Surgery

WHERE THE ART OF MEDICINE

IS LOVED, THERE IS ALSO LOVE
FOR HUMANITY.
HIPPOCRATES

DR. SANDEEP SEERAMREDDI

 BREAST

BREAST ANATOMY CLINICAL EXTENT OF BREAST

1
MICROANATOMY OF BREAST

GLANDULAR COMPONENT STROMAL COMPONENT

2
Breast lymphatics

Anatomical division Surgical division

3
Congenital breast disorders

Amastia

Amazia

Athelia

Polymazia

Polythelia

Poland syndrome

Symmastia

4
 CLINICAL APPROACH TO BREAST LUMP

STEP 1:

A: Clinical history

B: Clinical examination

Methods of palpation

5
Clinical findings

Nipple deviation

Nipple retraction

6
Nipple discharge

7
Skin over the lump

Axilla

8
STEP 2: RADIOLOGICAL ASSESSMENT
USG MAMMOGRAM MRI

9
STEP 3: CYTOLOGICAL ASSESSMENT
CRITERIA FNAC TRUE CUT BIOPSY

Pictorial representation

Size of needle

ER

PR

Her2Neu

Ability to Differentiate b/w

in-situ and invasive

Pain

Scar

IOC for breast cancer

STEP 1 + STEP 2 + STEP 3:

SENSITIVITY:

10
 BIRADS SCORING (Breast Imaging and Reporting Data System)
CAREGORY DISCRIPTION PROBABILITY OF MANAGEMENT
MALIGNANCY
0 Incomplete assessment N/A Repeat or recall for
additional Imaging
1 Negative 0% Routine screening
2 Benign 0% Routine screening
3 Probably benign ≤ 2% Follow up after 6 months
4 Suspicious of 4A: ≤ 10% Biopsy
malignancy 4B: 10-50%
4C: 50-95%
5 Highly suggestive of ≥ 95% Biopsy
malignancy
6 Biopsy proven 100% Stage wise management

BENIGN BREAST DISORDERS/ANDI (Aberrations of normal development and involution)

Age Disorders
15-25 yrs *Fibroadenoma
*Fibrocystic disease
*Breast cyst

25-40 yrs *Fibrocystic disease

*Fibroadenoma
*Breast cyst
*Phyllodes tumor

>40 yrs *Fibrocystic disease

*Duct ectasia
*Duct papilloma

11
CRITERIA FIBROADENOMA DUCT PAPILLOMA DUCT ECTASIA PHYLLODES TUMOUR
OF BREAST
Age

Site of origin

Characteristic
features

Probability of
malignancy

Clinical
features

1st INV

IOC

Management

12
 Management consideration in phyllodes tumor
Mitosis/10HPF Benign Borderline Malignant

13
BREAST ABSCESS
RISK FACTOR:

MOST COMMON ORGANISM:

MOST COMMON SOURCE:

CLINICAL FEATURES

Conditions associated with delayed

fluctuation sign

Investigation of choice

Management: 2nd line:

1st line:

14
MASTALGIA

CYCLICAL NON-CYCLICAL
Definition Pain that is related to Pain that is un-related to menstrual cycle
menstrual cycle
Age of onset 30 yrs >40 yrs
Laterality B/L U/L
Area involved Diffuse Localized
Example Nonspecific TIETZE'S DISEASE:

MONDOR'S DISEASE:

15
 GYNAECOMASTIA
CRITERIA: In a non-obese patient breast tissue measuring at least 2cm in diameter must be present
before a diagnosis of gynecomastia

CAUSES

PHYSIOLOGICAL NON-PHYSIOLOGICAL

1. At birth PRIMARY CAUSE SECONDARY CAUSE

2. At puberty
3. At old age

ABSOLUTE INCREASE IN RELATIVE INCREASE IN

ESTROGEN ESTROGEN
Drugs associated with gynecomastia

16
Clinical features

*Enlarged male breast

SIMONS GRADING OF GYNECOMASTIA

GRADE ENLARGEMENT SKIN REDUNDANCY

OF BREAST

IIA

IIB

III

Investigations:
Management:

17
BREAST CARCINOMA

RISK FACTORS
1.

2.

3.
BRCA 1 BRCA 2
CHROMOSOME
RECEPTOR STATUS
TUMOUR
FEMALE BREAST CANCER
OVARIAN CANCER
MALE BREAST CANCER
PROSTATE CANCER
PANCREATIC CANCER

4. Hormonal -HYPERESTROGENEMIA

-early menarche

-late menopause

-age at 1st childbirth

-nulliparity

-obesity

-nulliparity

-OCP

5. Miscellaneous risk factors

18
 GENETIC BASIC IN BREAST CANCER: Approach to a patient with BRCA mutation
HBOC SYNDROME:

CLINICAL FEATURES OF BREAST CANCER

1. Lump in breast
2. Associated changes in nipple
3. Associated changes in skin over lump
4. Axillary lymphadenopathy
5. Significant weight loss
6. Pathological fractures
7. Visceromegaly

19
INVESTIGATION OF CHOICE FOR DIAGNOSIS:
INVESTIGATION OF CHOICE FOR STAGING:

MANAGEMENT OF BREAST CARCINOMA

IN-SITU MALIGNANCY INVASIVE MALIGNANCY

DUCTAL CARCINOMA Vs LOBULAR TNM CLASSIFICATION
CARCINOMA

DUCTAL CARCINOMA IN-SITU LOBULAR CARCINOMA IN-SITU

AGE 50-55 yrs 40-45 yrs
C/F Mass, pain, discharge None
MULTICENTRIC 40-80% 60-90%
BILATERAL 10% 70%
SUBTYPES PAPILLARY This is a premalignant
CRIBRIFORM condition except
SOLID PLEOMORPHIC LCIS

COMEDO
DIAGNOSIS Stereotactic true cut biopsy Stereotactic true cut biopsy
MANAGEMENT

Prognosis VAN-NUYS INDEX

20
 TNM CLASSIFICATION OF BREAST CANCER: 8th AJCC

cTNM : Clinical
pTNM: Pathological
rTNM: Recurrent disease
mTNM: Multiple primary
yTNM: Post initial treatment

T
Tx Primary tumour cannot be assessed
T0 No evidence of primary tumour
Tis DCIS/Paget disease of the nipple NOT associated with invasive carcinoma
T1 Tumor ≤20 mm in greatest dimension
T1mi Tumor ≤1 mm in greatest dimension
T1a Tumor >1 mm but ≤5 mm in greatest dimension (round any measurement >l.0–1.9
mm to 2 mm).
T1b Tumor >5 mim but ≤10 mm in greatest dimension
T1c Tumor >10 mm but ≤20 mm in greatest dimension
T2 Tumor >20 mm but ≤50 mm in greatest dimension
T3 Tumor >50 mm in greatest dimension
T4a Extension to the chest wall
T4b Ulceration and/or ipsilateral macroscopic satellite nodules and/or edema (including
peau d’orange)
T4c Both T4a and T4b are present
T4d Inflammatory carcinoma (see section “Rules for Classification”)

N
Nx Regional lymph nodes cannot be assessed (e.g., previously removed)
N0 No regional lymph node metastases (by imaging or clinical examination)
N1 Metastases to movable ipsilateral Level I, II axillary lymph node(s)
N2a Metastases in ipsilateral Level I, II axillary lymph nodes fixed to one another (matted)
N2b Metastases only in ipsilateral internal mammary nodes in the absence of axillary lymph node
metastases
N3a Metastases in ipsilateral infraclavicular lymph node
N3b Metastases in ipsilateral internal mammary lymph node(s) and axillary lymph node(s)
N3c Metastases in ipsilateral supraclavicular lymph node(s)

M
M0 No clinical or radiographic evidence of distant metastases
M1c Distant metastases detected by clinical and radiographic means
M1p Any histologically proven metastases in distant organs; or if in non-regional nodes, metastases
greater than 0.2 mm

21
STAGING
STAGE T N M STAGE T N M STAGE T N M

I T1 N0 M0 IIIA T0 N2 M0 IV T N M1
any any

IIA T2 N0 M0 T1 N2 M0

T1 N1 M0 T2 N2 M0

T0 N1 M0 T3 N1 M0

IIB T2 N1 M0 T3 N2 M0

T3 N0 M0 IIIB T4 N0 M0

T4 N1 M0

T4 N2 M0

IIIC T N3 M0
any

EARLY INVASIVE BREAST CA. LOCALLY ADVANCED BREAST ADVANCED BREAST CA

CA
STAGE I, IIA, IIB STAGE IIIA, IIIB, IIIC STAGE IV

22
INDICATIONS OF FOLLOWING TREATMENT OPTIONS

CHEMOTHERAPY HORMONAL THERAPY RADIOTHERAPY

Regimens/agents used in breast cancer

CHEMOTHERAPY HORMONAL THERAPY RADIOTHERAPY

23
LUMINAL CRITERIA
CRITERIA ER PR HER-2-NUE
LUMINAL A

LUMINAL B

BASAL CELL

HER-2-NUE TYPE

BREAST SURGERY
INCISION

WEBSTER GAILLARO STEWART ORR

SIMPLE
MASTECTOMY

RADICAL
MASTECTOMY

MODIFIED
RADICAL
MASTECTOMY

PATEY’S SCANCON’S AUCHINCLOSS

24
STRUCTURES PRESERVED IN MRM
A

COMPLICATIONS ASSOCIATED WITH MRM

S

25
PAGETS DISEASE OF BREAST

26
PYQ

27
DEVELOPMENT OF THYROID GLAND ANATOMY OF THYROID GLAND

ARTERIAL SUPPLY VENOUS DRAINAGE NERVES

28
 MOVEMENT WITH DEGLUTINATION

INESTING LAYER OF DEEP CERVICAL FASCIA:

BASICS OF THYROID PHYSIOLOGY

I- I0

I0 + TYROSINE ORGANIC COMPOUND

MI + DI T3

DI +DI T4

T4 T3

 Daily I2 Req:
 t1/2 o T3:
 t1/2 of T4:

29
NECK LYMPHATICS

30
 CONGENITAL DISORDERS OF THYROID GLAND

ECTOPIC THYROID GLAND THYROGLOSSAL DUCT CYST

31
32
 CLASSIFICATION OF THYROID SWELLING

SIMPLE GOITRE TOXIC GOITRE INFLAMMATORY NEOPLASTIC THYROID

1. DIFFUSE 1. DIFFUSE TOXIC 1. HASHIMOTO’S
HYPLERPLASTIC GOITRE
GOITRE 2. DE’QUVERVIANS
2. TOXIC MNG
2. COLLOID GOITRE 3. REIDELS
3. TOXIC
3. MULTINODULAR ADENOMA
GOITRE

SIMPLE GOITRE
CAUSE

33
PATHOPHYSIOLOGY

CLINICAL FEATURES

WHO GRADING OF GOITRE

GRADE I:

GRADE II:

GRADE III:

COMPLICATIONS:

34
 INVESTIGATION

MANAGEMENT:

35
 RETROSTERNAL GOITRE

CRITERIA:

CLASSIFICATION

CLINICAL FEATURES:

INVESTIGATION:

MANAGEMENT:

Indication for median sternotomy:

1. Very large retrosternal goiter

2. Suspicious of malignancy

3. Mediastinal goiter

4. Recurrence is mediastinum

36
 TOXIC GOITRE

CRITERIA DIFFUSE TOXIC GOITRE TOXIC MNG TOXIC ADENOMA

PRIMARY THYROTOXICOSIS SECONDARY AUTONOMOUS

THYROTOXICOSIS ADENOMA
PATHOPHYSIOLOGY

AGE

SEX

Clinical features

SKIN OVER
SWELLING

SURFACE

M/C SYSTEM
INVOLVED

EXTRA THYROID
MANIFESTATION

INVESTIGATION

MANAGEMENT
1ST LINE

37
DEFENITIVE
MANAGEMENT

RADIOACTIVE IODINE SCAN FINDINGS

38
 INFLAMMATORY THYROID SWELLINGS

CRITRERIA HASHIMOTO'S DEQUERVIANS REIDELS

Type of inflammation

Etiology

Pathophysiology

Antibody

HLA

Age

Sex

Clinical features

Thyroid status (initial)

Intermediate

Final

Investigation

Management

39
 THYROID CANRCINOMA

FOLLICULAR PARA FOLLICULAR

ORIGIN ORIGIN

Well Difference Poorly Difference 1. Medullary.Ca

Tumor Tumor

1. Papilllary.Ca 1. Anaplastic.Ca

2. Follicular.Ca

40
 PAPILLARY FOLLICULAR ANAPLASTIC MEDULLARY
CANCER CANCER CARCINOMA CARCINOMA
Origin

Incidence 80% 10% 5% 2.5%

Age

Sex

Gene BRAF/PTC1/PTC2 PTEN /BAX RET

Risk factors

Clinical
features

Mode of
spread

m/c site for

Metastasis

Investigations

41
TNM CLASSIFICATION (8th AJCC)

Primary tumor (T)

TX = Primary tumor cannot be assessed
T0 = No evidence of primary tumour
T1 = Tumor ≤2 cm in greatest dimension limited to the thyroid
T2 = Tumour >2 cm but ≤4 cm in greatest dimension limited to the thyroid
T3 = Tumour >4 cm limited to the thyroid, or gross extrathyroidal extension invading only strap
muscles
T3a = Tumour >4 cm limited to the thyroid
T3b = Gross extrathyroidal extension invading only strap muscles
T4 = Includes gross extrathyroidal extension beyond the strap muscles
T4a = Gross extrathyroidal extension invading subcutaneous soft tissues, larynx, trachea,
oesophagus, or recurrent laryngeal nerve from a tumor of any size
T4b = Gross extrathyroidal extension invading prevertebral fascia or encasing the carotid artery
or mediastinal vessels from a tumour of any size

Regional lymph nodes

(N) NX = Regional lymph nodes cannot be assessed
N0 = No evidence of locoregional lymph node metastasis
N0a = One or more cytologically or histologically confirmed benign lymph nodes
N0b = No radiologic or clinical evidence of locoregional lymph node metastasis
N1 = Metastasis to regional nodes
N1a = Metastasis to level VI or VII (This can be unilateral or bilateral disease.)
N1b = Metastasis to unilateral, bilateral, or contralateral lateral neck lymph nodes (levels I, II, III,
IV, or V) or retropharyngeal lymph nodes

Distant Metastasis (M)

M0 = No distant metastasis
M1 = Distant metastasis

42
 MANAGEMENT OF DIFFERENCIATED THYROID CANCERS

PAPILLARY CANTHER THYROID FOLLICLULAR CANCER THYROID

PCT/FCT

Limited to INVOLVING LYMPH

Thyroid NODES

NOTE: T3/T4: PROPHYLATIC LEVEL ‘6’ CLEARANCE

43
 Whole body iodine scan

Measure TSH level (to determine

residual/metastatic disease)

TSH(>20 )
TSH (<20)

positive for residual or

No residual or metastatic disease
Metastatic disease

RAI2 Abalation with (I131)

Follow up > 6m Single Dose RAI2

 Clinical SERUM THYROGLOBUIN

Examination
 USG Neck
>2ng/mL
 Serum <2ng/ml
Thyroglobulin

Follow UP External Beam

Radiotherapy

44
45
MANAGEMENT OF ANAPLASTIC AND MEDULLARY CANTHER THYROID

ANAPLASTIC CANCER MEDULLARY CANTHER THYROID

46
THYROID SURGERY

POSITION

APPROACH

ANTI THYROID DRUGS

STEPS Of THYROD SURGERY

47
TYPES OF
SURGERY

HEMI- TOTAL
TOTAL THYROIDECTOMY OR LOBECTOMY
THYROIDECTOMY LOBECTOMY

SUB TOTAL HARTLEY DUNHILL ISTHMECTOMY

SX

Post operative
complications

48
PYQ

49
 PARATHYROID
PARATHYROID ANATOMY AND PHYSIOLOGY

HYPER PARATHYROIDISM

PRIMARY SECONDARY TERTIARY

HYPERPARATHYROIDISM HYPERPARATHYROIDISM HYPERPARATHYROIDISM

ETIOLOGY Increase in secretion of PTH Due to chronic hypocalcemia Autonomous reactive

Hyperplasia

PATHOPHYSIOLOGY

Cause 1. Parathyroid adenoma 1. Chronic renal failure 1. Post renal transplant

2. Parathyroid hyperplasia 2. Vit D3 deficiency
3. Parathyroid carcinoma 3. Intestinal
malabsorption
4. Lithium

50
CLINICAL FEATURES OF HYPERPARATHYROIDISM

KIDNEY PAINFUL ABDOMINAL PSYCHIC FATIGUE

STONES BONES GROANS MOANS OVERTONES

INVESTIGATIONS:
1 HPTH 2 HPTH
PTH

Serum calcium

Serum phosphate

51
X-RAY FINDINGS

Investigation of choice: SESTAMIBI SCAN

Best / gold standard: 4D CT

52
MANAGEMENT

PARATHYROID ADENOMA PARATHYROID HYPERPLASIA

INIDCATIONS FOR SURGERY IN ASYMPTOMATIC PRIMARY HYPERPARATHYROIDISM

AGE <50 years

S. calcium >1mg/dl above the upper limit

Renal Creatinine clearance <60ml/min

Urinary calcium >400ml/dl
Skeletal BMD by DEXA: T-score: -2.5

Miami criteria Persistent disease Recurrent disease Post-op complications

1. Hypoparathyroidism
2. RLN#
3. Hungry bone syndrome

53
PARATHYROID CARCINOMA

Incidence 1% of all primary hyperparathyroidism

0.005% prevalence
Risk factors 1. History of radiation exposure
2. Hyper parathyroid jaw tumor

Sex ratio 1:1

C/F - Palpable neck mass
- s/s of hyper calcemic condition
- Most common cause of death:
- Most common cause for morbidity:

Note Preoperative diagnosis of parathyroid cancer is very difficult as it presents

as primary hyperparathyroidism.
Investigation Serum calcium: >14mg%
PTH: 5-10 times of its normal value
Management En-bloc excision + i/p lobectomy + neck dissection if nodes positive

54
 TRAUMA
TRIAGE

CRITERIA: Triage involves the sorting of patients based on the

resources required for treatment and the resources that are available

BLACK

RED

YELLOW

GREEN

TRIMORDIAL DISTRIBUTION OF MORTALITY

Primary Survey with Simultaneous Resuscitation

A Airway maintenance with restriction of cervical spine motion

B Breathing and ventilation
C Circulation with hemorrhage control
D Disability (assessment of neurologic status)
E Exposure/Environmental control

55
A: Airway maintenance with restriction of cervical spine motion
Step 1 Stabilize cervical spine

Step 2 Assess ability to

communicate

Step 3 Examine oral cavity.

CRITERIA TO INTUBATE (definitive NEXUS CRITERIA FOR CERVICAL

airway) SPINE INJURY (national emergency X-
ray utilization study)

Airway patency

56
Methods of intubation

Contraindications of OROTRACHEAL INTUBATION:

If unable to secure airway

Emergency Definitive

57
B: BREATHING AND VENTILATION

ASSESSMENT CRITERIA

DEADLY DOZENS OF CHEST INJURIES

IMMEDIATE LIFE THREATENING (6) POTENTIALLY LIFE THREATINING (6)

1. Airway obstruction 1. Aortic injuries

2. Tension pneumothorax. 2. Myocardial contusion
3. Pericardial tamponade 3. Rupture of diaphragm
4. Open pneumothorax 4. Esophageal injuries
5. Massive Hemothorax 5. Pulmonary contusion
6. Tracheobronchial injuries 6. Flail chest

58
Comparative evaluation of immediate life-threatening injury
CRITERIA TENSION OPEN FLAIL CHEST PERICARDIAL
PNEUMOTHORAX PNEUMOTHORAX TAMPONADE
Definition >3cm OR >2/3
TRACHEAL
DIAMETER

MODE OF
INJURY

CLINICAL
FEATURES

INVESTIGATION

EMERGENCY
MANAGEMENT

59
DEFENITIVE
MANAGEMENT

60
C: CIRCULATION WITH HEMORRHAGE CONTROL

CIRCULATORY ASSESSMENT:
PR:
SBP:
BEST WAY TO CONTROL EXTERNAL HEMORRHAGE:

IF UNSTABLE VITALS:

FLUID PREFFERED FOR RESUSCITATION:

DAMAGE CONTROL RESUSCITATION

1. ANTICIPATE AND TREAT TRAUMATIC COAGULOPATHY

2. PERMISSIVE HYPOTENSION
3. LIMIT CRYSTALLOID INFUSION
4. DAMAGE CONTROL SURGERY

61
TRANEXIMIC ACID INDICATION

PR>110bpm
SBP <90mmHg.

D: DISABILITY LIMITATION

ASSESMENT PUPIL ASSESSMENT

CRITERIA

GLASSGOW
COMA SCALE
(GCS)/GCSP

62
MAXIMUM GCS

MINIMUM GCS

NORMAL GCS

RISK FOR COMA

INDICATION FOR
INTUBATION

GCS-P SCORE

63
64
 SKULL FRACTURES

ANTERIOR CRANIAL FOSSA# MIDDLE CRANIAL FOSSA # POSTERIOR CRANIAL FOSSA #

FEATURES

INVESTIGATION

MANAGEMENT
UNDISPLACED #

DISPLACED #

NICE GUIDELINES FOR CT HEAD IN TRAUMA

WITH IN 1 HOUR OF TRAUMA WITH IN 8 HOURS OF TRAUMA

65
 TRAUMATIC BRAIN INJURIES

PRIMARY SECONDARY

66
 EXTRA DURAL HEMORRHAGE SUB DURAL HEMORRHAGE

DEFENITION

MODE OF INJURY

MOST COMMON
SOURCE OF
BLEEDING

CLINICAL
FEATURES

INVESTIGATIONS

EMERGENCY
MANAGEMNT

DEFENITIVE
MANAGEMENT

67
 SECONDARY BRAIN INJURY
CEREBRAL PERFUSION
PRESSURE (CPP)
RAISED ICP AND ITS IMPACT

COMPENSATION

MANAGEMENT

MONITOR
MAP
ICP
CPP
Na
K
68
69
TRAUMATIC NECK INJURY

MX

70
 ABDOMINAL TRAUMA
OVERALL, MOST COMMON ORGAN INJURY IN ABDOMINAL TRAUMA

MOST COMMON ORGAN INJURY IN BLUNT ABDOMINAL TRAUMA

MOST COMMON ORGAN INJURY IN PENETRATING ABDOMINAL TRAUMA

MOST COMMON ORGAN INJURY IN ABDOMINAL TRAUMA ASSOCIATED WITH CAR

SEAT BELT

MOST COMMON ORGAN INJURY IN ABDOMINAL TRAUMA BY GUNSHOT

APPROACH TO BLUNT TRAUMA ABDOMEN

FAST:

eFAST:

71
HEMODYNAMIC HEMODYNAMIC STABLE
UNSTABLE

72
 APPROACH TO PENETRATING ABDOMINAL INJURY

GUN SHOT STAB WOUND

WOUND

73
SPLENIC INJURY

GRADE SUB CAPSULAR HEMATOMA DEPTH OF LACERATION MANAGEMENT

II

III

IV

VACINATION

ELECTIVE SPLENECTOMY EMERGENCY SPLENECTOMY

74
 LIVER INJURY

GRADE SUB CAPSULAR DEPTH OF LACERATION MANAGEMENT

HEMATOMA

II

III

IV

4P

PUSH

PRINGLES

PLUGH

PACK

75
 LETHAL TRIAD OF TRAUMA

DAMAGE CONTROL SURGERY

STAGE DISCRIPTION

76
RETROPERITORINAL HEMATOMA

77
 SHOCK

HYPOVOLEMIC CARDIOGENIC SEPTIC

SHOCK SHOCK SHOCK

CO

HR

SBP

JVP

PCWP

PVR

SKIN
TEMP

78
 HEMORRHAGIC SHOCK

CLASS I II III IV

% OF BLOOD
LOSS

HR

SBP

RR

URINE
OUTPUT

MENTAL
STATUS

MANAGEMENT

79
COLOUR CODE SIZE FLOW RATE

ORANGE

GREY

GREEN

PINK

BLUE

YELLOW

VOILET

INDICES TO MONITOR SHOCK

SHOCK INDEX:

MODIFIED SHOCK INDEX:

CVP

MVOS

URINE OUTPUT:

END POINT OF RESUSITATION

1. SYSTEMIC CIRCULATION

2. MUSCLE PERFUSION

3. BRAIN PERFUSION

4. GUT PERFUSION

80
PYQ

81
 BURNS

MANAGEMENT OF ACUTE BURNS

I. PRIMARY ASSESSMENT

A Airway control.

B Breathing and ventilation

C Circulation
D Disability – neurological status
E Exposure with environmental control
F Fluid resuscitation.

II. COOL THE BURN WOUND

Give a through wash :

Recommended period of wash:

Preferred fluid :

Effective till what time after burn :

III. GIVE OXYGEN

IV. ELEVATE THE PATIENT

82
WARNING SIGNS FOR INTUBATION

CRITERIA FOR ACUTE ADMISSION TO A BURN UNIT

• Suspected airway or inhalational injury

• Any burn likely to require fluid resuscitation
• Any burn likely to require surgery
• Patients with burns of any significance to the hands, face, feet or
perineum
• Patients whose psychiatric or social background makes it in
advisable to send them home
• Any suspicion of non-accidental injury
• Any burn in a patient at the extremes of age
• Any burn with associated potentially serious sequelae, including
high-tension electrical burns and concentrated hydrofluoric acid
burns

83
BURN WOUND ASSESSMENT WALLACE RULE (RULE OF 9)

ADULT CHILDREN

84
CLASSIFICATION OF BURN WOUNDS BASED ON DEPTH

CRITERIA FIRST SECOND SECOND THIRD FOURTH

DEGREE DEGREE DEGREE DEGREE DEGREE
SUPERFICIAL DEEP
Structures
involved

Pain

Blisters

Color

Heels

Scar

Eschar

85
 RESUSCITATION IN BURNS PATIENT

Crystalloids

PARKLAND 4ml/kg/%TBSA burnt

FORMULA
MOST COMMON FLUID USED:
ATLS

COLLOIDS

Most commonly used colloid in burn resuscitation:

Ideal time to administer colloids :

MUIR AND BARCLAY

PROTOCOL FOR ADMINISTRATION:

86
BURN WOUND MANAGEMENT

Topical agents Pseudomonas Gram Eschar Side effect

negative
1. 1% silver
sulphadiazine
cream

2. 0.5% silver
nitrate
solution

3. Mafenide
acetate cream

4. Silver
sulphadiazine
and cerium
nitrate

87
PYQ

88
 WOUNDS

EARLY PHASE INTERMEDIATE PHASE LATE PHASE

• Stages of haemostasis • Fibroblast migration • Collagen
• Inflammatory phase • Angiogenesis • Wound contraction
• Epithelialization • scar formation and
remodelling.

TIMELINE OF WOUND HEALING

89
CAUSES FOR DELAYED WOUND HEALING

LOCAL FACTORS SYSTEMIC FACTORS

90
CRITERIA HYPERTROPHIC SCAR KELOID

Extent

Etiology

Time taken

sex

Site

Collagen ratio

Pain

Itching

Family history

Management

91
 PRESSURE SORE/BED SORE/ DECUBITUS ULCER

CRITERIA:

RISK FACTORS:

SITES:

GRADE DISCRIPTION MANAGEMENT

I

II

III

IV

92
CLASSIFICATION OF SURGICAL WOUNDS
CLASS DISCRIPTION EXAMPLE % OF
SSI
CLEAN

CLEAN
CONTAMINATED

CONTAMINATED

DIRTY

93
 SURGICAL SITE INFECTION (SSI)

SOUTHAMPTON WOUND GRADING SYSTEM

GRADE DISCRIPTION

II

III

IV

94
ASEPSIS WOUND SCORE
A

95
PYQ

96
 PLASTIC SURGERY

GRAFT FLAP

TYPES OF GRAFT

AUTOGRAFT ISOGRAFT ALLOGRAFT XENOGRAFT

97
 SKIN GRAFTING
SPLIT THICKNESS FULL THICKENESS
ALTERNATE NAME

COMPOSITION

M/C DONOR SITE

DONOR SITE ASSESSMENT

DEFECT SIZE

REPEAT GRAFT FROM OLD

DONOR SITE

GRAFT SURVIVAL

GRAFT CONTARCTURE

COSMETIC OUTCOME

COMPOSITE SKIN GRAFT

98
DEVICE USED FOR GRAFT EXTRACTION

SKIN BANK ASSESSMENT FOR CORRECT THICKNESS

PHASES OF SKIN GRAFTING

PLASMA
CIRCULATION /
SERUM IMBIBATION

REVASCULARIZATION

ORGANIZATION

99
GRAFT RE-INNERVATION STARTS: 4-5 WEEKS POST GRAFTING

GRAFT RE-INNERVATION COMPLETES: 12-24 MONTHS POST GRAFTING

SEQUENCE OF RESTORATION:

PAIN LIGHT TOUCH TEMPERATURE

COMPLICATIONS AND CAUSES FOR GRAFT FAILURE

HEMATOMA

SEROMA

REPEATED MOVEMENT AT
GRAFTING SITE

WOUND BED INFECTION

ABSENCE OF
PERIOSTEUM

100
 FLAPS

5C CLASSIFICATION OF FLAPS
CIRCULATION
RANDOM BLOOD SUPPLY AXIAL BLOOD SUPPLY

COMPOSITION CUTANEOUS
FASCIOCUTANEOUS
FASCIAL
MYOCUTANEOUS
OSSEOCUTANEOUS
OSSEOUS

CONTIGUITY LOCAL
REGIONAL
DISTANT
CONTOUR
ADVANCEMENT ROTATION FREE

CONDITIONING FLAP DELAY

101
 THE MATHES AND NAHAI CLASSIFCATION OF MUSCLE FAPS

TYPE – I TENSOR FASCIA

LATA

TYPE- II GRACILIS

TYPE – III GLUTEUS

MAXIMUS

TYPE – IV SARTORIUS

TYPE - V LATISSIMUS
DORSI

102
103
 ARTERIAL OCCLUSIONS

ACUTE ARTERIAL OCCLUSION CHRONIC ARTERIAL OCCLUSION

ACUTE ARTERIAL OCCLUSION

CAUSE

EMBOLI THROMBUS

CLINICAL FEATURES

104
INVESTIGATION

MANAGEMENT

VIABLE LIMB NON-VIABLE LIMB

105
 CHRONIC ARTERIAL OCCLUSION

BUERGERS DISEASE ATHEROSCLEROSIS

AGE

SEX

R/F

SIZE OF VESSEL

M/C SITE

PATTERNT

CHARACTERISTIC
FEATURES

BUERGERS TRIAD

STRUCTURES
INVOLVED

106
CLINICAL FEATURES OF CHRONIC ARTERIAL OCCLUSIONS

BOYD’S CLASSIFICATION OF INTERMITTENT CLAUDICATION

GRADE I

GRADE II

GRADE III

GRADE IV

107
FONTAINE STAGING OF LIMB ISCHEMIA

STAGE CLINICAL DISCRIPTION

IIA

IIB

III

IV

RUTHERFORD CLASSIFICATION OF LIMB ISCHEMIA

GRADE CATEGORY CLINICAL DISCRIPTION

0 0

I 1

II 4

III 5

IV 6

108
INVESTIGATIONS

IOC:

ABPI INDEX

NORMAL

INTERMITTENT
CALUDICATION

REST PAIN

CRITICAL LIMB
ISCHEMIA

CALCIFIED BLOOD
VESSEL

109
 MANAGEMENT
BUERGERS DISEASE ATHEROSCLEROSIS

SITE AORTO-ILIAC ILIAC FEMORO-

POPLETIAL

CLAUDICATION

THIGH

CALF

ANKLE

BYPASS

110
 SUBCLAVIAN STEAL SYNDROME

CLINICAL FEATURES

INVESTIGATION

MANAGEMENT

111
 ANEURYSM
ANEURYSM
TRUE ANEURYSM FALSE ANEURYSM

CAUSE
1. ATHEROSCLEROSIS
2. UNCONTROLLED SYSTEMIC HTN
3. SYPHILIS
4. MARFANS SYNDROME
5. INFECTIVE CAUSE
6. MEDIAL FIBROPLASIA

OVERALL M/C SITE FOR ANEURYSM

M/C EXTRA CRANIAL SITE
M/C VISCERAL SITE
M/C PERIPHERAL SITE

MORPHOLOGICAL CLASSIFICATION
FUSIFORM SACCULAR

112
 CLINICAL FEATURES OF ABDOMINAL AORTIC ANEURYSM

INVESTIGATION

113
 MANAGEMENT
SYMPTOMATIC ASYMPTOMATIC

114
 REPAIRS
OPEN REPAIR EVAR

115
 DISECTING ANEURYSM

DEFENITION:

RISK FACTORS
1. UNCONTROLLED SYSTEMIC HNT
2. CYSTIC MEDIAL NECROSIS
3. MARFANS SYNDROME
4. EHLER DANLOS SYNDROME
5. 3RD TIMESTER PREGNANCY
6. TURNER SYNDROME

CLINICAL FEATURES

116
INVESTIGATION

DEBAKEYS CLASSIFICATION

START

EXTENT

MANAGEMENT

117
 ARTERO-VENOUS FISTULA

CAUSE

CONGENITAL AQUIRED

PATHOPHYSIOLOGY AND CLINICAL FEATURES

INVESTIGATIONS
CLINICAL EXAMINATION

MANAGEMENT

118
PYQ

119
 VARICOSE VEINS

DEFENITION

MOST COMMON SITE FOR VARICOSE VEIN

MOST COMMON VEIN INVOLVED IN VARICOSE VEINS

LOWER LIMB VENOUS ANATOMY

RISK FACTORS
1. CONGENITAL WEAK VALVES
2. POST DVT
3. DEFECTIVE VALVES
4. OBESITY
5. FEMALE
6. PREGNANCY
7. FAMILY HISTORY
8. KLIPPEL TRENAUNAY SYNDROME
9. PROLONGED STATIC STANDING

120
 PATHOPHYSIOLOGY OF VARICOSE VEIN

CLINICAL FEATURES

121
CLINICAL IMAGES

CEAP CLASSIFICATION

122
INVESTIGATION

CLINICAL TEST FOR VARICOSE VEIN

BRODIE
TRENDELENBURG
TEST
PERTH’S TEST

MODIFIED
PERTHE’S TEST

3 TOURNIQUET
TEST

SCHWARTZ TEST

FEGAN TEST

MORRISSEY’S
COUGH IMPULSE

123
 MANAGEMENT

GSV/SSV PERFORATOR # ULCER

124
 DEEP VEIN THROMBOSIS

MOST COMMON SITE OF DVT

MOST COMMON SITE OF DVT CAUSING PE

MOST FEARED COMPLICATION OF DVT

VIRCHOWS TRIAD

RISK FACTORS

CLINICAL FEATURES

125
INVESTIGATION

MANAGEMENT
0 1 2 3 4 5 6 7

Inj. LMWH

ORAL
WARFARIN

SPECIAL CONDITIONS

HIT SYNDROME

CONTRAINDICATIONS
FOR ANTICOAGULATION

1ST EPISODE OF DVT – DURATION OF

WARFARIN

2ND EPISODE OF DVT- DURATION OF

WARFARIN
HOW TO MONITOR THE EFFECT OF
WARFARIN

126
 DVT PROPHYLAXIS
MECHANICAL PHARMA

127
 HERNIA

RISK FACTORS
FACTORS CAUSING ABDOMINAL FACTORS INCREASING INTRA
WALL WEAKNESS ABDOMINAL PRESSURE
1. PATENT PROCESSUS VAGINALIS 1. CHRONIC COUGH
2. CT DISORDER 2. CHRONIC CONSTIPATION
3. EXTROPHY OF BLADDER 3. OBSTRUCTIVE UROPATHY
4. DEFECTIVE COLLAGENT 4. PREMATURITY
SYNTHESIS 5. CLD
5. HISTORY OF PREVIOUS SURGERY 6. INTRA ABDOMINAL MASS
6. SMOKING 7. WEIGHTLIFTING

128
ABDOMINAL WALL ANATOMY

129
 INGUINAL HERNIA

ANATOMY OF INGUINAL CANAL

130
 INDIRECT INGUINAL HERNIA DIRECT INGUINAL HERNIA

ENTRY

EXIT

SAC

CONTENT

RELATION OF SAC
AND CORD

RELATION OF
NECK AND IEA

RISK FOR
STRANGULATION

131
CLINICAL FEATURES OF INGUINAL HERNIA

RING OCCLUSION TEST

132
INVESTIGATION:

HERNIA REPAIR
OPEN REPAIR

❖ BASSINI
❖ SHOULDICE
❖ DESARDA
❖ MALONEY DARN

❖ Lichtenstein

HERNIOTOMY
HERNIORAPHY
HERNIOPLASTY

133
 LAPROSCOPIC REPAIR
TEP: TOTAL EXTRAPERITONEAL REPAIR

LAPROSCOPIC INGUINAL ANATOMY

134
TAPP

135
 MESH
MATERIAL

IDEAL
CHARACTERISTICS
OF MESH

IDEAL OVERLAP

136
POST OPERATIVE COMPLICATIONS
EARLY LATE
• PAIN • CHRONIC PAIN
• BLEEDING/HEMATOMA • TESTICULAR ATROPHY
• URINARY RETENTION
• SEROMA
• WOUND INFECTION

COMPLICATIONS ASSOCIATED WITH HERNIA

IRREDUCIBLE

OBSTRUCTED

STANGULATED

INCARCIRATED

137
SPECIAL FORMS OF INGUINAL HERNIA

RICHTERS
HERNIA

MAYDL’S
HERNIA

SLIDING
HERNIA

LITTERS HERNIA

AMYAND’S
HERNIA

138
 FEMORAL HERNIA

FEMORAL CANAL ANATOMY

CLINICAL FEATURES

INVESTIGATION

MANAGEMENT

OPEN
LOW APPROACH THE INGUINAL APPROACH HIGH APPROACH
LOCKWOOD LOTHEISSEN MCEVEDY
UNCOMPLICATED UNCOMPLICATED COMPLICATED

139
 OBTURATOR HERNIA

Obturator canal anatomy

Clinical presentation

Investigation

Management

140
 VENTRAL HERNIA

PRIMARY SECONDARY
• EPIGASTRIC • INCISIONAL
• UMBLICAL • PARASTOMAL
• SPIGELIAN
• LUMBAR
• TRAUMATIC

141
 UMBLICAL SPIGELAIN LUMBAR
DEFECT

SIZE OF DEFECT
ENTRY
EXIT
SAC
PRESENTATION
INVESTIGATION
MANAGEMENT

142
VENTRAL MESH PLACEMENT

143
 CONGENITAL ABDOMINAL WALL DEFECTS

OMPHALOCELE GASTROSCHISIS
PRESENTATION

DEFECT Central abdominal wall Right side of umbilicus

defect
SIZE >4cm 4cm
ASSOCIATED • Beckwith-wiedemann • Intestinal atresia
ANOMALIES syndrome
• Cardiac anomalies
MANAGEMENT

144
 SUTURES, KNOTTING AND ENERGY DEVICE

SUTURES CLASSIFICATION

ABSORBABLE SUTURES NON-ABSORBABLE SUTURES

NATURAL SYNTHETIC NATURAL SYNTHETIC

145
 MATERIAL PROPERTIES
CITERIA MONOFILAMENT POLYFILAMENT
threads

strength

Crevice’s

r/f infection

Elastic recoil

Suture
memory

texture

examples

146
SUTURING RULE
1. LENGTH OF THE

SUTURE MATERIAL

2. ANGLE B/W NEEDLE

AND SKIN

3. DISTANCE BETWEEN

2 SUTURES

4. LENGTH OF SUTURE

EAR

SUTURING TECHNIQUE

147
KNOTTING TECHNIQUE

SUTURE REMOVAL PERIOD

FACE

SCALP

ARMS

TRUNK

LEGS

HAND/FEET

PALMS/SOLES

148
ENERGY DEVICES

MONOPOLAR BIPOLAR HARMONIC THUNDERBEAT

149
150
 KIDNEY

RENAL DEVELOPMENT

SURFACE ANATOMY RENAL HILUM

151
URETERIC CONSTRICTION

152
 CONGENITAL DISORDERS

HORSESHOE KIDNEY ANOMALLY DUPLICATION POLYCYSTIC KIDNEY DISEASE

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

CLINICAL FEATURES

INVESTIGATION

MANAGEMENT

153
 NEPHROLITHIASIS/RENAL STONES

OXALATE STONES PHOSPHATE STONES URIC ACID STONE CYSTEINE STONE

Cause

Characteristic
features

Radio status

Urine
microscopy

154
Clinical features

INVESTIGATION
X-RAY KUB
USG
CT-UROGRAPHY

RADIONUCLEOTIDE SCAN

155
 MANAGEMENT OF NEPHROLITHIASIS
<5mm 5-20mm >20 mm OTHER CONDITIONS

156
 HYDRONEPHROSIS
DEFINITION:

CAUSES
UNILATERAL HYDRONEPHROSIS BILATERAL HYDRONEPHROSIS

CLINCIAL FEATURES OF HYDRONEPHROSIS

COMPLICATION

157
INVESTIGATION

MANAGEMENT

158
 TB KIDNEY

MODE OF SPREAD

RENAL MANIFESTATIONS

GENITOURINARY MANIFESTATIONS

159
INVESTIGATIONS

MANAGEMENT

KIDNEY DAMAGE

URETERIC DAMAGE

BLADDER DAMAGE

SCROTAL DAMAGE

160
161
 Renal Carcinama

M/C Type:

Clear Cell Papillacy Chromophobe Bellini

162
R/F:

C/F:

Para neoplastic syndrome

ROBSONS STAGING

163
MX:

164
Urinary Bladder

165
Bladder Rupture

166
 Schistosomiasis

C/F:

167
IOC:

DOC:

Bladder Carcinoma

C/F:

TNM-Classn

168
MALE URETHRA

URETHERAL INJURY

169
IOC:

170
 Hypospadias

C/F:

IOC:

171
MX:

PHIMOSIS

C/F:

IOC:

MX:

172
Para - Phimosis

173
IOC:

MX:

M/C/S:

C/F:

IOC:

MX:

174
 PENILE Carcinoma

C/F:

M/C/S:

175
IOC:

MX

176
PROSTATE MC’S NEALS SURGICAL ZONE

177
C/F:

INV:

IOC:

178
 P.S.A:

MX:

C/I: T.U.R.P:

OPEN SX:

179
NEW: HOLEP:

Carcinoma PROSTATE

M/C Type:

R/F:

M/C/S:

180
INV:

IOC:

BEST:

181
IOC for Staging:

182
TESTIS

183
 Congenital Disorder

Undersigned TESTIS Ectopic TESTIS

184
 TESTICULAR TORSION

R/F:

C/F:

185
O/E:

M/C:

PREHAN’S SIGN

186
 Varicocele

IOC:

MX:

187
 HYDROCELE

TYPE

C/F:

O/E:

188
IOC:

MX:

189
 TESTICULAR TUMOURS

C/F:

M/C ROUTE Of:

190
TM:

IOC:

IOC Staging:

Staging

Stage I:

Stage II:

Stage III:

Stage IV:

191
 Indeterminate Testicular mass

M/C:

M/c:

M/C:

M/C::

MX

192
193
 THE FUTURE BELONGS TO
THOSE WHO BELIEVE IN THE
BEAUTY OF THEIR DREAMS.
ELEANOR ROOSEVELT

ARISE-Chennai ARISE-Delhi
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