Surgery Practical

Dixitha A
• Instruments
• X Rays
• OSCE
• Specimens
• Operative surgery
• Sutures
 Long case 70marks
• Thyroid
• CA Breast
• Varicose veins
• Peripheral arterial disease
• Inguinal hernia
• Any abdominal mass
 Short Case 2x40= 80 marks
• Ulcer- Traumatic; Varicose; PAD; Diabetic;
Infectious; Malignancy
• Swelling- Lipoma; Sebaceous cyst; Dermoid
cyst; Nodes; Ganglion; Hydrocele( scrotal
swelling)
INSTRUMENTS
• Disposable/Non disposable
• What instrument it is?
• Parts of the instrument
• How to hold it?
• Traumatic/Atraumatic
• Uses
• Sterilization- Wash in running water and Dry it
Autoclave 120-130ºC for 20-30 mins
Disposable instruments- Gamma
radiation
 ALLIS TOOTHED
FORCEPS
1. It has a ratchet and triangular
expansion at the tip, where serration
are present.
2. It can be used to hold tough
structures such as fascia,
aponeurosis, etc.
3. Even though it can cause trauma,
because of its better grip, it can be
used to hold duodenum for
duodenal closure during
gastrectomy.
 BABCOCK’S FORCEPS
• An instrument with a ratchet and triangular
expansion with fenestration at the operating end.
It does not have teeth. The jaws are atraumatic
and cause minimal damage.
• It is used to grasp any part of the bowel.
• Thus it can be used to hold intestines during
anastomosis or resection.
• Used to hold other structure like, mesoappendix,
thyroid gland, fallopian tube, etc.
 KOCHER’S FORCEPS
1. It is similar to artery forceps with
serration. It is available as straight
and curved.
2. There is a sharp tooth at the tip of
the instrument for better grip.
3. It is used to hold tough structures
like aponeurosis, fascia, etc.
4. During thyroidectomy, it can be
used to hold the strap muscles for
dividing them.
 RAMPLEYS SPONGE HOLDING
FORCEPS
1. It has a ratchet and 2 long blades.
2. Operating end is rounded with serrations.
3. It is used to swab to prepare the parts
with antiseptic agents at the time of
surgery.
4. This instrument can also be used as a
blunt dissector with the swab, while
dissecting at a depth, eg. Lumbar
sympathectomy, vagotomy.
5. Used to hold gall bladder in open
cholecystectomy.
6. Used to remove calculi in bladder
CHEATLE FORCEPS
1. It is a long instrument
having long shaft.
2. The handle has no lock.
3. It is kept dipped in
antiseptic solution.
4. This instrument is used to
pick up sterilized articles
such as sponges, gauze
pieces or other instrument
and to transfer to the
instrument trolley.
 LISTER SINUS FORCEPS
1. This is like an artery forceps
which has no ratchet.
2. Serration is confined to the tip
so as to hold the wall of an
abscess cavity for biopsy.
3. In HILTON’S METHOD of
drainage of an abscess, once
incision is made, the sinus
forceps is thrusted into the
abscess cavity and by opening
the blades in all direction, the
loculi are broken. To facilitate
free opening of blade in all
direction, sinus forceps has no
ratchet.
Straight and curved surgical
scissors
• It has no lock.
• Straight scissors is used to cut suture
material
• Curved scissors is used to cut tissues.
 LANGENBECK RETRACTOR
1. It is small general purpose
retractor useful for holding
open wounds as in open
appendicectomy.
2. It is often used in pairs. They
stay in position best if the
handles are slightly lifted so
that the tips lock under the
fascia.
3. Used to retract layers of
abdominal wall, muscles, etc.
Thus, during
appendicectomy,
herniorrhaphy or
thyroidectomy, this
instrument is very useful.
 MORRIS RETRACTOR
1. This is a instrument with a
broad operating end.
2. This is used to retract the
abdominal wall, once the
peritoneum is opened.
3. It can be used to improve the
visibility on one side of an
incision; so it is useful in initial
phase of laparotomy.
 CZERNY RETRACTOR
1. This is a double ended retractor used
to retract wound ends for
intermediate type procedures.
2. One end has a blade with a lip that is
used to retract without the edge
slipping.
3. The other end has 2 prongs and
helps to retract the ends of an
incision.
4. When using it a slight upward tilt
gives better exposure.
5. This is a superficial retractor, can be
used to retract layers of the
abdominal wall, muscles, etc. Thus
during appendicectomy,
herniorrhaphy or thyroidectomy,
this instrument is useful.
 Triple hook

Catspaw Retractor
• It is a double ended small retractor for
skin retraction in small and delicate
wounds.
• It has 2 ends- Blunt end and triple
hook retractor.
• Blunt end is used to retract small
wounds

Blunt end
 DEAVER RETRACTOR
1. This is also called as Deaver liver
retractor.
2. It has a long blade and operating
end is curved.
3. It should be used carefully to
avoid damaging the liver.
4. It can be used to retract the liver
during vagotomy,
cholecystectomy or
gastrectomy, etc.
Handle with
sheath
Obturator
 Kelley’s Proctoscope
• It is a instrument used to visualise rectum and anal canal
• Lubricate the instrument well before introducing.
• In painful condition as in fissure in ano, proctoscope is contraindicated.
• Once rectal examination is done, proctoscope is held firmly in left hand,
the obturator supported in right hand. The instrument is slowly introduced.
The obturator is removed and rectum is visualized using light source.
• Used to diagnose hemorrhoids, ca rectum or rectal ulcer, anal polyp, etc.
• Biopsy can be taken with a biopsy forceps in non healing ulcer of rectum.
• Hemorrhoids can be injected and pelvic abscess is drained into rectum
with the help of proctoscope.
• Complication- Vasovagal attack
5% of people can develop bacteremia on using Proctoscope.
 MAYO TOWEL CLIP
• This instrument has a ratchet and the
operating end is sharp.
• This is available in different sizes.
• Once the part is cleaned and draped the clips
are used to hold the towels in place.
 DESJARDIN’S
CHOLEDOCHOLITHOTOMY
1. This is a long curved
instrument with no ratchet
2. The operating end is
expanded with fenestration
3. The tip is blunt
4. It is used to extract stones
from CBD. It can also be
used to extract stones from
ureter.
5. Since there is no ratchet,
free opening is possible and
the stones do not get
crushed.
 FOLEYS SELF RETAINING URINARY
CATHETER
1. This is made up of latex with
silicon coating. At the tip, there is
a bulb, capacity of which is written
at the other end.
2. Before inflating the bulb, one must
make sure that the catheter is in
the urinary bladder, not in the
urethra. This is assessed by free
flow of urine.
3. Size of Catheter is measured in
French(F)
4. Adult size= 16F
5. 16F means the circumference of
the catheter is 16mm
6. Sterilized by Gamma radiation.
7. Usually placed for 7 days
 Uses of Foley’s catheter
1. It is used to empty the bladder, to note the color
of the urine during operation and in postop and
the amount of urine that has being passed.
2. After introducing the catheter, the bulb is inflated
using saline. Thus, it becomes self retaining. It can
also be used to drain peritoneal cavity as in biliary
peritonitis.
3. Inflated bulb compresses the prostatic bed and
controls bleeding after prostatectomy.
4. It can be used to measure urine output in renal
failure, postop patients and terminally ill patients.
 Suction Catheter
• Proximal end-Smooth surface and tip allows
atraumatic insertion
• Distal end- Open and atraumatic
• Removing respiratory secretions from the airway,
so as to keep the airway clear of secretions and
prevent plugging
• To view bleeding points
• Metal suction catheter- Non disposable
• Plastic suction catheter- Disposable
 Lead shot

Infant feeding tube

 NASOGASTRIC TUBE/RYLE’S TUBE
• At the end of this tube is a lead shot. After introducing
within the stomach its position is confirmed by pushing 5-
10mL of air and auscultating in the epigastrium or
aspirating gastric juice.
• It is a long tube having 3 marking. When the tube is passed
up to the 1st mark, it enters the stomach. Usually it passes
up to 2nd mark.
• It is 1m in length:- 1st mark- 40cm (at the level of OG
junction); 2nd mark-50cm( at the level of body of stomach);
3rd mark- 60cm(at the level of pylorus of stomach)
• In case of volvulus of the stomach, it is impossible to pass
the Ryle’s tube.
• Diagnostic- For gastric function test- Assess free
and total acid
Diagnose tracheo-oesophageal
fistula
• Therapeutic-
1. It can be used to decompress the stomach as in
intestinal obstruction or pyloric stenosis.
2. It is used to diagnose GI hemorrhage.
3. It is also used to provide enteral nutrition to
comatosed patient or critically ill patients.
 Infantile feeding tube
• It does not a lead shot and markings on the
tube
• It is used for feeding purpose in infants with
maxillofacial injuries and anorexia
 STRAIGHT AND CURVED
ARTERY FORCEPS
1. It is also called as Spencer Well’s
Forceps. It has a ratchet and 2 blades
with uniform serration.
2. It is used to control bleeding, not only
from arteries but also from veins and
capillaries.
3. Once the bleeding points are caught,
they are coagulated or ligature is
applied.
4. The curved artery is commonly used.
MOSQUITO STRAIGHT AND
CURVED ARTERY FORCEPS
1. The smaller version of artery forceps is
called as mosquito forceps. This
extremely useful in repair of harelip,
cleft palate or other plastic surgery
operation.
2. It is also available as straight artery
which is used to hold the stay sutures.
 NEEDLE HOLDER
• This is a long instrument with a ratchet at non
operating end.
• The operating end has 2 small blades with a
crisscross serration and a prominent vertical
groove in its inner surface.
• The instrument is used to hold the curved
needles which is used to suture the parts.
• A firm grip is essential to apply proper sutures.
SCALPEL WITH BLADE
1. This is popularly called as surgeon’s
knife.
2. Consist of 2 parts:- Handle and
Blade.
3. Its handle is called as Bard Parker
handle which is reusable.
4. Used to incise the skin and
subcutaneous tissue.
5. Due to its sharp nature, it can be
used to divide a major vascular
pedicle once ligature are applied.
• Tongue depressor
• Endotracheal tube These can also be
kept
• Toothed forceps
• Non toothed forceps
SPECIMENS
 Appendix
STUDY-
1. Anatomy
2. Pathology that can see in
appendix
3. Blood supply
4. Position of appendix
5. Indication of appendicetomy
6. Surgery

Mesoappendix
 Gall Bladder( Empyema
of gall bladder)
Cut section of globular structure
with a tubular end
STUDY-
1. Anatomy
2. Various pathology
3. Calot’s Triangle
4. Blood supply
5. Surgery- Indication
 Lipoma
Lobular and yellow in colour
STUDY-
1. What it is
2. Common sites
3. How to differentiate from
other swelling?
4. Complication
 Multinodular goitre
• Cut section of a bilobed
structure with nodular
changes does not show
hemorrhage
STUDY-
1. Anatomy
2. Blood supply
3. Hypo- and Hyperthyroidism-
Clinical Feature and causes
4. Pathophysiology
5. DD for solitary nodule thyroid
6. Management
 CA Thyroid
• Cut section of a bilobed
structure
• Cut section shows multiple
erythematous hemorrhagic
structure
STUDY-
1. Anatomy
2. Blood supply
3. Types of thyroid ca
4. Metastasis
5. Management
 Renal cell carcinoma
• Cut section of a bean
shaped viscera showing
ulceroproliferative growth
STUDY-
Ulceroproliferative growth 1. Anatomy
2. Primary tumours of
kidney
3. Metastasis
4. Management
 CA Breast
READ-
1. Anatomy
2. Lymphatic drainage
3. Risk factor
4. Pathology
5. TNM staging
6. Management
OSCE
ANS
1. Procedure- Open
appendicectomy
2. Structure- Appendix
3. Instrument- Babcock’s forceps
4. Complication- Postoperative
fever; Wound infection; Faecal
fistula; Intraabdominal abscess
5. Blood supply- Appendicular
artery branch of ileocolic
artery
Accessory appendicular
artery of Sheshachalam branch of
ileocolic artery.
ANS-
1. Ganglion cyst( Tense and
cystic swelling containing
gelatinous material)
Commonly seen in dorsum of
wrist/ palm of hand
2. Treatment- Aspiration of
ganglion
Excision and biopsy
3. Complication- Restriction
of movement
ANS-
1. Most probably Dermoid cyst
2. Cystic swelling, midline
swelling, fluctuant with bony
indentation
3. Common sites- Outer canthus;
Post auricular; Below tongue in
midline.
4. Excision of the cyst
ANS-
1. Multiple sebaceous
cyst/Wen
2. Features- Hemispherical
swelling with punctum; Skin
nonpinchable; Fluctuant but
not transilluminant
3. Infection; Ulceration;
Rupture; Calcification;
Cock’s peculiar tumour;
Sebaceous horn
4. Incision and drainage;
Remove the capsule to
prevent recurrence
5. Slow discharge of sebum
from a wide punctum may
hardens as soon as it comes
out to form Sebaceous horn
which is nothing but
inspissated sebaceous
material.
ANS-
1. Sebaceous cyst
2. Clinical findings-
Hemispherical swelling
with punctum; Skin
nonpinchable; Fluctuant
but not transilluminant
3. Cock’s peculiar tumour-
After the sebaceous cyst
ruptures and chronic
infection spreads to the
surrounding tissue from
the sebaceous cyst it may
lead to painful, boggy,
fungating and discharging
mass which is called as
Cock’s peculiar tumour.
ANS-
1. DD- Hypertrophic scar
2. Hypertrophic scar- Does
not extend beyond the
boundary of the original
wound and non tender.
3. Common sites-
Skin over ear lobe, sternum,
Deltoid and upper back
4. Intra lesional steroid
injection- Triamcinolone
Intra keloidal excision and
skin grafting.
ANS-
1. Kelley’s proctoscope
2. Parts- Sheath with handle and
obturator
3. Used to visualise lower part of
rectum and anal canal.(Mass
in lower rectum; polyp;
hemorrhoids; pelvic abscess)
4. Cidex; Autoclave- 120-130ºC
for 20-30 mins.
5. 5%
ANS-
1. Proliferative growth with
everted edges on the
lateral side of tongue
2. Carcinoma of tongue-
Squamous cell carcinoma
3. Wedge biopsy
ANS-
1. Split skin graft
2. Humby’s knife
3. Autoclave
4. Infection by Beta
hemolytic streptococci;
Presence of infected
wound with copious
discharge in the vicinity;
Avascular wound
5. Graft rejection;
Contracture of grafted
site; Loss of hair growth
 Ranula
• Diagnosis- Ranula( Extravasation cyst arising from
sublingual salivary gland)
• Cause- Blockage of duct of salivary gland; Trauma
• Clinical Features- Bluish smooth, soft, fluctuant and
trans-illuminant swelling
• Plunging ranula- When a ranula extends into neck so it
can be palpated in submandibular triangle; This type of
ranula is derived from cervical sinus; Bimanual
palpation reveals Cross fluctuation
• Treatment- Marsupilation(initially); Excision( if the
ranula is thick; small ranula) and biopsy
Follicular CA thyroid with metastasis to
skull bone
• Diagnosis- Follicular ca thyroid with metastasis to skull
• Characteristic feature- Pulsatile secondary
• Investigation- USG of neck- To demonstrate nature of
carcinoma; Guide FNAC
FNAC- Cannot differentiate follicular adenoma
from follicular ca(in follicular ca there will be breach of
capsule and blood vessel that cannot be demonstrated in
FNAC)
Alkaline phosphatase- Increased bone scan should
be done
• Treatment- Total thyroidectomy with modified radical
neck dissection; For 2°- Radioactive iodine, RT
ANS-
1. Butterfly shaped specimen most probably
Thyroid
2. Total thyroidectomy
3. Indication- MNG, Toxic goitre, Colloid
goitre and malignant goitre
4. Complication- Hemorrhage; RLN paralysis(
voice change); Respiratory obstruction(
Tracheomalacia; Laryngeal edema);
Parathyroid insufficiency
5. Signs of Hypocalcemia- Carpopedal spasm;
Chvostek’s and Trousseau’s sign
ANS-
1. Diagnosis- Plain X ray chest
showing air under the diaphragm
2. Causes-Hollow viscus perforation;
Stab injury; Post Laparoscopic
surgery; Rupture of liver abscess
caused by anaerobic organism
Hollow viscus perforation- Peptic
perforation; typhoid ulcer
perforation; Ulcerative colitis
perforation
3. Obliteration of liver dullness is
classical if there is free air under the
diaphragm
ANS-
1. Thyroglossal cyst
2. DD-Ludwig’s angina; Enlarged
submental lymph node;
Sublingual dermoid cyst;
Subhyoid bursitis; Pretracheal
and prelaryngeal lymph nodes
3. Sites- Subhyoid; At the level of
thyroid cartilage; suprahyoid; In
the floor of the mouth
4. Clinical features- Painless midline
swelling; Soft, cystic, fluctuant
but not transilluminant. Moves
with protrusion of tongue and
with deglutition.
5. Surgical procedure- Sistrunk’s
operation( Excision of the cyst
along with thyroglossal tract
which includes the part of hyoid
bone)
X-RAY
• Plain/Contrast radiograph
• Which part is radiographed?- Chest/Abdomen
• View
• Plain X-Ray
1. Plain X-ray of chest PA view- Air under the
diaphragm(Crescent sign)-Pneumoperitoneum

Causes- Hollow viscus

perforation; Stab injury;
Post Laparoscopic
surgery; Rupture of liver
abscess caused by
anaerobic organism

Fundus Gas
shadow
2. Plain X-Ray Chest PA view with intercostal
drainage tube in right side
READ ABOUT- Safety triangle for ICD

3.Plain radiograph of chest PA view with pleural

effusion-
Blunting of costophrenic angle
Ellis S shaped curve

4.Plain radiograph of chest PA view-Normal

without any pathologies
Pleural effusion
• Contrast radiograph
• Barium sulphate is the contrast material used. It
is radio-opaque
1. Barium swallow- 30-50 ml- Visualize upto OG
junction/esophagus
2. Barium meal- 500ml- esophagus, stomach,
duodenum
3. Barium follow through(also called as
ENTEROCLYSIS)- 500-1000ml- Till small intestine
4. Barium enema(LOWER GI CONTRAST STUDY)-
Rectum,anal canal, large intestine
• Contraindication- Allergy to barium, peritonitis
and in pregnancy
• Complication- Kidney damage, Nausea,
Vomiting, Abdominal pain, Leakage from
unsuspected perforation, aspiration of
stomach contents containing barium,
Hypersensitivity reaction
• RFT should be done before starting Barium
study
1. Contrast radiograph showing esophagus- Barium
Swallow
A. Parrot beak appearance- Achalasia cardia
B. Rat tail appearance- Irregular filling defects-
Carcinoma esophagus
2. Contrast radiograph of abdomen, Barium follow
through- Normal/Obstruction
3. Contrast radiograph of abdomen, Barium enema-
Normal/with obstruction(malignancy)
4.Contrast radiograph KUB(also called as IV
Pyelogram-Normal/with obstruction
(stone/stricture)
 Barium meal follow through
Barium enema- -follow
Normalthrough-
Normal Normal
Barium enema- Ascending
colon(Obstructive feature suggestive of Barium meal follow through showing
malignancy) obstructive features

Barium meal follow through-

Normal
Barium swallow- Rat tail Barium swallow- Parrot beak
appearance appearance
Normal IVP
Contrast IV pyelogram- Right side normal; Left side Pelvis
dilated and ureter is not seen
 IVP- R side ureter not seen( maybe obstruction)

IVP- R side pelviureter dilation

OPERATIVE SURGERY
 STUDY for
• Phimosis
• Appendix
• Inguinal hernia surgery
• Hydrocele
• Thyroid
• Cholecystectomy
SUTURES
FOR ALL SUTURES READ-
1. Absorbable/ Not Absorbable
2. Where it is used?
3. Property of the material