Bedside Clinics in Surgery Makhan Lal Saha
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1Bedside Clinics in Surgery2
SECOND EDITION
3Bedside Clinics in Surgery Long and Short Cases, Surgical Problems, X-rays, Surgical Pathology, Preoperative Preparations, Minor Surgical Procedures, Instruments, Operative Surgery and Surgical Anatomy
Makhan Lal Saha MBBS MS (Surgery) FMAS FAIS Professor Department of General Surgery IPGME & R/SSKM Hospital, Kolkata, West Bengal, India Formerly Associate Professor Department of General Surgery, Calcutta Medical College North Bengal Medical College Forewords N Chintamani Manoj Kumar Bhattacharya
4
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This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device.
Bedside Clinics in Surgery
First Edition: 2004
Second Edition: 2013
9789350906453
Printed at5
Dedicated to
My late parents Madhusudan Saha and Pushpa Rani Saha,
my revered uncle Shri Jadulal Saha
and my teachers
for whom what I am today.6
7Foreword to the Second Edition
“He who loves his work never labors.”
—Jim Stovall
It gives me great pleasure and joy to write a foreword for this extra-ordinary book on Bedsideclinics insurgery the 2nd edition by Dr Makhan Lal Saha published by M/s Jaypee Brothers Medical publishers (P) Ltd, New Delhi, India. The book is a classic example of how to make reading exhaustive yet lucid and enjoyable.
I have known the author for more than a decade and I can vouch for his dedication and keen interest in the teaching of the science and art of surgery. Having authored a few books myself, I am sure that any book is a true reflection of the author's love for the subject, his readers and students and it is clearly palpable in this book. Dr Saha's exceptional way of narrating the text makes this book a masterpiece for bedside learning of surgery.
Like in the first edition, the very simple way of teaching even the complex aspects of surgery has its impact on the reader. The litmus test for any book on bedside clinics is the utility during various undergraduate and postgraduate examinations. The book is surely going to pass that test with flying colors as it is a wonderful blend of all the essential aspects of performance in the examinations and in real-life scenario as a doctor.
The mandatory aspect of learning of surgery involves a thorough understanding of the surgical anatomy. The addition of various essential aspects of surgical anatomy with very easily discernible pictures adds tremendous value to this book. There are very limited texts available that address the issue of surgical anatomy of relevant regions.
A picture is worth a thousand words and the presentation of various clinical scenarios with real-life clinical pictures is truly remarkable. The demonstration of bedside physical signs and performance of certain important procedures have been addressed using a very simple and understandable method. The book is strongly recommended for all undergraduate, postgraduate trainees and trainers alike.
N Chintamani
MS FRCS (Ed) FRCS (Glas) FRCS (Irel)
FACS FICS (Surg Oncol) FIMSA
Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
Honorary Secretary—Association of Surgeons of India-2012
Governing Council member—Association of Surgeons of India
President (elect)—Association of Breast Surgeons of India
Editorial Secretary—Indian Association of Surgical Oncology
Controller of Examinations—College of Surgeons of India
Past President—Indian Society of Wound Management
Chief Editor—Surgical Clinics of India
Joint Editor—Indian Journal of Surgical Oncology
Associate Editor—Indian Journal of Surgery8
9Foreword to the First Edition
It is my pleasure to write a foreword for Dr Makhan Lal Saha's book, Bedside Clinics in Surgery. I know him for more than a decade and though he being a general surgeon worked under me in my neurosurgery department for two years with keen interest and proved his worth.
I have gone through the proofs of his venture and I am sure his efforts will prove results both to the undergraduate and postgraduate students in surgery.
I am confident that his dedication to author this book for last five years and practical experience will be very much useful to them for whom he has written. I am sure his book will be highly appreciated, amply rewarded and accepted by the entire medical students community.
HB 267 Salt Lake, Sector-3
26th January, 2004
Manoj Kumar Bhattacharya
MS MCh (Neurosurgery)
Former Dean
Faculty of Medicine
University of Calcutta
Kolkata, West Bengal, India10
Preface to the Second Edition
11 Bedside Clinics in Surgery released in the year 2004 was well accepted by both undergraduate and postgraduate students. The book was also read by students of allied disciplines. Subsequently, there have been repeated revised reprints. I worked on for last 9 years for necessary changes for the second edition of the book. All the sections of the book have been thoroughly revised and updated. All the recent guidelines for treatment have been incorporated in the book. In the first edition, surgical anatomy and operative surgery was discussed along with the long and short cases. In practical examination, emphasis is given on surgical anatomy and operative surgery. Keeping in mind that, I have added two new sections in the second edition—a section on surgical anatomy and another section on operative surgery. The section on surgical anatomy is not exhaustive—the important topics required for undergraduate examination have been covered. The operative section is little more elaborate and covers almost all common operations. The topics required mainly for postgraduate students are in italics.
The first edition of the book contained black and white pictures except the surgical pathology section. With the idea of publishing the book in a better way, the second edition is being published and marketed by M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India. I am grateful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director) and Mr Tarun Duneja (Director-Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for their interest in publishing the book.
My sincere thanks to editing team members of M/s Jaypee Brothers Medical Publishers (P) Ltd at New Delhi—Ms Sunita Katla (Publishing Manager), Mr KK Raman (Production Manager), Mr Rajesh Sharma (Production Coordinator), Ms Seema Dogra (Cover Designer), Ms Geeta Srivastava, Mr Laxmidhar Padhiary, Mr Sarvesh Kumar Singh (Proof readers), Mr Kapil Dev Sharma, Mr Kulwant Singh (DTP Operators) and Mr Sumit Kumar, Mr Rajesh Ghurkundi (Graphic Designers), and at Kolkata Mr Sandip Gupta, Mr Sabyasachi Hazra and Mr Suman Dutta for their dedicated and affectionate working in the second edition of the book. I am sure the quality of the book in respect of paper, binding and design will be liked by all the readers.
In this second edition, the book contains approximately 1,100 figures. Most of the pictures for demonstration of clinical signs have been replaced by new color photographs. The schematic diagrams in instrument section have been replaced by actual photographs. The instruments required for laparoscopic surgery has been included. My postgraduate trainees Dr Subhamitra Chowdhury, Dr Vivek Sharma, Dr Sidhartha Bhattacharya, Dr Sarvesh Gupta, Dr Asif Ayaz, Dr Subhendu Majhi, Dr Kamal Singh Kanowar; my daughters Dr Priyanka Saha (Internee at Medinipur Medical College) and Monica Saha (student at KPC Medical College), and my friends Dr Kaushik Ghosh, Dr Partha Bhar and Dr Soumen Das has taken the new photographs included in the second edition of the book. My colleagues at Institute of Postgraduate Medical Education and Research (IPGME & R) Prof Bitan Kumar Chattopadhyay, Prof Amitava Sarkar, 12Prof Prasanta Bhattacharya, Prof Diptendra Kumar Sarkar, Dr Shyamal Kumar Halder, Dr Anadi Nath Acharya, Dr RS Moral, Dr Susnata De, Dr Subhasis Saha, Dr Subhra Ganguly, Dr Soumya Mondal, Dr Saurav Das, Dr Prakash Kumar Bhagat, Dr Mainak Pal, Dr Partha Sarathi Dutta, Dr Sunanda De were all helpful and provided many clinical photographs for inclusion in the book. Some of the clinical photographs are also provided by my well-wishers Prof Sukumar Maity, Prof Sasanka Sekhar Chatterjee, Prof Biswanath Mukhopadhyay, Dr Kalyani Saha Basu and Dr Shamik Bandopadhyay. My wife Smt Priti Saha has also worked hard and helped me during computer typing of different sections of the book.
My friend Prof Sekhar Mukhopadhyay, Bidhannagar Government College, West Bengal, India, always encouraged and helped me with his artistic idea during the preparation of the second edition of this book.
I received numerous suggestions from my colleagues and students and I have tried my best to incorporate all these in the second edition of the book.
I thank all the students and faculty members for their applauding remarks about the book. I am sure the students will be benefited by this book. However, I once again like to emphasize that this book is not a substitute for a standard textbook of surgery, which every student should read for acquiring a basic concept of surgery.
I am sure there is scope for further improvement in the next edition of the book. I would request all the readers, my students and colleagues to give me their opinion and valuable suggestion. The suggestion may please be sent to me in my e-mail address.
Makhan Lal Saha
Preface to the First Edition
13Practical examination in surgery is exhaustive, encompassing long cases, short cases, surgical problems, surgical pathology, radiology, surgical instruments, minor surgical procedures, preoperative preparation and operative surgery. At present, there is no book available, which covers all these aspects in a comprehensive manner, suitable for preparation in final MBBS examination. The impetus for writing a book was primarily initiated by one of my favorite students, Dr Shamik Nandy of Calcutta Medical College. This book, very different in its approach, content and design, provides students of MBBS the basic and accurate knowledge of the practical problems, which can be assimilated in a reasonable but short time. With six years of extensive hard work, I have been able to present this book to the students of surgery.
This book covers discussions on almost all aspects of practical examinations. In long and short cases, a sample summary is given and management is discussed based on that particular case. The detailed discussion about that particular disease is presented afterward. The summary described may not be reproducible in examination, but provides a valuable guideline as to how to write a good summary of a particular case. Demonstration of physical signs with photographs and schematic diagrams are also included in each section of the long and short cases. In long and short case discussions, the students have to plan relevant management of the particular clinical situation presented by him in the said examination. The section on surgical problems covers both emergency and non-emergency conditions. A general outline for answer in such a situation is presented. In X-rays section, representative plates are presented and discussion is based on the findings of the particular X-rays. Discussions on the relevant clinical situation are also covered. In surgical pathology section, a representative specimen is described and this section mainly deals with the pathological aspects of the particular disease. For better clarity and understanding, the surgical pathology specimens are printed in color. Preoperative preparations for elective major surgery as well as those associated with common coexisting medical diseases are discussed. The section on minor surgical procedures is not exhaustive and only covers the important procedures commonly asked in examinations. Operative surgery is not discussed in a separate section but important operations are discussed with long and short cases and in other sections of the book. In instrument section, relevant points for identification of the instrument are mentioned. While discussing the use of instruments, emphasis has been given to mention the particular operations where the instrument is used. Sterilization of instruments are discussed in detail. Every attempt has been made to create a condensation of information by pointwise framing that will fulfil the students’ need during examination. Throughout the text, emphasis has been given for methods of demonstration of clinical signs. An attempt has been made to maximize the number of illustrations to complement the general text materials. Photographs and schematic diagrams have been used for demonstration of clinical signs and operative procedures. The book contains 485 illustrations, numerous photographs and X-ray plates.
14This book, however, is not a textbook of surgery. I would recommend all the students to go through standard textbooks of surgery for acquiring basic concepts. This book provides a very simple, comprehensive, updated, and well-illustrated account, which may be used as a revision book for preparation for practical examination in surgery. At places, the discussions are exhaustive and may not be required for undergraduate students. These are indicated by italic fonts. I would like to thank Dr Shamik Nandy, who has gone through the whole manuscript and suggested important modifications to make the book suitable for undergraduate students. I would like to thank Prof Biswanath Mukhopadhyay, Professor of Pediatric Surgery, Dr Anadinath Acharya, Assistant Professor of Surgery, Dr Sasanka Sekhar Chatterji, Associate Professor of Plastic Surgery and Dr Sukumar Maiti, Associate Professor of Surgery who have provided majority of the clinical photographs included in the long and short case sections of the book. I would like to thank all the faculty members of the Department of Surgery IPGME & R/SSKM Hospital, Kolkata, West Bengal, India, namely Prof PK Gupta, Dr Sushma Banerji, Dr QM Rahaman, Dr PK Sarkar, Dr Abhimanyu Basu, Dr PS Paul, Dr DK Sarkar, Dr S Das Chowdhury, and Dr SK Halder for their constant help and encouragement while I was preparing this book. They have also gone through the proof of the book. One of my postgraduate students, Dr Srinjoy Saha spent lots of his time in taking different photographs included in this book. Dr Krishnendu Maity, postgraduate student at Calcutta Medical College has also taken some photographs included in this book. Dr Ranjit Das, Dr Kaushik Ghosh, Dr Budhadeb Saha for help in preparation of some sections of this book. I thank my friend and well wisher Prof Sekhar Mukhopadhaya for his constant encouragement while I was writing this book. He has also helped in designing the cover page of this book. I would like to thank Dr Bansari Goswami, Professor and Head, Department of Surgery, NRS Medical College, and Dr Mrityunjoy Mukherji, Professor and Head, Department of Surgery, Calcutta National Medical College for allowing me to take the photographs of surgical pathology specimens included in this book. Dr Sudip Chakraborty, Professor and head, Department of urology, and Dr AG Ghosal, Professor and Head, Department of Chest Medicine, IPGME & R, provided some X-ray plates for inclusion in this book. Dr Satinath Mukherji, Associate Professor, Department of Endocrinology for help in writing the section on diabetes and surgery.
I would like to thank Mr Bimal Dhur and Sri Dipankar Dhur of Academic Publishers who were always after me over these years and for their sincere efforts to publish this book in time. Other members of staff of Academic Publishers Sri Abhijit Chakraborty, Sri Biswajit Seal and Sri Swapan Dutta also worked hard for making this publication successful. I thank Mr Narayan Sur and Mr Dilip Das who have drawn the different diagrams included in this book.
I am indebted to my wife Smt Priti Saha and my daughters Priyanka and Monica for their wholehearted support in this endeavor. I will never forget their sacrifice of long hours of family associations over these years while I was busy preparing this book.
My sincere thanks are due to my enthusiastic young students, friends, relatives and well-wishers for their constant support, encouragement and help.
In spite of all precautions, a good number of printing errors might have gone unnoticed. I would request all the students to go through the corrigendum and correct the text to avoid confusion.
I hope this book will be beneficial to students of surgery and my efforts will be amply rewarded only if this book is accepted by the students and teachers of surgery. I apologise for any inadvertent mistakes, which might have been overlooked. I will be happy to receive comments, criticisms and suggestions for the improvement of this book in future from my readers, which I shall duly incorporate in the next edition of the book. The comments and the suggestions may please be sent to me at my residential address or to my e-mail address.
Makhan Lal Saha
Acknowledgments
15Prof Susanta Banerjee (Director of Medical Education), Prof Indrajit Saha (Joint Secretary, Department of Health and Family Welfare), Swasthya Bhavan (Salt Lake City, Kolkata), for giving me necessary permission for publishing this book.
My sincere thanks and gratitude to the following persons for their constant help and encouragement during preparation of this book:
Surgery Curriculum for MBBS Students
27 Clinical classes in surgery: Total 26 weeks
3rd Semester
:
6 weeks
4th semester
:
Nil
5th Semester
:
4 weeks
6th semester
:
Nil
7th semester
:
4 weeks
8th semester
:
6 weeks
9th semester
:
6 weeks
Final MBBS surgery Examination: Marks distribution for Surgery
  • Theory: 2 Papers: 120 (60+ 60)
  • 2½ hours duration in each paper
    • Paper I:
      • : General surgery
      • : Orthopedic surgery
    • Paper II:
      • General surgery
      • Anesthesiology
      • Dentistry
      • Radiotherapy
      • Radiology
  • Oral:
  • Practical:
    • Internal assessment:
    • Total marks:
    • Pass criteria: 50% in aggregate.
      • Practical minimum 50%
      • Theory and oral minimum 50%.
  • 20 marks
  • 100 marks
  • 60 (Theory 30 + Practical 30)
  • 300 marks
Honours: 75% marks in the subject provided other subjects are cleared in one chance.
Surgery theory examination
    • Paper I:
    • 60 marks
:
  1. Long question type (compulsory) 10 + 5 = 15
    • »General principle/Basic science.
  2. Long question (1 out of 2) − 15
    • »Gastrointestinal tract.
  3. 28Short answer type (5 out of 6) 2 × 5 = 10
    • »General surgery.
      :
  4. Short notes (5 out of 7) 4 × 5 = 20
    • »Orthopedics.
    • Paper II:
    • 60 marks
  1. Long question (Compulsory) – 15
    • »Endocrine and breast:
      Thyroid
      Parathyroid
      Adrenal
      Breast.
  2. Long question (1 × 15 = 15) or Short notes (3 out of 5) 3 × 5 = 15
    • »Genitourinary.
  3. 29Short answer type (2 out of 3) 2 × 5 =10
    • »Pediatric
    • »Plastic
    • »Neurosurgery
    • Cardiothoracic and vascular surgery.
  4. Short notes (4 out of 5) 4 × 5 = 20
    • »Anesthesiology
    • »Radiology
    • »Dental
    • »Radiotherapy, etc.
Surgery practical examination
One long case (30 minutes)
40 marks
Two short cases (5 × 2 = 10 minutes) − 20 × 2 = 40 marks
Operative: 20 marks
Oral : 20 marks
Opinions About the Book
“Bedside Clinics in Surgery, a book which is needed by the undergraduate and postgraduate students alike. It forms the logical next step to ‘Clinical Surgery’ by Dr Das, and may even replace it as the student's companion for clinical cases.
One of the prime difficulties in reading textbooks is the long paragraphs and prose, uninterrupted by photographs, diagrams or color diagrams. The author has successfully overcome this by formatting the text as questions and answers. The inclusion of photographs, especially color pathology slides, is welcome.
Each section starts with an outline for describing a case. This would be extremely useful for the students, as they know which points are to be stressed during presentation. I would further commend the author in pointing out errors usually made by the students, e.g. saying ‘nothing significant’ in family history.”
I have not come across another book, which covers the case, from a clinical point of view so well, e.g. even the doses and side effects of antituberculous drugs are given. Hence, the student does not have to cross-refer to a number of books.
One of the problems, postgraduate students face, is the variety of ways in which a problem can be tackled. This book gives the most widely accepted technique of doing so.
The inclusion of pathology specimens is the first of its kind as far as I know. Description of X-rays and instruments makes it a complete book for the exam-going students.
—AK Attri, JIMA, November 2005 Issue
“The book has an interesting question and answer format, which is exam oriented. I found it to be informative and accurate. The diagrams are clear and simple. The instruments and pathology specimens are clear.”
—Dr Benjamin Perakath, Professor and Head
Department of Surgery Unit V, Christian Medical College, Vellore, India
“I like it very much. I have recommended it to my students. The clinical examination, eliciting signs, writing a case sheet, common questions that will be asked and answers to the questions, surgical pathology, instruments, operative procedures and totally the presentation of book shows the experience and expertise of the author. I am sure a student who has no knowledge can excel with this book in hand and do well in the examination.”
—Dr B Kanchana, Professor and Head, Department of Surgery
Aarupadai Veddu Medical College and Hospital
Kirumampakkam, Puducherry, India
“Students from our institute are also looking for an additional book on surgery clinics to do better than others in practical examination.”
—Dr Suneel Kumar Gadikota, Associate Professor of General Surgery
Kamineni Institute of Medical Sciences, Narketpally, Nalgonda, Andhra Pradesh, India
“The book has great scope for undergraduates, postgraduates and staff as well. It includes all contemporary material. The book is a boon for undergraduates as the text is made very easy to understand and in friendly language with most frequently asked questions in examinations.”
—Dr Gurpal Singh Chhabda, Associate Professor of General Surgery
Kamineni Institute of Medical Sciences, Narketpally, Nalgonda, Andhra Pradesh, India
“I have gone through the book titled as Bedside Clinics in Surgery by Dr Makhan Lal Saha, which is highly educative and complete in all aspects of the surgery for the students of undergraduate and postgraduate courses. Everything is discussed in a comprehensive manner on long and short cases including traumatic and emergency services. It is also a rare phenomenon to discuss in detail about the X-ray procedures and surgical pathology pertaining to the patients. It has also a practical discussion procedures. No other book discusses in such a great length about the instruments which are quite crucial for exam-appearing students. Though it is not a substitute for textbook of surgery, it gives readymade guidelines for the students appearing for undergraduate and postgraduate examinations.”
—Superintendent, Osmania General Hospital, Hyderabad, Andhra Pradesh, India
“The book is good and it will be useful to the undergraduates and postgraduates in surgery.”
—Dr BS Gedam, Professor
Department of Surgery, Government Medical College, Nagpur, India
“It has plenty of information for a quick revision before examinations or even before presentations. Highly recommended.”
—Dr RCM Kaza, Professor
Department of Surgery, Maulana Azad Medical College, New Delhi, India
“The question and answers given in each chapter are the frequently asked questions in any standard examination by the examiner.
The author should be congratulated for using the clinical photographs from his own collection and colleagues. The book covers not only clinical surgery but also X-rays, surgical pathology, preoperative preparations, minor surgical procedures and instruments.”
—Dr N Dorairajan, Professor, Department of Surgery
Madras Medical College, Chennai, Tamil Nadu, India
“Keeping in view the practical and viva-voce of MBBS examinations, the book has been designed in a different style. The content of the book is precise and methodical. Series of common long and short cases with related questions will prove helpful to the students. The author has very well compiled the common operative procedures; details of routine instruments and various common radiographs.”
—Prof M Amanullah Khan, Chairman, JN Medical College
Aligarh Muslim University, Aligarh, Uttar Pradesh, India
“Dr Saha has done a very good job and the book is a very useful not only for undergraduates but also for postgraduate students as well. The section on short cases in surgery is particularly helpful for the students and gives them relevant information as a question-answer session.”
—Dr Navneet Kaur, UCMS and Guru Tegh Bahadur Hospital, Delhi, India
“I have gone through the book and found to be useful for the undergraduate students of MBBS, and I strongly recommend this book for reference to MBBS students.”
—Dr AT Kamble, Professor and Head, Department of Surgery
Indira Gandhi Government Medical College, Nagpur, Maharashta, India
“The book discusses all the probable questions that may be asked in the clinical examination. The author must be a good examiner and also observed the questions asked by other examiners in the clinical examination. The investigations described are relevant to the clinical cases. The surgical pathology, X-rays, surgical procedures and instruments described are adequate and essential for surgical students.
I recommend this book for all MBBS students. Junior teaching faculty members will be benefited by reading this book and will help them in taking bedside clinics.”
—Dr D Premkumar, Professor and Head, Department of Surgery
IRT—Perundurai Medical College and Hospital, Tamil Nadu, India