Basics in General Surgery

R  Rajamahendran; Panchadcharam  Harinath

BASICS IN GENERAL SURGERY1

ULCER
• An ulcer is a break in continuity of the covering epithelium either in skin or mucus membrane due to molecular death.
Parts of ulcer
• Margin • Edge—that connects floor to margin • Floor—is one that is seen • Base—is one on which the ulcer rests. May be bone or soft tissue
Types of ulcer
1. Sloping ulcer ✓ Healing ulcer ✓ Inner part is red	2. Punched out ✓ Syphilitic gumma ulcer ✓ Trophic ulcer ✓ Due to end arteritis		3. Undermined edge ✓ Tuberculosis
4. Raised + beaded and rolled out ✓ Basal cell carcinoma (BCC) (rodent ulcer)		5. Everted and ✓ Squamous cell carcinoma

SINUS
• Definition: It is a blind track leading from the surface down into tissues.
Examples:
• Preauricular sinus • Pilonidal sinus—in midline in anal region • Osteomyelitis • Tuberculuos sinus • Actinomycosis—multiple sinuses in faciocervical

FISTULA
○ An abnormal communication between lumen of one viscus to lumen of another viscus (internal fistula) or ○ An abnormal communication between one hollow viscus with the exterior, i.e. body surface (external fistula)
Examples of internal fistula:
• Tracheoesophageal fistula • Colovesical fistula
Examples of external fistula:
• Orocutaneous fistula • Branchial fistula • Thyroglossal fistula

SWELLINGS IN SKIN
✓ Lipoma		✓ Sebaceous cyst		✓ Dermoid cyst
A-Lipoma
• M/c benign tumor in the body • Universal tumor—occur anywhere in body			Complications:
Characteristic feature:			• Sarcomatous change • Saponification • Calcification • Submucous lipoma in intestine causes intussusception and intestinal obstruction
✓ Non-tender ✓ Semi-fluctuant ✓ Mobile (slip sign) ✓ Skin is free
B-Dercum disease
• Multiple painful lipomas (adiposis dolorosa)		Treatment: Excision or enucleation
C-Cysts
• Cyst is a collection of fluid in a sac lined by epithelium or endothelium.
Cysts that are transilluminant:
✓ Ranula	✓ Cystic hygroma	✓ Hydrocele	✓ Epididymal cyst	♦ Meningocele
D-Dermoid cyst
1. Sequestration dermoid 2. Tubulodermoid			3. Implantation dermoid 4. Teratomatous dermoid
1-Sequestration dermoid
• Occurs at line of embryonic fusion • Epithelium gets sequestrated				MC sites of sequestration:
Clinical features:				• Forehead • External angular dermoid • Root of nose • Sublingual dermoid • Anywhere in midline at fusion
• Free skin • Not transilluminant • Fluctuant • Indentation of bone
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SWELLINGS IN SKIN
2-Tubulo-dermoid		4-Teratomatous dermoid
• Arises from embryonic structures Thyroglossal cyst Post-anal dermoid		• Arises from all germinal layers ecto, endo and mesoderm • Occurs in ovary, testis, retroperitoneum and mediastinum • Contains hair, teeth, cartilage and muscle • Can be benign or malignant • Teratomatous dermoid
3-Implantation dermoid
• Due to minor pricks or trauma, epithelium get buried into deeper subcutaneous tissue • M/c site is fingers
E-Sebaceous cyst
• It is a retention cyst due to blockage of the duct of sebaceous gland causing cystic swelling. • Not seen in palms and soles
Characteristic feature
1. Smooth, soft and non-tender, mobile 2. Moulds on finger indentation 3. Punctum—70% cases 4. 30 percent cases the cyst opens into hair follicles and punctum not seen.
F-Punctum with sebum: MCQ points in sebaceous cyst
• Parasite seen in the cyst—demodex folliculorum • Cock peculiar tumor—surface gets ulcerated leading to painful fungating mass • Sebaceous horn—hardening of slow discharge sebum via the punctum.			• Gardners syndrome → associated with multiple sebaceous cysts • Fordyce's disease→ ectopic sebaceous glands in lip and oral mucosa.

INFECTIONS IN GENERAL
✓ Cellulitis	✓ Abscess	✓ Carbuncle	✓ Hidradenitis
✓ Erysipelas	✓ Boils (furuncle)	✓ Pott puffy tumor	✓ Suppurativa
A-Follicular infections
Boils/furuncles:
• Hair follicle infection • Due to Staphylococcus
Carbuncle:
• Infective gangrene of skin and subcutaneous tissue • m/c Staphylococcus aureus • m/c site is nape of neck • m/c in diabetics
B-Hidradenitis suppurativa
1. Chronic fibrous and infective disease of skin-bearing apocrine sweat glands. 2. Apocrine glands are those, which open into hair follicle 3. m/c in diabetics 4. m/c in axilla 5. m/c due to staphylococci 6. Treatment: Excision with grafting.
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INFECTIONS IN GENERAL
C-Pott puffy tumor
• It is a misnomer • Diffuse external swelling in scalp due to subperiosteal pus formation and scalp edema		• Etiology—chronic frontal sinusitis, trauma • Complications—frontal bone osteomyelitis, intracranial abscess formation.

Cellulitis	Erysipelas
• Spreading inflammation of subcutaneous tissue and fascial planes	• Spreading inflammation of skin and subcutaneous tissue
• m/c due to Streptococcus pyogenes	• m/c due to streptoccal pyogenes
• Sequelae—abscess, bacteremia, pyemia, local gangrene	• Toxemia is always a feature
• Red shiny stretched warm skin	• Always associated cutaneous lymphangitis + vesicles form
• Discharge is purulent	• Serous
• Elevation limb, antibiotics	• Rx: Penicillins
• Milian ear sign—cellulitis not involve because skin is closely adherent to subcutaneous tissue	• Positive in ear lobule.

Pyogenic abscess	Cold abscess
✓ Pyogenic bacteria- Staphylococcus, Streptococcus	✓ Tuberculosis
✓ Red warm with inflammatory signs	✓ No signs of inflammation
✓ Dependent drainage	✓ Non-dependent drainage
✓ Drain placed	✓ No need of drain

INFECTIONS IN THE HAND
• Acute paronychia→ subcuticular infection caused by Staphylococcus aureus • Chronic paronychia→ chronic nail infection caused by Candida • Felon→ Terminal pulp space infection • Deep Palmar abscess→ abscess beneath flexor tendons (Frog hand) • Dupuytrens contracture→ Thickening of palmar/plantar fascia

NUTRITION IN SURGERY
Indications for artificial nutrition	Types of nutrition
• Any patient, who has sustained 5–7 day of inadequate intake	• Enteral nutrition
• Any patient, who is anticipated to have no intake for 5–7 day	• Parenteral nutrition

TYPES OF ENTERAL NUTRITION
1. Sip feeding	2. Tube feeding			3. Nasogastric feeding
1. Sip feeding	A. Nasogastric tube	B. Gastrostomy	C. Jejunostomy	3. Nasogastric feeding
✓ Ryles tube is the preferred method for most patients. ✓ If the tube has to be left for more than a week a fine bore tube (diameter < 3 mm) is used, which is inserted via a guide wire.
Gastrostomy		Jejunostomy
• Indication: If a patient needs enteral nutrition for a period of 4–6 weeks then percutaneous endoscopic gastrostomy (PEG) is preferred • Types of insertion: Surgical gastrostomy or PEG under local anesthesia.		• Main indication of jejunal feed is where we want to give rest to gastric secretion and function • For example, pancreatitis • Types: surgical or nasojejunal tubes.
Complications of enteral nutrition
✓ Tube related—malposition, blockage ✓ Gastrointestinal—diarrhea (30%), nausea, bloating, aspiration and constipation		✓ Electrolyte and metabolic disturbances ✓ Infection

PARENTERAL NUTRITION
• Provision of all nutrients by means of intravenous route and without utilizing the alimentary tract • Types: Peripheral and central nutrition
Peripheral	Central
• Appropriate for feeding less than 2 week. • Types: Conventional wrist vein canulas. Peripherally inserted central venous catheter (PICC). Mean survival period 7 days. Major disadvantage is thrombophlebitis.	○ Parenteral feeding for greater than 2 week. Via: subclavian vein, external or internal jugular vein. Infraclavicular subclavian vein approach is best because of the suitable location of the catheter in the chest. Always do a post insertion chest X ray—to r/o pneumothorax and to confirm distal tip lies in the distal superior vena cava to minimise central vein or cardiac thrombosis.

INDICATIONS OF TOTAL PARENTERAL NUTRITION
As primary therapy	As supportive therapy
1. Gastrointestinal fistulas 2. Renal failure (Acute tubular necrosis) 3. Short gut syndrome 4. Severe burns 5. Hepatic failure 6. Crohn disease 7. Anorexia nervosa	1. Radiation enteritis 2. Acute chemotoxicity 3. Prolonged ileus 4. Weight loss preliminary to surgery
	• In acute pancreatitis cases, there will be mild GOO hence nasojejunal feeding or jejunostomy advised. But if the patient cannot tolerate give them total parenteral nutrition (TPN).
Complications	Metabolic complications
1. Catheter related 2. Infection 3. Injuries→Pneumothorax, hydrothorax, cardiac tamponade, injury to artery and vein, injury to thoracic duct, nerves. 4. Thrombosis 5. Air embolism, catheter embolism 6. Post-cannulation	1. Azotemia 2. Essential fatty acid deficiency 3. Fluid overload 4. Metabolic bone disease 5. Liver dysfunction 6. Glucose imbalance(hyperglycemia, hypoglycemia) 7. Trace element and vitamin deficiency. 8. Electrolyte abnormalities

Character	Hypertrophic scar	Keloid
Race	–	Black
Genetic	–	Yes
Sex	Male = Female	Female > Male
Age	Children	10–30 year
Border	Confined to wound	Outgrows wound
Site	Flexor	Triangle—sternum, right and left shoulder
Cause	Tension	Unknown
Natural	Subsides with time	Rarely subsides

Salmon patch	Port-wine stain	Strawberry angioma
• Present since birth • Disappears before 1 yr	• Since birth • Does not disappear	• Not present at birth • Appears 1–3 week • Starts disappearing after 1 yr and completely disappears at 7 yr

FLUIDS AND ELECTROLYTES
Hyperkalemia & Hypokalemia
Characteristics	Hyperkalemia	Hypokalemia
1. Definition	• K+ > 5.5 mmol/L	• K+ < 3.5 mmol/L
2. Etiology	✓ Hypoaldosteronism ✓ Trimethoprime ✓ Pentamidine	✓ Drugs (Insulin, alpha blocker & beta2 agonist). ✓ Metabolic alkolosis. ✓ Hyperaldosteronism ✓ Cushing syndrome. ✓ Diabetic ketoacidosis ✓ Bartter syndrome. ✓ Congenital adrenal hyperplasia. ✓ Hypoventilation
3. Clinical presentation	• Muscle weakness • Flaccid paralysis • Hypoventilation if respiratory muscle involved • Cardiac toxicity causing ventricular fibrillation or asystole.	• Hypotonia and paralytic ileus. • Abdominal distension. • Fatigue, myalgia and episodic muscle weakness.
4. Electrocardiogram (ECG)	✓ Tall peaked T wave^* ✓ Sine wave pattern ✓ Increased PR and increased QRS duration	✓ Prominent U wave^* ✓ Flattening/inversion of ‘T’ wave. ✓ ST depression ✓ Prolonged ‘QT’ interval
5. Treatment	• Ca gluconate • Insulin with dextrose • HCo₃ (severe) • Peritoneal dialysis	• Oral KCL, IV KCI (severe cases)

HYPERCALCEMIA AND HYPOCALCEMIA
Characteristics	Hypercalcemia	Hypocalcemia
1. Definition	• Serum calcium >5.5 mEq/L.	• Serum Ca⁺ < 4.5 mEq/L
2. Etiology	✓ Milk alkali syndrome ✓ Sarcoidosis ✓ Multiple myeloma ✓ Ca-breast, kidney, bronchus ✓ Lithium excess ✓ Hyperthyroidism ✓ Hyperparathyroidism	✓ Tumor lysis syndrome. ✓ Hypoparathyroidism. ✓ Chronic renal failure. ✓ Heparin, protamine, glucagon. ✓ Acute pancreatitis. ✓ Hypoalbuminemia.
3. Clinical presentation	• Fatigue • Depression • Mental confusion • Lethargy • Anorexia, nausea, vomiting • Constipation • Polyuria • Stupor and coma (severe cases) • Decreased QT interval • Nephrocalcinosis.	• Increased neuromuscular excitability. • MuscIe spasm • Laryngeal spasm and convulsion (in severe cases) • Chovstek's, trousseau's sign • Increased QT interval
4. Treatment	✓ Diuresis ✓ Calcitonin and biphosphonates. ✓ Glucocorticoids ✓ Dialysis	✓ Vit D + IV Ca gluconate ✓ Thiazide

HYPERNATREMIA AND HYPONATREMIA
Characteristics	Hypernatremia	Hyponatremia
1. Definition	• Plasma Na+ > 145 mmol/L	• Plasma Na + < 135 mmol/L
2. Etiology	✓ Diarrhea ✓ Osmotic diuresis ✓ Decreased fluid intake ✓ Central diabetes insipidus (DI)	✓ Chronic renal failure (CRF) ✓ Nephrotic syndrome and cirrhosis. ✓ SIADH ✓ Diuretic
3. Clinical presentation	• Altered sensorium • Irritability, seizure. • Thirst, polyuria • Weakness, twitching	• Hypoaldosteronism • Nausea, headache, confusion • Stupor, seizure, coma • lncreased ICT
4. Treatment	• Water intake • Correct etiology	• Fluid and salt restriction • Diuretics • Hypertonic saline

FLUID THERAPY: TWO TYPES OF FLUIDS CRYSTALLOIDS AND COLLOIDS
Crystalloids	Colloids
1. May be isotonic/hypertonic	1. Hypertonic solution.
2. Expands plasma volume for less time	2. Expands plasma volume for 2–4 hour.
3. Cheap	3. Expensive.
4. Can precipitate cerebral edema.	4. Decreased cerebral and pulmonary edema.
5. For blood loss replacement 3 times of the lost be given	5. Replaced in 1: 1 ratio of lost fluid.
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FLUID THERAPY: TWO TYPES OF FLUIDS CRYSTALLOIDS AND COLLOIDS
6. Examples are ✓ Ringer lactate ✓ Normal saline ✓ Glucose solution. ✓ Dextrose with N.S. ✓ Hypertonic saline	6. Examples are ✓ Dextrans ✓ Albumin ✓ Gelatins ✓ Hydroxyethyl starch ✓ Blood replacement.

CHOICE OF FLUID
1. Ringer lactate (Balanced salt solution)		2. Colloids
✓ Intestinal obstruction ✓ 1st 24 hours of burn ✓ Intraoperative fluid management		✓ Renal failure ✓ Liver failure (albumin)
3. Normal saline		4. Hypertonic saline
✓ Hyponatremia ✓ Brain injury ✓ Diabetic ketoacidosis ✓ Hypochloremic metabolic alkalosis.		✓ Cerebral and pulmonary edema ✓ Hyponatremia
Types of wound
Clean uncontaminated (Infection rate < 2%)	Clean contaminated (Infection rate upto 30%)	Infected wound (Infection rate> 50%)	Unclean contaminated
• Examples are wound of heart, brain, joint and transplant surgery. • Wounds of herniorrhaphy • Excision	• Wounds of bowel surgery, biliary and pancreatic surgery appendicectomy, gastrojejunostomy	• Appendiceal abscess • perirectal abscess drainage • Infected laceration • Fecal peritonitis	• Worst wound • Acute cholecystitis with spillage of pus from gallbladder. • Traumatic wound • Bowel obstruction with enterotomy and spillage of content.
Type of wound suturing
✓ Primary suturing—done for clean wound within 6 hour.	✓ Delayed primary suturing—done for lacerated wound within 48 hour		✓ Secondary suturing—done for infected wound in 10–14 day

Absorbable suture materials	Time of absorption
1. Plain catgut	7–10 day (Derived from sheep's intestine)
2. Chromic catgut	90 day
3. Polyglactin	60–90 day
4. Polyglyconate	180 day
5. Polyglycolic acid (Vicryl)	60–90 day
6. Polydiaxanone (PDS)	180 day (longest absorbable suture material)
7. Polyglycaprone	90–120 day

FMGE QUESTIONS

Commonest complication of parenteral nutrition includes all, except: (Sep 2003)
1. Hyperglycemia
2. Hyperkalemia
3. Hyperosmolar dehydration
4. Azotemia

Ans: d (Azotemia)

Which of the following is preferred cannulation site for total parenteral nutrition: (Sep 2003)
1. Subclavian vein
2. Great saphenous vein
3. Median cubital vein
4. External jugular vein

Ans: a (Subclavian vein)

Which is best method for supplementing nutrition in patients, who have undergone massive resection of the small intestine is: (Sep 2004)
1. Parenteral
2. Enteral
3. Gastrostomy
4. All of the above

Ans: a (Parenteral)

Which of the following solution is a colloid: (March 2004)
1. Normal saline
2. Albumin
3. Ringer lactate
4. Dextrose 5%

Ans: b (Albumin)

Which of the following is true regarding tuberculous lymphadenitis: (Sep 2005)
1. History of contact with TB patient may be present
2. Commonly seen in the young and children
3. Mostly in the cervical region
4. All of the above

Ans: d (All the above)

Pneumoperitoneum is created by: (Sep 2008)
1. O₂
2. CO
3. CO₂
4. N₂O

Ans: c (CO₂)

All of the following conditions result in chronic thick walled pyogenic abscess, except: (Sep 2008)
1. Inadequate surgical drainage
2. Virulent strain of offending organism
3. Prolonged course of antibiotic therapy
4. Presence of foreign body

Ans: b (Virulent strain of offending organism)

Cock's peculiar tumor is: (March 2006)
1. Infected sebaceous cyst
2. Osteomyelitis of skull
3. Cyst in the skull
4. Tumor of the skull

Ans: b (Osteomyelitis of skull)

Cellulitis is most commonly caused by: (Sep 2006)
1. Clostridia
2. Staphylococci
3. Streptococci
4. Haemophilus influenzae

Ans: c (Streptococci)

All of the following are complications in a patient on total parenteral nutrition, except: (March 2006)
1. Hyperchlosterolemia
2. Hyperglycemia
3. Hypotriglyceriedemia
4. Hypophosphatemia

Ans: c (Hypotriglyceridemia)

The metabolic complications associated with PN in adult patients include hyperglycemia, hypoglycemia, hyperlipidemia, hypercapnia, refeeding syndrome, acid-base disturbances, liver complications, manganese toxicity and metabolic bone disease.

Bed sore is an example of: (Sep 2003, 2009)
1. Tropical ulcer
2. Trophic ulcer
3. Venous ulcer
4. Post-thrombotic ulcer

Ans: b (Trophic ulcer)

Tropical ulcer is a lesion occurring in cutaneous leishmaniasis. It is caused by a variety of microorganisms, including mycobacteria. It is common in tropical climates. Ulcers occur on exposed parts of the body, primarily on anterolateral aspect of the lower limbs and may erode muscles and tendons and sometimes, the bones.10

Trophic ulcer (Neurogenic ulcer): Trophic ulcers occur in diseases and injuries to the spinal cord and peripheral nerves; for example, they may arise on the foot after injury to the sciatic nerve. It may also result from local circulatory impairment as in bed sore.

Marjolin ulcer is: (Sep 2003)
1. Malignant ulcer found on the scar of burn.
2. Malignant ulcer found on infected foot
3. Trophic ulcer
4. Meleney gangrene

Ans: a (Malignant ulcer found in scar of burn)

Which of the following catheter material is most suited for long term use is: (Sep 2007)
1. Latex
2. Silicone
3. Rubber
4. Polyurethane

Ans: b (Silicone)

Silicone materials can be used for even upto 12 weeks

Potts puffy tumor is: (Sep 2005)
1. Osteomyelitis of frontal skull
2. Abscess in the skull
3. Carcinoma of the frontal bone
4. None of the above

Ans: a (Osteomyelitis of frontal bone)

Most common mode of spread to cervical lymphnode in TB is: (Sep 2005)
1. Hematogenous
2. Lymphogenic
3. Contact
4. None

Ans: a (Hematogenous)

Collar stud abscess seen in: (Sep 2005)
1. TB
2. Syphilis
3. Actinomycosis
4. Staphylococcal

Ans: a (TB)

Bezold abscess is seen in: (Sep 2010)
1. Sternocleidomastoid muscle
2. stylohyoid muscle
3. Sartorius muscle
4. semimembranosus muscle

Ans: a (Sternocleidomastoid muscle)

Bezold's Abscess is an abscess in the sternocleidomastoid muscle, where pus from a mastoiditis escapes into the sternocleidomastoid. It is a rare complication of acute otitis media.

Best prophylaxis by surgeon in preventing the gas gangrene as a complication is: (Sep 2009)
1. Antibiotics
2. Strict antiseptic protocol
3. Sterilization methods
4. All the above

Ans: d (All the above)

The following are absorbable suture materials, except: (Sep 2010)
1. Catgut
2. Polyglycolic acid
3. Prolene
4. Polydiaxone

Ans: c (Prolene)

The ulcer which has undermined edge is due to the cause: (Sep 2010)
1. Arterial
2. Venous
3. Tuberculous ulcer
4. Malignancy

Ans: c (Tuberculous ulcer)

Dermoid cyst are commonly seen in: (Sep 2011)
1. Finger
2. Skin
3. Skull
4. Hip

Ans: c (Skull)

Chapter Notes

BASICS IN GENERAL SURGERY1