Contents

General Surgery : Part 1  1

General Surgery : Part 2  15

Breast  24

Thyroid, Parathyroid and Adrenal Glands  36

Oral Cancer, Salivary Glands and Neck Swellings  52

Gastrointestinal Surgery : Part 1  61

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Gastrointestinal Surgery : Part 2  81

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Gastrointestinal Surgery : Part 3  96

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Hepatobiliary and Minimally Invasive Surgery  111
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Urology : Part 1  135

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Urology : Part 2  147

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Speciality Surgery  162

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Trauma and Burns  172

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Hernia, Thorax and Skin  199

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Vascular Surgery  212

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 General Surgery : Part 1 1

GENERAL SURGERY : PART 1 ----- Active space -----

Day Care Surgery 00:02:05

Definitions :
• Daycare/Same-day surgery : Admitted + discharged within 12 hours.
• Overnight stay : 23-hour admission + early morning discharge.
• Short stay surgery : Admission up to 72 hours.

Selection Criteria :
Medical Social Surgical

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• Availability of responsible

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• Physiological > Chronological age.

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adult carer for 1st 24 hrs. Operations up to 2 hrs :
• ASA status > 2 : Careful review

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• Suitable home conditions. Recognized as day care
(Involve anaesthetist). 7@
• Ability to contact hospital in surgeries.
• BMI < 40 : Surgery not C/I.
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an emergency.
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Eligibility based on ASA grade 1 and 2 : Stand alone day care unit.
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3 : Integrated day care surgery centre.

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Other criteria :
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• BP < 180/100 mmHg.

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• In a diabetic : HbA1C < 8.5 (Skip morning dose of OHA).

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• Eligible BMI (kg/m2) : 

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- < 40 Surface procedures.

- < 38 Laparoscopic procedures.
• Well controlled case of epilepsy are eligible.

Anaesthesia and Analgesia Used :

• Total intravenous anaesthesia (TIVA) Propofol (↓Post-op nausea + vomiting).
• Post-op analgesia : Infiltration with bupivacaine (Long acting, most cardiotoxic).
Post-operative Complications :
• M/c complication (Post-day care Sx) : Nausea + vomiting (Assessed using
Apfel score).
• M/c complication requiring readmission : Hemorrhage.
• Pain.

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 2 Surgery

----- Active space ----- Discharge Criteria :

• Vital signs stable (Atleast 1 hour) + oriented to time, place, person.
• Adequate pain control with oral analgesia and understands how to use it.
• Has taken oral fluids, has passed urine (If appropriate).
• Minimal wound discharge/bleeding.
• Able to dress + walk where appropriate + responsible adult to take them home.

ERAS PROTOCOL
ERAS : Enhanced Recovery After Surgery.
Preoperative Intra-operative Post-operative
• Counselling.
• Use NSAIDs, avoid opioids.
• Avoid mechanical bowel • Surgical approach :
• Within 24 hours :
preparation (D/t fluid + Minimally invasive.
- Discontinue IV fluids.

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electrolyte imbalance). • Bupivacaine infiltration.
- Start with liquids f/b

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• Permitted to take prior to Sx : • Keep patient warm.
regular diet.

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a. Solids up to 6 hours. • Nausea + vomiting

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- Ambulate.
b. Clear carbohydrate rich prophylaxis. (At least 2
liquids up to 2 hours.
7@
classes of medications).
• Avoid drains./Plan early
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removal.
(Carbohydrate loading).
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Patient Safety, OT Zones, Surgical Positions

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00:07:14
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IV Cannulas :
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Colour-coding :
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Maximal Flow
Color Gauge
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Rate (mL/min)
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Yellow 24G 13
Blue 22G 30
Pink 20G 67
Green 18G 96
Gray 16G 240
Orange 14G 270
IV cannulas
• Violet : 26G.
• White : 17G. Swelling
Superficial thrombophlebitis :
• M/c complication of cannula insertion.
• Presentation : Cord-like tender swelling at the
site and takes few weeks to resolve.
• Mx : Topical heparinoids (Thrombophobe).
Superficial thrombophlebitis

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 General Surgery : Part 1 3

Surgical Safety Checklist : ----- Active space -----

Sign in Time out Sign out

Before induction of anesthesia. Before patient leaves
Before skin incision.
(Ward OT) OR (At skin closure).
• Confirm : Patient identity, • Verbal confirmation of : Patient,
Confirmation :
site, procedure. site & procedure name.
• Nurse : Gauze +
• Written consent to be taken. • Surgeon confirms :
instrument count.
• Surgical site marking. - Operative duration.
• Surgeon : Specimen
• Inquire about allergies. - Anticipated blood loss.
labelling.
• Confirm pulse oximeter • Anaesthetist : Antibiotic
• Anaesthetist : Actual
functioning. prophylaxis (To be given within
blood loss.
• Evaluate risk of blood loss. 60 minutes of the procedure).
OT Zones :
Clean zone (Connects

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Protective zone
protective zone to aseptic zone)

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• Change rooms

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• Transfer bay • Equipment store room
• Pre & post op rooms • Maintenance workshop 7@
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• ICU/ PACU
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Aseptic zone Disposal zone

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• OT • Waste disposal
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OT Positions :
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Surgical position Uses

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1. Supine (M/c used) Abdominal and breast surgeries.

©

Foot
end : ↑
2. Trendelenburg Pelvic surgeries.
Head
end : ↓

Foot
3. Reverse Upper abdominal surgeries. Head end : ↓
Trendelenburg (E.g : Laparoscopic cholecystectomy) end : ↑

• Obstetric, gynaecological,
urological procedures.
4. Lithotomy
• Common peroneal nerve injury :
If legs not properly supported.

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 4 Surgery

----- Active space ----- Surgical position Uses

• Thoracotomy, kidney
surgeries. (Eg : Nephrectomy)
5. Lateral/kidney position
• Brachial plexus injury due to
hyperextension of arms.

Spinal surgeries and

6. Prone
pilonidal sinus surgeries.

• Posterior cranial fossa

procedures.
• Advantage :
7. Sitting/Fowler’s position - Better exposure.

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- Bloodless field.

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• Disadvantage : ↑Risk of air

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embolism.
7@
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Not preferred
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8. Jack-knife
(D/t positional asphyxia)
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Note :
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Air embolism :
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• 50 to 100 cc of air getting sucked into the vein.

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• Clinical scenarios :
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a. During thyroid/head and neck surgery Vein nicked. Sudden

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b. While operating in sitting position. desaturation.

• Mx of suspected air embolism : Durant’s position/Left lateral (Right side up) +
legs up.
• Significance : Air remains in right side of heart Easy aspiration.
(Image guided)

Surgical blades and Energy Sources 00:18:28

SURGICAL BLADES
Surgical blades Uses
• Incision and drainage
No. 11 (Pointed/stab blade)
• Arteriotomy
No. 12 (Curved blade) Suture removal
No. 10, 15, 20, 21, 22, 23
Making incisions
(Blades with a belly) Surgical blades No. 11 blade
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 General Surgery : Part 1 5

Blade handling : ----- Active space -----

• Blades passed in a kidney tray to prevent injuries.
• Blades mounted on BP handle.
• Incision made from far to near.
Bard Parker (BP) handle
Note : Langer’s lines.
• AKA relaxed tension lines.
• Lines are perpendicular to action of underlying
muscle.
• Incisions are made parallel to the lines (Give good
scars).

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ENERGY SOURCES Langers line
Monopolar v/s Bipolar Cautery : 7@
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Monopolar cautery Bipolar cautery

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Flow of current :
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Tip Body Cautery pad Machine. Flow of current (Locally completed) :

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(To cut/
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Prong 1 Body Prong 2

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coagulate)
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Cautery pad :
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• Placed over well vascularized area.

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No cautery pad required

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• Wide area of contact required.

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• If small Burns at attachment site.

Disadvantages : Advantage :
• Thermal damage to nearby nerves & vital • Safe to use with pacemakers.
structures. • Can be used near vital structures, end
• Interference with cardiac conduction arteries.
Surgeries used :
Thyroid, parotid, penile, CNS sx, ear lobule.
Can cut and coagulate Only coagulate

Buttons
Cautery pad
Yellow : Cut
Blue : Coagulate

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 6 Surgery

----- Active space ----- Modes of currents :

Cutting Coagulation
Current Low voltage, continuous High voltage, alternating
Uses Cuts the tissue Stops bleeding
Cutting mode Coagulation mode

Other modes :
Peak voltage
Average
voltage
Blend mode Fulguration mode
Harmonic Scalpel :

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• Working principle :

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- Ultrasonic, coagulation without heat production.
7@
- Oscillatory blade (20,000–50,000 Hz oscillation).
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• Advantage :
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- Precise cut.
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- Can cut through scar tissue. Harmonic scalpel

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- Can be used close to vital structures.

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Drains, Sutures and Knots

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00:24:40
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DRAINS
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Drains Significance
• Used in abscess cavities.
Corrugated • Rarely used.
Open drain
rubber drain • Disadvantage : Pus drains out,
soaks dressing.

• Negative pressure exerted.

Romovac
• Used after mastectomy, Bag
suction drain
thyroidectomy, neck dissection.

Closed drains

Mini-vac Smaller version of Romovac drain

drain (Works on the same principle).

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 General Surgery : Part 1 7

----- Active space -----

Drains Significance

Bulb
• Works on negative pressure.
Jackson Pratt
• Flat tubing and a bulb instead
drain
of a bag.
Flat tube

Abdominal • Placed in abdomen.

drain • No negative pressure.
Closed drains

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gm
Connected to chest tubes. (End of
Under water
seal bag
tube is submerged under water : 7@
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Prevents air getting sucked in.)
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Surgical Knots, Sutures

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Types of surgical knots :

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a. Square/Reef knot :
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• Secure knot; does not open up.

• 2 throws f/b a single throw.
b. Granny’s knot/Slip knot : Not secure, opens up (Avoided).
c. Surgeon’s knot : 2 throws f/b single throw.
Crossings are opposite

Below Above Above Below

Below Above Below Above

Reef/Square knot Granny/Slip knot Surgeon’s knot

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 8 Surgery

----- Active space ----- SUTURES

Skin suturing :
• Edge should be everted.
• Needle entry : 90° with skin.
• Bite on each side : X.
• Distance b/w 2 sutures : 2X.
Needle entry X : Depth of wound.
Types :
a. Simple sutures : Fail to cause edge eversion.
b. Mattress suture : Hemostatic sutures, causes eversion of edges.

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B

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Superficial

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Deep A Same
7@ depth
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Vertical mattress Horizontal mattress

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c. Subcuticular sutures :
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• No needle marks on the skin.

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• Suture is buried from inside.

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• Cosmetically better.
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• Suture material : 3-0/4-0 Monocryl

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(Absorbable) on cutting needle. Subcuticular sutures

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d. Purse string sutures :

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Uses :
• Rectal prolapse surgery (Thiersch wiring).
• Cervical encerclage in cervical incompetence.
• Bury appendicular stump.

Purse string suture

Needle : Terms and Types

Point Swaged end • Swaged end : End of needle where

2/3rd 1/3rd suture material is attached.
Body • Needle to be held at : 1/3rd from swaged
(Shaft) end and 2/3rd from pointed end.

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 General Surgery : Part 1 9

Types : ----- Active space -----

Round body (RB) needle Cutting/Reverse cutting needle

Rounded cross section; atraumatic Triangular cross section
Used for delicate structures (All B’s) : Used for tough structures (All S’s) :
Bowel, Bladder, Common Bile Duct (CBD), Blood vessels. Skin, Sheath, Fa�cia

Numbering of Sutures :
• No. 1 suture Thickest,
No. 11-0 Finest suture (Suture becomes finer : Number ↑ + zero added
after number.)
• Thick suture : Easier to handle.
• Finer suture : Difficult to handle (Break/fractures more common).
Types of Sutures :

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Absorbable sutures Non-absorbable sutures

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gm
Natural Synthetic Natural Synthetic
a. Monocryl (Poliglecaprone) :
7@ a. Prolene (Polypropelene
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• Monofilament suture. monofilament) :

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Uses :
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• Subcuticular suturing
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Eg : Catgut on cutting needle • Rectus sheath closure :

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• Sheep gut derived. Jenkins theory Minimum

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• Tensile strength : length required to close rectus

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Duration for which Eg : Silk sheath = 4 times the length of

b. Vicryl (Polyglactin) :
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suture can hold Used for : the wound.

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• Braided suture.
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tissue together • Skin • Vascular repair/anastomosis

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• ↑Infection rate.
(21-28 days). (3-0/cutting). (RB needle) :
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• Absorption (Hydrolysis) :
• Absorption time • Fix drains
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- 2-0 : Aorta.
60-90 days.
(By enzymatic (No. 1/cutting) - 4-0 : Femoral.
• Uses : Bowel, bladder
degradation) : • Bowel - 6-0 : Popliteal.
and CBD.
90 days. anastomosis • Mesh (Hernia repair).
• Chromic catgut (3-0/RB).
(With chromic salt
coating) : c. PDS (Polydioxanone) : b. Nylon/Ethilon :
No role in Sx. • Absorption time : • Monofilaments.
180 days. • Uses : Skin , fixing drains,
• Monofilament suture. nerve & tendon repair.
• Same use as vicryl.
• Natural sutures (Overall) : More tissue reaction/inflammation.
• Synthetic non-absorbable sutures :
a. Polyester : Tendon repair.
b. Steel sutures : Sternotomy wound closure (Post CABG).

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 10 Surgery

----- Active space ----- Suture removal in non-absorbable sutures :

• Scalp : 5-7 days. • Thorax : 10-12 days.
• Face : 3-5 days. • Abdomen : 12-14 days.
• Neck : 5-7 days. • Perineum : 10-12 days.

Bowel Anastomosis & Staplers 00:39:43

Bowel Anastomosis :
• Strongest layer in bowel anastomosis : Submucosa.
• Inverted edges suturing.
• 3 methods Single layer extra-mucosal
Two layer Similar results.
Using staplers

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Outer suture

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(Non-absorbable) :

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Seromuscular layer.
7@ Inner suture
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(Absorbable) :
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All layers.
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Single layer anastomosis Double layer anastomosis

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Surgical Staplers :
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Staplers Uses
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• Bowel anastomosis
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Linear • Sleeve gastrectomy

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• Zenker’s diverticulum surgery

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• Hemorrhoidopexy
Circular • Low anterior resection (LAR)
for rectal cancer surgery

Post-Op Fever and Wound Infection 00:41:40

CAUSES OF POST-OP FEVER

• Day 1 :
- M/C cause : Atelectasis.
- Prevention :
i. Chest physiotherapy : Incentive spirometer.
ii. Pain control.
iii. Steam inhalation. Incentive spirometer
iv. Cessation of smoking (4-6 weeks prior to surgery).
Surgery Revision • v4.1 • Marrow 8.0 • 2025
 General Surgery : Part 1 11

• Day 2-3 : ----- Active space -----

- Superficial thrombophlebitis.
- UTI : M/c hospital acquired infections.
- Pneumonia.
• Day 4-5 :
- Surgical site infection.
- Deep Venous Thrombosis (DVT). Pneumonia : Middle lobe
consolidation
• Day 6 : Burst abdomen/Abdominal wound dehiscence.
• Day ≥ 7 : Intra-abdominal abscess/collection.

Surgical Site Infection (SSI) :

• Wound infection within 30 days of surgery.
Post implantation : within 1 year of surgery.

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SSI
• Scoring systems :

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ASEPSIS Score Southampton wound score

gm
ASEPSIS : 7@
• Additional treatment •
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O : Normal healing
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• Serous discharge • I : Normal healing + mild bruising/erythema

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• Erythema • II : Erythema + other inflammatory signs

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• Purulent exudate • III : Clear discharge

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• Separation of deep tissues • IV : Pus discharge

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• Isolation of bacteria • V : Deep/severe wound infection ± tissue breakdown

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• Prolonged Stay > 14 days

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DVT Prophylaxis :
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Pneumatic compression stockings used.

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No numbering
Numbering +

Pneumatic anti-DVT stockings Anti-shock garment

Burst Abdomen :
Rectus sheath wound opens up : Bowel exposed out.
C/f : Salmon fluid sign/Serous fluid sign (Large quantity
of clear fluid oozes out of the wound).
Mx :
• In emergency : Urobag or bogota bag laparostomy.
• Definitive : Rectus sheath resuturing. Burst abdomen Urobag laparostomy
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 12 Surgery

----- Active space ----- Factors predisposing to burst abdomen :

Patient factors : Surgery factors :

• Chronic cough. • Midline incision > Transverse.
• Constipation. • Emergency > Elective.
• Infection/obesity. • Continuous sutures > Interrupted.
• Immunocompromised. • Large bite > Short bite (Ideal : 0.5 cm).
• Malnourished. • Short thread > Long thread
(Minimum 4 times the length preferred).
Intra-Abdominal Abscess :
• M/c site overall.
Pelvis/Pouch of Douglas (POD).
• M/c site in an ambulatory patient.
• M/c site in supine patient : Morrison’s/hepatorenal

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pouch.

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Presentation :

gm
• Fever + chills and rigors. 7@
a4

• Pelvic abscess : Present with pelvic diarrhoea

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Pelvic abscess
(Repeated episodes of loose stools + mucus).
ga
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IOC : CECT.
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Mx : Drainage with pigtail catheter

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under imaging guidance.

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Pigtail catheter
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Wounds 00:49:40

Percentage of SSI
Types of With Without
Examples
wound antibiotic antibiotic
prophylaxis prophylaxis
Clean incised wound : 1-2%
• Thyroid surgery. • Knee replacement. No role of prophylactic
Clean wound • Breast surgery. • Uncomplicated inguinal
antibiotic in clean wound except
• CABG. hernia surgery. when implant or mesh is placed.
GI/GU system but there is no inflammation :
• Elective/interval cholecystectomy.
Clean • Elective appendectomy.
contaminated • Urinary stone removal when no UTI. 3% 6-9%
wounds • LSCS.
• Laparoscopic abdominal hysterectomy.
• Bowel surgery, if the bowel is prepared.

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 General Surgery : Part 1 13

Percentage of SSI ----- Active space -----

Types of With Without
Examples
wound antibiotic antibiotic
prophylaxis prophylaxis
GI/GU system but there is non purulent
inflammation :
• Emergency/interval cholecystectomy.
Contaminated • Emergency appendectomy.
6% 20%
wounds • If the bowel is opened while operating a
case of intestinal obstruction.
• Breach in sterile protocol :
Eg. Open cardiac massage.
Pus present :
• All abscesses.
Dirty wound • Peritonitis/Fecal contamination. 7-8% 20-40%

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• Any neglected traumatic wound > 6 hours

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Note :
7@
Elective OT list : Clean cases (Eg : Implant insertion) posted first.
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Prevention of Wound Infection :

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a. Hand hygiene :
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• Steps :
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 14 Surgery

----- Active space ----- • Areas missed while hand washing :

3
1
1. Thumb.
2 2. Inter digital areas.
3. Finger tips.

• 5 moments of hand hygiene :

“2 Before” : “3 After” :
1. Before touching a patient. 3. After body fluid exposure risk.

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2. Before clean/aseptic procedure. 4. After touching a patient.

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5. After touching patient’s surroundings.
• Soap and water/sanitizer should be used. 7@
a4

- C/I for sanitizer use :

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i. After toilet visit.

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ii. Visibly soiled hands.

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b. Parts preparation :
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Hair clipper :
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- Used to trim hair (Prior to surgery).

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- Avoid shaving before surgery (↑Infection rates). Hair clipper

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c. Cleaning of the part of body :

©

• Agent used : Betadine/Alcohol.

• Area cleaned Abdominal Sx Males : Nipples to mid thigh.
Females : Inframammary fold to mid thigh.
Limb Sx : Till 1 joint up.
• Direction of cleaning :
- Abdomen : Midline to lateral. F/b Sponge disposal.
- Limbs : Lateral to medial.
- Circumferentially outwards from incision site/ Circumferential cleaning
midline.
d. Prophylactic antibiotics :
• Given 30 to 60 minutes before Sx.
• Prolonged Sx : Repeat dose after 4 hours.
e. Prevent hypothermia.
f. Prevent blood loss : Achieve proper hemostasis.
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 General Surgery : Part 2 15

GENERAL SURGERY : PART 2 ----- Active space -----

Surgical Nutrition 00:00:32

Nutrition Assessment :
• No single reliable biochemical marker to identify malnutrition.
• Indicator of poor prognosis : Unintentional weight loss of >10% in 3 months.
• Indicator of poor outcome : Low albumin, BMI <15.
Fat : Skin fold thickness.
• Assessment
Muscle mass : Mid arm circumference.

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Malnutrition Universal Screening Tool (MUST) :

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BMI + Weight loss + Acute disease = Overall risk of

gm
score score effect score malnutrition.
7@
Types :
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• Enteral (Oral/gut).
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• Parenteral (IV route).

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Enteral Nutrition 00:01:42

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• Better method.
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- More physiological.
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- Prevents translocation of gut bacteria.

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• Best route : Oral.

Not possible Good Feeding gastrostomy.
>3 weeks
Duration of Poor Feeding jejunostomy.
Gastric
requirement emptying Good Nasogastric (NG) tube.
<3 weeks (Ryle’s tube)
Poor Nasojejunal (NJ) tube.
Ryle’s tube :
Check NG tube position by :
• Clinical methods :
- Aspirating gastric contents.
- Pushing air F/b  Auscultation
in epigastrium.
Length assessment NG tube (Ryle’s tube) • Imaging : Chest X-ray.
Patient position for insertion : Sitting with neck slightly flexed.
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 16 Surgery

----- Active space ----- Other enteral methods :

NJ tube Feeding gastrostomy : Feeding jejunostomy

(Bypasses stomach) • More physiological.
• ↑Risk of aspiration.
Techniques for Gastrostomy and Jejunostomy :
1. Open techniques :

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Purse string Tunnel

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Stab suture
incision 7@
a4
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a. Stamm method : b. Witzel technique :

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↑Chances of peri-drain leak. ↓Chances of peri-drain leak.

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2. Percutaneous Endoscopic Gastrostomy (PEG) :

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Method of insertion :
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Endoscope passed in stomach Illuminated site palpated + punctured

PEG tube inserted

over the guide
wire and secured
Introducer
of PEG

PEG set
3. Radiologically Inserted Gastrostomy (RIG) : Done when endoscopy is not possible.

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 General Surgery : Part 2 17

Complications of Enteral Nutrition : ----- Active space -----

Tube related (M/c) Feeding regime related

• Blockade
• Osmotic diarrhoea (Sugar rich fluids)
• Migration
• Overfeeding (↑Risk of aspiration)
• Leak

Parenteral Nutrition 00:08:40

Best route : Central line.

Indications :
• Prolonged paralytic ileus (>72 hours).
• Short bowel syndrome (<200 cm small intestine).
• High output faecal fistula (>500 cc/24 hours).
• Acute episodes of inflammatory bowel disease.

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• Acute severe pancreatitis (Initial phase only).

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Fecal fistula
Central Line :

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Subclavian vein 7@Internal jugular vein Femoral vein
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Risk of thrombosis & infection Least Intermediate Maximum

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Risk of pneumothorax Maximum Intermediate Least

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Ease of insertion Maximum ease.

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M/c used in Total

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Others M/c used vein overall

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Parenteral Nutrition (TPN)

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Post-insertion : Chest x-ray (Look for central line tip & rule out pneumothorax).
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Catheter tip position :

• In SVC.
• Just above the
Rt atrium.
Inserted like IV line
Central venous catheter Peripherally Inserted
Central Catheter (PICC line)
TOTAL PARENTERAL NUTRITION (TPN)
Contents : (Lacks fibre content) Protein : Fat : Carbohydrate
20 : 30 : 50
Infusion rate : 1-2 litres/24 hours.
TPN solution modifications :
Respiratory failure Renal failure
• ↓Carbohydrate (↓Osmolar) • ↑Carbohydrate
• ↓Quantity • ↓Quantity TPN solution
Surgery Revision • v4.1 • Marrow 8.0 • 2025
 18 Surgery

----- Active space ----- Monitoring of Patients on Feeding Regimes :

Recommended schedule for monitoring feeding regimens
• Pulse, blood pressure and temperature.
• Body weight (↑ : Earliest sign of overfeeding).
Daily (Clinical measures)
• Input/output chart.
• Type of nutrition given.
• Sodium, potassium, urea and creatinine.
Biochemical measures :
• Blood glucose.
• Initially daily.
• Magnesium and phosphate.
• Later once/twice a week.
• Liver function tests.
(When on stable regime)
• C-reactive protein.
Complications of TPN :
Central line related Feeding regime related
• Pneumothorax. • Hyperglycemia (M/c).

om
• Arrhythmias. • Excess weight gain.

l.c
ai
• Thrombosis. • Cholestasis (Withhold TPN).

gm
• Air embolism. • Micronutrient deficiency
• Migration. 7@ (M/c : Zinc deficiency).
a4

• Catheter related sepsis (M/c central line complication). • Refeeding syndrome.

tiy

Catheter related sepsis :

ga
ar

• On fluid administration Fever + chills & rigors.

ik
sh

• Ix : Cultures from Catheter tip.

va
ur

Peripheral line.
|

Central line.
w
ro

• Mx : Remove catheter if it is the source.

ar
M

Refeeding syndrome :
©

• Large quantities of nutrition given to chronically malnourished.

• Main cause of death Congestive Metabolic derangements
heart failure. • ↓K+ • ↓Mg2+.
Arrhythmias. • ↓Ca2+. • Fluid overload.
• ↓PO43- : Main driver.
• Patient at risk of developing refeeding syndrome :
- BMI <16 kg/m2.
- Unintentional weight loss >15% within last 3-6 months. ≥ 1 factor.
- Little/no nutrition intake for >10 days.
- ↓K+/↓PO43-/↓Mg2+ prior to feeding.
Prevention :
1. ↑Feeds gradually (Initially 10 kcal/kg/day Full feeds in 4-7 days).
2. Strict electrolyte levels monitoring.
3. Thiamine supplementation.
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 General Surgery : Part 2 19

Liver dysfunction in TPN : ----- Active space -----

Long term TPN use
Fatty liver (M/c) :
• Children (M/c).
25% liver derangement
• Modified using lipid free solutions.
Intestinal Failure Associated Liver Disease (IFALD) :
Small number of patients.
Hartmann's/Ringer Lactate (RL) Solution :
Composition (In mEq/L) :
Na+ K+ Ca2+ Cl- Lactate
131 5 2 111 29
Note :

om
• Metabolic derangements in fecal fistula : Fluid + electrolyte imbalance.

l.c
• Maximum in pancreatic and biliary fistula Opening Duodenum.

ai
in

gm
7@
a4

Hypovolemic/Hemorrhagic Shock 00:21:19

tiy
ga

M/c type of shock.

ar
ik
sh

Types of hemorrhage :
va
ur

a. Overt/Visible hemorrhage : b. Concealed/Covert hemorrhage :

|
w

Sites :
ro
ar

• Neck.
M
©

• Thorax.
• Abdomen.
• Pelvis.
• Long bones.
Hemorrhage in surgery :
Primary Reactionary Secondary
Duration During Sx Within 24 hours. After 7-14 days.
Clot dislodgment or Sloughing of wall.
Reason
knot slippage. (D/t infection.)

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 20 Surgery

----- Active space ----- Classification of Hypovolemic Shock :

Class I Class II Class III Class IV
Mild/ Moderate/
Other names - Severe
Compensated Decompensated
% of blood volume lost 0–15% 15–30% 31–40% >40%
Amount of blood lost <500 cc 500 cc – 1 litre 1–1.5 litres >2 litres
Pulse rate ↑ (Earliest sign) ↑ Not recordable
Blood pressure N SBP,↑DBP ↓SBP Not recordable
Respiratory rate Normal ↑ ↑
Urine output Normal Normal ↓ No output
Thirsty &
Mental status Confused Comatose
anxious
Base deficit (mEq/L) -2 to -6 -6 to -10 > -10

om
IV crystalloids +

l.c
Oral Massive blood
Management IV crystalloids colloids

ai
liquids transfusion

gm
(3 : 1 ratio)
7@
Management of Hypovolemic Shock :
a4
tiy

Dynamic fluid response :

ga

After 1 litre of fluid (IV bolus) administration :

ar
ik
sh

Responder Transient responder Non-responder

va

PR
ur

↓↓ ↑
|

SBP ↑↑ ↓
w
ro

JVP ↑↑ ↓
ar
M

Response Sustained Reversed in 15-20 mins d/t ongoing loss Ongoing loss
©

Hemorrhage resuscitation :
Responders Prioritise Perfusion targeted resuscitation.
- perfusion
Ongoing losses
+ Prioritise Damage control resuscitation.
Transient/ coagulation
non-responders
Indicators :
• Determining amount of fluid requirement in shock.
PCWP CVP
• Pulmonary Capillary Wedge Pressure. • Central Venous Pressure.
• Measures left heart pressure. • Measures rt. heart pressure.
• Best indicator, more accurate. • M/c used indicator.
• Best clinical indicator of adequate fluid resuscitation in shock : Urine output.

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 General Surgery : Part 2 21

Indices : ----- Active space -----

Rate over pressure

Shock index Modified shock index
evaluation (ROPE)
Heart rate Pulse rate Heart rate
= = Pulse pressure =
Systolic BP Mean arterial pressure
(MAP)
>3 = Decompensated
>0.9 = ↑Mortality rate Best index
hemorrhagic shock
End points of Resuscitation :
Systemic perfusion :
To normalise Mixed Venous Oxygen Saturation (MVOS) : Best indicator.
Base deficit Acidosis.
Serum lactate

om
Massive Blood Transfusion :

l.c
ai
gm
Definitions :
• Replacement of entire circulating volume in 24 hours. 7@
a4

• >10 units of blood in 24 hours.

tiy
ga

• >4 units of blood in 1 hour.

ar

Complications :
ik
sh

• Hypothermia.
va
ur

• Hypocalcemia (Citrate chelates Ca2+).

|
w

• Metabolic alkalosis.
ro

D/t citrate toxixity.

ar

• Hypomagnesemia.
M

• Hyper K+ >> Hypo K+ (D/t RBC lysis in stored blood).

©

• Coagulopathy : M/c cause of death after massive transfusion

Prevention
1 : 1 : 1 transfusion (RBC : Platelet : FFP)
Complications of Blood Transfusion 00:36:11

Transfusion Related Acute Lung Injury (TRALI) :

• M/c cause of death after transfusion.
• Antibodies against HLA antigen Non-cardiogenic
pulmonary oedema.
• Occurs within 6 hours of blood transfusion. B/L lung
infiltrates
Multiparous women.
• Implicated donors
FFP donors.
TRALI : ARDS like picture
Surgery Revision • v4.1 • Marrow 8.0 • 2025
 22 Surgery

----- Active space ----- Transfusion Associated Cardiac Overload (TACO) :

• Volume overload Facial puffiness, pedal edema, breathlessness.
• Chest x-ray : N .
• Rx : Diuretics (Lasix). Leucoreduction
chamber (↓ in
Transfusion Reactions :
WBC number)
Febrile non-hemolytic transfusion reactions :
• M/c, caused by graft-versus-host response.
• Leucoreduction filter : ↓Febrile reactions.
Leucoreduction filter

Other Types of Shock 00:39:23

Septic
Hypovolemic Cardiogenic Neurogenic Anaphylactic

om
Warm Cold

l.c
ai
PR ↑ ↑/↓ ↓ ↑ ↑ ↑/↓

gm
CO ↓ ↓ ↓ ↓ ↑ ↓
7@
SBP ↓ ↓ ↓ ↓ ↑ ↓
a4
tiy

PVR ↑ ↑ ↓ ↓ ↓ ↑
ga

Extremities Cold Cold Warm Warm Warm Cold

ar
ik

N
sh

JVP ↓ ↑ ↓ ↓ ↑
va

Acidosis ↑
ur
|

Mismatched
w

Pump Spinal cord

ro

blood Heart
Class III failure (MI, transection Hyperdynamic
ar

Features transfusion fails in

M

type heart block, ( - sympathetic state

allergic reaction sepsis
©

arrhythmia) system)
(↑Histamine)

Obstructive shock Distributive shock

Mechanical impairment of cardiac filling
Blood redistributes to peripheries.
(Type of cardiogenic shock).
Warm shocks :
Eg :
1. Anaphylactic.
1. Tamponade.
2. Warm septic.
2. Pulmonary embolism.
3. Neurogenic.

Note : MVOS.
• Percentage of oxygen that returns to the heart after being utilized in the
body.
• Only ↑ in warm septic shock/distributive shock.

Surgery Revision • v4.1 • Marrow 8.0 • 2025

 General Surgery : Part 2 23

Sepsis and Septic Shock 00:46:54 ----- Active space -----

Terminologies :
Definition & criteria
2 or more of the following criteria :
Systemic Inflammatory
• Temperature >38°C or <36°C.
Response Syndrome (SIRS)
• Heart rate >90 beats/min.
(Mediated by IL-1, IL-6,
• Respiratory rate >20 breaths/min or PaCO2 <32 torr (<4.3 kPa).
TNF-α)
• WBC >12000 cells/mm3, <4000 cells/mm3, or >10% immature forms.
Sepsis SIRS + known foci of infection.
Septic shock Sepsis leading to hypotension not responding to fluids.
MODS (Multiple Organ
Failure of ≥2 organ systems.
Dysfunction Syndrome)
Quick Sequential Organ Failure Sepsis (New definition) :

om
Assessment Score (qSOFA) : SOFA Score ≥2 + known foci of infection.

l.c
ai
gm
7@
a4
tiy
ga
ar
ik
sh
va
ur
|
w
ro

Sepsis 3.0 Guidelines :

ar
M

SIRS Terminology removed, replaced with qSOFA/SOFA

©

Sepsis Dysregulated host response to infection Life-threatening organ dysfunction

Severe sepsis Terminology removed
Septic shock Need vasopressors & lactate >2 mmol/L
Sepsis Bundle :
Completed within 3 hours Completed within 6 hours
• Measure lactate levels.
• Give vasopressors (Maintain MAP ≥65 mmHg).
• Obtain blood cultures.
• In persistent arterial hypotension Measure MVOS.
• Give antibiotics.
• Remeasure lactate (If initial levels↑).
• Administer IV fluids.
Within 1 hour
Sepsis Six :
Mnemonic : Give 3 & Take 3. Give 3 + Take 3
• IV fluids. • Blood culture.
• IV antibiotics. • Urine output.
• Oxygen. • Serum lactate.

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 24

----- Active space ----- BREAST

Work Up of Breast Disorders  00:00:24

Clinical Signs :
Dimpling Retraction Peau d’orange (PDO)
Structure Superficial (Subdermal)
Ligaments of Cooper Lactiferous ducts
involved lymphatics
Skin involvement
- - + (T4b disease)
in breast cancer
• Circumferential :

om
Seen in inflammatory
Other features - Malignancy
breast cancer

l.c
• Slit-like : Duct ectasia

ai
gm
7@
a4
tiy

Images
ga
ar
ik
sh
va
ur
|
w
ro

Triple Assessment :
ar
M
©

History + Radiological Ix Histopathological Ix

clinical examination • FNAC
<40 years : >40 years : • Biopsy (Bx)
USG Mammogram

Dial clock method (Best)

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 Breast 25

Breast Imaging Reporting and Data Systems (BIRADS) : ----- Active space -----

BIRADS score Inference Mx

0 Incomplete Ix Additional imaging
1 Negative
No Bx; Follow up after 1 year
2 Benign
Follow up after 6 months
3 Probably benign
(Risk of cancer : <2%)
Suspicious :
• 4a : Low suspicion
4 Biopsy
• 4b : Moderate suspicion
• 4c : High suspicion
5 Highly suggestive of malignancy Biopsy
6 Biopsy proven malignancy Sx excision when appropriate

om
ASBRS Breast Cancer Screening Guidelines :

l.c
ai
gm
Category Screening guideline
7@
Annual screening mammography
a4
Average risk of breast cancer
from 40 years of age
tiy
ga

• BRCA mutation : + Annual MRI at 25 years.

ar

• Prior chest wall radiation 3D mammography at 30 years

ik

Higher than
sh

average risk : • Predicted lifetime risk

va

Annual 3D mammography/
(By Gail, BRCA pro model) >20%
ur

MRI at 35 years
|

• Strong family history

w
ro

When life expectancy becomes <10 years Stop screening.

ar
M

Mammograph :
©

• Breast X-ray. • Advantages of MLO :

• Radiation exposure : 0.1-0.2 cGy. - Axilla can be visualized.
- Maximum breast tissue seen.

2 views :

Craniocaudal Medio-lateral oblique (MLO)

Popcorn calcification Spiculated mass

(Fibroadenoma) (Malignancy)
Surgery Revision • v4.1 • Marrow 8.0 • 2025
 26 Surgery

----- Active space ----- MRI :

Indications
• Breast implants.
• Multifocal & multicentric lumps. Imaging IOC
• Detection of local recurrence or scar recurrence.
• Screening modality : Young & high-risk patients.
• Suspected ductal lesions with inconclusive USG
(Most sensitive in Ductal Carcinoma In Situ (DCIS)).

Breast implant rupture USG findings

Intracapsular Stepladder
Extracapsular Snowstorm
Linguini sign (MRI) :

om
Intracapsular breast implant rupture

l.c
ai
Biopsy techniques :

gm
7@
Incisional biopsy
a4
tiy

Punch biopsy Tru-cut/core needle biopsy

ga

• Skin lesions/cancers • IOC

ar

• Paget’s disease of breast • 14 G biopsy gun used

ik
sh
va
ur
|
w
ro
ar
M
©

Breast Cancer 00:09:44

Risk Factors :
• ↑Age. • Family history.
• Early menarche, late menopause. • Hormone replacement therapy
• Nulliparity. (Estrogen + progesterone).
• Smoking. • Maternal age at first live birth :
• Obesity, alcohol. >30 yrs.
Note :
Smoking is associated with : Factors ↓ breast cancer risk
• Breast cancer. • Breastfeeding (For 1 year).
• Duct ectasia. • Maternal age at first live birth <20 years.
• Mondor’s disease.

Surgery Revision • v4.1 • Marrow 8.0 • 2025

 Breast 27

Features : ----- Active space -----

• Most common type of breast cancer : Invasive ductal carcinoma.
- Origin : Terminal duct lobular unit (TDLU; functional unit of breast).
• Quadrants affected : M/C Upper outer; L/C Lower inner.
Genetic Mutations :
Breast cancer M/C gene mutation BRCA 1 BRCA 2
Sporadic cases (90%) p53 Chr 17q Chr 13q
Familial cases (10%) BRCA-1 BRCA 1 > 2 : BRCA 2 > 1 :
ER + , PR + PI3CK • Breast cancer • Pancreatic cancer
• Ovarian cancer • Prostate cancer
Triple negative/
p53 • Male breast cancer
HER-2 neu +

Indications for BRCA testing :

om
For all patients :

l.c
ai
• Deleterious BRCA 1/2 gene mutation in a blood relative.

gm
• History of ovarian, fallopian tube and/or 1° peritoneal cancer.
Patients with breast cancer :
7@
a4
tiy

• ≥1 blood relatives diagnosed with breast cancer ≤45 years.

ga

• H/o B/L breast cancer at ≤50 years.

ar

• H/o triple negative breast cancer (TNBC) at ≤60 years.

ik
sh

• H/o male breast cancer.

va
ur

Immunohistochemistry (IHC) :
|

1. ER, PR : Nucleus stains brown (Steroid receptor).

w
ro

• Measured with Allred score (0-8).

ar
M

2. HER 2 neu : Cell membrane stains brown (membranous receptor).

©

• Result:
- 0, 1+ : - .
Amplified : +
- 2+ : Equivocal FISH
Non-amplified : -
- 3+ : + .
3. Ki-67 : Proliferation index marker (Cell multiplication).
Molecular Subtypes :
Based on gene
ER PR Her 2 Ki-67 CK 5/6
expression profiling. Luminal A + + - Low -
+ + - High -
Luminal B
+ + + Any -
Her 2 enriched - - + Any -
Basal like (TNBC) - - - Any +
Unclassified/Claudin-low - - - Any -

Surgery Revision • v4.1 • Marrow 8.0 • 2025

 28 Surgery

----- Active space ----- CK : Cytokeratin

Luminal A Basal like (TNBC)

• Seen in young patients.
• Exhibit TNBC paradox : Initial
M/C type good response to chemo Rx
↑Chances to recur
(D/t aggressive nature).
Best prognosis Worst prognosis

Tumor Staging : Immunohistochemistry (IHC)

Done by PET-CT : 18-Fluorodeoxyglucose (FDG) t1/2 : 110 minutes.
T staging N staging

om
l.c
Tis Cancer in situ (DCIS, Paget’s disease) N0 No Regional node metastasis

ai
gm
T1 ≤2 cm N1 Mobile I/L axillary LN
T2 >2cm-5cm 7@ N2a Fixed I/L axillary LN
a4
tiy

T3 >5 cm Internal mammary LN,

N2b
ga

Involvement of chest wall (Serratus in absence of axillary LN

ar

T4a
ik

anterior, ribs, intercostal muscles) N3a Infraclavicular LN

sh
va

Involvement of skin (Ulceration, direct N3b Internal mammary + axillary LN

T4b
ur

infiltration, PDO, satellite nodules) N3c Supraclavicular LN

|
w

T4c T4a + T4b

ro

M staging
ar

Inflammatory cancer : >1/3 of rd

M

T4d M0 No distant metastasis

breast involvement + PDO
©

M1 Distant metastasis

Metastasis :
• M/C site : Bones Lumbar vertebrae (M/C) d/t Batson’s plexus.
• Bony metastasis : Osteolytic > osteoblastic.
Note :
Lobular carcinoma insitu (LCIS) : No longer an insitu cancer.

Breast Cancer Management 00:21:42

SURGERY
Breast Conservative Surgery (BCS)/Lumpectomy :
Tumour removal With 1 mm margin.
F/b mandatory radiotherapy (D/t ↑local recurrence rate).

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 Breast 29

Oncoplasty : ----- Active space -----

Types of oncoplasty Breast volume resected

Volume displacement
10-15%
(Round block technique)
Volume replacement >15%
Volume displacement

Round block technique Volume replacement with Latissimus dorsi (LD) flap

C/I for BCS :

om
C/I for Radiotherapy (RT) Technical C/I

l.c
ai
• Multicentric

gm
• Pregnancy
• Lobular cancer (If multicentric)
• Prior RT to chest wall
• Large tumour : breast ratio 7@
a4
• Collagen vascular disease
• Locally advanced breast cancer (LABC)
tiy

(SLE, rheumatoid arthritis) Relative C/I

• Multifocal disease
ga
ar
ik

Mastectomy :
sh
va
ur
|

Radical/Halsted Modified radical Simple

w

• Elliptical Stewart incision • Breast + NAC removed

ro

Structures removed :
ar

• Breast • Structures removed : • LN not removed

M

• Nipple areolar complex (NAC) - Breast + NAC • If done in fungating

©

• Pectoralis major & minor - Pectoral fascia breast cancer :

• Level 1, 2, 3 axillary lymph nodes - Level 1, 2, 3 axillary Toilet/palliative
lymph nodes (LN) mastectomy
- ± Pectoralis minor

Retracted : Cut :
Auchincloss (M/C) Scanlon, Patey
Axillary LN Clearance :
Minimum LN removed : 10.
Nerves saved during Sx Key :
• Medial pectoral nerve (Laterally located) • S : Superior
• Lateral pectoral nerve (Medially located) • L : Lateral
• Long thoracic nerve : • M : Medial
- Not a boundary • I : Inferior

Boundaries of axillary clearance

Surgery Revision • v4.1 • Marrow 8.0 • 2025
 30 Surgery

----- Active space ----- Complications of Modified Radical Mastectomy (MRM) :

1. Hemorrhage.
2. Injury to nerves :
a. Intercostobrachial nerve (M/C nerve injured) :
• Numbness + paraesthesia in axilla.
• Phantom breast syndrome.
Winging of scapula
b. Long thoracic nerve/Nerve of Bell :
Winging of scapula.
3. Seroma (Fluid accumulation) :
• M/c complication.
• Prevention : Romovac drain.
• Mx : Aspirate ↓ aseptic conditions.

om
4. Lymphedema (Post-mastectomy) of upper limb :

l.c
Lymphedema

ai
• M/C cause of upper limb lymphedema.

gm
• Develops weeks to months post Sx. 7@
a4
• Long standing (8-10 years) : Angiosarcoma
tiy

(AKA Stewart Treves syndrome) Reddish

ga
ar

or bluish nodules.
ik
sh

• ↑Incidence :
va
ur

- LN removed above axillary vein. Stewart Treves syndrome

|

- RT given to axilla after clearance.

w
ro
ar

5. Recurrence :
M
©

• Local : • Diffuse : Cancer en curasse.

- IOC : MRI.
- Biopsy.
Local recurrence
Reconstructive Sx :
TRAM flap DIEP flap
Transverse rectus abdominis
Deep inferior epigastric artery perforator flap (Best flap)
myocutaneous flap
↑ abdominal wall morbidity ↓ abdominal wall complications
(Muscle removed) (Muscle not removed)

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 Breast 31

Sentinel Lymph Node Biopsy (SLNB) : ----- Active space -----

• 1st draining LN in cancer : Cancers where SLNB used
Sentinel LN (1st described by Cabana). • Malignant melanoma.
• M/C nerve injured : Intercostobrachial nerve. • Breast cancer.
• Penile cancer.
Identification : • Vulval cancer.
• Head & neck cancer.
1. Blue dye technique :
• Isosulfan blue/methylene blue dye used.
• Injected in periareolar region
(Subcutaneous plane).
• Complications : Blue LN
- Skin tattooing (M/C).
- Anaphylaxis.

om
- Bluish discolouration of urine.

l.c
Blue dye technique

ai
2. Radionucleotide technique :

gm
Tc99 tagged sulphur colloid injected 7@
a4
(Periareolar region)
tiy
ga
ar

Hot nodes (Radioactive) identified

ik
sh

on gamma camera.
va

Gamma camera Hot node

ur

3. Indigocyanine green (ICG) :

|
w

New method.
ro
ar

4. Dual technique (Best) :

M
©

Radionucleotide + Blue dye or Blue dye + ICG.

ICG technique
CHEMOTHERAPY
Indications : Neoadjuvant chemoRx (NACT) indications :
• LN + . • LABC.
• LABC. • TNBC.
• ER - , PR - tumours. • HER 2 neu + .
• HER 2 neu + tumours. • Large tumour with patient desirous of BCS.

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 32 Surgery

----- Active space ----- Response Evaluation Criteria in Solid Tumours (RECIST) :
Single largest diameter (SLD) measured : Assess tumour shrinkage.
Complete response (CR) Disappearance of all lesions + pathologic LN
Partial response (PR) ≥30% ↓ in SLD
Progressive disease (PD) ≥20% ↑ in SLD while/despite chemoRx or new lesions forming
Stable disease Neither PR nor PD

Documenting stage (Tumour) after chemotherapy :

y c T2 N0 M0
After neoadjuvant chemoRx Clinical
Tip lies in SVC
Avoidance of Chemotherapy : above right atrium
• Patient not fit for chemoRx/poor Chemoport
(To deliver chemoRx medication)

om
performance status (ECOG/Karnofsky).

l.c
ai
• Early breast cancer (T1 , T2 /N0 /M0 ) + Molecular tests

gm
Hormone + but HER 2 neu - 7@ Oncotype Dx 21 gene assay
a4
Mammaprint 70 gene assay
tiy

Molecular tests show low risk Endopredict 12 gene assay

ga
ar

PAM 50 50 gene assay

ik

No chemoRx.
sh

CAN assist (For Indian patients)

va

RADIOTHERAPY
ur
|

Indications :
w
ro

• LN + . • LABC.
ar
M

• Tumour >5 cm. • After BCS.

©

HORMONAL RX
Only given in ER + , PR + breast cancers.
Premenopausal Postmenopausal
Selective estrogen receptor Aromatase inhibitor
Drug
modulator (SERM) : Tamoxifen (Letrozole/anastrozole)
Duration 10 years 10 years
Hot flashes (M/C), DVT,
Side effects Osteoporosis (M/C)
endometrial hyperplasia
TREATMENT SUMMARY
Surgery ChemoRx RT Hormonal Rx
• BCS C/I Mastectomy • LN + , LABC, TNBC, HER 2 neu +
ER +
• If LN not enlarged : SLNB • Molecular tests Low risk + Post BCS
PR +
(↓Lymphedema incidence) hormone + + HER 2 neu -

Surgery Revision • v4.1 • Marrow 8.0 • 2025

 Breast 33

Special Breast Neoplasms 00:39:30 ----- Active space -----

LABC :
Definition :
• T3 N1 M0
• Any T4 Peau d’orange
• Any N2 With M0
• Any N3
LABC (T4 B)
Mx : NACT MRM/BCS RT.
Pregnancy Associated Breast Cancer :
• Develop during pregnancy/within 1 year of delivery.
• Aggressive tumours (Usually ER, PR - ).

om
Ix : Core biopsy (Diagnostic).

l.c
ai
gm
Mx :
1. Sx BCS in 2nd/3rd trimester only RT after delivery7@
a4

MRM (1st trimester)

tiy
ga

2. Chemo C/I in 1st trimester

ar
ik

Best : 2nd trimester

sh

3. Hormonal Rx + RT : C/I in all trimesters.

va
ur
|

Phyllodes Tumour/Cystosarcoma Phyllodes :

w
ro

C/F :
ar
M

• 3rd/4th decade.
©

• Rapidly enlarging breast lump.

• Dilated veins over chest wall.

Spread :
Phyllodes tumor
• <10% : Metastasize to LN.
• Hematogenous spread (If malignant) :
Lungs (M/c).

HPE : Arborizing pattern and slit-like

cystic areas seen.

Mx : HPE of Phyllodes tumor

Sx Lumpectomy.
Simple mastectomy for malignant phyllodes, recurrence.

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 34 Surgery

----- Active space ----- Benign Breast Conditions 00:42:11

MASTALGIA
M/C cause : Fibrocystic disease/fibroadenosis.
C/F : Cyclical mastalgia (↑before menses, settles after periods) +
breast nodularity.
Cardiff-Lucknow scale : Assess nodularity.
Mx :
Rx of pain + nodularity :
• Maintain pain diary.
2 months • Tamoxifen
• Reassure that it is not malignancy. M/C used
No benefit • Ormeloxifen
• Flaxseed/evening primrose oil.
• Danazol
BREAST CYST

om
l.c
Simple cyst Complex cyst Complicated cyst

ai
gm
No solid component Solid component + Intracystic floating debris
(BIRADS 2) 7@
(BIRADS 4a) (Infective)
a4
Mx : Solid component biopsied
Mx : Observation Mx : Antibiotics
tiy

(To rule out carcinoma)

ga
ar

MONDOR’S DISEASE
ik
sh

• Thrombophlebitis of chest veins.

va
ur

• Always rule out carcinoma.

|
w
ro

C/F : Mastalgia, O/E : Cord-like swelling.

ar
M

Risk : ↑in smokers.

©

Mondor’s disease
Mx : Anti-inflammatory agents (Settles in few weeks).

NIPPLE DISCHARGE
Duct Ectasia :
• M/C pathological cause for nipple discharge.
• Dilated duct + greenish discharge.

Periductal Mastitis (Zuska’s Disease) :

• Seen in perimenopausal (A/w smoking).
• Present with Pain + greenish discharge.
Periareolar abscess/sinuses (Aerobic + anaerobic).
IOC : Ultrasound.

Mx : Antibiotic Not responding Sx : H adfield procedure

(Cone excision of all affected ducts).

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 Breast 35

Duct Papilloma : ----- Active space -----

• Have central fibrovascular core + papillary projections
(Epithelium and myoepithelial cells).
• M/C cause of bloody nipple discharge (From single duct).

Solitary papilloma : Relative risk (RR) of cancer 1.5-2.

Types Papillomatosis (≥5 papillomas) : RR ≥3.
Juvenile papillomatosis : Multiple papillomas (Swiss cheese disease).

Ix : USG Dilated duct + intraductal growth.

Mx : Microdochectomy (Single affected duct + lump removed).

Paget’s disease vs Eczema :

om
Paget’s disease Eczema

l.c
ai
Eczema like condition + itching Itching

gm
Entire NAC destroyed No NAC destruction
7@
U/L B/L
a4
tiy

• 70% patients have underlying

ga

lump : DCIS (M/C), invasive

ar

- Paget’s disease
ik

ductal cancer (Rare).

sh

• ER & PR - (Usually), CEA + .

va
ur

Mx of underlying carcinoma Mx : Topical steroids

|
w
ro
ar
M
©

Paget cells in epidermis

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 36

----- Active space ----- THYROID, PARATHYROID AND ADRENAL GLANDS

Thyroid Gland 00:00:49

STA
Key :
(External Carotid A. Branch)
STA : Superior thyroid artery
Ligated close to gland ELN : Cricothyroid ELN : External laryngeal nerve
during surgery to save ELN (Vocal cord tensor) STv : Superior thyroid vein
STV IJv : Internal jugular vein
MTv : Middle thyroid vein
IJV ITv : Inferior thyroid vein
Butterfly RLN : Recurrent laryngeal nerve

om
MTV 30% shaped ITA : Inferior thyroid artery

l.c
(1 vessel ligated
st

ai
during thyroid Sx)

gm
7@
Parathyroid ITV
a4
RLN (Helps in its
tiy

identification)
ga

RLN Brachiocephalic vein ITA

ar

Capsular branches (ITA) :

ik

ITA : Branch of Ligated close to gland (Avoid

sh
va

thyrocervical trunk parathyroid devascularisation)

Common carotid artery
ur

Thyroid surgical anatomy Beahr’s triangle boundaries

|
w
ro

Note : Thyroid ima artery is a direct branch of aortic arch.

ar
M
©

Berry’s ligament :
• Pre-tracheal fascia condensation (Attaches thyroid gland to trachea).
• RLN Injured at this site during thyroid surgery.

Thyroid Examination :
Pizzillo’s method : Patient’s hand on the occiput & leans back to examine.
Lahey’s method : To feel margin of gland.
Crile’s method : To palpate nodules.
Lahey’s method Crile’s method

Investigations in Thyroid Disorders 00:03:54

TSH N /↑ USG Neck FNAC (IOC) :

Thyroid function test :
• 1st Investigation done Cannot differentiate b/w follicular
• T3, T4, TSH adenoma v/s carcinoma.
• Anti-thyroid antibodies TSH ↓ Thyroid scan.
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 Thyroid, Parathyroid and Adrenal Glands 37

Thyroid USG : ----- Active space -----

Features of malignant thyroid nodule :
• Hypoechoic. • Microcalcifications.
• Border irregularity. • ↑Intranodular vascularity.
Note : Gross features Taller > wider.
Abnormal cervical lymph nodes
(Round shape + Loss of fatty hilum).
TI-RADS Score : TR3, TR4, TR5 lesions only FNAC
Thyroid Fine-Needle Aspiration Cytology (FNAC) :
Royal College of Pathologist Classification :
(Similar to Bethesda classification)
FNAC Report Inference Management
Thy 1 Non diagnostic

om
Repeat FNAC under USG guidance
Thy 1c Non diagnostic cystic

l.c
ai
Thy 2 Non neoplastic (Benign) Follow up

gm
Thy 3 Follicular a4 Hemithyroidectomy
7@
Thy 4 Suspicious of malignancy
Surgery
tiy

Thy 5 Malignant
ga
ar

Criteria for specimen : 

ik
sh

At least 6 groups of follicular cells Each group composed adequacy of at least 10

va

cells on a single slide.

ur
|

Thyroid Scan :
w
ro

Isotopes : Technetium 99/Iodine 123.

ar
M

Indications Features of hyperthyroidism & ↓TSH.

©

Ectopic or aberrant thyroid tissue.

Solitary
Toxic
Nodule

Cold Nodule : Hot Nodule : Toxic Multinodular Goitre

• Non-functioning • Hyperfunctioning (Plummer’s Disease) :
• ↑Malignancy risk (20%) • Malignancy risk : 4% Multiple hot nodules

Normal Scan

Graves Disease Toxic Adenoma Thyroiditis :

(Diffuse ↑uptake) (Diffuse ↓uptake)
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 38 Surgery

----- Active space ----- Thyroglossal Cyst 00:10:30

• Persistent thyroglossal tract.

• M/c location : Subhyoid.
• Long standing thyroglossal cyst Papillary Thyroid Carcinoma
C/f : Midline swelling moves on Deglutition.
IOC : FNAC. Tongue protrusion.
Mx : S istrunk Surgery
Removal of cyst + part of hyoid bone + tract till base of tongue. Thyroglossal Cyst
(I & D : C/I Can cause thyroglossal fistula).
Thyroidectomy 00:12:16

Total thyroidectomy

om
(Removal of both lobes + Isthmus)

l.c
ai
gm
7@
a4
Hemithyroidectomy Subtotal thyroidectomy Near-total Thyroidectomy
tiy

(Lobectomy + isthmusectomy) (Hartley-Dunhill procedure)

ga

Not done presently

ar
ik
sh

Difficult to redo surgery in case of recurrence.

va
ur

Incidence of hypothyroidism, RLN injury, and hypoparathyroidism : Equal in all types

|

of surgery.
w
ro
ar

Open Thyroidectomy :
M
©

1. Rose position 2. Collar incision 3. Subplatysmal tunnel

Neck extended + Incision : Just 2 finger

30° head elevation breadths above the
(Exposing incision site). suprasternal notch.
4. Strap muscles retraction 5. Cutting of strap muscles

• To expand surgical field.

• If strap muscles cut : Done high up (To prevent ansa cervicalis injury).
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 Thyroid, Parathyroid and Adrenal Glands 39

6. Localization of parathyroid gland 7. Thyroid gland removal ----- Active space -----

Yellowish d/t RLN Trachea

Sentinel pad of fat.

8. Incision closure

om
l.c
Joll’s thyroid retractor

ai
Romovac suction drain

gm
Minimally Invasive Video-Assisted Thyroid Surgery (MIVAT) : 7@
a4
tiy

Approaches Indications
ga
ar

• Transaxillary (m/c)
ik

• <3 cm nodule
•
sh

Trans-oral
• T1 papillary thyroid cancer
va

• Retroauricular
• Parathyroid adenoma
ur

• Nipples
|
w
ro

Complications of Thyroid Surgery : MIVAT

ar

1. Hemorrhage.
M
©

2. Nerve injury :
External laryngeal nerve Recurrent laryngeal nerve
M/c, goes unnoticed Less common
U/L or B/L : Hoarseness/inability to
U/L : Hoarseness of voice
speak at high pitch
B/L : S tridor, aphonia, breathlessness (Life threatening)
(Not life threatening)

3. Post-operative respiratory distress :

• Laryngeal edema : M/c cause.
• Tension hematoma Mx : Open sutures Evacuate hematoma.
• Reactionary hemorrhage.
• Laryngomalacia.
• Bilateral RLN injury.
• Hypoparathyroidism : Late cause (>48-72 hours after surgery).

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 40 Surgery

----- Active space ----- Hypoparathyroidism :

D/t vascular insult (ITA) to the gland during surgery.
C/f :Perioral numbness (Initially) Tetany (Trousseau sign + & Chvostek sign + )
Respiratory muscle paralysis (M/c cause of death) Respiratory distress
Mx : Monitoring symptoms, serum calcium & serum PTH levels.
Presentation Management
S. Ca >8 mg/dL + Minor symptoms
2+
Oral Ca2+ + Oral vitamin D3
S. Ca2+ <8 mg/dL (OR) Major symptoms IV Calcium Gluconate + Oral Ca2+ + Oral vit D3

Thyroid Cancers 00:21:41

F > M.

om
l.c
Syndromes associated with thyroid cancers :

ai
gm
Type Syndrome Gene
7@
Medullary MEN 2 RET
a4
tiy

Cowden syndrome PTEN

ga

Follicular
Werner syndrome WRN
ar
ik

Familial Adenomatous Polyposis APC

sh

Papillary
va

Cowden Syndrome PTEN

ur
|
w

Differentiated Thyroid Cancer (DTC) staging updates :

ro
ar

(DTC includes : Papillary, follicular, hurthle cell ca.)

M

• Age cut off : Age at diagnosis <55 years (Good prognosis).

©

• T3 T3a: Tumor >4 cm confined to thyroid gland.

T3b: Strap muscles involvement.
• Anaplastic cancers will now use the same ‘T’ definitions as DTC (Previously
classified as T4 disease).

Papillary Thyroid Carcinoma (PTC) :

M/c Thyroid cancer, F > M, Best prognosis.

Risk factors :
• Radiation exposure to neck More aggressive tumour arises.
• Long standing thyroglossal cyst.
• Genetic : BRAF gene (M/c involved).

Features : Thyroid swelling Multifocal (Usually).

Spread : Lymphatic Level 6/Delphian LN > Hematogenous Lungs (M/c site).
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 Thyroid, Parathyroid and Adrenal Glands 41

Lateral aberrant thyroid : Palpable LN d/t mets from PTC. Lindsay tumour ----- Active space -----
Thyroid incidentaloma : Incidentally detected <1 cm tumour. Follicular variant of PTC.

Histology of PTC :
• Orphan annie eye/Coffee bean nuclei. Note : Psammoma bodies also seen in
• Intranuclear inclusions. • Serous cystadenocarcinoma
ovary.
• Psammoma bodies. • Meningioma.
• Papillary RCC.

Surgical Approach for DTCs :

Indications
• Low risk, unilateral DTC
Hemithyroidectomy • DTC b/w 1-4 cm
• No extrathyroidal extension

om
l.c
• Radiation induced DTC

ai
• Familial non-medullary thyroid Ca

gm
Total thyroidectomy (TT)
• Multifocal B/L DTC
•
7@
Extra-thyroidal extension
a4
tiy

TT + Central Neck Dissection (CND) Level 6 lymph nodes +

ga

Prophylactic CND T3, T4 disease +

ar
ik
sh

TT + CND + Modified Radical ND (MRND) Other nodes +

va
ur

Post-Operative Mx :
|

Traditional wait 4-6 weeks + Radioiodine ablation (I131)

w

↑TSH ( >20 IU/L) Whole body I2 scan :

ro

New Recombinant TSH given Residual disease F/b

ar

- Life long follow-up :

M

or metastasis
©

1. Thyroxine (TSH suppression)

2. USG neck & s.Tg (6 monthly)

Tumour marker for all DTCs.

Note : Serum thyroglobulin (s.Tg)
If >2 ng/mL : Suspect recurrence.
Radioiodine ablation (I131) :
• T1/2 : 8 days, acts via b-rays
• Indications : Residual disease + , Lymph nodes + , Metastasis + .

Follicular Thyroid Carcinoma (FTC) :

2nd m/c thyroid cancer, F > M, 2nd best prognosis.

Risk factors :
• Long-standing multinodular goitre (Rapid ↑size).
• Genetics PTEN & BAX gene mutations.
Up-regulation of miRNA 197, 346. FTC : Bony metastasis

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 42 Surgery

----- Active space ----- Spread :

• Hematogenous : Bones (M/c site) May be pulsatile (D/t vascularity).
• Lymph node (LN) : Level 6.
Mx :
FNAC Reports Follicular Neoplasm (Thy3) Hemithyroidectomy f/b frozen section
(For diagnostic confirmation of Carcinoma)
+ -
Sx approach for DTC Close up.
+ Post Op Mx.

Hurthle Cell Carcinoma :

• Earlier considered to be a variant of FTC. • More aggressive than FTC.
• Seen : Elderly (6-7 decade of life).
th
• Less radioiodine avid than

om
• HPE : Oxyphilic Hurthle cell + (Mitochondria rich). other DTC.

l.c
ai
Prognostic Indicators of DTCs :

gm
7@
a4
AGES system AMES system MACIS (Post-operative score)
tiy

• Metastases
ga

• Age • Age • Age

ar
ik

• Histologic Grade • Metastases • Completeness of original

sh

• Extrathyroidal invasion • Extrathyroidal spread Sx resection

va
ur

• Size • Size of tumours • Extra thyroidal Invasion

|

• Size of original lesion

w
ro
ar

Anaplastic Carcinoma Thyroid :

M

L/C, seen in 5-7th decade of life, worst prognosis.

©

C/f :
• Rapidly enlarging swelling.
• Hoarseness of voice (RLN involved).
• Stridor (Tracheal compression).

Mets : Lungs (M/c) Anaplastic Thyroid Ca

Genetic risk factor : p53 mutation.

Mx :

Restricted to thyroid : Extrathyroidal spread :

Aggressive Sx. • Palliative Mx.
• Tracheal compression : Isthmusectomy.

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 Thyroid, Parathyroid and Adrenal Glands 43

Medullary Thyroid Carcinoma : ----- Active space -----

Origin : Parafollicular ‘C’ cells (From ultimobranchial bodies of neural crest).
(Do not take up iodine)
MEN-2B Syndrome
Calcitonin produced (Tumor marker of MTC).
• Most aggressive MTC.
Etiology : Sporadic > Familial (A/w MEN-2 syndrome). • Seen in young patients.
Features : Thyroid swelling ± diarrhea, aggressive tumors. • Multifocal.
Spread : Lymphatic (Level 6 LN) + Hematogenous (M/c : Liver).
HPE : Amyloid rich stroma.
IOC : FNAC.
Note :
Surgical Mx Indication • Always rule out
TT + CND MTC restricted to thyroid pheochromocytoma
TT + CND + MRND Thyroid tumor + level 6 LN before Sx.
• No role of thyroid
TT + CND + B/L MRND Thyroid tumor + level 6 LN + other nodes

om
scan & radioactive

l.c
Vandetinib, Carbozantinib Metastases + iodine.

ai
gm
MEN Syndromes 7@ 00:39:10
a4
tiy

Multiple Endocrine Neoplasia (MEN) 1 Syndrome :

ga
ar

AKA Wermer Syndrome.

ik
sh

• Pituitary adenomas : Prolactinoma (M/c type in MEN-1).

va

• Parathyroid adenoma (M/c presentation in MEN-1) > Hyperplasia. Mnemonic :

ur
|

• Pancreatic endocrine tumors : Gastrinoma (M/c in MEN-1). 3Ps.

w
ro
ar

Other tumors : Thymic tumors, collagenomas, adrenal cortical tumors.

M
©

MEN 2 Syndrome :
MTC only MEN 2A/Sipple syndrome MEN 2B/MEN 3 syndrome
Exon 618 mutation Exon 634 mutation Exon 918 mutation
• MTC (M/c), most aggressive
• MTC (M/c)
• Marfanoid feature
• Parathyroid adenoma
MTC only • Mucosal neuromas
• Pheochromocytoma
• Megacolon
• Megacolon
• Medullated corneal nerve fibres
Prophylactic thyroidectomy should be done by Prophylactic thyroidectomy should be
5-6 years of age. done by 1 year of age.

MEN 4 Syndrome :
• CDKN1B gene mutation on chromosome 12.
• Can develop pituitary adenomas and parathyroid adenomas, renal tumors,
adrenocortical tumors, reproductive organ tumors.

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 44 Surgery

----- Active space ----- Hyperthyroidism 00:43:21

Clinical features Causes

• Thin & irritable • Grave’s disease : M/c cause
• Weight loss despite • Solitary toxic nodule
good appetite • Toxic nodular goitre
• Tachycardia • Factitious hyperthyroidism : ↑Exogenous thyroxine intake
• Diarrhea • Jod-Basedow phenomenon : I2 induced hyperthyroidism
• Tremors • TSH secreting pituitary adenoma
• Heat intolerance • Struma ovarii : Thyroid tissue in ovary (Usually malignant)
Mx :
1. Drugs only Propyl thiouracil (PTU) :
Safe in 1st pregnancy. S/E : Agranulocytosis.
Carbimazole

om
2. Drugs f/b radioactive iodine (I131).

l.c
3. Drugs f/b Sx (Inadequate preparation prior Sx Thyroid storm).

ai
gm
Preparation of a hyperthyroid patient for surgery : 7@
a4

• Start anti-thyroid medications 6-8 weeks before surgery.

tiy
ga

• Long acting beta blockers should be given : Nadolol.

ar

• Last dose of anti thyroid medication is to be given evening before surgery.

ik
sh

• Beta blockers continued for 7 days post surgery.

va
ur

Grave’s Disease :
|
w

• 1° thyrotoxicosis, autoimmune condition.

ro
ar

• Auto antibodies : Long acting thyroid stimulating antibodies.

M
©

Associated with : Pernicious anemia, myasthenia

gravis.
Clinical Features :
• Diffuse enlargement of gland.
• Hyperthyroidism, pretibial myxedema. Pretibial myxedema Exophthalmos
• Eye Signs (Classical) : Infrequent blinking.
- Stellwag sign Earliest and m/c sign.
- Von Graefe sign : Lid Lag
- Dalrymple sign : Lid retraction D/t spasm of muller’s muscle.
- Joffroy sign : No forehead wrinkling on looking up
- Moebius sign : Loss of accommodation reflex (Severe toxicity)
HPE :
• Scalloping of colloid. Scalloping of colloid with
• Tall columnar cells. tall columnar cells
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 Thyroid, Parathyroid and Adrenal Glands 45

Management : ----- Active space -----

Patient’s status Mx
Children Drugs only
Pregnant Anti-thyroid drugs (1st trimester : Only PTU)
Without goitre Drugs f/b radio iodine ablation
Adult
With goitre Drugs f/b Sx (Near total/total thyroid Sx)
Elderly with co morbidities Drugs f/b radio iodine ablation (RIA)
Patients with eye signs Drugs f/b Sx (RIA worsens eye signs)

Hypothyroidism 00:50:00

Clinical Features Causes

• Dull

om
• Slow, lethargic • Iodine deficiency : M/c cause overall.

l.c
ai
• Cold intolerant • Hashimoto’s thyroiditis : M/c in western world.

gm
• Bradycardia • Wolf-Chaikoff effect : I2 induced hypothyroidism.
• Constipation • Non-functioning pituitary adenoma.7@
a4
• Weight gain
tiy
ga

Hashimoto’s/Lymphocytic De Quervain’s/Viral Granulomatous

ar

Riedel’s Thyroiditis
ik

Thyroiditis Thyroiditis
sh
va

Autoimmune
• H/O URTI + • IgG4 mediated
ur

A/w :
Etiology • A/w HLA B35 • Fibrous deposition in and
|

• Down’s Syndrome
w

• Subacute around the gland.

ro

• Turner Syndrome
ar
M

Painless neck swelling Painful neck swelling Painless neck swelling

©

Course : Course : • Woody hard gland

C/f Hashitoxicosis (↑T3, ↑T4 briefly) Hyperthyroidism Hypothyroidism • Hoarseness of voice
Spontaneous (RLN involvement)
Prolonged hypothyroidism Euthyroid recovery • Stridor (Tracheal compression)
1. Autoantibodies (Diagnostic)
against :
- Thyroid receptor (Blocking) Trucut biopsy : To rule out
Ix ↑ESR
- Thyroglobulin anaplastic thyroid cancer.
- Thyroid peroxidase
2. HPE : Lymphocytic infiltration
1. Thyroxine replacement
Rx Supportive care Steroids, Tamoxifen
2. Surgery (Diffuse goitre + )

Note :
• Hashimoto’s thyroiditis ↑Risk of FTC, lymphoma.
• Postpartum thyroiditis : Subacute, painless.

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 46 Surgery

----- Active space ----- Goitre 00:55:16

Thyroid gland enlargement.

Types :
1. Diffuse : 2. Multinodular :
Seen in : Seen in :
- Puberty, Pregnancy. Long-standing I2 deficiency
- Hashimoto’s thyroiditis (Variable gland stimulation
- Graves disease. by TSH).
- Iodine deficiency
(Initial phase).

om
Retrosternal Goitre :

l.c
ai
1° Mediastinal 2° Retrosternal

gm
Ectopic thyroid • M/c 7@
a4
Features tissue in • Starts in neck Goes behind sternum
tiy

mediastinum (Plunging goitres).

ga

Neck vessels
ar

Blood Mediastinal
ik

(Neck incision made Ligate neck vessels,

sh

Supply vessels
gland removed easily)
va
ur

Clinical features : Dyspnoea, stridor, Pemberton sign.

|
w

CXR : Retrosternal goitre

Ix : CECT Neck/Thorax (IOC).
ro
ar
M

Mx : Surgery Neck only (Cervical only).

©

Fails
Median sternotomy.
Other Indications of Median Sternotomy :
1° mediastinal goitre, large malignant retrosternal goitre,
recurrence in mediastinum. Pemberton Sign : Facial congestion on raising
hands above head

Hyperparathyroidism 00:57:09

Embryology of parathyroid glands :

• Superior parathyroid : 4th pharyngeal arch.
• Inferior parathyroid : 3rd pharyngeal arch.

Clinical Features :
1. Bones : Pathological #, Brown tumours (Von Recklinghausen disease of bone).
2. Stones : Multiple + recurrent renal stones (M/c feature).
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 Thyroid, Parathyroid and Adrenal Glands 47

----- Active space -----

Osteitis fibrosa cystica/Brown

tumors Sub periosteal resorption Salt and pepper skull
3. Abdominal Groans : Colicky abdominal pain, pancreatitis.
4. Psychiatric Overtones.

1° Hyperparathyroidism :
Adenoma > Hyperplasia
Ix Biochemical : s.PTH↑, s.Ca2+↑, s.PO43-↓, urinary Ca2+↑, urinary PO43-↑.
Imaging : Sestamibi scan (Best type : SPECT Localises parathyroid gland).

om
l.c
ai
Mx :

gm
Sestamibi scan a4
7@
tiy

Adenoma Hyperplasia
ga
ar
ik
sh

Remove affected
31/2 gland
va

1/2 gland autotransplanted in

gland (Miami
ur

removed. brachioradialis (M/c) of

|

criteria done).
w

forearm of non-dominant hand.

ro
ar

(If recurrence + : Easy removal)

M

Sestamibi Scan
©

Miami Criteria (Intra-op PTH assay)

Pre-op PTH level 10-15 mins after Sx PTH level ↓by >50% Correct gland removed.

2° Hyperparathyroidism :
↑PTH + Parathyroid hyperplasia, reversible condition.
Causes : Mx :
• Chronic Renal Failure (CRF). • Correction of CRF.
• Defective intestinal absorption. • Vit D3 Supplement.
• Lithium intake. • Low phosphate diet.
• Vitamin D3 deficiency • Cinacalcet.

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 48 Surgery

----- Active space ----- Pseudohyperparathyroidism :

AKA Hypercalcemia of malignancy.
M/c paraneoplastic syndrome PTH related peptide mediated A/w
• SCC lung.
• Metastatic :
C/f : Altered Sensorium & dehydration.
- Prostate Ca.
Mx :
- Breast Ca.
• IV fluids (1st line) F/b Diuretics (Lasix).
• DOC : Bisphosphonates (When RFT N and urine output adequate).

Adrenal Incidentaloma 01:04:06

Incidentally detected adrenal tumour.

om
Workup :

l.c
ai
• Serum cortisol

gm
• 7@
Plasma free metanephrines (To rule out phaeochromocytoma)
a4
• Serum DHEA
tiy

• Dexamethasone suppression test (Cushing’s syndrome)

ga
ar

• Urinary cortisol
ik
sh

+ -
va
ur
|

Functional Tumour : Non-functional tumour :

w
ro

Manage accordingly. MRI (Check for malignancy).

ar
M
©

Radiological features suspicious of malignancy are :

• Diameter >4 cm and density >10 HU. Adrenal incidentaloma : CT
• CECT : Wash out.
• MRI chemical shift : No change in signal intensity on out of phase imaging.
• FDG PET : Positive uptake.

Management :
U/L adrenal mass

Radiological suspicion of malignancy

No Yes
Functional tumour Local invasion
No Yes Yes No Yes
No Sx Laparoscopic Diameter ≤6 cm Open adrenalectomy.
Monitor adrenalectomy No
Imaging : >25% ↑in size Individualized Sx approach.

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 Thyroid, Parathyroid and Adrenal Glands 49

Phaeochromocytoma 01:06:41 ----- Active space -----

• Tumour of adrenal medulla.

Extra adrenal phaeochromocytoma.
• Paraganglioma
M/c site : Organ of Zuckerkandl (Sympathetic Chain).
Rule of 10 Associated Syndromes
10 % familial • MEN 2 (m/c)
10 % bilateral • Neurofibromatosis-1
10 % malignant • Von-Hippel-Lindau Syndrome
10 % extra adrenal • Familial paraganglioma syndrome
10 % in children

Clinical Features : Gross Appearance :

• Headache (M/c symptom). • Tan brown colour.

om
• Sweating. • Areas of necrosis & hemorrhage.

l.c
• Episodic HTN (M/c sign) in young patients.

ai
gm
Note : Young onset HTN D/D Hyperthyroidism, renal artery stenosis, polycystic
7@
kidney disease, phaeochromocytoma.
a4
tiy
ga

Investigations :
ar

Screening test : 24 hr Urine VMA

ik
sh

(Vanillyl mandelic acid).

va
ur
|

IOC : Serum plasma free metanephrines.

w
ro

Imaging IOC : MRI (Light bulb sign). Phaeochromocytoma : MRI

ar
M

IOC Extra adrenal phaeochromocytoma : Gallium dotatate scan.

©

Mx :
• a blockade F/b b blockade.
Phenoxybenzamine (a blocker) ↑Dose gradually till postural hypotension +
• Sx : L aparoscopic/Open adrenalectomy.
(Open Sx if malignancy + ).

Neuroblastoma 01:10:23

Features :
• M/c abdominal malignancy in children : Neuroblastoma > Wilms tumour.
• M/c age : <5 years.
Site : Adrenal medulla > Sympathetic chain.
Genetics : n-myc amplification.

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 50 Surgery

----- Active space ----- Clinical Features :

• Abdominal lump crossing midline (Wilm’s tumour : Does not cross).
• >50% present with metastasis.
Metastatic features :

Eyes swollen

Blueberry muffin lesions on skin (Characteristic) Racoon eyes

Ix : Mx :
IOC : MRI (Tumour site, intratumoral calcifications + ). Chemotherapy and Sx.

Carcinoids

om
01:12:14

l.c
ai
AKA Neuroendocrine tumours (NET) New term.

gm
Site : Appendix > Small bowel. a4
7@
Types :
tiy
ga
ar

Foregut/Bronchial Carcinoids Midgut Carcinoids Hindgut Carcinoids

ik
sh

Site Stomach, duodenal Appendix, ileum Colon, rectum

va
ur

Metastases Bones (M/c) Liver Liver

|

Argentaffin - +
w
ro
ar

Serotonin - + Metabolised in Liver

M

Carcinoid Syndrome Uncommon If liver metastasis +

©

Features :
• Cutaneous flushing (M/c symptom).
• Abdominal pain, sweating.
Carcinoid syndrome :
Serotonin enters in circulation Bronchospasm.
Right heart valve involved : Tricuspid valve (M/c)
Investigations :
Urine : 5-Hydroxy indole acetic acid (5-HIAA).
Blood : Serum chromogranin.
Imaging CECT.
Serotonin receptor Scintigraphy. (Localise tumour)

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 Thyroid, Parathyroid and Adrenal Glands 51

Management : ----- Active space -----

Sx F/b Ki67 If↑levels Malignant NET Require Chemo Rx.

Ki67 : Proliferation Index marker.

Appendicular carcinoid Mx :

<2 cm, away from base >2 cm, close to base

Simple appendicectomy. Right hemicolectomy.

om
l.c
ai
gm
7@
a4
tiy
ga
ar
ik
sh
va
ur
|
w
ro
ar
M
©

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 52

----- Active space ----- ORAL CANCER, SALIVARY GLANDS & NECK
SWELLINGS

Oral Cancers 00:00:35

FEATURES
• m/c site (Overall) : Lateral border of tongue.
Keratin
• m/c site (India) : Gingivo-buccal sulcus. pearls
• m/c gene mutation : p53.
RISK FACTORS

om
• Smoking. • Immunosuppression. HPE : Squamous cell carcinoma (SCC)

l.c
• Alcohol. • Sharp, ill - fitting denture.

ai
gm
• Betel quid. • Chronic infections (HPV : Oropharyngeal SCC >> Oral SCC).
Note : EBV a/w nasopharyngeal cancer. 7@
a4
tiy

PRE-MALIGNANT CONDITIONS
ga
ar

Risk factors for malignant transformation in pre-existing dysplastic lesions :

ik
sh

• Female sex.
va
ur

• Non-smoker.
|

• Lesion specific :
w
ro

- Size > 200 mm2. - Multiple.

ar
M

- Non-homogenous. - Site : Lateral border of tongue/floor of mouth.

©

Dysplastic lesions :
Leukoplakia Erythroplakia Chronic submucous fibrosis
• White patch • Red patch. • Hypersensitivity reaction
(Cannot be • ↑ Risk of cancer by to betel nuts .
Features rubbed off). 6 - 9 times. • Inadequate mouth opening
• ↑ Risk of cancer • Most aggressive form : d/t fibrous deposition in
by 3 - 5 times. Speckled. oral cavity.
• Stop risk factors for oral cancer.
Mx Intra-lesional triamcinolone.
• Biopsy (Confirmatory).

Appearance

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 Oral Cancer, Salivary Glands and Neck Swellings 53

Other conditions ↑ risk for malignancy : ----- Active space -----

• Chronic hyperplastic candidiasis.
• Oral lichen planus (Ulcerative).
• 2° Syphilis.
• Plummer-Vinson Syndrome (aka Paterson Kelly Brown Syndrome/
Sideropenic dysphagia) :
- Seen in perimenopausal women.
- C/f : a. Iron deficiency anemia (Koilonychia + ).
b. Angular stomatitis & glossitis.
c. Post cricoid web or upper esophageal webs.
- ↑Risk (d/t webs) SCC esophagus.
Hypopharyngeal cancer.
Note : Oral candidiasis White patch can be rubbed off (Leaves reddish border).

om
INVESTIGATIONS

l.c
ai
Biopsy :

gm
• Edge/wedge biopsy (Centre avoided d/t necrotic tissue).7@
a4

• Pattern of invasion : (DOI is a prognostic factor).

tiy
ga
ar
ik

Basement membrane
sh

Tumor
va

Depth of thickness
ur

invasion
|

(DOI)
w
ro
ar

Staging :
M
©

T stage N stage
Stage Size (cm) + DOI (mm) N0 No Lymph node (LN) involved
T1 ≤2+≤5 N1 Single I/L LN ≤ 3cm in size
≤ 2 + 5 to 10 N2a Single I/L LN 3 - 6 cm in size
T2 (or) N2 N2b Multiple I/L LN, all ≤ 6 cm in size
2 to 4 + ≤ 10 N2c Any B/L (or) C/L LN, all ≤ 6 cm in size
T3 > 4 (or) > 10 N3a Any LN > 6 cm + ENE -
N3
Invasion of adjacent N3b Any ENE + (Clinical/radiological)
T4
structures

Note : 
• Clinical extra nodal extension (ENE) Matting, skin fixity.
• M/c site of distant metastasis : Lungs.

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 54 Surgery

----- Active space ----- TREATMENT

• Surgery :
- Wide local excision (0.5 cm margin).
Commando procedure
- Mandibular resection (If involved).
f/b reconstruction
- Neck dissection (Lymph node clearance).
• Chemotherapy.
• Radiotherapy.
Neck Dissection (ND) :
Incision : Modified Schobinger’s incision (MRND).
Types :
Radical ND (Given by Crile) Modified radical ND (MRND) Selective ND
Structures removed

om
• Level 1-5 LN + • Level 1-5 LN + At least 1 extra- • Central ND :

l.c
3 extra-lymphatic structures : lymphatic structure saved. Level 6 LN (Delphian LN).

ai
- Sternocleidomastoid (SCM) - Based on structure saved : • Supra omohyoid ND (SOHND)

gm
- Internal jugular vein (IJV) a) MRND I : SAN. : Level I, II and III.
- Spinal accessory nerve (SAN) b) MRND II : SAN + IJV. 7@ • Extended SOHND : Level I, II,
a4

+ c) MRND III : All 3 saved III and IV.

tiy

• Submandibular gland.
ga

(Functional ND).
ar

• Tail of parotid. • Submandibular gland.

ik

• Tail of parotid.
sh
va

Note : T1/T2 lesions Sentinel lymph node biopsy (SLNB).

ur
|

Prophylactic ND (SOHND) Better prognosis.

w
ro
ar
M

Hypoglossal nerve
©

SCM

IJV
SAN

Ansa cervicalis

Modified Schobinger’s incision Post MRND III : Intraoperative field

Complications :
• Haemorrhage.
• Carotid artery blowout : Maximum mortality.
• Nerve injury :
- Marginal mandibular nerve/ramus mandibularis (M/c injured) :
• Causes drooping of angle of mouth.
• Prevention : Incision should be 2 finger breadth below the mandible.
- Spinal accessory nerve Shoulder dysfunction.
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 Oral Cancer, Salivary Glands and Neck Swellings 55

Flaps for Reconstruction : ----- Active space -----

1. Deltopectoral flap
2. Pectoralis major myocutaneous flap (PMMF) : M  /c used by head and neck
surgeons.
3. Radial artery forearm flap :
- m/c used free flap + most versatile.
- Allen’s test done prior.
4. Free fibular flap : Mandibular reconstruction.

om
l.c
ai
Free fibular flap PMMF

gm
7@
a4
tiy
ga
ar
ik
sh
va
ur
|

Radial artery forearm flap

w

Deltopectoral flap
ro
ar

Adjuvant Therapy :
M
©

Indications High risk features :

• Major : ENE, margins involved + / - .
• Minor :
- Close margins.
- Multiple nodes involved.
- Largest node > 3 cm.
- Lymphovascular invasion (LVI).
- Peri-neural invasion (PNI).
- T3/T4.
Modalities :
1. Radiotherapy : If 1 major + or 2 minor risk factors + .
2. Concurrent chemo - radiation : Cisplatin-based regimen (High risk patients).
3. Immunotherapy : PDL - 1 inhibitors (Recurrent/metastatic SCC).

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 56 Surgery

----- Active space ----- Benign Conditions of Salivary Glands 00:17:17

Condition Description

Mucus
• Blockade of minor salivary gland
retention
• Mx : Excision
cyst

Mucus extravasation cyst of sublingual salivary gland.

• Site : Floor of mouth
• C/F : Brilliantly transilluminant & fluctuant
• Mx :
Ranula - Cyst + sublingual salivary gland excision (Best Rx)
- Marsupialization

om
• Surgical Complications :

l.c
ai
- M/c injured structure : Submandibular duct

gm
- M/c nerve injury : Lingual nerve
7@
Plunging • Mucus retention cyst (sublingual + submandibular gland)
a4

ranula • Mx : Excision of intra - oral swelling + neck swelling aspiration

tiy
ga
ar
ik

• In immunocompromised patients
sh

Parotid
• C/F : Painful swelling + fever on lateral parotid region
va

abscess
ur

• Mx : Incision + drainage (Avoid facial nerve injury)

|
w
ro
ar
M
©

Stafne
Mandibular cyst : M/c site of ectopic salivary tissue
bone cyst

• Rapid swelling of 1/both glands

• Aggravated by chewing
Recurrent
• Symptoms for 1 week f/b quiescent period
parotitis in
• Age : 3 - 6 years
childhood
• X - ray : Snowstorm appearance
• Rx : Long course of antibiotics + repeated endoscopic washouts
Snowstorm appearance
• Submandibular > Parotid gland
• Composition : Calcium phosphate
Sialolithiasis • C/F : Post - prandial painful neck swelling
• IOC : NCCT
• Mx : Endoscopic mx fails Duct slitting fails Excision

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 Oral Cancer, Salivary Glands and Neck Swellings 57

Salivary Gland Tumors 00:21:59 ----- Active space -----

• Benign tumours : Parotid > Submandibular > Sublingual > Minor

• Malignant : Minor > Sublingual > Submandibular > Parotid
Milan system for reporting salivary gland cytopathology :
Group Diagnostic criteria Management
I Non-diagnostic Repeat FNAC (IOC) with ultrasound guidance
II Non-neoplastic Follow up
AUS (Atypia of undetermined Repeat FNAC (Fine needle aspiration cytology)
III
significance) /Surgery
IVA Benign neoplasm Surgery/follow up
IV SUMP (Salivary gland neoplasm
IVB Conservative surgery
of uncertain malignant potential)

om
V Suspicious of malignancy Surgery

l.c
VI Malignant Surgery (Depending on extent)

ai
gm
PAROTID TUMORS
90 % Benign. 7@
a4
tiy

Clinical features :
ga

• Lateral facial swelling Lifts ear lobule.

ar
ik

• If deep lobe enlarged Tonsillar fossa pushed medially.

sh
va

M/c tumour : Pleomorphic adenoma.

ur

M/c malignant tumour : Mucoepidermoid carcinoma.

|
w
ro

Benign Tumours :
ar
M
©

Pleomorphic adenoma Warthin’s tumor

• Benign, slow growing • 2 m/c tumour, mostly bilateral
nd
Features
• A/w PLAG - 1 mutation • M>F
Lobe involved Superficial lobe Superficial lobe
• IOC : FNAC
Investigations • IOC : FNAC
• Imaging : CT/MRI
Treatment Superficial parotidectomy Superficial parotidectomy
Triphasic tumour with epithelial cells in • Two layers of cells (Mitochondria rich)
myxoid backgrounds • Lymphocytic infiltration

HPE findings

Epithelial 2 layers
cells of cells
Carcinoma ex pleomorphic adenoma
Complication -
(Malignant transformation)

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 58 Surgery

----- Active space ----- Malignant Tumours :

1. Mucoepidermoid carcinoma.
2. Adenoid cystic carcinoma :
- 2nd m/c parotid tumour.
- PNI + .
• Extremely painful.
• ↑ Recurrence rate. HPE : Adenoid cystic carcinoma
- HPE : Swiss cheese appearance.
3. Carcinoma ex pleomorphic adenoma/mixed malignant tumor :
- Malignant transformation of pleomorphic adenoma.
- Signs of malignant change :
• Rapid ↑ in size.
• Painless painful (D/t capsular stretching).

om
• Ulceration.

l.c
ai
• Facial nerve involvement.

gm
• Lymph node enlargement. 7@
a4

- IOC : FNAC.
tiy

- Mx : Surgery f/b radiotherapy.

ga
ar
ik

Treatment :
sh
va

Principles :
ur

• Margin : 0.5 cm.

|
w
ro

• Elective SOHND : T3/T4 tumours and high-grade tumours.

ar
M

• Adjuvant radiotherapy indicated if :

©

- Stage 3 and 4. - PNI + /LVI + .

- High grade tumours. - ENE + .
- Positive margins.
Parotidectomy :
Incision : Lazy S incision/modified Blair’s incision.
Types :
• Superficial.
• Total (Superficial + deep lobe removed).
- Conservative (Facial nerve spared).
- Radical (Facial nerve removed).
Cable graft (Sural nerve > Greater auricular nerve).

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 Oral Cancer, Salivary Glands and Neck Swellings 59

Complications : ----- Active space -----

• Haemorrhage.
• Nerve injury :
- Facial nerve.
- Greater auricular nerve : Anaesthesia over beard region.
- Marginal mandibular branch > Cervical branch of facial nerve :
Drooping of angle of mouth.
• Parotid fistula.
• Frey’s syndrome :
- Gustatory sweating.
- Auriculotemporal nerve involved :
Post ganglionic parasympathetic fibers Supplies Skin glands Sweating over
parotid region.

om
- Ix : Starch iodine test.

l.c
ai
- Mx TOC : Tympanic neurectomy.

gm
First line : Botox and anti-perspirants. 7@
a4
- Prevention : SCM flap/digastric muscle flap to cover parotid bed.
tiy
ga
ar
ik
sh
va

Sweat + , starch
ur

turns blue
|
w

Starch iodine test

ro
ar

SUBMANDIBULAR TUMORS
M
©

• M/c tumour : Pleomorphic adenoma.

• M/c malignant tumour : Adenoid cystic carcinoma.
O/E : Bimanual palpation.
- Submandibular gland : Palpable. Submandibular swelling
- Submandibular LN : Not palpable.
Diagnosis : FNAC (lOC).
Mx : Submandibular excision.
Complications of Submandibular excision :
• Haemorrhage.
• Nerve injury :
- Marginal mandibular nerve (M/c injured).
- Lingual nerve.
- Hypoglossal nerve. Bimanual palpation
• Injury to other structures : Anterior facial vein, facial artery.

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 60 Surgery

----- Active space ----- SUBLINGUAL TUMOUR

M/c tumour of sublingual gland : Adenoid cystic carcinoma.
MINOR SALIVARY GLAND TUMORS
• M/c tumour : Adenoid cystic carcinoma.
• M/c site : Hard palate.

Neck Swellings 00:34:00

Dermoid Cyst :
Formed at lines of embryonic fusion.
Classical site : Post auricular/outer canthus of eye.
O/E : Fluctuant swelling.
Imaging : Done prior Sx, to rule out intracranial

om
l.c
extension.

ai
Dermoid cyst

gm
Mx : Surgery.
7@
Tubercular Cervical Lymph Node :
a4
tiy

Collar stud/cold abscess.

ga

Mx : Anti-gravity aspiration. (Avoid dependant aspiration

ar
ik

to prevent sinus/fistula formation).

sh
va
ur
|
w
ro

Cold abscess
ar
M
©

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 Gastrointestinal Surgery : Part 1 61

GASTROINTESTINAL SURGERY : PART 1 ----- Active space -----

Surgical Anatomy of Esophagus  00:00:50

3 main constrictions
Structures associated Distance from upper incisor Relevance
• Narrowest portion of GIT
1. Pharyngoesophageal
15cm • Foreign bodies can get stuck
junction (C6)
• Iatrogenic perforations
2. Left main bronchus &
25cm -
arch of aorta

om
3. Esophagus pierces
40cm -

l.c
diaphragm

ai
gm
Foreign Body 7@ 00:01:30
a4

Features :
tiy
ga

Location Lateral view Frontal view Symptoms

ar
ik

Esophagus Side of coin seen Face of coin seen Difficulty swallowing

sh
va

Trachea Face of coin seen Side of coin seen Stridor & choking
ur
|
w
ro
ar
M
©

X-ray : FB in trachea X-ray : FB in esophagus

Note : Button battery Double ring sign.

Management :
• Beyond C6 : Patient observation.
If coin
• Impacted at C6 : Endoscopic removal.
• Button battery : Endoscopic removal (D/t corrossive nature Perforation).

Corrosive Injury 00:03:12

Causes :
1. Alkali : Liquefactive necrosis Penetrates deeper (More dangerous).
2. Acids : Pylorospasm Gastric damage.

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 62 Surgery

----- Active space ----- Grading :

Zargar classification.

Endoscopic finding Grading

Normal 0
Superficial edema/erythema 1
Mucosal/Submucosal ulceration 2
Transmural ulceration with necrosis 3
Perforation 4

Management :
• IV fluids & NPO.
• NG tube should not be inserted blindly Can cause
perforation.

om
•

l.c
No role of prophylactic antibiotics.

ai
•

gm
Most important intervention : Early skilled endoscopy.
• No role of steroids. 7@
a4

• Definitive management : Mx of stricture.

tiy
ga

Barium swallow : Stricture

ar
ik
sh

Tracheoesophageal Fistula (TEF) 00:05:39

va
ur

Types :
|
w
ro
ar
M
©

Type A : Type B : Type C : Type D : Type E (or H) : Type F :

Isolated EA Proximal TEF Proximal EA with Proximal and TEF without EA Esophageal
with distal EA distal TEF (M/c) distal TEF (Patent esophagus) stenosis
EA : Esophageal atresia.

Clinical Features :
• Respiratory distress. VACTERAL
• Excessive drooling of saliva. Vertebral Tracheoesophageal
• Coiling of oro-gastric tube. Anorectal Renal
• Rule out : VACTERAL anomalies. Cardiac (M/c) Limb defects

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 Gastrointestinal Surgery : Part 1 63

Investigations : ----- Active space -----

1. Contrast study : Confirmatory Iohexol > Dinosil.
2. Combined tracheoesophagoscopy : Tracker
IOC for H-type.
Esophagus

Management :
Waterson’s criteria : H-type TEF

Birth weight Pneumonia Management

≥ 2.5 kg - Surgery
1.5-2.5 kg Nutrition supplementation for weight gain Sx.
+/-
< 1.5kg Feeding gastrostomy for nutrition Delayed Sx.

om
l.c
Surgery :

ai
gm
1. Type A Two ends are close : Anastamose.
Two ends are far : Gastrostomy 7@
Anastamosed when ends
a4

are close.
tiy

2. Type B, C, D, E : Cameron haight surgery

ga
ar

Posterolateral thoracotomy Cut fistula Repair trachea & esophagus.

ik
sh
va

GERD 00:09:46
ur
|
w

Factors which maintain LES Patency :

ro
ar

1. Length of intra abdominal esophagus 3. Orientation of gastroesophageal

M

(Most important) :
©

Angle of His.
• 3-5 cm : Normal. 4. Arrangement of mucosal folds
• <2 cm : Predisposition to GERD. (Least important).
2. Pinching effect of right diaphragmatic crura.
Note : Lower esophageal sphincter (LES) pressure <6 mmHg GERD.

Pre-disposing Factors :
• ↑Transient LES relaxation : Earlient physiological indicator.
• ↑Obesity & ↓H. Pylori infection rate ↑GERD.
Note : Central obesity ↑Risk of Barrett’s & adenocarcinoma.

Clinical Features :
• Restrosternal burning sensation (Heart burn). • Chronic cough.
• Water brash. • Wheezing.
• Pharyngitis/Laryngitis. • Dental caries.

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 64 Surgery

----- Active space ----- Investigations :

1. Endoscopy : IOC.
2. 24 hr pH monitoring : Gold standard.

Management :
1. Lifestyle changes : 2. Medical Mx : PPI & prokinetics.
• Reduce weight. 3. Surgical Mx : Fundoplication.
• Small frequent meals.
• Last meal 2 hrs before bed.

Fundoplication :
Indications : Principles of fundoplication :
1. Not responding to medical Mx. • To restore adequate intra-abdominal
2. Complications of GERD + . length.

om
• To tighten the diaphragmatic crura.

l.c
3. GERD a/w large hiatal hernia.

ai
• To wrap fundus around esophagus.

gm
4. Patient wants to stop medical Mx.
7@ • To preserve vagus nerves.
a4

• To re-establish the angle of His.

tiy
ga
ar

Types of fundoplication :
ik
sh

1. Complete wrap (Nissen’s 360°) Gas bloat syndrome (M/c complication).

va

2. Partial wrap (Prevents gas bloat) :

ur
|

- Dor (180° anterior).

w
ro

- Toupet (180-270° posterior).

ar
M

- Belsey mark (270° anterior).

©

Note : Collis gastroplasty Create new esophagus, ↑length by ≥3 cm.

Nissen’s Toupet’s Collis gastroplasty

Newer Modalities :
1. Polymer injection : High recurrence.
2. Endoscopic RFA : Good longterm results.
3. Magnetic sphincter augmentation (LINX).
4. Transoral incision less endoscopic fundoplication (TEMPO trial).

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 Gastrointestinal Surgery : Part 1 65

Barrett’s Esophagus 00:15:20 ----- Active space -----

Features :
1. Complication of long standing GERD.
2. Specialised intestinal metaplasia (Squamous Columnar epithelium).
3. Red velvety mucosa.

Investigations :
1. Endoscopic biopsy : Diagnosis.
2. HPE : Goblet cells (Pathognomonic).
3. Chromoendoscopy :
- For microscopic involvement. OGD : Red velvety nucosa
- Methylene blue for Barrett’s/AdenoCa.
- Lugol’s iodine for SCC.

om
l.c
Note : For goblet cells Use alcian blue.

ai
gm
7@
a4
tiy
ga
ar
ik
sh
va
ur
|

Chromoendoscopy HPE : Goblet cells

w
ro

Types :
ar
M

1. Long segment : >3 cm.

©

2. Short segment : <3 cm.

3. Cardia metaplasia : Microscopic.

Risk of Malignancy :
High grade dysplasia > Low grade dysplasia > Barrett’s esophagus (0.2-0.5%).
Prague C & M Criteria :
16
gastroesophageal junction

14 M : Maximum extent = 14 cm
↑C & M score
Distance in cm from

12
10
8 C : Circumferential extent = 6 cm ↑Risk of Adenocarcinoma.
6
4
2 Correctly identify the gastroesophageal junction
0 Recognize haitus and hernia

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 66 Surgery

----- Active space ----- Seattle Protocol for Biopsy :

1. No dysplasia : Repeat OGD 3-5 yearly (Except with >3 cm : 2-3 yearly).
2. Low grade dysplasia :
Endoscopic ablation (RFA) of dysplastic mucosa

OGD every 6 months : Till 2 consecutive non dysplastic biopsies.

3. High grade dysplasia/T1a :
• MDT discussion.
• ± Esophagectomy/RFA.
Biopsy : 4 quadrant biopsies every 2cm + Targeted biopsies of macroscopic lesions.

Treatment :
1. RFA : Cost effective + ↓S/E.

om
2. EMR (Endoscopic mucosal resection) :

l.c
• Removes whole mucosa.

ai
gm
• Higher rate of strictures.
7@
a4

Esophageal Cancer
tiy

00:20:55
ga
ar

Squamous cell carcinoma Adenocarcinoma

ik
sh

M/c in Asia ; M/c overall M/c in western world

va

Location in
ur

Middle one-third Lower one-third

|

esophagus
w
ro

• Smoking, alcohol
ar

• Preservative rich food

M

• Smoked food
©

• Smoking, alcohol
• Tylosis
• GERD
Risk factors • Achalasia cardia
• CREST syndrome
• Vit E and selenium deficiency
• Barrett’s esophagus
• Zenker’s diverticulum
• Corrosive injury
• Plummer Vinson syndrome

Clinical Features :
• Progressive dysphagia (Solids more than liquids).
• Weight loss.
• Hoarseness : Sign of advanced disease (Left Recurrent laryngeal nerve (RLN)
involvement).
• Chronic cough.

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 Gastrointestinal Surgery : Part 1 67

Investigations : Siewerts classification ----- Active space -----

1. Endoscopic biopsy : IOC. Used for GE junction tumours.
2. PET-CT : IOC for staging (F18-FDG).
3. Endoscopic USG : IOC for T-staging.
4. Barium swallow : Rat tail appearance
(Apple core deformity).

Shouldering
effect Rat tail
appearance

Barium swallow Type I & II : Esophageal Ca

om
Type III : Gastric Ca

l.c
Treatment :

ai
gm
Esophagectomy :
7@Minimum lymph nodes removed
• Margins :
a4
• Breast : 10
tiy

- Proximal : 10 cm. • Colorectal : 12

ga

- Distal : 5 cm. • Esophagus : 15

ar
ik

• Minimum lymph nodes removed : 15. • Stomach : 16

sh
va
ur

Esophageal replacements :
|
w

1. Gastric tube (Best) :

ro
ar

Based on right gastroepiploic artery & right gastric artery.

M

2. Jejunum/colon : If stomach is affected. (Corrosive injury.)

©

3. SEMS (Self Expanding Metallic Stents) :

- Used in malignant TEF.
- M/c complication : Migration.

SEMS

Note : Main prognostic factor for esophageal Ca. T-stage (Depth of invasion).

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 68 Surgery

----- Active space ----- Esophageal Leiomyona 00:26:36

• M/c benign tumour of esophagus.

• Site : Mid to distal esophagus.
• M > F.
• Usually asymptomatic (Dysphagia ±).
• Barium swallow : Punched out appearance.

Management :
• Enucleation
• STER : Submucosal Tunnelling Endoscopic
Resection. Punched out appearance

Zenker’s Diverticulum 00:27:39

om
l.c
AKA Cricopharyngeal achalasia.

ai
gm
Features : 7@
a4
1. Killian’s dehisence (Site) : Potential space b/w thyropharyngeus &
tiy

cricopharyngeus.
ga
ar

2. Pulsion diverticulum : D/t ↑pressure.

ik
sh

3. False diverticulum : Only mucosa comes out.

va
ur

4. Position : Posterior midline (Starts) Left of midline (Final).

|
w

Clinical Features : Investigation :

ro
ar

• Regurgitation (Earliest). Barium swallow (IOC).

M
©

• Halitosis.
• Aspiration pneumonitis (M/c complication).
Management :
1. Diverticulectomy + Cricopharyngeal myotomy.
(Best, ↓recurrence rate).
2. If not fit for Sx : Dohlmann’s procedure.
- Endoscopic diverticulopexy + Cricopharyngeal myotomy.
- Linear stapler/Laser used.
- ↑Recurrence.
Note : Mid-esophageal/Parabronchial diverticulae.
• True diverticulum.
• Traction diverticulum.
• Cause : TB/Histoplasmosis.
• Large/Symptomatic Diverticulectomy.
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 Gastrointestinal Surgery : Part 1 69

Hiatal Hernia 00:30:39 ----- Active space -----

Type I/Sliding Hiatal Hernia :

• M/c diaphragmatic hernia. (M/c congenital
diaphragmatic hernia: Bochdalek).
• GE junction : Moves proximally
C/f : GERD/Asymptomatic. (Not life threatening)
IOC : CT with oral contrast.
Mx : Surgery only in large/symptomatic hernia
Sliding hiatal hernia
Type II/Rolling/Paraesophageal Hiatal Hernia :
• Portion of stomach herniates into
thoracic cavity Volvulus & necrosis (Life threatning).
• GE junction : N .

om
l.c
Mx : Surgery.

ai
gm
Type III : 7@ Rolling hiatal hernia
Sliding + Rolling.
a4
tiy

Mx : Based on rolling component.

ga
ar
ik

Type IV :
sh
va

Paraesophageal (Content : Not stomach).

ur
|

Esophageal Perforation
w

00:33:02
ro
ar

Iatrogenic Perforation :
M
©

Cause : Post endoscopy (Therapeutic, Cancer related etc).

Site : Upper 1/3rd (Narrowest constriction).
C/f : Chest/Abdominal pain post endoscopy.
IOC : CECT
Rx :
• Small perforation + Stable patient + No sepsis : Conservative NPO.
• Large perforation + Sepsis + : Surgical repair. 1V fluids.
1V Antibiotics.
Spontaneous Perforation/Boerhaave Syndrome :
Analgesics.
Cause :
• Forceful vomiting against a closed glottis.
• Seen in alcoholics.
Site : M/c lower 1/3rd (Lt posterolateral wall).

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 70 Surgery

----- Active space ----- Clinical features :

• Mackler’s triad : S/c emphysema + Retching + Chest pain.
• Hamman’s crunch : Crunching sound on heart auscultation.
• High mortality. Mallory Weiss tear
D/D : Mallory weiss tear. • Split in mucosa/submucosa
• Upper GI hemorrhage
Investigations :
• Stable patients : CECT.
• Unstable patients : Contrast study.
• X-ray : Pneumomediastinum
a. Naclerio V sign.
b. Continuous hemidiaphragm.
c. Ginkgo leaf sign.

om
d. Pleural effusion.

l.c
ai
Pleural effusion Contrast leak

gm
Management :
1. Conservative Mx : Stable pts. 7@
a4

Objectives Seal perforation.

tiy
ga

Adequate drainage.
ar
ik

Nutritional support.
sh
va

2. Endoscopic sealing with clips/SEMS.

ur

3. T-Tube placement & open repair.

|
w
ro

Other Benign Esophageal Conditions

ar

00:37:57
M
©

Shatzki Ring :
B ring (Mucosal submucosal).
C/f : Intermittent dysphagia.
Mx : If symptomatic Dilatation.

Schatzki ring
Feline Oesophagus :
• Lines markings on imaging.
• Endoscopy : Stacked up appearance.
• Seen in :
- GERD (M/c), lower 1/3rd.
- Eosinophilic esophagitis, upper 1/3rd.

Feline oesophagus
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Eosinophilic Esophagitis : ----- Active space -----

• Chronic immune/antigen mediated disease.
(D/t food antigens Cytokines release Eosinophilia).
• Peak age : 20-30 yrs.
• Endoscopy : Rings, furrows, crepe paper mucosa.
• Biopsy + : ≥15 eosinophils/hpf.
• Treatment :
- Steroids
Goal : <5 eosinophils/hpf.
- PPI

Esophageal Infections :
1. Esophageal candidiasis :
• A/w oral thrush.

om
• Seen in immunocompromised patients.

l.c
• Endoscopy : Shaggy appearance.

ai
gm
• Barium swallow : Worm like ulcers.
7@
a4

2. CMV :
tiy
ga

• Seen in post transplant patients/GVHD. worm like ulcers

ar

• Ulcers : Serpigenous/Geographical.
ik
sh
va

3. Herpes :
ur
|

• A/w herpes labialis.

w
ro

• Ulcers : Small with raised margins.

ar
M
©

Achalasia Cardia 00:40:50

M/c motility disorder.

Cause :
Failure of LES to relax (D/t loss of ganglion cells in Myenteric & Auerbach plexus).

Types of Achalasia :
• Primary achalasia : Loss of ganglion cells.
• Secondary achalasia : Secondary to Chagas disease (Trypanosoma cruzii).
• Vigorous achalasia : Rapidly progressive.
• Pseudoachalasia : Seen in malignancy.
• Triple A syndrome (Allgrove syndrome) : Alacrimia, Achalasia, ACTH resistant
adrenal insufficiency.

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----- Active space ----- Clinical Features :

• Triad : Dysphagia, regurgitation (Earliest) & weight loss.
• Dysphagia Initially : Liquids > Solids.
Later : Solids > Liquids.
• Heart burn.
• Nocturnal coughing.
• Post prandial choking.
Complication : Aspiration pneumonitis (M/c).
Gradual
Investigations : tapering
1. Barium swallow
Rule out cancer.
2. Endoscopy
Birds beak appearance
Classification of Achalasia Cardia : (Barium swallow)

om
Chicago classification :

l.c
ai
IOC : Manometery.

gm
Type I 7@
Type II Type III
a4

• Achalasia with esophageal

tiy
ga

• Classical compression • Spastic

Features
ar

• DCI <100 mmHg • Pan esophageal pressurisation in • DCI >450 mmHg

ik
sh

>20% Swallows
va

Peristalsis No normal peristalsis (100% failed)

ur
|

Median IRP Elevated (> 15 mmHg)

w
ro

Eckardt score :
ar

• Weight loss.
M

• Retrosternal pain.
©

• Dysphagia. • Regurgitation.
Treatment :
1. Botox : 2. Pneumatic dilatation :
• Highest recurrence. • Similar efficacy as myotomy.
• Repeated injections : Scarring. • Indications : Elderly, female undilated
• Restricted to elderly patients with esophagus, type II achalasia.
co-morbidities.

3. Heller’s myotomy : 4. POEM :

• Laparascopic myotomy : • Per-oral endoscopic myotomy.
6cm proximal to 2-3 cm distal. • Best for type III & other spastic conditions.
• Better outcome in type I & II. • Submucosal tunnelling Muscles cut
• M/c complication : GERD Mucosa sutured.
(Prevention : fundoplication). • ↑Rate of esophagitis.
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Distal Esophageal Spasm 00:46:54 ----- Active space -----

Features :
• 5 times less common than achalasia.
• F > M.
• Simultaneous, repetitive, high amplitude contractions.

Clinical features :
• Chest pain (Angina like).
• Dysphagia.

Investigations :
1. ECG.
2. Manometry.

om
3. Barium study : Corkscrew/Rosary bead

l.c
Rosary bead esophagus

ai
appearance.

gm
Congenital Hypertrophic Pyloric Stenosis (CHPS)
7@
00:48:51
a4
tiy

Features :
ga
ar

• Pyloric hypertrophy Gastric outlet obstruction.

ik
sh

• Usually affects first born male child.

va
ur

Clinical Features :
|
w

Normal at birth 2-3 weeks Projectile, non-bilious vomiting.

ro
ar
M

On examination :
©

• Palpable olive shaped epigastric mass

Feeding : Best time to examine.
• Visible peristalsis (Left Right)

Differential Diagnosis :
CHPS Duodenal atresia
At birth Normal Bilious vomiting
Non-bilious projectile vomiting
Complaints Bilious vomiting
after few weeks
Seen m/c in First born male child Down syndrome
10C USG X-ray
Mx Ramstedt pyloromyotomy Duodenoduodenostomy

Investigations :
1. USG : IOC Pyloric channel Thickness >4 mm.
Length >16 mm.
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 74 Surgery

----- Active space ----- 2. Contrast study :

- Mushroom sign.
- Double track sign.
3. Labs : Hypochloremic hypokalemic metabolic
alkalosis with paradoxical aciduria
(M/c metabolic abnormality).

Treatment :
Contrast study
Correction of metabolic abnormality :
• Best fluid = 0.45% NS + Dextrose + KCl (If urine output : N ).
• RL.
Ramstedt’s pyloromyotomy :
• Surgical Mx of CHPS.

om
• Pylorus cut Mucosa should bulge out.

l.c
• Resume

ai
gm
feeding Uneventful Sx : Within 4-6 hrs.
7@ Ramstedt’s procedure
Mucosal injury + : After 24-48 hrs.
a4
tiy
ga

Peptic Ulcer Disease

ar

00:52:44
ik
sh

Features :
va
ur

• M/c type : Duodenal ulcers (90%. a/w H. Pylori & ↑acid production).
|
w

• M/c complication : Bleeding.

ro
ar

• M/c cause of upper GI hemorrhage.

M
©

Duodenal Ulcers :
Posterior ulcers :
• M/c complication : Bleeding (D/t erosion of gastroduodenal artery).
• Mx : Endoscopic (2 attempts) Fails Open surgery (Underrunning
of vessel).
Anterior ulcers :
• M/c complication : Perforation Perforation peritonitis.
• C/f :
- Pain.
- ↑HR, ↓BP.
- Rebound tenderness.
- Board like rigidity.
• Investigation : X-Ray Gas under diaphragm
(Hollow viscus perforation).
Air under diaphragm
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 Gastrointestinal Surgery : Part 1 75

• Treatment : ----- Active space -----

- NPO. - 1.V Antibiotics.
- 1.V fluids. - Painkillers.
- Emergency exploratory Laparotomy + Omental patch repair.

Graham’s omental patch repair

Gastric Ulcers :

om
60% a/w H. Pylori..

l.c
ai
Johnson criteria :

gm
Type Location 7@ Features
a4
tiy

Type I Along the lesser curvature Most common type

ga

Type 2 Prepyloric + duodenal Associated with acid

ar
ik

Type 3 Only prepyloric hypersecretion

sh
va

Bleed most commonly :

ur

Type 4 Body of stomach

|

D/t left gastric artery branches

w
ro
ar

Mx :
M

• Biopsy must be done to rule out malignancy.

©

• Antrectomy.
• Pauchet’s procedure (Type IV ulcers).

H. Pylori :
• CAG-A & VAC-A genes : Toxins.
• Urease : Helps it survive in acidic environments.
• A/w :
a. Peptic ulcers. c. Gastric cancer.
b. Type B gastritis. d. MALTomas.
• Slightly protective against adenocarcinoma esophagus & Barrett’s esophagus.

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 76 Surgery

----- Active space ----- Gastric Reconstruction 00:57:52

Procedure Image

• Gastric resection
Bilroth 1
• Gastroduodenal anastomosis

• Gastric resection
Bilroth 2 (Poly a
• Close duodenal stump
reconstruction)
• End-to-side gastrojejunal anatomosis

om
l.c
ai
gm
7@ Stomach
• Gastric resection
a4

Roux-en-Y gastro
tiy

• Close duodenal stump Bilio Roux

jejunostomy
ga

• End-to-side gastrojejunostomy (GJ) pancreatic limb (GJ)

ar

(M/c) limb (JJ)

• End-to-side jejunojejunostomy (JJ)
ik
sh
va
ur
|
w

Vagotomy :
ro
ar

Replaced by PPIs currently.

M
©

Truncal vagotomy Highly selective vagotomy

• Maximal acid reduction
• Least acid reduction
• Least ulcer recurrence
• Max ulcer recurrence
• Max vagotomy related complication

Complications of Vagotomy & Reconstruction :

1. Nutritional deficiencies :
- M/c : Iron deficiency.
- Other deficiencies : Vit B12, Vit D3.
2. Internal hernia :
Petersen’s hernia Stemmer hernia
Bowel loop herniates Bowel loops herniate through
behind roux limb the transverse mesocolon
Antecolic reconstruction Retrocolic reconstruction

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 Gastrointestinal Surgery : Part 1 77

3. Dumping Syndrome : ----- Active space -----

Early Late
Occurs due to rapid influx of fluid in the bowel Rebound hypoglycaemia due to excessive
due to hyperosmolar contents in the bowel insulin release
Hypoglycemia (Tachycardia, sweating,
Epigastric fullness, nausea & vomiting
headache)
Worsens with more food Improves with more food
Starts in 15-20 mins after food Starts in 30-40 mins after food
Prevention :
• Small frequent meals.
• Avoid liquid with meals.
• Avoid sugar rich liquids
• Avoid simple sugars.

om
• Take high protein/fat diet.

l.c
ai
• Resistant cases : Try octreotide.

gm
7@
Gastric Cancer 01:05:53
a4
tiy
ga

Risk Factors : Lauren’s Classification :

ar
ik

1. Smoking.
sh

Intestinal Diffuse
va

2. Alcohol Environmental Familial

ur
|

3. Smoked fish/food. Gastric atrophy, intestinal

w

Blood type A
ro

4. Preservative rich food. metaplasia

ar

M>F F>M
M

5. H. Pylori.
©

6. Gastric resection. ↑Incidence with ↑age Younger age

• Poorly differentiated
7. Polyps. Gland formation
• Signet ring cells
Mutated E-Cadherin gene
APC gene mutations
(↓E-cadherin)

Other Classifications :
1. Japanese classification :
• For early gastric cancers : Above muscle layer.
• Type 1 : Best prognosis.
2. Borrmann’s classification :
• For advanced gastric Ca : Invading the muscle layer.
• Type IV (Linitis plastica) : Worst prognosis.

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 78 Surgery

----- Active space ----- Atypical Presentations of Gastric/Gl cancers:

Presentation Description
Left supraclavicular lymph node (LN)
Troisier sign/Virchow LN
(Sign of advanced Ca in any GI malignancy)
Irish nodule Left axillary lymphadenopathy
Mets into pelvis/pouch of Douglas.
Blumer’s shelf
(Sign of advanced ca in any GI malignancy)
• Periumbilical mets.
Sister mary joseph nodule
• M/c : Gastric > Ovarian Ca
• B/L ovarian mets.
• Seen in gastric or lobular breast ca.
Krukenberg tumor
• Diffuse gastric ca : Signet ring cell (HPE).
• Spread : Retrograde lymphatic spread
Leser-Trelat sign Multiple seborrheic keratosis (Internal malignancy)

om
Tripe palms Hyperkeratotic palms (Internal malignancy)

l.c
ai
gm
7@
a4
tiy
ga
ar
ik
sh
va
ur

Sister Mary Joseph’s nodules

|

Sign of leser trelat Tripe palms

w
ro

Investigations :
ar
M

1. Endoscopic biopsy : IOC.

©

2. PET-CT : IOC for overall staging.

3. EUS : IOC for T-staging (Main prognostic factor).

Surgical Management :
1. Primary tumour :
• Margins : Proximal margin 5 cm, Distal margin Pylorus.
• Resection : Distal/Subtotal (Antral tumor)/ Total
Total. gastrectomy
2. Lymph nodes : Subtotal/Partial
(60-70%)
• D1 gastrectomy : 1-6 stations removed.
• D2 gastrectomy (Optimal) : 1 - 11 Stations Distal
removed. gastrectomy
Minimum no. of lymph nodes removed : 16.
Note : M/c site of mets Liver. Distal

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 Gastrointestinal Surgery : Part 1 79

----- Active space -----

1 Right para-cardial 2 Left para-cardial 3 Lesser curvature

4 Greater curvature 5 Suprapyloric 6 Infrapyloric

om
7 Left gastric 8 Common hepatic 9 Celiac

l.c
10 Splenic hilum 11 Splenic artery 12 Hepatoduodenal

ai
gm
ligament
13 Retropancreatic
7@
a4
tiy

Gastrointestinal Stromal Tumours

ga

01:12:02
ar
ik

Features :
sh
va

• Origin : Intestinal pacemaker cells of Kajal.

ur

• M/c site : Stomach.

|
w
ro

• Sporadic > Familial.

ar
M

Carney stratakis syndrome :

©

Carney’s triad :
1. Gastric GIST : A/w SDH-B mutation 1. Gastric GIST.
(1° imatinib resistance). 2. Paraganglioma.
2. Pulmonary chondromas.
3. Paragangliomas.
Management : Clinical features :
IOC : CECT (Radiological diagnosis). • Upper GI hemorrhage (m/c)
Treatment : • Lump
1. Surgical resection : 2cm margin. • Perforation
2. Malignant/Metastasis (M/c liver) : Sx + Imatinib.
3. Imatinib resistant : Sunitinib/Sorafenib.
IHC Markers :
• CD117/CKIT (M/c). • DOG 1 : Most specific.
• CD34 (60-65%). • Wild type : CD117 - & PDGFα - .

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 80 Surgery

----- Active space ----- Note : Fletcher’s classification.

• Differentiate b/w benign & malignant GIST.
• Based on size & mitotic figures.

Gastric Lymphoma 01:14:17

• M/c extranodal site for lymphoma : Stomach.

• M/c type : Diffuse large B-cell lymphoma.
C/f : Lump, upper GI bleed.
Mx : Chemotherapy (RCHOP) Radiotherapy.

MALToma :
• A/w H. Pylori.
• Low grade : Responds to H. pylori eradication.

om
• High grade : Treat like lymphoma.

l.c
ai
gm
Gastric Volvulus 01:15:13
7@
a4

Twisting of stomach Borchardt’s triad :

tiy

• Unproductive retching.
ga
ar

• Inability to pass ryle’s tube.

ik
sh

• Epigastric pain.
va
ur
|

Types :
w
ro
ar

Organoaxial Mesenteroaxial
M

• M/c type • Chronic symptoms

©

• A/w diaphragmatic defect • Diaphragmatic defects :

• Vascular compromise + Less common.

Organoaxial Mesenteroaxial

Management :
IOC : CECT.
Sx :
• Derotate stomach.
• Fix underlying cause.
Note : Trichobezoar.
• Hairball in the stomach.
• 2° to trichophagy (Eating one’s own hair).
• Mx : Surgical removal Psychiatry reference. Gastric volvulus

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 Gastrointestinal Surgery : Part 2 81

GASTROINTESTINAL SURGERY : PART 2 ----- Active space -----

Bariatric Surgery 00:00:50

Indications : Types :
1. BMI >40 kg/m2.
Bariatric surgery
2. BMI >35 kg/m2 with obesity complications.
M/c Sleeve gastrectomy
3. Asian population : Lower cutoff for Sx. Most
Roux-en-Y gastrojejunostomy
acceptable
OS-MRS (Obesity Surgery - Mortality Risk Score) :
Maximum Duodenal switch/
The risk factors : weight loss Biliopancreatic diversion.

om
a. Arterial hypertension. Reversible Gastric banding & intragastric

l.c
b. Age >45.

ai
Sx balloon placement.

gm
c. Male gender.
7@
d. BMI >50kg/m2.
a4
tiy

e. Risk for pulmonary thromboembolism.

ga

Diabetes mellitus is not part of the criteria.

ar
ik
sh

Irreversible Procedures :
va
ur

1. Biliopancreatic diversion (BPD) & Duodenal switch (DS) :

|
w

• Common channel : • Maximum weight loss (D/t malabsorption).

ro
ar

- Biliopancreatic switch : 50 cm. • Disadvantage : Maximum surgical

M
©

- Duodenal switch : 100 cm. complications.

BPD DS
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 82 Surgery

----- Active space ----- 2. Roux-en-Y gastrojejunostomy :

• Roux limb length : 100 cm. a

• Nutritional deficiencies :
- Iron (M/c).
- Vit D3/Ca2+
- Vit B12

3. Lap. Sleeve gastrectomy :

• M/c done procedure.
• Restrictive surgery :
Greater curvature of stomach is removed.

om
• Complications :

l.c
ai
i. M/c : Bleeding from staple line.

gm
ii. Nutritional deficiencies. a4
7@
iii. Leak from angle of His.
tiy

(Most distressing Peritonitis).

ga
ar

iv. Redistension of sleeve (Mx : TOGA).

ik

Sleeve gastrectomy
sh
va
ur
|
w
ro
ar
M
©

TOGA (Transoral gastroplasty)

Reversible Procedures :
1. Gastric banding :
• Band placed 6cm from the GE junction.
• Reversible pressure adjustable balloon

Weight loss can be titrated.

• Complications :
i. Prolapse (M/c)
ii. Nutritional complications.
iii. Erodes into stomach.
iv. Rupture. Gastric banding

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 Gastrointestinal Surgery : Part 2 83

2. Intragastric balloon placement : ----- Active space -----

• Balloon is distended in the stomach.
• Removed after weight loss is achieved.
• Self dissolvable balloon : Dissolves after 3 months.

Features Of Bariatric Sx :
• M/c cause of death : DVT Pulmonary embolism.
• AKA metabolic surgery : Weight loss + Improvement in DM/HTN/hyperlipidemia.
• Nutrient replacement :
- Iron
- Vit B12
- Vit D3 & Ca2+
- Fat soluble vitamins : In sleeve gastrectomy & Roux-en-Y bypass.

om
l.c
Mesenteric Cyst

ai
00:09:35

gm
IOC : CECT. 7@
a4

Tillaux Triad :
tiy
ga

1. Periumbilical swelling.
ar
ik

2. Tillaux sign : Swelling moves at right angle to attachment of mesentery.

sh
va

3. Transverse band of resonance.

ur
|

Types :
w
ro
ar

Chylolymphatic cyst (M/c) Enterogenous

M

Tissue Sequestered lymphatic tissue Sequestered bowel tissue

©

Cyst wall Thin Thick

Fluid Clear Turbid
Blood supply Independent Shared with bowel
Rx Enucleation Resection & anastomosis

Upper GI Hemorrhage 00:11:01

Bleeding proximal to ligament of Treitz.

Causes :
1. Non-variceal bleeding (M/c) :
- Peptic ulcer (M/c) : Duodenal > Gastric.
- Mallory Weiss tear.
- Gastritis.
2. Variceal bleeding.
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 84 Surgery

----- Active space ----- Gastritis types :

Gastritis Features
• Autoimmune gastritis (Auto-ab against parietal cells).
Type A
• Antral sparing, pernicious anemia, achlorhydria.
Type B H. pylori induced (Affects antrum).
• Cushing’s ulcer : In head injury, involves the stomach.
Stress induced
• Curling ulcer : In burns, involves first part of duodenum.
NSAIDS Due to chronic use.
AIDS D/t cryptosporidium.
Mallory Weiss Tear :
• Longitudinal tear in mucosa/submucosa
(GE junction Cardia).
• M/c in alcoholics : After a bout of forced vomiting.

om
• Vessel : Left gastric artery.

l.c
ai
Rx : Self limiting.

gm
D/D : Boerhaave syndrome 7@ Mallory weiss tear
a4
tiy

GAVE (Gastric Antral Vascular Ectasia) :

ga

• Seen at antrum.
ar
ik

• Autoimmune.
sh
va

Endoscopy : Watermelon stomach.

ur

(D/t dilated venules)

|
w

Mx : Argon photocoagulation.
ro
ar

Watermelon stomach
M
©

Portal Gastropathy :
Seen in portal hypertension.
Endoscopy : Strawberry stomach
(Reddish nodules)
Strawberry stomach
Menetrier’s Disease :
• Hypertrophy of gastric mucosal folds
d/t overexpression of TGF α.
• ↑Risk of cancer.
C/f :
• Protein losing enteropathy (Earliest).
• Upper Gı hemorrhage.
Mx : Hypertrophied folds
Cetuximab (Monoclonal ab against EGFR) Fails Gastrectomy (Severe cases).

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 Gastrointestinal Surgery : Part 2 85

Portal Hypertension : ----- Active space -----

• Variceal cause of upper GI bleeding.
• Doppler (Diagnosis) : Hepatic Venous Pressure Gradient (HVPG).
Measurement Significance
1-5 mm Hg Normal
6-10 mmHg Preclinical sinusoidal portal HTN
≥10 mm Hg Clinically significant portal HTN Variceal formation
≥12 mm Hg ↑Risk for rupture of varices
Porto-systemic shunts:
1. Left gastric + short gastric veins Distal esophgeal veins.
2. Left gastric/gastroepiploeic vein Esophageal/paraesophageal veins.
3. Caput medusae : Periumbilical.

om
4. Rectum.

l.c
5. Bare area of liver (Segment 7).

ai
gm
Caput medusae
C/f : 7@
a4

• Upper GI bleeding. • Ascites.

tiy
ga

• Splenomegaly. • Signs of liver failure.

ar
ik
sh

Management :
Bleeding
va

Note :
ur
|

1. Airway Mx : To prevent aspiration.

ABC management
w
ro

2. IV Pantoprazole : Given after endoscopy.

ar
M

1V drugs :
©

• Best : 1V terlipressin
• M/c used : 1V octreotide
• Not used : 1V propranalol
Patient stabilised
Upper GI endoscopy :
Banding (M/c) > Sclerotherapy (Sodium tetradecyl sulphate)
Assess bleeding

Controlled Uncontrolled

24hr observation 2nd attempt at UGI-scopy

Normal Fail
Discharge on oral propranolol Sengstaken blakemore tube

Prepare for TIPSS

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 86 Surgery

----- Active space ----- For temporary control of bleeding (Until patient is ready for TIPSS) :
Sengstaken Blakemore tube Minnesota tube Linton tube
3 channels, 2 balloons 4 channels, 2 balloons 3 channels, I balloon

Gastric Esophageal

Transjugular Intra-hepatic Portosystemic Shunt (TIPSS) :

• Shunt b/w portal vein & hepatic vein.
• Non-selective

om
(Splenic & bowel blood are both shunted).

l.c
• Complications :

ai
gm
a. Rupture of capsule : Earliest.
7@
b. Blocked Rebleeding : M/c.
a4
tiy

c. Encephalopathy : D/t nonselective shunt.

ga
ar

Other shunts :
ik
sh
va

Selective Non selective

ur

• Warren : Distal splenorenal shunt. • Linton : Proximal splenorenal shunt.

|
w

• Inokuchi : Left gastric venocaval shunt. • Eck fistula : Portocaval shunt.

ro
ar

Advantage :
M

• Shunts only splenic blood. Risk of encephalopathy

©

• Avoids encephalopathy.

Scoring systems :
1. Rockall’s score. 4. Forrest’s classification :
Prognostic scores
2. BLEED criteria. - For peptic ulcer bleeding.
3. Child Pugh Turcotte score. - Endoscopic assessment.

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 Gastrointestinal Surgery : Part 2 87

Forrest’s classification : ----- Active space -----

Classification Description
Acute hemorrhage (High risk)
Class la Spurting hemorrhage
Class Ib Oozing hemorrhage
Signs of recent hemorrhage
Class Ila (High risk) Non bleeding visible vessel
Class 1lb (Intermediate risk) Adherent clot
Class IIc (Low risk) Flat pigmented spot
Lesions without acute bleeding
Class I11 (Low risk) Clean ulcer base

Bowel Obstruction 00:24:52

om
Cardinal Features :

l.c
ai
• Non passage of flatus • Distention

gm
& faeces (Obstipation). 7@
• Abdominal pain.
a4

• Vomiting.
tiy
ga

Investigations :
ar
ik

1. X-ray abdomen erect & supine : Initial Ix.

sh
va

Air fluid levels (>3)

2. CECT : IOC in adults.
ur
|

3. USG : IOC in children.

w
ro
ar

X-ray Features :
M

1. Erect x- ray : >3 air fluid levels.

©

2. Supine x-ray :
Site of obstruction Features
• Feathery appearance.
Jejunum
• Valvulae conniventes (Concertina effect). Concertina effect
Ileum Featureless (Loops of wangensteen).
Large bowel Incomplete haustrations.

Management of Bowel Obstrution :

1. NPO 4. Ryle’s tube insertion.
2. 1V fluids 5. Sx : Emergency laparotomy.
3. IV antibiotics & painkillers.

Incomplete haustrautions
Surgery :
Distended : Large bowel obstruction.
Caecum is visualised 1st
Collapsed : Small bowel obstruction.
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 88 Surgery

----- Active space ----- Intussusception :

Telescoping of one bowel loop into another.
(Intussuscipiens : Receiving loop, Intussusceptum : Loop going inside).
Types :
Primary Secondary
Age group 6 months - 2yrs Adults
2˚ to pathological lead point :
Hypertrophy of • Polyp (M/c).
Trigger
peyer’s patches • Diverticulum.
• Cancer.
• Ileocolic (M/c).
• Red currant jelly stools.
Features -
• Sign of dance : Empty RIF
(Lump is in lumbar region).

om
l.c
Colon

ai
gm
Intussuscipiens : Receiving loop
7@
a4

Intussusceptum : Loop going inside

tiy
ga
ar
ik
sh
va

Ileum
ur
|
w

Neck
ro
ar

Caecum
M
©

Investigations :
1. X-ray abdomen : Erect & supine (Initial). Note : IOC.
2. USG : Target/Donut/Pseudokidney sign. • In children : USG.
3. Contrast enema : Pincer/claw sign. • In adults : CECT.
- Diagnostic & therapeutic.
- C/I : Perforation, recurrence or 2˚ to pathological lead point.

Target/donut sign Pseudokidney sign Pincer claw sign

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 Gastrointestinal Surgery : Part 2 89

Sigmoid Volvulus : ----- Active space -----

Pre-disposing factors :
• Long & narrow mesentery.
• Redundant sigmoid.
• Loaded sigmoid.
Commonly seen in patients : Coffee bean sign
(Dilated large bowel)
• On antipsychotic meds.
• With constipation.
Rotation : Anticlockwise > Clockwise. Erect X-Ray abdomen

D/D coffee bean sign :

Sigmoid volvulus Caecal volvulus
Apex Points towards Rt Shoulder. Towards Lt shoulder.

om
Large Collapsed.

l.c
Dilated.
bowel Note : Small bowel dilated.

ai
gm
Management : 7@
a4
tiy

Contrast Enema :
ga

Stable, no peritonitis : Unstable, peritonitis Bird’s beak appearance

ar
ik

Sigmoidoscopic decompression
sh
va

(Flatus tube) Hartmann’s procedure :

ur
|

1. Resect perforated
w
ro

Definitive surgery : segment.

ar
M

Sigmoidectomy. 2. Proximal colostomy.

©

3. Distal end closed

and kept inside.
Intestinal Structure :
Causes :
1. Cancer.
2. Post radiotherapy.
3. TB.
4. Crohn’s disease.

Mx :
Heinke’s stricturoplasty
1. Strictures are close : Resection & anastomosis.
2. Strictures are far apart : Heinke Mikulicz stricturoplasty.

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 90 Surgery

----- Active space ----- Meckel’s Diverticulum :

• Remnant of vitellointestinal duct.
• Present along the antimesenteric border.
• True diverticulum : All layers +
• Independant blood supply : Safe resection possible.
Rule of 2 :
• 2% of population, 2 inches long, 2 feet from ileocolic junction.
Meckel’s diverticulum

Vitellointestinal Duct Abnormalities :

om
l.c
Vitelline

ai
vessel

gm
remnant
7@
1. Completely patent : 2. Fibrous band formation : Leads to volvulus
a4
tiy

Fecal discharge
ga
ar
ik
sh
va
ur
|
w
ro
ar
M

3. Patent umbilical end : 4. Ileal end patent :

©

Umbilical cyst/polyp Purulent discharge ± Meckel’s diverticulum.

Duodenal Atresia :
Common in Down’s syndrome.
C/f : Billious vomiting since birth.
D/D : CHPS.
X-ray : Double bubble sign.
S
Mx : Duodenoduodenostomy. D J
Jejunal Atresia :
X-Ray : Triple bubble sign. Double bubble sign Triple bubble sign
(S : Stomach, D : Duodenum, J : Jejunum)

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 Gastrointestinal Surgery : Part 2 91

Adhesive Intestinal Obstruction : ----- Active space -----

M/c cause of small bowel obstruction (Dynamic).
Causes :
1. Post surgery (M/c).
2. Non-surgical causes :
- Crohn’s disease. - Endometriosis
- PID - Cancer
- TB
IOC : CECT.
Mx : Conservative for 48-72 hours Fails Surgery (Adhesiolysis).

Superior Mesenteric Artery Syndrome :

• Normal angle b/w aorta & SMA : 25-45˚.

om
• Angle <22˚ compresses D3 (Content).

l.c
Causes : Rapid weight loss, spinal cast.

ai
gm
C/f : Bilious vomiting after meals.
7@
IOC : CT Angiography.
a4
tiy

Rx :
ga

a. Encourage weight gain.

ar
ik

b. Strong’s procedure :
sh
va

Duodenal derotation (Cut ligament of Trietz).

ur
|

c. Duodeno-jejunostomy.
w
ro
ar

Ladd’s Band :
M

• M/c intestinal malrotation abnormality.

©

• Runs from Rt hypochondrium to caecum

Duodenal compression.
Mx : Excision of band.

Hirschsprung’s Disease & Paralytic Ileus 00:42:09

Hirschsprung’s Disease :
AKA congenital megacolon.
Etiopathogenesis :
• Absence of ganglion cells in auerbach & myentric plexus.

Adynamic/functional obstruction.
• Common in Down’s syndrome & MEN 2A/2B.
• Mutation in GDNF (Glial derived neurotropic factor).
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 92 Surgery

----- Active space ----- Clinical Features :

• Non-passage of meconium (M/c).
• Distention. Transitional zone
• Constipation. Constricted zone

Investigations : Dilated zone

1. Full thickness rectal biopsy : IOC.
- Loss of ganglion cells.
- Hypertrophied nerve trunks. Barium enema
- IHC : Acetylcholinesterase +
2. Barium enema :
Dilated normal proximal bowel Transition zone Constricted distal part.
(Lack ganglion cells)
Management :

om
l.c
Bypass/resection of abnomal portion Intraoperative frozen section.

ai
gm
Paralytic Ileus : 7@
• Stunned bowel Functional block.
a4
tiy

• Causes :
ga
ar

a. Surgical c. Hypothermia
ik
sh

b. Hypokalemia d. Uremia
va

(M/c cause of prolonged ileus)

ur
|

• Last to recover : Rectum.

w
ro
ar
M

Mesenteric Ischemia 00:45:14

©

Acute mesentric artery Acute mesentric artery

embolism (M/c cause) thrombosis
Source of embolism : Heart.
Etiology 2˚ to atherosclerosis
Risk factors : IHD, A-fib.
X-ray findings :
• Irregulary irregular pulse. Bowel angina :
• Bowel attacks : • Post prandial abdominal pain
Clinical Sudden abdominal pain (Starts 15-20 min after food).
features • Food avoidance & weight loss.
Ends with peritonitis.
Thumb IOC : CT Angiography
printing
• Early presentation (6-8 hours) :
sign Mx Embolectomy.
Bypass grafting
• Late presentation (Gangrene + ) :
Resection & anastamosis.

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 Gastrointestinal Surgery : Part 2 93

Appendictis 00:47:34 ----- Active space -----

Surgical Anatomy :
• Appendicular artery : Branch of lower division of ileocolic artery.
• Appendicular base : Junction of 3 taenia coli.

Preileal : 1%
Postileal : 0.5%
• L/c
Retrocaecal • Most difficult to diagnose.
(M/c) : 74% Pelvic : 21%
Paracaecal : 2%
Subcaecal : 1.5%
Symptoms :

om
1. Pain abdomen. 3. Anorexia

l.c
ai
2. Nausea & vomiting (M/c) 4. Fever

gm
Signs : 7@
a4
1. McBurney’s point tenderness.
tiy

2. Rovsing sign : Pain in RIF on pressing LIF.

ga
ar

Umbilicus
3. Psoas sign : Pain in RIF on flexion against resistance.
ik

2/3rd
sh

4. Obturator sign : Flexion + internal rotation of hip Pain. ASIS 1/3 rd

va
ur

5. Dunphy’s sign : Pain on coughing.

|

McBurney’s point
w

Modified Alvarado (MANTRELS) Score :

ro
ar
M

Finding Score
©

Migration of pain to right lower quadrant 1

Anorexia 1
Nausea & vomiting 1
Score >7 : Likely appendicitis
Tenderness in right lower quadrant 2
Rebound pain 1
Elevated temperature 1
Leukocytosis 2
Left shift of WBC 1
Possible total 10
Investigations :
1. CECT : IOC in adults.
2. USG : IOC in children.
- Blind ending tubular structure.
- Probe tenderness.
- Periappendiceal fluid collection. USG
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 94 Surgery

----- Active space ----- Mangement (Appendicectomy) :

Do not crush the base.
• Inflamed base
Bury with purse string suture.
• Gangrenous base : Right hemicolectomy.
• Appendix not inflamed : Rule out meckel’s diverticulum (Distal 2 feet of ileum).

Appendicectomy 00:52:38

Incisions Used :
1. McBurney’s incision :
- Grid iron : Muscle splitting.
- Rutherford morrison : Muscle cutting.
2. Lanz/skin crease/bikini incision :

om
Better cosmesis.

l.c
3. Lower midline abdominal incision :

ai
gm
For perforated appendix.
7@
a4

Note : Gibson’s incision Renal trasplant

tiy
ga

(Above inguinal ligament) (To identify ureter)

ar

Structures Passed :
ik
sh

1. Skin
va
ur

2. Superficial fascia.
|
w

3. External oblique aponeurosis.

ro
ar

4. Muscles
M
©

5. Peritoneum
Complications :
1. Wound infection (M/c).
2. Bleeding.
3. Portal pyemia.
4. Stump appendicitis (If stump >4mm).
Lap. appendicectomy

Other Conditions Of Appendix 00:55:09

Appendicular Perforation :
• Omentum dysfunction.
• Seen in :
- Children - Pregnant females.
- Elderly - Immunocompromised patients.
- Adhesions
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 Gastrointestinal Surgery : Part 2 95

Appendicitis in Pregancy : ----- Active space -----

• M/c non obstetrical emergency. • ↑ Risk of preterm labor/abortions.
C/f : Pain in RIF (Can be higher up also).
Ix : USG if uncomfirmed MRI.
Mx : Lap. appendicectomy in all trimesters.
Appendicular Lump :
Mx : Ochsner-Sherren regime (Conservative).

Monitor : Mx :
• Size of lump. • NPO.
• Tenderness. • IV fluids
• Temperature. • IV antibiotics.
• •

om
Pulse rate. Analgesics.

l.c
ai
Outcomes

gm
Recovers : 7@
Deteriorates (↑Pain, fever & lump size) :
a4

• Discharge. • Suspect abscess.

tiy
ga

• Interval appendicectomy • Extraperitoneal drainage

ar
ik

after 6 weeks. (Pigtail catheter).

sh
va

Tumours Of Appendix
ur

00:58:13
|
w

Neuroendocrine Tumour (NET) of Appendix :

ro
ar

• M/c tumour of appendix (AKA carcinoid of appendix).

M

• M/c site : Tip of appendix.

©

C/f :
• Pain & appendicitis.
• May be detected incidentally.
Mx :
1. Close to the base & >2 cm : Right hemicolectomy.
2. Close to the tip & <2 cm : Simple appendicectomy.
Epithelial Tumours :
A. Non-mucinous : Adenocarcinoma (Mx : Same as colorectal cancer).
B. Mucinous : Gives rise to pseudomyxoma peritonii.
• Mucinous deposits in the peritoneum Obstruction, distention.
• Mx : Cytoreductive Sx HIPEC.
- Hyperthermic intraperitoneal chemotherapy.
- With Paclitaxel/Mitomycin-C at 41-44˚C.
• Seen in appendicular, ovarian & 1˚ peritoneal tumours.
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 96

----- Active space ----- GASTROINTESTINAL SURGERY : PART 3

Ileostomy & Colostomy 00:00:45

Ileostomy Colostomy
Output More; liquid Less; semi-solid
Skin excoriation More Less
Fluid and electrolyte
More Less
imbalance
Ease of management - Easier

om
Raised above the skin (Pouting)

l.c
Flat

ai
Technical difference

gm
(Same level as skin)
7@
a4
tiy
ga

Types of Stoma :
ar
ik
sh
va
ur
|
w
ro
ar
M
©

End stoma Double barrel Loop stoma

One end is taken out Two ends taken out, Two ends taken out but
not joined to each other are joined

End colostomy Double barrel stoma Loop ileostomy

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 Gastrointestinal Surgery : Part 3 97

Complications of Stoma : ----- Active space -----

1. Skin excoriation : M/c complication.
2. Parastomal herniation : M/c long term complication.
3. Necrosis : Earliest.
4. Fluid & electrolyte imbalance.
5. Bowel obstruction.
6. Prolapse.
7. Retraction.

Faecal Fistula 00:03:59

Factors Favoring Spontaneous Closure :

1. Esophageal, duodenal, jejunal stump.

om
2. Enteric wall defects <1 cm.

l.c
3. Fistula tract >2 cm.

ai
gm
4. No abdominal wall defect.
7@
5. Good nutrition (Albumin >25 g/L).
a4
tiy

6. Low output fistula (<200 mL/day).

ga

7. No FRIEND factors :
ar
ik

- Foreign body. - Epithelialisation of fistula tract.

sh
va

- Radiation. - Neoplasm.
ur
|

- Inflamation, Infection, IBD. - Distal obstruction.

w
ro
ar

Note : High output fistula : >500 mL/day.

M
©

Management :
+
Spontaneous closure Conservative Mx.
- SNAP protocol
Skin care, sepsis control.
Nutrition.
Anatomical delineation (Imaging).
Planned surgery.

Prognostic grouping :
I II III
Degree of complexity of fistula Low Intermediate High
Mortality Low 10 - 25% >25%
Early surgical Late surgical
Rx goals Spontaneous closure
closure closure

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 98 Surgery

----- Active space ----- Short Bowel Syndrome 00:06:21

Definition : <200 cm of small intestine. Causes :

• Net secretors : <100 cm of SI. • Crohn’s disease (M/c).
• Net absorbers : >100 cm of SI. • Superior mesenteric artery (SMA)
• Ileocaecal junction saved Good syndrome.
prognosis. • Trauma.

Clinical features : Management :

• Malabsorption. • TPN.
• Diarrhea. • Small intestine transplantation.
• Weight loss. • Teduglutide (GLP2 analogue).
• Bacterial overgrowth.

om
Bowel lengthening procedures :

l.c
ai
1. 2.

gm
Incision
7@
a4
tiy
ga
ar
ik
sh
va
ur
|
w
ro
ar

BIANCHI STEP
M

(Serial transverse enteroplasty)

©

Diverticular Disease 00:08:42

Features :
• M/c site : Sigmoid colon.
• False diverticulae (Mucosal herniation).
• Forms along mesenteric border.
• 4th - 5th decade; A/w constipation.
• M/c cause of massive lower GI hemorrhage.
• IOC of diverticulosis : Barium enema Sawtooth
appearance.
Sawtooth appearance

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 Gastrointestinal Surgery : Part 3 99

Complications : ----- Active space -----

• Bleeding : Right > Left (SMA > IMA).
• Diverticulitis.
• Colorectal cancers.

Diverticulitis :
Clinical features :
• Left lower quadrant pain.
• Diarrhea.
• Fever.
Diverticulitis with abscess
• Raised TLC.
Hinchey staging system : Based on CECT (IOC).

om
Stage Features Management

l.c
ai
I Colonic inflammation with pericolic abscess

gm
Pigtail catheter
II Colonic inflammation with pelvic abscess
7@
III Purulent peritonitis
a4
Laparotomy + Hartmann
tiy

IV Fecal peritonitis procedure

ga
ar

Note : Barium enema/colonoscopy is avoided d/t ↑ risk of perforation.

ik
sh
va

Angiodysplasia
ur

00:11:32
|
w

Features :
ro
ar

• 2nd m/c cause of lower GI bleed.

M
©

• Dilated arterioles + .
• M/c site : Caecum.
Clinical features :
• Seen in elderly (5th - 6th decade).
• Heyde syndrome :
Angiodysplasia + Aortic stenosis. Angiodysplasia

Management :
Investigation :
• Colonoscopy.
• Capsule endoscopy.
Treatment : Coagulation/cauterisation.
Capsule endoscopy

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 100 Surgery

----- Active space ----- Inflammatory Bowel Disease 00:12:28

Crohn’s disease Ulcerative colitis

20-40 years
Age Bimodal peak 25 - 40 years
70 years
Sex F>M M>F
Smoking ↑ Risk Protective
Gene NOD 2/CARD 15 -
• Any portion : Lips to anus
• Skip lesion +
• Rectum Pancolitis Backwash ileitis
• Anal involvement is common
• Continuous lesion
• Relative rectal sparing
• Anal involvement uncommon
Features • Transmural involvement :
• ↑ Risk of toxic megacolon
- Strictures
• Mucosal/Submucosal

om
- Colovesical/colovaginal fistulae
involvement Pseudopolyps

l.c
• Creeping fat

ai
• Non-caseating granuloma

gm
• Mimics acute appendicitis 7@• Bloody diarrhea
Clinical features
• Abdominal pain + diarrhea • Toxic megacolon
a4
tiy

Diagnosis Biopsy
ga
ar
ik
sh
va
ur
|
w
ro

Radiological sign
ar
M
©

String sign of Kantor : Toxic megacolon (Diameter >6 cm)

• Terminal ileum stricture
• Also seen in TB ↑ Risk of perforation
Medical Mx Steroids + S-ASA derivatives
Conservative resection Total proctocolectomy + ileoanal pouch
Surgical Mx
(↑Resection Short bowel syndrome) anastomosis (IAPA)

Extraintestinal Manifestations : Indications for Sx :

1. Erythema nodosum. 1. Not responding to medical mx.
2. Primary sclerosing cholangitis. 2. Steroid toxicity.
3. Episcleritis, uveitis. 3. Complications of IBD.
4. Ankylosing spondylitis (A/w HLA B27). 4. Extraintestinal manifestations.
Note : Conditions which do not improve on surgery.
• Primary sclerosing cholangitis.
• Ankylosing spondylitis.
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 Gastrointestinal Surgery : Part 3 101

Colonic Polyps 00:17:57 ----- Active space -----

Types :
1. Inflammatory : Ulcerative colitis Pseudopolyps.
2. Hamartomatous :
• Seen in Peutz Jegher syndrome.
• Types :
- Single juvenile polyp : Not premalignant.
- Juvenile polyposis : ↑Risk of cancer.
3. Adenomatous polyp : ↑Risk of cancer.
Inflammatory pseudopolyps
Peutz Jegher’s Syndrome :
• Gene : STK 11 (chr 19).
• M/c location : Jejunum.

om
l.c
• Increased risk of :

ai
gm
- Pancreatic cancer (100x).
- Duodenal cancer. 7@
a4

- Thyroid cancer.
tiy
ga

- Colonic cancer. Perioral melanosis

ar
ik
sh

Clinical features :
va

• M/c presentation : Intussusception.

ur
|

• Pathognomonic finding : Perioral melanosis.

w
ro
ar

HPE : Arborising pattern.

M
©

Arborising pattern

Adenoma Carcinoma Sequence :

Normal mucosa APC Hyperproliferative Early adenoma K-RAS Intermediate
epithelium adenoma
DCC (Chr 18)
AK53 Late adenoma
First hit : APC p53
Last hit : p53 Carcinoma.

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 102 Surgery

----- Active space ----- Haggit Classification :

• For cancer in a polyp.
• Sessile polyp : Starts at level 4.
• Pedunculated polyp : Includes levels
0 to 4.

Familial Adenomatous Polyposis (FAP) :

• Autosomal dominant APC gene
mutation (Chr 5).
• Pathognomonic finding : >100
adenomatous polyps
(100% risk of cancer). Haggit classification
• M/c site : Rectum.

om
l.c
Surgery : Total proctocolectomy + 1APA.

ai
gm
Variant Associated with 7@
• FAP
a4
tiy

• Sebaceous cysts
ga

Gardner syndrome
ar

• Osteomas
ik
sh

• Desmoid tumour
va

• FAP
ur
|

• CNS tumours :
w

Turcot’s syndrome
ro

- Gliomas
ar
M

- Medulloblastomas
©

Familial Adenomatous Polyposis (FAP)

Screening : Genetic counselling + Testing for 1st degree relatives

If mutation +

Screening from age 10 yrs : Sigmoidoscopy.

MUTYH Associated Polyposis :
• Similar to FAP.
• Autosomal recessive APC mutation not identified.
• Multiple colonic polyps.
• 3-6x risk of cancer.
• Surveillance for duodenal adenomas : 2 year colonoscopies.
HNPCC :
• Hereditary non-polyposis colonic cancer syndrome.
• Defect in mismatch repair genes (MLH, MSH).
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 Gastrointestinal Surgery : Part 3 103

Modified Amsterdam criteria : ----- Active space -----

1. Rule out FAP.
2. At least 3 relatives affected by HNPCC tumours of which at least I should be a
first degree relative.
3. 2 consecutive generations affected.
4. At least one should develop tumours at <50 years.

Lynch syndrome :
Lynch 1 Lynch 2
• Extracolonic cancers
Colorectal cancers are m/c
• M/c : Uterine, cervical

Colorectal Cancers (CRC) 00:24:45

om
M/c site : Rectum > Rectosigmoid > Sigmoid.

l.c
ai
gm
Screening :
• Starts : 50 years of age. 7@
a4

• If Family history + : 10 yrs before diagnosis of youngest relative.

tiy
ga
ar

Modalities :
ik
sh
va

Colonoscopy Sigmoidoscopy FOBT

ur

Duration Every 10 years Every 5 years Annually

|
w

110 - 140 cm (Rectum

ro

Length of scope 60 - 90 cm -
ar

to caecum visualised)
M
©

Virtual colonoscopy :
• CECT f/b 3D reconstruction.
• Used for screening.
• Advantages :
- Better extracolonic details.
- Better patient compliance. virtual colonoscopy
• Disadvantage : Mucosal details are not well appreciated.

Investigations of Choice :
• Diagnosis : Colonoscopic biopsy.
• Staging : PET-CT.
• T & N staging for rectal Ca : MRI with endorectal coil.

Apple core deformity

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 104 Surgery

----- Active space ----- Presentation :

Right sided CRC Left sided CRC
• Annular growth
Ulcero-proliferative growth Bleed • Altered bowel habits
Early onset
Iron deficiency anemia • Bowel obstruction
• Apple core deformity (Radiology)
Duke’s Staging :
Depends on depth of the tumour.
A : Mucosa + Submucosa involved.
B : Muscle involvement with no LN. Mucosa
BI Into muscle layer. Submucosa
B2 Beyond muscle layer. A

om
B1 C1
C : Muscle involvement with LN positive. B2 C2

l.c
ai
Cl Into muscle layer.

gm
C2 Beyond muscle layer. 7@ Muscle
a4
D : Distant metastasis. Serosa
tiy
ga

Management :
ar
ik

Surgery : Colectomy.
sh
va

A. Right hemicolectomy B. Extended right hemicolectomy

ur
|

• Lesion in caeum Half of transverse colon removed

w
ro

• Structures removed :
ar

- Terminal ileum : 10-12 cm

M

- Ascending colon
©

- 1/3rd of transverse colon

C. Transverse colectomy D. Left hemicolectomy

Only Traverse colon removed completely Lesion in splenic flexure

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 Gastrointestinal Surgery : Part 3 105

Surgery in rectal lesions : ----- Active space -----

Tumour location Procedure Structures removed

Low Anterior Resection (LAR)
> 5 cm from • Rectum
+
anal verge • Part of sigmoid
Colo-anal anastamosis (Sphincters spared)
Abdomino-Perineal Resection (APR) • Rectum
< 5 cm from
+ • Anal canal
anal verge
Permanent end colostomy (Sphincters cut) • Part of sigmoid

om
l.c
ai
gm
LAR APR
7@
a4

Plane of dissection for LAR/APR :

tiy
ga

• B/w neurovascular bundle of prostate & Sacrum.

ar

• Total mesorectal excision : To remove lymph nodes.

ik
sh
va

Complications of surgery : Plane of dissection

ur
|
w

Nerve injured Procedure Clinical features

ro
ar

Superior hypogastric
M

High IMA ligation Retrograde ejaculation

plexus or it’s branches
©

Division of lateral stalks Erectile dysfunction,

Pelvic plexus
close to pelvic sidewall impotence, atonic bladder
Periprostatic plexus Anterior dissection Sexual & bladder dysfunction

TaTME :
• Transanal total mesorectal excision.
• Type of NOTES procedures.
• Done in early rectal cancers (T1, T2).
Anal Carcinoma :
• Usually SCC.
• Mx : Nigro’s regime x 1 month (Combined chemoradiation).

If residual disease/recurrence +

Surgery : APR. TaTME

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 106 Surgery

----- Active space ----- Pilonidal Sinus 00:34:43

Features : Management :
• Sinus/abscess in natal cleft. • Excision Rhomboid/Limberg flap.
• D/t ingrowing of hair. • Bascom’s technique.
• Seen m/c in hairy men. • Kardayakis surgery.
• AKA jeep driver’s disease.

Pilonidal sinus Rhomboid flap

om
l.c
ai
Hemorrhoids/Piles

gm
00:35:54

Dilated vascular channels 7@

Bleeding from sinusoids.
a4

M/C cause of bleeding P/R.

tiy
ga

1° hemorrhoids location : 3,7, 11 o’ clock.

ar
ik
sh

Clinical Features :
va

• Painless bleeding P/R.

ur
|

• Constipation.
w
ro

• Painful if :
ar
M

External hemorrhoids
- External (Below dentate line).
©

- Thrombosed hemorrhoids/Meleney’s 5 day self healing lesion : Felt on DRE.

Investigation :
IOC : Proctoscopy.

Proctoscopy Thrombosed piles

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 Gastrointestinal Surgery : Part 3 107

Grades & Management of Piles : ----- Active space -----

Grade Description Management

1. High fibre diet + ↑ fluid intake
I Only bleeds; no prolapse 2. Laxatives
3. Sitz bath
II Prolapse but spontaneously reduces Grade I Mx + Banding/Sclerotherapy
III Prolapse ; Have to be pushed inside 1. Hemorrhoidectomy :
- Open : Milligan morgan
- Closed : Ferguson
IV Remains prolapsed 2. Stapled hemorrhoidopexy : TOC
3. DGHAL (Doppler guided hemorrhoidal
artery ligation)

om
l.c
ai
gm
7@
a4

Open hemorrhoidectomy : Banding (Barron’s band)

tiy

Hemorrhoid resection wound left open

ga
ar
ik

Complications of Hemorrhoid Surgery :

sh
va

1. Urinary retention (M/c).

ur

2. Reactionary hemorrhage.
|
w

3. Pain.
ro
ar

4. Stenosis.
M
©

5. Incontinence.
6. Recurrence.

Stapler hemorrhoidopexy

Anal Fissure 00:40:07

Breach in epithelium, M/c site : Posterior midline.

Clinical Features :
1. Painful bleeding P/R.
2. Constipation.
3. Skin/Sentinel tag +
(Chronic anal fissure : >4 weeks).
Chronic anal fissure

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 108 Surgery

----- Active space ----- Management : 3. Local xylocaine, CCB cream.

IOC : External inspection (DRE is C/I). 4. Surgery : If medical mx fails.
Rx : - Lateral anal sphincterotomy.
1. Lifestyle changes. - Anal advancement flap.
2. Laxative.

Rectal Prolapse 00:41:30

Types :
Partial thickness Full thickness/complete
• Mucosal prolapse • All layers prolapse
• Common in children • Common in adults
• D/t incomplete sacral curve • D/t weak pelvic floor

om
l.c
ai
gm
7@
a4
tiy
ga
ar
ik
sh
va

Partial prolapse
Complete prolapse
ur
|

Management :
w
ro

Partial thickness prolapse :

ar
M

• First episode : Digital repositioning.

©

• Recurrent :
- Thiersch wiring.
- Sclerotherapy.

Complete thickness :
Perineal procedures Abdominal procedures
Easy to perform Difficult to perform
Less complications ↑↑ complications
High recurrence rate Least recurrence rate
1. Thiersch repair : Purse string sutures 1. Ripstein rectopexy
2. Delorme’s repair : Plication of prolapse 2. Weil rectopexy
3. Altemier : Perineal rectosigmoidectomy 3. Goldman Frykberg : Resection rectopexy

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 Gastrointestinal Surgery : Part 3 109

----- Active space -----

Thiersch wiring Delorme’s repair Rectopexy

Anorectal Malformations 00:44:20

Level of anomaly Male Female

High Rectovesical fistula Rectovaginal fistula

om
Low Anal stenosis Anal agenesis

l.c
ai
Miscellaneous - Persistent cloacal anomaly

gm
A/w other malformations : VACTRL. 7@
a4

Invertogram :
tiy
ga

Done 24 hours after birth.

ar

Patient is inverted
ik
sh
va
ur

Metallic marker is placed at anal opening

|
w

X-ray taken
ro
ar

Distance b/w gas bubble & marker measured :

M
©

- <2 cm : Low anomaly.

- >2 cm : High anomaly. Invertogram

Note : MRI is IOC.

Mx : Surgery to bring the rectum down.

Anorectal Abscess & Fistula 00:46:31

Forms close to the dentate line

Source of infection : Anal glands.

Perianal Abscess :
C/f : Pain & fever.
Mx : Incision & drainage.
Complication : Perianal fistulae.
Perianal abscess

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 110 Surgery

----- Active space ----- Perianal Fistula :

Complication of improperly managed perianal abscess.
Clinical features : Pus discharge P/R.

Goodsall’s rule :
• Imaginary line drawn through the anal verge.
• Fistulae anterior to the line Straight tracts.
• Fistulae posterior to the line Curved tract.
• Exception : Long anterior fistula (>3 cm).
Goodsall’s rule
Park’s classification : Watercan perineum :
IOC : MR fistulogram. Multiple perianal fistulae.
Causes :

om
• Crohn’s disease.

l.c
ai
• Trauma.

gm
7@ • TB.
a4

• Cancer.
tiy
ga

• Immunocompromised patient.
ar
ik
sh
va
ur

Types of fistulae
|
w

(M/c)
ro
ar

Sphincter
M
©

High
Management : Low
1. Low fistulae :
- Fistulectomy/Fistulotomy. Based on internal opening :
• Above anorectal ring : High.
- LIFT (Ligation of fistulous tract). • Below anorectal ring : Low.
- VAFT (Video assisted fistula therapy).
2. High fistulae : Seton’s procedure (↓Chance of incontinence).

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 Hepatobiliary and Minimally Invasive Surgery 111

HEPATOBILIARY & MINIMALLY INVASIVE SURGERY ----- Active space -----

Surgical Anatomy of Liver 00:00:52

Couinaud Segments :
Liver 7 8 4A 2
LPV
Cantlie line/MHV RPV 3
4B
5
Right hemiliver Left hemiliver 6
RHV LHV
LHV

om
Right Right Left Left RHV MHV

l.c
posterior : anterior : medial : lateral :

ai
MHV : Middle hepatic vein

gm
6, 7. 5, 8. 4A, 4B. 2, 3. LHV : Left hepatic vein
7@
RHV : Right hepatic vein
a4
Note : Cantlie’s line joins IVC to gallbladder.
tiy

RPV/LPV : Right/Left portal vein

ga

Other Features :
ar

: Liver sectors (4)

ik

• Structures dividing liver : Portal vein & hepatic veins.

sh
va

• Portal veins of either side Superior & inferior divisions.

ur
|

Segment Significance Feature

w
ro
ar

7 Bare area M/c site for amoebic liver abscess.

M

Removed in radical cholecystectomy in

©

4B & 5 Gall bladder (GB) fossa

GB Ca.
Hypertrophied in Budd Chiari syndrome.
1 Caudate lobe
(D/t direct drainage into IVC.)
Fissures :
• Major fissures (3) : LHV, MHV, RHV.
• Minor fissures (3) : LPV, RPV, Fissure of Ganz.

Brisbane Classification of Liver Resection :

Procedure Segments removed
Left hepatectomy 2, 3, 4A & 4B
Right hepatectomy 5, 6, 7 & 8
Left trisectorectomy (Extended left hepatectomy) 2, 3, 4A, 4B, 5 & 8
Right trisectorectomy (Extended right hepatectomy) 5, 6, 7, 8, 4A & 4B

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 112 Surgery

----- Active space ----- Liver Pedicle :

• Duplex scan : Mickey mouse sign.
• Formed by :
i. Hepatic artery.
ii. Common bile duct.
iii. Portal vein.

Mickey mouse sign

Liver Abscess 00:05:08

Amoebic Pyogenic
• M/c : E. Coli.
Organism Entamoeba histolytica • M/c in asia : Klebsiella.

om
• Chronic granulomatous disease : S. aureus.

l.c
ai
Small/large bowel infection

gm
Route of Portal vein (Laminar flow towards right) 7@ Ascending cholangitis (Via biliary tree).
infection
a4
tiy

M/c segment affected : 7.

ga
ar

No. of • 50% Solitary

ik

Solitary
sh

abscesses • 50% Multiple

va

Right hypochondriac pain + feve.r

ur

C/f
|

- More toxic/sick.
w
ro

• ↑↑PT/INR
ar

Labs ↑↑ALP
• Aspirate : Anchovy-sauce pus.
M
©

IOC CECT (Pus collection)

Metronidazole (8oo mg) TDS

Not responding : Responding :

Drainage with pigtail Continue for
catheter 2-3 wks.
• Broad spectum IV antibiotics
Mx
Other indications : • Early drainage with pigtail catheter
• 2° infections
• Abscess cavity >5cm
• Left lobe abscess
• Pregnancy
• Impending rupture.

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 Hepatobiliary and Minimally Invasive Surgery 113

Hydatid Cyst 00:08:15 ----- Active space -----

Features :
Organism : Echinococcus granulosus.
Definitive host : Dog.
Intermediate host : Sheep.
Accidental intermediate host : Man.
C/f : Right hypochondruim pain.
IOC : CECT
Classification :
WHO-IWGE 2001 Gharbi 1981 (USG based) Description
CE 1 Type I Unilocular anechoic cystic lesion with double-line sign.

om
CE 2 Type III Multiseptate, Rosette-like, Honeycomb cyst.

l.c
CE 3a Type II Cyst with detached membranes (Water-lily sign).

ai
gm
CE 3b Type III Cyst with daughter cysts in a solid matrix.
7@
Cyst with heterogeneous hypoechoic/hyperechoic
a4

CE 4 Type IV
tiy

contents. No daughter cysts.

ga

CE 5 Type V Solid cyst with a calcified wall (Dead cyst).

ar
ik
sh
va
ur
|
w
ro
ar
M
©

Management :
1. Albendazole (First line).
2. PAIR :
• Percutaneous Aspiration, Injection, Re-aspiration.
• Aspirate fluid Inject scolicidal : Reaspirate agent.
• Hypertonic saline (M/c).
• Cetrimide
• Mebendazole
• Alcohol
Note : Formalin not used. (Causes chemical cholangitis). Water-lily sign

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 114 Surgery

----- Active space ----- • C/I for PAIR :

a. Dead cyst. d. Deep seated cyst.
b. Calcified cyst. e. Multiloculated cyst.
c. Extrahepatic cyst. f. Cystobiliary communication.
3. Surgery :
• Done if PAIR is C/I.
• Liver resection or cystopericystectomy.

Benign Liver Tumours 00:12:15

Liver Hemangioma :
• M/c benign tumour of liver.
• Usually asymptomatic.
• CT : Peripheral nodular enhancement.

om
l.c
• No surgical intervention required.

ai
gm
Hepatic Adenoma : 7@
• A/w OCP intake.
a4

Liver hemangioma
tiy

• Risk of malignant conversion : 10%.

ga
ar

• F >> M.
ik
sh

Clinical presentation :
va
ur

• Mostly symptomatic (Right hypochondrium pain/lump).

|

• Hemoperitoneum (D/t spontaneous rupture).

w
ro
ar

Investigations : Bordeaux classification :

M
©

• IOC : CECT. • Inflammatory : Highest bleeding risk.

• HPE : • β-catenin mutated : ↑Risk of cancer.
- Sheets of hepatocytes. • HNF 1a mutated :
- No ducts. - Young pts.
- No Kupffer cells. - Multiple lesions.
Management : Resection (Indications : N >5 cm, High risk : >2 cm).

Focal Nodular Hyperplasia (FNH) :

• Etiology : ↓Blood supply.
• HPE :
Central
- Hepatocytes. stellate scar
- Bile duct structures.
- Kupffer cells + : Hotspot on Tc99 scan.
• IOC : CECT Central stellate scar.
• Mx : Conservative.
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 Hepatobiliary and Minimally Invasive Surgery 115

Hepatocellular Carcinoma (HCC) 00:14:41 ----- Active space -----

• M/c 1° malignant tumour of liver : HCC.

• M/c malignant tumour of liver : Metastasis.

Risk Factors :
1. HBV. 5. Thorotrast.
2. HCV. 6. Aflatoxin.
3. Alcohol. 7. DM.
4. Obesity. 8. NASH/NAFLD.

Note : Thorotrast is a/w HCC, cholangiocarcinoma & renal cell carcinoma.

Features :
• M > F.

om
l.c
• M/c presentation : Hepatomegaly (Hard & nodular liver).

ai
gm
• Paraneoplastic syndromes :
- Hypoglycemia (M/c). - Gynecomastia.7@
a4

- Hyperlipidemia (M/c biochemical). - Hypercalcemia.

tiy
ga

- Cushing’s syndrome.
ar
ik
sh

Investigations
va
ur

1. Triple phase CT : IOC, used for LIRADS score.

|
w

Phases Finding
ro
ar

A : Non contrast Hypodense

M
©

B : Arterial Enhancement
C : Venous Early washout

Note :
• In triple phase CT of metastasis, all phases are hypodense.
• AFP (a-fetoprotein) : Tumour marker for HCC.

2. Biopsy : Confirms diagnosis.

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 116 Surgery

----- Active space ----- Child-Turcotte-Pugh Score :

Used to assess functional liver tissue.
Points
Clinical and lab criteria
1 2 3
Mild to moderate Severe
Encephalopathy None
(Grade 1 or 2) (Grade 3 or 4)
Mild to moderate Severe
Ascites None
(Diuretic responsive) (Diuretic refractory)
Bilirubin level (mg/dL) <2 2-3 >3
Albumin level (g/dL) >3.5 2.8-3.5 <2.8
Prothrombin time :
• Seconds prolonged (s) <4 4-6 >6
• International <1.7 1.7-2.3 >2.3
Normalized Ratio (INR)

om
Class A (5-6) : Least severe.

l.c
ai
Class B (7-9) : Moderately severe.

gm
Class C (10-15) : Most severe. 7@
a4
tiy

MELD & PELD Score :

ga

MELD PELD
ar
ik

(Model for end stage liver disease) : (Pediatric end-stage liver disease) :
sh
va

1. Creatinine. 1. Albumin.
ur
|

2. Serum bilirubin. 2. Total bilirubin.

w
ro

3. INR. 3. INR.
ar
M

4. Growth failure.
©

5. Age (<1yr).
Management :

Localised Advanced

Poor functional liver Good functional liver

reserve/Child Pugh B or C reserve/Child pugh A

Milan criteria : Resection Palliative :

1. Single lesion ≤ 5cm. • Multiple lesion in one lobe : TACE
2. 1-3 lesions ≤ 3cm. (Transarterial chemo embolisation).
3. No distant mets. • Radiofrequency ablation.
• Microwave ablation.
Satisfied • Chemotherapy.
• Intralesional ethanol injection.
Liver transplant
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 Hepatobiliary and Minimally Invasive Surgery 117

Barcelona clinic criteria : ----- Active space -----

Hepatocellular carcinoma (HCC)

Stage O : Stage A-C : Stage D :

PST O, Child-Pugh A PST 0-2, Child-Pugh A-B PST >2, Child-Pugh C

Very early stage (O) : Early stage (A) : Intermediate Advanced stage (C) : Terminal stage (D)
Single 2cm carcinoma Single or nodules stage(B) : Portal invasion N1, M1,
in situ ≤3cm, PST O Multinodular, PST O PST 1-2

Single 3 nodules <3cm

om
l.c
ai
Portal pressure

gm
and/or bilirubin
Increased 7@
a4
Associated diseases
tiy

No Yes
ga

Normal
ar
ik

Liver RF/PEI/PVE
sh
va

transplantation Best supportive

ur

Resection (DDLT/LDLT) TACE Sorafenib care

|
w
ro
ar

RFA : Radiofrequency ablation.

M

PVE : Portal vein embolization.

©

PE1 : Percutaneous ethanol injection.

Prognostic indicators for HCC Fibrolamellar variant of HCC

OKUDA : BATA • M/c in young females
B Bilirubin • Occur in non cirrhotic liver
A Ascites • AFP not raised
T Tumor size • Tumour marker : Neurotensin B
A Albumin • Good prognosis

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 118 Surgery

----- Active space ----- Surgical Anatomy of GB 00:23:28

Hepatocystic triangle Calot’s triangle

Boundaries : Boundaries :
• Inferior edge of liver • Cystic artery
• Common hepatic duct (CHD) • Common hepatic duct
• Cystic duct • Cystic duct
Contents : Contents : Cystic lymph
• Cystic artery (From right nodes of Lund.
hepatic artery)
• Calot’s triangle.

Moynihan’s Hump :

om
• Tortuous right hepatic artery.

l.c
• Lies in front of Calot’s triangle.

ai
gm
• Injury Torrential bleeding.
7@
a4

Cystic Plate :
tiy
ga

• Flat, ovoid fibrous sheet, continuous with the liver capsule of segments 4 & 5.
ar

• Location : GB bed.
ik
sh

• Exposure Critical view of safety during lap. cholecystectomy.

va
ur
|

Rouviere’s Sulcus :
w
ro

• Under surface of the right lobe of the liver Right of the hepatic hilum.
ar
M

• Marks position of right posterior sectoral pedicle.

©

R4U line :
• Line joining rouviere’s sulcus (R),
Segment 4B & Umbilical fissure.
Rouviere’s
• Above : Cystic artery + Cystic sulcus (R)
duct. 5 4B
• Below : CBD.
• Dissection to be done above R4U
line during cholecystectomy.
Fundus folded inwards
Phrygian Cap :
• Physiological variant.
• Not an indication for cholecystectomy.
• Not a risk for cancer.
Phrygian cap USG

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 Hepatobiliary and Minimally Invasive Surgery 119

Gall Stones 00:27:44 ----- Active space -----

TYPES

Pure cholesterol stones Mixed stones Pigment stones :

• M/c overall. • M/c in Asia.
• Cholesterol + pigment. • <30% cholesterol.

Black pigment stones : Brown pigment stones :

• Composition : Insoluble bilirubin • Composition : Ca bilirubinate,
pigment + CaPO4 + CaHCO3. Ca palmitate, Ca stearate.
• Hemolytic conditions : • Infected bile :
- Sickle cell anemia. - Clonorchis.
- Hereditary spherocytosis. - Cholangitis.
INVESTIGATIONS

om
l.c
IOC : USG Abdomen : Posterior acoustic shadow +

ai
gm
7@
a4
tiy
ga
ar
ik
sh
va
ur

Gallstones GB polyp : No shadow

|
w
ro

PRESENTATION
ar
M

1. Asymptomatic :
©

Indications for surgery :

a. Porcelain GB (Calcification of GB c. Salmonella typhi carrier.
wall) : ↑Risk of malignacy by 10%. d. DM.
b. Polyp > 1 cm. e. Stone size >2 cm.
Porcelain GB
2. Acute Cholecystitis :
Tokyo guidelines for diagnosis :
a. Local signs of inflammation etc : c. Imaging findings :
1. Murphy’s sign. 1. Thickened GB wall.
2. Right upper quadrant pain/tenderness/mass 2. Probe tenderness.
+ Nausea & vomiting. 3. Pericholecystic fluid.
b. Systemic signs of inflammation, etc : Suspected diagnosis : 1 item in A & B but not C.
1. Fever. Definitive diagnosis : 1 item in A+B+C.
2. Elevated CRP.
3. Elevated WBC count.
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 120 Surgery

----- Active space ----- Note : HIDA scan for acalculous cholecystitis.

Grading of cholecystitis (Tokyo consensus guidelines) :

Grade Severity Features
Grade III Severe acute cholecystitis Organ dysfunction
Any 1 of the following :
• Elevated white cell count > 18000/mm3.
• Palpable tender mass in right upper
abdominal quadrant.
Grade II Moderate acute cholecystitis
• Duration of complaint >72 hours.
• Marked local inflammation. (Emphysematous/
gangrenous cholecystitis, pericholecystic
abscess, biliary peritonitis).
No organ dysfunction & mild inflammatory
Grade I Mild acute cholecystitis
changes.

om
l.c
Management : Based on Tokyo guidelines.

ai
gm
NPO.
Antibiotics + General supportive care
7@ IV fluids.
a4
tiy

Grade I Observation Painkillers.

ga
ar
ik
sh

Early laparoscopic cholecystectomy (LC).

va

Grade II & III : Antibiotics + General supportive care

ur
|
w
ro

• No negative predictive factors

ar

• Negative predictive factors +

M

• Good facities available • Poor performance score (PS)

©

Urgent LC. Urgent GB drainage(Tube cholecystostomy)

Good PS
Delayed/Elective LC.
Note : Chronic cholecystitis (D/t repeated attacks) Mx : Cholecystectomy

3. Mucocele :
• Aseptic dilatation of GB with mucus.
• D/t impacted stone at neck of GB (Hartman’s pouch).
• Infected Empyema.
• Mx : Cholecystectomy.

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 Hepatobiliary and Minimally Invasive Surgery 121

4. Mirizzi’s Syndrome : ----- Active space -----

GB adherent to CBD Stone pushes Obstruction Fistula b/w CBD & GB
against CBD
C/f : Obstructive jaundice + ↑ALP.
IOC : MRCP (Magnetic resonance cholangiopancreaticography).
Mx :
• Ideal : Cholecystectomy + Fistula repair.
• Adherent GB : Subtotal cholecystectomy.
Fistula formation
5. Gallstone Ileus :
2° to cholecystoduodenal fistula Dynamic bowel obstruction
(M/c site : Last 60cm of ileum).

Investigations :

om
l.c
a. X-ray abdomen : Erect & supine X

ai
gm
Riggler’s triad seen :
i. Pneumobilia. 7@
a4

ii. Features s/o SI obstruction.

tiy
ga

iii. Radio opaque shadow in Rt lower quadrant.

ar

b. CECT : Ioc.
ik
sh
va

Management :
ur
|

a. Mx of intestinal obstruction.
w
ro

b. 2nd Sx (Cholecystectomy + Fistula repair).

ar
M
©

Complication :
Bouveret syndrome : Gall stone causing gastric outlet obstruction.
6. Choledocolithiasis :
Stones in the CBD
Charcot’s triad Reynolds pentad
Presentation :
Pain + Fever + Jaundice Charcot’s triad +
• Asymptomatic.
Septic shock +
• Obstructive Jaundice. (↑ALP). Intermittent Altered mental status
• Cholangitis : Charcot’s triad.

Investigations :
1. MRCP : IOC.
2. Endoscopic ultrasound (EUS) : IOC for CBD microliths.

MRCP : Choledocholithiasis
Surgery Revision • v4.1 • Marrow 8.0 • 2025
 122 Surgery

----- Active space ----- Risk factors for CBD stones :

History of Further
Risk of CBD Liver function Abdominal USG :
cholangitis or evaluation
stones tests CBD diameter
pancreatitis required
Low, 2-3% Absent Normal ≤6 mm None
MRCP +/- ERCP
Medium, 20-40% Present 2x normal 8-10 mm
stone extraction
Present, with MRCP +/- ERCP
High, 50-80% 2x normal ≥10 mm
jaundice stone extraction

Management :
1. CBD/GB stone detected before cholecystectomy :
ERCP F/b Cholecystectomy. ERCP
2. CBD Stones detected during surgery :

om
• Side viewing
Lap cholecystectomy +

l.c
endoscope used

ai
Exploration of CBD to remove stones • Endoscope visualised

gm
• S/E : Pancreatitis
7@
a4
T-Tube insertion Dye injected after 5-7 days
tiy
ga
ar

No residual stones : Stones +

ik
sh

Remove T-Tube.
va
ur

Burhenne’s technique : T-Tube

|
w

Retain T-Tube
ro
ar

2-3 wks
M

Remove stones using choledochoscope.

©

3. Stones detected after surgery :

T-tube cholangiogram
Within 2yrs : After 2 years :
Residual stones. Recurrent/1° CBD stones.
ERCP
Laproscopic Cholecystectomy 00:45:39

Be safe method
Visualise the following :
• Bile duct. Cystic artery
• Sulcus of rouviere. Cystic duct
• Hepatic artery.
• Umbilical fissure.
• Duodenum.
Critical view of safety (Lap. view)
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 Hepatobiliary and Minimally Invasive Surgery 123

Bailout strategies : ----- Active space -----

Indication : Standard lap. cholecystectomy fails/not feasible.
1. Abort the procedure. 4. Subtotal cholecystectomy.
2. Convert to open procedure. 5. Fundus first procedure.
3. Tube cholecystostomy using 14f
foley’s.

Complications :
1. Right shoulder tip pain (M/c) : D/t retained co2 irritating diaphragm.
2. Bleeding.
3. CBD injury.
4. Residual/recurrent stones.
5. Post cholecystectomy syndrome : Pain d/t to Retained stones.

om
Sphincter of oddi dysfunction.
Bile Duct Injury :

l.c
ai
gm
Bile leak during surgery : Surgical repair.
Bile leak after surgery : 7@
a4

Bile leak after surgery

tiy
ga
ar
ik

Major leak :
sh

Minor leak
va

• Patient is stable • Fever + MRCP showing bile leak

ur

• No fever • Jaundice +
|

• Pain +
w
ro

Conservative mx. • USG : Collection +

ar
M
©

Within 24-48 hrs : >48 hrs :

Re-explore & Repair. • Antibiotics.
• Pigtail drainage of collection MRCP (IOC).
• ERCP followed by stenting.
Bismuth & Strasberg Classification :
Bile duct injury Bismuth Strasberg
Cystic duct leak or leaks from small ducts in liver bed - A
Occlusion of aberrant right hepatic duct (RHD) - B
Leak from an aberrant RHD - C
Lateral injury to CBD (<50% circumference) - D
Common hepatic duct (CHD) stricture, stump >2 cm Type 1 E1
CHD stricture, stump <2cm Type 1I E2
Hilar stricture with preserved biliary confluence Type 1II E3 Note :
Hilar stricture with involvement of confluence Type 1V E4 Hannover classification Bile duct +
Stricture to an aberrant RHD and to CHD Type V E5 Vascular injury.
Surgery Revision • v4.1 • Marrow 8.0 • 2025
 124 Surgery

----- Active space ----- Gallstones in Pregnancy :

• Hormonal changes :
↑Cholesterol secretion.
+
↓Bile acid secretion ↓Ability of bile to solubilise Promotes formation
+ cholesterol of stones.
↓GB emptying
(D/t progesterone).
• First trimester : Conservative Mx (Avoid NSAIDs).
• Second trimester : Moderate/Severe disease Lap cholecystectomy.
• Third trimester : Conservative Mx.

GB Cancer 00:51:00

Risk Factors :

om
1. Gallstones (90%).

l.c
ai
2. Salmonella typhi carrier.

gm
3. Porcelain gall bladder. 7@
4. GB polyps (>1 cm in size, multiple).
a4
tiy

5. Abnormal pancreatico-biliary duct

ga
ar

Junction (APBDJ) : ↑Risk of GB cancer &

ik
sh

cholangiocarcinoma.
va

6. Heavy metal contamination of water. Cholesterosis

ur
|

Note : Cholesterosis (Strawberry GB) is NOT a risk factor.

w
ro
ar

Clinical Features :
M
©

1. GB mass.
2. Jaundice (Late sign).

Management :
IOC : CECT (Used for staging also)
PET-CT (IOC for staging).
Stage Feature Rx
GB polyp
T1a Above muscle layer Simple cholecystectomy
Involves muscle • Radical/Extended cholecystectomy Radical cholecystectomy
T1b
layer • No chemotherapy Structures removed :
1. Radical cholecystectomy 1. GB.
T2, T3 2. Chemotherapy (Gemcitabine) f/b 2. Liver segments 4B & 5.
radiotherapy ± 3. Lymph node along
Gemcitabine chemotherapy hepatoduodenal ligament.
Invades adjacent Good response 4. CBD (If involved)
T4
structures
Surgery

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 Hepatobiliary and Minimally Invasive Surgery 125

Extrahepatic Biliary Atresia (EHBA) 00:54:27 ----- Active space -----

Japanese & Anglo-Saxon classification :

Type 1 : Atresia restricted to CBD.
Type II : Atresia of CHD
Type III : Atresia of right, left hepatic ducts & entire extra hepatic biliary tree.

Patent

Patent Atretic Atretic Atretic

Type I Type II Type III

om
l.c
Associated Anomalies :

ai
gm
• Cardiac lesions. • Absent vena cava.
• Polysplenia. 7@
• Pre duodenal portal vein.
a4

• Situs inversus.
tiy
ga
ar

Clinical Features :
ik
sh

Jaundice at birth. D/d :

va

i. Neonatal hepatitis.
ur
|

ii. Alagille syndrome : Biliary atresia, congenital heart

w
ro

disease, skeletal abnormalities.

ar
M
©

Investigations :
1. Fasting USG (Gold standard) : Atretic biliary tree.
2. MRCP : Sensitive + Specific.
3. Liver Biopsy : Confirmatory.
Management :
1. EHBA : M/c indication for liver transplant in children.
2. Kasai procedure : Portoenterostomy.

Stomach

Small intestine
Duodenum connected to liver
Kasai’s procedure

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 126 Surgery

----- Active space ----- Choledochal Cysts 00:57:31

Todani/Modified Alonso-Lej Classification :

Type Description Image Rx
Cyst resection
Type I Diffuse dilatation of the
+ Roux-en-Y
(M/c) CBD
hepaticojejunostomy

Diverticulum
Type II Diverticulum of CBD
resection & repair

ERCP +
Dilatation of
Sphincterotomy +
Type III intraduodenal portion of

om
Removal of abnormal
CBD (Choledochocele)

l.c
mucosa

ai
gm
Intrahepatic +
7@
Type IV A Extrahepatic biliary tree Liver transplant
a4
tiy

dilatation
ga
ar

Only extrahepatic biliary Kasai procedure

ik

Type IV B
sh

tree dilatation (Portoenterostomy)

va
ur

Dilatation of only
|
w

Type V intrahepatic biliary tree Liver transplant

ro
ar

(Caroli’s disease)
M
©

Features :
↑Risk of cholangiocarcinoma.
C/f : Lump, Jaundice, pain.
IOC : MRCP.

Pancreatic Malformations 00:59:58

Pancreas Divisum :
• M/c congenital anomaly of pancreas. Common bile duct
Dorsal duct of saantorini
• Failure of fusion of dorsal & ventral ducts

Ineffective drainage
Ventral duct of wirsung

↑Risk of pancreatitis.

Mx : ERCP + Sphincterotomy.
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 Hepatobiliary and Minimally Invasive Surgery 127

Annular Pancreas : ----- Active space -----

D/t failure of complete rotation of ventral pancreatic bud

Forms circular tissure around 2nd part of duodemum

Obstruction.
Features : Non-bilious vomiting (M/c) + Double bubble sign.
Mx : Duodeno-duodenostomy.

Acute Pancreatitis 01:01:47

Causes : Pathophysiology :
1. Gall stones (M/c). Theory of co-localisation : Activation of
2. Alcohol (2nd m/c). pancreatic enzymes within pancreas

om
l.c
3. Trauma (M/c cause in children).

ai
gm
4. Drug induced (ART/Chemotherapy/ Autodigestion
Thiazides). 7@
a4

5. Hyperparathyroidism. Inflammation.
tiy
ga

6. Scorpion bite.
ar
ik
sh

Clinical Features :
va

1. Epigastric pain :
ur
|

• Radiates to the back.

w
ro

• Relieved by bending forward.

ar

Cullen’s sign
M

2. Acute hemorrhagic pancreatitis :

©

• Cullen’s sign : Discolouration around umbilicus.

• Grey turner sign : Discolouration in flanks.

Grey Turner sign

Investigations :
1. Lab Ix : S. Amylase & S. lipase
(Sensitive) (Specific, late).
2. X-ray :
a. Colon cutoff sign.
b. Sentinel loop sign.
c. Gasless abdomen.
3. CECT : IOC.
Sentinel loop sign Colon cutoff sign

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 128 Surgery

----- Active space ----- Scoring for Acute Pancreatitis :

Severe pancreatitis :
1. Glasgow criteria ≥3.
2. BISAP score ≥3.
3. Ransons criteria ≥3.
4. CT severity index/Balthazar grading ≥6 : Best scoring system.
Ranson’s criteria
On admission : Within 48 hours of admission :
• WBC >16,000/μL. • Hct decrease >10%.
• Age >55 years. • BUN increase >5 mg/dL.
• Glucose >200 mg/dL. • Serum calcium <8 mg/dL.
• AST >250 IU/L. • Arterial pO2 <60 mmHg.
• LDH >350 IU/L. • Base deficit >4 mEq/L.
• Fluid needs >6 L.

om
l.c
CT Criteria for Pancreatitis :

ai
gm
Acute peripancreatic
7@
Acute necrotic collection Walled-off necrosis Pseudocyst
collection
a4
tiy

<4 weeks <4 weeks >4 weeks >4 weeks

ga

Homogenous Heterogenous Heterogenous Homogenous

ar
ik
sh

No fully definable wall No fully definable wall Well defined wall Well defined wall
va

Mx : Pigtail catheter. -
ur
|
w

Local Complications of Acute Pancreatitis :

ro
ar

1. Pseudocyst.
M

2. Pseudoaneurysm (In splenic artery).

©

3. Splenic vein thrombosis Portal HTN.

4. Pleural effusion (Left-side).

Pseudocyst 01:07:47

Stomach
Features :
• False cyst : Lined by granulation tissue.
• M/c site : Lesser sac.
C/f : Epigastric mass, nausea & vomiting, Lesser Sac
↓appetite.
Pancreas
IOC : CECT.

Pseudocyst
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 Hepatobiliary and Minimally Invasive Surgery 129

d’Egidio’s Classification : ----- Active space -----

Cyst type Pancreatitis Cystoductal communication

Type 1 Acute pancreatitis -
Type 11 Acute on chronic pancreatitis +/-
Type III Chronic pancreatitis +

Management :
• Mostly resolves spontaneously.
• Indications for intervention >6cm size.
>6 weeks old.
>6mm thickness of wall.
Intervention :

om
1. External drainage : 2. Internal drainage :

l.c
- For infected cyst. - Cystogastrostomy.

ai
gm
- C/1 : Communication with - Cystojejunostomy.
7@
pancreatic duct (D/t risk of
a4
tiy

fistula formation).
ga
ar

Chronic Pancreatitis
ik

01:10:09
sh
va

Causes :
ur
|

TIGAR-O classification.
w
ro

• Toxins : Alcohol (M/c), dietary.

ar
M

• Idiopathic.
©

• Genetic/Hereditary :
- PRSS I mutation : Hereditary pancreatitis.
- SPINK I mutation : Tropical calcific pancreatitis (D/t cassava consumption,
↑risk of Ca).
• Autoimmune (IgG4).
• Recurrent (D/t stones).
• Obstruction.

Clinical Features :
1. Malabsorption & steatorrhea : D/t exocrine insufficiency.
2. DM : D/t endocrine insufficiency (↓Insulin).
3. Pain : Stones in main pancreatic duct (MPD) Ineffective drainage.

Tropic calcific pancreatitis

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 130 Surgery

----- Active space ----- Management :

• Exogenous enzymes, OHAs.
• Analgesics for pain

Good response No response

Chain of lakes appearance
Continue. Intervention (D/t stones in the MPD)

Drainage (Based on MPD diameter) : Resection :

1. <5 mm : ERCP + sphincterotomy. 1. Inflammation restricted to tail :
2. >5 mm : Pancreaticojejunostomy. Distal pancreatectomy.
a. Puestow’s : Longitudinal anastomosis. 2. Restricted to head & neck :

om
l.c
b. Duval’s : End to End anatomosis. Beger’s procedure.

ai
gm
7@
a4
tiy

Jejunum
ga
ar
ik
sh
va
ur

Puestow’s procedure Duval’s procedure

|
w
ro

Endocrine Tumours of Pancreas

ar

01:14:18
M
©

INSULINOMA Whipple’s triad

• M/c pancreatic endocrine tumour. • Fasting hypoglycemia
• 90% Benign. symptoms.
• Tumour of b-cells. • Blood sugar <40mg/dl.
- Equally distributed in pancreas. • Rapid resolution on giving
glucose.
Management :
Investigations :
1. Fasting insulin : ↑.
2. C-peptide : ↑.
3. 72 hour fasting test (Gold standard).
4. Endoscopic USG (EUS) : Best to localize.

Rx : Enucleation.

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 Hepatobiliary and Minimally Invasive Surgery 131

GASTRINOMA ----- Active space -----

• Tumour of G cells (Gastrin producing) Zollinger Ellison Syndrome (±).
• M/c pancreatic tumour in MEN 1 Syndrome.
• Malignant : 70%.

Clinical Features :
1. Recurrent ulcers.
2. Ulcers at atypical locations.
3. Diarrhea, malabsorption.

Investigations :
1. S. gastrin >1000 pg/ml : Diagnostic.
2. S. gastrin <1000 pg/ml Secretin/pentagastrin stimulation test

om
↑s. Gastrin by >200 pg/mL Gastrinoma + .

l.c
ai
gm
3. EUS : For localisation.
7@
Passaro’s Triangle :
a4
tiy
ga

Boundaries Contents
ar

1. CHD & Cystic duct junction.

ik

1. 1st part of duodenum (D1).

sh

2. D2-D3 junction.
2. Head of pancreas.
va

3. Junction of head & neck

ur

3. Lymph nodes.
with body of pancreas.
|
w

Gastrinoma triangle/
ro

Significance : Passaro’s triangle

ar
M

• M/c site for gastrinoma : Wall of D1.

©

• Gastrinomas outside Passaro’s triangle : More aggressive.

Management :
1. Surgery.
2. Chemotherapy : If malignant.

GLUCAGONOMA
Clinical features : 4 Ds
1. DM.
2. Dermatitis.
3. DVT.
4. Depression.

Necrolytic migratory rash

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 132 Surgery

----- Active space ----- Pancreatic Ductal Adenocarcinoma 01:18:26

M/c exocrine tumour of pancreas.

Risk Factors :
• Smoking.
• Obesity.
• DM.
• African American.
• Alcohol.
• Hereditary pancreatitis : PRSS gene.
• Tropical calcific pancreatitis : SPINK I gene.
• Chronic pancreatitis.
• Syndromes : Peutz Jeghers syndrome (>100 times risk).

om
l.c
ai
Genetic mutations : KRAS (1st & m/c) CDKN2A SMAD4 P53(Last).

gm
Clinical Features : 7@
a4

Presents with periampullary cancers.

tiy
ga

Common C/f : Obstructive jaundice with palpable GB (Courvoisier’s law).

ar
ik
sh

Types :
va
ur

1. Head of pancreas (M/c).

|

2. Ampullary variety : Waxing & waning of jaundice + Melena.

w
ro

3. Distal CBD cholangiocarcinoma.

ar
M

4. Duodenal adenocarcinoma.
©

Investigations :
1. CECT : IOC.
2. MRCP : Double duct sign.
3. Duodenography : Frostberg reverse 3 sign.
4. PET-CT : IOC for staging. PD
CBD
5. Ca 19-9 : Tumour marker.

Double duct sign

Treatment :
1. Resectable tumour : Head of pancreas Whipple’s surgery (Pancreatic
duodenectomy).
2. Chemotherapy :
• Gemcitabine + Capecitabine.
• mFOLFIRINOX : Better results.
Surgery Revision • v4.1 • Marrow 8.0 • 2025
 Hepatobiliary and Minimally Invasive Surgery 133

Whipple’s surgery : ----- Active space -----

Incision : Rooftop/Chevron incision.
Pylorus preserving Whipple’s : ↓Chances of dumping syndrome
Structures removed 3 Anastomoses Complications
1. Altered gastric emptying (M/c)
2. Hemorrhage.
• CBD 1. Gastrojejunostomy. (GJ) 3. Pancreatic fistula.
• GB 2. Pancreaticojejunostomy (PJ) 4. wound infection.
• Head of pancreas 3. Choledochojejunostomy (CJ) 5. Anastomotic leak :
- M/c cause of death.
- M/c site : PJ.

Intraductal Papillary Mucinous Neoplasm (IPMN)

CJ

om
l.c
Ohashi’s triad :

ai
GJ Fish mouth appearance

gm
PJ + Mucin from ampulla
7@
+ Dilated main pancreatic duct.
a4
tiy
ga

ERCP
ar

Whipple’s anastomoses
ik
sh
va

Laparoscopy 01:23:53
ur
|
w

Minimally invasive surgery.

ro
ar
M

Pneumoperitoneum :
©

• Gas : CO2 (Non combustible) • Pressure : 10-14 mmHg.

Physiological Effects :
1. Sinus Bradycardia :
• Due to peritoneal stretching Vagal stimulation.
• M/c arrythmia in laparoscopy.
2. Reflex tachycardia & ↓CO, ↓SBP : D/t IVC compression.
3. ↑Airway resistance & PEEP : As diaphragm is pushed up ↓Thoracic volume.
4. ↓Urine output : D/t compression of renal artery.
5. ↑Intracranial pressure.

Instruments :
1. Veress needle :
• Used in closed method to create pneumoperitoneum.
• Has bevelled edge.
Veress Needle
Surgery Revision • v4.1 • Marrow 8.0 • 2025
 134 Surgery

----- Active space ----- 2. Sharp trocar :

- Inserted after Veress needle.
- Used to insert other instruments.
- If bowel injury : Keep in place &
convert to open procedure. Trocar

3. Hasson’s Cannula : 4. Optiport/Visiport :

For open method (Hasson’s) - Transparent end Prevents
- Can hold camera bowel
- Clear ends injury.

om
5. Laparoscopic instruments :

l.c
ai
gm
7@
a4
tiy
ga
ar
ik
sh

• Has insulation (Black coating).

va
ur

• If insulation breaks Capacitance coupling Bowel injury (Burns).

|
w

(Prevention : Plastic trocar)

ro
ar

Other Minimally Invasive Procedures :

M
©

1. SILS :
• Single incision Laparoscopic surgery
• Multiple instruments can be inserted from a
single post.
2. Robotic surgery : Da vinci system
• Advantages :
SILS port
i. Finer dissection.
ii. Better movement (7 degrees of freedom).
iii. Tremor reduction.
• Disadvantages :
i. Expensive.
ii. Loss of tactile feedback.
3. NOTES : Natural Orifice Transluminal Endoscopic Surgery
• Eg : POEM, TATME, TOGA.
• No scar over abdomen.
Surgery Revision • v4.1 • Marrow 8.0 • 2025
 Urology : Part 1 135

UROLOGY : PART 1 ----- Active space -----

Kidney Disorders  00:01:01

Duplication Of Ureteric System :

Wiegert meyer rule :
• Ureter draining upper pole Inserted Ectopic site : Infero-medial to normal.
• Ureter draining middle + lower pole Normal.
1
Ectopic sites :
• M Urethra.

om
• F Vagina (C/f : Urinary dribbling).

l.c
2

ai
gm
Ix : Intravenous Urogram (IVU)
• Dye : Urograffin. 7@
a4

• Drooping lily sign :

tiy
ga

Duplication + malrotation of pelvis.

ar
ik
sh

Mx : Re-implantation of ureter.
va

IVU : Drooping lily sign IVU : Duplicated ureter

ur
|
w

Polycystic Kidney Disease (PCKD) :

ro
ar

Types :
M
©

Infantile PCKD Adult PCKD

Autosomal recessive. Autosomal dominant.
PKHD on Chr 6. PKD 1 on Chr 16/PKD 2 on Chr 4.
Not compatible with life. Compatible with life.
• Hypertension : 3rd decade of life (M/c feature).
Death due to hepatic fibrosis. • Abdominal mass, hematuria, multiple cysts.
• Cysts ↑ size Symptomatic +

Extrarenal manifestations :
1. Liver cysts (M/c).
2. Cysts in spleen, pancreas or lungs.
3. Colonic diverticulosis.
4. Mitral valve prolapse.
5. Berry aneurysms in circle of willis.
Rupture
Subarachanoid haemorrhage (SAH) Polycystic Kidney

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 136 Surgery

----- Active space ----- Ix : USG, can be detected on prenatal USG.

Mx :
Note : No role of cyst
• Transplant.
deroofing Sx.
• Dialysis.

Horseshoe kidney :
• Lower poles (Both kidneys) Ascent restricted by :
. fused at L3-L4 level Inferior mesenteric artery.
• Adrenal glands : Normal position.
(D/t separate embryogenesis).
• IVU : Flower vase/hand shake sign.
Mx :
• Pyeloplasty (If hydronephrosis/malrotated pelvis).

om
• Do not cut fused portion (Risk of devascularization).

l.c
Horseshoe kidney

ai
gm
Hydronephrosis : 7@
Intermittent partial/complete blockade of urine flow
a4
tiy
ga

Aseptic dilatation of pelvi-calyceal system.

ar
ik

Unilateral hydronephrosis :
sh
va

Causes :
ur
|

Intraluminal Intramural Extraluminal

w
ro

1. Stone disease : 1. PUJ obstruction : 1. Aberrant renal vessel :

ar

M/c cause • M/c cause of congenital • Usually U/L; never cut it.
M
©

of acquired hydronephrosis. • Mx : Pyeloplasty.

hydronephrosis. • Adynamic obstruction. 2. Advanced cancers :
• IVU : Clubbing of calyces + Colorectal, cervical, prostate.
• Sx : Anderson Hynes Pyeloplasty
2. Sloughed 2. Ureterocele : 3. Retroperitoneal fibrosis
papillae • IVU : Cobra head/Adder head sign + (Ormond’s disease) :
(Ureteric terminal ends dilated). • Maiden waist deformity
• Sx : Ureter re-implantation. (Medial indrawing of ureters).
3. Transitional cell carcinoma pelvis/ureter : • Causes :
Goblet sign on IVU. - Idiopathic.
- Post radiotherapy.
- Drug induced : Methysergide.
• Mx : DJ Stenting.
4. Retrocaval ureter :
• Right ureter goes behind IVC.
• Reversed J/Fish hook sign.

Surgery Revision • v4.1 • Marrow 8.0 • 2025

 Urology : Part 1 137

----- Active space -----

Goblet sign Cobra head sign Maiden waist Fish hook/

deformity Reverse-J sign
Bilateral hydronephrosis :
Causes :
• Any U/L cause of both sides. • Posterior urethral valves.

om
• BPH. • Phimosis.

l.c
• Bladder outlet obstruction. • Meatal stenosis.

ai
gm
(Eg : Urethral stricture)
7@
Ix :
a4
tiy

• IVU : Clubbing of calyces +

ga

• Renal isotope scans

ar
ik
sh

IVU (PUJ obstruction) :

va

Detect scarring : Detect kidney Clubbing of calyces

ur
|

Technetium-99m Dimercapto function

w
ro

Succinic acid (DMSA) scan Best

ar
M

Diethylene triamine Mercaptoacetyl

©

pentaacetate triglycine
(DTPA) scan (MAG3) scan
Renal Stones  00:12:40

Types :
Stones Features Image
• M/c type, radio-opaque.
• Formed in acidic urine.
• Types :
1. Monohydrate :
Calcium - Dumb-bell shaped.
oxalate - Very hard.
2. Dihydrate :
- Envelope shaped.
- Spiculated margins (Mulberry stones) :
Present early (Pain + hematuria).

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 138 Surgery

----- Active space ----- Stones Features

• Proteus urine infection.
Triple phosphate/
• Radio-opaque.
Struvite/Staghorn
• Coffin lid shaped.
(Calcium ammonium
• Urine : Alkaline.
Mg P04 )
• Smooth surface, large size.
• Radio-opaque.
• Very hard : Crystaline lattice.
• Hexagonal.
Cystine stones
• Difficult to break by ESWL.
• Seen in cystinuria.
• Mx of recurrent stones : d-Penicillamine.
• M/c radiolucent stones.
• Crystals : Glass shreds.
Uric acid • Seen in : •

om
- Tumour lysis Syndrome.

l.c
- Gout.

ai
gm
Rare stones :
7@
• Xanthine
a4
tiy

• Triamterene Radiolucent
ga

• Indinavir stone (On anti-retroviral Rx)

ar
ik
sh

Presentation :
va
ur

• Pain (M/c) Staghorn calculus

|
w

Pelvis : Radiating from loin groin.

ro
ar

Upper & mid ureter : Iliohypogastric nerve.

M

Fixed renal pain. Colicky pain

©

Lower ureter : Ilioinguinal nerve.

(At renal angle) (Based on stone site)
Impacted intramural portion :
• Hematuria Strangury (Intense pain or urge to pass
• Hydronephrosis. urine Few drops of bloody urine + )
• Dietl’s crisis :
Stone blocks Pain + palpable mass Stone Large quantities
urine flow (Dilated kidney) shifts of diluted urine
Mx : Ix :
Dietary advise (Recurrent calcium oxalate stones) : NCCT (IOC).
• ↓Fat content.
• ↑Calcium intake.
• ↑Pyridoxine dose.
• Cholestyramine (Binds oxalate in gut ↓Incidence).

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 Urology : Part 1 139

< 5mm : No active intervention. ----- Active space -----

Based on stone size 5-6 mm, symptomatic : Medical Mx (1st line) Fails ESWL.
> 2cm : PCNL.

Medical Mx : Tamsulosin (α blocker) Relaxes distal ureteric muscle.

Fails
Extracorporeal shock wave lithotripsy (ESWL) :
• Principle : Ultrasonic waves Fragments stone Passed in urine.
• Complications : Pain (M/c). Ureter
Hematuria
Clogged with
Stone street/Steinstrasse stone fragments
UTI
Contraindications

om
l.c
• Pregnancy • Obese

ai
• Uncontrolled bleeding disorder • Very hard stones

gm
• Cardiac Pacemaker (Cysteine > Calcium oxalate monohydrate)
• Stone size > 1.5 cm • Obstructed system
7@
a4

• Children • Lower calyx Stone

tiy
ga
ar

Fails or C/I
ik
sh

PCNL RIRS/URS
va
ur
|
w
ro

Percutaneous nephrolithotomy (PCNL) :

ar
M

• Indications Stones >2cm.

©

Lower pole stone with anatomy unfavourable for SWL.

Failed ESWL/RIRS for renal calculi.
Staghorn calculi.
• Mini PCNL : Children; <22 F tracks used.
PCNL
Retrograde intra renal surgery (RIRS) :
Indications :
a. Stones <2 cm.
b. Lower pole.
c. Obesity
d. Musculoskeletal deformities.
RIRS

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 140 Surgery

----- Active space ----- Ureteroscopic removal of stones (URS) :

Dormia
basket

Basket Opened Stone enclosed, B/L Double J (DJ) stents :

introduced ready for • Inserted by cystourethroscope.
past stone withdrawal • Facilitates passage of stone fragments.

om
Bladder Stones & VUR 00:22:39

l.c
ai
Bladder Stones :

gm
M/c : Children. 7@
a4
M/c stones : Mixed urate.
tiy

Mx :
ga
ar

1st line : Perurethral cystolithotomy.

ik
sh

If C/I d/t :
va

• Urethral stricture.
ur

• Bladder diverticulae.
|
w

Bladder stone
Suprapubic cystolithotomy
ro
ar

Vesicoureteric reflux :
M
©

Grades :
Grade 1 : Reflux into non dilated ureter.
Grade 2 : Reflux into pelvis but no distension.
Grade 3 : Reflux with mild distension.
Grade 4 : Blunting of calyces/tortuous ureter.
Grade 5 : Severe distension of ureter along
with loss of papillary impressions.
Ix : Micturating cystourethrogram (MCU). MCU : VUR
Rx :
• Grade 1, 2, 3 : Prophylactic antibiotics.
(D/t recurrent UTIs)
• Grade 4, 5 : Prophylactic antibiotics Sub ureteric
Do not recover Teflon injection
STING procedure.
(Prevent urinary reflux) STING procedure
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 Urology : Part 1 141

Renal Infections 00:25:35 ----- Active space -----

RENAL TUBERCULOSIS
2° infection d/t hematogenous spread.
Presentations :
Ulcers Caseous necrosis Calcification (Putty/cement kidney)

Perinephric
abscess
Perinephric abscess
Damaged/ghost calyx Kerr's kink
Pseudo calculi
Papillary ulcer
(Earliest)

om
l.c
ai
gm
7@
Putty kidney
a4

Stricture
tiy

Shortening of ureter
ga
ar

Golf-hole ureteric orifice

ik

(Orifice remains open)

sh

Golf-hole
va

Thimble bladder ureteric orifice

ur

(Heal with fibrosis)

|
w
ro
ar

Urethroscopy
M
©

Clinical features : Hematuria, pain, mass, weight loss.

Ix :
• Urine examination : Sterile pyuria (Pus cells + , culture - ).
• Confirmatory : Centrifuge 3 morning urine samples ZN Staining.
Rx :
1. Medical Mx : Anti-tubercular treatment (ATT).
2. Sx :
- Perinephric abscess : Drainage.
- Ureteric kinking : DJ stenting. Bladder flap
- Golf hole ureteric orifice : Ureteric re-implantation.
- Thimble bladder : Augmentation cystoplasty.
- Lower part of ureter : Boari flap repair for lower part of ureter. Boari flap repair

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 142 Surgery

----- Active space ----- PYELONEPHRITIS

Types :
Emphysematous pyelonephritis Xanthogranulomatous pyelonephritis
Causative organism E.coli Proteus
Commonly seen In immunocompromised, DM. Middle aged females, in DM.
Symptoms Fever, pain Flank pain, pyrexia and abdominal mass.
Gas in and around kidney Non-functioning kidney,
calculi, low density masses

Low density
IOC : CECT masses +
Stones

om
l.c
Antibiotics + drainage

ai
Fails

gm
Mx Subcapsular nephrectomy
Nephrectomy. 7@
a4
tiy

Renal Tumours
ga

00:32:24
ar
ik

BOSNIAK CLASSIFICATION FOR RENAL CYSTS

sh
va
ur
|
w
ro
ar
M
©

Class 1 2 2F 3 4
Minimally complex
Description Simple cyst Minimally complex Indeterminate Clearly malignant
(Need follow up)
USG/CT Partial Partial/Total
work up Nil
Follow up nephrectomy nephrectomy
% risk of
malignancy 0% 5% 50% 100%

BENIGN RENAL TUMOURS

Angiomyolipoma :
Benign tumour : 5-6th decade of life.
0rigin : Perivascular epitheloid cells (EPC).

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 Urology : Part 1 143

C/f : ----- Active space -----

• Asymptomatic (Usually).
Lenk’s triad
• Wunderlich syndrome :
• Mass
- Massive retroperitoneal hemorrhage. • Hypotension
- Lenk’s triad. • Flank pain

Ix : CECT (IOC).
Fat
Mx :
• <4cm + asymptomatic : Observation. CECT : Angiomyolipoma (Bosniak : 3)
• >4cm + symptomatic : Partial nephrectomy or nephron sparing Sx.
• Bleeding + : Angioembolisation F/b Partial nephrectomy.

Oncocytoma :
M/c benign tumour of kidney.

om
l.c
HPE :

ai
• Eosinophilic cytoplasm

gm
Cell rich in mitochondria.
(Plant like cell, raisin like nucleus) 7@ HPE : Oncocytoma
• Tan brown appearance.
a4
tiy

• Cytokeratin - (Differentiates from chromophobe RCC).

ga
ar
ik

Etiology : Sporadic > Familial (Common in Birt Hogg Dube Syndrome).

sh
va

C/f : Asymptomatic (Usually).

ur

Ix : CECT (IOC) Central stellate scar.

|
w

Mx <4cm : Observation.
ro
ar

>4cm : Partial nephrectomy.

M
©

Note : CECT : Central stellate scar

Birt Hogg Dube Syndrome : Oncocytomas, Chromophobe RCC, Fibrofolliculomas and Trichodiscomas.
MALIGNANT RENAL TUMOURS
Renal cell carcinoma (RCC) :
Risk factors :
1. DM 4. ↑Protein intake.
2. Hypertension. 5. Thorotrast exposure.
3. Tobacco intake.
Types of RCC :
Clear cell RCC Papillary RCC Chromophobe RCC
Loss of multiple
Genetics 3p & 6p deletion CMET mutation
chromosomes (1, 2, 6, 10, 13)
Associated Von-Hippel-Lindau Hereditary papillary
Birt Hogg Dube syndrome
conditions syndrome RCC syndrome
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 144 Surgery

----- Active space ----- Clear cell RCC Papillary RCC Chromophobe
Arises Proximal convoluted PCT > Distal convoluted tubule
-
from tubule (PCT) (DCT)
Psammoma bodies
Plant-like cells and
HPE Clear cells • Seen : Long term dialysis.
raisin-like nucleus.
• Foci of dystrophic calcification.
Other • Best prognosis.
M/c type -
features • Cytokeratin + .
Note :
• Collecting duct RCC has worst prognosis.
• Medullary RCC : A/w sickle cell anemia.

Psammoma
bodies

om
Plant-like cells +

l.c
raisin-like nucleus

ai
gm
7@
a4
tiy
ga

Papillary RCC Chromophobe RCC

ar
ik

C/f :
sh
va

• Hematuria (M/c presentation) + pain + mass : Symptom triad.

ur

• Paraneoplastic syndrome : ↑ESR (M/c).

|
w
ro
ar

Endocrine Nonendocrine
M

• Hypercalcemia.
©

• Hypertension. • Amyloidosis.
• Polycythemia. • Anemia.
• Nonmetastatic hepatic dysfunction : Stauffer syndrome. • Vasculopathy.
• Galactorrhea. • Coagulopathy.
• Cushing’s syndrome.
Note :
Stauffer Syndrome : IL-6 mediated, labs (↑s. bilirubin,↑ALP) Improves after Sx.
Ix : CECT (IOC).

CECT: Renal cell carcinoma

(Restricted to upper/lower pole of kidney)
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 Urology : Part 1 145

Staging of RCC : ----- Active space -----

Stage Definition Subdivision

Tumor stage
TO No evidence of primary tumor -
<7 cm in greatest dimension, 1a : <4 cm.
T1
confined to the kidney 1b : >4 cm and <7 cm
>7 cm in greatest dimension, 2a : ≥7 cm and <10 cm
T2
confined to the kidney 2b : >10 cm
3a : Tumor extends into renal vein
Extends into major veins or branches, or invades perirenal
perinephric tissues but not and/or renal sinus fat.
T3 into the ipsilateral adrenal 3b : Tumor extends into the
gland or beyond Gerota subdiaphragmatic inferior vena cava.
fascia. 3c : Tumor extends into the

om
supradiaphragmatic inferior vena cava.

l.c
Tumor invades beyond

ai
gm
the Gerota fascia and/or
T4 -
contiguous extension into the 7@
a4
ipsilateral adrenal gland.
tiy

Regional lymph nodes

ga
ar

N0 No regional lymph node metastasis

ik
sh

N1 Metastasis to regional lymph nodes

va
ur

Distant metastasis
|

M0 No distant metastasis
w
ro
ar
M

Mx :
©

1. Partial nephrectomy :
Indications Relative indications
• T1 tumours (< 7 cm). RCC in a kidney where other
• Restricted to poles. kidney is affected by :
• B/L RCC. • Hydronephrosis.
• RCC in solitary functioning kidney. • Stones.

2. Radical nephrectomy :
Structures removed :
• kidney • Gerota’s fascia.
• Para-aortic lymph nodes. • Ureter till the brim.
• ± I/L adrenal gland.
3. Cryoablation of renal tumours : T1a RCC (<4cm).
Tumour freezing (-20 degrees) in Elderly patients.
Advanced/metastatic tumours.
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 146 Surgery

----- Active space ----- Wilms Tumour :

• M/c paediatric renal malignancy. Note : M/c abdominal malignancy
• 2 m/c abdominal malignancy in children.
nd
in children is Neuroblastoma.
C/f :
• Mass : Does not cross midline (Help differentiate from Neuroblastoma).
• Hematuria.
Etiology : Sporadic > Familial.

Familial syndromes with B/L wilm’s tumour

• Beckwith Wiedemann syndrome.
• Denys Drash Syndrome.
• WAGR syndrome :
- Wilm’s tumor

om
- Anirdia.

l.c
ai
- Genitourinary malformations.

gm
- Mental retardation. 7@
a4
tiy

IOC : CECT (Help differentiate from neuroblastoma).

ga
ar

National wilms tumour Staging (NTWS) :

ik
sh

Stage V : B/L wilms tumour.

va
ur
|
w
ro

CECT : Wilms tumour

ar

Treatment Of RCC vs. Wilm’s Tumour :

M
©

RCC Wilm’s tumour

Resistant Sensitive
Chemo/Radio Rx
(Surgery : Only Rx of choice) (Used along with Sx)
Surgical principles Same
Prognostic factor Pathological stage Tumour histology

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 Urology : Part 2 147

UROLOGY : PART 2 ----- Active space -----

Prostate 00:00:37

Zones of Prostate :
• Transitional zone : M/c involved in BPH.
• Peripheral zone : M/c involved in cancer.

Corpora Amylacea :
• Lamellated eosinophilic stones.
• Precursor for prostatic stones (CaPO4 ).

om
l.c
ai
gm
7@
a4

LOWER URINARY TRACT SYMPTOMS (LUTS)

tiy
ga

Divided into voiding & storage symptoms. Corpora amylacea

ar
ik
sh

Voiding Storage
va

• Hesitancy.
ur

• Frequency (Earliest & M/C).

•
|

Poor flow.
• Nocturia.
w

• Intermittent stream.
ro

• Urgency.
ar

• Post-void dribbling.
• Urge incontinence.
M

• Sensation of poor bladder emptying.

©

• Nocturnal incontinence (Enuresis).

• Episodes of near retention.
Workup :
1. Digital rectal examination (DRE) :
• BPH : Rubbery, mobile mucosa.
• Cancer : Hard, fixed mucosa.
2. USG KUB : Prostatic volume, upper urinary changes, residual urine.
3. Prostate specific antigen (PSA) :
Value (At 50 - 69 yrs) Inference Mx
Normal, • No biopsy needed.
0 - 3 ng/ml
BPH • BPH : Start Mx.
Transrectal ultrasound (TRUS) guided biopsy :
BPH, • Minimum 12 cores to be taken.
>3 - 4 ng/ml cancer • ↓LA.
• Posterior lobe.
Prostatitis Antibiotics
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 148 Surgery

----- Active space ----- 4. Uroflowmetry :

• >15 ml/sec : N . Transperineal biopsy
• 10 - 15 ml/sec : Equivocal. • Done under GA.
• <10 ml/sec : Low flow. • Done for anterior lobe biopsy.

Benign Prostatic Hyperplasia (BPH) 00:05:13

Components :

Dynamic : Static :
↑Smooth muscle tone. Stromal hyperplasia.
Management :
Medical Mx : α-blockers + 5α reductase inhibitors.

om
1. α-blockers : Tamsulosin.

l.c
ai
• Fast acting.

gm
• ↓Muscle tone (Action on dynamic component).
a4
7@
2. 5α reductase inhibitors :
tiy

• Slower acting but sustained effect (In 6 months : 50% ↓ in PSA).

ga
ar

• ↓Gland size (Action on static component).

ik
sh
va

Surgical Mx :
ur

1. TURP (Transurethral resection of prostate).

|
w

2. TULIP (Transurethral laser incision of prostate).

ro
ar

3. Nd YAG (M/c).
M
©

4. KTPA (Best laser).

Indications for surgical Mx :

1. Hydronephrosis/upper urinary tract changes.
2. Recurrent UTI.
3. Urinary retention.
4. <15 ml/sec on uroflowmetry.
5. Complications : Hematuria, stones, bladder diverticulae.

TURP Prostatic
urethra
Irrigation fluid :
1. 5% dextrose. Sphincter
2. Distilled water.
3. Isotonic glycine (M/c used).
4. Normal saline : Only with bipolar cautery. Verumontanum
(Distal limit of resection)
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 Urology : Part 2 149

Complications : ----- Active space -----

1. Retrograde ejaculation (M/c) :
D/t bladder neck injury.
2. Hemorrhage : D/t Badenoch arteries.
3. Clot retention :
Prevented by using 3-way Foley’s catheter.
4. Incontinence : D/t resection beyond verumontanum Bladder injury.
5. Water intoxication/dilutional hyponatremia/TURP syndrome :
- M/c with distilled water/5% dextrose.
- Isotonic glycine usage ↓Incidence.
- During Sx : Urethra Water diffusion Blood vessels Hyponatremia.
- Altered sensorium + Headache (Few hours post-op).

om
- Management :

l.c
• Mild (120 - 130 mEq/L) : Water restriction.

ai
gm
• Severe (<120 mEq/L) : 3% hypertonic saline (≤8-10 mEq/L/day gradually).
7@
a4

Note : Rapid, >8-10 mEq/day correction Central pontine demyelinosis.

tiy
ga

Prostatic Cancer
ar

00:12:04
ik
sh
va

Risk Factors :
ur

• Increasing age (M/c >5th decade). Indications for bone scan

|
w

• Increased testosterone. 1. PSA >10 ng/ml.

ro
ar

• African American. 2. Gleason >7.

M
©

• BRCA 2 > BRCA 1. 3. Symptomatic.

• Obesity.
Spread :
Mets
• Local.
• Lymphatic (1st : Obturator LN).
• Distant mets : Bones (Lumbar vertebrae).
- Osteoblastic > Osteolytic.
- Travels via Batson’s plexus.
Investigations :
IOC : TRUS guided biopsy. Bone scan
Gleason’s score :
• Based on M/c gland type + 2nd M/c gland type.
• Each type is graded ( 1 Well differentiated to 5 Poorly differentiated)
& summed.
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 150 Surgery

----- Active space ----- Risk group ISUP grade group Gleason score
Low 1 ≤6
Intermediate (Favourable) 2 7 (3+4)
Intermediate (Unfavourable) 3 7 (4+3)
High 4 8
High 5 9-10

Management :
T1, T2a

Radical prostatectomy Observation/surveillance

Indications : Indications :
• <70 yrs. • >70 yrs.
• Life expectancy : >10 years. • Life expectancy : <10 years.

om
• G3, G4 tumours. • G1, G2 tumours.

l.c
ai
Structures removed :

gm
• Prostate.
• Iliac + obturator lymph nodes. 7@
a4

• Seminal vesicles.
tiy
ga
ar

T2b, T3, T4
ik
sh
va

• <70 yrs. • >70 yrs.

ur
|

• >10 years of life expectancy. • <10 years of life expectancy.

w

• G3, G4 tumours. • G1, G2 tumours.

ro
ar
M

Brachytherapy (I125, Pd103 ) Brachytherapy ±

©

Androgen deprivation therapy (ADT).

No residual disease Residual disease +

Surveillance. Radical prostatectomy.

Metastasis

First line : ADT Brachytherapy

Surgical : B/L orchidectomy. Medical : LHRH agonists (Zoladex : Goserelin, buserelin)

Antiandrogens (Flutamide, abiraterone : Zytiga).

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 Urology : Part 2 151

Hormone resistant disease : ----- Active space -----

• Chemotherapy : Cabazitaxel, paclitaxel.
• Radiotherapy.
• Sipuleucel-T : T-cell vaccine (Provenge).
• Hormone resistant bony mets : Radium 233 (α rays).

Foley’s Catheter 00:19:07

French (Fr) : Outer circumference.

Normal Foley’s : 3-way Foley’s :
Colours :
• White : 12 Fr.
• Green : 14 Fr.
Balloon port
• Orange : 16 Fr.

om
Urine drainage
• Red : 18 Fr.

l.c
Irrigation port

ai
2 channels • 3 channels.

gm
Types of Foley’s : • Used in clot retention.
7@
• Rubber Foley’s : 25-30 days.
a4
tiy

• Silicone Foley’s : 90 days (3 months).

ga
ar

Note : Stuck foley’s USG guided suprapubic puncture.

ik
sh
va

Bladder Trauma
ur

00:20:12
|
w
ro

Extraperitoneal rupture Intraperitoneal rupture

ar
M

2° to blunt/penetrating trauma to
2° to pelvic fracture
©

a full bladder
A/w deep perineal hematoma A/w peritonitis, syncopal attack
IOC : CT urography
Mx : Foley’s/suprapubic catheter Mx : Laparotomy + Bladder repair MCU
(SPC) x 7 days in 2 layers + Foley’s/SPC

Bladder Cancer 00:21:39

Types :
1. Transitional cell carcinoma : 2. Squamous cell carcinoma :
• M/c overall. • M/c in Africa.
• Etiology (3Cs) : • Etiology (2S) :
- Chemical. - Smoking.
- Cyclophosphamide. - Schistosomiasis.
- Cigarettes.

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 152 Surgery

----- Active space -----

3. Adenocarcinoma :
• Rare.
• Develops at persistent urachus.
Clinical Features :
Gross painless hematuria. Cystoscopy
Investigations :
1. USG KUB : Shows clots/growth inside bladder.
2. Urine cytology : To look for malignant cells in urine.
3. Cystoscopic biopsy (IOC) : TURBT f/b HPE.
4. MRI : For staging.
TNM Staging :

om
Ta : Non invasive papillary carcinoma

l.c
Tis : Carcinoma in situ Superficial.

ai
gm
T1 : Above muscle layer
7@
a4
Management :
tiy

TURBT (Trans Urethral Resection of Bladder Tumor)

ga
ar
ik
sh

Muscle invasive Non muscle invasive

va
ur
|

T2 : Surgery T3 , T4 : Chemo Surgery Ta Tis T1

w
ro
ar

Observation/single dose of Intravesical BCG Intravesical

M
©

intravesical mitomycin C (Immunotherapy) chemotherapy/BCG

(Chemotherapy) x 6 cycles
• Check cystoscopy every 3 months : To look for recurrence.
• Nuclear matrix protein (NMP) : Urinary marker.
Surgery

Radical cystectomy Partial cystectomy

Removal of : Bladder + Iliac LN + For small tumor restricted to domes

Obturator LN + (In females : Urethra + TAH) + & not involving the ureteric orifice
Urinary diversion

Continent Non continent Obsolete d/t :

• ↑Risk of cancer
Neobladder (Ileum) 1. Ureterosigmoid anastomosis. • Recurrent UTI
2. Ileal conduit (M/c used) : • Hyperchloremic hypokalemic
Ureters Ileostomy. metabolic acidosis
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 Urology : Part 2 153

Urethra 00:27:42 ----- Active space -----

Length :
• Female : 3-4 cm. Prostatic
• Male : 18-21 cm. Membranous
Bulbar
Parts :
Penile
• Proximal : Membranous + prostatic urethra.
• Distal : Penile + bulbar urethra. Retrograde urethrogram (RGU)

Hypospadias 00:28:46

Features : Types :
• M/c congenital urogenital anomaly.

om
• Ventrally placed urethral opening.

l.c
• A/w micropenis & undescended testis.

ai
gm
• M/c & most mild type : Glanular.
7@
• Most severe : Perineal. More
a4
tiy

Clinical Features : severe

ga

• Downward directed urine stream.

ar
ik
sh

• Downward bending of penis (Chordee).

va

• Infertility.
ur
|

• O/E :
w
ro

- Urethral opening in lower aspect.

ar
M

- Hooded prepuce.
©

Management :
Steps of Sx :
Orthoplasty Urethroplasty Glanuloplasty Skin cover.
(Chordee (Placement of urethral
correction) opening at normal position)

Surgeries :
1. Single stage procedures :
• Distal hypospadias : Mustardee, Mathieu. Hypospadias
• Mid hypospadias : Snodgrass, TIP.
2. Double staged procedure : Proximal hypospadias.
Thiersch duplay, Dennis brown.
Note : Circumcision is contraindicated as foreskin is used for reconstruction.
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 154 Surgery

----- Active space ----- Ectopia Vesica 00:31:47

• AKA bladder extrophy.

• Anterior abdominal wall & anterior wall
of bladder is deficient below umbilicus.

Clinical features :
• Urine dribbling from bladder.
• Undescended testis.
• Bifid clitoris.
• Pubic diastasis.

Urethral Trauma 00:32:26

om
Types :

l.c
ai
Anterior urethral injury Posterior urethral injury

gm
Injured part Penile/bulbar urethra 7@
Membranous/prostatic urethra
a4
Mode of injury Direct trauma/straddle injury Secondary to pelvis fracture
tiy

Superficial perineal hematoma • Deep perineal hematoma

ga
ar

around penis/scrotum • Vermooten sign Floating prostate

Features
ik
sh

• Blood at tip of meatus

va

• Inability to pass urine

ur
|
w

Management :
ro
ar

IOC : RGU.
M

Treatment :
©

Suspected trauma

Bladder full Bladder not full :

Wait for bladder to fill RGU : Membranous
Fails urethral injury
SPC One trial of micturition
Note : Do not pass Foley’s.

Complications :
Urethral stricture

Short incomplete stricture Short complete stricture Long complete stricture

VIU : Visual OIU : Excision + End to end Excision + urethroplasty

internal Optical internal anastomosis with buccal mucosal graft
urethrotomy urethrotomy
Urethral stricture
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 Urology : Part 2 155

Fracture Shaft of Penis : ----- Active space -----

Clinical features :
• Tear in the corpora cavernosa of penis.
• Usually seen in erect penis (During sexual activity).
• Popping sound f/b pain.
• Eggplant deformity of penis.
Eggplant deformity
Mx : Hematoma evacuation & penile repair.

Posterior Urethral Valve 00:36:03

Young’s classification :
Type 1 (M/c) : Anteroinferior to verumontanum.
Type 2
Rare.
Type 3 (Cobb’s collar)

om
l.c
ai
Clinical features : MCU

gm
Male child with recurrent UTI.
7@
a4

Investigation :
tiy
ga

1. MCU
Keyhole sign.
ar

2. USG
ik
sh
va

Mx : Fulguration of the valve.

ur

USG
|
w

Phimosis
ro

00:37:28
ar
M

Inability to retract foreskin.

©

Clinical features :
• Asymptomatic.
• Symptomatic :
- Ballooning of foreskin.
- Balanoposthitis.
- Difficult micturition.
Mx : Circumcision.

Paraphimosis 00:37:50

Failure to reposition foreskin after

catheterisation Constriction ring around the penis.
Mx : Conservative reduction Fails Dorsal slit.

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 156 Surgery

----- Active space ----- Peyronie’s Disease & Priapism 00:38:22

Peyronie’s Disease :
Calcific deposition in corpora P enis bends
to one side.

C/F : Pain during intercourse.

Dx : Clinical examination + MRI.
Mx : Intralesional collagenase Clostridium histolyticum (Xiaflex) injection
Fails
Nesbit’s technique/16 dot technique.
Priapism :
• Prolonged erection >4 hours.

om
• Erection >6 hours Ischemia/necrosis of penis.

l.c
ai
gm
Types :
7@
High flow priapism Low flow priapism
a4
tiy

Etiology ↑Blood flow into penis Venous obstruction, M/C

ga

Secondary to : Hypercoagulable states :

ar
ik

• Trauma. • Children
sh

Causes
• Spinal injury. • Leukemia.
va
ur

• Papaverine injection. • Sickle cell anemia.

|

Pain Painless Painful

w
ro

Penile ABG Oxygenated blood Deoxygenated blood

ar
M
©

Ix : Angiography for low flow priapism.

Mx : Sedate patient Adrenaline inj. Fails Shunt Sx : G

 rey hack shunt.
(Corporo saphenous)

Penile Cancer 00:40:52

Squamous cell carcinoma.

Premalignant Conditions :
• Bowens disease of the shaft.
• Erythroplasia of Queyrat (Reddish papules).
• Balanitis xerotica obliterans.
• Genital warts : HPV.
• Leukoplakia. Ulceroproliferative lesion

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 Urology : Part 2 157

Jackson Staging : ----- Active space -----

T1 : Skin involved.
T2 : Corpora involved.
T3 : Urethra involved.
T4 : Adjacent structures involved.

Management :
Dx : Biopsy of lesion.
Tumor Mx
A. In situ carcinoma Topical 5-FU/laser
B. Distally placed Partial penectomy (If residual stump : ≥2 cm)
C. Proximally placed Total amputation + Perineal urethrostomy
Lymph node Mx

om
Not enlarged Sentinel lymph node biopsy.

l.c
ai
T3 , T4 Prophylactic superficial inguinal lymph node dissection Total amputation +

gm
Ilioinguinal lymph node clearance
Enlarged 7@
Ilioinguinal lymphnode clearance or radiotherapy
a4
tiy

Undescended Testis 00:44:47

ga
ar

Testicular Descent :
ik
sh

Triggers :
va
ur

1. Differential growth of abdominal wall : Most important.

|
w

2. Hormonal factors.
ro
ar

3. Pull of gubernaculum : Least important.

M
©

Normal descent :
Iliac fossa Inguinal canal Superficial ring Scrotum
(6 months) (7 months) (8 months) (9 months)
Features :
• M/c site : Inguinal canal.
• Right > Left.
• B/L : Cryptorchidism.
Changes Complications
• Decreased volume • T : Trauma
• Increased risk of intra tubular germ cell neoplasm. • E : Epididymoorchitis
• Sertoli cells : More affected • S : Sterility
(Spermatogenesis affected) • T : Torsion
• Leydig cells : Less affected • I : Indirect inguinal hernia (M/c)
(Normal secondary sexual character) • S : Seminoma

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 158 Surgery

----- Active space ----- Consequences (Updated) :

• Men with undescended testis : ↓Fertility (Even after orchidopexy).
• Unilateral cases : Infertility rates same as general population.
• B/L cases operated as adults : Azoospermic & infertile.

Malignancy risk :
• M/c : Seminoma.
• Risk of cancer :
- Sx before puberty : 2-3 times
More than the general population
- Sx after puberty : 5-6 times

Management :
1. B/L non-palpable testis :
β-hCG injection given

om
l.c
ai
gm
No response Increased testosterone
7@
(And increased FSH, LH)
After 5-6 months
a4
tiy

Anorchia. Laparoscopy ± exploration. Intra abdominal testis

ga
ar

2. U/L non-palpable testis :

ik
sh
va

Laparoscopy
ur
|

Orchidopexy
w

Blind-ending vessels Vessels exiting internal ring Intra abdominal testis

ro

• Manoeuvre to bring
ar

the testis down.

M

Monorchia Inguinal exploration Necrosis + • 3-point fixation is done.

©

Excise remnant. Orchidopexy Orchidectomy.

Ectopic Testis : Retractile Testis :

• Testis deviated from normal path of • Normal variant.
descent. • Testis in scrotum but occasionally
• M/c site : Superficial inguinal pouch. jump into inguinal canal.
Mx : Orchidopexy. Mx : Reassurance.

Testicular Torsion 00:50:10

Risk Factors :
• Testicular inversion.
• Torsion of cyst of Morgagni Blue dot sign.
• Undescended testis.
• Bell Clapper testis (High attachment of tunica vaginalis).
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 Urology : Part 2 159

Clinical Features : ----- Active space -----

• Acute scrotal pain & swelling (D/d : Epididymo-orchitis).
• Prehn sign : Pain ↑ (Pain in epididymo-orchitis).
• Deming sign + : Affected testis lies at a higher level.
• Angel sign + : Transversely placed testis.
• 720° twist (Double twist) : Rapid ischemia.

Note :
• Twisting within :
- <6 hours : ≈ 100% salvageable.
- >24 hours : <20% salvageable.
• Prophylactic orchidopexy is done on the other side always.

Hydrocele & Varicocele

om
00:52:42

l.c
ai
HYDROCELE

gm
Accumulation of fluid in tunica vaginalis. a4
7@
M/C : Vaginal hydrocele.
tiy
ga

Types of Vaginal Hydrocele :

ar
ik

1. Primary :
sh
va

• D/t ↓ absorption.
ur

• M/c type.
|
w

• C/f : Transillumination +
ro
ar

- Tense swelling.
M
©

- Testis not palpable separately.

- Brilliantly transilluminant.
2. Secondary : D/t ↑secretion 2° to infections (M/c), trauma & tumours.

Management :
Surgery Smaller sac : Lord’s plication.
Larger sac : Jaboulay’s procedure (Eversion of sac).

VARICOCELE
Features :
• Dilated tortuous pampiniform plexus of veins.

↑Temperature inside testis Infertility.

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 160 Surgery

----- Active space ----- • Left > Right :

- Lt testicular vein is longer.
- Opens at right angles to the left renal vein.
- Sigmoid colon can press on lt testicular vein.
- Lt RCC can grow along the renal vein 2° varicocele.

Clinical Features :
• Majority : Asymptomatic.
• Infertility.
O/E : Bag of worms consistency.

Mx :
IOC : Doppler.
Rx : Percutaneous embolisation of gonadal veins (1st line).

om
l.c
• Percutaneous Rx not possible.

ai
• Recurrence.

gm
7@
Surgical ligation : Microsurgical varicocelectomy.
a4
tiy

Fournier’s Gangrene 00:56:20

ga
ar
ik

Features :
sh

Meleney’s gangrene
va

• Necrotising fasciitis in perineal region

ur

(Synergistic : Aerobic + Anaerobic bacteria). Gangrene extending into

|
w

• M/C seen in immunocompromised patients : the abdominal wall.

ro
ar

- DM.
M
©

- Alcoholics.
• Testis spared d/t dual blood supply.

Management :
1. Aggressive debridement.
2. Broad spectrum antibiotics + IV fluids.
3. Hyperbaric oxygen (Latest).

Testicular Tumours 00:57:45

Most Common :
• In children : Yolk sac tumour.
• Overall : Seminoma.
• In elderly : Lymphoma.

Cannonball metastasis
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 Urology : Part 2 161

Clinical Features : ----- Active space -----

• Painless testicular mass.
• Abdominal lump : Paraaortic lymph nodes (1st draining LN).
• Precocious puberty & masculinisation : Leydig cell tumour.
• Feminisation & gynecomastia : Sertoli cell tumours.

Tumour Markers :
1. AFP
2. β-hCG Included in TNMS staging.
3. LDH
4. PLAP : ↑ in seminoma (Not included in TNMS). Seminoma

Diagnosis :
Suspected case C hevassu manoeuvre : + High inguinal orchidectomy.

om
l.c
High inguinal incision

ai
gm
f/b frozen section.
7@
HPE : Seminoma Lymphocytic infiltration (Good prognosis).
a4
tiy
ga

Note : NO FNAC (Can lead to spread).

ar
ik
sh

Management :
va

Post orchidectomy.
ur
|
w
ro

Stage Seminoma Non seminomatous

ar
M

I One cycle of carboplatin + RT Chemo BEP ± RPLND

©

II Chemo BEP
Chemo BEP + RPLND
III & IV Chemo BEP + RT
BEP : Bleomycin + etoposide + cisplatin.
RPLND : Retroperitoneal LN dissection.

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 162

----- Active space ----- SPECIALITY SURGERY

Graft  00:00:38

Split thickness skin graft (STSG) Full thickness skin graft (FTSG)
Donor site
AKA Thiersch graft AKA Wolfe graft
Epidermis & part of dermis taken Epidermis & whole dermis taken
M/c donor sites : M/c sites :
• Anterolateral thigh • Post auricular skin
• Buttocks • Supra/infraclavicular skin

om
l.c
Only dressing done for donor site after

ai
Donor site sutured after harvesting graft

gm
harvesting graft
Donor site can be reused 7@ Donor site cannot be reused
a4
Recipient site
tiy
ga

Secondary contracture : Primary contracture :

ar

Occurs when graft has been placed on the • Occurs immediately after harvesting graft
ik

recipient bed • Depends on dermis

sh
va

• Cosmetically better
ur

Better survival of graft

• More resistant to trauma .
|
w
ro
ar
M
©

Humby’s knife STSG : Punctate hemorrhages Healed STSG donor site

Meshing of STSG
• ↑surface area of graft
• Prevents hematoma formation

FTSG
Graft Survival :
Methods :
1. Imbibition : 1 - 2 days.
2. Inosculation : 2-4 days (Graft draws nutrients by giving out buds).
3. Neovascularization : >4 days (Anastomosis of graft & recipient).

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 Speciality Surgery 163

Causes of graft failure : ----- Active space -----

1. Seroma/hematoma formation (M/c).
2. Infection.
3. Movement/shearing force.
4. Poor recipient bed :
- Excessive granulation tissue.
- Lack of periosteum.
Graft failure
- Infected recipient bed.
Flaps 00:05:07

Flap has independent blood supply.

Random Flaps :
• Based on dermal vessels.

om
• Eg : V-Y plasty/Z-plasty.

l.c
ai
• Elongation of wound :

gm
Helps in post burn contractures. 7@
Z-plasty
a4
tiy
ga

Rhomboid/Limberg flap :
ar

V-Y plasty
ik

• Type of random flap.

sh
va

• Used in pilonidal sinus.

ur
|
w
ro
ar

Axial Flap : Rhomboid flap

M
©

Based on known blood vessels.

1. Deltopectoral flap : Floor of 2. PMMC : Pectoralis major myocutaneous flap,

mouth reconstruction m/c used in head & neck surgery

3. Abbe Estlander flap : Angle 4. Latissimus dorsi flap :

of mouth & lip reconstruction Based on thoracodorsal pedicle

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 164 Surgery

----- Active space ----- Abdominal Flaps :

1. TRAM : Transversus rectus 2. DIEP : Deep inferior epigastric artery perforator flap
abdominis myocutaneous flap. • Only skin + fat No abdominal wall weakness.
Muscle used for flap ↑risk of incisional hernias • Best flap for breast reconstruction.

Free Flap :
Disconnected from donor site Anastomosed at recipient site.

om
l.c
ai
gm
7@
a4
tiy

1. Radial artery forearm flap : 2. Free fibular flap :

ga

• Used for head & neck surgery. • Based on peroneal vessels.

ar

• Prior test : Modified Allen’s test. • Use : Mandibular reconstruction.

ik
sh
va

Mathes and Nahai Classification for Axial Flaps :

ur
|
w

Mathes and Nahai Dominant pedicle Minor pedicle Muscle

ro
ar

• Gastrocnemius
M

Type I 1 - • Rectus femoris

©

• Tensor fascia lata

• Pectoralis major
Type V 1 Multiple
• Latissimus dorsi

Flap Failure :
D/t vessel blockade.
Arterial block Venous block
Temperature Cold Warm
Color Pale Congested
Capillary refill Reduced Quick
Pinprick ↓Blood flow ↑Blood flow Breast flap failure

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 Speciality Surgery 165

Bed Sores 00:11:25 ----- Active space -----

Staging of Pressure Sores :

Stage Description
1 Non blanchable erythema without a breach in epidermis
2 Partial thickness skin loss involving epidermis and dermis
3 Full thickness skin loss extending into the subcutaneous tissue
4 Full thickness skin loss involving muscle, bone, tendon or joint
Features :
• Pressure >30 mmHg Bed sore.
• M/c site : Ischium > Greater trochanter > Sacrum.
Risk factors :
• Prolonged immobilisation.

om
l.c
• Malnutrition.

ai
gm
• Maceration of area.
7@
Prevention :
a4
tiy

Grade 4 bed sore

• Frequent change in position : 10 minutes every 2 hours.
ga
ar

• Air/water mattress : To offload the weight.

ik
sh
va

Management :
ur
|

Grade I : Keep dry + offloading.

w
ro

Grade II/III : Debridement + VAC dressing.

ar
M

Grade IV : Debridement + VAC/flap.

©

Vacuum Assisted Closure (VAC) :

• AKA negative pressure dressing : -120 mmHg to -125 mmHg.
• Hastens healing process.
Uses :
• Chronic non-healing wounds.
• Venous ulcer without slough.
• Burn wound without eschar.
• Bed sores after debridement.
• Diabetic ulcer without osteomyelitis.
VAC dressing

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 166 Surgery

----- Active space ----- Wound Healing 00:14:51

Phases :
Hemostasis Inflammation phase Proliferative phase Remodelling.
Wound Strength :
• 10% of normal : After 1 week.
• 70-80% of normal (Maximum) : After 3 months/12 weeks.
• Original strength is never regained.
Collagen type :
Type 3 (Initially) Type 1 : Type 3 = 4 : 1.
(In remodelling)
Types of Healing :
1. Primary intention : Clean incised wound Sutured Good scar.

om
2. Secondary intention : Wound left open Gradual contracture ↑
 Granulation tissue,

l.c
ai
(D/t infection) hypertrophic scar.

gm
7@
3. Tertiary intention : Wound left open initially Sutured after few days.
a4
(Delayed primary closure)
tiy
ga
ar

Keloid v/s Hypertrophic Scar :

ik
sh

Keloid Hypertrophic scar

va
ur

M/c site : Sternum, shoulder region M/c site : Extensor surface

|
w

Racial predisposition for dark skinned people More common in children

ro
ar

Grows beyond the boundary of scar Remains in the boundaries of scar

M

Doesn’t subside with time & pressure Subsides with time & pressure
©

Mx : Intralesional triamcinolone Mx : Silicone pads/gel

Cleft Lip/Palate  00:18:17

Features :
• Seen in 1 in 600 live births.
• Males > females.
• M/c defect : Combined lip plus palate.

Cleft lip
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 Speciality Surgery 167

Documentation : ----- Active space -----

Capital letters (Eg : “L” ) for complete involvement.
Small letters (Eg : “l”) for partial involvement.
L : Lip.
A : Alveolus.
H : Hard palate.
LAHSAL system
S : Soft palate.
A : Alveolus.
L : Lip.

Management :
Cleft palate : Cleft lip :
• Timing : • Timing of repair : 3 - 6 months.

om
- Soft palate : 3 - 6 months. • Repair techniques :

l.c
- Hard palate : 9 - 12 months. - Millard.

ai
gm
• Repair techniques : - Tennison.
7@
- Wardill-Kilner.
a4
tiy

- V-Y plasty.
ga
ar
ik

Transplant Surgery
sh

00:20:34
va
ur

Types of Grafts :
|

• Autograft : Graft from the same person (Eg : Skin graft).

w
ro

• Isograft : Graft from identical twin (Eg : Kidney transplant).

ar
M

• Allograft : Graft from same species.

©

• Xenograft : Graft from different species.

Maastricht Classification :
Maastricht
Presentation of death DCD situation Organs procurable
classification
I Dead on arrival Uncontrolled Heart valves, cornea
II Unsuccessful resuscitation Uncontrolled Kidney, heart valves, cornea
III Anticipated cardiac arrest Controlled
IV Cardiac arrest in brain dead donor Controlled All organs except heart
V Unexpected cardiac arrest in a hospital patient Uncontrolled

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 168 Surgery

----- Active space ----- Flushing of UW Solution :

UW solution at 4°C Flushed through aorta & S tatic cold storage of
portal vein of donor harvested organs.

Advantages :
• Flushes out blood to prevent thrombosis. Cold ischemia time
• Cools organs : ↓Metabolic needs. • Longest : Kidney (24-36 hrs)
• Replaces ECF with preservative fluid. • Shortest : Heart (3-6 hrs)

Disadvantage : Delayed graft function. Key components of UW solution

1. Hydroxyethyl starch
Normothermic Machine Perfusion : 2. Lactobionic acid
• Used for heart, lung, liver & kidney perfusion. 3. Adenosine
4. Allopurinol
• Provides more physiological environment.

om
l.c
Advantage : Early allograft function (Replenishes depleted ATPs).

ai
gm
Renal Transplant  7@ 00:24:05
a4

• Most common indication in adults : Diabetic nephropathy.

tiy
ga

• Most common indication in children : Glomerulonephritis.

ar
ik
sh

Extended Donor Criteria for Renal Transplant :

va

• Fit patient more than 60 years (OR)

ur
|

• More than 50 with two or more of the following :

w
ro

a. Death due to stroke

ar
M

b. History of HTN Dead donors.

©

c. Serum creatinine >1.5 mg/dL

Dual Kidney Transplant :
• Involves transplantation of a pair of marginal quality kidneys from one donor
into one recipient in order to provide adequate nephron mass.
• Usually transplanted in same iliac fossa.
• Used in elderly DCD donors or expanded donor criteria.
Anastomosis :
• Heterotopic (Iliac fossa).
• Structures anastomosed :
- Ureter Bladder.
- Renal vein External iliac vein.
- Renal artery :
• Dead donor External iliac artery (End to side).
• Living donor Internal iliac artery (End to end).
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 Speciality Surgery 169

Complications : ----- Active space -----

1. Rejection :
Hyperacute Acute Chronic
• Dusky kidney on table
• M/c type of rejection
• D/T preformed antibodies • Immunological/non-immunological
• 6 months after transplant
(Anti-HLA Ab) • ↓incidence d/t effective immunosuppression
• Type IV hypersensitivity
• Type II hypersensitivity >90% 5-year survival of graft
• HPE : Glomerular sclerosis
• HPE : Intravascular thrombosis

2. Infection : Maximum in 1st 6 months.

- M/c in 1st month : Bacterial.
- M/c overall : Viral (M/c CMV)
3. Malignancy : Skin cancer (SCC)
4. Post-transplant lymphoproliferative disorder (PTLD) : D/t EBV (B-cell mediated)

om
5. Renal vein thrombosis : M/c vascular complication.

l.c
ai
gm
Liver Transplant 00:28:45
7@
a4

Indication :
tiy
ga

M/c in adults : Cirrhosis.

ar
ik

M/c in children : EHBA.

sh
va

Note : HLA matching is not important.

ur

Types :
|
w

1. Dead donor liver transplant (DDLT).

ro
ar

2. Live donor liver transplant (LDLT).

M
©

3. Split & reduced size liver transplant :

- Segments 2 + 3 donated to child.
- Segments 4 + 5 + 6 + 7 + 8 donated to adult. Split LT
4. Auxiliary LT :
- Recipient’s liver is not removed.
- Donor liver : Piggybacks the existing liver.
5. Domino LT : Donor & recipient both suffer the same systemic disease.
6. Paired exchange programme.

Sequence of Anastomosis :
1. Suprahepatic IVC.
2. Infrahepatic IVC.
3. Portal vein.
4. Hepatic artery.
5. Bile duct.
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 170 Surgery

----- Active space ----- Complications :

1. Chronic rejection : Vanishing duct syndrome.
2. Hepatic artery thrombosis.
3. Infections
4. PTLD Same as renal transplant.
5. Cancer.

King’s College Criteria :

• Used for acute liver failure.
• Has acetaminophen induced & non-acetaminophen induced.

Liver Transplant for Hepatic Malignancy :

LT simultaneously treats both the tumor & underlying cause.
Milan criteria : Indication for LT in HCC.

om
• One lesion ≤ 5cm.

l.c
ai
• Two to three lesions ≤3 cm.

gm
• No vascular invasion 7@
On imaging.
a4

• No metastatic disease
tiy
ga

Candidates :
ar

• Children with hepatoblastoma & HCC (M/c).

ik
sh

• Liver metastasis from colorectal & neuroendocrine tumors.

va
ur

Note : Sequence of heart transplant.

|
w

• Lt. atrium Rt. atrium Pulmonary artery Aorta.

ro
ar

• If suspecting rejection Subendocardial biopsy.

M
©

Berry Aneurysm 00:33:39

• Occurs in the circle of Willis.

• Rupture SAH.
• M/c site : Junction of
anterior communicating artery with ACA.
• M/c site of rupture : Apex of aneurysm.

Subarachnoid Hemorrhage :
Clinical features : Thunderclap headache (worst headache of life).
Diagnosis :
• NCCT.
• Xanthochromia in CSF (Delayed).
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 Speciality Surgery 171

Management : ----- Active space -----

Post-op
Angiography f/b Intervention CCBs (Nimodipine) :
• Coiling (Interventional radiology). To prevent vasospasm.
• Surgical clipping of aneurysm.
CNS Tumours 00:35:37

• M/c 1˚ brain tumour : Glioma > Meningioma.

• M/c 1˚ brain tumour in children : Medulloblastoma.
• M/c brain tumour : Metastasis.
IOC : MRI.
Note : PET-CT can miss brain lesions.
Treatment : Surgery, chemotherapy, radiotherapy.
Brain Metastasis :

om
• M/c cancer metastasizing to cerebrum : Lung cancer.

l.c
• M/c cancer metastasizing to leptomeninges : Breast cancer.

ai
gm
Management :
7@
• Radiotherapy : For multiple mets.
a4
tiy

• Surgery : For solitary lesions.

ga

• Steroids : DOC for vasogenic edema d/t ↑ICT.

ar
ik
sh

Astrocytoma :
va

Grade I :
ur
|

• Pilocytic astrocytoma.
w
ro

• M/c astrocytoma in children.

ar
M

• Presents as mural nodule.

©

• Rx : Excision. Mural nodule

Grade 4 :
• Glioblastoma multiforme (Bad prognosis).
• Crosses corpus callosum.
• Forms butterfly shaped tumour.
• Rx :
- Surgery Radiotherapy. Butterfly tumor
- Oral temozolomide.
Oligodendroglioma :
• Chicken wire vascularity.
• Fried egg appearance.

HPE
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 172

----- Active space ----- TRAUMA AND BURNS

Basics of Trauma Management 00:00:42

Pre Hospital Care :

Information from :
Driver/responder Patient
Mnemonic : MIST Mnemonic : AMPLE
• Mechanism of injury • Allergies
• Injuries • Medications
• Sign & symptoms • Past history

om
l.c
• Treatment given • Last meal

ai
gm
• Events leading to trauma
7@
a4
Transfer of patient :
tiy

Supine position : 3 Straps for stabilization Head & neck.

ga
ar

Thorax.
ik
sh

Pelvis.
va
ur
|
w
ro
ar
M
©

Manual in-line stabilization Complete immobilization (c + d)

• Prone position : Prevent aspiration.
• Never transferred in lateral position (Cervical spine cannot be stabilized).
• 2 persons required for helmet removal in trauma patients.

Trimodal Distribution of Mortality in Trauma :

At impact
Within 1 hour
Days/weeks
Mortality

Time

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 Trauma and Burns 173

Causes of mortality : ----- Active space -----

At impact within 1 hour (Life-threatening) Days/weeks

• Airway causes :
- Airway obstruction
- Tracheobronchial injury
• Breathing :
• Severe head injury - Open pneumothorax • Delayed head injury
• Aortic transections - Tension pneumothorax • Sepsis
• Circulatory :
- Acute circulatory arrest
- Haemothorax
- Cardiac tamponade
Golden hour : 1st hour following trauma
(If patient managed within this I hour ↓mortality).

om
Triage :

l.c
ai
Sort out on the basis of treatment priority.

gm
Priority group 7@
Description
a4

Number Name Colour

tiy
ga

Emergency/ • Causes that lead to death within 1 hour

P1 Red
ar

Immediate • Mx : immediate
ik
sh

• Includes fractures
P2 Urgent Yellow
va

• Mx : Stabilize first, Rx can wait

ur
|

• walking wounded patients (Minor

w

P3 Delayed Green bruises, lacerations)

ro
ar

• Mx : First aid
M

• Moribund patients
©

• Rx :
P4 Expectant Blue
- supportive care (Pain relief)
- Definitive Rx not possible
- Dead Black Dead bodies

Advanced Trauma Life Support (ATLS) 00:05:52

ATLS :
Followed by
1° Survey 2° Survey
(Stabilizing life threatening injuries : ABCD) (Detailed : to look for other injuries).

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 174 Surgery

----- Active space ----- PRIMARY SURVEY

1. Cervical Spine Assessment and Stabilization :
Assessment NEXUS criteria :
• Neurological deficit
• EtOH (Alcohol/Intoxication)
If any 1 +
• Extreme distracting injuries Imaging : X-ray cervical
• Unable to provide history (Altered sensorium) spine ± CT head.
• Spinal tenderness (midline)
2. Airway :
Any +
Danger signs Secure airway
• Unable to speak (Orotracheal intubation)
• GCS ≤8

om
if fails
• Coma

l.c
• Severe maxillofacial Emergency mx : Definitive mx :

ai
gm
injury
Needle cricothyroidotomy Tracheostomy
7@
a4
Tracheostomy
Note :
tiy
ga

Nasotracheal intubation : C/I in head injury (D/t anterior cranial fossa #).
ar
ik

Needle cricothyroidotomy :
sh

• 2-3 minutes procedure :

va
ur

Local anaesthesia Needle is put through cricothyroid membrane.

|
w

• Useful for 20-30 mins : Can carry out tracheostomy.

ro
ar

• C/I in < 12 years of age.

M
©

Video laryngoscope (Used for intubation) Laryngeal mask airway (LMA)

(Easier to insert)
3. Breathing :
• Chest examination.
• Pulse oximetry (Adjunct).
• Imaging : Chest X ray (AP view) ; Pelvic and cervical x-ray (Adjuncts).
• eFAST scan (Adjunct).
• Chest tubes placed (If required).
Note : CT scan is not a part of I° survey.
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 Trauma and Burns 175

4. Circulation : ----- Active space -----

• Minimum 2 IV Cannulas inserted : 18G (Minimum)/Grey/Orange.
• 1 litre of IV fluids administered (ATLS 10th edition update).
• If IV line insertion fails :

Emergency method : Definitive method :

• Central line.
Intraosseous Venous cut down
• M/c insertion site :
Needle inserted Done in great saphenous Internal jugular vein.
just below tibial vein (Anterior to medial
tuberosity malleolus)

om
l.c
ai
gm
7@
a4
tiy
ga
ar
ik

Intraosseous infusion Venous cut down

sh
va

CRASH-2 trial :
ur
|

Systolic BP <90 mmHg Give

w

Tranexamic acid :
ro

Heart rate >110 bpm 1g infusion F/b 1g infusion ↓ mortality.

ar
M

(Over 10 mins) (Over 8 hrs)

©

Pelvic binder :
• Used in trauma + hypovolemic shock.
• Bed sheet/formal binder tied till
pelvic # is ruled out.
• Stops bleeding by tamponade effect.

Pelvic binder
Damage control resuscitation :
• Permissive hypotension.
• Minimization of crystalloids.
• 1 : 1 : 1 blood product ratios.
• Early haemorrhage control.

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 176 Surgery

----- Active space ----- 5. Disability :

Glasgow coma scale (GCS) :
Behaviour Response Score
Spontaneously 4
To speech 3
Eye opening To pain 2
No response 1
Cannot be tested (D/t intubation) NT
Fully oriented 5
Confused 4
Inappropriate words 3
Best verbal response
Incomprehensible 2
No response 1

om
l.c
Cannot be tested NT

ai
gm
Obeys commands 6
7@
Moves to localised pain 5
a4

Flexion withdrawal to pain 4

tiy

Best motor response

ga

Abnormal flexion (Decorticate) 3

ar

Abnormal extension (Decerebrate) 2

ik
sh

No response 1
va
ur
|

• GCS-P score : • Head injury (Based on GCS) :

w
ro

Pupils unreactive to light Pupils reactivity score (PRS)

ar

Mild : 13-15.
M

Both pupils 2 moderate : 9-12.

©

One pupil 1 severe : ≤8.

Neither pupil 0
Calculation : GCS-P = GCS - PRS.
Note :
Log roll :
• To examine the back of trauma patients (4 people required).
• If limb fracture + : 5th person required.
Trauma Scores :
Revised trauma score mangled extremity severity score (MESS)
• Type of injury
• Shock + / -
• Systolic BP
• Signs of ischemia + / -
• Respiratory rate
• Age group
• GCS
Score ≤ 6 : Limb salvageable
Score ≥ 7 : Amputation necessary
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 Trauma and Burns 177

Abdominal Trauma 00:19:02 ----- Active space -----

M/c organ/structure injured :

• Overall & blunt trauma : Spleen.
• Penetrating injuries : Liver > small intestine.
• Gun shot wound (GSW) : Small intestine.
• Seat belt syndrome : Mesentery (Compressed b/w seat belt and vertebrae).
• Deceleration injury : Duodeno-jejunal flexure (DJ flexure).
• Children (Overall) : Spleen > kidney.

MECHANISMS
Blunt Abdominal Trauma :
Mx :
FAST Hemodynamically Stable : CECT abdomen (IOC).

om
l.c
(First Ix) Unstable : FAST (IOC) Fluid + O pen exploration

ai
gm
or laparotomy.
7@
Focused assessment sonogram in trauma (FAST) :
a4
tiy

• USG done in emergency room.

ga
ar

• Detects free fluid in abdomen/pericardium.

ik
sh

• Probe placement :
va
ur

Order Sites
|

1 Epigastrium (Cardiac window)

w
ro

2 Right hypochondrium
ar
M

3 Left hypochondrium
©

4 Suprapubic region
• eFAST (Extended FAST) : Probe placed at 4
(FAST sites) + 2 (Right + Left thorax).
• Disadvantages :
- Will not reliably detect < 100 cc of Sites of probe placement
free blood.
- Does not directly identify hollow viscus
injury.
- Not reliable in penetrating trauma.
- may need repeating/supplementing with
other investigations.
- Unreliable for assessment of
retroperitoneum.
FAST : hypoechoic collection

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 178 Surgery

----- Active space ----- Penetrating Abdominal Trauma :

Injury superficial to Injury causing peritoneal breach :

peritoneum • Peritonitis (Rebound tenderness
+ , guarding/rigidity + ).
Sx : Local exploration and • Omentum hanging out.
suturing • Bile stained dressing
No Ix done
Ix : CECT. • Sx : Laparotomy.
Note : Penetrating object.
• Never remove in ER d/t ↑bleeding risk.
• Always remove in OT.

om
l.c
Diagnostic peritoneal lavage (DPL) :

ai
• Indication : FAST is not available. Omentum

gm
• Positive DPL : 7@ Penetrating trauma
a4

- 10 cc gross blood aspirated

tiy
ga

- > 1 lakh RBC/mm3

ar

Any 1 +
- >500 WBC/mm3 Sx : Laparotomy.
ik
sh

- S. amylase >175 IU/L

va
ur

- Presence of fecal content

|
w
ro

SPLENIC TRAUMA
ar
M

• # 9-11 rib on left side

©

Suspect splenic injury.

• Bruising along lower left chest wall
Grades of Splenic Trauma :
Grade Features
• Subcapsular hematoma < 10% surface area (SA).
Grade 1 • Parenchymal laceration < 1 cm depth.
• Capsular tear.
• Subcapsular hematoma 10-50% SA.
Grade 2 • Intraparenchymal hematoma <5cm.
• Parenchymal laceration 1 - 3 cm depth.

• Subcapsular hematoma > 50% SA, ruptured subcapsular or intraparenchymal hematoma ≥ 5 cm.
Grade 3
• Parenchymal laceration > 3 cm depth

• Any injury in presence of splenic vascular injury or active bleeding confined within splenic capsule.
Grade 4
• Parenchymal laceration involving segmental/hilar vessels producing ≥ 25% devascularisation.
Grade 5 Shattered spleen.

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 Trauma and Burns 179

Note : ----- Active space -----

Updated definitions
• Vascular injury (Pseudoaneurysm/Arteriovenous
fistula) : Vascular contrast ↓in attenuation with
delayed imaging.
• Active bleeding (From a vascular injury) : Vascular
contrast ↑ in size/attenuation in delayed imaging.

Splenic trauma
Management :
Grade of injury Hemodynamic status Ix Management
• Conservative (Monitor vitals,

om
hematocrit, serial 24h CECT)

l.c
• If ↑ grade of injury/contrast

ai
gm
blush on CT
7@
I and II Usually stable CECT (10C)
a4
Angioembolization
tiy

Fails/unstable
ga
ar

Sx : Splenic preservation/
ik

Splenorraphy
sh
va
ur

Stable Same as grade I, II

|

III
w

Unstable Same as grade IV, V

ro
ar

IV and V Usually unstable FAST (10C) Sx : Splenectomy

M
©

Post-splenectomy Complications :
1. Left lower lobe atelectasis : M/c complication.
2. Haemorrhage.
3. Pancreatic injury : Tail of pancreas affected.
4. Hematological changes :
- Transient ↑in all 3 cell lines (Persist x 2 weeks).
- Permanent changes : Basophilic stippling, Reticulocytes, Howel Jolly bodies,
Hypersegmented WBC’s.
5. Opportunistic post splenectomy infections (OPSI) :
- M/c organism encapsulated bacteria :
• Pneumococcus (M/c organism).
• Meningococcus.
• H. influenzae.

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 180 Surgery

----- Active space ----- - Features :

• Children > Adults.
• Occurs within 1st 2 years of splenectomy.
• High mortality.
• M/c seen in splenectomy for : Hematological conditions > Trauma.
- Prevention : Vaccines In elective Sx : 2 weeks prior (↑Antibody titre).
In emergency Sx : Post-op day 2.
LIVER TRAUMA
Grades of Injury :
Grade Features
• Hematoma, subcapsular < 10% SA.
Grade 1
• Laceration : Capsular tear, < 1 cm parenchymal depth.

om
• Hematoma : Subcapsular, 10 - 50% SA.

l.c
Grade 2 • Hematoma : Intraparenchymal, <10 cm diameter.

ai
• Laceration : Capsular tear 1 - 3 cm parenchymal depth, < 10 cm length.

gm
• Hematoma : Subcapsular, > 50% SA. 7@
•
a4
Hematoma : Intraparenchymal, > 10 cm.
Grade 3
tiy

• Laceration : Capsular tear, > 3 cm depth.

ga

• Vascular injury with active bleeding contained within liver parenchyma.

ar
ik

• Laceration : Parenchymal disruption involving 25 - 75 % of lobe or 1 - 3 Couinaud

sh

segments.
va

Grade 4
ur

• Vascular injury with active bleeding breaching the liver parenchyma into
|

peritoneum.
w
ro

• Laceration : Parenchymal disruption involving > 75% of lobes.

ar

Grade 5
• Vascular : Juxtahepatic venous injuries.
M
©

Management :
Liver trauma Resuscitate Unstable Surgery.

Stable Investigate, Remains Manage complications

imaging, stable
laparoscopy, Discharge.
angiography
Pringle’s manoeuvre :
• Compression of the portal triad for 10-15 mins at
foramen of Winslow.
• Portal triad : Hepatic artery, common bile duct
& portal vein.

Pringle’s manoeuvre
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 Trauma and Burns 181

• Manoeuvre If bleeding↓ : Cause is portal vein/hepatic artery. ----- Active space -----
If bleeding continues : Cause is hepatic veins.
• Significance :
- Temporarily control bleeding.
- Identification of source of bleeding.
mops
Packing :
Bleeding can be stopped by mops
(D/t tamponading effect).

MESENTERIC INJURY
Packing
M/c in seat belt syndrome.
Types :

om
l.c
Longitudinal tear Transverse tear

ai
gm
7@
a4
tiy
ga
ar
ik
sh

Only 1 branch cut, No loss of vascularity All vessels are cut, loss of vascularity
va
ur

Sx : Repair of tear Sx : Resection & Anastomosis

|
w
ro

DAMAGE CONTROL SURGERY (DCS) AND EARLY TOTAL CARE (ETC)

ar
M
©

Criteria for DCS Criteria for ETC

• Hypothermia (< 34°c) Terrible triad

• Stable hemodynamics
• Acidosis (pH < 7.2) of trauma • S. lactate : N
• coagulopathy
• Coagulation : N
• S. Lactate (>5 mmol/L)
• Normothermia
• BP <70 mmHg
• No need of vasoactive/inotropic
• Transfusion approaching 15 units
stimulation
• Injury severity score >36

ETC :
• Definitive Mx of patient’s injuries within 36 hours (After resuscitation).
• ETC approach Patient deteriorates DCS approach.

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 182 Surgery

----- Active space ----- DCS (Abbreviated Laparotomy) :

Done in terrible triad of trauma.
Phases of DCS (ATLS) :
Temporary 24-48
Phase 0 : Phase 1 : Phase 2 : Phase 3 :
abdomen hours
Identification of • Emergency • In ICU • Re-exploration
closure
patient in ER. laparotomy in OT • Aim : Correct in OT
• Aim : physiology • Aim : Correct
- Stop bleeding (Terrible triad) anatomy
- Prevent
contamination

Stages of DCS :
Stage Mx Outer layer
Abdominal swab/cotton drape

om
1 Patient selection Suction drain

l.c
Control of Haemorrhage and

ai
2 Abdominal Inner layer

gm
contamination
contents
3 ICU care 7@
a4

4 Definitive Sx
tiy

Temporary abdominal closure

ga

5 Abdominal closure
ar
ik
sh
va

Urobag/Bogota
ur

bag abdominal
|

closure
w
ro
ar

ABDOMINAL COMPARTMENT SYNDROME (ACS)

M
©

Intra-abdominal pressure (IAP) : Measured by bladder pressure.

Causes :
• Bowel obstruction. • Massine ascites.
• Massive burns.
Definitions :
• Intra-abdominal hypertension (IAH) :
Sustained/repeated pathological ↑in 1AP > 12 mmHg.
• ACS : Sustained ↑IAP ≥ 20mmHg + New organ dysfunction.
Clinical features :
1. Renal : Renal vessels compressed ↓GFR ↓urine output.
2. Cardiac : ↓BP, ↑HR (D/t ↓ venous return).
3. Respiratory : ↑RR, ↓Lung volumes.
4. Intracranial : ↑ in intracranial tension.
Management : Decompressive laparotomy.
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 Trauma and Burns 183

RETROPERITONEAL TRAUMA ----- Active space -----

Zone 1 : Major vessels

IVC Aorta (Maximum mortality)

s Zone 2 : Kidney, Ureter, renal vessels

a
ncre
Pa IOC Stable : CECT.
Unstable : Single shot IVU.

Zone 3 : P elvic structures (M/c

injured zone, Majority :
Conservative Mx)

om
l.c
Zones of retroperitoneal trauma

ai
gm
RENAL TRAUMA
7@
Grades and Management :
a4
tiy
ga
ar
ik
sh
va

Yes CECT, monitoring.

ur

Mx : Stable
|

No Sx intervention.
w
ro
ar
M
©

Grade I Grade II Grade III

Sterile Mx : wait Fails DJ stenting.

Urinary leak Urinoma to resolve
Infected Mx : Pigtail catheter.

vascular injury Pulsatile retroperitoneal Non-visualization Mx : Sx

hematoma of Kidney exploration
+ repair.

Grade IV

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 184 Surgery

----- Active space -----

Mx : Nephrectomy (Partial/total)

Grade V
Complications of renal trauma :
1. Hematuria.
2. Urinoma (IVU : Dye used Collected outside kidney).
3. Arterio venous fistula.

om
4. Renal artery thrombosis Renal infarct.

l.c
5. Meteorism : Gut distension d/t pressure over splanchnic nerves

ai
gm
(48-72 hours after renal trauma).
7@
a4

Thoracic Trauma
tiy

00:44:19
ga
ar

• Common in polytrauma patients.

ik
sh

• Majority can be managed conservatively.

va

• M/c cause of death in blunt thoracic trauma : Tracheo bronchial injury.

ur
|

• M/c cause of d eath in penetrating thoracic trauma :

w
ro

Pulmonary laceration Haemothorax.

ar
M
©

Ix : eFAST can be used.

Rib Fractures :
• M/c type of thoracic trauma.
• M/c ribs # during CPR: 3-5th ribs.
Rib # Injured structures
Subclavian vessels, brachial
1st rib (D/t high impact)
plexus, apex of lung
10th-12th ribs (Floating ribs) Right liver, Left Spleen
Mx : Analgesia.

callus formation over rib #

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 Trauma and Burns 185

Flail Chest : ----- Active space -----

Fracture of ≥ 2 consecutive ribs at ≥ 2 places.
Complications :
Pulmonary contusion (M/c cause of death).
C/f : Paradoxical chest wall movement.

Flail chest
Expiration Inspiration Flail segment

A B

om
l.c
ai
gm
7@
a4

Flail segment moves out Flail segment moves in

tiy

Paradoxical chest wall movement A : Multiple rib # B : Flail chest

ga
ar
ik
sh

Mx :
va

If insufficient Insufficient
O2 + Analgesia RR> 20 cpm/ pO < 60 mmHg IPPV Surgical
ur
|

2
(Intermittent positive fixation.
w
ro

pressure ventilation)
ar
M

PNEUMOTHORAX
©

Hemodynamic status :
• Stable : Simple pneumothorax.
• Unstable : Tension pneumothorax.

Tension Pneumothorax :
Pathophysiology : Stab injury Open, sucking wound (One way valve)

Affected lung : Collapsed

Opposite lung : Hyperinflated
Mins/hours

Tracheal shift (Opposite side).

Heart compressed.

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 186 Surgery

----- Active space ----- Clinical features :

• ↑RR.
• ↓Cardiac output.
• ↓Systolic BP, tachycardia + . Tracheal shift
• JVP↑.

CXR : Left pneumothorax

Tension pneumothorax v/s differentials :
Tension pneumothorax Cardiac Tamponade Hemothorax Simple pneumothorax
No hemodynamic
Clinical features ↑ RR, ↑ HR, ↓ BP
compromise
JVP - -

om
↑

l.c
Breath sounds - N - -

ai
gm
Percussion note Hyperresonant N Dull Hyperresonant
N
7@ N N
Cardiac sounds Muffled
a4
tiy
ga

Investigations :
ar
ik

1. Chest X-ray : Absent lung markings, mediastinal shift, collapsed lung + .

sh
va

2. eFAST : Loss of seashore/barcode/stratosphere sign in M mode.

ur
|

Management :
w
ro

• Emergency : Needle thoracocentesis.

ar
M

- Adults : 5th I/C space, mid axillary line.

©

- Children : 2nd I/C space, mid clavicular line.

• Definitive : Tube thoracocentesis.
- Chest tube in triangle of safety.
- Cover sucking wound :
3 sided occlusive dressing (Reverses flow of one way valve).

3 sided occlusive dressing

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 Trauma and Burns 187

HAEMOTHORAX ----- Active space -----

Trauma Blood accumulation in pleural space.

Clinical features : Air fluid

• ↓ SBP, ↑ HR. level
• ↓ Cardiac output.
• Percussion : Dull note.
• Breath sounds - .
CXR : Left hemothorax
Mx : Chest tube insertion.

Indications for Emergency Thoracotomy in Thoracic Trauma :

1. >1-1.5 litres blood at insertion.
2. >200 cc/hr for 3 consecutive hours.

om
3. Cardiac tamponade.

l.c
ai
4. Tracheobronchial injury.

gm
5. Thoracic aortic injury. a4
7@
tiy
ga
ar
ik
sh
va
ur

Chest tube insertion : Upper border of rib

|

(Never lower border d/t Neurovascular bundle + )

w

CHEST TUBES
ro
ar

Triangle of safety :
M
©

Apex : Axilla
A
B

Base : 5th 1/c space

A : Anterior axillary line

B : Mid axillary line posteriorly
Structures pierced :
1. Skin. 5. 3 layers of intercostal muscles.
2. Superficial fascia. 6. Endothoracic fascia.
3. Deep fascia. 7. Parietal pleura.
4. Serratus anterior.
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 188 Surgery

----- Active space ----- Chest Tube Functioning :

• Connected to underwater seal bag.
• Functioning assessed : Water column movement in chest tube (Every breath).

Chest tube
Chest
tube
Filled with water :
Prevent air being sucked
back during inspiration
Under water seal Chest X-ray confirming tube position

om
Chest Tube Removed :

l.c
ai
Breath sounds + .

gm
When lung is expanded
Chest X-ray N . 7@
a4

• Output < 100 cc in 24 hours.

tiy
ga

• Removed when patient is holding breath (At the peak of inspiration).

ar
ik
sh

CARDIAC TAMPONADE
va

• Rapid blood accumulation in pericardial space. Beck’s triad

ur

• Muffled heart sounds

|

• M/c with penetrating injury.

w

• ↑ JVP
ro

Clinical features : Beck’s triad.

ar

• ↓ BP
M

Investigations : FAST/eFAST.
©

Mx :
• Emergency thoracotomy (Left antero lateral)
or sternotomy : *
Evacuation of hematoma + myocardium repair.
• No role for needle pericardiocentesis in traumatic
cardiac tamponade.
FAST + : Hypoechoic collection
DIAPHRAGMATIC INJURIES
• M/c : Left > Right (Protected by liver).

C/f :
• Breathlessness.
• Bowel sounds + in thoracic cavity.
• Coiling of Ryle’s tube in thoracic cavity.
Rt diaphragmatic injury (rare)
Surgery Revision • v4.1 • Marrow 8.0 • 2025
 Trauma and Burns 189

Mx : ----- Active space -----

• Laparotomy Reduce bowel contents Repair diaphragm Chest tube
(Prolene sutures) insertion.
• Avoid blind chest tube insertion d/t risk of bowel injury.

Neck Trauma 01:00:32

Zones :
• Zone 1 : Thoracic inlet to cricoid cartilage Hard signs
(Maximum mortality). • Subcutaneous
• Zone 2 : Cricoid to mandible angle. emphysema.
• Air bubbling from a
- most exposed zone ↑Surgically accessible. penetrating wound.
- M/c injured zone. • Expanding neck
• Zone 3 : Angle of mandible to base of skull. hematoma.

om
• Hoarseness of voice.

l.c
ai
gm
7@ Mx :
• Zone 1 & 3 Angiography
a4
tiy

Fails
ga

Any hard sign +

ar

• Zone 2 Sx exploration.
ik
sh

Zone 3
va

Zone 2
ur
|

Cricoid cartilage
w
ro

Zone 1
ar

Neck trauma Zones

M
©

Head Trauma 01:01:53

Anatomy of Scalp :
1. Skin.
2. Connective tissue : Adherent vessels ↑Bleeding of lacerations.
(Cannot vasoconstrict)
3. Aponeurosis : Sub aponeurotic bleeding Black eye.
4. Loose areolar tissue :
Retrograde infection
Dangerous area of face via emissary veins Cavernous sinus thrombosis.
5. Periosteum.

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 190 Surgery

----- Active space ----- SKULL FRACTURES

Management :
Non-depressed # : No intervention required.
Depressed # :
If focal neurological signs +
or Sx elevation
Depression > Depth of adjacent structures and fixation.

Depressed skull #
Base of Skull # :
Anterior cranial fossa # Middle cranial fossa # Posterior cranial fossa #
Cribriform plate # Petrous part of temporal bone # Occipital bone #

om
Signs : Signs : Signs :

l.c
• Black eyes/Racoon eyes • Temporal bone contusions • Visual problems

ai
• CSF rhinorrhea, epistaxis : • Battle sign (Classical) • occipital contusion

gm
Differentiate Target/Halo sign • Hemotympanum • 6th nerve injury
7@
• CSF otorrhea • Vernet/Jugular foramen syndrome :
a4
CSF :
B2 transferrin + • Facial nerve injury 9-11th cranial nerve injury
tiy
ga

• Paradoxical rhinorrhea (Rare) :

• Anosmia
ar

Middle ear collection

ik

• Frontal lobe contusion

sh

Eustachian tube
va

Nose
ur
|
w
ro
ar

Discolouration
M

CSF over the mastoid

©

process
Blood

Blotting
paper
Racoon eyes Target/Halo sign in CSF Battle sign
rhinorrhoea
Management (NICE Guidelines) :
IOC in head injury : NCCT.
1. All patients with cervical spine injury : Suspect head injury.
2. Frequency of GCS monitoring :
- First 2 hours : Every 1/2 hour.
- Next 4 hours : Every 1 hour.
- After 6 hours : Every 2 hours.

Surgery Revision • v4.1 • Marrow 8.0 • 2025

 Trauma and Burns 191

3. CT within 1 hour : ----- Active space -----

- With involvement of neurosurgeon :
• LOC + .
• Seizures.
• >1 episode of vomiting.
• ENT bleed.
• Focal neurological signs.
• Penetrating CNS injuries.
- without involvement of neurosurgeon :
• GCS <13.
• GCS <15 at 2 hours of admission.
4. CT within 8 hours :
- Age > 65 years.

om
- Coagulopathy.

l.c
ai
- Retrograde amnesia > 30 minutes.

gm
7@
BRAIN INJURY
a4
tiy

Types :
ga

• 1° injury : Due to impact.

ar
ik

• 2° injury : Due to ↑intracranial pressure (ICP).

sh
va
ur

1° Brain Injury :
|
w

1. Concussion :
ro
ar

- Mildest type of 1° Brain injury.

M

- Mx : Avoid contact sports for

©

short duration (No surgical intervention).

2. Diffuse axonal injury (DAI).
3. Intracranial hemorrhages :
a. Intra parenchymal hemorrhage/contusion :
• M/c type.
MRI : Punctate hemorrhages (DAI)
• Mx : Conservative (Manage ↑ ICP).
b. Extradural hematoma (EDH).
c. Subdural hematoma (SDH) :
Types Acute : Present in few hours of injury.
Subacute : Few hours to days of injury.
Chronic : Days to weeks of injury.

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 192 Surgery

----- Active space -----

EDH Chronic SDH Diffuse axonal injury

History Young patient Elderly patient Any trauma patients (Most severe)
• High velocity impact
• Trivial injury (Venous • High velocity impact.
Middle meningeal artery rupture
Cause bleed) • D/t shearing force between grey &
• M/c site : Pterion/temporal
• Not restricted by sutures white matter
region
Coma (GCS not improving,
Features Lucid interval Gradual altered sensorium
no signs of recovery)
• NCCT : Normal
NCCT : Concavo convex/
Imaging NCCT (IOC) : Bi convex hemorrhage. • IOC : MRI (Punctate hemorrhages at
crescentic hemorrhage
grey & white matter junction)
Rx Burr hole/craniotomy Burr hole/craniotomy Worst prognosis

om
l.c
ai
gm
7@
a4
tiy
ga
ar
ik
sh
va
ur
|

CT : Contusion CT : Biconvex/Lens shape (EDH) CT : Concavo-convex/

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Cresentric SDH
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©

• Indications for craniotomy :

- >30 cc clot size.
- >5 mm midline shift.
- >1.5 cm clot thickness.

2° Brain Injury : Pterion : Preferred site for craniotomy

• Occurs due to ↑ICP.
• Cerebral perfusion pressure (CPP) :
- CPP = MAP - ICP (Normal = >60 mmHg).
- Trauma ↑ ICP ↑ MAP : C ushing’s reflex (↓HR,
↑BP, Altered respiration).

Intracranial volume pressure curve

Surgery Revision • v4.1 • Marrow 8.0 • 2025
 Trauma and Burns 193

Mx of ↑ICT : Goals of Rx ----- Active space -----

• Adequate O2. • ICP 20 - 25 mmHg
• Adequate perfusion (SBP >100 mmHg). • CPP ≥ 60 mmHg
• Avoid hyperglycemia (↑ cerebral oedema). • Na+ : 135 - 145
• Administer IV mannitol. • SBP ≥ 100 mmHg
• hyperventilation (Moderate amount).
• No steroids in head trauma.

Note : Seizure prophylaxis (Phenytoin/valproate).

• Not recommended for late post-traumatic seizures (PTS).
• Useful for early PTS.
GLASGOW OUTCOME SCORE
Prognostic score following head injury.

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l.c
Score Prognosis

ai
gm
1 Death
2 Persistent vegetative state 7@
a4
tiy

3 Severe disability + conscious

ga

4 Moderate disability
ar
ik

5 Good recovery
sh
va
ur

BRAIN DEATH
|

2 experts required to certify brain death.

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ro
ar

Criteria to declare brain death :

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©

• GCS = 3. • Absence of confounding factors

• Non-reactive pupils. (Alcohol, drug intoxication,
• Absent brainstem reflexes. hypothermia).
• No spontaneous ventilatory effort.

Thermal Injury 01:21:03

BURNS
Referral criteria to a burns Unit :
• Burns involving face, hands, feet, genitalia, perineum, major joints.
• Chemical burns.
• Electrical burns
• Inhalational injury.
• Partial thickness burns : > 10% of total body surface area (TBSA).
• Third degree (Full thickness) burns in any age group.

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 194 Surgery

----- Active space ----- Initial Management :

ABCDE : Airway, Breathing, Circulation, Disability, Exposure (Extent/cause).

Airway :
1. Signs of airway burns :
- Burnt/singed nasal hair (Most significant)
- Hoarseness of voice
- Carbonaceous deposits in sputum Any Prophylactic intubation
- Closed room burns + (Prevent airway collapse).
- Burns involving head, face, neck
- Altered mental sensorium
2. stages of airway injury following burns :

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1. Acute pulmonary 2. ARDS like picture 3. Bronchopneumonia

l.c
insufficiency (Hypoxia, B/L lung (D/t ↓ immunity)

ai
gm
(Breathlessness, infiltrates + ).
↓SPO2 : D/t CO build up). 7@
Early (1-3 days) : Late (>3 days) :
a4
tiy

Staphylococcus. Gram - bacteria.

ga

Breathing : Hypoxia, CO poisoning, eschar (Thickened tissue) around chest.

ar
ik
sh

Circulation :
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• Inflammatory response Localised : Burns < 10% TBSA.

ur
|

Generalised : Burns > 10% TBSA.

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• Vasodilatation + leaky capillaries Dehydration.

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Edema/3rd space loss.

©

Burns resuscitation : IV fluid replacement.

1. Crystalloid resuscitation formulae :
- Old Parkland’s formula = 4 x Body weight (kg) x TBSA burned.
Fluid in 24 hours First 1/2 amount : 1st 8 hours.
Next 1/2 : next 16 hours.
- Galveston formula (Used in paediatric burns).
LR : Lactated Ringer’s
- Latest formulas :
Category of burns Age & weight Adjusted fluid rates Urine output
Adults & older children (≥ 14 years). 2 ml LR x kg x % TBSA 0.5 ml/kg
Children (≤ 14 years) 3 ml LR x kg x % TBSA 30-50 ml/hour
Flame or scald
3 ml LR x kg x % TBSA + solution
Infants & young children (≤ 30 kg) 1 ml/kg/hour
with sugar at maintenance rate
Electrical injuries 4 ml LR x kg x % TBSA until urine 1-1.5 ml/kg/hour until
All ages
(3rd/4th grade) clears urine clears
Surgery Revision • v4.1 • Marrow 8.0 • 2025
 Trauma and Burns 195

2. Colloid resuscitation formula : ----- Active space -----

- M/c : Muir and Barclay formula.
- Colloids : Given after 1st 12 hours (To ↓ risk of edema).

Calculating TBSA :
• Wallace rule of 9.
• Lund and Browder chart (Best).

Zones of Burns :
• Zone of coagulation/necrosis : Irreversible, non salvageable.

• Zone of stasis Infected

Well managed

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• Zone of hyperemia : Vasodilatation, salvageable.

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gm
7@
a4
tiy
ga
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sh
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ur
|
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ar
M
©

Adults Children
Wallace rule of 9
Degree of Burns :

First degree Second degree burns Third & fourth degree

burns Superficial Deep burns
• 3rd : SC tissue
Layer Only epidermis Epidermis & papillary dermis Epidermis & dermis (Entire)
• 4th : Muscle
• Red, tender • Black & charred
Wound Red, tender Red, less tender
• Blister formation • Painless
Blanching Present Present Some area only Absent
Heal without Heals after application of Early excision STSG
Heals with hypertrophic
Rx scarring in dressing materials (Split thickness skin
scars and keloids
3 - 5 days without scarring grafting)

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 196 Surgery

----- Active space -----

Blister

2nd degree superficial burns 2nd degree : Deep burns Hypertrophic scars

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l.c
ai
gm
7@
a4
tiy

Desquamation Depigmentation Healing 3rd and 4th degree burns

ga
ar

Burns Management :
ik
sh

• ABCDE. • IV fluids.
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ur

• Wash : Given with room temperature • Avoid : IM and s/c injections.

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water. • NG tube if > 15% TBSA burned (D/t

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• Do not burst blisters. possibility of ileus).

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©

Split thickness skin grafting (STSG) after debridement

Nutrition in Burns :
• Basal energy expenditure (BEE/REE) is increased in patients with burns.
• Severe burns : 40 kcal/kg/day (2x normal).

Surgery Revision • v4.1 • Marrow 8.0 • 2025

 Trauma and Burns 197

• Max nitrogen loss : Day 5 to 10 (Atleast 20% calories should be from proteins). ----- Active space -----
Davies formula used to calculate protein requirement :
i. Children : 3 g/kg + 1 g% TBSA.
ii. Adults : 1 g/kg + 3 g% TBSA.

Escharotomy :
Eschar Compartment syndrome ↑↑pain Escharotomy.
(Thickened tissue (Pressure : > 30 mmHg)
post burns)
• Deep fascia is cut and muscle released.
• Wound extended beyond deep burn.
• Any significant bleeding vessels : Diathermy.
• Post-op hemostatic dressing + Limb elevation.

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Dressing Materials for Burns Mx :

l.c
ai
gm
Aim :
• Protect damaged epithelium. 7@
a4

• minimize bacterial/fungal contamination.

tiy
ga

Degree Dressing used

ar
ik

1 degree
st
No dressing required, expose the wound
sh
va

• Vaseline/Paraffin gauze
2nd degree : Superficial
ur

• Collagen dressing (If non infected)

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2nd degree : Deep Collagen dressing, Hydrocolloid dressing (Duoderm)

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ar
M

Special agents :
©

1. Silver sulphadiazine ( 1% ) : M/c agent. • Good action against

Frequent change of dressing required pseudomonas & Gram -
2. Silver nitrate : bacteria.
Stains everything black (Not useful). • Does not penetrate eschar.
3. mafenide acetate (5%) : Penetrates eschar.
Problems : Painful application & metabolic acidosis.
4. Cerium nitrate (Best agent).

Causes of Death in Burns :

Immediate : Early (1-3 days) : Late (> 3 days) : Overall :

Asphyxia > Neurogenic. Hypovolemic shock. Septic shock Septic shock
shock (M/c organism :
Pseudomonas).

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 198 Surgery

----- Active space ----- Special Situations :

a) Acid/alkali burns :
• More severe : Alkali burns (Liquefactive necrosis, deeper penetration).
• Never neutralise (To avoid ↑ in burnt area).
• Wash with water, brush off chemical powder.

b) Hydroflouric acid burns :

• ↑S. k+, ↓s. Ca2+, ↓ pH (Acidosis), Arrythmias (Cause of death).
• mx : Calcium gluconate.

c) Electrical burns : High degree burns.

• Alternating current Arrythmias (Death).
Tetany (Myoglobinuria).
• Examine : Entry and exit burn.

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• Mx : IV fluids

l.c
↑Urine output Prevent tubular necrosis d/t myoglobinuria.

ai
gm
(Old Parkland’s formula)
7@
HYPOTHERMIA
a4
tiy

• Rectal temperature : Best to measure core temperature.

ga

• Cardiopulmonary bypass machine : B est way to warm severely hypothermic

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sh

patients.
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Frost Bite and Trench Foot :

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Frost bite Trench foot

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• Prolonged exposure to dry cold

©

• Prolonged exposure to cold

• Ice crystals formed in tissue
+ moisture, tissue : wet
Membrane damage +
• Microvascular damage
Microvascular damage
• Stasis & occlusion
• Rewarming Re-perfusion injury

Mx of frost bite and trench foot :

• Rapid re-warming of leg (Water : 40°).
• Do not rub the tissues (Pain ++).
• Beware of re-perfusion injury.
• Hyperkalemia, acidosis can occur.
• If gangrene Wait for demarcation line Amputation.

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 Hernia, Thorax and Skin 199

HERNIA, THORAX AND SKIN ----- Active space -----

Hernia and Hernia Surgeries  00:00:52

Types of Hernia :
Simple/Uncomplicated Obstructed Strangulated
Obstructed hernia +
Hernia Reducible Irreducible compromised blood
supply + skin inflamed
Cough impulse + - -
Forceful taxis C/I d/t reduction en masse.

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(Hernia Possible (Reduction of contents + constriction ring

l.c
Strangulated hernia

ai
reduction) causing obstruction.)

gm
Contents of Hernia : 7@
a4
tiy

Omentocele Enterocele
ga

Peristalsis - +
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Consistency Doughy -
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Reducing 1st part Easy Difficult

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Percussion note Dull Tympanic

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HERNIA SURGERY Reduction en masse

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©

Herniotomy Herniorraphy Hernioplasty

Procedure Identify sac Cut open + reduce contents.
Edges sutured
Closed with
Defect Not repaired together (No mesh
Mesh
d/t infection risk)
Recurrence rate Highest - Least
TOC in :
• Congenital inguinal hernia obstructed and For all other
Performed in
• Inguinal hernia in children strangulated hernia hernias
• Congenital hydrocele

Mesh :
Best material of mesh : Placement :
• Low weight Less shrinkage. At least 2 cm overlap all around
• Thin fibres. the defect (To avoid recurrence).
• Large pores.

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 200 Surgery

----- Active space ----- Mesh materials

Synthetic Biological
Avoid in infection & strangulation Can be used in infection
Eg. :
Eg. :
• Prolene Not used intraperitoneally
• Acellular human dermis (Alloderm)
• Vipro d/t bowel adhesions. • Acellular porcine dermis
• PTFE (Intraperitoneally)

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l.c
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gm
Synthetic (Prolene) mesh 7@ Biological mesh (Alloderm)
a4
tiy
ga

Inguinal Hernia 00:06:16

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• M/c type of hernia.

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• M/c type of inguinal hernia

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Indirect inguinal hernia.

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• M/c hernia in females

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Note : Femoral hernia is F >> M

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M
©

Clinical tests :
• Deep ring occlusion test : Single best test.
• Zieman’s three finger test, ring invagination test : Low sensitivity.

Types of Indirect Inguinal Hernia :

Deep inguinal
ring Deep inguinal ring

Hernial sac Hernial sac

Superficial Superficial inguinal ring
inguinal ring

Testis Testis

Bubonocele Funicular Inguinoscrotal

(Complete)
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 Hernia, Thorax and Skin 201

INGUINAL HERNIA ANATOMY ----- Active space -----

Hesselbach’s Triangle (HT) :
Key : ral)
V ( Late
• V : vessels a stric
Epig
• : Indirect hernial (Lateral to HT) rior
Infe Outer Border
• : Direct hernia (Through HT) of rectus
Inguinal Ligament (Medial)
Note :
(Inferior)
Modification of Boundaries
Deep ring Fascia transversalis
External oblique
Superficial ring
aponeurosis

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Myopectineal Orifice of Fruchaud :

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Transverse
Boundaries :

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Anterior superior abdominis

gm
• Superior : Arching fibres of internal oblique iliac spine
7@
• Inferior : Pectineal/Cooper’s ligament.
a4
Rectus abdominis
tiy

• Lateral Tendon of iliopsoas. Inguinal ligament

ga

• Medial : Outer border of rectus.

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Iliopsoas muscle Cord structures

ik
sh

Myopectineal
Significance :
va

orifice
ur

Mesh placement in orifice covers defect of Femoral vessels

Lacunar ligament
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inguinal, femoral & obturator hernia. Cooper’s

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(Pectineal) ligament
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©

Myopectineal orifice of Fruchaud

Hernioplasty 00:08:36

Open Sx :
Lichtenstein’s tension free Mesh hernioplasty

Complications of open inguinal hernia Sx :

1. Hemorrhage.
2. Injury to vas/cord structures.
3. M/c nerve Injured at superficial ring : Ilioinguinal nerve.
Entrapped below mesh : Iliohypogastric nerve Chronic inguinal
pain.
4. Recurrence.
5. Wound infections.

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 202 Surgery

----- Active space ----- Laparoscopic Inguinal Sx :

TEP TAPP
Total Extraperitoneal repair Trans Abdominal Preperitoneal repair
Peritoneum remains intact Peritoneum breached Mesh placed
Technically more challenging, better repair
Balloon Skin and
Dilating trocar subcutaneous Laparoscope
tissue
Umbilicus Peritoneum
Anterior fascia
and muscle

Abdominal
cavity

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Posterior fascia Preperitoneal

l.c
ai
and peritoneum space

gm
7@
Structures Encountered During Sx :
a4
tiy

Iliopubic
ga

Deep ring Peritoneal reflection

tract
ar
ik
sh

Triangle of pain
va

(M) Vas External iliac vessels

ur

deferens Genital branch of genitofemoral nerve

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Testicular vessels (L)

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ar
M

Triangle of doom
©

Key : L Lateral ; M Medial

of doom and of pain

Triangle of Doom Triangle of Pain

Medial Vas deferens Testicular vessels
Lateral Testicular vessels Peritoneal reflection
Boundries
Inferior Peritoneal reflection -
Superior - Iliopubic tract
a. External iliac artery
a. Lateral cutaneous nerve of thigh
b. External iliac vein
Contents b. Femoral nerve
c. Genital branch of
c. Femoral branch of genitofemoral nerve
genitofemoral nerve
Meralgia paresthetica : Shooting pain along
Torrential bleeding :
Complication lateral aspect of thigh d/t entrapment of
If stapler/tacker applied
lateral cutaneous nerve of thigh (M/c)

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 Hernia, Thorax and Skin 203

Corona mortis (Circle of death) : ----- Active space -----

• Abnormal communication b/w obturator and iliac vessels.
• Injury Torrential bleeding.

Note : Special types of inguinal hernia

Sliding hernia Sportsman hernia
• AKA Gilmore’s groin
• Posterior boundary formed by visceral structure • M/c seen in athletes
(M/c : Sigmoid colon) • Tear in posterior wall muscle
• Visceral structure can get injured during sac
dissection Extreme pain +
• Seen in elderly males • Sac not palpable (Small sac)
• Left >> Right • IOC : MRI
• Sx : Laparoscopic repair

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Classification of Hernia

l.c
00:12:33

ai
gm
European Hernia Society Classification :
7@
Inguinal hernia : Ventral hernia :
a4
tiy

• Defect measured by size of finger breadth. Hernia Characteristics Term

ga

Subxiphoid M1
ar

• Classified as 1°/recurrent.
ik

Epigastric M2
sh

Location : Lateral, medial, femoral.

va

Medial Umbilical M3
ur

1°/Recurrent Infraumbilical M4
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• Lateral/Indirect hernia Suprapubic M5

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• Medial/Direct hernia Subcostal L1

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• Femoral hernia
©

Femoral L2
Lateral
Iliac L3
Lumbar L4

Nyhus Classification for Inguinal Hernias :

Type Description
1 Indirect inguinal hernia + Normal ring
2 Indirect inguinal hernia + Enlarged ring
3a Direct hernia + Posterior floor defect
3b Indirect hernia + Posterior floor defect (Pantaloon hernia)
3c Femoral hernia
4 Recurrent hernia

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 204 Surgery

----- Active space ----- Other Hernias 00:13:49

FEMORAL HERNIA
• Through femoral ring (Small defect). Bounded by
• F >> M. • Superiorly : Inguinal ligament
• ↑Risk of strangulation/obstruction • Medially : Lacunar ligament
(Ring can not dilate). • Inferiorly : Pectineal/Cooper’s
• Richter’s hernia can be seen. Ligament

On examination :
Inguinal hernia Femoral hernia
Pubic tubercle Above and medial Below and lateral
D/D : Inguinal hernia, Psoas abscess, Inguinal lymph node, saphena varix

om
l.c
Mx Open Sx.

ai
gm
Laparoscopic hernioplasty (M/c).
7@
a4
Bulge in
VENTRAL/ABDOMINAL WALL HERNIAS
tiy

scar site
ga

• Epigastric hernia. • Spigelian hernia.

ar

• Umbilical hernia. • Lumbar hernia.

ik
sh

• Paraumbilical hernia. • Parastomal hernia.

va
ur

• Traumatic hernia. • Incisional hernia (M/c).

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Incisional hernia
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Hernioplasty for ventral hernias :

©

Onlay Top of rectus sheath

Inlay With rectus sheath
Preperitoneal Above peritoneum
Intraperitoneal IPOM (M/c) : PTFE mesh
Retromuscular Behind rectus muscle

Paraumbilical
Epigastric hernia Umbilical hernia
hernia
Xiphisternum till Adjacent to
Location Through umbilicus
umbilicus umbilicus
High
Chances of Low
Low (Narrow
strangulation (Large defect)
defect)
Surgery Revision • v4.0 • Marrow 8.0 • 2024
 Hernia, Thorax and Skin 205

Paraumbilical ----- Active space -----

Epigastric hernia Umbilical hernia
hernia
• Fatty hernia of linea alba
Unique (Midline hernia) Umbilicus forms
Umbilicus everted
features • Pain similar to peptic one boundary
ulcers
Young, fit males Common in newborn
Seen in -
(Thin, muscular) (Wait 2-3 yrs for Sx)

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l.c
ai
gm
Epigastric hernia Umbilical hernia Paraumbilical hernia
7@
Omphalocele vs Gastroschisis :
a4
tiy

Omphalocele Gastroschisis
ga

Sac
ar

Defect through umbilicus, bowel

ik

Defect adjacent to umbilicus

sh

fails to return inside Liver

va
ur

No sac covering
Covered with a sac
|

Can get dry, shriveled

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Large defects (Liver can also

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Bowel exposed Omphalocele

M

herniate)
©

A/w other congenital defects,

Beckwith weidmann sydrome, ↓ congenital anomalies
Trisomy 13, 18, 21
Atresia, infection/perforation
-
can occur Gastroschisis
Mx : Sx (Gradual closure To avoid abdominal compartment syndrome).
Spigelian Hernia (Intra Parietal Hernia) :
• Occurs at outer border of rectus close to spigelion line
(Mid point between umbilicus and pubic symphysis).
• Lies in between muscle layers

Not palpable outside (Narrow defect).

Spigelian hernia
• Detected only if strangulation + .
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 206 Surgery

----- Active space ----- Obturator Hernia (Little Old Lady’s Hernia) :
Seen in elderly, multiparous women.
Narrow defect (↑Chances of strangulation/Richter’s hernia).
C/f :
• Bowel obstruction, pain.
• Howship romberg sign : Adduction + Internal rotation Shooting pain along
obturator nerve.
• Hannington kiff sign.

Richter’s Hernia :
• Seen in : Femoral hernia > Paraumbilical, obturator hernia.
• Small defect : Only a part of circumference of bowel herniates.
C/f :

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Richter’s hernia

l.c
• 1st sign : Gastroenteritis.

ai
gm
• Strangulation can get missed.
7@
Maydl’s Hernia :
a4
tiy

• Wide defect.
ga
ar

• ‘W’ shaped hernia.

ik
sh

• >1 bowel loop herniates

va

• If strangulation + : Intraperitoneal part affected first.

ur

Maydl’s hernia
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Congenital Diaphragmatic Hernia

ro

00:22:19
ar
M

Bochdalek hernia Morgagni hernia

©

Left posterolateral Right anteromedial

Defective development of Defective central tendon of
pleuroperitoneal cancel/membrane diaphragm
Structure herniating : Stomach, Structure herniating : Transverse
spleen, transverse colon colon
More common -
Bochdalek hernia
Ix : Prenatal detection can be done.
Other features :
Best ventilation : IPPV
• M/c cause of death : Pulmonary hypoplasia
Bag and mask ventilation : C/I.
(Respiratory distress + scaphoid abdomen)
• 2 m/c cause of death : Pulmonary Hypertension (Mx
nd
Inhaled nitrates)
Management :
Sx : Circular incision around diaphragm Bowel reduced Mesh placed.

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 Hernia, Thorax and Skin 207

Thorax 00:24:24 ----- Active space -----

Thoracoscore :
Prognostic score (Mortality/Morbidity risk after lung resection).

Video Assisted Thoracoscopic Surgery (VATS) :

Used for :
• Resections.
• Decortication.
• Biopsies.

Method : Lung collapsed to create space (Using double

VATS
lumen endotracheal tube).

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Empyema :

l.c
Pus in pleural space.

ai
gm
Phases : 7@
a4

Exudative Fibrinopurulent Organized *

tiy
ga

• Thick pus, fever Thickening of pus + Thickening of pleura, Lung *

ar
ik

• No lung changes pleura becomes entrapped

sh

Empyema
va

Mx : Aspiration + Mx : Chest tube (D/t Mx : Stripping of pleura/

ur

Antibiotics difficult aspiration) VATS * Fibrosis * Pus

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ro
ar

Lung Cancer
M

00:26:38
©

Risk Factors :
• Smoking.
• Pollution.
• Asbestos exposure.

Small Cell/Oat Cell Carcinoma :

• Strongest a/w smoking.
• M > F, poor prognosis. Azzopardi
effect
• Highly chemosensitive
Salt and pepper
(Fast growing cancer).
chromatin
• Maximum Paraneoplastic syndromes +
(Cushing’s syndrome, SIADH, acromegaly,
various neurological syndromes). HPE : Small cell carcinoma

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 208 Surgery

----- Active space ----- Non Small Cell Carcinoma :

Squamous cell carcinoma Adenocarcinoma
• Upper and centrally placed
• Peripherally placed
• Strongly a/w smoking
• F>M ; Slow growing
• M/c lung cancers in
• M/c lung cancer (Overall)
smokers
• Markers NAPSIN 4
• Leads to hypercalcemia of
ALK, RAS
malignancy (PTHrp related) Pancoast tumour

Pancoast Tumour :
• Squamous cell carcinoma Sympathetic chain compressed Horner’s
syndrome (Ptosis, Miosis, Enopthalmos, Anhydrosis).

om
• Mx : Radiotherapy.

l.c
ai
Lung Cancer Staging :

gm
7@
T1 staging Tumor size
a4
tiy

T1a <1cm
ga

T1b 1-2cm
ar
ik
sh

T1c 2-3cm
va
ur

Ix :
|
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• Biopsy : Endo bronchial ultrasound (EBUS) FNAC. EBUS

ro
ar

• PET-CT : Staging of tumour.

M
©

HAMARTOMA
M/c benign tumour of lung.
C/f : Asymptomatic OR cough + hemoptysis.
Mx : Excision with VATS.

Hamartoma : Coin shaped lesion

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 Hernia, Thorax and Skin 209

Mediastinal Tumours 00:30:20 ----- Active space -----

MEDIASTINAL TERATOMA

• M/c mediastinal germ cell tumour.

• M/c seen in anterior mediastinum.
• Mature teratoma : A/w klinefelter’s
syndrome.
Imaging :
Well defined mixed density lesions
(Displacing structures > invading) +
Cystic areas + Calcification.

THYMOMA

om
• A/w myasthenia gravis : Weakness/lethargy,

l.c
ai
breathing difficulties.

gm
• MRI/CT to stage to stage lesions : 7@ Mediastinal tumours ( : M/c tumor)
a4
tiy

Masaoka staging
ga

Stage Description
ar
ik

I Macroscopically completely encapsulated + No capsular invasion.

sh
va

II Invading into surrounding structures + Capsular invasion

ur

III Invading neighbouring organs (Pericardium, great vessels, Lungs)

|
w
ro

IVA Pleural/Pericardial dissemination

ar

IVB Lymphatogenous/Hematogenous metastasis

M
©

Skin 00:32:57

Types of Ulcers :
Based on edge

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 210 Surgery

----- Active space ----- Basal Cell Carcinoma :

• AKA Rodent ulcer, locally invasive (Does not metastasize) Lymph nodes - .
• M/c seen : Face (Above line joining angle of mouth to ear lobule).
Palisading
Mx : Wide Local Excision (WLE).
pattern

Basal cell carcinoma (BCC) HPE of Basal cell carcinoma

om
Malignant Melanoma :

l.c
Risk factors : UV radiation, white population,

ai
gm
familial atypical mole melanoma syndrome.
7@
Types :
a4
tiy
ga

Type Description
ar

• M/c in pre-existing mole

ik
sh

Superficial spreading • Seen in sun exposed areas

va

• Eg : Subungual melanoma Malignant melanoma

ur

•
|

In situ melanoma in elderly

Lentigo maligna
w

• Best-prognosis
ro
ar

Acral melanoma M/c in dark skinned patients

M
©

• Most aggressive, rapid vertical phase of growth.

Nodular melanoma • Worst prognosis
• Amelanotic melanoma : Variant of nodular type

Ix :
Biopsy (Confirmatory) : IHC markers

S-100, Melan-A, HMB-45 .

Subungual melanoma
ABCDE changes in pre existing mole : (Hutchinson sign)
Asymmetry
Borders (Irregular) Indicates malignant
Colour change transformation
Diameter becomes >6 mm
Evolution
ABCDE Changes
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 Hernia, Thorax and Skin 211

Staging : ----- Active space -----

1. Clarke & Breslow : Depends on depth of invasion.
2. TNM staging.

Mx : Wide local excision.

Prognostic factor : Lymph node status (Most important).

Marjolin’s Ulcer :
• Squamous cell carcinoma in pre existing burns
scar/venous ulcer.
• Mx : Surgery (Radiotherapy does not work well).

Marjolin’s ulcer

om
Soft Tissue Sarcoma (STS)

l.c
00:36:52

ai
gm
• M/c STS : Liposarcoma. 7@ Sarcoma spreading to LN
• m/c STS in children : Rhabdomyosarcoma.
a4

(Exceptions)
tiy

• Common STS in males : Malignant fibrous histiocytoma

ga

Mnemonic : MARCES
ar
ik

C/f : Lump/mass (M/c). • Malignant fibrous histiocytoma

sh

• Angiosarcoma
va

Spread : Hematogenous > Lymphatic (Rare).

ur

• Rhabdomyosarcoma
|
w

• Clear cell
ro

• Limbs Lungs
ar

• Epithelial
M

• Retroperitoneum Liver
©

• Synovial
Ix : Mx : Lymph node (LN) clearance
• Tru-cut/Core biopsy : Confirmatory.
• PET-CT : Staging.
Mx : Wide local excision + Radiotherapy + Chemotherapy.
Prognostic factor : Grade of tumour (Most important).

Desmoid Tumour :
• STS of anterior abdominal wall,
seen in site of scar.
• ↑Chances of recurrence.
• A/w Gardner Syndrome.
Mx : Wide local excision.
Desmoid tumour

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 212

----- Active space ----- VASCULAR SURGERY

Acute Arterial Occlusion  00:01:23

Features :
• M/c cause : Embolus (M/c source Heart).
• H/o ischemic heart disease ; H/o A-fib (Irregularly irregular heart beat).

Clinical features (6Ps) :

• Pain. • Poikilothermia (Cold limbs).
• Pallor. • Pulselessness.

om
• Paresthesia. • Paresis/paralysis (Late signs).

l.c
ai
gm
Management :
IOC : Doppler/Duplex Scan. 7@
a4

Rx : Patient presented within 6-8 hours

tiy
ga

Yes No
ar

Late
ik
sh

Embolectomy using Gangrene +

va

Fogarty’s balloon
ur

Acute arterial embolus : No collaterals

|

Amputation.
w

Complication
ro
ar

Reperfusion injury
M
©

Muscle swelling

Fasciotomy. Fogarty’s balloon Embolectomy angiogram : Revascularisation

Chronic Arterial Occlusion  00:04:17

Features :
• Gradual occlusion (D/t thrombus) Formation of collaterals.

Clinical Features :
• Intermittent claudication Cramping pain.
• Rest pain
Progressive pain.
• Gangrene Chronic arterial occlusion :
Formation of collaterals

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 Vascular Surgery 213

Differentials : ----- Active space -----

Intermittent claudication Osteoarthritis Neurogenic claudication

Cramping pain after Maximum pain Pain varies with posture
Walking a certain distance. on first step. • Bending forward : Relieved.
Pain is one level below Pain in • Standing straight : Aggravated.
site of occlusion. affected joint.
• Due to substance P.
- D/t lumbar canal stenosis.
• Progresses to rest pain.
Boyd’s Classification :
Class 1 Class 2 Class 3 Class 4
Pain on walking Pain on walking

om
Pain forces

l.c
Pain at rest

ai
Reduces as patient Able to walk patient to stop

gm
continues to walk despite pain 7@
a4

Site of Obstruction :
tiy
ga

1. Aortoiliac : 2. Iliac : Thigh pain.

ar

- Buttock claudication (Earliest). 3. Femoropopliteal : Calf pain.

ik
sh

- Pain in thigh & calves. 4. Distal obstruction : Ankle pain.

va
ur

- Bruit over aortoliac region.

|
w

- Impotence in males (Leriche Syndrome).

ro
ar
M

Investigations :
©

IOC : Doppler or Duplex (Doppler + B-mode USG) scan.

Max systolic BP at ankle
ABPI : Ankle brachial pressure index =
Max systolic BP at brachial artery
Values Inference
> 1.4 Calcifled vessels (DM/CKD)
0.9 - 1.4 Normal
< 0.9 Intermittent claudication
< 0.4 CLTI
> 20% drop after exercise Flow limiting arterial disease
Bailey updates :
• Patients with ABPI < 0.5 are twice as likely to deteriorate more than those with
> 0.5.
• Gradually decreasing ABPI : Sign of imminent limb loss.
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 214 Surgery

----- Active space ----- • For every 0.1 decrease in ABPI below 0.9 - Risk of cardiac mortality increases
by 10%.

Note : CLTI (Chronic limb threatening ischemia)

• Ischemic rest pain ± ulceration/gangrene.
• Require urgent assessment & treatment.
TBI (Toe brachial pressure index) :
• Used in DM patients with ABPI > 1.4.
• More reliable : Digital arteries are rarely affected by sclerosis.
• TBI < 0.6 indicates an arterial lesion.
Digital subtraction angiography (DSA) :
• Only done if intervention is planned.
• Provides dynamic arterial flow + anatomy of vessels.

om
• Complications :

l.c
- Bleeding. - Renal dysfunction.

ai
gm
- Dissection. - Aneurysm.
7@
- Thrombosis.
a4
tiy

Buerger’s vs Atherosclerosis 
ga

00:13:47
ar
ik
sh

Buerger’s disease
va

Atherosclerosis
ur

(Thromboangitis obliterans)
|
w

Gender M>F M=F

ro
ar

Age 3 decade
rd
≥ 5 decade
th
M
©

Smoking, alcohol, type A

Risk factors Smoking
personality, hyperlipidemia
Limbs affected Lower limbs > Upper limbs Lower limbs > Upper limbs
Affected structures Artery, vein, nerve Arteries
Progression Distal Proximal Proximal Distal
Vessels affected Small to medium Large to medium
Other features Confirmatory test : Muscle biopsy -
1. Stop smoking. 1. Angioplasty (First line)
2. Pentoxyphylline. 2. Bypass (Best) : Using grafts
3. Conservative amputation
Management 4. Lumbar sympathectomy :
- Only if rest pain + , C/I : Claudication
- If B/L, conserve L1 ganglion on one side
(To prevent impotence)

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 Vascular Surgery 215

Buerger’s disease : 1. Gangrene of toes 2. CT angiography ----- Active space -----

Line of
demarcation Corkscrew
Collaterals

Management of Atherosclerosis :
1. Angioplasty & stenting :
- 1st line Rx.
- Successful for iliac & femoropopliteal
(Less successful below knee).
- Complications :

om
• Failure Endovascular stenting

l.c
ai
• Hematoma

gm
• Bleeding 7@
a4
• Thrombosis
tiy

2. Grafting : Best method.

ga
ar

- Suprainguinal :
ik

Synthetic graft
sh

• Aorto-bifemoral.
va
ur

• Dacron graft (Best).

|

- Best infra-inguinal graft : Reversed saphenous vein (GSV).

w
ro

• S/E during harvesting : Saphenous nerve injury.

ar
M

- Best synthetic graft : PTFE.

©

Gangrene  00:20:02

Dry gangrene Wet gangrene

• Dessicated tissue : D/t • D/t venous blockade or superadded infection.
gradual slowing of blood. • Poor line of Can be proximal d/t
• Good line of demarcation. demarcation extension of infection
• If bone involved : Conical
stump.

Dry gangrene Wet gangrene

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 216 Surgery

----- Active space ----- Amputation :

Indications : Cancer, gas gangrene, contractures.
Types :
• Local amputation of digits : DM.
• Ray excision : Metatarsophalangeal joint.
• Transmetatarsal : Several toes affected.
Below knee amputation Above knee amputation
• Preserves knee. • Heals well.
• Best chance of walking. • Amputation stump : ≥ 2ocm.
• Amputation stump : ≥ 8cm below knee (10-12cm).
• Flaps : Long posterior, skew flap.

om
l.c
ai
gm
7@
a4
tiy
ga
ar
ik
sh
va

Long posterior flap marking

ur
|

Complications :
w
ro

• Early :
ar
M

a. Hemorrhage.
©

b. Infection.
c. Flap necrosis.
d. DVT.
• Late :
a. Pain.
b. Phantom limb syndrome.

Aortic Aneurysm  00:22:27

Aneurysm vessels :
• M/c vessel involved : Circle of Willis.
• M/c extracranial vessel : Infrarenal abdominal aorta.
• M/c peripheral vessel : Popliteal artery.
• M/c visceral vessel : Splenic artery
• M/c vessel in mycotic aneurysm : Abdominal aorta (D/t S. aureus).
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 Vascular Surgery 217

ABDOMINAL AORTIC ANEURYSM (AAA) : ----- Active space -----

M/c site : Infrarenal abdominal aorta.
Most important risk factor : Atherosclerosis.
Screening : USG (From 65 yrs).

Critical Diameter :
• Abdominal aortic aneurysm : 5.5cm.
• Ascending thoracic aortic aneurysm : 5.5cm.
↑ Risk of rupture
• Descending thoracic aortic aneurysm : 6cm.
beyond this size.
• Marfan’s + thoracic aortic aneurysm : 4.5 - 5cm.

Clinical Features :
• Asymptomatic. • Abdominal pain.
• Blue toe syndrome (D/t emboli from • Pulsatile mass.

om
l.c
aneurysm).

ai
• Rupture into left retroperitoneum

gm
(High mortality > 50%). 7@
a4
tiy

Management :
ga
ar

IOC : CT Angiography.
ik
sh

Treatment : AAA
va

1. Open repair :
ur
|

- Indication
w

Longer life expectancy

ro

- Advantage
ar
M

2. EVAR (Endovascular aneurysm repair) :

©

CT Angiogram
- Indications : High risk patients, hostile abdomen.
- Disadvantage : Life long follow-up.
- Complications : Endoleaks.

Open repair EVAR

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 218 Surgery

----- Active space ----- Types of endoleaks :

Type Cause M/c procedure Image

Type 1 Improper seal Thoracic aortic aneurysm repair

Retrograde leak
Type 2 Abdominal aortic aneurysm repair
from lumbar vessels

om
Note : Exposure of great vessels.

l.c
Mattox manoeuvre Cattle-Brasch manoeuvre

ai
gm
• Left medial visceral rotation 7@ • Right visceral medial rotation
of descending colon. of ascending colon.
a4
tiy

• Exposes abdominal aorta. • Exposes IVC.

ga
ar

(Aneurysm repair)
ik
sh

Complications of EVAR :
va
ur

1. Cardiovascular causes : M/c cause of mortality.

|

2. Renal failure.
w
ro

3. Aortoduodenal fistula (Haematemesis).

ar
M

4. Left sided colonic ischemia :

©

- D/t splenic flexure / Griffith point (Watershed

area).
- C/f : Bloody diarrhea. Ruptured aneurysm
5. Paraparesis : D/t artery of Adamkiewicz.
6. Mortality : 2-3%. ( > 50% if rupture + ).

Aortic Dissection  00:29:41

False lumen is formed Blood flows b/w intima & media.

Features :
• M/c site : Lateral wall of ascending • M > F.
thoracic aorta. • Seen in 5th decade.
• Most important risk factor : HTN. • Causes coronary insufficiency.
• M/c symptom : Chest pain radiating • B/L upper limbs : Different BP
to the back. readings.
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 Vascular Surgery 219

Investigations : ----- Active space -----

1. Chest X-ray :
- Widening of mediastinum.
- Depression of the
left main bronchus.
2. CT angiography :
IOC in stable patients. Chest X-Ray CT angiogram
3. Transesophageal echocardiography : IOC in unstable patients.

Classification : DeBakey Classification

DeBakey Extent Stanford
Ascending +
I (M/c) descending A

om
l.c
II Only ascending

ai
gm
III Only descending B
7@
a4
tiy

Stanford Classification
ga

Management :
ar

(1st Step) IV Esmolol for permissive hypotension

ik
sh

DeBakey type
va
ur
|

1&2 3
w
ro
ar

Monitor Deterioration Surgery.

M

Graft repair (Open/EVAR).

©

Popliteal Aneurysm  00:34:10

M/c peripheral vessel involved.

Features :
• Loss of contour of popliteal fossa.
• Pulsatile swelling behind knee.

Management :
Indications :
1. All symptomatic patients.
2. Asymptomatic + >2cm size.
Treatment : Graft repair.

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 220 Surgery

----- Active space ----- Raynaud’s Phenomenon  00:34:35

Causes :
1. Cold weather
Vasospasm.
2. H/o use of drilling equipment

Features :
Colour change : White Blue Red
( Pain + )

Primary vs Secondary :

Primary Secondary
Prevelance Common Rare

om
Association with collagen vascular diseases No Yes

l.c
ai
Complications Rare Yes

gm
Pharmacological Rx 7@
No (Occasional) DOC : CCB
a4
tiy
ga

Subclavian Steal Syndrome  00:36:01

ar
ik
sh

Pathophysiology :
va
ur

Subclavian artery (1st part) stenosis

|
w

Upper limb exercise

ro
ar

Retrograde blood flow vertebral/basilar artery

M
©

Clinical feature : Syncopal attack after exercise.

IOC : CT angiography.
Rx : Angioplasty.

Thoracic Outlet Syndrome  00:36:53

Etology :
• Poor muscle tone.
• Cervical rib.
Clinical Features :
• Arterial occlusion Gangrene/claudication.
• Venous occlusion Subclavian vein thrombosis.
• Compression of brachial plexus Pain along ulnar border.

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 Vascular Surgery 221

Tests : ----- Active space -----

Test Positive sign

Adson’s test ↓ / Absence of ipsilateral pulse.
Roos/Elevated arm Continuous pain, paresthesia, heaviness/
stress test weakness.
Management :
1. Cut cervical rib.
2. Physiotherapy.
3. Angioplasty / grafting for thrombosis.

AV Malformations  00:38:59

Causes :

om
1. Traumatic.

l.c
ai
2. Iatrogenic (M/c) :

gm
- Cimmino/Radiocephalic fistula : For dialysis. a4
7@
- Test for radioulnar patency : Allen’s test.
tiy

3. Congenital
ga
ar

Note :
ik
sh

Crisoid Aneurysm :
va

Crisoid aneurysm
• AV malformation of superficial temporal vessels.
ur
|

• Pulsatile swelling on the head.

w
ro

Clinical Features :
ar
M

• Pulsatile swelling
©

• Hypertrophy of limb Congenital fistula.

• High output cardiac failure Size↓
• Nicoladoni/Branham sign : Pressing feeding vessel Pulse↓
Management : Systolic BP↑
IOC : CT/MR Angiography.
Rx : Embolisation.
Deep Vein Thrombosis (DVT)  00:41:21

Risk Factors : Virchow’s triad

Stasis : Endothelial injury : Hypercoagulable state :

Obesity. • Trauma. • Immobility. • Pregnancy.
• Surgery. • Puerperium. • Malignancy.
• High dose estrogen.
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 222 Surgery

----- Active space ----- Clinical Features :

1. Pain & swelling.
2. Limb edema (Constant sign) : Mostly U/L lower limb.
3. Homan’s sign : Dorsiflexion of foot Resistance in calf.
4. Moses sign : Squeeze calf Pain.

Phlegmasia alba dolens : Phlegmasia cerulea dolens :

• Painful white/milk limb. • Painful blue limb.
• Thrombosis of : • Thrombosis of : Major
Major axial veins. axial veins + collaterals.

Investigations :

om
1. Doppler/Duplex Scan : IOC.

l.c
2. CT Angiography : If suspecting pulmonary embolism.

ai
gm
Treatment : 7@
a4

1. Patient presents within 6-8 hours :

tiy

Well’s criteria
ga

Yes No
ar

Score Probability
ik
sh

Direct Anticoagulants : -2 to 0 Low

va

thrombolysis • First 5 days : LMWH + warfarin.

ur

1 to 2 Moderate
|

• After 5 days : Only warfarin.

w

>2 High
ro

• Target INR : 2-3.

ar
M

2. Pregnancy : LMWH.
©

3. Heparin Sensitive : INR = PT Patient

- Fondaparinux (International Normalised Ratio) PT
- Bivalirudin Control

- NOAC (DOC) : Rivaroxaban, Apixaban

4. Greenfield filter :
- Recurent thromboembolism despite auticoagulation.
- C/I to anticoagulation (Eg : Brain hemorrhage).
- Complications of recurrent PE Pulmonary hypertension.
- Complications of anticoagulation.

IVC filter
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 Vascular Surgery 223

Complications : ----- Active space -----

Post thrombotic leg :
• In 2/3rd patients : 2˚varicose veins following DVT.
• Maximum blood flow shifts from deep to superficial system.
• C/f : Varicose veins, pigmentation, lipodermatosclerosis.
Post thrombotic leg
• Varicose vein surgery is contraindicated.

DVT Prophylaxis :
High risk patients :
1. Major orthopedic surgery/fracture of hip, pelvis, lower limb.
2. Major abdominal/pelvic surgery.
3. Major surgery in patient with h/o DVT/pulmonary embolism.
4. Lower limb paralysis.

om
5. Lower limb amputation.

l.c
ai
gm
Prophylaxis in high risk patients : Dual prophylaxis.
Pharmacological : + Mechanical : 7@
a4

LMWH • Early ambulation.

tiy
ga

• Pneumatic compression
ar
ik

stockings.
sh
va

Pneumatic compression stockings

ur
|
w

Varicose Veins 
ro

00:50:17
ar
M

Anatomy :
©

Site of origin Drains into

Saphenofemoral junction
Medial & anterior
GSV (Constant : 4 cm below &
part of foot
lateral to pubic tubercle)
Saphenopopliteal junction
SSv Posterior part of foot
(Variable location)

Note : Vein of Giacomini (Connects SSV to GSV) ↑ Recurrence rate.

Vein Associated neve Surgical implication

GSV Saphenous nerve (Below knee) No stripping below knee
SSV Sural nerve No stripping

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 224 Surgery

----- Active space ----- Perforators : Superficial Deep.

• Hunterian : Thigh.
• Dodd : Above knee.
• Boyd : Below knee.
• Cockett : 5, 10, 15 cm above medial malleolus.
• May Kuster : Heel.

Clinical Features :
1. Dilated veins (M/c) :
- >3mm : Varicose veins. Varicose veins
- 1-3mm : Reticular veins.
- <1mm : Thread veins /Dermal flares/Telengiectatic veins.
2. Corona phlebectasiae/Malleolar flare :

om
- Fan shaped arrangement of thread veins around ankle.

l.c
- Early sign of advanced disease.

ai
gm
3. Atrophie blanchie : Areas of depigmentation surrounded by dilated veins.
7@
4. Pigmentation : D/t hemosiderin deposition.
a4
tiy

5. Lipodermatosclerosis : D/t obliteration of fat.

ga

- Shiny skin.
ar
ik

- Tendoachilles contracture.
sh
va

- Inverted champagne bottle appearance.

ur
|

6. Dull aching pain.

w
ro

7. Venous ulcers.
ar
M
©

Thread veins Atrophie blanchie Lipodermatosclerosis

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 Vascular Surgery 225

CEAP Classification : ----- Active space -----

Grade Clinical features

C0 No visible or palpable signs of venous disease
C1 Telangiectasias or reticular veins
C2 Varicose veins (> 3 mm)
C2r Recurrent varicose veins
C3 Edema
Changes in skin and subcutaneous tissue secondary to
C4
chronic venous disease
C4a Pigmentation or eczema
C4b Lipodermatosclerosis or atrophie blanche
C4c Corona phlebectatica

om
C5 Healed ulcer

l.c
ai
C6 Active venous ulcer

gm
C6r Recurrent active venous ulcer7@
a4
tiy

Investigations :
ga

IOC : Doppler.
ar
ik

Mickey mouse sign :

sh
va

CFA (Common femoral artery)

ur

+
|
w

GSV (Great saphenous vein)

ro

+
ar
M

FV (Femoral vein)
Mickey mouse sign
©

Note : Profunda femoris is not a part of mickey mouse sign.

Clinical Tests :
For SFJ incompetence For perforator incompetence For DVT
• Trendelenburg test. • Trendelenburg test.
Modified Perthe’s
• Morrisey cough impulse. • Multiple tourniquet test.
test.
• Schwartz test. • Fegan’s method.
Management :
1. Adjuncts to surgery : Compression garments class III (25-35mmHg).
2. Surgery :
a. EVLT (Endovenous laser therapy)
TOC.
b. RFA (Radiofrequency ablation)
c. Trendelenberg procedure (Flush ligation of SFJ) ± stripping of veins.
Prevention of recurrence : Ligation of tributaries.

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 226 Surgery

----- Active space ----- 3. Foam sclerotherapy : Tessari technique.

- Sclerosant : Sodium tetradecyl sulphate.
- Air : Sclerosant = 3 : 1 or 4 : 1.
- Rx for thread veins/dermal flares.

Corona
phlebectasia

Foam sclerotherapy
Complications :
Complications of varicose vein surgery Complications of varicose veins

om
• Injury to nerves (M/c) : Saphenous • Bleeding.

l.c
ai
nerve, sural nerve. • Calcification.

gm
• Wound infection. 7@ • Superficial thrombophlebitis.
• Bruising. • Pigmentation.
a4
tiy

• Recurrence (SSV > GSV). • Lipodermatosclerosis.

ga

• Bleeding. •
ar

Ulceration.
ik
sh

• Injury to vessels.
va
ur
|

Ulcers  01:02:00
w
ro
ar

Venous Ulcer :
M
©

M/c site : Medial malleolus/Gaiter’s. area.

Cause : Ambulatory venous hypertension theory.
Clinical Features :
1. Shallow ulcer.
2. Sloping edges.
3. Pale graulation tissue.
4. Pigmented margins.
Venous ulcer
Management :
1. Bisgaard’s regime :
- Education. - Elastic compression stockings.
- Elevation of limb. - Dressings.
2. Surgery.
3. Pentoxyphylline : Increases microvascular perfusion.

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 Vascular Surgery 227

Complication : ----- Active space -----

Marjolin’s ulcer :
• SCC developing from longstanding venous ulcers/burn scars.
• Mx : Wide local excision.

Note :
Marjolin’s ulcer
Types of ulcer edges.
Edge Condition
Sloping venous ulcer, healing ulcer
Punched out Arterial ulcer, neuropathic ulcer, bed sores, syphilis
Undermined TB

om
Rolled out BCC(Rodent), Marjolin’s ulcer

l.c
Cauliflower Squamous cell carcinoma

ai
gm
D/D of Leg Ulcers : 7@
a4
tiy

Venous ulcer Arterial ulcer Trophic ulcer Diabetic ulcer

ga
ar

Medial malleolus/ Dorsum/ Sole/base of Sole/base of

ik

Site
sh

Gaiter area lateral side the great toe the great toe
va

Arterial Absent Normal

ur

Normal May be absent

|

pulsations pulsations pulsations

w
ro

Dilated
ar

Present N/A N/A N/A

M

veins
©

Reduced Reduced
Sensation Normal Painful
sensations sensations
Margins Sloping Punched out Punched out Punched out
1. Debridement.
Mx
2. VAC Dressing (-125 mmHg) : C/I in osteomyelitis with DM.

Arterial ulcers :
• H/o claudication.
• Loss of muscle mass/hair.

Diabetic ulcers :
• Microangiopathy.
• Increased glucose.
Arterial ulcer Diabetic ulcer
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 228 Surgery

----- Active space -----

Basal cell carcinoma (BCC) Squamous cell carcinoma (SCC)

om
l.c
ai
gm
Tubercular ulcer VAC dressing Trophic ulcer
7@
a4

Cystic Hygroma  01:09:07

tiy
ga

• Sequestered lymphatic tissue.

ar
ik

• M/c site : Posterior triangle of neck.

sh
va

• Clinical features : Fluctuant swelling,

ur
|

brilliantly transilluminant, partly compressible.

w
ro

• Mx : Aspiration f/b surgery.

ar
M

• Nerve at risk during Sx : Spinal accessory nerve.

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Lymphedema  01:09:54

Excessive interstitial fluid.

Classification :
Congenita Praecox Tarda
Primary :
0 - 2 yrs 2 - 35yrs > 35 yrs
M>F F>M
• Multiple limbs
• Face U/L till knee
• Genitalia -
Noone Milroy syndrome : Meig’s disease :
• Familial • Familial
• FLT-4 gene • GJC gene

Surgery Revision • v4.0 • Marrow 8.0 • 2024

 Vascular Surgery 229

Secondary (M/c) : ----- Active space -----

• Upper limb m/c cause : Post mastectomy/Post lymph node clearance.
• Lower limb m/c cause : Filariasis/Elephantiasis.

Post mastectomy Filariasis

Brunners Classification :

om
l.c
Subclinical

ai
Excess interstitial fluid with no clinical signs

gm
(Latent)
7@
Stage I Pitting edema
a4
tiy

Stage II Non pitting edema

ga
ar

Edema + irreversible skin changes :

ik
sh

Stage III • Stemmer’s sign : Inability to pinch the skin.

va

• Buffalo hump : Loss of ankle contour. Skin changes

ur

in lymphedema
|
w
ro

Stewart-Treves Syndrome :
ar
M

• Developement of angiosarcoma in long

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standing lymphedema (8-10 yrs).

• Bluish / Reddish nodules.

Investigations :
Gold standard : Water plethysmography Mild : < 20%.
Moderate : 20-40%.
Severe : > 40%.
Management :
1. Skin care :
- Protect skin while chopping - Treat cuts with antibiotics.
vegetables/gardening. - No blood sampling from affected
- Never walk barefoot. limb.
- Use electric razors to depilate. - Use sunscreen.
- Never let the skin become
macerated.
Surgery Revision • v4.0 • Marrow 8.0 • 2024
 230 Surgery

----- Active space ----- 2. Decongestive lymphedema therapy :

1st Intensive phase 2nd Maintenance phase

Supervised
• Manual lymphatic drainage Self care
• Multilayer lymphedema bandaging

3. Exercises :
- Slow rhythmic isotonic (Eg : Swimming).
- Vigourous, anaerobic, isometric exercise worsens lymphedema.
4. Surgery :
- Lymphovenous anastamosis : TOC.
- Reduction procedures : Not done.

om
l.c
ai
gm
7@
a4
tiy
ga
ar
ik
sh
va
ur
|
w
ro
ar
M
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Surgery Revision • v4.0 • Marrow 8.0 • 2024