA
Papillary Carcinoma
Predisposing Factors
Clinical Features
Pathology
Prognostic Indicators
Treatment
Follicular Carcinoma
Clinical Features
Treatment
Other Modalities of Treatment
Hurthle Cell Cancer
Differ from Follicular Carcinoma by
Treatment
Medullary Carcinoma
Clinical Features
Pathology
Treatment
VIVA QUESTION
Anaplastic Cancer (Figs 2.17 and 2.18)
Lymphoma of Thyroid Gland
Treatment
Discussion of Thyroid Case (Flow chart 2.3)
Goiter
Clinical Features
Investigations
Treatment
Hyperthyroidism
Grave's Disease (Primary Thyrotoxicosis) (Fig. 2.19)
Clinical Features
Investigations
Treatment
Toxic Multinodular Goiter (Secondary Thyrotoxicosis)
Investigation
Treatment
Toxic Adenoma
Thyroiditis
Types
Hashimotos Thyroiditis
CD4+ Helper Cells Directed Against Thyroglobulin, Thyroid Peroxidase [Most Common], TSH-R
Treatment
RiEDEL’S THYROIDITIS
Features
DE QUERVAIN’S sUBACUTE THYROIDITIS
Infective Thyroiditis
Treatment
Booster Points
CASE 3:
Cancer Breast
History
Complaining of
History of Presenting Illness
Other History
Past History
Personal History
Menstrual and Marital History
Family History
General Examination
EXAMINATION OF BREAST (Figs 3.2A to C)
INSPECTION
Palpation
EXAMINATION OF NIPPLE
Examination of Axillary Lymph Nodes
Percussion
Diagnosis
Differential Diagnosis of Carcinoma Breast
Investigations
Mammography (Figs 3.8 and 3.9)
Indications
Features Suggestive of Cancer
Magnetic Resonance Imaging (Fig. 3.10)
Indicated in
TREATMENT MODALITIES
Various Surgeries to be Discussed
Discussion of Cancer Breast
Incidence of Carcinoma in each Quadrant
Types of Carcinoma Breast
Carcinoma in situ
Invasive Carcinoma
Invasive Cancers
Invasive Lobular Carcinoma
Etiological Factors of Carcinoma Breast
Exogenous Hormones Increase the Risk
BLOOM AND RICHARDSON’S GRADING
TNM STAGING OF BREAST
BREAST CONSERVATIVE SURGERY (Figs 3.17A and B)
AUTOGENOUS TRANSPLANT
Chemotherapy
CMF REGIMEN
HORMONE THERAPY
Estrogen Receptor Status
TAMOXIFEN
SELECTIVE ESTROGEN RECEPTOR MODULATORS
RADIOTHERAPY
FOR IN SITU CANCERS
EARLY INVASIVE CANCER (Stage I, IIa or IIb)
ADVANCED LOCOREGIONAL CANCER
DISTANT METASTASIS
Other Swellings in Breast of Special Interest
Treatment
Treatment
Treatment
Questions from Examiners
CASE 4:
Stomach
History
Presenting Complaints
Cancer Stomach
Peptic Ulcer
Pain Related Viva Questions
Past History of
Personal History of
Family History of
General examination
Examination of Abdomen
Inspection
Palpation
Pulsation over the Swelling (Expansile or Transmitted)
Plane of Swelling (Parietal or Intra-abdominal)
Percussion
Per-rectal Examination
Investigations
Basic Investigations
Specific Investigations
Scopy Finding (Figs 4.6 to 4.9)
Barium Meal (Figs 4.10 and 4.11)
X-ray Abdomen Erect
Staging Investigations
Other Investigations (Not Essential to Say in Exams)
H. pylori Infection
Gastric Function Tests
Discussion of the Topics
Anatomy (Figs 4.17A and B)
Blood Supply
Nerve Supply
Lymphatic Drainage
Physiology
Gastric Acid
Cancer stomach
Predisposing Factors
Premalignant Factors
Site
Histological Types
Classification
Macroscopic
Microscopic
Lauren's Classification
Serological Marker
Methods of Spread
Signs of Inoperability
TNM Staging (Fig. 4.23)
TREATMENT MODALITIES
Surgical Modalities
Operable
Oncology Clearance
Inoperable
Inoperable Tumors
RECONSTRUCTION PROCEDURES AFTER SUBTOTAL GASTRECTOMY
Reconstructive Procedures after Total Gastrectomy
Chemotherapy
Peptic Ulcer disease
Sites
Most Common Sites
Classification (Flow Chart 4.1)
Etiology of Chronic Peptic Ulcer
Chronic Duodenal Ulcer
Chronic Gastric Ulcer
Complications Of Peptic Ulcer Disease
Duodenal Ulcer (Fig. 4.32)
Truncal Vagotomy with Posterior Vertical Retrocolic Isoperistaltic no Loop-no-tension Gastrojejunostomy (Mayo's GJ) (Figs 4.33, 4.36A and B)
Viva Questions
Disadvantages
Truncal Vagotomy with Heineke-Mikulicz Pyloroplasty (Figs 4.33 and 4.34)
High Selective Vagotomy (Fig. 4.35)
Taylor's Procedure
Hill's Procedure
Truncal Vagotomy with Antrectomy
Gastric Ulcer
Depending on the Site
Viva: What is the difference between partial and subtotal gastrectomy?
Kelling Madlener Procedure
Sequence of Gastric Surgeries
Due to Gastrojejunostomy
Causes of Recurrent Ulcer
Miscellaneous
Zollinger-Ellison Syndrome (Gastrinomas)
Gastrinomas
Gastric Lymphoma
Pathology
Complications
Treatment
Gastrointestinal Stromal Tumors
CASE 5:
Obstructive Jaundice
HISTORY
Presents with Complaints
History of PRESENTING COMPLAINTS
Past History
GENERAL EXAMINATION
Abdominal Examination
Inspection
Palpation
Courvoisiers Law
Explanation (Figs 5.2A to D)
Exceptions to this Law
INVESTIGATIONS
Basic Blood Investigations
Radiological Investigations
Ultrasonogram—Most Useful Noninvasive Investigation
Invasive Investigations
Complications of ERCP
Percutaneous Transhepatic Cholangiogram (Fig. 5.7)
DIAGNOSTIC LAPAROSCOPY
DISCUSSION OF EACH TOPIC
Cholelithiasis
Gall Stones
Types of Stones
Lithogenic Bile
Normal Ratio
Nucleation
Stasis
Predisposing Factors
Pigment Stones
Black Pigment
Brown Pigment
Black Pigment (Fig. 5.9)
Brown Pigment (Fig. 5.10)
Complications
Mirrizi Syndrome (Figs 5.11A and B)
Cholecystoenteric Fistula
Treatment Options
Common Bile Duct Stones
Clinical Features
Treatment Options
CBD Exploration and T-tube Removal (Figs 5.13A to C)
Missed/Retained/Residual Stones (<2 Years)
Recurrent Stones (>2 Years)
CARCINOMA PANCREAS AND PERIAMPULLARY CARCINOMA (Figs 5.15 to 5.17)
Pancreatic Tumors
Exocrine Tumors
Whipples Procedure (Fig. 5.18)
Removal of
Carcinoma Gallbladder
Risk Factors
Clinical Features
Investigations
Diagnostic Laparoscopy is a Must
Contraindications for Surgery
Treatment
Cancers Diagnosed in Cholecystectomy Specimens
Palliative Treatment
Bile duct cancers
Risk Factors
Clinical Features
Bismuth Classification (Fig. 5.19)
Investigations
Treatment
Operable Tumors
Inoperable Cancers
CASE 6:
Right Iliac Fossa Mass
History
History of Present Illness
Past History
Family History
General Examination
Examination of Abdomen
Inspection
Palpation
Auscultation
Examination Findings for Each Swelling (Flow chart 6.1)
Investigations
Routine and Blood Grouping
Specific
Investigations
Discussion
Appendicular Mass
History
Definition
Treatment of Appendicular Mass
Criteria for Stopping Conservative Regimen
On Conservative Regimen
Viva questions
Appendicular Abscess
Clinical Features
Types of Appendicular Abscess
Treatment
Abdominal Tuberculosis
Intestinal Tuberculosis (Flow chart 6.2)
Types (Table 6.1)
Treatment
Intestinal Obstruction (Complete)
Strictures
Carcinoma cecum
Remove
Mesenteric lymph nodes
Tuberculous Mesenteric Lymphadenitis
Mesenteric cyst
Clinical Features
Classification
Chylolymphatic Cyst (Fig. 6.14)
Enterogenous Cyst (Fig. 6.15)
Other Cysts
RETROPERITONEAL SARCOMA
Clinical Features
RIF MASS IN FEMALES
Rare Lumps in RIF Region
Barium Meal Shows
CASE 7:
Liver Secondaries (Topic Focused More on Colorectal Cancers)
History
History with Regard to Primaries
General Examination
Examination of Abdomen
Criteria for Liver Secondaries
Evidence of Primaries
Per Rectal Examination
Investigations
Colonic Study
Length of Each Study
Discussion
Hepatocellular Carcinoma
Treatment
Indications for Resection
Milan's Criteria for Liver Transplantation for HCC
Treatment for Secondaries Liver
Indications for Surgery in Secondary Liver
Chemotherapy
Other Modalities
Discussion
Cancer Colon and Rectum
Precancerous Lesions
Pathological Types
Incidence of Colonic Carcinoma (Fig. 7.2)
Duke's Classification
Astler Coller Further Divided the C
Modified Duke's Classification (Fig. 7.3)
Investigations
Treatment
No Touch Technique of Turnbull
Adjuvant Therapy
Cancer Rectum
Histology
Pathological Types (Fig. 7.7)
SPREAD OF CARCINOMA
Clinical Features
Treatment
Abdominal Surgeon
Structures Removed
Radiotherapy
Chemo/Immunotherapy
Inoperable Cases
Hartmann's Operation
CASE 8:
Varicose Veins
History
Symptoms
History of Suggestive Secondary Causes
Past History
Personal History
Family History
General Examination
Examination of Other Systems
Examination of Varicose Veins
Perforator—Anatomy (Fig. 8.1)
Perforators of Lower Limb—Landmark (Fig. 8.2)
Inspection
Palpation (Flow chart 8.1)
Inference
Short Saphenous Venous Incompetence
Method 1
Method 2
CEAP Classification of Varicose Veins
Varicose Veins—Discussion
Classification
Hypothesis for Varicosity
Clinical Features
Venous Claudication
Complications of Varicose Veins
Discussion
Varicose Vein Surgery
Venous Ulcer
Definitive Treatment
Sclerotherapy
Surgical Procedures
DEEP VEIN THROMBOSIS
Conservative
Surgical
Palma Operation (Fig. 8.14)
May-Husni Operation
Latest Treatment in Varicose Veins
CASE 9:
Peripheral Vascular Disorders
Atherosclerotic Diseases
HISTORY
CHIEF COMPLAINTS
PAIN
Negative History
Etiological History
History of Involvement of Other Vessels
Local Examination
Inspection
Gangrene
Tests in Inspection
PALPATION
OTHERS
PALPATION OF PULSES
Disappearing Pulse
DISCUSSION
Atherosclerotic Disorders
Risk Factors (Flow chart 9.1)
Classification of Limb Ischemia
CHRONIC LIMB ISCHEMIA
Clinical Categories (For PG Standard)
Differential Diagnosis (Claudication Like Symptoms)
Popliteal Artery Entrapment Syndrome
Treatment
Persistent Sciatic Artery
Fibromuscular Dysplasia
Cystic Adventitial Disease
Cauda Equina Compression Syndrome
Osteoarthritis
Compartment Syndrome (Skin Splints)
Venous Claudication
Morphological Types of Iliac Lesions (For PG Standard) (Fig. 9.8)
Morphological Types of Femoropopliteal Lesion
INVESTIGATIONS FOR PVD
Blood Investigations
X-ray Chest
ECG
Noninvasive Vascular Assessments
Applications
Ankle Brachial Pressure Index (Fig. 9.10)
Exercise Tests (Increases Ankle Pressure)
Toe/Brachial Pressure
Segmental Pressure—Lower Limb
Preoperative Assessment of Amputation Level
Lower Limb Assessment
Invasive Vascular Assessments
Catheter Angiography
Routes
METHODs
Percutaneous or Open Approach
Vessel Puncture
Vascular Access Sites
DIAGNOSTIC CATHETERS (Fig. 9.13)
BALLOON ANGIOPLASTY CATHETERS (Fig. 9.14)
Other Investigations (Mention Only if Asked)
Treatment Options for Peripheral Vascular Disease
Surgical Intervention
Endovascular Intervention (Fig. 9.17)
Surgical Options
Suprainguinal Disease (Best Graft—PTFE or Dacron Materials)
Infrainguinal Disease (Best Graft—Saphenous Vein)
Management of PVD
Modify the Risk Factors
PHARMACOTHERAPY (Flow chart 9.4)
Thienopyridine Group
PROSTAGLANDINS
OTHERS
Endovascular Intervention
Extra-anatomical Reconstructions
Infrainguinal
INDEX
TOC
Index
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