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General Surgery Revision 1 01 1

GENERAL SURGERY REVISION 1 ----- Active space -----

Day Care Surgery 00:01:16

Terms used in ambulatory surgery :

• Outpatient surgery : Not admitted to a ward facility
• Day-care or same-day surgery : admitted and discharged within 12 hours
day.
• Overnight stay : 23 hour admission with early morning discharge.

Selection criteria :
Social : Carer must be present for the first 24 hours.
Surgical : Operations upto 2 hours.
ASA 1 & II : eligible in a stand alone day care unit.
ASA III : eligible in an integrated day care surgery centre (attached to hospital )
Other criteria :
• BP < 180/100.
• In a diabetic, HbA1c <8.5 (should omit morning dose of oral hypoglycemic
drugs/ OHA).
• BMI < 40 kg/m2 for surface procedures.
• BMI < 38 kg/m2 for laparoscopic procedures.
• Well controlled case of epilepsy are eligible.

Anaesthesia & analgesia :

• Total intravenous anaesthesia (TIVA) → propofol → post operative nausea
& vomiting.
• Analgesia infiltration post surgery → bupivacaine (long acting local anaes-
thetic with side effect of cardiotoxicity).

Post operative complications :

• Post op nausea & vomiting (PONV) : m/c complication of day care surgery
• Hemorrhage : M/c complication requiring readmission after day care
surgery (Reactionary Hemorrhage).
• Pain

APFEL score is used to predict risk for post operative nausea and vomiting (PONV).

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

Discharge criteria :
• Vital signs stable for atleast 1 hour.
• Oriented to time place and person.
• Adequate pain control with a supply of oral analgesia.
• Understands how to use oral analgesia supplied.
• Ability to dress and walk where appropriate.
• minimal nausea, vomiting or dizziness.
• Has taken oral fluids.
• Minimal bleeding or wound drainage.
• Has passed urine (if appropriate).
• Has a responsible adult to take them home.
• Written and verbal instructions given about post operative care.
• Knows when to come back for follow up.
• Emergency contact number supplied.

ERAS protocol (Enhanced Recovery After Surgery Protocol) :

Preoperative Intraoperative Post operative
• Avoid mechanical • Minimally invasive • Opioids only for
bowel preparation surgical approach breakthrough pain
• Solids up to 6 hours • Local anaesthetic or • Regular diet within
prior to surgery long acting local (lipo- 24 hours
• Clear fluids up to 2 somal bupivacaine) • Discontinue IV fluids
hours prior to surgery • Prophylaxis for nau- within 24 hours
(carbohydrate loading sea and vomiting • Ambulate within 24
can be done). (atleast 2 classes of hours
medications)

Patient safety, OT zones and surgical positions 00:10:52

Events in patient safety :

• An adverse event : An incident that results in harm to the patient.
• A near miss : An incident that could have resulted in unwanted consequenc-
es but did not, either by chance or through a timely intervention preventing
the event from reaching the patient.
• A no-harm event : An incident that occurs and reaches the patient but re-
sults in no injury to the patient. Harm is avoided by chance or d/t mitigating
circumstances.

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General Surgery Revision 1 01 3

IV Cannulas : ----- Active space -----

Color Gauge Maximal Flow
Rate (mL/min)
Yellow 24G 13
Blue 22G 30
Pink 20G 60
Green 18G 96
Gray 16G 240
Orange 14G 270

Superficial thrombophlebitis :
m/c complication of canula insertion.
Cord like structure formed, can persist for 3-4
months.
Associated with pain, fever.
Treatment: Topical thrombophobe ointment.
Surgical safety checklist :
Sign in Time out Sign out
Before induction of Before skin incision Before patient leaves oper-
anaesthesia . ating room, at skin closure.
From ward to OT table
written consent Re confirm identity of patient Nurse : Gauze and
Confirm identity of Surgeon says : instrument count
patient Name of procedure Anaesthetist : Actual blood
Confirm site marking Estimated blood loss loss
Inquire about allergies Anaethetist says : Surgeon : Specimen
Antibiotic prophylaxis given labeling

OT zones :
Protective Zone Clean Zone (Connects protective zone to aseptic
zone)
• Change rooms • Equipment store room
• Transfer bay • Maintenance workshop
• Pre & post op rooms
• ICU/ PACU
Aseptic zone Disposal zone
• OT • waste disposal

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----- Active space ----- OT positions :

Supine position :
M/c position for abdominal and breast surgeries.

Trendelenburg position :
Used in pelvic surgeries.
Foot end is raised, head end is low.

Reverse trendelenburg position :

Used in laparoscopic cholecystetomy.
Head end is raised, foot end is low.

Lithotomy position :
Used in obstetric, gynaecological and urological
procedures.
Common peroneal nerve injured if legs are not
supported properly in lithotomy position.

Lateral or kidney position :

Uses :
• Thoracotomy
• Pyelolithotomy
• Nephrolithotomy
• Nephrectomy
Brachial plexus injury if arms are hyperextended in lateral position.

Prone position :
used for spinal surgery and pilonidal sinus surgery

Sitting/Fowler’s position :
used for posterior cranial fossa surgeries.
Advantage : Relatively bloodless field
Good exposure
DIsadvantage : Air embolism if veins are nicked.

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General Surgery Revision 1 01 5

Air embolism : ----- Active space -----

• 50-100 cc of air
• Typical clinical presentation : During thyroid/head & neck surgery or CNS
surgery.
• Vein gets nicked → Sudden desaturation
• Can occur in Sitting position
• Rx : Durant position (recovery position)/ Left lateral legs up position
a. Air remains in right side of heart
b. Air can be aspirated through a central line or direct aspiration under
image guidance.

Jack knife position :

Earlier used for hemorrhoid and fissure surgeries
Not preferred these days d/t positional asphyxia

Surgical Blades & Energy Sources 00:23:12

• Number 11 (Pointed/tab blade) : For incision & drainage

• Number 12 (Curved) : For suture removal
• Number 10, 15, 20, 21, 22, 23 : For making incisions
• Blades are passed in a kidney tray to prevent injury
• Incisions must be made from far to near

Bard Parker handle

Factors while planning an incision :
• Skin tension lines (Langer’s lines) : represent
orientation of dermal collagen fibres and
incisions should be placed parallel to them.
• Incision not to be made directly over vital
Anatomical structures.
• Cosmetic factors : try to make incisions over
skin creases so that they remain hidden.
• Incision must give adequate access for surgery. Langer’s lines

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

Energy sources :
Monopolar Cautery Bipolar Cautery
Current flow : • Current enters through one
• Current from machine to tip. surgeon uses tip to channel and exits from an-
cut or coagulate. other channel
• Current leaves body through cautery pad. • Circuit is getting locally
• Cautery pad should be placed over a well completed
vascularized area & should have a wide area of
contact
• If small cautery pad/improperly placed pad :
there can be burns at the site of attachment
• Cautery pad not placed → Incomplete circuit
→ Cautery won’t work
Can injure nerves and end arteries and nearby vital Can be used near vital
structures (Current traveling throughout the body) structures, end arteries.
Avoid near nerves, end arteries (Eg: ear lobule, penis) Suregries used :
and in patients with cardiac pacemakers. Thyroid
Parotid
Penile
Can cut and coagulate Only coagulate

Monopolar cautery Bipolar cautery

Cutting vs Coagulation/ Fulgration

• Cutting current : Low voltage continous current and sufficient heat to
cause cell water to explode into steam
• Coagulation : High voltage Alternating current
Cell death by dehydration and protein denaturation.
Ligasure :
• Heat plus pressure. • Can coagulate vessels upto 7mm in diameter.
• Uses collagen & elastin to seal & divide.

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Harmonic Scalpel : ----- Active space -----

Works on the ultrasonic principle : Coagulation without heat production.
Oscillatory blade : Oscillates b/w 20,000–50,000 Hz.
Advantages :
• Precise cut
• Can cut through scar tissue
• Can be used close to vital structures
• Can coagulate vessels upto 7 mm in diameter.

Radiofrequency ablation (RFA) and microwave ablation :

RFA Microwave ablation
High frequency Alternating current In between infra red & radiowaves
Similar to electrocautery Oscillation & frictional heat
Grounding/cautery pad needed No grounding pad
Till 3 cm tumors Less time than RFA
Larger, more homogenous zone of ablation

Argon photocoagulation :
• Rapid activity
• Shallow penetration
• Faster heat dissipation
• Less eschar
• Ineffective for large vessels → avoided close to larger veins → can give
rise to gas embolism
• Used in Barrett’s esophagus, Gastric Vascular Antral Ectasia (GAVE)

Drains, sutures and knots 00:23:12

Drains :
Corrugated rubber
drain : Open drain for
abscesses. Rarely used.

Romovac suction drain :

Closed drain with negative pressure. Can be used after
mastectomy, thyroidectomy, neck dissection.

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

Minivac drain : Negative pressure Jackson Pratt drain : Closed suction negative
drain (smaller version of romovac pressure drain. Flat tubing and bulb instead of bag in
drain). the end (romovac is rounded)
Used in sentinel lymph node biopsy. Mainly used for abdominal surgery.

Abdominal
drain :
Connected
to abdominal
drainage bag. Underwater seal bag :
Connected to intercostal chest tubes.

Knots :

Square/reef knot : Surgeon's knot : Two

secure knot, doesn't throws followed by one
open up. throw. Secure knot.

Below Above Above

Below

Below Above Below Above

Granny knot/Slip knot :

Insecure knot.

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Skin suturing : ----- Active space -----

• Angle at which suture bite should be taken=90°
• If length of bite on each side = x
• Distance between 2 sutures = 2x
1. Mattress sutures : Placed where edges aren’t
everted.
• Help in eversion and are Hemostatic
While suturing the skin,
• 2 types : Horizontal & vertical.
needle should enter the
2. Subcuticular sutures : Cosmeticallly better. Sutures skin at 90˚ angle.
buried inside skin, hence no mark.
• 3-0 Monocryl on a cutting needle : best material used for suturing.

Subcuticular sutures

Vertical mattress
Horizontal mattress

Other Suture techniques :

Continuous suture Interrupted suture Purse string suture : Used

in cervical cerclage and to
bury appendicular stump

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----- Active space ----- Needles :

Swaged end : End of the needle where the thread is attached.
Needle to be held at : 1/3rds from swaged end and 2/3rds from Pointed end.
Types of needles :
• Round body needle : Rounded cross section.
For delicate structures → Bowel, Bladder, CBD,
Blood vessels.
• Cutting/ reverse cutting needles : Triangular
crosssection → For tough structures → Skin,
Sheath, Fascia

Sutures :
Number of suturing :
No 1 : thickest suture
Suture becomes finer as number increases and 0 is added after number (Eg:
1-0, 2-0)
Thicker sutures are easier to handle and fracture less easily.

Type of sutures :

Absorbable sutures
Natural Synthetic
Catgut : Monocryl (Polyglyceparone) :
• Derived → Sheep submu- • Monofilament (less infection rate, diffi-
cosa. cult to handle).
• Absorbed by Enzymatic • Subcuticular suturing (3-0)
degradation in 90 days. Vicryl (polyglactin) :
• Tensile strength (duration • braided suture (Multiple intertwined
upto which it can hold to- hair) → Easier to handle but more
gether) : 21-28 days. chances of infection.
• No role in surgery these • Absorption by hydrolysis : 60-90 days.
days. • Uses : Bowel (3-0), bladder (3-0), CBD
(5-0).
Polydiaxone :
• Monofilament suture
• absorbed in 180 days
• uses are same as vicryl

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Non-Absorbable sutures ----- Active space -----

Natural Synthetic (most inert type of suture)

Silk : Prolene (polypropelene) :
• Skin : 3-0 cutting. • Monofilament
• Fix drains : No. 1 cutting. • Rectus sheath : No. 1 Cutting.
• 2nd layer of bowel anasto- • Minimum length required to close the rectus
mosis : 3-0 Round bodied. sheath is 4 times the length of the wound →
Jenkin’s rule to avert wound dehiscence
• Vascular repair : Aorta (Round body 2-0),
• Femoral (4-0)
• Popliteal (6,0).
• Mesh in hernioplasty
Nylon (monofilament) /Ethilon :
• Skin : 3-0 cutting.
• Tendon and skin repair.
• Nerve repair.
Polyester/Ethibond : Skin and tendon repair
Steel : close sternum after CABG

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 :
• Single layer extra-mucosal.
• Two layer bowel anastomosis. Same outcome
• Stapled bowel anastomosis.
Strongest layer in bowel anastomosis : Submucosa

Surgical staplers :

Linear stapler : Bowel Circular stapler :

anastomosis • Low anterior resection after
• Sleeve Gastrectomy rectal cancer surgery.
• Zenker's diverticulum • Stapler Haemmorhoidopexy

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----- Active space ----- Post op fever and wound infection 00:51:35

Causes of post op fever :

Day 1 : M/c cause : Atelectasis
Prevention :
• Chest physiotherapy.
• Pain control.
• Steam inhalation.
• Cessation of smoking 4-6 weeks Incentive spirometry
prior to surgery.
Day 2-3 :
• Superficial thrombophlebitis.
• UTI (M/c Hospital acquired infection).
• Pneumonia.
Day 4-5 :
• SSI (Surgical Site Infection). Pneumonia : Atelectic
• DVT (Deep venous thrombosis). patch in the middle lobe.
Day 6 : Burst abdomen/abdominal wound dehiscence
Day 7 : Inta abdominal abscesses

Surgical site infections :

Wound infection which occurs within 30 days of surgery or within one year of
implant placement.

ASEPSIS score : To predict prognosis of surgical site infection :

Components :
• Additional treatment
• Serous discharge
• Erythema
• Purulent exudate
• Separation of deep tissues
• Isolation of bacteria from wound Surgical site infections
• Stay as an impatient prolonged for over 14 days due to wound infection

Southampton wound score :

0 : Normal healing
I : Normal healing with mild bruising or erythema
II : Erythema plus other signs of inflammation
III : Clear or hemoserous discharge
IV : Pus/purulent discharge
V : Deep or severe wound infection with or without tissue breakdown
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Predisposing factors : ----- Active space -----

• Extremes of age : neonates, older adults
• Recent surgery : especially of the chest or abdomen
• Co existing infection • Hypercholesterolemia
• Diabetes Mellitus • Obesity
• Corticosteroid therapy • malnutrition
• Hypothermia • Chronic inflammation
• Hypoxemia • Prior site irradiation
Note : Hypertension is NOT a risk factor

Deep venous thrombosis :

To prevent DVT :
• Mechanical methods : Early ambulation and use of
pneumatic compression stockings
• Pharmacological : Low molecular weight heparin
(Superior to mechanical methods).

Burst abdomen/Abdominal wound dehiscence :

Salmon fluid sign/serous fluid sign : large quantities of serous
fluid comes out.
Emergency management: Urobag/Bogota bag laparostomy.
Definitive management : resuturing of rectus sheath.
Factors predisposing to burst abdomen :
Patient factors : Surgeon/ Surgery factors :
• Chronic cough • Midline incision > transverse
• Constipation • Emergency > elective
• Infection • Continuous sutures > interrupted
• Obesity • Long bites > short bites (O.5cm bites preferred
• Immunocompromised • Short thread > long thread (minimum 4 times
• Malnourished the length preferred)
Intra abdominal abscesses :
Fever (spikes of chills and rigors) beyond POD 7.
Most common site overall : Pelvis/ Pouch of Douglas.
Most common site in a supine patient : Morrison’s pouch
(Hepatorenal pouch).
Most common site in an ambulatory patient : Pelvis.
IOC : pelvic abscess : CECT.
Drainage : Pigtail catheter.
Pigtail catheter
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----- Active space ----- Wounds 01:02:40

Types of wound Examples Percentage of SSI

I. Clean wound Clean incised wound : Without With antibi-
• Thyroid surgery antibiotic otic prophy-
• Breast surgery prophylaxis laxis
• CABG No role of prophylactic an-
• knee replacement tibiotic (1-2%) except when
• Uncomplicated inguinal hernia surgery implant or mesh is placed.
2. Clean GI/GU system but there is no inflammation :
contaminated • Elective/interval cholecystectomy
wounds • Elective appendectomy
• Urinary stone removal when no UTI 3% 6-9%
• LSCS
• Laparoscopic abdominal hysterectomy
• Bowel surgery, if the bowel is prepared
3. Contaminated GI/GU system but there is no inflammation :
wounds • Emergency/interval cholecystectomy
• Emergency appendectomy 6% 20 %
• If the bowel is opened while operating a
case of intestinal obstruction
4. Dirty wound Pus present :
• All abscesses
• Peritonitis/ fecal contamination 7-8% 20-40%
• Any neglected traumatic wound >6
hours
Note :
Prophylactic antibodies : Ideally 60 min before, repeat dose after 4 hours.
In an elective OT list, clean cases get posted first.
Hand hygiene :
Most important factor for preventing wound infection.
Hand wash for a minimum of 2 minutes
Thumbs, interdigital clefts and tips are often missed.
5 moments of hand hygiene (WHO) :
1. Before touching a patient
2. Before clean/aseptic procedure
3. After body fluid exposure risk
4. After touching a patient
5. After touching patient surroundings
Soap and water should be used for hand hygiene :
• After using toilet
• When hands are visibly soiled
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General Surgery Revision 1 01 15

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

Patient care :
To remove hair, hair clipper is used.
Shaving increases chances of infection
Cleaning of parts :
Abdominal surgery :
Male patient : Nipples to mid thigh
Female patient : inframammary crease to mid thigh
Limbs till one joint up.
Clean incision site first and then clean circumferentially outward.
Prophylactic antibiotics : 30 to 60 minutes before
If prolonged case, repeat antibiotic dose after 4 hours

OT parameters :
Optimum temperature : 18 to 22°C
Should avoid hypothermia, hyperglycemia.
Adequate hemostasis should also be maintained.

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

GENERAL SURGERY 2 & SHOCK

Surgical Nutrition 00:00:35

Nutritional Assessment :
• There is no single reliable biochemical marker for malnutrition.
• Low albumin is an indicator of poor outcome.
• Unintentional weight loss > 10% in 6 months (significant weight loss) is an
indicator of poor prognosis.
• Body Mass Index (BMI) < 15 → Poor outcome.
• Skin fold thickness : Body fat.
• Midarm circumference : Muscle mass.
Parameters of Malnutrition Universal Screening Tool (MUST) :
• BMI.
• Unplanned weight loss. To assess the risk of malnutrition
• Acute disease effect

Enteral Nutrition 00:03:04

Nutrition

Enteral nutrition > Parenteral nutrition

Best route : Oral cavity
If not possible

Requirement < 3 weeks Requirement > 3 weeks

Good gastric Poor gastric Good gastric Poor gastric

emptying emptying emptying emptying

Ryle's tube Naso-Jejunal tube Feeding Feeding

Gastrostomy Jejunostomy

A. Ryles tube/Nasogastric tube (NG tube) : Tip of Ear lobule

nose
• Measuring the length of Ryle’s tube : NEX method
(Nose → Ear lobule → Xiphosternum).
• Insertion :
Sitting position with neck slightly flexed. Tip of xiphisternum
NG Tube Length assessment

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General Surgery 2 and Shock 02 17

• Methods to confirm NG tube position : ----- Active space -----

a. Aspiration of gastric contents.
b. Insufflation of air → Auscultation of epigastrium.
c. Chest X-ray → Tip below diaphragm.
• Tube feeding :
Rate of feeding should start from 10 to 20
ml/hr & can be increased to 75 ml/hr if tolerated.

B. Nasojejunal tube :
• Longer than NG tube .
• Insertion : Fluoroscopy guided.
Nasojejunal tube
C. Gastrostomy v/s Jejunostomy :

Oesophagus
Oesophagus

Stomach Stomach
Gastrostomy
Feeding tube Jejunostomy
Feeding tube
Gastrostomy is more physiological than Jejunostomy, but has risk of aspiration.
Open technique for gastrostomy & jejunostomy :

Stam technique → Stab incision. Witzel technique → Tunnel incision (Less leakage).

D. PEG (Percutaneous Endoscopic Gastrostomy) :

A B C
Endoscope is passed into the stomach. The site where the light emitted from
endoscope is palpated.

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----- Active space ----- E. RIG (Radiologically Inserted Gastrostomy) :

Done in patients when esophageal intubation is not possible/there is
compromised respiratory function or oropharyngeal anatomy.

Complications of enteral nutrition :

• Tube related : blockade, displacement (M/C Overall).
• Feeding regime related : Osmotic diarrhoea (M/c in feeding regime related).
• Overfeeding.

Parenteral Nutrition 00:09:44

Indications :
• Prolonged paralytic ileus > 72 hours.
• Short bowel syndrome.
• High output faecal fistula (>500 cc/ 24 hours).
• Acute episodes of Inflammatory Bowel Disease.
• Initial phase of acute severe pancreatitis.

Central line : Faecal fistula

Best route for parenteral nutrition.
Route Subclavian vein Internal Jugular vein Femoral vein
Risk of thrombosis & Least + Maximum
infection
Risk of pneumothorax Maximum + Least
Ease of insertion - Maximum ease. -
Others M/c used in Total M/c used vein overall. -
Parenteral Nutrition (TPN)

Central line tip in

SVC just above
right atrium

Central line
• After Central line insertion → Check chest X-ray → Tip of central line
should lie in SVC just above Right atrium.
• If it is deep into right atrium → ectopics on ECG is seen.

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General Surgery 2 and Shock 02 19

PICC line : ----- Active space -----

• Peripherally Inserted Central Catheter.
• Used for TPN nutrition
Peripheral Intravenous line : End of catheter
• Least preferred route. Catheter Tail with cap

• Risk of thrombophlebitis is present. PICC catheter

Total Parenteral Nutrition 00:14:03

• Composition of TPN : 20 : 30 : 50. (20% protein, 30% fat, 50% carbohydrates)

• Dose : 1 to 2 L/24hr.
• In respiratory failure, low osmolar (carbohydrate) TPN is preferred → Low
CO2 production.
• In renal failure, low quantity TPN with high carbohydrate & low protein is used.
Monitoring of patients on feeding regimens :
Earliest sign of overfeeding → Excessive weight gain.
Recommended schedule for monitoring feeding regimens
Daily (clinical measures) • Pulse, blood pressure and temperature
• Body weight
• Input/Output chart
• Type of nutrition given
Initially daily. • Sodium, potassium, urea and creatinine
Later once/twice a week • Blood glucose
(Biochemical measures) • Magnesium and phosphate
• Liver function tests
• C-reactive protein
Complications of TPN :
Central line related Feeding regime related
• Pneumothorax. • Hyperglycemia (M/c).
• Arrhythmias. • Excess weight gain.
• Thrombosis. • Cholestasis.
• Air embolism. • Micronutrient deficiency
• Migration. (M/c : zinc deficiency).
• Catheter related sepsis (m/c Central line complication). • Refeeding syndrome.
Catheter related sepsis :
• Fever with chills & rigors on fluid administration.
• Ix : Tip culture/endoluminal brush culture/Peripheral blood culture/Central
line blood culture.
• Rx : Remove the central line in severe cases.

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----- Active space ----- Refeeding syndrome :

• Develops when large quantities of nutrition is given to a chronically
malnourished patient.
• Metabolic derangements :
a. Hypophosphatemia ( Main driving process)
b. Hypomagnesemia + Fluid overload.
c. Hypokalemia
• Main cause of death : Arrhythmias, CHF.
• Patients who are at risk of developing refeeding syndrome :
a. BMI < 16 kg/m2.
b. Unintentional weight loss > 15% within the last 3-6 months.
c. Little or no nutritional intake for more than 10 days.
d. Low potassium, phosphate or magnesium levels prior to feeding.
• Prevention :
• Initially 10 kcal/kg/day & gradually to full needs by 4 to 7 days.
• Strict monitoring of electrolytes.
• Thiamine Supplementation.

Liver dysfunction on TPN :

Long term TPN use → 25% liver derangement.

Fatty liver (M/c) IFALD (Intestinal Failure Associated

• M/C in children Liver Disease)
• Modified by using lipid free solutions. • Small no. of patients develop IFALD.

Crystalloids and colloids :

• Hartmann’s/Ringer Lactate (RL) solution :
Na+ → 131, k+ → 5, Ca2+→ 2, Cl- → 111, Lactate → 29.
• Gelofusine, Haemacel, Hetastarch are colloid preparations.

Metabolic derangements in fistula :

Duodenal fistulas → Very high rate of fluid &
electrolyte imbalance as pancreatic & biliary secretion drains into duodenum.

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General Surgery 2 and Shock 02 21

Hemorrhagic/ hypovolemic shock 00:24:53 ----- Active space -----

Blood loss

Overt hemorrhage. Concealed hemorrhage.

Sites :
• Abdomen. • Long bones
• Thorax. • Pelvis
• Neck.

Concealed hemorrhage
Overt hemorrhage
Bleeding in hemithorax
Types of hemorrhage :
• Primary : during surgery.
• Reactionary : Within 24 hours of surgery. Usually d/t dislodgment of clot/
Slippage of knot.
• Secondary : 7-14 days after surgery. D/t infection (sloughing of wall)

Classification of hypovolemic shock :

Classes I II III IV
Other names Mild/ Moderate/
- Severe
Compensated Decompensated
% of Blood volume lost 0-15% 15-30% 31-40% >40%
Amount of blood lost 400-500 cc 1L 1.5L >2L
Pulse Rate Normal  (Earliest sign)  Not recordable
Blood Pressure Normal SBP - Normal SBP - Not recordable
Respiratory Rate Normal Normal  
Urine Output Normal Normal  
Mental status Normal Thirsty & anxious Confused Comatose
Base deficit ( mEq/L) Normal -2 to -6 -6 to -8 > -10
Management Oral Liquids IV crystalloids IV Crystalloids + Massive blood
colloids transfusion
(3 : 1 ratio)
Occult hypoperfusion :
Normal CVS parameters & urine output but low MVOS (mixed venous O2
saturation) & acidosis.

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

Dynamic fluid response :
After administration of 1 L fast fluid,
Responder Transient responder Non responder
PR  
SBP  
JVP  
Response Sustained Reversed after 15-20 mins -
Mx Resuscitation Bleeding should be stopped first followed by
resuscitation.

Monitoring of shock :
• Best indicator to determine the amount of fluid required in shock : PCWP
(Pulmonary capillary wedge pressure) > CVP (Central venous pressure).
Practically feasible : CVP /JVP.
• Best clinical indicator of fluid resuscitation in shock : Urine output.
Shock index :
• Shock index = Heart Rate/Systolic Blood Pressure.
• Shock index > 0.9 : Higher mortality.
Modified shock index :
• Modified shock index = HR/Mean Arterial Pressure.
• Most sensitive indicator.
ROPE (Rate Over Pressure Evaluation) :
• ROPE = HR/Pulse Pressure.
• ROPE < 3 : Stable patient.
ROPE > 3 : Decompensated hemorrhagic shock.
End Points of Resuscitation :
Systemic perfusion : Normalize the :
• Base deficit Acidosis
• Serum lactate
• MVOS (Best) → Low in hypovolemic shock.
Note : MVOS → It is the percentage of oxygen
that returns to the heart after being utilized in the body.

Massive blood transfusion 00:41:10

1. Replace the entire circulating volume in 24 hours.

2. > 10 units of blood /24 hours.
3. > 4 units of blood given in one hour.

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General Surgery 2 and Shock 02 23

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

• Hypothermia. • Hypomagnesemia.
• Hypocalcemia • Hyperkalemia > Hypokalemia.
• Coagulopathy  Leading cause of death. • Metabolic alkalosis
• TRALI, TACO.
Note : Prevention of coagulopathy  Massive transfusion in 1 : 1 : 1 = PRBC : FFP :
Platelets
Trauma induced coagulopathy (TIC) :
Fibrinolysis Hypothermia
Trauma TIC
Inflammation Acidemia
TRALI (Transfusion Related Acute Lung Injury) :
• Ab against HLA Ag  Non cardiogenic pulmonary
edema within 6 hours.
• Implicated donors are usually multiparous women
• M/c with FFP administration.
• Chest X-ray : ARDS like picture.
TACO (Transfusion-associated cardiac overload) :
• C/F : Puffiness of face, Pedal edema, dyspnea.
• X-ray : Normal. TRALI
• Rx : I/v Diuretics.
Transfusion Reactions :
• If antibodies in the recipient’s serum are
incompatible with the donor’s cells → transfusion
reaction (acute hemolytic reaction).
• Febrile transfusion reactions (M/c) are
non-hemolytic & are usually caused by
graft-versus-host from leukocytes response in
transfused components. Leukoreduction filter
• To reduce febrile transfusion reaction → Leukoreduction filter is used.

Other types of shock 00:48:10

Hypovolemia Cardiogenic Obstructive Distributive

Cardiac output Low Low Low High
Vascular resistance, High High Low , Warm
High
Extremities Cold extremities Cold extremities extremities
Venous pressure Low High High Low
MVoS Low Low Low High
Base deficit
High High High High
(Acidosis)

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

Obstructive shock :
Type of cardiogenic shock where preload is reduced due to mechanical
impairment in cardiac filling.
E.g : Tamponade , Pulmonary embolism

Distributive shock :
Redistribution of blood in peripheries.
E.g :
• Warm Septic shock.
• Neurogenic shock  Spinal cord transection (bradycardia & hypotension).
• Anaphylactic shock  Mismatch blood transfusion (tachycardia).

Note : Perioperative Red blood cell transfusion criteria :

Hemoglobin level (g/dL) Indications
<6 Probably will benefit from transfusion.
6 to 8 Unlikely to benefit from transfusion if there’s no bleeding/
impending surgery.
>8 Transfusion not indicated in the absence of other risk factors

Sepsis 00:53:50

SIRS (Systemic Inflammatory Response Syndrome) : Body’s response to in-

flammation mediated by IL-1, IL-6, TNF α
Definition & criteria.
SIRS 2 or more of the following criteria:
• Temperature > 38°C or < 36°C.
• Heart rate > 90 beats/min
• Respiratory rate > 20 breaths/min or
PaCO2 < 32 torr (< 4.3 kPa)
• 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 Failure of 2/more organ systems.
organ dysfunction
syndrome)

Is there a foci of Is there How many organs

Is there SIRS ? infection ? hypotension ? not working ?
Yes  Sepsis Yes  Septic shock If 2/more  MODS

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General Surgery 2 and Shock 02 25

qSOFA (Quick Sequential Organ Failure Assessment Score)

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

Hypotension Altered mental Tachypnea

SBP < 100 mmHg. status. RR > 22/min.

Score of ≥ 2 criteria suggests a poor outcome.

Sepsis 3.0 :
• Sepsis : Life threatening organ dysfunction caused by a dysregulated host
response to infection.
• Septic Shock : Need for Vasopressors and Lactate > 2mmol/L.
• Severe Sepsis term is removed.
• SIRS is OUT and qSOFA/SOFA are IN.

Surviving sepsis guidelines/ Surviving sepsis campaign bundles :

1. During the first six hours of resuscitation, the goals of initial resuscitation
of sepsis induced hypoperfusion should include all the following as a part of a
treatment protocol :
a. CVP 8–12 mm Hg
b. MAP ≥ 65 mm Hg
c. Urine output ≥ 0.5 ml/kg/hr
d. Superior vena cava oxygenation saturation (Scvo2) or mixed venous
oxygen saturation (MVoS) 70% or 65%, respectively.
2. Normalize lactate in patients with elevated lactate levels as a marker of
tissue hypoperfusion.

Sepsis Six :
Give 3 :
• I/V Fluids.
• I/V Antibiotics.
• O2.
Take 3 :
• Urine output.
• Blood culture.
• Lactate

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----- Active space ----- TRAUMA - 1

Basics of trauma management 00:00:50

Manual in line stabilization Complete immobilization

Transfer of trauma patient in supine/prone position.

• 2 persons required for helmet removal in trauma patients.

• Trauma patients never transferred in lateral position.

Trimodal distribution of mortality in trauma :

Causes of mortality at time of impact :
• Aortic transections • Severe head injury

Causes of morality within 1 hour (life threatening injuries) :

• Airway obstruction • Acute circulatory shock
• Tracheobronchial injury • Hemothorax
• Open/ tension pneumothorax • Cardiac Tamponade

Causes of mortality days/weeks later :

• Delayed head injury • Sepsis
At impact
Within 1 hour
Days/ weeks

Majority of deaths occur at time of impact (d/t severe head injury).

Many patients die within 1 hour (golden hour) d/t life threatening Injuries.

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Triage (sort out on basis of urgency of treatment) : ----- Active space -----
Type Colour Description
Emergency/ Red Life threatening injury +,good chance of recovery if
immediate immediate treatment given.
Urgent Yellow Treatment maybe delayed for some time without
significant mortality or in ICU setting patients for
whom life support may or maynot change outcome
of disease.
Delayed Green Patients with minor injuries or ICU patients do not
require life support.
Expectant Blue Require extensive treatment for which resources not
available or in whom life support is futile.
Dead Black patients who are in cardiac arrest and resuscitation
efforts not given.

ATLS (Advanced trauma life support) 00:06:09

Advanced trauma life support consists of :

• Primary survey : ABCD + identifying & stabilizing life threatening injuries.
• Secondary survey : Detailed survey after stabilization in which all other
injuries are seen.

Airway :
• Cervical spine stabilisation using Philadelphia collar followed by airway
management).
IF
• NEXUS criteria : Cervical spine radiograph with any 1 of the following :
Neuological deficits, Ethanol intoxication, extreme distracting injury, altered
consciousnesss (unable to provide history), spinal tenderness.
• Indications to acheive definitive airway (endo/orotracheal intubation) :
a. Unable to speak.
b. GCS ≤ 8.
c. Coma.
d. Severe maxillofacial injury. Video laryngoscope LMA
Laryngeal mask airway (less technical skills)
• Nasotracheal intubation is contraindicated in Anterior skull base fracture.
otomy
• If intubation fails : Needle cricothyroidectomy done ( C/I in <12y due to risk
of subglottic stenosis), buys 20-30 mins (time to create definitive airway
(tracheostomy)).

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

Breathing :
a. Chest examination.
b. Pulse oximetry (adjunct to primary survey).
c. Imaging (chest x ray, pelvic x ray & cervical x ray) : Adjuncts to primary
survey.
d. eFAST scan.

Circulation :
• Insert minimum 2 18 guage IV lines (green) &
1 litre 1L fluids given (Judicious approach).

• If IV line insertion is not possible :

a. Emergency : Intraosseous infusion (just
below tibial tuberosity). Venous cut down
(MC vein - Great saphenous vein just
anterior to medial malleolus).
b. Definitive : Central line (MC in trauma -
Intraosseous infusion
IJV).
• CRASH 2 trial (role of tranexamic acid) : Trauma patients with a
significant hemorrhage (SBP <90 mmHg or HR >110/ min) or those considered
to be at significant risk of hemorrhage, should be given a loading IV dose of
1g tranexamic acid over 10min, followed by an IV infusion of 1g over 8h.
• Pelvic binder used till pelvic # ruled out.

Damage control resuscutation :

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Disability : 00:15:42
----- Active space -----
Glasgow coma scale :
Eye opening Spontaneously 4
To speech 3
To pain 2
No response 1
Cannot be tested NT
Best verbal Fully oriented 5
response Confused 4
Inappropriate words 3
Incomprehensible 2
No response 1
Cannot be tested NT
Best motor Obeys commands 6
response Moves to localised pain 5
Flexion withdrawal to pain 4
Abnormal flexion (decorticate) 3
Abnormal extension (decerebrate) 2
No response 1

GSC - P Score : Pupils unreactive to light Pupils reactivity score

Both pupils 2
One pupil 1
Neither pupil 0
GCS-P score : GCS (-) Pupillary response score.

Head injury classified (based on GCS) :

a. Mild : 13-15
b. Moderate : 9 -12
c. Severe : 8 or less than 8
Log roll : To examine back of trauma patient (Minimum 4 people required).

Trauma scores : Mangled extermity severity score (MESS)

Revised trauma score : 1. Type of injury
1. GCS 2. Shock
2. Systolic BP 3. Signs of ischemia
3. Respiratory rate. 4. Age group.
Score ≥ 7 : Amputation necessary
Score ≤ 6 : limb salvageable.

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

Abdominal trauma 00:20:45

MC injured :
• Overall : Spleen (also in children).
• Blunt : Spleen.
• Penetrating : Liver > Small intestine.
• Gun Shot Wound : Small Intestine.
• Seat belt syndrome : Mesentry.
• Deceleration injury : D-J flexure.

Blunt trauma to abdomen :

• Stable :
a. 1st investigation : FAST.
b. Investigation of choice/IOC : CECT abdomen.
• Unstable :
a. 1st investigation/IOC : FAST.

FAST (focussed assessment sonogram in trauma) :

Sites of examination :
1. Epigastrium (to look for cardiac
tamponade).
2. Right hypochondrium. Free fluid
3. Left hypochondrium. (hypoechoic)
4. Suprapubic region (pelvis).
• eFAST : extended FAST : Adds left & right
thorax to FAST sites. FAST +ve
• Hypoechoic collection : Free fluid present
(FAST positive).
• Detects free fluid in the abdomen or pericardium.
• Disadvantages :
• Will not reliably detect <100 ml of free blood.
• Doesn’t directly identify injury to hollow viscous.
• Cannot reliably exclude injury in penetrating trauma.
• ls unreliable for assessment of retroperitoneum.

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Blunt trauma abdomen

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

Abdominal examination
Peritonitis/ hemodynamic instability No peritonitis/hemodynamic
with FAST +ve instability

Exploratory laprotomy Abdominal CT scan

Penetrating abdominal injury :

Superficial to peritoneum Peritoneum breached/ Peritonititis/

Omentum hanging out/ Bile staining of
Local exploration & suturing dressing
followed by CECT.
Laparotomy

• Never remove stab weapon from the body until inside OT as it might have a
tamponading effect.
Diagnostic peritoneal lavage / DPL :
• Done when FAST is not available (patient unstable).
• Positive DPL :
• 10 cc of gross blood is aspirated • Amylase >175 IU/L
• > 1 lakh RBC/mm 3
• Fecal contamination +
• > 500 WBC/mm 3

Splenic trauma : 00:28:15

Suspected when # of ribs (9 to 11) on left side/bruising on lower left chest wall.
Grades of splenic trauma :
Grade Features Management
Grade 1 • Subcapsular hematoma <10% SA.
• Parenchymal <1cm depth. IOC : CECT
• Capsular tear.
Grade 2 • Subcapsular hematoma 10-50% SA. Conservative
• Intraparenchymal <5cm.
• Parenchymal laceration 1-3cm.
Grade 3 • Subcapsular hematoma >50% SA, ruptured subcapsular or Stable :
intraparenchmal hematoma ≥ 5 cm. Conservative
• Parenchymal laceration >3 cm depth. Unstable :
Splenectomy
Grade 4 • Any injury in presence of splenic vascular injury or active
bleeding confined within splenic capsule. IOC : FAST
• Parenchymal laceration involving segmental/hilar vessels
producing ≥ 25% devascularisation. Splenectomy
Grade 5 • Shattered spleen

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----- Active space ----- Vascular injury is defined as a pseudoaneurysm or arteriovenous fistula &
appears as a focal collection of vascular contrast that decreases in
attenuation with delayed imaging. Active bleeding from a vascular injury
presents as vascular contrast, focal or diffuse, that increases size or
attenuation in the delayed phase.
Conservative management includes :
• Monitor vitals, hematocrit, Serial 24hrs CECT required.
• Angio-Embolisation can be done if progression of the injury seen.
• If it fails/ patient becomes unstable/ contrast blush on CT : Surgery
(Splenorrhaphy/ Splenic preservation).

Complications of splenectomy :
• Hemorrhage.
• Injury to pancreas (Tail). Closely associated with the hilum of the spleen
• Haematological changes : Transient increase in all 3 cell lines (2-3 weeks).
Permanent changes :
1. Basophillic stippling.
2. Howel Jolly bodies.
3. Reticulocytes.
4. Hypersegmented WBC’s.
• MC complication – left lower lobe atelectasis/ pulmonary complications.

OPSI (Opportunistic Post splenectomy infections) :

• MC organism : Encapsulated bacteria (Pneumococcus (MC),Meningiococcus,
H. Influenzae).
• More common in children > adults.
• More common within 1st 2yrs of splenectomy.
• High mortality.
• More likely in splenectomy done for hematological conditions > trauma.
Prevention by vaccines :
• Elective Sx : 2 weeks before.
• Emergency Sx : Post op day 2.

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Liver trauma ----- Active space -----

Grade Features Remember the spleen

Grade 1 • Hematoma,subcapsular <10% SA. classification and then the
differences (Highlighted)
• Laceration : capsular tear, < 1 cm parenchymal depth.
Grade 2 • Hematoma : Subcapsular, 10-50% SA.
• Hematoma : Intraparenchymal, <10 cm diameter.
• Laceration : Capsular tear 1-3 cm parenchymal depth,<10 cm length.
Grade 3 • Hematoma : Subcapsular, >50% SA.
• Hematoma : Intraparenchymal, >10 cm.
• Laceration : Capsular tear, >3 cm depth.
• Vascular injury with active bleeding contained within liver parenchyma.
Grade 4 • Laceration : Parenchymal disruption involving 25-75 % of lobe or 1-3
Couinaud segments.
• Vascular injury with active bleeding breaching the liver parenchyma
into peritoneum.
Grade 5 • Laceration : Parenchymal disruption involving >75% of lobes.
• Vascular : Juxtahepatic venous injuries

Unstable Surgery
Unstable
Liver trauma
Resuscitate Investigate
DPL
USG,CT
Stable Laproscopy Uneventful
Angiography
Stable
Manage complications

Pringles Maneouver Packing

• Pringle’s Maneouver : Clamp across Hepatic pedicle at foramen of Winslow
containing Hepatic artery, Common bile duct & Portal vein (done for 15mins in
one go).
• Pringles help to locate as well as control bleed.
a. If bleeding reduces, cause is Hepatic artery & portal vein.
b. If bleeding continues, cause is hepatic veins.
• Plugging.
• Packing.

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

Mesenteric injury
Most common in Seatbelt syndrome.
Longitudinal tear Transverse tear

Only some branches cut so no bowel ischemia Entire blood supply is cut → Necrosis
T/t : Repair of tear T/t : Resection & Anastomosis

Duodenal & pancreatic injury

• Duodenal haematoma : Bowel rest ( NPO).
• Perforation : Omental/ Grahm patch repair.
• Pancreatic injury : Most important prognostic factor : Injury to main
pancreatic duct (intervention required).

Damage control surgery (DCS) & Early total care (ETC) 00:40:46
Criteria for ETC: • ETC : Definitive management of a patients injuries within 36h of
Stable hemodynamics
No need for vasoactive injury after an initial resuscitation.
stimulation
No hypoxemia, no • DCS : Rapid life/limb saving surgery (correction of physiology given
hypercapnia
Normal coagulation importance than correction of anatomy).
• If during ETC approach patient deteriorates then DCS can be done :
Normothermia

Lethal triad of trauma :

1. Acidosis. Criteria for DCS
pH<7.2
2. Coagulopathy.
3. Hypothermia.<34 C

Temporary closure of abdomen using

bagota bag /urobag Laparostomy

Phases of DCS in terminology used in ACLS :

Temporary
Phase 0 Phase 1 abdominal Phase 2 Phase 3
Identification of Emergency closure Correction of (re-exploration)
patient for DCS in laparotomy in OT physiology in ICU Definitive
emergency room (Lethal triad of surgery (correct
AIM
Stop bleeding trauma) anatomy)
Prevent contamination
Finish the surgery early

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Stages of DCS (abbreviated laparotomy) : ----- Active space -----

1. Patient selection
2. Control of hemorrhage & resuscitation.
3. ICU care
4. Definitive surgery after 24-48hrs.
5. Abdominal closure.

Abdominal compartement syndrome (ACS) 00:44:17

• Seen in bowel obstruction, massive ascites, extensive burns.

• Intra abdominal pressure (IAP) can be measured by bladder pressure.
• Intra abdominal hypertension : Sustained/repeated pathologic elevation of
IAP >12 mm Hg.
• ACS : Sustained elevation of IAP of >20mm Hg with new organ dysfunction. Effects of raised IAP
Renal Decreased GFR
CVS Tachycardia, Hypotension
Management of ACS : Respi Decrease lung volumes
Decreased visceral perfusion
• IV fluids. Increased ICP

• Correct acidosis.
• Decompressive laprotomy.

Retroperitoneal trauma
Zone 1 Major vessels.
Zone 2 Kidney, ureter & renal vessels
Zone 3 Pelvic structures

• FAST is not useful in assessing retroperitoneal

injury.
• Zone associated with max mortality : Zone 1.
• M/C injured zone : Zone 2 (most surgically
accessible). Correction: Zone 3
• IOC for Zone 2 injury :
a. Stable patients : CECT.
b. Unstable patients : Single shot IV Urogram.

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----- Active space ----- TRAUMA - 2 AND BURNS

Thoracic trauma 00:01:37

Common in polytrauma patients.

Rx : Conservative with chest tubes.
M/c cause of death in :
• Blunt thoracic trauma : Tracheobronchial injury.
• Penetrating thoracic trauma : Hemothorax 20 to lacerations.

Rib fractures :
• M/c type of thoracic trauma.
• Rx : Analgesia (No strapping).
• M/c ribs fractured during CPR : 3rd - 5th ribs.
• High velocity impact → 1st rib fracture : Subclavian vessels, brachial plexus &
apex of lung can be injured.
• 10th - 12th rib fractures : Spleen (left) & Liver (right).

Flail chest :
• Fracture of ≥ 2 consecutive ribs at ≥ 2 more places.
• Pulmonary contusion : Leading cause of death following flail chest.
• C/f : Paradoxical chest wall movement.
• Rx :
• O2+ analgesia through thoracic epidural catheter.
• RR >20/mins or pO2 < 60 mm Hg : IPPV. Intermittent Positive Pressure Ventilation
• IPPV fails : Surgical fixation.

A : Flail chest
Paradoxical chest movements Flail chest B : Multiple rib fractures

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Pneumothorax ----- Active space -----

Tension pneumothorax Simple pneumothorax

Hemodynamic compromise. No hemodynamic compromise.

Tension pneumothorax :
Sucking wound or open wound (one way valve) →
Air accumulates → Lung collapses + shift of
mediastinum + other lung hyperinflates.
Ix : Extended FAST (eFAST) - Loss of Seashore, bar
code, or stratosphere sign in M mode.

Tension pneumothorax
Mx :
• Emergency - Needle thoracocentesis :
• Adults : 5th intercostal space mid axially line.
• Children : 2nd Intercostal space mid clavicular line.
• Definitive : Tube thoracocentesis (triangle of safety
+ cover the sucking wound with gauze piece on three
sides).

Tension Cardiac Hemothorax Simple

pneumothorax tamponade pneumothorax
C/f RR + tachycardia + hypotension No change
JVP Normal/ Low Normal
Breath Reduced Normal Reduced -
sounds
Difference
between Percussion Hyper - Dull -
tension
pneumothorax resonant
and cardiac
tamponade
eFAST can
Cardiac - Muffled - -
also be used to sound
differentiate
between the
two
Hemothorax :
• Accumulation of blood in thorax.
• Dx : Xray - blunting of CP angle.
• Rx : Insertion of intercostal tube (28-32 Fr chest
tube used for hemothorax (not 36-40 Fr)
Hemothorax

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

Indications for thoracotomy (anterolateral) :
1. > 1-1.5 L of blood at insertion of ICT.

line
line
Axil
2. > 200 cc/hour for 3 consecutive hours. la

xillary
ry
xilla
3. Cardiac tamponade.

Mid a
ra
4. Tracheobronchial injury.

erio
5th IC space

Ant
5. Thoracic aortic injury.
Triangle of safety
Structures pierced on insertion of chest tube (upper border of rib) :
1. Skin.
2. Superficial fascia.
3. Deep fascia.
4. Serratus anterior.
5. 3 layers of intercostal muscles.
6. Endothoracic fascia.
7. Parietal pleura. Chest tube
Note : Neurovascular bundle is present in the lower border of rib.
Chest tube connected to underwater seal bag (tube submerged, air bubbles out).
Functioning of chest tube : Assessed by column
movement in the bag.
Position of the chest tube : Checked by X-ray.
Chest tube is removed if :
• Lung has expanded.
• Output < 100 cc in 24 hours.
Chest tube

Cardiac tamponade : 50cc

• Rapid accumulation of blood in pericardial space.

• Beck’s triad : Muffled heart sounds + Raised JVP +
Hypotension
• Dx : eFAST.
• Mx : Hypoechoic collection :
• Emergency : Needle pericardiocentesis FAST +ve
(subxiphoid route under ECG & Echo).
• Definitive : Emergency thoracotomy, repair of tear & pericardial drain.
No role for pericardiocentesis in traumatic cardiac tamponade (20 to penetrating
trauma).
Mx : Left anterolateral thoracotomy/ sternotomy with evacuation of
hematoma + repair of myocardium.

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Traumatic thoracic aortic injury : ----- Active space -----

M/c site : Distal to ligamentum arteriosum.
C/F :
• Chest pain.
• Difference in BP between two limbs.
• Absent pulsation in one limb.
Widened mediastinum
IOC :
• If stable : CT angiogram.
• If unstable : Transesophageal Echo (TEE).
X-ray : Widened mediastinum.
Rx :
• Short-acting Beta-blocker (Esmolol) (goal : Permissive hypotension,
HR <80bpm & MAP 60-70 mm Hg).
• Graft repair.

Diaphragmatic injury :
More common on left side.
C/F :
• Breathlessness.
• Bowel sounds in thoracic cavity.
Mx :
• Never insert a chest tube blindly. Right diaphragmatic injury
• Laparotomy (Preferred).
• Bowel reduction + repair diaphragm + chest tube insertion.

Neck trauma 00:23:08

Zone 1 : Thoracic inlet to cricoid cartilage (maximum mortality).

Zone 2 : Cricoid to angle to mandible.
Most exposed.
M/c injured & most surgically accessible.
Rx : Conservative/ exploration if hard signs +ve.
Zone 3 : Angle of mandible to base of skull.

Hard Signs of neck trauma :

• Subcutaneous emphysema (increasing).
• Air bubbling from a penetrating wound.
• Expanding neck hematoma.
• Hoarseness of voice.
• Unstable patient.
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----- Active space -----

Head trauma 00:25:17

Anatomy of the scalp

• Skin.
• Connective tissue : Vessels adherent to fibrous tissue septae (cannot
vasoconstrict → increased risk of bleeding).
• Aponeurosis (sub-aponeurotic bleeding → Black eye/ raccoon eyes).
• Loose areolar tissue : Emissary vein (Cavernous sinus thrombosis).
• Periosteum.

Skull Fractures :
Non depressed skull fracture → No intervention.
Depressed skull fracture :
• Focal neurological signs present.
Surgical elevation
• Depression > depth of adjacent segment.
Clinical features :
Anterior Cranial Fossa # Middle Cranial Fossa # (# of Posterior Cranial Fossa
(# of cribriform plate) : petrous part of temporal bone) : Fractures :
• Black eyes/ raccoon Temporal lobe contusions • Visual problems.
eyes. • Battle sign : Discoloration over • Occipital contusions.
• CSF rhinorrhea. mastoid, seen 24h after injury. • 6th nerve injury.
• Epistaxis. • Hemotympanum. • Vernet syndrome/ Jugular
• Anosmia. • CSF otorrhea. foramen syndrome :
• Frontal lobe contusion. • Facial nerve injury. 9th to 11th cranial nerve
• Paradoxical rhinorrhea : CSF in injury.
middle ear → Eustachian tube
→ Nose.
CSF rhinorrhea + Epistaxis
central circle - blood
outer circle - CSF beta 2 transferrin

Black eyes Target/ Halo sign Battle sign

NICE guidelines (National Institute of Clinical Excellence) :

Suspect Cervical spine injury in all patients with head injury.
GCS frequency :
First 2 hrs : Every half hour; Next 4 hrs : Every 1 hour; After 6 hrs : Every 2 hrs.
Indications to involve a neurosurgeon :
• GCS ≤ 8. • >1 episode of vomiting.
• Fall in GCS after admission. • ENT bleed.
• Unexpected confusion >4 hours. • Focal neurological signs.
• LOC present. • Penetrating CNS injury.
• Seizures.
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Indications for NCCT : ----- Active space -----

• GCS < 13.
• If GCS fails to reach 15 within 2 hours of admission.

Indications for CT within 8 hours :

• Age > 65 years.
• Coagulopathy (e.g. aspirin, warfarin or rivaroxaban use).
• Dangerous mechanism of injury (e.g. Fall from a height, road traffic
accident).
• Retrograde amnesia >30 mins.

Brain Injury :
Impact → Primary brain injury.
Raised ICP → Secondary brain injury.

Primary brain injury :

Concussion :
• Mildest type of primary brain injury.
• CT : Normal.
• Rx : Conservative, avoid contact sports for sometime (No surgical
intervention).
• Repeated concussion can lead to post concussion syndrome.

EDH Chronic SDH Diffuse axonal injury

History Young patient Elderly patient Any trauma patients
(most severe)
Cause High velocity impact → Middle Trivial injury. High velocity impact. D/t
meningeal artery rupture. Not restricted by shearing force between
M/c site : Pterion/ Temporal region. sutures. grey & white matter.
Features Lucid interval Gradual altered senso- Coma
rium (no signs of recovery).
Imaging NCCT (IOC) : NCCT : NCCT : Normal
Bi convex Concavo convex/ cres- IOC : MRI (Punctate
hemorrhage. centic hemorrhages at grey &
hemorrhage white matter junction)
Rx Burr hole/ Burr hole/ Worst prognosis
Craniotomy Craniotomy

Diffuse axonal injury Contusion

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

EDH Pterion : SDH

Various cranial sutures meet
Indications for Craniotomy :
• >30 cc clot size.
• >5 mm midline shift.
• >1.5 cm thickness.

Secondary Brain Injury :

• Rise in ICT occurs d/t swelling of brain.
• Body compensates for the ↑ICT but on reaching
the `point of decompensation´, sudden
decompensation occurs → May cause herniation
of brain downwards.
• Cerebral Perfusion Pressure = Mean arterial pressure - ICP.
• Cushing reflex : HTN + Bradycardia + Altered respiration.
• Rx :
1. Adequate O2.
2. Adequate perfusion - SBP >100 mm Hg.
3. Avoid hyperglycemia.
4. IV Mannitol.
5. Hyperventilation (only in moderate amounts).
• Steroids : No role in raised ICT d/t trauma.
• Prophylactic use of phenytoin or valproate : Not recommended for preventing
late posttraumatic seizures (PTS). Can be used in early post trauma.

Glascow Outcome Score (Prognostic score) :

Score Prognosis
1 Death
2 Persistent vegetative state.
3 Severe disability + conscious.
4 Moderate disability.
5 Good recovery.

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Brain death : ----- Active space -----

No possibility for recovery of brain function.
Two experts required to certify brain death.
Criterias :
• GCS = 3
• Nonreactive pupils.
• Absence of confounding factors (alcohol/ drug intoxication/ hypothermia).
• Absent brainstem reflexes.
• No spontaneous ventilatory effort.

Thermal injuries 00:43:27

Burns :
Referred to burn clinics if :
• Patient has comorbidities.
• Burns on face, hands, feet, genitalia, perineum, or major joints.
• Chemical burns.
• Electrical burns, including lightning injury.
• Inhalation injury.
• Partial-thickness burns > 10% of the total body surface area.
• Third-degree (full-thickness) burns in any age group.

Signs of airway burns :

• Burnt/ singed nasal hair (Most specific).
• Hoarseness of voice.
• Carbonaceous deposits in sputum.
• Burns in a closed room.
• Burns involving head, face, neck.
• Altered mental sensorium.
Management : Prophylactic intubation to prevent airway collapse.
Initial management for any burns
ABCDE : Airway, Breathing, Circulation, Disability, Exposure
1. Airway - Stages of airway burns :
a. Acute pulmonary insufficiency : Breathlessness + SpO2.
b. ARDS like picture : B/L infiltrates in lungs + hypoxia.
c. Bronchopneumonia (d/t reduced immunity) :
• Early phase (1-3 days) : Staph.
• Later (>3 days) : Gram negative bacteria.

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

2. Breathing - Eschar formation can lead to chest movement difficulties.
3. Circulation :
• < 10% TBSA : Localized inflammatory response.
• > 10% TBSA : Generalized inflammatory response.
• Dehydration d/t leaky capillaries, vasodilation, evaporation & tissue edema/
3rd space loss.
• >10% burns in children & >15% burns in adults → Can cause hypovolemic shock.
Burns resuscitation : Crystalloids/ colloid solutions.
Old Parkland formula :
• 4 x body weight (kg) x total body surface area burnt (1st degree burns not
included) → Fluid in 24 hours.
• 1/2 in 1st 8 hours, 1/2 in next 16 hours.

Latest formulas : ATLS RL/LR

Category Age & weight Adjusted fluid rates Urine output

of burns
Flame or Adults & older 2 ml LR x kg x % TBSA 0.5 ml/kg
scald children (≥ 14 years).
Children (≤ 14 years) 3 ml LR x kg x % TBSA 30-50 ml/ hour
Infants & young chil- 3 ml LR x kg x % TBSA 1 ml/kg
dren (≤ 30 kg) + solution with sugar at
maintenance rate
Electrical All ages 4 ml LR x kg x % TBSA 1-1.5 ml/kg/hour until
injuries until urine clears urine clears

New Parkland formula & Brooke formula : 2 x body weight (kg) x total body
surface area burnt.
Galveston formula used in pediatric burns.
Colloids in burns :
• Given after first 12 hours of burns to reduce risk of increasing tissue edema.
• Muir & Barclay formula (M/c colloid-based formula).

Wallace rule of 9 Lund & Browder chart (most accurate)

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Depth of burns : 00:51:13 ----- Active space -----

First degree Second degree burns Third & fourth de-

burns Superficial Deep gree burns
Layer Only epidermis Epidermis & Epidermis & 3rd : SC tissue
Papillary dermis dermis 4th : Muscle
Wound Red, Tender Red, Tender. Red, Black & charred,
Blister formation. Less tender. Painless.
Blanching Present Present Absent
Rx Heal without Heals after Heals with Early excision →
scarring in 3-5 application of dress- hypertrophic STSG (Split thick-
days ing materials scars and ke- ness skin grafting)
without scarring loids

2nd degree : Superficial - Blisters 2nd degree : Deep

Desquamation → Pigmentation → Healing Hypertrophic scars/ keloid

Rx of burns :
1. ABCDE.
2. Wash (room temperature water).
3. Don’t burst blisters.
4. IV fluids.
5. IM & S/C injections avoided.
6. NG tube if > 15% TBSA.

Nutrition in burns :
• Basal Energy Expenditure (BEE/REE) is increased in patients with burns.
• Severe burns : 2x normal (40kcal/kg/day).
• Max nitrogen loss : Day 5 to 10 (atleast 20% calories should be from proteins).
• Davies formula used to calculate protein requirement.
• Curreri formula, Sutherland formula can be used to calculate calories.

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

Escharotomy :
• Circumferential burn (eschar) → Can lead to compartment syndrome.
• Extend the wound beyond the deep burn.
• Diathermy can be used to prevent bleeding.

Dressing materials :
1. To protect damaged epithelium.
2. Minimize bacterial and fungal contamination.
3. Occlusive dressing : Prevents evaporation.
Degree Dressing used
1 degree
st
Expose the wound
2nd degree : Superficial Vaseline/ paraffin gauze
Collagen dressing ( if non infected)
2nd degree : Deep Collagen dressing, Hydrocolloid dressing (Duoderm)
Special agents :
Silver sulphadiazine (1%) : M/c agent.
• Frequent change of dressing required.
• Good against pseudomonas, gram negative bacteria.
• Cannot penetrate eschar.
Silver nitrate :
• Good action against pseudomonas, little action against gram-negative.
• Stains everything black in color.
Mafenide acetate (5%) : Used carefully as
• Penetrates eschar.
• Painful application.
• Metabolic acidosis.
Cerium nitrate : Best.
Contractures :
• V-Y plasty or Z plasty can be used to relieve
the contractures.
Causes of death following burns :
• Immediate : Asphyxia > Neurogenic shock.
• Early (1-3 days) : Hypovolemic shock.
• Late (> 3 days) : Septic shock.
• M/c overall : Septic shock (M/c organism : pseudomonas). Contractures

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Special situations : ----- Active space -----

Acid/ Alkali burns Hydrofluoric Electrical burns Lightning injury

acid burns
Notes • Alkali burns are • Hyperkalemia. • High degree burns. • Direct : Same as electrical.
more severe. • Hypocalcemia. • A/C burns : Arrhythmias, • Indirect : Strikes an object
• Arrythmias. myoglobinuria (renal damage) & sparks flyoff causing
d/t tetany. superficial burns :
• Always note entry & exit burns. Filigree Burns.
Rx • Never neutralise. • Calcium • Aggressive IV fluid therapy
• Wash with water. gluconate. (4 x BW x TBSA).
• Elemental sodium, • Debride the wound & STSG.
phosphorous &
chemical powder :
Brush them off.
Hypothermia : STAGE
1 Conc shivering
Best way to measure temperature : Rectal temperature. 2 Impaired conc NOT shivering
3 Unconc NOT shivering vital
Best method to warm a hypothermic patient : Cardio pulmonary bypass. signs present
4 No vital signs

Frost bite :
• Prolonged exposure to dry cold.
• Ice crystals formed in tissue → Membrane injury & microvascular damage.
• Rewarming can lead to re-perfusion injury.
Stage C/F
1 Hyperemia
2 Large vesicles, skin loss
3 Hemorrhagic vesicles, full thickness skin loss
4 Muscle & bone involved
Trench foot :
• Prolonged exposure to cold & tissue is wet.
• Microvascular damage.
• Stasis & occlusion.

Rx of frostbite & trench foot :

• Gradual re-warming of leg (water at 40 degrees).
• Don’t rub the tissue - extremely painful.
• Be aware of re-perfusion injury.
• Hyperkalemia & acidosis can occur.
• If gangrene : Wait for demarcation line to appear before amputation.

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

Workup of breast disorders 00:01:15

Clinical signs :
Sign Structure involved
Dimpling Ligament of Cooper Not a sign of skin
Dimpling Retraction : Lactiferous ducts involvement
• Circumferential : Malignancy.
• Slit like : Duct ectasia. Sign of skin
Peau d’ orange Subdermal lymphatics involvement
≥ 1/3rd of skin with PDO → Inflammatory breast cancer.
Retraction
Investigations : Triple assessment

Clinical examination Imaging HPE

Peau d’ orange < 40 years > 40 years

USG Mammography
DENSE BREASTS

A : Dial clock method (Best)

BIRADS score : Breast Imaging and Reporting Data System

BIRADS score Inference Mx

0 Incomplete investigation. Additional imaging.
1 Negative. Follow up after 1 year.
2 Benign. Follow up after 1 year.
3 Probably benign. Follow up after 6 months.
4 Suspicious Biopsy.
4a : Low suspicion.
4b : Moderate suspicion.
4c : High suspicion.
5 Highly suggestive of malignancy. Biopsy.
6 Known biopsy proven. Surgical excision when clini-
cally appropriate.

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ASBRS breast cancer screening guidelines : ----- Active space -----

Category Screening guideline
Average risk of breast cancer Annual screening mammo
at 40 years.
Higher than • BRCA mutation present Annual MRI at 25 years.
average risk : • Prior chest wall radiation 3D mammo at 30 years.
• Predicted lifetime risk (By Annual 3D mammo/MRI
Gail, BRCA pro model) > 20% at 35 years.
• Strong family history
Note : Stop screening, when life expectancy becomes < 10 years.

Mammography : Axilla
Radiation exposure : 0.1-0.2 cGy. BIRADS 2
2 views :
• Craniocaudal (CC).
• Mediolateral oblique (MLO).

Advantages of MLO : CC : Benign MLO : Malignant

• Axilla can be visualised. (Popcorn calcification) (Spiculated calcification)
• Maximum breast tissue seen.
MRI :
Indications :
1. Imaging IOC in :
• Breast implants.
• Multifocal & multicentric lumps. Multifocal Multicentric
• To detect local recurrence/scar recurrence.
2. Screening modality in young, high risk women.
3. Most sensitive in DCIS.
4. MRI should be done in patients with suspected ductal lesions, where USG is
inconclusive.

Rupture of breast implants (USG)

Intracapsular Stepladder
Extracapsular Snowstorm
Biopsy techniques : Linguini sign : Intracapsular rupture
Trucut biopsy/core needle biopsy : IOC. of breast implant in MRI.
Punch biopsy : Skin lesions (Paget’s disease). Incisional biopsy

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

14 G is best for breast biopsy.

Punch biopsy Trucut biopsy gun

Breast cancer 00:13:10

Risk factors :
• ↑ age.
• Early menarche, late menopause.
• Nulliparity.
• Obesity.
• Alcohol.
• Smoking : ↑risk of breast cancer, Mondor’s disease, duct ectasia.
• Family history.
• Hormone replacement therapy (Low dose OCPs don’t ↑ the risk).
• Maternal age at first live birth >30 yrs.
Note : Breastfeeding is protective.

M/c pathological type : Invasive ductal cancer (NOS). Not Otherwise Specified
M/c quadrant affected : Upper outer.
Least common quadrant : Lower inner.
Invasive lobular cancer :
• Single file/Indian file pattern.
• A/w E-cadherin mutation.

Gene mutations :
M/c gene mutated in :
• Breast cancer : p53 (Sporadic).
• Familial breast cancer : BRCA.
• ER, PR +ve breast cancer : PI3CK.
• TNBC/Her 2 neu +ve : p53.

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BRCA genes : ----- Active space -----

BRCA 1 BRCA 2
Chr 17q. Chr 13q.
BRCA 1>2 : BRCA 2>1 :
• Breast cancer. • Pancreatic cancer.
• Ovarian cancer. • Prostate cancer.
• Male breast cancer.
More aggressive (Basal subtype). Less aggressive.
BRCA testing is done in :
All patients with :
1. Deleterious BRCA 1/2 gene mutation in a blood relative.
2. H/o ovarian, fallopian tube and/or primary peritoneal cancer.
Patients with breast cancer :
1. ≥ 1 blood relatives diagnosed with breast cancer ≤ 45 years.
2. H/o B/L breast cancer at ≤ 50 years.
3. H/o triple negative breast cancer (TNBC) at ≤ 60 years.
4. H/o male breast cancer.

Immunohistochemistry
ER, PR Her 2 neu
Allred score (0-8). 0 not amplified
1+ -ve
2+ Equivocal → FISH Fluorescent In-Situ Hybridization
3+ +ve amplified
Nuclear steroid receptors. Membrane receptors.

Molecular subtypes :
Based on gene expression profiling.
ER PR Her 2 Ki67 CK 5/6
Means
Luminal A + + - Lowmultiplying -
slowly
Luminal B + + - High -
+ + + Any -
Her 2 enriched - - + Any -
Basal like (TNBC) - - - Any +
Claudin - low - - - Any -

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

Luminal A : (M/c) Best prognosis.
TNBC :
• Worst prognosis.
• Seen in young patients.
• Responds best to chemotherapy.

In ER/PR +ve, centre gets stained

brown

In Her2 neu +ve, membrane gets

stained brown

TNM staging : 00:22:14

T staging
Tis Cancer in situ (DCIS & Paget’s).
T1 ≤ 2 cm.
T2 2-5 cm.
T3 ≥ 5 cm.
T4a Involvement of chest wall (Ribs, intercostal
muscles, serratus anterior).
T4b Involvement of skin (Ulceration, direct infiltration,
PDO & satellite nodules).
T4c T4a + T4b.
T4d Inflammatory cancer (>1/3rd skin involved).
N staging
N0 No nodes.
ipsilateral
N1 Mobile I/L axillary nodes.
N2 Fixed I/L axillary nodes.
N3a Infraclavicular nodes.
N3b Internal mammary nodes + axillary nodes.
N3c Supraclavicular nodes.
M staging
M0 No metastasis.
M1 Presence of distant mets.

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Metastasis : Bones (M/c). ----- Active space -----

• Lumbar vertebra involved d/t Batson plexus.
• Osteolytic M/c than osteoblastic.
IOC : Trucut biopsy.
Staging : PET CT.
If lymph nodes enlarged : FNAC (or) biopsy from nodes.

Surgery :
2 options : Breast Conserving Surgery (BCS) & mastectomy.
Overall survival is same in both.
Locoregional recurrence : 4-5% in BCS & < 1% in mastectomy.
Hence, RT IS
MANDATORY
BCS : in BCS

Lumpectomy with a margin of 1 mm.

Radiation therapy (RT) is mandatory (D/t locoregional recurrence).
C/I for RT :
• Pregnancy.
• Prior RT to chest wall.
• Collagen vascular disease (SLE/RA).
Technical C/I :
• Multicentric, multifocal.
• Lobular cancer (If multicentric).
• Locally advanced breast cancer (LABC).
• Large tumor : breast ratio.

Types of oncoplasty :
1. Volume displacement : 10-15% breast volume resected.
2. Volume replacement : ≥ 15% breast volume resected.

Mastectomy :
Radical Modified Radical Mastectomy
Incision Halstead. Elliptical Stewart.
Structures Breast. Breast.
removed Nipple areolar complex (NAC). NAC.
Pectoralis major & minor. Pectoral fascia.
Level 1, 2, 3 axillary lymph Level 1, 2, 3 axillary lymph nodes.
nodes. ± Pectoralis minor.

Retracted Cut
Auchincloss Scanlon, Patey

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

Axillary lymph nodes :
• Level 1 : Lateral to pectoralis minor.
• Level 2 : Behind pectoralis minor.
• Level 3 : Medial to pectoralis minor.

Simple mastectomy : Breast + NAC removed.

(No LN removed). Phyllodes, TCIS

Nipple sparing mastectomy : NAC spared.

Boundaries of axillary dissection
Note : Minimum 10 nodes are removed in MRM.

Complications of MRM :
1. Hemorrhage.
2. Injury to nerves :
• M/c - Intercostobrachial nerve (ICBN) : Altered
sensation in underarm.
Winging of scapula
• Long thoracic nerve : Winging of scapula.
3. Seroma (M/c complication) :
• Prevention : Romovac drain.
• Rx : Aspiration under aseptic conditions.
4. Lymphedema of upper limb :
• Occurs after few months.
• Post mastectomy lymphedema is the m/c cause of Lymphedema
upper limb lymphedema.
• Incidence : 2-15%. Higher, if lymph nodes
above axillary vein are removed (or) RT
given to axilla after clearance.
• Long standing (8-10 years) : Reddish/ Angiosarcoma
bluish nodules → Angiosarcoma/
Stewart Treves syndrome.
5. Local recurrence :
• Imaging IOC : MRI.
• If extensive → Cancer en curasse.
• Next step → rebiopsy.
6. Phantom breast syndrome : ICBN neuralgia. Local recurrence

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Flaps : ----- Active space -----

Deep inferior epigastric perforator Transverse rectus abdominis myocu-
flap (DIEP) taneous flap (TRAM)
Best flap. ↑ abdominal wall morbidity.
Only skin & s/c tissue removed. Skin, s/c tissue & muscle removed.
↓ Abdominal wall morbidity.

Sentinel lymph node biopsy (SLNB) : 00:36:34

Sentinel lymph node : 1st draining lymph node in cancer. first described by Cabana in penile cancer

Cancers where SLNB is used :

• Malignant melanoma.
• Breast cancer.
• Penile cancer.
• Vulval cancer.
• Head & neck cancer.

Indications :
• Clinically N0 axilla.
• Enlarged nodes with FNAC negative.

Techniques :
1. Blue dye : Methylene blue/isosulfan blue injected →
search for blue lymph nodes → frozen section. Blue dye technique
Complications :
• Skin tattooing (M/c).
• Anaphylaxis.
• Bluish discoloration of urine.
2. Radionucleotide : Tc99 tagged sulphur colloid → radioactivity Hot nodes
generated → hot nodes identified by gamma camera.
Best technique is combination of both techniques.
M/c injured nerve : ICBN.
3. Indocyanine green method : Dye injected & special filter is
used → green nodes. ICG method
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----- Active space -----

Chemotherapy :
Indications :
• Positive lymph nodes.
• LABC.
• ER, PR -ve.
• Her 2 neu +ve (Trastuzumab/herceptin is also added).

Neoadjuvant chemotherapy :
• Down stage the tumor.
• Deals with micromets.
• In vivo chemosensitivity indicator.
Indications :
• TNBC.
• Her 2 neu +ve.
• LABC.
• Large tumor.
Staging after chemotherapy : ‘y’ is added as prefix.

RECIST : Response evaluation criteria in solid tumors.

Complete response (CR) Disappearance of all lesions & pathologic lymph nodes.
Partial response (PR) ≥ 30% ↓ in size.
No new lesions.
Progressive disease (PD) ≥ 20% ↑ while on chemotherapy.
Stable disease Neither PR nor PD.

Chemoport : Tip lies in central vein (Subclavian vein/IJV).

Avoid chemo :
• If patient not fit for chemo/poor performance status (ECOG/Karnofsky).
• > 70 years of age.
• T1, T2/N0/M0 & ER, PR ± but Her 2 neu -ve → If molecular tests show low
risk of recurrence.

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Molecular tests : ----- Active space -----

• Oncotype Dx : 21 gene assay.
• Mammaprint : 70 gene assay.
• Endopredict : 12 gene assay.
• PAM 50 : 50 gene assay.
• CAN assist.
Radiotherapy :
Indications :
1. Positive lymph nodes.
2. Tumor > 5 cm.
3. LABC.
4. After BCS.
Hormonal therapy : For ER, PR +ve.
Premenopausal Postmenopausal
Drug Selective estrogen receptor Aromatase inhibitor (Letrozole/
modulator (SERM) (Tamoxifen). Anastrozole).
Duration 10 years. 10 years.
Side effects Hot flashes (M/c). Osteoporosis (M/c).
DVT.
Endometrial hyperplasia.

Treatment summary :
Early breast cancer (T1, T2/N0, N1/M0) : BCS + RT

Sx Chemo RT Hormonal therapy

BCS. T1, T2/N0/M0 & ER, PR ±, Her Post BCS. ER, PR +ve.
No Chemo, do
2 -ve → Molecular tests.
If BCS is C/I → Chemo if : +ve lymph
Mastectomy. +ve lymph nodes. nodes.
If cN0 → SLNB. LABC.
Her 2 neu +ve.
LABC :

T3N1M0.
Any T4. Skin involvement :
Any N2. M0 Peau d orange (T4b)
Any N3.
LABC
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----- Active space -----

Mx :
NACT → MRM → RT.
If Her 2 +ve : Add Herceptin.
If ER, PR +ve : Hormonal therapy.

Pregnancy associated breast cancer :

Develop during pregnancy or within 1 year of delivery.
Aggressive tumors.
Usually ER, PR +ve.
Imaging IOC : USG.
Diagnosis : Trucut biopsy.
Mx :
• Sx : MRM in 1st & 2nd trimester. BCS in late 2nd trimester/3rd trimester.
• Chemo : C/I in 1st trimester. Best in 2nd trimester.
• HT & RT : C/I in all trimesters.

Male breast cancer :

Incidence : 1%.
Diagnosis, prognosis & Mx is same as of female breast cancer.

Prognostic factors :
Most important prognostic factor : Axillary LN status.
Most important prognostic factor in metastatic breast cancer : ER, PR status.

Ductal carcinoma insitu (DCIS) : 00:51:08

Types :
• Papillary (M/c).
ER, PR +ve.
• Cribriform.
Presents with microcalcification.
• Solid.
• Comedo : With necrosis → Most aggressive.
Presents as lump. ER, PR -ve.
Non-invasive : Doesn’t spread beyond basement membrane. Mammo showing
Diagnosis : Stereotactic trucut biopsy. cluster microcalcification
Sx : Lumpectomy/ BCS (or) simple mastectomy.
No role of chemo.
RT : Post BCS.
HT : If ER, PR +ve.

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Van Nuys prognostic index : Prognostic score for DCIS. ----- Active space -----
Parameters :
• Size.
• Margins.
• Grade & necrosis.
• Age.
ER, PR status is not included.

Lobular carcinoma insitu (LCIS) :

No longer considered as in situ. Now considered as benign disease with risk of
cancer.
1% per year progression.
Tends to be B/L & multicentric.
Usually ER, PR +ve.
Pleomorphic LCIS : ER, PR -ve. Behaves like high grade DCIS.
Gets converted to invasive ductal cancer (or) invasive lobular cancer.
HPE: SINGLE FILE/INDIAN FILE PATTERN

Benign breast conditions 00:54:43

Breast abscess :
Organism : S. aureus (M/c).
Source : Oropharynx of child.
Clinical features : Pain, fever, swelling.
Fluctuation is a late sign.
Diagnosis : USG.
Rx : Antibiotics (Amoxy clav/Cloxacillin).
If pus + → 2 attempts of USG guided aspiration → fails → I & D.

Causes of recurrent breast abscess in non lactating females :

• TB. Treatment ATT
• Idiopathic granulomatous mastitis. Diagnosis of EXCLUSION
• Inflammatory cancer. Differentiated from TB by AFB staining and gene expert for TB
Treatment STEROIDS

Fibroadenoma :
M/c cause of breast lump.
15-25 years.
Mobile : Breast mouse.
Sx done if :
• Giant fibroadenoma (> 5 cm).
• Family h/o cancer.
Mammo showing
• Pain.
popcorn calcification.
• ↑ in size.

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

Rx : Traditionally → open Sx → subcuticular suture with 3-0 monocryl.
Now, vacuum assisted breast surgery (7 G probe) → scarless breast sx.

Open surgery Vacuum assisted breast surgery

Phyllodes tumor :
3rd/4th decade.
Clinical feature : Rapidly progressing breast lump.
Dilated veins over chest wall.
< 10% : Mets to lymph nodes.
If malignant : M/c distant mets to lungs.
Diagnosis : Trucut biopsy.
Mx :
Lumpectomy or simple mastectomy : In malignant phyllodes (post sx RT is
needed), recurrent phyllodes, large phyllodes.

Mastalgia :
M/c cause : Fibrocystic disease/fibroadenosis.
Clinical features : Cyclical pain before menses, nodularity of breast.
Diagnosis : USG.
Mx :
1. Exclude cancer & reassure.
2. Adequate breast support.
3. Flax seed or primrose oil.
4. Topical NSAIDs.
If above methods don’t work :
• Tamoxifen 10 mg daily.
• Danazol.
• Ormeloxifene (Centchroman) : In nodular breast lumps.

Cardiff Lucknow scale (0-4) is used to assess degree of nodularity.

Breast cysts :
Types :
• Smooth walled cyst (BIRADS 2) : Observe.
• Complex cyst (solid component in cyst wall) : Do core biopsy to rule out cancer.
• Complicated cyst : Infected cyst. Require antibiotics.

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Mondor’s disease : ----- Active space -----

Thrombophlebitis of chest veins.
Non cyclical mastalgia.
↑ risk in smokers.
Rule out cancer.
Mx : Pain control, topical heparinoid cream. Mondor’s cord

Nipple discharge :
Duct ectasia :
Greenish discharge, multiple ducts involved.
M/c cause of pathological nipple discharge.
> 40 years.
Zuska’s disease : Periductal mastitis (A/w smoking).
R/o cancer from an USG.
Rx : Antibiotics.
Sx : Hadfield procedure (cone excision of all ducts).
Duct papilloma : 3 TYPES: solitary papilloma, papillomatosis, juvenile papillomatosis
Have central fibrovascular core & papillary projections.
M/c pathological cause of bloody discharge from a single duct.
Diagnosis : USG.
Rx : Microdochectomy.

Paget’s disease v/s eczema :

Paget’s disease Eczema

Destruction of NAC No destruction of NAC
U/L B/L
70% have a lump (DCIS in majority) No lump
Mx : Mx of underlying lump Mx : Topical steroid

Paget’s disease :
Diagnosis :
Punch biopsy shows paget’s cells in epidermis.
ER, PR -ve.
CEA +ve.

Paget’s disease Paget’s cells in epidermis

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----- Active space ----- THYROID AND PARATHYROID

Thyroid and parathyroid 00:01:25

• Superior thyroid artery (branch of external carotid artery).

• Superior thyroid artery and vein should be ligated close to the gland to
prevent injury to the external laryngeal nerve.
• External laryngeal nerve supplies only one muscle in the larynx : Cricothyroid
(increases pitch of voice).
• Middle thyroid vein (seen in 30%) is the first vein ligated during surgery.
• Inferior thyroid artery (branch of the thyrocervical trunk), also supplies the
parathyroid gland.
• Main trunk of Inferior thyroid artery is never ligated to prevent
devascularisation of the parathyroid gland.
• Thyroidima artery (direct branch of arch of aorta).
• Beahrs triangle : Bounded by Common carotid artery ,Inferior thyroid
artery, Recurrent laryngeal nerve.

Thyroid Examination :
1. Pizzillo’s method
• Patient’s hands kept behind the head, and asked
to push against clasped hand on the occiput.
2. Lahey’s method
• Examiner stands in front of the patient. Laheys method
• Gland is pushed to one side, ideal for palpating
margins.
3. Crile’s method
• Thumb on the gland, patient is asked to swallow
(to look for nodularity).
Investigations in thyroid disorders :
Criles method
1. First investigation : Thyroid function tests (T3,T4,TSH,
Anti thyroid antibodies).
2. USG neck.
3. FNAC (Investigation of choice) : Cannot differentiate between follicular
adenoma vs follicular carcinoma.
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USG parameters in benign & malignant nodules : Holds true for thyroid as well
as breast ----- Active space -----

Benign Malignant
Iso/hyperechoic. Hypoechoic.
Macrocalcifications. Microcalcifications.
Regular borders. Border irregularity.
No infiltrative margins. Infiltrative margins.
Absence of abnormal cervical nodes. Abnormal cervical nodes.
Peripheral nodular vascularity. Increased intranodular vascularity.
Taller than wider on USG.
TIRADS score : FNAC done for TR3,TR4, TR5 lesions only. TR1 and TR2 no FNAC done

Bethesda classification of FNAC cytology report :

FNAC report Inference Management
Thy 1 Non diagnostic. Repeat FNAC under USG guidance.
Thy 1c Non diagnostic cystic.
Thy 2 Non neoplastic (benign). Follow up.
Thy 3 Follicular. Hemithyroidectomy.
Thy 4 Suspicious of malignancy Surgery.
Thy 5 Malignant.
Criteria for adequacy of FNAC :
• Specimen should display at least 6 groups of follicular cells with each group
having at least 10 cells preferably on single slide.
Thyroid scan done when patient has features of hyperthyroidism & low TSH or
when ectopic/aberrant thyroid is suspected.

Normal Cold nodule Toxic multinodular goitre Toxic adenoma

(Non functioning) (Plummers disease)
Solitary
Toxic
Nodule

Hot nodule Graves disease

(diffusely increased uptake) Thyroiditis (diffusely
decreased uptake)

• Solitary toxic nodules/hot nodule : 4% risk for cancer.

• Cold nodules : 20% risk for cancer.

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

Thyroglossal cyst (TG cyst) :
• Persistent thyroglossal tract.
• M/C location : Subhyoid/infra hyoid.
• Midline neck swelling which moves on
deglutition & protrusion of tongue.
• IOC : FNAC.
• Management : Sistrunk procedure - removal
of cyst, part of hyoid bone and tract till
Inflamed TG cyst
base of tongue.
• I & D C/I (creates TG fistula).
• Long standing disease : Risk of papillary Ca of thyroid
Goitre :

Diffuse goitre Multinodular goitre

Diffuse goitre seen in Multinodular goitre seen in
Iodine deficiency Long standing Iodine deficiency
Pregnancy Sx : Total thyroidectomy

Puberty
Graves disease
Hashimotos
Retrosternal goitre :
Thyroid present behind sternum in mediastinum (can be primary or secondary).
Primary mediastinal (10%) Secondary retrosternal (90%)
Ectopic thyroid tissue in mediastinum. Start in neck but goes behind sternum
(plunging goitre).
Supply by mediastinal vessels. Supply by neck vessels.
• Clinical features : Dyspnea (M/C) > Stridor.
• O/E : Pemberton sign (facial congestion on lifting the arms above the head).
• IOC : CECT neck/thorax.
• Management : Surgery (majority removed by cervical incision only).
• Indications for median sternotomy :
a. Malignant.
b. Primary mediastinal.
c. Large retrosternal goitre (diameter more than thoracic outlet) .
d. Recurrence.

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Thyroid surgeries : ----- Active space -----

Rose position • Collar incision made.

• Romovac suction drain

placed post Sx. Hemithyroidectomy Near total thyroidectomy
(Lobectomy + Isthmectomy) (Hartley-Dunhill procedure)

MIVAT( minimally invasive video

assisted thyroid surgery)
Approaches
• M/C : Transaxillary. Subtotal thyroidectomy
• Trans-oral
• Retroauricular
• Nipples
Indications are :
• <3 cm nodule.
• T1 Papillary thyroid cancer.
Jolls thyroid retractor MIVAT
Complications of thyroid surgery :
• Hemorrhage (reactionary hemorrhage occurs few hours after surgery)
• Injury to the nerves :
a. ELN injury is more common than RLN (but usually goes unnoticed as it
supplies only cricothyroid muscle).
b. ELN injury : Hoarseness / inability to speak at a high pitch
c. Bilateral RLN injury : Life threatening (stridor, dyspnea).
• Post operative respiratory distress :
a. Laryngeal edema (M/C).
b. Tension haematoma : Evacuate haematoma.
Early
c. Laryngomalacia.
d. Bilateral RLN injury. Carpopedal Spasm

e. Hypoparathyroidism (late cause, manifests after

48-72 hours). Trousseau sign
Hypoparathyroidism :
• M/C cause : Vascular insult to the gland.
• Initial symptom : Perioral numbness → Paresthesia → Tap on the facial nerve
Tetany → Respiratory distress → Respiratory muscle causes spasm

paralysis ( M/C cause of death).

• Trousseau & Chovstek sign +.
Chvostek sign

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

Thyroid cancers 00:20:11

• Medullary Ca a/w RET gene mutation and MEN 2 syndrome.

• Follicular Ca (2nd MC) a/w PTEN gene mutation and Cowden syndrome.
• Papillary Ca (M/C,best prognosis) )a/w cowden syndrome and FAP syndrome
(APC mutation).
• In latest TNM staging of differentiated thyroid cancers (DTC) cut off age
For good and bad prognosis has increased from 45 to 55, T3b stage introduced (cancers extending into

strap muscles) & anaplastic (Least common but worst prognosis) cancers are
now staged similar to DTC.
V.IMP FOR Papillary Follicular Medullary Anaplastic
ALMOST ALL
THYROID CA (M/C & best prognosis) (2nd M/C) (least common & worst
QUESTIONS F>M F>M prognosis)
Risk Radiation Iodine deficiency - -
factors TG cyst MNG derived from neural
crest and
Hashimotos ultimobranchial
bodies
Origin Follicular cells,Multi- Follicular cells Para fol- Follicular cells
focal licular cells
(C cells)
Metastasis Lymphatic (level 6 Hematogenous Both Both
node) > Hemtaogenous (pulsatile bone
(Lungs) mets)>lymphatic
Genetics BRAF KRAS RET P53,Beta catenin mu-
RET-PTC P13K MEN 2 tation
H&E Orphan annie eye nu- Follicles Amyloid
cleus (coffee bean), FNAC cannot rich stro-
Psamomma bodies, In- differentiate
Hence,
ma
tra nuclear inclusions hemithyroidectomy

Papillary thyroid cancer (PTC) :

• IOC : FNAC.
• Lateral aberrant thyroid : Papillary thyroid not palpa-
ble but cervical lymph node associated with it is pal-
pable.
PTC
• Other tumors with Psammoma bodies : Dystrophic calcifications
a. PTC
b. Serous cystadenocarcinoma of ovary
c. Papillary RCC
d. Meningioma
Psammoma body

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• Lindsay tumor : Follicular variant of PTC (same prognosis). ----- Active space -----
• Hemithyroidectomy : Acceptable alternative to total thyroidectomy in low
Unilateral and without extrathyroidal
risk DTC between 1-4cm except in : extension

Radiation induced DTC, familial non medullary thyroid cancer, multifocal

bilateral DTC, extra-thyroidal extension
• Other patients : Total thyroidectomy.
• If level 6/central lymph nodes are involved : Total thyroidectomy + Central
neck dissection (CND).
• If T3,T4 disease : Prophylactic Central neck dissection.
• If other nodes : Total thyroidectomy + Central neck dissection + Modified
radical neck dissection (MRND).
Follow up of PTC :
Post surgery

Traditional method New method

Wait for 4-6 weeks for Recombinant TSH is given

TSH to increase ( > 20 IU/L) to raise TSH > 20 IU/L

Whole body Iodine scan

(to see residual disease/ mets in the body)

Present Absent

Radiodine ablation ( I131 ) Life long follow up

Half life : 8 days TSH suppression with Thyroxine
Acts via : β rays
Dose : 50-100 mCi 6 monthly :
- USG neck
Indications : - S. thyroglobuin (tumor
Residual disease + marker for differentiated tumors)
If LN + (single dose) S. Tg > 2 ng/ml indicates recurrence
If mets +
Whole body scan
Follicular thyroid cancer :
• FNAC cannot differentiate between adenoma and carcinoma so hemithy-
roidectomy is done (if cancer then completion of surgery is done).
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----- Active space ----- Hurthle cell carcinoma :

• Earlier considered to be a variant of FTC.
• 6-7th decade of life.
• Presence of oxyphilic Hurthle cell (rich in
mitochondria).
• More aggressive than FTC.
• Less Radioiodine avid than other Differentiated
thyroid cancer. Hurthle cell carcinoma

Prognostic factors in well differentiated thyroid cancers (post op score) :

AGES system AMES system MACIS system
•Age •Age •Metastasis ONLY THIS IS A
•Histological grade •Metastasis •Age POSTOP SCORE

•Extrathyroidal invasion •Extrathyroidal spread •Completeness of surgery

•Size •Size of tumor •Extrathyroidal invasion
•Size of original lesion
Anaplastic carcinoma thyroid :
• Seen in 5-7th decade.
• Rapidly progressive.
• M/C site of distant mets : Lungs.
• Mx : If restricted to thyroid : Aggressive surgery , otherwise : Palliation.
Medullary thyroid cancer (MTC) :
• Sporadic > familial.
• Most aggressive : A/w MEN2B.
• Familial variants seen in young patients and is
often multifocal.
• Lymphatic spread to lung & hematogenous
spread (M/C liver) seen.
• IOC : FNAC. MTC AMYLOD RICH STROMA

• CEA increased,serotonin secretion seen (causes diarrhoea ).

Management : (Mnemonic : one step ahead).
a. If tumor in restricted to thyroid gland : TT + CND.
b. If thyroid + Level 6 LN : TT + CND + MRND.
c. If thyroid + Level 6 + other nodes : TT + CND + B/L MRND.
d. If metastasis : Vandetinib, Carbozantinib (tyrosine kinase inhibitor).
• No role of thyroid scan & RIA. because they arise from parafollicular cells

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MEN (multiple endocrine neoplasia) syndrome : ----- Active space -----

MEN 1 (WERMER syndrome) : MEN 1 (WON) WERMER
MEN gene mutation on chromosome 11.
Tumors seen : 3 Ps
• �ituitary adenomas : M/C in MEN 1 is prolactinomas.
• Parathyroid (95% cases) : Adenoma > Hyperplasia.
• Pancreatic endocrine tumors : M/C in MEN 1 is gastrinoma.
• Thymic tumors.
• Collagenomas.
• Adrenal cortical tumors.
MEN 2 :
RET protooncogene mutation on chromosome 10.
MTC only MEN 2A / Sipple syndrome MEN 2B/ MEN 3 syndrome
Exon 618 Exon 634 mutation Exon 918 mutation
mutation MOST AGRESSIVE
MTC only MTC (M/C) MTC (M/C)
Parathyroid adenoma Marfanoid feature
Pheochromocytoma �ucosal neuromas
Megacolon Megacolon
Medullated corneal nerve fibres
Prophylactic thyroidectomy should be done Prophylactic thyroidectomy should be done
by 5-6 years of age. by 1 year of age.( aggressive).

MEN 4 syndrome :
• CDKN1B gene on chromosome 12.
• Pituitary adenomas.
• Parathyroid adenomas.
• Renal tumors.
• Adrenocortical tumors.
• Reproductive organ tumors.

Hyperthyroidism & Hypothyroidism 00:39:36

Features of hyperthyroidism Features of hypothyroidism

• Thin . • Dull
• Irritable. • Lethargic person
• Weight loss despite a good appetite. • Alopecia
• Tachycardia. • Bradycardia
• Diarrhoea. • Constipation
• Tremors. • Weight gain
• Heat intolerance. • Cold intolerance
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----- Active space ----- Causes of hyperthyroidism Causes of hypothyroidism

• M/C cause : Grave’s disease. • M/C overall : Iodine
• Solitary toxic nodule deficiency.
• Toxic nodular goitre. • In western world :
• Factitious hyperthyroidism (exogenous Hashimoto’s thyroiditis.
consumption). • Wolf Chaikoff phenomena
• Jod- Basedow phenomenon (Iodine induced). (Iodine induced
• TSH secreting pituitary adenoma. hypothyroidism).
• Struma ovarii (ectopic thyroid tissue in the • Non functioning pituitary
ovary). adenoma.

Management of hyperthyroidism :
• Drugs only :
a. PTU (safe in pregnancy) (S/E : Agranulocytosis)
b. Carbimazole
• Drugs followed by RIA .
• Drugs followed by surgery :
a. Inadequate preparation is the leading cause of thyroid storm.
Preparation of a hyperthyroid patient for surgery :
• Start anti-thyroid medications 6-8 weeks before surgery.
• Long acting beta blockers should be given : Nadolol.
• Last dose of anti thyroid medication is to be given evening before surgery.
• Beta blockers continued for 7 days post surgery

Graves disease : Hyperthyroidism

Autoimmune (CTL4) condition : Increased synthesis of thyroid hormone d/t long
acting thyroid stimulating auto antibodies.

Associations :
• Pernicious anemia
• Myasthenia gravis
• Diabetes mellitus
Clinical features :
• Diffuse enlargement of the gland.
• features of hyperthyroidism
• Eye signs Graves disease : scalloping of
colloid with tall columnar cells

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Eye signs : ----- Active space -----

1. Exophthalmos
Staring Look 2. Stellwag sign : Infrequent blinking
3. Von-Graffe sign : Lid lag on down gaze. Autonomic component of Levator Palpebrae Superioris (LPS)
4. Dalrymple’s sign : Lid retraction Spasm of mullers muscle.
5. Joffroy sign : Absence of forehead wrinkling when the patient looks up.
6. Moebius sign : Seen in severe toxicity (loss of accommodation).

Exopthalmos Pretibial myxedema

Management of graves disease
• Children : Drugs only.
• Pregnant : PTU.
• Adult without goitre : Drugs followed by RIA
• Adult with goitre : Drugs followed by near total / Total thyroidectomy.
• Elderly with comorbid conditions : Drugs followed by RIA.

Thyroiditis :
Hashimoto (lymphocytic) thyroiditis Subacute (De quervain) thyroiditis Riedels (fibrosing) thyroiditis
M/C. History of URTI. Fibrosis - Hence, IgG4 mediated

Painless neck swelling. Painful neck swelling. Painless hard neck swelling.
Diffuse goitre.
Initially hyperthyroidism then pro- Initially hyperthyroid then Steroids used for MX.
longed hypothyroidism. hypothyroid then recovers
spontaneously.
Prolonged
HYPOTHYROIDISM
Hashimoto’s thyroiditis / Lymphocytic thyroiditis :
• Associated with HLA DR 3/ B8.
• A/w Down’s & Turner syndromes.
Autoantibodies against :
a. Thyroid receptors
b. Thyroglobulin
c. Thyroid peroxidase (TPO).
Hashimotos thyroiditis
• Initial transient hyperthyroidism (Hashitoxicosis) then prolonged hypothyroidism.
• Diagnosis : Autoantibody levels .
• Management : Thyroxine replacement , If goitre : Surgery .
• HPE : Lymphocytic infiltration.

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

Post partum thyroiditis :
• 2nd most common autoimmune thyroiditis.
• 10 % women.
• 2-12 months Post partum.
• Similar to Hashimoto’s.
• Short thyrotoxic phase.
• Presence of anti TPO antibody.
• 10 fold risk of hashimoto.
De Quervain/ Viral/ Granulomatous/subacute thyroiditis :
• Associated with HLA B 35
• Initial transient hyperthyroidism then hypothyroidism (once follicles regener-
ate condition resolves).
• ESR is raised.
• Management : Supportive care
Riedels thyroiditis :
• Mediated by Ig G4.
• Fibrous deposition with in the gland and in vicinity of gland.
• Woody hard thyroid gland.
• Painless.
• Hoarseness of voice (RLN involvement).
• Stridor (tracheal involvement).
• D/D : Anaplastic carcinoma
• Diagnosis by : Tru-cut biopsy.
• Management : Steroids, Tamoxifen (SERM).

Parathyroid 00:51:02

• Superior Parathyroid : Arise from 4th pharyngeal arch.

• Inferior Parathyroid (variable location) : Arise from 3rd pharyngeal arch.
Hyperparathyroidism features :
• Bones :
a. Brown tumors (Osteitis fibrosa cystica/ Von Recklinghausen’s disease
of bone).
b. Subperiosteal bone resorption (radial aspect) .
c. Salt and pepper skull.
• Stones : Multiple renal stones.
• Abdominal groans : Colicky pain, pancreatitis.

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• Psychiatric overtones. ----- Active space -----

Brown tumors Subperiosteal resection Salt & pepper skull

• Primary hyperparathyroidism : S. PTH increased, S. Ca2+ Increased,, U. Ca2+
Increased, U. Po43- Increased, S. Po43- : decreased.
Two causes

Adenoma > Hyperplasia

Remove involved gland Remove 3 and 1/2 glands

To ensure that the right gland I/2 glad : auto transplanted

is removed in brachioradialis of non-
dominant hand.
Miami protocol
(half life of PTH is 7 minutes)

There is > 50% fall in PTH, 15-20 mins

after gland removal

• Sestamibi scan : Locate enlarged parathyroids.

Role of thymectomy (helps in improving the yield) :
a. If inferior parathyroids are involved.
b. In familial syndromes.
c. In secondary hyperparathyroidism.
Sestamibi scan
• Indication of surgery in asymptomatic primary hyperparathyroidism :

Variable 2002 Guidelines Pseudohyperparathyroidism

hypercalcemia of malignancy
Serum Calcium concentration 1.0 mg/dl above upper limit of normal PTH related peptide
M/C paraneoplastic syn
commonly associated with
24 hr urinary calcium excretion >400mg SCC lungs, Breast And
Prostate Ca
Reduction in creatinine clearance 30% C/f Conf. Dehydration
Mx
iv fluids
Bone mineral density T score below -2.5 at any site diuretics
KFT normal - bisphosphonates
Age <50 year

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----- Active space ----- GIT - 1

Surgical Anatomy of Esophagus 00:01:27

3 constrictions are encountered on endoscopy :

Measured from upper incisor :
1. 15 cm : Pharyngo-esophageal
junction (C6) → Narrowest portion
of GIT.
2. 25 cm : Left main bronchus &
arch of aorta.
3. 40 cm : Esophagus pierces the
diaphragm.
Mnemonic for diaphragmatic opening :
1 8 10 eggs at 12
1. T 8 : IVC.
2. T 10 : Esophagus, vagus. Esophageal constrictions
3. T 12 : Aorta, Thoracic duct.

Foreign Bodies in Esophagus 00:02:25

Beyond C 6 : Observation.
Impacted at C 6 : Endoscopic removal.
Button batteries : Endoscopic removal (Even if it has gone beyond C 6, as it can
corrode and perforate stomach).
Position of foreign body (coin) on X-ray chest :
Location Lateral view Frontal view Symptoms
Esophagus Tracheal gas shadow Entire coin is visible Difficulty
present anteriorly swallowing
Trachea No tracheal gas shadow Rim of coin seen Breathlessness
seen above or chocking

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Corrosive injuries of Esophagus 00:04:15 ----- Active space -----

Alkali injuries : More severe than acid injuries (As it penetrates deeper).
Acid injuries cause pyrolospasm → Cause more gastric damage.

Grading used : Zargar grading.

Management :
• IV fluids & NPO (Nil per oral).
• NG tube should not be inserted blindly → Can cause perforation.
• No role of prophylactic antibiotics.
• Most important intervention : Early skilled endoscopy.
• No role of steroids.
• Definitive management : Mx of developed stricture.

Tracheo-esophageal fistula 00:06:19

Seen in newborn.
Types :

(Type C is Most common)

Clinical features :
• Respiratory distress.
• Excessive drooling of saliva.
• Coiling of oro-gastric tube.

Investigations :
• Confirmatory test : Contrast study
(Dye : Iohexol > Dinosil).
• IOC for H type : Combined trachea-
esophagoscopy. H type of TEF on contrast study.
• Rule out other congenital anomalies : VACTERL
(Vertebral, anorectal, cardiac, Tracheo-esophageal renal & limb defects).

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

Management :
Waterson’s criteria :
Birth weight Pneumonia Management
≥ 2.5 kg Absent Immediate sx
1.5-2.5 kg Nutrition supplementation for weight gain and
Present/ Rx of pneumonia f/b Sx.
< 1.5 kg absent Feeding gastrostomy for nutrition and Rx of
pneumonia f/b delayed Sx.
Surgery :
1. Kamron haight procedure (Type B, C, D and E) : Fistula dismantled
→ Trachea & esophagus are repaired.
If two ends are close : Anastomosed.
2. Type A :
If two ends are far apart : Gastrostomy for
nutrition → Anastomosed later in life.
GERD 00:11:08

Factors which prevent GERD (Maintain patency of LES) :

1. Length of intra-abdominal esophagus (Most important factor) :
Normal → 3-5 cm, if < 2cm → Predispose to GERD.
2. Pinching effect of right diaphragmatic crura.
3. GE angle : Angle of His.
4. Arrangement of gastric mucosal folds.
Earliest physiological indicator : ↑↑Transient LES relaxation.
↑ obesity & ↓ rates of H. pylori → ↑ GERD
Clinical features :
• Retrosternal burning sensation (Heartburn).
• Water brash.
• Pharyngitis/Laryngitis.
• Chronic cough.
• Wheezing.
• Dental caries.
Management :
• IOC : Endoscopy.
• Gold standard investigation : 24 hr pH monitoring
(Done if planning intervention, Demeester’s score measured).
• Medical mx : Weight control, small frequent meals, avoid foods that relax LES

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(Chocolates, mint, citrus, spicy food, fried food) PPI and prokinetic agents. ----- Active space -----
• Surgical management : Fundoplication.
• Indications for Sx :
a. Patient not responding to medical Mx.
b. Patient suffering from complications of GERD.
c. GERD associated with large hiatal hernia.
d. Patient wanting to stop medical Mx.
• Principles of fundoplication :
• To restore adequate intra-abdominal length (Min 3 cm).
• To tighten the diaphragmatic crura around esophagus.
• To wrap fundus around esophagus (Shoe shine manneuver).
• To preserve vagus nerves.
• To re-establish the angle of His.
• Types of fundoplication :
a. Complete wrap/ Nissen’s (3600 wrap) : Gas bloat syndrome
(M/c complication).
b. Partial wraps : Dor (1800 anterior), Toupet
(180-2700 posterior), Belsey Mark (2700
anterior).
c. Collies gastroplasty : To gain length of
esophagus
Updates → Newer modalities in Mx of GERD : Collies gastroplasty
• Polymer injection around LES to tighten sphincter : Higher recurrence rate,
not preferred.
• Endoscopic Radiofrequency ablation (RFA) : Good longterm results.
• LINX device (MSAD : Magnetic sphincter augmentation) in patients with
minimal or no hiatal hernia.
• Transoral incisionless fundoplication : 2700 (NOTES procedure - Natural orifice
transluminal endoscopic surgery).

Barrett’s esophagus :
Specialized intestinal metaplasia :
Squamous → columnar epithelium.
Red velvety mucosa +nt.
Diagnosis : Endoscopic biopsy. Barrett’s esophagus : Endoscopy
Pathogonomic finding : Goblet cells.
Types :
• Long-segment : > 3 cms.
• Short-segment : < 3 cms.
• Cardia metaplasia : Microscopic.
HPE of BE
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----- Active space -----

PRAGUE C & M criteria :
Higher C & M value : More is the risk
of conversion to adenocarcinoma.

Chromoendoscopy :
• Methylene blue : Identify the
abnormal areas of Barrett’s
esophagus/adenocarcinoma.
• Lugol’s iodine : Squamous epithelium.

Chromoendoscopy showing
Barrett’s esophagus
Seattle biopsy protocol : Four quadrant biopsy every 2 cms in addition to tar-
geted biopsy on macroscopically visible lesions.
Treatment :
• RFA is most popular, cost effective and favourable side effect profile.
• EMR (Endoscopic mucosal resection) by cap or multiband technique can re-
move whole mucosa, but has higher rate of stricture.
BE : Barrett’s esophagus
Flat columnar mucosa HGD : High-grade dysplasia
LGD : Low-grade dysplasia
Systematic cold biopsy EGD : Esophagogastroduodenoscopy

Confirm dysplasia by 2 diffferent pathologists

No dysplasia Indefinite for LGD HGD or T1a

dysplasia Adenocarcinoma
EGD every
Repeat EGD with 6 months
Therapeutic
maximal acid intervention
suppression 2 consecutive
non-dysplastic BE
Repeat EGD Definite dysplasia Endoscopic eradication
every 3-5 therapy
years Follow no-dysplasia
Follow LGD or HGD
flowchart
flowchart
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Neoplasia of Esophagus 00:11:08

Esophageal cancer
Criteria Squamous cell carcinoma Adenocarcinoma
Overall M/C M/C in western world
Location in esophagus Middle one third Lower one third
Smoking, alcohol
Preservative rich food
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 of Esophageal Cancer :
• Progressive dysplasia (Solids more than liquids).
• Weight loss.
• Hoarseness : Sign of advanced disease → Left Recurrent laryngeal nerve
(RLN) involvement.

Investigations :
• IOC : Endoscopic biopsy.
• IOC for staging : PET CT → Isotope used is 18 FDG.
• IOC for T staging : Endoscopic USG.
• On barium swallow :
Rat-tail appearance/ Apple-core deformity. Barium swallow showing
Siewert classification : rat tail appearance
Used for GE tumors.
Type 1 and 11 are treated as esophageal
cancer : Esophagectomy.
Type 111 are treated as gastric cancer :
Total gastrectomy.

Surgical management :
• Esophagectomy.
• Margins : Proximal → 10 cm, distal margin
→ 5 cm.
• Minimum nodes removed : 15.
Siewert classification

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Types of esophagectomy :
----- Active space -----
Orringer/Transhiatal Ivor Lewis Mc Keown/Three field
Site Lower 1/3rd Mid 1/3rd Upper and middle 1/3rd
No. of incisions 2 2 3
Site of incisions Midline abdominal Abdominal Abdominal
Lt neck Rt thoracotomy Rt thorax
Lt neck
Site of anastomosis Neck Thorax Neck
M/C cause of death Mediastinitis (d/t
anastomotic leak)
Esophageal replacements :
• Best esophageal replacement : Gastric tube (Blood supply is based on Rt
Gastroepiploic & Rt Gastric vessels.
• If stomach is affected : Jejunum or colon used.
• SEMS (Self expanding metalic stents) :
• Used in case of malignant TEF.
• M/C complication : Migration.
Most important prognostic factor :
Depth of invasion.
M/C site of distant metastasis : Liver. SEMS
Combined chemo RT can be used as neo-adjuvant or after Sx.

Esophageal leiomyoma : Most common benign tumor of esophagus.

Site : Mid-distal esophagus.
M : F → 2:1.
usually asymptomatic.
Only large lesions : Cause dysphagia.
On barium swallow : Punched-out appearance.
Management :
• Enucleation.
• STER : Submucosal tunneling endoscopic resection. Barium swallow showing
punched out appearance
Esophageal diverticulae & hernias 00:37:28

Zenker’s diverticulum (Cricopharyngeal achalasia) :

Through Killian’s dehiscence : Potential space between
Thyropharyngeus & Crycopharyngeus muscles.
Pulsion diverticulum : Due to increased pressure.
Only mucosa comes out : False diverticulum.
Starts in midline posteriorly (Final position : Left of midline).
Zenker’s diverticulum

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

• Regurgitation (Earliest).
• Halitosis.
M/C complication : Aspiration pneumonitis.
Investigation : Barium swallow.
management :
• Best : Diverticulectomy + Cricopharyngeal myotomy (Linear stapler or laser
used).
• If patient not fit for major Sx → Dohlmann’s procedure :
Endoscopic diverticulopexy + Cricopharyngeal myotomy.
• Cricopharyngeal myotomy : ↓ risk of recurrence.

Mid esophageal diverticulae (Parabronchial) :

Only true diverticulum : All layers of bowel +ve.
Traction diverticulum.
Cause : TB/Histoplasmosis.
If large or symptomatic : Diverticulectomy.

Hiatal hernia :
Type 1 - Sliding hiatal hernia :
M/C diaphragmatic hernia.
Bochdalek hernia : M/C congenital diaphragmatic
hernia.
GE junction moves proximally.
Clinical feature : GERD.
Not life threatening.
Barium swallow showing
IOC : CT with oral contrast.
sliding hernia
Sx : Only in symptomatic pts.

Type 2 - Rolling or paraesophageal hernia :

Portion of stomach migrates through the hiatal
opening into the thoracic cavity.
GE junction is usually normal.
Herniated portion can undergo volvulus & necrosis :
Can be life threatening → All require Sx. Barium swallow showing
Type 3 : Mixed (Sliding + rolling). rolling hernia
Type 4 : Paraesophageal hernia but content other than stomach herniates
through.
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----- Active space ----- Esophageal perforation 00:43:03

Iatrogenic (M/C) :
Post endoscopic.
Commonly occurs in the upper 1/3rd.
Increased risk in therapeutic endoscopy, endoscopy in cancer.
Clinical features : Chest pain/abdominal pain post endoscopy.
Management :
• IOC : CECT.
• Majority are small, stable and no sepsis → Conservative management :
a. NPO. c. I/V antibiotics.
b. I/V fluids. d. Analgesics.
• If large/sepsis +nt : Sx → Repair esophagus.

Spontaneous esophageal perforation (Boerhaave syndrome) :

Forceful vomiting against a closed glottis, common in alcoholics.
Most common site : Lower 1/3rd (Lt posterolateral wall).
Clinical features → Mackler triad :
• S/c emphysema.
• Retching.
• Chest pain.
Hamman’s crunch : Crunching sound when heart is auscultated, d/t
pneumomediastinum.
Investigations :
• IOC : Contrast study (Contrast leak → Perforation).
• If stable : CECT.
• Pneumomediastinum signs :
a. Spinnaker sign.
b. Naclerio’s V sign.
c. Continuous hemi-diaphragm sign.
• Lt sided pleural effusion. Lt sided pleural effusion
Management :
• Patients with cervical esophageal and pharyngeal
perforations are less septic than those with
intra-thoracic perforations.
• Stable patients : Conservative Mx.
• Objectives :
a. Seal perforations : Clips & SEMS, T-tube
placement and repair.
b. Adequate drainage
c. Nutritional support. Contrast study showing leak
• Cervical esophagostomy : Not done now.

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Other Non-neoplastic Conditions of Esophagus 00:48:48 ----- Active space -----

Schatzki ring
B ring seen on barium study.
Gives rise to intermittent dysphagia.
Only symptomatic patients : Dilatation done.
Schatzki ring
Feline Esophagus
Lines seen on esophagus on barium study.
On endoscopy : Stacked up appearance.
Seen in : GERD (M/C seen, lower 1/3rd), eosinophilic esophagitis (upper 1/3rd).

Barium swallow showing feline Endoscopy showing stacked up

esophagus appearance
Eosinophilic Esophagitis
• Chronic immune/antigen mediated disease with esophageal dysfunction.
• Endoscopy : Rings, furros, crepe paper mucosa.
• Biopsy : 15 or more eosinophils per hpf, taken atleast at 2 different places.
• Treatment goals : Reduce eosinophilia (< 5/hpf), control of symptoms with
steroids (Topical), PPI.

Esophageal infections :
1. Esophageal candidiasis :
Associated with oral thrush.
Seen in immunocompromized patients.
Endoscopy : Worm like ulcers.
On barium swallow : Shaggy appearance and worm
like ulcers.
2. CMV :
Seen in post transplant patients and GVHD.
Appearance : Serpiginous/Geographical ulcers.
Barium swallow showing
Esophageal candidiasis
3. Herpes :
Associated with herpes labialis.
Appearance : Ulcers with raised margins.

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

Esophageal motility disorders 00:53:20

Achalasia cardia
C/F Female with regurgitation, Patient with chest pain similar
nocturnal cough, dysphagia & to angina.
weight loss. Cardiac enzymes are normal.
Differentials Achalasia, cancer. DES, Angina.
Work-up Endoscopy ECG
Manometry Manometry
Barium study Barium study
D/t failure of LES to relax.
Loss of ganglion cells (Derived from neural crest) in Myenteric & Auerbach
plexus.
Types of achalasia :
• Primary achalasia : Loss of ganglion cells.
• Secondary achalasia : Secondary to Chaga’s disease (Trypanosoma cruzii).
• Vigorous achalasia : Rapidly progressive.
• Pseudoachalasia : Seen in malignancy.
• Triple A syndrome (Algrove syndrome) : Alacrimia, achalasia, ACTH resistant
adrenal insufficiency.
Clinical features :
• Triad : Dysphagia, regurgitation (Earliest) & weight loss.
• Dysphagia : Liquids → solids.
• Heart burn.
• Nocturnal coughing.
• Post prandial choking.
Complications : Aspiration pneumonitis (M/C), lung abscess.
Investigations : Barium swallow → Bird’s beak appearance (Gradual tapering).
Classifications :
Types according to Chicago classification :
• Type 1 : Classical achalasia.
• Type 11 : Achalasia with esophageal compression.
• Type 111 : Spastic achalasia.
Eckardt score in achlasia : Takes into account the following
• Weight loss score • Retrosternal pain
• Dysphagia • Regurgitation
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Treatment : ----- Active space -----

1. Botox :
• High recurrence rate.
• Repeated injections can lead to scarring.
• Restricted to elderly patients with co-morbidities.
2. Pneumatic dilatation : Serial dilatation have similar efficacy to surgical
myotomy.
3. Heller’s myotomy :
• Laparoscopic myotomy : 6 cm proximal to 2-3 cm distal.
• Sx outcomes are better in type 1 & 2 achalasia than 3.
4. POEM :
• Per-oral endoscopic myotomy (NOTES , scarless procedure).
• Circular ± longitudinal muscles are cut using endoscopic submucosal
dissection (ESD).
• Type 111 responds best.
• High rate of esophagitis/GERD : 57% in 3 months.

Distal esophageal spasm :

5 times less common than achalasia.
Females > males.
Motor abnormality of esophageal body (lower 2/3rd).
Contractions : Simultaneous, repetitive & high amplitude.

Clinical features :
• Chest pain (Angina like).
• Dysphagia.
• Acid reflux not seen.
ECG and cardiac enzymes are normal.

Investigations : Barium study → Cock screw/Rosary bead appearance.

Treatment :
• CCB.
• Nitrates.
• Dilatation.

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Congenital hypertrophic pyloric stenosis (CHPS) 00:01:08

Also known as idiopathic hypertrophic pyloric stenosis.

Hypertrophy of pylorus muscle → Gastric outlet
obstruction.
Usually affects first born male child.
Child is normal for first 2 - 3 weeks of life.
Complaints : Projectile non bilious vomiting.
Best time for examination : During feeding. Thick pylorus muscle
O/E : before surgery
• Palpable olive shaped swelling in epigastrium.
• Visible peristalsis from left → Right.
CHPS Duodenal atresia
At birth Normal Bilious vomiting
Non bilious projectile vomit-
Complaints Bilious vomiting
ing after few weeks.
M/c First born male child Down syndrome
IOC USG X ray
Mx Ramstedt pyloromyotomy Duodenoduodenostomy

Investigations :
IOC : USG - Pyloric channel thickness > 4mm & length > 16mm.
Contrast study :
• Mushroom sign
• Rail track sign
Metabolic abnormality : Hypochloremic hypokalemic
metabolic alkalosis with paradoxical aciduria.
Best fluid : 1/2N NS + KCl + Dextrose or Ringer lactate.

Surgical Management : Mushroom sign

• Ramstedt pyloromyotomy.
• If uneventful sx : Feeding can be started in 4 - 6 hrs.
• If mucosa is injured : Repair mucosa & feeding can be started in 24 - 48 hrs.

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Peptic ulcers 00:05:15 ----- Active space -----

M/c peptic ulcers : Duodenal ulcers (90% d/t H. pylori & associated with Acid
production).
M/c complication of peptic ulcers : Bleeding.
M/c cause of upper GI hemorrhage : Peptic ulcers.

Duodenal ulcers :
Posterior Ulcers :
M/c complication : Bleeding (Vessel : Gastroduodenal artery).
Mx : Endoscopic (Atleast 2 attempts should be tried) → Failure → Surgery (un-
der running of vessel).
Anterior ulcers :
M/c complication : Perforation → Perforation peritonitis.
C/f :
• Pain.
• Rebound tenderness.
• Board like rigidity.
Initially clean contaminated wound → Dirty.
Dx :
• CXR : Gas under diaphragm (Hollow viscus perfo-
ration). Gas under diaphragm
Mx :
• Nil per oral (NPO).
• I.V fluids.
• I.V antibiotics.
• Pain killers.
• Emergency exploratory laparotomy.
Duodenal perforation : Omental patch repair
(Graham’s patch). Graham’s patch
Gastric ulcers :
Johnson’s
Type classification :
Location Features Sx
Along the lesser
Distal gastrectomy
Type 1 curvature, near Most common type.
(DG)
incisura.
Prepyloric + Associated with acid
Type 2
duodenal hypersecretion, respond DG + Acid reduction
Type 3 Only prepyloric to PPI/vagotomy.
Bleed most commonly : Pauchet procedure
Type 4 Body of stomach
D/t left gastric artery. /Csendes procedure

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----- Active space ----- M/c complication : Perforation.

Mx : Gastrectomy
(Biopsy to be taken to r/o malignancy).

H pylori :
CAG A & VAC A : Gene which encode for toxins.
Urease enzyme : Helps survive in acidic environment.
H. pylori can cause :
• Peptic ulcers.
• Type B gastritis.
• Gastric cancer.
• MALTomas (Low grade MALTomas respond to H. pylori eradication).
H. pylori is slightly protective against adenocarcinoma esophagus.

Vagotomy & gastric reconstruction :

Vagotomy :
Replaced by PPIs currently.
Truncal vagotomy with antrectomy Highly selective vagotomy
• Maximal acid reduction. • Least acid reduction.
• Least ulcer recurrence. • Max ulcer recurrence.
• Max vagotomy related complication.

Gastric reconstruction :
Bilio
pancreatic limb
Roux
limb

Billroth 1 : Billroth 2 : Roux en Y gastrojejunostomy :

End to end Close duodenal stump + Close duodenal stump +
gastroduodenal End to side gastro jejunal End to side gastro jejunal
anastomosis. anastomosis. (aka Polya anastomosis + End to side
reconstruction). jejuno jejunal anastomosis
Complications of vagotomy & Gastric reconstruction :
1. Nutritional deficiencies :
• M/c : Iron deficiency.
• Other deficiencies : Vit B12, Vit D3.
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2. Internal hernia : ----- Active space -----

Antecolic : Retrocolic :
If bowel loop herniates If bowel loops herniate through the transverse
behind Roux limb. mesocolon/ window in the mesentery.

Peterson's hernia Stemmer's hernia

3. Dumping syndrome :
Early Late
Occurs due to rapid influx of fluid in the Rebound hypoglycaemia due to
bowel due to hyperosmolar contents in excessive insulin release.
the bowel.
Epigastric fullness Hypoglycemia, tachycardia,
Nausea & vomiting. sweating, headache.
Worsens with more food. Improves with more food.
Starts in 15-20 min after food. Starts in 30-40 minutes.
Prevention :
• Small frequent meals.
• Avoid liquid with meals.
• Avoid sugar rich liquids.
• Avoid simple sugars.
• Take high protein/fat diet.
• Resistant cases : Try octreotide.
• If dumping is more with Polya, switch to Roux en Y gastrojejunostomy.

Gastric cancer 00:23:22

Risk factors :
• Smoking.
• Alcohol consumption.
• Consumption of smoked food/fish.
• Preservative rich food.
• H. pylori.
• Menetrier’s disease.
• Gastric resections.
• Polyps (Adenomatous polyps : Familial adenomatous polyposis syndrome).
• Gastritis.
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----- Active space -----

Classification :
Lauren’s classification :
Intestinal type Diffuse type
Environmental Familial
Gastric atrophy, intestinal metaplasia. Blood type A
Men > women Women > men
ing incidence with age. Younger age group
Gland formation Poorly differentiated, signet ring cells.
Hematogenous spread Transmural/lymphatic spread.
Microsatellite instability APC gene
Decreased E-Cadherin
mutation.
p53, p16 inactivation p53, p16 inactivation
Other classifications :
1. Japanese classification :
• For early gastric cancers : Above muscle layer.
• Type 1 Polypoidal type : Best prognosis

2. Borrmann’s classification :
• For advanced gastric ca : Invading the muscle layer.
• Type IV (Linitis plastica) : Diffusely infiltrating type (Leather bottle
appearance → Worst prognosis.

Atypical presentation :
Atypical presentations of Gastric/GI cancers
Left supraclavicular lymph node (LN)
Troisier sign/Virchow LN
(Sign of advanced Ca in any GI malignancy)
Irish nodule Left axillary LN in gastric Ca
Mets into pelvis/pouch of Douglas.
Blumer's shelf
(Sign of advanced Ca in any GI malignancy).
Sister mary joseph Periumbilical mets.
nodule M/c : Gastric > ovarian Ca
B/L ovarian mets.
Seen in gastric or breast Ca.
Krukenberg tumor
Diffuse gastric ca : Signet ring cell can be seen.
Spread : Retrograde lymphatic spread theory.
Lesser Trelat sign Multiple sebhorric keratosis (Internal malignancy)
Tripe palms Hyperkeratotic palms (Internal malignancy)
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----- Active space -----

Sister mary joseph nodule Tripe palms Lesser Trelat sign

Investigation of gastric Ca :
IOC for diagnosis : Endoscopic biopsy.
IOC for overall staging : PET-CT.
IOC for T Stage : EUS.

Mx :
D1 Gastrectomy : 1 - 6 stations removed.
D2 Gastrectomy : 1 - 11 stations removed.
Minimum no. of lymph nodes to be removed : 16.
Sx → Chemo & radiotherapy.
Surgical management

Primary tumor Gastric LN

Margins :
• Proximal : 5 cm
• Distal : Pylorus

TOTAL
GASTRECTOMY
SUBTOTAL/
PARTIAL
(60-70%)

DISTAL
GASTRECTOMY

DISTAL

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Other gastric malignancies 00:32:16

Gastrointestinal stromal tumors :

Arises from interstitial pace maker cells of Cajal.
M/c site : Stomach.
Sporadic > Familial.
Syndromes associated : C/f :
• Carney’s triad (Sporadic) : • Upper GI hemorrhage (M/c).
1. Gastric GIST. • Lump.
2. Paraganglioma. • Perforation.
3. Pulmonary chondroma. IOC : CECT (Radiological Dx).
Occurs due to Succinyl Dehydrogenase B mutation → Resistance to imatinib.
• Carney Stratakis syndrome (Familial) :
1. Gastric GIST.
2. Paraganglioma.

Mx :
• Surgical resection with 2 cm margin.
• If malignant or metastatic GIST : Sx + Imatinib (tyrosine kinase inhibitor).
• If imatinib resistant → Sunitinib/Sorafenib (Can also be used in Hepatocellu-
lar Ca & RCC).
IHC markers :
• CD117/C-KIT : M/c (> 90%).
• CD34 : 60-65%.
• DOG 1 : Most specific marker.
• Wild type : CD117 and PDGFα negative.

Fletcher’s classification :
Used to classify benign & malignant GIST based on size & mitotic figures.

Gastric lymphoma :
M/c site : Stomach (Extra nodal GI lymphoma).
Usually diffuse large B cell lymphoma.
C/f :
• Lump.
• Upper GI bleed.
Dx : Endoscopic Bx.
Mx : Chemo (RCHOP) → Radiotherapy.
RCHOP : Rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, predniso-
lone.
High grade MALToma is treated as lymphoma.

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Other gastric conditions 00:36:12 ----- Active space -----

Gastric volvulus :
Types : Based on axis
Organoaxial Mesenteroaxial
Twist occurs along a line connecting Twist occurs along a plane perpen-
the cardia & pylorus along the luminal dicular to luminal axis of the stomach
axis of the stomach. from lesser to greater curvature.
• Most common type. • Chronic symptoms common.
• A/w diaphragmatic defect. • Diaphragmatic defects less com-
• Vascular compromise common. mon.

C/f : Organoaxial Mesenteroaxial

Borchardt triad : (Longitudinal) (Vertical)
1. Retching.
2. Inability to insert Ryle’s tube.
3. Epigastric pain.

Sx : Derotate & fix the stomach.

Trichobezoar :
Hair ball inside stomach.
2˚ to psychiatric condition Trichophagy (Psychiatry ref-
erence needed).
Causes obstruction.
Mx : Surgery.
Trichobezoar

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Bariatric surgery 00:00:50

Indications :
• BMI >40 kg/m2.
• BMI >35 kg/m2 with obesity complications.
• BMI 30-34.9 kg/m2 with onset of type 2 diabetes within 10 yrs.
• Asian population have a lower cutoff (2.5 kg/m2 lesser than above mentioned
cutoff).

Obesity surgery- mortality risk score (OS-MRS) :

The risk factors included in the are :
a. Arterial hypertension
b. Age >45
c. Male gender
d. BMI >50 kg/m2.
e. Risk for pulmonary thromboembolism
Diabetes mellitus is not part of the criteria.

Bariatric surgery
M/C Lap sleeve gastrectomy.
Most acceptable Roux en Y gastrojejunostomy
Max weight loss Duodenal switch/Biliopancreatic diversion.
Reversible Sx Lap adjustable gastric banding & intragastric balloon placement.

A. Roux en Y gastrojejunostomy :
Roux limb length : 100 cms.
Nutritional complication :
• M/c : Iron deficiency.
• Vit D3/Ca2= deficiency.
• Vit B12 deficiency. Roux en Y gastrojejunostomy

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B. Sleeve gastrectomy : ----- Active space -----

Complications :
• M/c : Bleeding from staple line.
• Nutritional deficiencies.
• Leak from angle of His. Sleeve gastrectomy
• Redistension of sleeve.
C. NOTES (Natural orifice transluminal endoscopic surgery) :
• TOGA (Transoral gastroplasty ) : Stomach is sutured from inside.
D. Gastric banding :
• Band placed 6 cm from GE junction.
• Band is adjustable balloon with port at umbilicus.
• Weight loss attained by inflating balloon.
E. Intragastric balloon placement :
Gastric banding
• ORBERA & RESHAPE.
• Baloon inside stomach keeps it distended.
• Early satiety & weight loss.
Bariatric surgery referred to as metabolic surgery as it
leads to :
• Weight loss.
• Improvement of diabetes, hypertension & hyperlipidemia .
Max weight loss :
Duodenal switch (DS)/Biliopancreatic diversion (BPD) > Sleeve gastrectomy &
gastric bypass > Gastric banding.
Nutritional supplementation :
1. After gastric banding :
• Multivitamin & mineral supplementation, vitamin D, iron supplementation.
• Thiamine (if vomiting).
2. After sleeve gastrectomy/gastric bypass/BPD/DS :
• Same as banding, also give selenium, copper, zinc, folic acid.
• Vitamin B12, A, E, K.
• Gastric bypass/BPD/DS : Require higher doses.

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

Mesenteric cyst 00:10:30

Tillaux triad :
• Periumbilical swelling.
• Tillaux sign : Swelling moves at right angle to mesentery.
• Transverse band of resonance.
IOC : Contrast enhanced CT.
Two types of mesenteric cysts :
Chylolymphatic cyst (M/C) Enterogenous
Sequestered lymphatic tissue Sequestered bowel tissue
Thin wall Thick wall
Clear fluid Turbid fluid
Independent blood supply Shares blood supply with bowel
Rx : Enucleation Rx : Resection & anastomosis

Upper GI hemorrhage 00:12:21

Bleeding proximal to ligament of treitz.

Upper GI hemorrhage

Non variceal bleeding (M/C) Variceal bleeding

Non variceal bleeding :

Causes :
• Peptic ulcer (M/c). • Mallory weiss tear.
• Gastritis. • Gastric antral vascular ectasia.
• Cryptosporidiosis in AIDS patients. • Menetriers disease.

Gastritis Features
• Autoimmune gastritis.
Type A
• Occurs at body of stomach a/w pernicious anemia, achlorhydria.
Type B • H. pylori induced (affects antrum).
• Cushing’s ulcer : In head injury, occurs in acid producing area of
Stress
stomach.
induced
• Curling ulcer : In burns, involves first part of duodenum.
NSAIDs • Due to chronic use.

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Mallory weiss tear : ----- Active space -----

• Common in alcoholics.
• Occurs after a bout of forceful vomiting.
• Tear in mucosa/submucosa from GE junction upto cardia.
• Vessel implicated : Left gastric artery.
• Self limiting.

Gastric antral vascular ectasia (GAVE) :

Autoimmune.
Dilated venules.
Endoscopy : Watermelon stomach.
M/x : Argon photocoagulation. Watermelon stomach

Menetrier’s disease :
Overexpression of TGF-α.
Hypertrophy of gastric mucosal folds.
Earliest feature : Protein losing enteropathy.
M/x :
• Cetuximab (Monoclonal antibody against EGFR).
• In severe cases : Gastrectomy.
Variceal bleeding & Portal hypertension :
Menetrier’s disease
Diagnosis : Doppler.
Hepatic venous pressure gradient (HVPG) values :
Measurement Significance
1-5 mm Hg Normal.
6-10 mmHg Preclinical sinusoidal portal HTN.
≥ 10 mm Hg Clinically significant portal HTN. Caput medusae
≥ 12 mm Hg ↑ risk for rupture of varices

Portosystemic shunts :
• Left gastric (coronary) vein, short gastric veins → Distal esophageal veins :
Form esophageal varices.
• Coronary vein → Azygos & hemiazygos veins in vertebral venous plexus
• Splenic vein → Left renal vein.
• Left gastric or gastroepiploic vein → Esophageal or paraesophageal veins :
Form esophageal varices.
C/F of portal HTN :
• Caput medusae : Periumbilical shunts in portal HTN form caput medusae.
• Ascites.
• Splenomegaly.
• Liver failure.

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

Management of variceal bleeding :
Variceal bleed
Emergency
ABC management

I/V agents & fluids :

Best : IV Terlipressin.
M/c : IV Octreotide.
Not used : IV propranolol

Patient stabilized

Upper GI endoscopy

Banding >> Sclerotherapy (M/C : Sodium tetradecyl sulphate).

Bleeding controlled : If rebleeds

Discharge on oral propranolol
Second attempt at endoscopic control
If fails : TIPSS

PPI given after endoscopy.

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, 1 balloon

Transjugular intra-hepatic portosystemic shunt (TIPSS) :

Shunt b/w branch of portal vein & hepatic vein.
Complications :
• Early complication : Rupture of capsule.
• M/c : Blockade → Rebleeding.
• Encephalopathy (d/t non selective shunt).

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Other shunts : ----- Active space -----

Selective Non selective

• Warren : Distal splenorenal shunt • Linton : Proximal splenorenal shunt
• Inokuchi : Left gastric venocaval shunt • Eck fistula : Portocaval shunt
Advantage :
• Shunts only splenic blood. Risk of encephalopathy
• Avoids encephalopathy.

Child pugh score :

Factor. 1 point. 2 points. 3 points
Encephalopathy None. Grade 1 -2 Grade 3 - 4
Ascitis Absent Mild to moderate Severe (diuretic
(diuretic responsive) refractory)
Bilirubin (mg/dl) <2 2-3 >3
Albumin (g/dl) > 3.5 2.8 - 3.5 < 2.8
Prothrombin time <4 4-6 >6
Seconds prolonged
INR < 1.7 1.7 - 2.3 > 2.3
• Child Pugh A : Score 5 - 6 (least severe liver disease).
• Child Pugh B : Score 7 - 9 (moderately severe).
• Child Pugh C : Score 10 - 15 (most severe).
Forrest’s classification for peptic ulcer bleeding :
Endoscopic classification : Assesses risk of rebleeding.
Classification Description
Acute hemorrhage (high risk)
Class Ia Spurting hemorrhage
Class Ib Oozing hemorrhage
Signs of recent hemorrhage
Class IIa (high risk) Non bleeding visible vessel
Class IIb (intermediate risk) Adherent clot
Class IIc (low risk) Flat pigmented spot
Lesions without acute bleeding
Class III (low risk) Clean ulcer base

Prognostic scoring sytems : Rockall’s score, BLEED criteria, Glasgow score

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

Bowel obstruction 00:25:05

Cardinal features :
• Non passage of flatus & faeces (obstipation).
• Vomiting.
• Distention
• Abdominal pain.
Investigation :
• Initial investigation : X-ray abdomen erect & supine.
• IOC in adults : CECT.
• IOC in children : USG.
Erect X ray features :
Air fluid levels >3 suggestive of obstruction.
Supine X ray : Tells us about site of obstruction.
Site Features
Feathery appearance
Jejunum
Complete volvulus
Ileum Featureless
Large bowel Incomplete haustrations.

Erect X-ray Supine X-ray Haustrations supine X-ray

Jejunum & ileal features
Initial M/x :
• NPO.
• IV fluids.
• Ryles tube.
• IV antibiotics & pain killers.
• Surgery : If conservative m/x fails

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Surgery : ----- Active space -----

First structure visualized : Caecum.

Caecum

Collapsed : Distended :
Small bowel obstruction Large bowel obstruction

Duodenal atresia :
Common cause of obstruction in neonates.
Common in Down’s syndrome.

Clinical features :
Bilious vomiting since birth.

X ray :
Double bubble sign. Double bubble sign

M/x : Duodeno-duodenostomy.

Jejunal atresia :
Triple bubble sign on X ray.
• Type 3b : Apple tree or christmas tree de-
formity with mesenteric gap.
• Type 4 : Multiple atresia with string of sau-
sage appearance. Triple bubble sign
Intussusception :
Telescoping of one bowel loop into another.
Receiving loop : Intussuscipiens.
Loop going inside : Intussusceptum

Narrowest portion : Neck.

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

Types :

Primary intussusception (M/C) Secondary intussusception

Seen in children 6 months-2yrs. Seen in adults.
20 to pathological lead point
Trigger : Hypertrophy of peyers • M/c polyp.
patches. • Diverticulum.
• Cancer.
M/C Ileocolic. M/C colocolic.
Clinical features & signs :
Features of intestinal obstruction.
In children :
• Red currant jelly stools.
• Sign of dance : Empty right iliac fossa & lump is felt in right lumbar region.
Investigations :
• Initial : X ray abdomen erect & supine.
• In children IOC : USG.
• USG features : Target sign/donut sign.
• IOC in adults : CECT
Contrast enema :
• Pincer/claw sign. Target sign
• Diagnostic & therapeutic.
• C/I of surgery :
a. Perforation.
b. Strangulation.
c. 20 pathological lead point.
Sigmoid volvulus :
Predisposing factors : Claw sign
• Long & narrow mesentery.
• Redundant sigmoid.
• Loaded sigmoid.
Commonly seen in patients :
• On antipsychotic meds.
• Constipation.
Rotation in anticlockwise > clockwise.
Coffee bean sign
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Investigations : ----- Active space -----

X -ray abdomen erect & supine showing :
• Coffee bean sign or bent inner tube sign.
• Dilated large bowel.
• Haustrations.
Contrast enema : Bird’s beak appearance.

M/x : Birds beak

Sigmoid volvulus appearance

Stable, no peritonitis Unstable, peritonitis

Sigmoidoscopic decompression
Hartmann’s procedure :
Definitive surgery : Sigmoidectomy 1. Resect perforated segment.
2. Proximal colostomy.
Intestinal stricture : 3. Distal end closed and kept inside.
Causes :
• Cancer.
• Post Radiotherapy.
• TB.
• Crohn’s disease.
M/x : If strictures are :
a. close to each other : Resection & anastomosis.
b. far apart : Stricturoplasty.
Types of stricturoplasty :

Heinke miclulicz Finney

Longitudinal incision Side to side anastomosis of bowel
Sutured transversely

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

Meckel’s diverticulum :
• Remnant of vitellointestinal duct.
• Outpouching along antimesenteric border.
• True diverticulum : All layers of intestine.
• Independent blood supply.
• Rule of 2 :
a. 2% population. Meckels diverticulum
b. 2 inches long.
c. 2 feet proximal to ileocolic junction.
Presentations :
Presentation Features
Asymptomatic broad based Mx : Observe.
Mimics appendicitis
Meckel’s diverticulitis
M/x : Diverticulectomy.
Presents with peritonitis
Perforation
M/x : Resection & anastomosis
M/c presentation in children.
• Bleed d/t ectopic gastric mucosa.
• 2nd m/c ectopic mucosa : Pancreatic mucosa.
Bleeding
IOC : Tc99 pertechnetate scan/pentagastrin
(detects bleeding upto 0.1 ml/sec).
M/x : Angioembolization → Diverticulectomy.
M/c presentation in adults
Obstruction M/c cause : Intussusception d/t diverticulum.
Rarely : Twisting of bowel around meckel’s.
Cancer in meckel’s Rare
Adhesive obstruction :
• M/C cause of bowel obstruction. • Investigation :
• Occurs post surgery. CECT to r/o other causes.
• Non surgical causes : • M/x :
a. Crohn’s disease. Conservative m/x can be done for 48-72 hrs.
b. TB.
c. Cancer.
d. Post Radiotherapy.
e. Endometriosis.
f. PID
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Superior mesenteric artery syndrome (wilkie’s syndrome) : ----- Active space -----
Normal angle b/w aorta & superior mesenteric artery where D3 lies : 25-450.
Rapid weight loss & spinal cast reduces angle.
Angle < 220 compresses third part of duodenum.
Features :
• Bilious vomiting after meals.
M/x :
• Encourage weight gain.
• Strong’s procedure : Duodenal derotation or cut ligament of trietz.
• Duodenojejunostomy.

Ladd band :
M/c intestinal malrotation abnormality.
Band runs b/w right hypochondrium & caecum.
Compresses duodenum.
M/x : Excision of ladd’s band.
Adynamic bowel obstruction 00:44:42

Congenital megacolon or Hirschsprung’s disease :

Absence of ganglion cells in aurebach’s & myenteric plexus.
Functional obstruction.
Common in Down’s & MEN syndromes.
Features :
• M/c : Non passage of meconium.
• Distention.
• Constipation.
Due to mutation in gene coding for glial derived neurotrophic factor (GDNP).
Investigation :
IOC : Full thickness rectal biopsy showing :
• Loss of ganglion cells.
• Hypertrophied nerve trunks.
• Immunohistochemistry for acetylcholinesterase.
Barium enema :
• Dilated normal bowel proximally. Barium enema :
• Constricted bowel lacking ganglion cells. Hirschsprung’s disease
Best method of diagnosis : Intra op frozen section.

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

M/x :
Bypass/resection of abnormal portion.

Paralytic ileus :
Bowel stunned leading to functional block.
Causes :
• Surgery (M/C).
• Hypokalemia.
• Hypothermia.
• Uremia.
Last to recover : Rectum.
Management includes supportive care & correct metabolic changes.
Mesenteric ischemia 00:49:07

Acute mesenteric artery embolism Acute mesenteric artery thrombosis

M/c cause
20 thrombus
Source of embolism : Heart.
Atherosclerosis
Risk factors : IHD, atrial fibrillation.
Bowel angina : Post prandial
Bowel attacks : Sudden abdominal pain
abdominal pain
ends with peritonitis.
Food avoidance & weight loss
IOC : CT angio. IOC : CT angio.
M/x

Early presentation Late :

(within 6-8 hrs). Gangrene +ve M/x : Bypass grafting.
Embolectomy. Resection (may lead to
short bowel syndrome).

Thumb print sign in mesenteric ischemia

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Appendix 00:51:54 ----- Active space -----

M/c location : Retrocaecal.

Least common : Post ileal.
Appendicular base is at junction of 3 taenia coli.
Surgical anatomy :
• Appendicular artery (end artery) :
Branch of lower division of ileocolic artery.
• Accessory appendicular artery :
Artery of Seshachalam (branch of posterior caecal artery).
Mcburney’s point : Constant site for base of appendix where tenderness is elic-
ited.

Umbilicus

2/3rd
ASIS
1/3rd

1 : Mcburneys point
Appendicitis :
Symptoms Signs
• Pain • Tenderness at mcburney’s point
abdomen. • Rovsing sign : Pain in right iliac fossa (RIF) on pressing left
• Nausea & iliac fossa.
vomiting. • Psoas sign : Flexion against resistance causes pain in RIF.
• Anorexia. • Obturator sign : Flexion & internal rotation gives rise to
• Fever. pain.
• Aaron’s sign : Pressing RIF causes pain in epigastrium (not
specific)
• Dunphy’s sign : Pain on coughing (not specific)
Lab findings :↑TLC, neutrophils.
Mantrels scoring system (modified alvarado score) :
High negative predictive value.
Score less than 7 makes the diagnosis of appendicitis less likely.

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----- Active space ----- Characteristic Points

Migration of pain to right lower quadrant 1
Anorexia 1
Nausea & vomiting 1
Tenderness in right lower quadrant 2
Rebound pain 1
Elevated temperature 1
Leukocytosis 2
Left shift of WBC 1
Possible total 10

Investigations :
IOC in adults : CECT.
IOC in children : USG.

Findings on USG :
• Blind ending tubular structure.
• Probe tenderness.
• Appendiculolith can be seen.
• Peri appendiceal fluid collection. USG showing appendicitis

M/x :
• Appendicectomy : Currently done laparoscopically.
• If base inflamed : Should not be crushed, bury with purse string suture.
• If base is gangrenous : Perform right hemicolectomy.
• If appendix not inflamed : Search last 2 feet of ileum for meckel’s divertic-
ulum.

Appendicectomy :

(Muscle splitting) (Muscle cutting)

Traditional incision :
McBurneys incision.
(Skin crease incision)
(For perforated appendix)
Modified incisions for open appendicectomy

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Structures passed : ----- Active space -----

1. Skin.
2. Superficial fascia.
3. External oblique aponeurosis.
4. Muscles split/cut.
5. Peritoneum.
Lap appendicectomy :
3 ports are used.
Complications :
M/C : Wound infection.
Bleeding. Port placement in laproscopic
Portal pyemia. appendicectomy
Stump appendicitis : If stump >4mm.

Appendicular perforation :

Common in :
• Children.
• Elderly.
• Pregnant patients.
• Adhesions.
• Immunocompromised patients.

Appendicitis in pregnancy :

M/C non obstetric abdominal emergency.

Pain is M/C in RIF but can be higher up.
MRI is necessary if USG cannot confirm the diagnosis
If perforation present, high chance for fetal loss.
Lap appendicetomy can be done in all trimesters.

Appendicular lump :

Management :
Oshner sherren regime (conservative M/X).

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----- Active space ----- Oshner sherren regime

Monitor : M/x
• Size of lump. • NPO.
• Tenderness. • IVF.
• Temperature. • IV antibiotics.
• Pulse rate. • Analgesics.

Recovers : Deteriorates (↑ pain, fever & lump size) :

• Discharge. • Suspect abscess.
• Interval appendicectomy • Extraperitoneal drainage.
after 6 weeks.

Neuroendocrine tumours (NET) of appendix :

At tip.
M/c b/w 40-50 yrs.
Diagnosis : IHC for synaptophysin & chromogranin A.
M/x :
> 2cm & close to base : Right hemicolectomy.
< 2 cm & away from base : Simple appendicectomy.
Epithelial tumours :
1. Non mucinous.
2. Mucinous :
• Presents as :
a. Mucocele.
b. Pseudomyxoma peritonei : Locally invasive jelly like material in
peritoneum which does not metastasize. Seen in appendicular tumors,
ovarian tumors, peritoneal tumors. M/x by cytoreductive surgery
followed by hyperthermic intraperitoneal chemotherapy (HIPEC).

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GIT 4 ----- Active space -----

Ileostomy and Colostomy 00:01:25

Colostomy (Sigmoid/Transverse
Ileostomy
colon)
Output More; liquid Less; semi-solid
Skin excoriation More Less
Fluid and electrolyte
More Less
imbalance
Ease of management Easier
Raised above the skin
Technical difference Flush with the skin

Types of stoma :

End stoma Double barrel Loop stoma

One end is taken out. Two ends taken out. Loop is taken out.
No continuity.

End colostomy Double barrel stoma Loop stoma

(Flush with skin)

M/C complication of ileostomy and colostomy : Skin excoriation.

M/C long term complication of colostomy : Parastomal herniation.

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

Faecal fistula :
Spontaneous closure No spontaneous closure
Enteric wall defects < 1 cm. Enteric wall defects > 1 cm.
Fistula tracts >2 cm. Fistula tracts <2 cm.
No FRIEND factors. FRIEND factors +nt.
Low output (<200 mL/day). High output (>200 mL/day).
FRIEND factors :
F : Foreign body. Management : “SNAP” principle.
R : Radiation. 1. S : Skin excoriation prevention,
I : Inflammation, infection, IBD. sepsis contol.
E : Epithelialisation of fistula tract. 2. N : Nutrition.
N : Neoplasms. 3. A : Anatomical delineation (Imaging).
D : Distal obstructions. 4. P : Planned surgery.

Short Bowel Syndrome 00:07:19

Definition : <200 cm of Small Intestine. Features :

• Net secretors : <100 cm of SI. • Malabsorption.
• Net absorbers : >100 cm of SI. • Diarrhoea.
Causes : • Weight loss.
• Superior mesenteric artery (SMA) embolism (M/C). • Bacterial overgrowth.
• Crohn’s disease.
• Trauma.
Management :
• Total parentral nutrition (TPN).
• Small intestine transplantation.
• Teduglutide (GLP-2 analogue).Bowel lengthening procedures :
Bianchi STEP
(Serial Transverse Enteroplasty)

↓ ↓
↑Length of bowel ↑ Transit time
↓
↑ Absorption

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Lower GI Haemorrhage 00:10:05 ----- Active space -----

Diverticulosis :
False diverticula (only mucosa).
M/C site : Sigmoid.
Age : 4th-5th decade.
Associated with constipation.
M/C cause of massive lower GI haemorrhage Saw tooth appearance
(Right side bleeds more). on barium enema.
�OC for diverticulosis : Barium enema.

Complications :
1. Bleeding :
• Right > Left (SMA > IMA).
• Mx : Angioembolisation → Definitive surgery (Resection).
2. Diverticulitis :
• Presentation : Pain abdomen, diarrhoea, ↑ TLC.
• Avoid colonoscopy/barium studies (Perforations maybe present).
• IOC : CECT.

Hinchey’s staging :
Stage Features Management
I Colonic inflammation with pericolic abscess
Pigtail catheter
II Colonic inflammation with pelvic abscess
III Purulent peritonitis
Hartmann procedure
IV Fecal peritonitis

Angiodysplasia :
A cause of lower GI haemorrhage.
Dilated vessels.
Seen in caecum and right side of colon.
M/C in elderly.
If associated with aortic stenosis : Heyde syndrome.
Diagnosis : Colonoscopy/Capsule endoscopy.
Mx : Coagulation.

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----- Active space ----- Management of acute lower GI bleeding

Active bleeding with features Without features of

of hypovolemic shock hypovolemic shock
↓
↓ Significant bleeding
CT angiogram & embolisation ↓
Inpatient colonoscopy &
consider upper GI
endoscopy
Bleeding treated Bleeding continues ↓
↓ ↓ Normal
↓
Inpatient colonoscopy Therapeutic endoscopy/ • Capsule endoscopy.
surgery • CT angiogram.
• Tc99 Pertechnate scan.
Inflammatory Bowel Disease 00:16:04

Crohn’s disease Ulcerative colitis

20-40 years
Age 25-40 years
70 years (2nd peak)
Gender F>M M>F
Risk Smoking ↑ risk Smoking is protective
factors Refined diet ↑ risk
Gene NOD-2/CARD-15 -
• Any portion from oral cavity to anal • Starts in rectum → Pancolitis → Backwash
canal. ilieitis.
• Relative rectal sparing. • Anal involvement is uncommon.
• Anal involvement is common • Continuous.
(Fistulae/abscesses). • Mucosa & submucosa
Lesions • Skip lesions. involvement → Pseudopolyps.
• Transmural involvement : • Toxic megacolon is common.
a. Strictures. • Crypt abscesses.
b. Colovesical > Colovaginal fistulae.
• Creeping fat.
• Non-caseating granuloma.
• Mimics acute appendicitis.
Features Bloody diarrhoea
• Abdominal pain & Diarrhoea.
• String sign of Kantor. Toxic megacolon
Radiology • Aphthous ulcers. (>6 cm diameter of LI)
Marker Stool calprotectin -
• Mild : <4 stools/day.
• Moderate : >4 stools/day. No systemic signs.
Severity Modified Montreal classification • Severe : > 6 stools/day with systemic signs.
• Fulminant : > 10 stools/day with toxic megacolon.
Rx Steroids + 5-ASA derivatives.
Conservative resections. Total proctocolectomy +
Sx If not → Short bowel syndrome. Ileoanal pouch anastamosis

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Indications for surgery : ----- Active space -----

• Not responding to medical Rx.
• Steroid toxicity.
• Complications.
• Extra-intestinal manifestations.

String sign of kantor Toxic Megacolon

Extra-intestinal manifestations :
Organ system Manifestation
• Erythema nodosum
Dermatologic • pyoderma gangrenosum
• Oral ulcers
Hepatobiliary • Primary sclerosing cholangitis
• Episcelritis
• Scleritis
Ophthalmologic • Uveitis
• Iritis
• Conjunctivitis
• Anemia
Hematologic • Thrombocytosis
Renal Nephrolithiasis (Calcium oxalate)
Musculoskeletal Ankylosing spondylitis

Conditions which do not improve on surgery :

1. Primary sclerosing cholangitis.
2. Ankylosing spondylitis.

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

Colorectal Polyps 00:22:21

Types Conditions
Inflammatory Ulcerative colitis : Not pre-malignant
Single juvenile polyp : Not pre-malignant
Juvenile polyposis syndrome :
• Gene : SMAD-4 (Chr. 18)
• ↑ Cancer
Cowden syndrome :
• Gene : PTEN (Chr. 10)
• Presentations :
a. GI polyps (M/C) : Not pre-malignant
b. Thyroid cancer
Hamartomatous c. Breast cancer
Peutz-Jegher syndrome :
• Gene : STK-11 (Chr. 19)
• M/C location of polyps : Jejunum
• M/C presentation : Intussusception
• Pathognomonic : Perioral melanosis.
• HPE : Arborizing pattern of hamartomatous polyps.
• ↑ Risk of :
a. Pancreatic cancer (100 times)
b. Duodenal adenocarcinoma
c. Thyroid cancer
d. Colonic cancer
• ↑ Risk of cancer (Villous > tubular)
Adenomatous polyp
• Risk ↑with number & size of the polyp.

Arborizing pattern Inflammatory polyps Perioral melanosis

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

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Haggit classification : Levels 0-4. ----- Active space -----

Sessile polyp : Starts from Level 4.
Pedunculated polyp : Ranges from Level 0-4.

Familial Adenomatosis Polyposis (FAP) :

Autosomal dominant.
Mutation : APC gene (Chr. 5).
Pathognomonic : > 100 adenomatous polyps.
M/C site : Rectum.
100% risk of cancer.
Surgery : Total proctocolectomy followed by ileo-anal pouch anastamosis.

Variants :
Variant Associated with
• FAP
• Sebaceous cysts
Gardner syndrome
• Osteomas
• Desmoid tumour
• FAP
• CNS tumours :
Turcot’s syndrome
a. Gliomas
b. Medulloblastomas

MUTYH Associated Polyposis (MAP) :

• Similar to FAP.
• Autosomal recessive with multiple colonic polyps.
• Considered when APC pathogenic variant not identified.
• 3-6 times↑ risk of cancer.
• 2 yearly colonoscopy.
• Surveillance for duodenal adenomas.

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

HNPCC/Lynch syndrome :
Mismatch repair gene defect (MSH/MLH).

Amsterdam criteria :
1. R/o FAP.
2. At least 3 relatives affected by HNPCC tumours of which at least 1 should
be a first degree relative.
3. 2 consecutive generations affected.
4. At least one should develop tumours <50 years.
Types :
Types Tumours
Lynch I M/C : Colorectal cancers (CRC)
Extra-colonic.
Lynch II
M/C extra-colonic : Endometrial.

Colorectal Cancers 00:30:03

M/C site : Rectum > Rectosigmoid > Sigmoid.

Risk factors and protective factors :
Risk factors Protective factors
Polyps Selenium
High-fat diet Metformin
Family h/o CRC Aspirin
Diverticular disease High fibre diet
IBD

Screening :
FOBT
Colonoscopy Sigmoidoscopy
(Fecal Occult Blood Testing)
Every 10 years. Every 5 years Yearly
Started at :
• 50 years (or)
• If family history present →
10 years before diagnosis of
youngest relative.

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Virtual colonoscopy : ----- Active space -----

• CECT followed by 3D reconstruction.
• Advantages :
a. Better extra-colonic details.
b. Better patient compliance. Virtual colonoscopy
• Disadvantage : Mucosal details are worse than actual colonoscopy.
Investigation of choice :
• Diagnosis : Colonoscopic biopsy.
• Staging : PET/CT.
• For rectal Ca T & N staging : MRI with endorectal coil.
Presentation :
Right sided CRC Left sided CRC
• Ulcero-proliferative growth → Bleed → • Annular growth.
Iron deficiency anemia. • Altered bowel habits → Early.
• Mass. • Bowel obstruction → Early.
• Altered bowel habits → Uncommon/late.
TNM staging (Update) :
Minimum 12 LN must be removed for LN staging.

Note : 16-15-12-10 Lymph nodes

removed for esophageal, stomach,
CRC, Breast ca respectively.

Apple core deformity

Duke staging : (Annular growth)
Depends on depth of the tumour. A
A : Mucosa + Submucosa involved. B1 C1
B2 C2
B : Muscle involvement with no LN.
B1 → Into muscle layer.
B2 → Beyond muscle layer.
C : Muscle involvement with LN positive. Mucosa Submucosa
C1 → Into muscle layer. Muscle Serosa
LN
C2 → Beyond muscle layer.
D : Distant metastasis.

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

Management :
Colon cancer :
Surgery : Colectomy.
Procedure Vessels ligated
Tumour location

Right 1. Ileocolic artery

hemicolectomy 2. Right colic artery
Caecum 3. Right branch of middle colic
artery
Extended right 1. Ileocolic artery
hemicolectomy 2. Right colic artery
Ascending colon 3. Middle colic artery (Both
branches)
Left 1. Left colic artery
Splenic felxure/ hemicolectomy 2. Left branch of middle colic
Descending colon artery

Sigmoidectomy/
Low Anterior
Sigmoid Resection (LAR)

Sigmoidectomy
Rectal cancer : Surgery.
Principles:
Anal canal length 4-5cm
• Distal margin : 2 cm. The internal and external sphincters lie in this length
• Proximal margin : 5 cm.
Tumour location Procedure Structures removed
Low Anterior Resection (LAR) • Rectum
> 5 cm from anal + • Part of sigmoid
verge Colo-anal anastamosis
(Sphincters spared)
Abdomino-Perineal • Rectum
Resection (APR) • Anal canal
< 5 cm from anal
+
verge
Permanent end colostomy
(Sphincters cut)

LAR
Tumour
Colo-anal anastamosis resected Stoma
(With circular stapler) APR
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TaTME (Trans-anal Total Mesorectal Excision) : ----- Active space -----

• Local surgery.
• Type of NOTES procedure.
• Done in early rectal cancer (T1, T2 tumours).
• Sphincter preserving.
• Concerns :
a. Urethral injury.
b. Multifocal recurrences. TaTME
Plane of dissection :
• Total mesorectal excision → The ‘holy’ plane.
• Can injure the nerves if cut beyond the plane. Prostate

Neurovascular
bundle

‘Holy’ plane
Plane of dissection
Nerve injuries during surgery :
Procedure Injury to Results in
High Inferior Superior hypogastric Retrograde ejaculation
mesentric artery plexus near the sacral (Sympathetic nerve injury from
(IMA) ligation promontory L1-L3)
Division of lateral Pelvic plexus Erectile dysfunction
stalks too close to the Nervi erigentes Impotence
pelvic side wall Atonic bladder
Anterior dissection Periprostatic plexus Sexual & bladder dysfunction

M/I prognostic factor : LN status.

Tumour marker : CEA.
Metastasis :
• M/C site : Liver.
• Resection of liver mets improves survival.

Anal Cancers 00:43:39

Usually squamous cell carcinoma. 5-FU Mitomycin-C + Radiotherapy

Caused by HPV.
Observation
Mx : Nigro’s regimen. Residual/recurrent disease
Combined chemo-radiation.
Chemotherapy acts as a radio-sensitiser. Surgery : APR

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

Benign conditions of Rectum & Anal canal 00:44:32

Instruments :

10 cms 13 cm
Anoscope Proctoscope :
Used in OPD.

Sigmoidoscope :
• 60 cm long. Colonoscope :
• 60-90 cm till sigmoid • 110-140 cm.
colon is visualised. • Visualised upto caecum.
Pilonidal sinus :
Sinuses/abscesses in natal cleft.
Etiology : Ingrowing hair.
Maybe seen in inter-digital cleft of barbers.

Management : Pilonidal sinus

Drain the abscess.
Mx of sinus :
• Rhomboid flap/Limberg flap.
• Latest techniques :
a. Bascom’s technique.
b. Kardyakis surgery.
Sinus approached away from the midline &
sinus tract cleared. Rhomboid flap

Bascom’s technique

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Haemorrhoids : ----- Active space -----

Dilated vascular channels.
M/C cause of bleeding P/R (Arterial bleeding).
C/F : Painless, bleeding P/R, constipation (painful if below dentate line)
Can be :
a. Internal.
b. External (Palpated on DRE).
Location : 3, 7 & 11 o’clock positions.
IOC : Proctoscopy.
Thrombosed piles : Thrombosed piles
Aka Meleney’s 5 day self healing lesion (Can be excised as well).
Painful.
Felt on Digital Rectal Examination (DRE).
Grades of haemorrhoids :
Grade Features
1 Only bleed, no prolapse.
2 Prolapse but spontaneously reduces
3 Prolapse but have to be pushed inside
4 Remain prolapsed
Management :
Grade Management
Grade 1 1. Lifestyle changes :
• High fibre diet.
• ↑ Liquid intake.
2. Laxative.
3. Sitz bath.
Grade 2 1. Lifestyle changes.
2. Laxative.
3. Sitz bath.
4. Banding (Better), Sclerotherapy.
Grade 3 1. Open haemorrhoidopexy.
2. Stapler haemorrhoidopexy (Latest) : Circular stapler used (Purse
Grade 4
string sutures above dentate line).

Banding
(Done above dentate line) Open haemorrhoidopexy

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

Complications of haemorrhoid surgery :
1. Urinary retention (M/C). 4. Stenosis.
2. Reactionary haemorrhage. 5. Incontinence.
3. Pain. 6. Recurrence.

Anal fissure :
Breach in anal epithelium. Management :
M/C site : Posterior midline. 1. Conservative Mx :
a. Lifestyle changes.
Clinical features : b. Sitz bath.
• Painful bleeding P/R. c. Laxative.
• Constipation. d. Local application of xylocaine
jelly, CCB cream.
IOC : External inspection (DRE is C/I). 2. Surgery : If patient does not respond
to conservative Rx.
a. Lateral anal sphincterotomy
(Internal sphincter).
b. Anal advancement flap.
Chronic anal fissure :
>4 weeks duration.
Can present as a sentinel pile/skin tag.

Anal fissure

Sentinel pile
Perianal abscess :
Extremely painful.
Presentation : Fever.
Fluctuation → Late sign.
Rx : Drainage.
Complication : Perianal sinus/fistula (If not drained properly).
Perianal abscess

Perianal fistula/sinus :
Presentation : Pus discharge P/R.
IOC : MRI Fistulogram.

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Goodsaal’s rule : ----- Active space -----

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).

Watercan perineum :
Multiple perianal fistulae. Goodsaal’s rule
Causes :
• Crohn’s disease. KROHN
• Trauma. KRUSH
• TB. KOCHS
• Cancer. KANCER
• Immunocompromised patient.
Parks’ classification :

Extrasphincteric
Suprasphincteric

Trans-sphincteric
Intersphincteric (M/C)
Management :
Below anorectal ring (Low fistula) Above anorectal ring (High fistula)
Fistulectomy/fistulotomy Seton surgery
(Low chance of incontinence) (High chance of incontinence)
Rectal prolapse :
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
Management :
Partial thickness prolapse :
• First episode : Digital repositioning.
• Recurrent :
a. Thiersch wiring : Purse string sutures used.
b. Sclerotherapy.
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----- Active space -----

Complete prolapse :
Perineal procedure Abdominal procedure
Easy to perform. Difficult to perform.
Less complications. ↑↑ Complications.
High recurrence rate. Least recurrence rate.
Done in frail & elderly patients. Done in fit & young patients.
1. Thiersch repair. 1. Ripstein rectopexy.
2. Delrome repair : Continuous sutures used. 2. Weil rectopexy.
3. Altemier (Perineal rectosigmoidectomy). 3. Goldman Frykberg
(Resection rectopexy).
Anorectal malformations :
Associated with other malformations (VACTRL) :
• V : vertebral defects.
• A : Anorectal malformations.
• C : Cardiac abnormalities.
• T : Tracheo-esophageal atresia/fistula.
• R : Renal anomalies.
• L : Limb abnormalities.
Delrome repair
Malformations :
Level of anomaly Male Female
High Anorectal agenesis. Rectovaginal fistula.
Rectovesical fistula. Rectal atresia.
Rectal atresia.
Low Anal stenosis Anal agenesis without fistula
Invertogram :
Usually done 12 hours after birth (Ideal : After 24 hours).
Patient is inverted.
↓
Metal coin placed at anal opening and X-ray taken.
↓
Distance between gas bubble and anal opening mea-
sured.
↓
<2 cm : Low anomaly.
>2 cm : High anomaly. Invertogram
Best investigation : MRI.
Management : Anorectoplasty.
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HEPATOBILIARY - 1 ----- Active space -----

Liver Anatomy 00:01:43

Couinad’s Functional classification :

Liver is divided into 4 sectors.
Structures which divides the liver : Portal vein > Portal vein & Hepatic vein.
Major fissure Minor fissure
• Left hepatic vein (LHV) • Left portal vein
• Right hepatic vein (RHV) • Right portal vein
• Middle hepatic vein (MHV). • Fissure of Ganz.
Liver
Cantlie’s line/MHV

Right hemiliver Left hemiliver

Segments 5, 6, 7, 8 Segments 4a, 4b, 2, 3

Segment Forms Important points

5, 4b Gallbladder (GB) Fossa. Removed during radical cholecystectomy for GB cancer.
7 Bare area of liver. M/c involved in amoebic liver abscess.
1 Caudate lobe . Independent venous drainage directly into IVC.
Hypertrophied in Budd Chiari syndrome (Hepatic
venous outflow obstruction).

Procedures & segments removed :

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

Liver pedicle on duplex scan :

Mickey mouse sign which includes,
• Hepatic artery
• Common bile duct
• Portal vein.

Mickey mouse sign

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

Scoring systems :

Child-Turcotte-Pugh Score :
Points
Clinical and lab criteria
1 2 3
Encephalopathy None Mild to moderate Severe
(grade 1 or 2) (grade 3 or 4)
Ascites None Mild to moderate Severe
(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 normalized ratio (INR) < 1.7 1.7 - 2.3 > 2.3

Child - Turcotte - Pugh score is obtained by adding total points for all the parameters :
Class A = 5 - 6 points : Least severe.
Class B = 7 - 9 points : Moderately severe.
Class C = 10 - 15 points : Most severe.

Model for end - stage liver disease (MELD) scoring system :

Parameters included :
• S. bilirubin. • Creatinine.
• INR.
Pediatric end-stage liver disease (PELD) scoring system :
Incorporates the following criteria :
• Albumin. • Growth failure.
• Total bilirubin. • Age < 1 year.
• INR.

Liver Abscess 00:06:20

Amoebic liver abscess Pyogenic liver abscess

Organism Entamoeba histolytica M/C overall : E. coli.
In Asia : Klebsiella.
Chr. granulomatous disease :
S. aureus.
Route Small & large intestine → Portal vein. Ascending cholangitis
Laminar flow is more towards right side. (Biliary tree).
Hence, M/C segment affected is 7.

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Amoebic liver abscess Pyogenic liver abscess ----- Active space -----

No. of abscess Solitary. Usually multiple.

C/f Right hypochondrial pain, fever, dysentery. More toxic/more sick.

Investigations Raised PT/ INR. Raised ALP.

Aspirate → Anchovy sauce pus.
IOC CECT. CECT.

Management Metronidazole 800mg Broad spectrum I/V antibiot-

Not TDS ics & Early aspiration.
Responding Responding

Aspiration with Pig Continue same

tail catheter. for 2-3 weeks.
Indications :
• No response to medical Mx.
• Abscess cavity > 5cm.
• Left lobe liver abscess.
• Pregnancy.
• Impending rupture.

Hydatid Liver Disease 00:10:28

• Organism : Echinococcus granulosus.

• M/C organ involved : Liver followed by lungs.
C/f :
• Pain or Lump in the right hypochondrium.
• H/o contact with dog/sheep.
IOC : CECT.

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

Classification of hepatic hydatid cyst :
WHO-IWGE Gharbi Description Stage
2001 1981
CE 1 Type I Unilocular anechoic cystic lesion with double line sign. Active
CE 2 Type III Multiseptate, rosette like, honeycomb cyst. Active
CE 3a Type II Cyst with detached membranes (Water lily sign) Transitional
CE 5 Type V Solid cyst with a calcified wall. Inactive

Management :
1. �ll intervention are done under albendazole cover.
2. First line Mx : PAIR (Percutaneous Aspiration, Injection, and
Re-aspiration) :
2. Inject scolicidal agents
• Hypertonic saline (M/c) Water lily sign → CE 3a
1. Aspirate fluid. • Cetrimide. 3. Reaspiration
• Mebendazole.
• Alcohol.

Note : Formalin is not used as scolicidal agent as it causes cholangitis.

Contraindications of PAIR :
• Dead cyst. • Deep seated cyst.
• Calcified cyst. • Multiloculated cyst.
• Extrahepatic cyst. • Cystobiliary communication.
3. If PAIR contraindicated : Liver resection/Cysto pericystectomy/ Capitonnage.
Benign tumours of liver 00:14:18

Hepatic Adenoma :
• Benign tumor with risk of malignant conversion > 10%.
• Strongest association with OCP intake (Females >> males).
• Usually symptomatic  Pain/lump in right hypochondrium .
Sometimes  Non traumatic/Spontaneous hemoperitoneum (rupture).
• IOC : CECT.
• HPE : Sheets of hepatocyte, No ducts, No kupffer cells.
• Management : Adenoma > 2cm  Resection.
Focal Nodular Hyperplasia (FNH) :
• Benign tumour.
• Etiology : blood supply.
• Asymptomatic.
• HPE : Hepatocytes, Bile duct structures.
Kupffer cells (hot spot on Tc99 scan).
• IOC : CECT  Central stellate scar seen. Central stellate scar in FNH

• Management : Conservative mx..

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Hepatocellular Carcinoma(HCC) 00:16:27 ----- Active space -----

Risk factors :
• Hepatitis B virus. • Cirrhosis.
• Hepatitis C virus. • Wilson’s disease.
• Alcohol intake. • Hemochromatosis.
• Male > Female.
Presentation :
• M/c  Hepatomegaly (Hard & nodular).
• Pain abdomen.
• Paraneoplastic syndromes : Non contrast phase : Hypodense
M/c  Hypoglycemia.
M/c biochemically  Hyperlipidemia.
Others : Cushing syndrome, Gynaecomastia, Hypercalcemia.
Note : m/c malignant tumour of liver : Metastasis
M/c primary malignant tumour of liver : HCC Arterial phase : Enhancement
Investigation :
Triple phase CT (IOC).
• Metastasis :
Hypodense lesion in all three phases.
Management : Venous phase :
Management of HCC Quick washout

Localised Advanced

Poor functional liver Good Functional liver

reserve/Child pugh B or C reserve/Child pugh A
Metastasis
Look at Milan criteria : Resection • Sorafenib.
• Single tumour < 5 cm • Sunitinib.
OR 1-3 tumour < 3cm.
• No distant metastasis. Palliative
• Multiple lesion in one lobe <3cm :
Not satisfied Satisfied TACE (Trans Arterial Chemo Embo-
NIMURA Technique/ Liver transplant
lisation)/TARE (Trans Arterial Radio
ALPPS procedure/ Embolisation  Yt spheres are used).
Portal vein embolisation • Radiofrequency ablation.
• Microwave ablation.
Hypertrophy of other
• Chemotherapy.
segments & adequate FLR.
• Intralesional ethanol injection.
Resection
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----- Active space ----- Prognostic indicators for HCC Tumour markers for HCC
OKUDA : BATA • Alpha Feto Protein.
B  Bilirubin. • PIVKA.
A  Ascites.
T  Tumor size.
A  Albumin.

Fibrolaminar variant of HCC :

• M/c in young females.
• Occur in non cirrhotic liver.
• AFP not raised.
• Tumour marker : Neurotensin B.
• Good prognosis.

Gallbladder 00:23:21

Hepatocystic triangle Calot’s triangle

Boundaries : Boundaries :
• Inferior edge of liver • Cystic artery
• Common hepatic duct (CHD). • Common hepatic duct.
• Cystic duct. • Cystic duct.
Content : Cystic artery arising
from Right hepatic artery

Moynihan’s Hump :
• Right hepatic artery can have a tortuous course & can lie in front of calot’s
triangle. If it gets injured  Torrential bleeding.

Phyrigian cap : Physiological variant.

Phyrigian cap Phyrigian cap

Cystic plate :
• Flat ovoid fibrous sheet continuous with the liver capsule of segment 4
(Medially) and 5 (Laterally).
• Located in the GB bed and needs to be exposed to achieve the critical view
of safety during lap cholecystectomy.

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Rouviere’s sulcus: ----- Active space -----

On the under-surface of the right lobe of the liver running to the right of the
hepatic hilum & marks the position of the right posterior sectoral pedicle.

R4U line :
• From roof of the Rouviere’s sulcus to the base of the segment 4.
• Cystic duct and artery lie ventral (Anterosuperior) to the line and CBD lies
below the line.
• CBD injury can be minimized by maintaining the dissection above this line
during cholecystectomy
Rouviere’s sulcus
4B
R4U Line

5
Cystic plate

Gallstones 00:27:57

Gallstones

Pure cholesterol stones. Mixed stones Pigment stones

M/c overall. M/c in Asia.
< 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.

IOC : USG Abdomen  Post acoustic shadow.

Gallstones  Post acoustic shadow. GB polyp  No shadow.

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

Presentations of gallstones :
1. Asymptomatic :
Indications for surgery in asymptomatic stones :
• Porcelain GB (Calcification of GB wall) 
Increased risk of malignancy.
5
• True GB polyp >1cm.
• Salmonella typhi carrier.
• Diabetes mellitus.
• Stone size >2 cms.
2. Acute cholecystitis : Porcelain GB
C/f : Right hypochondrial pain/nausea/vomiting.
Tokyo Consensus Guidelines diagnostic criteria for acute cholecystitis :
A. Local signs of inflammation, etc.
1. Murphy’s sign
2. Right upper quadrant pain/tenderness/mass
B. Systemic signs of inflammation, etc.
1. Fever
2. Elevated CRP
3. Elevated WBC count
C. Imaging findings characteristic of acute cholecystitis.
Suspected diagnosis : 1 item in A + 1 item in B
Definite diagnosis : 1 item in A + 1 item in B + 1 item in C
IOC : USG
Note : HIDA scan is used for Acalculous cholecystitis.
Management :
Suitable for within 48 - 72 hrs
Antibiotics (First line) cholecystectomy Emergency Laparoscopic
Nil Per Oral. cholecystectomy
I/V fluids. Interval
Not suitable for >72 hrs cholecystectomy
cholecystectomy Conservative Mx after 6 weeks
Grading of cholecystitis :
Grade Severity Features
Grade III Severe acute cholecystitis Organ dysfunction.
Grade II Moderate acute cholecystitis. • Elevated white cell count > 18000/mm3.
• Palpable tender mass in right upper abdominal
quadrant.
• Duration of complaint >72 hours.
• Marked local inflammation.
Grade I Mild acute cholecystitis. No organ dysfunction & Mild inflammatory
changes.
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3. Mirizzi syndrome : Mirizzi ----- Active space -----

• GB is adherent to Common bile duct (CBD)  Fistula syndrome
formation b/w CBD & GB.
• C/F : Features of cholecystitis + jaundice.
• Management :
Laparoscopic cholecystectomy (LC) + repair of fistula.
If LC not possible, Partial cholecystectomy + repair of fistula.

4. Gallstone ileus :
Cholecysto -
• Dynamic bowel obstruction. duodenal
fistula
• Secondary to a cholecysto-duodenal fistula.
• M/C site of obstruction : Last 60 cm of ileum/
Last 2 ft of ileum.
C/F :
• Obstipation, abdominal distension, pain, vomiting.
• Can give rise to Gastric Outlet Obstruction (Bouveret syndrome).
Investigations :
• X-ray abdomen (Erect & supine).
Rigler triad :
Pneumobilia.
Features of small intestinal (SI) obstruction.
Radio-opaque shadow in right lower quadrant.
• IOC : CECT.
Management :
Emergency surgery for bowel obstruction  2nd surgery (Cholecystectomy +
Repair of fistula).

Pneumobilia S/I obstruction

Radio opaque shadow

Rigler triad - Gallstone ileus

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----- Active space ----- 5. Choledocholithiasis : Charcot’s triad Reynolds pentad

Stones in the CBD Intermittent pain. Charcot’s triad +
Presentation : Intermittent fever. Septic shock +
• Asymptomatic. Intermittent jaundice. Altered mental status.
• Obstructive Jaundice.
• Cholangitis : Charcot’s triad.
Investigation :
• IOC : MRCP (Magnetic resonance cholangio pancreatography).
• IOC for CBD microliths : Endoscopic ultrasound.

Management :
1. CBD stone and GB stone detected before surgery :
ERCP  Laparoscopic cholecystectomy.
2. CBD stone detected during surgery :
Lap cholecystectomy + Exploration of CBD + Insertion of T- tube in CBD.
Burhenne technique : No residual stones.
Remove T-tube
Insert a T-tube Inject dye after
in CBD few days Stones Present
Retain T-tube & Extract
stones through T tube
after 2-3 weeks.

3. CBD stone detected after surgery :

CBD stone after surgery

Within 2yrs : Residual/Retained stones > 2 yrs : Recurrent stones

Secondary CBD stones. Primary CBD stones (10%).

Extraction through ERCP

Note : ERCP (Endoscopic retrograde cholangio pancreatography) : Sphincteroto-
my + extraction of stone.

Endoscope

MRCP  CBD stones ERCP

ERCP : Risk of pancreatitis

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Complications of Laparoscopic cholecystectomy 00:45:37 ----- Active space -----

• Right shoulder tip pain (M/c)  D/t retained CO2.

• Bleeding.
• Injury to bile ducts.
• Injury to bowel.
• Residual/Recurrent stones.

Cystic duct

Cystic artery

Critical view of safety

Bile duct injury :

• Bile leak during surgery : Surgical repair.
• Bile leak after surgery :
Bile leak after surgery

Minor leak Major leak MRCP  Bile leak

Patient is stable • Fever + .
No fever • Jaundice +.
• Pain +.
Conservative Mx • USG : collection in right hypochondrium.

Within 24- 48 hrs : > 48 hrs :

Re- explore & Repair • Antibiotics.
• Pigtail drainage of collection.
• ERCP followed by stenting.
MRCP  To confirm bile leak (Diagnostic).
ERCP  To put a stent (Therapeutic).

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

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 I E1
CHD stricture, stump <2 cm Type II E2
Hilar stricture with preserved biliary confluence Type III E3
Hilar stricture with involvement of confluence Type IV E4
Stricture to an aberrant RHD and to CHD Type V E5

B safe method  To prevent injuries during LC :

• Visualize
a. Bile duct
b. Sulcus of rouviere
c. Umbilical fissure.
• Save the hepatic artery.
• Orient bowel/ duodenum to correctly place a cognitive map during
dissection.
Bailout strategies in frozen calot’s :
• Abort the procedure.
• Convert to open procedure.
• Carry out tube cholecystostomy using 14F foley.
• Carry out subtotal cholecystectomy.
• Fundus first technique  GB is dissected first & then, cystic artery is clipped.
Gall stones 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 : Mainstay for mild cases  Conservative (NSAIDS are usually
avoided).
• Second trimester : Moderate/ severe disease  Lap cholecystectomy.
• Third trimester : Non operative management.

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Extra-Hepatic Biliary Atresia (EHBA) 00:52:10 ----- Active space -----

Japanese & Anglo Saxon classification :

Type 1 : Atresia restricted to CBD.
Type II : Atresia of CHD & CBD.
II A  Patent GB.
II B  GB obliterated.
Type II1 : Atresia of right, left hepatic ducts & entire extra hepatic biliary tree.

Atretic

Patent Atretic Patent Atretic

Type 1 Type II Type III

Associated anomalies :
• Cardiac lesions. • Absent vena cava.
• Polysplenia. • Pre duodenal portal vein.
• Situs inversus.
Clinical features : Jaundice at birth (progressive), liver failure.
Differential diagnosis :
• Neonatal hepatitis.
• Alagille syndrome  Biliary atresia, congenital heart disease, skeletal
abnormalities .
Investigations :
• Fasting USG  gold standard.
• MRCP highly sensitive & specific.
• Liver biopsy  To differentiate b/w neonatal hepatitis & Alagille syndrome
from EHBA.
There will be neo-duct formation in EHBA in liver biopsy.
Surgical Management :
• Kasai procedure  Porto- Enterostomy Stomach
• Liver transplant is done in majority of
EHBA patients.
Small intestine
Note : M/C cause of liver transplant in
Duodenum connected to liver
children  EHBA.
Kasai's procedure

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----- Active space ----- HEPATOBILIARY 2 & PANCREAS

Hepatobiliary system 00:00:15

1. Choledochal cyst :
C/f : Lump, jaundice, pain.
risk of cholangiocarcinoma.
IOC : MRCP.

Todani/modified Alonso–Lej classification :

Type Description Image Rx

Type I Roux-en-Y
Diffuse dilatation of the CBD.
(M/C) hepaticojejunostomy.

Type II Diverticulum of CBD. Resection & repair.

Dilatation of intraduodenal ERCP + sphincterotomy

Type III
portion of CBD (Choledochocele). + removal of tissue.

Intrahepatic + extrahepatic
Type IV A Liver transplant.
biliary radical tree dilation.

Only extrahepatic biliary radical Kasai procedure

Type IV B
tree dilation. (Portoenterostomy).

Dilatation of only intrahepatic

Type V Liver transplant.
biliary tree (Caroli’s disease).

2. Gallbladder Cancer :
Risk factors :
1. Gallstones (90% GB cancers associated with gall stones)
2. Salmonella typhi carrier.
3. Porcelain gall bladder.
4. GB polyps (>1 cm in size, multiple).
5. Abnormal Pancreatico-Biliary Duct Junction (APBDJ) : Risk of GB cancer &
Cholangiocarcinoma.
6. Heavy metal contamination of water.
Note : Cholesterosis (Strawberry gallbladder) not a risk factor.

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C/F : ----- Active space -----

• Gallbladder mass.
• Jaundice (Late sign).

IOC : CECT (Staging is also done).

Mx :
• T Ia (Above the muscle layer) : Simple cholecystectomy. GB polyp
• T Ib (Involves muscle layer) :
• T2 : Radical Cholecystectomy Gemcitabine.
• T3 & T4 : Chemotherapy
(Gemcitabine) Structures removed :
a. Gallbladder.
Good response Poor response b. Lymph node along
hepatoduodenal ligament.
Surgery Palliative Rx c. Segment 4b & 5.
d. CBD (Removed if involved).
Most important prognostic factor : Depth of invasion/T stage.
Port site excision not recommended presently.

Pancreas 00:05:24

1. Pancreas divisum :
M/C congenital anomaly of pancreas.
Caused by failure of fusion of the dorsal and
ventral pancreatic ducts.
Risk of pancreatitis (D/t inadequate
drainage of duct of Santorini). Pancreatic divisum
Mx : ERCP & Sphincterotomy.

2. Annular pancreas :
Annular pancreas is due to failure of complete rotation of ventral pancreatic
bud.
Forms circular tissue around duodenum Duodenal obstruction.
M/c presentation : Non bilious vomiting.
IOC : CECT.
Mx : Duodeno-duodenostomy.

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

Acute pancreatitis 00:07:48

Causes :
• M/c cause : Gall stone induced.
• 2nd M/c cause : Alcohol.
• M/c cause in children : Blunt trauma to abdomen.
• Drug induced : Antiretroviral drugs, thiazide diuretics, metronidazole, chemo-
therapeutic agents.
• Hyperparathyroidism.
• Hyperlipidemia : triglycerides.
• Scorpion bite : Rare cause.

Theory : Co-localization theory.

Inactive pancreatic enzymes Activate within pancreas Autodigestion
Inflammation.

C/F :
1. Epigastric pain : Radiates to back & relieved by
bending forwards.
2. In acute hemorrhagic pancreatitis : Cullen sign
a. Cullen sign : Discoloration around umbilicus.
b. Grey turner sign : Discoloration in flanks.

Investigations :
Initially : S. Amylase & S. Lipase (More specific).
IOC : CECT. Grey Turner sign
Non-specific radiological sign (Suggestive of ileus d/t
inflammation) :
1. Sentinel loop sign : A focal dilated proximal jejunal loop
in left upper quadrant.
2. Gasless abdomen.
3. Colon cutoff sign.
Scores to determine severity of pancreatitis :
1. Glasgow criteria ≥3. Colon cut off sign
2. BISAP score ≥3. Severe pancreatitis
3. Ransons criteria ≥3.
4. CT severity index/Balthazar grading :
• Best scoring system.
• Score ≥6 (severe pancreatitis).

Note : S. amylase & S. Lipase do not tell us about severity. Sentinel loop sign

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Ranson criteria BISAP Score ----- Active space -----

On admission: BUN >25 mg / dL

WBC > 16,000/mL Impaired mental status
Age >55 years SIRS (Systemic Inflammatory
Glucose >200 mg/dL Response Syndrome)
AST >250 IU/L Age >60 years
LDH >350 IU/L Pleural effusions
Within 48 Hours of admission :
Hct decrease > 10%
BUN increase >5 mg/dL
Serum calcium <8 mg/dL
Arterial pO2 <60 mmHg
Base deficit >4 mEq/L
Fluid needs >6 L
Balthazar Grade Points
Normal pancreas 0
Focal or diffuse enlargement of the pancreas 1
Pancreatic gland abnormalities and peripancreatic inflammation 2
Fluid collection in a single location 3
Two or more collections and/or gas bubbles in (or) adjacent to pancreas 4
Pancreatic Necrosis Points
No necrosis 0
Necrosis of one third of the pancreas 2
Necrosis of one half of the pancreas 4
Necrosis of more than one half of the pancreas 6

ATLANTA criteria : CT criteria for peripancreatic & pancreatic fluid collections in

acute pancreatitis.
Acute Peripancreatic Acute Necrotic Collection
Collection
<4 weeks. <4 weeks.
In interstitial pancreatitis. In necrotizing pancreatitis.
Homogeneous fluid density. Heterogeneous collection.
No fully definable wall. No fully definable wall.
Adjacent to pancreas. Intra/extrapancreatic.
Confined by normal fascial planes. Rx : Pigtail catheter.
Rx : Observation.

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----- Active space ----- Pseudocyst Walled-off Necrosis

>4 weeks. >4 weeks.
In interstitial pancreatitis. In necrotizing pancreatitis.
Homogeneous fluid density. Heterogeneous collection.
Well defined wall. Well-defined wall.
Adjacent to pancreas. Intra/extrapancreatic.
No non-liquid component. Rx : Pigtail catheter.

Complications of acute pancreatitis :

Local complications Systemic complications
1. Pseudocyst 1. ARDS
2. Necrosis Rx Pigtail catheter, IV meropenem. 2. MODS
3. Pseudoaneurysm (In splenic artery). 3. Sepsis
4. Splenic vein thrombosis Lt. sided portal 4. SIRS
hypertension.
MODS : Multiple Organ Dysfunction Syndrome.

Beger’s procedure : Drainage of

CT : Pancreatic necrosis necrotic pancreas

Pseudocyst of pancreas 00:15:36

Site :
• Lesser sac : M/C site.
• Can occur anywhere in the abdomen.
C/F : Lump & epigastric fullness.
IOC : CECT.
M/C complication : Infection. Lesser sac
D’Egidio’s classification : Pseudocyst of pancreas
Cyst type Pancreatitis Cystoductal communication
Type I Acute pancreatitis. No
Type II Acute on chronic pancreatitis. +/-
Type III Chronic pancreatitis. Yes

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Mx : Mostly resolves spontaneously. ----- Active space -----

Indications for intervention :
a. >6 cm in size.
b. >6 weeks old.
c. >6 mm thickness of wall.
Intervention

External drainage Internal drainage

• Using pigtail catheter. • Cystogastrostomy
• R/o communication with main pancreatic • Cystojejunostomy
duct.
• Done for infected pseudocyst.

Chronic Pancreatitis 00:18:06

Causes :
TIGAR-O classification.
Toxins : Alcohol (M/C cause), dietary.
Idiopathic.
Genetic/Hereditary :
• PRSS 1 mutation : Hereditary pancreatitis.
• SPINK 1 mutation : Tropical calcific pancreatitis.
Autoimmune (IgG4).
Recurrent (D/t stones).
Obstruction.

Clinical features :
1. Pain : D/t ineffective drainage & stones.
2. DM : D/t endocrine dysfunction.
3. Malabsorption : D/t exocrine pancreas insufficiency.

Investigations :
IOC : MRCP with secretin stimulation.
Gold standard : ERCP.

Management :
• DM : Insulin/oral hypoglycemic drugs. Chain of lake appearance
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----- Active space -----

• Malabsorption : Exogenous enzyme replacement.
• Pain : Analgesics (Till the time patient is responding).
• If patient is not responding to pain Mx then Intervention : Either drainage/
resection.

Drainage

Diameter of main pancreatic duct Puestow procedure

<5 mm >5 mm

ERCP +
Sphincterotomy
Duval’s procedure
Duval’s procedure Puestow procedure :
procedure : Longitudinal pancreaticojejunostomy
End to end (Side to side)
pancreaticojejunostomy

Resection
(Based on location of inflammation)

Restricted to head Restricted to tail

& neck
Distal
Beger's procedure : pancreatectomy
Duodenal preserving
pancreatic head
resection

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Tumors of Pancreas 00:21:50 ----- Active space -----

Endocrine tumors of pancreas :

1. Insulinoma :
M/C pancreatic endocrine tumour.
Origin : Beta cells of islet of Langerhans.
Equally distributed in pancreas.
90% are benign.
C/F : Whipple triad.
a. Fasting hypoglycemia ( S. Insulin).
b. Blood sugar <40 mg/dL.
c. Rapid resolution on giving glucose.
Differentiated from exogenous insulin by C-peptide value ( in insulinoma).
Gold standard investigation : 72 hrs fasting test.
Best investigation to localize : EUS (Endoscopic USG).
Mx :
• If <2 cm : Enucleation.
• Metastatic/Malignant : Radical surgery + Streptozocin (In metastatic).
2. Gastrinoma :
Origin : G cells. a
Leads to Zollinger Ellison syndrome.
M/C pancreatic tumour in MEN I syndrome. c
Malignant : 70-80%.
b
Site : 90% of Gastrinoma lie in Passaro’s triangle. Passaro's triangle
Boundaries : (Acc to image) Contents :
a. Junction of cystic duct with CHD. • 1st Part of duodenum
b. Junction of D2 with D3. • Lymph nodes
c. Junction of head & neck with body of pancreas. • Head of pancreas
Tumors that lie outside this triangle : More aggressive & malignant.
M/c site : Wall of D1.
C/f : Gastrin Hcl
a. Recurrent ulcers.
b. Ulcers at atypical locations : D3/D4, first part of jejunum.
c. Diarrhoea, malabsorption.
Investigation :
• S. gastrin >1000 pg/ml (Diagnostic).
• If < 1000 pg/ml : Secretin/pentagastrin stimulation test to be done :
• If S. gastrin ses by >200 Gastrinoma.
• To localize : EUS.
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----- Active space -----

Mx :
• Surgery.
• PPI : acid formation.

3. Glucaganoma :
Origin : Alpha cells of islets of Langerhans.
C/f : 4 ‘D’ s.
1. DM.
2. Dermatitis : Necrolytic migratory rash.
3. DVT.
4. Depression.

Exocrine tumors of pancreas :

Pancreatic ductal adenocarcinoma :
M/c exocrine tumor of pancreas.
Risk factors :
• Smoking.
• Obesity.
• DM.
• African American.
• Alcohol.
• Hereditary pancreatitis : PRSS gene.
• Tropical calcific pancreatitis : SPINK 1 gene.
• Chronic pancreatitis.
• Syndromes : Peutz Jeghers syndrome (>100 times risk).

Gene mutations in pancreatic neoplasia :

• 1st & m/c : Kras mutation.
• Last mutation : p53.
Sequence : Normal Kras CDKN2A P53, SMAD4

C/F : Progressive jaundice with palpable gall bladder (Satisfies Courvoisier’s law)
Periampullary cancers : All have same c/f.
1. Head of pancreas (M/C site).
2. Cholangiocarcinoma of distal CBD.
3. Ampullary variety of periampullary cancer (Waxing & waning of jaundice
when the growth sloughs off) + melena.
4. Duodenal adenocarcinoma.
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Investigations : ----- Active space -----

• CECT.
• MRCP : Double duct sign.
• Duodenography : Frostberg reverse 3 sign.
• IOC for staging : PET-CT.
8th AJCC TNM staging : Pancreatic cancer.
Stage Features
T1 Maximum tumor diameter ≤2cm.
T2 Maximum tumor diameter 2-4 cm.
T3 Maximum tumor diameter >4 cm.
T4 Tumor involves the celiac axis, common hepatic
artery or superior mesentric artery.
N0 No regional LN metastasis.
N1 Metastasis in 1-3 regional LN.
Double duct sign
N2 Metastasis in 2-4 regional LN.
MO No distant metastasis.
M1 Distant metastasis.
Management :
• Resectable tumor : Based on location of tumor
a. Head/Periampullary : Whipple’s surgery.
b. Distal pancreas : Distal pancreatectomy.
• Unresectable tumor : If involvement of any of the following.
1. Ascites
2. Metastasis
3. Involvement of superior mesentric artery, hepatic artey, superior
mesentric vein-portal vein junction by > 180o.
Rx :
• Triple by pass : Gastrojejunostomy + jejunojejunostomy, hepaticojejunostomy.
• Pain control : Coeliac plexus block.
• Palliative chemotherapy : Gemcitabine.

Whipples Procedure :
(Pancreaticoduodenectomy + 3 anastomosis)
1. Gastrojejunostomy.
2. Choledochojejunostomy.
3. Pancreaticojejunostomy.
Incision : Rooftop chevron incision. Whipples Surgery
Plane b/w vessels & Pancreatic head & neck : Tunnel of love.

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

Note : In Whipples, distal stomach is removed Altered gastric emptying.
Longmire & Traverso procedure : Pylorus preserving Whipple’s.

Complications of Whipples :
1. Altered gastric emptying : M/c.
2. Hemorrhage.
3. Pancreatic fistula.
4. Wound infection.
M/c anastomotic leak is seen at pancreaticojejunostomy.
M/c cause of death : Anastomotic leakage.

Chemotherapy :
Gemcitabine + Capecitabine : More effective than only Gemcitabine.
mFOLFIRINOX : Better survival than only Gemcitabine.
NACT (Neo-Adjuvant Chemotherapy) in borderline resectable group.

Cystic neoplasms of pancreas

1. Serous cystic neoplasms :
• M/C site : Head.
• Seen in older patients.
• Cells : Glycogen rich cells
(Large & multiloculated masses).
• CEA : Normal.
• Benign in nature.
• Imaging : Sunburst appearance on CT. Serous tumour
• Management : Resection.

2. Mucinous tumours :
• M/C in females. Mucinous tumour
• Site : Body & tail of pancreas.
• Seen : Pre menopausal women.
• Ovarian like stroma.
• ER, PR positive.
• Increased CEA : Differentiates from pseudocyst.
• H/o pancreatitis can be present : Confused Mucinous tumour
• with pseudocyst.
• Imaging : Egg shell calcification on CT.
3. Intraductal papillary mucinous neoplasm (IPMN) :
ERCP : Fish mouth appearance of ampulla & Mucin coming out of ampulla.

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Minimally invasive surgery 00:38:37 ----- Active space -----

Laparoscopy
Pneumoperitoneum :
• Created using CO2.
• Pressure : 10-14 mmHg

Physiological effects of pneumoperitoneum :

1. On lungs & heart : Pneumoperitoneum
Peritoneal stretching
Vagal stimulation
Sinus bradycardia
(M/C Arrhythmia in lap). Fish mouth appearance

2. Increased intra abdominal pressure → IVC compressed → venous return → CO & BP.
3. Pneumoperitoneum also Intracranial tension (ICT).
4. On kidneys & Renal vessels : Pneumoperitoneum → Pressure on renal arteries→ Renal
blood flow, GFR & urine output → Renin angiotensin system activated→ Aldosterone → Na+
retention.
Instruments used for creating pneumoperitoneum :

Closed/Blind method Open

Veress needle Hasson's method

Dilating tip bladeless trocar

Veress needle : for Hasson's technique
Beveled edge & stop valve.
For confirmation of intra abdominal
placement : NS can be pushed freely
& cannot be aspirated.
Note : If bowel injured d/t sharp trocar, convert to open but keep trocar in posi-
tion (To localise the injury)

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----- Active space ----- Other Laparoscopic instruments :

Optiport/visiport : Clear ends,

useful in obese patients. Sharp trocar

Laparoscopic instruments

Note :
• Fracture of the black insulation → Capacitance injury.
• If plastic trocar used → Capacitance injury can be prevented.

Types :
1. Conventional (Eg. : Laparoscopic cholecystectomy) : Multiple ports.
• Surgeon stands on left side.
• Position : Reverse trendelenburg & rt side up (Gas accumulates under rt
dome of diaphragm Rt shoulder tip pain).
• Conventional laproscopic Cholecystectomy : 3 or 4 ports.

2. SILS (Single Incision Laparoscopic surgery) :

• Infraumblical incision is used.
• Multiple instruments can be inserted from single
port.
SILS
3. NOTES : Natural orifice transluminal endoscopic surgery.
Through natural orifice (Umblicus is not used).
Example : Uterus, oral cavity (POEM, ROSE, POSE), rectum (Tatme),
bladder.

Robotic surgery
Da vinci robotic system.
Advantages :
1. Finer dissection.
2. Better movement with more degree of freedom.
3. Tremor reduction.
Drawback : Expensive.
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VASCULAR SURGERY ----- Active space -----

Arterial System 00:01:20

Acute arterial occlusion :

• M/c cause : Embolism.
• M/c source : Heart (Atrial fibrillation).
• 6 P’s.
1. Pain. 4. Paraesthesia. Acute arterial occlusion
2. Pallor. 5. Poikilothermia (Cold).
3. Paresis. 6. Pulselessness.
• IOC : Doppler.
• Mx :
1. within 6-8 hrs : Embolectomy using Fogarty’s balloon.
2. Late presentation (Gangrene) : Amputation.

Fogarty’s catheter Fogarty’s thrombectomy Angiography (before & after

embolectomy)
Chronic arterial occlusion :
• Gradual occlusion (D/t thrombus
→ Collateral formation +).
Clinical features :
• Intermittent claudication.
• Rest pain.
• Gangrene. Chronic arterial occlusion
• Aorto-iliac obstruction :
Claudication in buttocks (Earliest), thighs, and calves.
Femoral and distal pulses absent in both limbs.
Bruit over the aortoiliac region.
Leriche syndrome : Impotence in males + Gluteal claudication.

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

Differentials :
Intermittent (Vascular) claudication Osteoarthritis Neurogenic claudication
Cramping pain (d/t substance P)
Maximum pain on first step Pain varies with posture
after walking a certain distance
Pain is usually in one muscle group
Pain in affected joint -
lower than block
Progresses to rest pain - -

Boyd’s classification of intermittent claudication :

• Class 1 : Pain on walking → Reduces with continued walking.
• Class 2 : Pain on walking → Patient continues to walk despite pain.
• Class 3 : Pain forces patient to stop.
• Class 4 : Pain at rest.

Investigations : Doppler/Duplex scan (IOC), ABPI, TBI, DSA.

1. Ankle brachial pressure index (ABPI) :
ABPI = Maximum ankle systolic BP
Maximum brachial systolic BP
Values :
• 0.9 – 1.4 : Normal.
• < 0.9 : Intermittent claudication. Doppler
• < 0.4 : Chronic limb threatening ischemia (CTLI).
• Drop in resting ABPI of > 20% after exercise → arterial disease.
ABPI – Important points (Bailey updates) :
• ABPI <0.5 → Double risk of deterioration.
• Gradually decreasing ABPI → sign of imminent limb loss.
CTLI :
• Patients with ischaemic rest pain ± ulceration/gangrene (Tissue loss).
• Rx : Early revascularization (To prevent major amputation).
2. Toe brachial pressure index (TBI) – Bailey update :
• If ABPI > 1.3-1.4 (D/t calcification : Seen in DM, CKD.), Then ABPI + TBI is done
: To assess thrombosis. (TBI is a better indicator as Sclerosis rarely affects
the digits).
• TBI < 0.6 suggests significant arterial lesion.

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3. Digital subtraction angiography (DSA) : ----- Active space -----

• Provides dynamic arterial flow with delineation of vessels.
• S/E : Bleeding, thrombosis, aneurysm, dissection, renal dysfunction.
• Indications : Done in patients only if intervention is planned.
• Can't be used to assess aneurysm size (Falsely narrowed app. of lumen).

Buerger’s disease vs Atherosclerosis :

Buerger (thromboangitis obliterans/TAO) Atherosclerosis
M > F. M = F.
3rd decade. ≥ 5th decade.
LL > UL. LL > UL.
Smoking (Main risk factor). Multifactorial risk factors.
Artery, vein & nerves are affected. Only artery is affected.
Distal to proximal spread. Proximal to distal spread.
Small to medium vessels. Large to medium vessels.
Not suitable for endovascular & bypass Suitable for endovascular & bypass
procedures. procedures.
Diagnosis : Muscle Biopsy.
Angiography : Corkscrew collaterals.
Mx : 1st line of Mx : Endovascular procedure
• Stop smoking. (Angioplasty).
• Pentoxyphylline. • Balloon inflated for 30 sec & then deflated.
• Conservative amputations. • Successful for iliac & femoro-popliteal.
• If rest pain + : Lumbar sympathectomy • Below knee results less successful.
(If B/L, then L1 ganglion should • Complications : Failure, hematoma, bleeding,
be saved on one side to prevent thrombosis.
impotence). Other Mx : Grafting.
• Leriche’s : Aorto-bifemoral (Dacron).
• Infra inguinal grafts :
- Reversed saphenous vein (overall best).
- Best synthetic graft : PTFE.

Beurger's Corkscrew Endovascular Stenting Synthetic graft-

disease collaterals Dacron/PTFE
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----- Active space -----

Gangrene :
Dry gangrene Wet gangrene
Desiccated tissue by gradual slowing of blood. Venous blockade or super-added infection
Good line of demarcation. Poor line of demarcation.
If bone involved : Stump is conical. Infection can extend to neighbouring tissues
: final line of demarcation is more proximal.

Key points :
• In DM pts : Local amputation of digits.
• If metatarso-phalangeal joint involved : Ray excision.
• If several toes are affected : Transmetatarsal amputation.
• Below knee amputation : Preserves knee; best chance of walking.
• Above knee amputation : Heals well.
Amputation stump :
• Below knee : Not < 8 cm below knee (10-12 cm).
1. Long posterior flap (M/c).
2. Skew flap.
• Above knee : Not < 20 cm.

Long posterior flap

Complications of amputation :
• Early complications : Hemorrhage, infection, flap necrosis, DVT.
• Late complications : Pain, phantom limb.

Aneurysms : 00:22:39

• M/c vessels involved : Circle of willis.

• M/c extra cranial vessel : Infrarenal abdominal aorta.
• M/c peripheral vessel : Popliteal.
• M/c visceral vessel : Spleen
• M/c vessel in mycotic aneurysm : Aorta.
• M/c organism in mycotic aneurysm : Staph. aureus.
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----- Active space -----

Abdominal aortic aneurysm (AAA) :
• M/c site : Infrarenal abdominal aorta.
• Most important risk factor : Atherosclerosis.
• Critical diameter for AAA : 5.5 cm.
Note : Critical diameter for other aneurysms : Abd. Aortic Aneurysm
Ascending thoracic aortia : 5.5 cm (↑in 0.5 cm/yr : Significant).
Descending thoracic aortia : 6 cm.
In Marfan patients → thoracic aortia : 4.5 – 5 cm.
• Clinical features :
1. Asymptomatic.
2. Abdominal pain.
3. Mass.
4. Blue toe syndrome (D/t emboli).
5. Rupture into Lt retroperitoneum (>50% mortality). Ruptured aneurysm
• IOC : CT Angiography (size can be assessed).
• Mx : Endovascular Aneurysm Repair (EVAR).
Complication of EVAR : Endoleaks.

Types of endoleaks :
Type Cause M/C procedure Image

Thoracic aortic
Type 1 Improper seal
aneurysm repair

Retrograde leak Abdominal aortic

Type 2 from lumbar aneurysm
vessels repair
EVAR

Open aortic aneurysm repair

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

Methods to expose aorta/IVC in aneurysm repair :
Mattox maneuver Cattle-brasch maneuver
Left medial visceral rotation to expose aorta. Right medial visceral rotation to expose IVC.
Descending colon is mobilized medially.

Complications of AAA repair :

• Cardiovascular failure (M/C cause of death).
• Renal failure.
• Aorto-duodenal fistula (Rare cause of upper GI hemorrhage).
• Left sided colonic ischaemia (Presents with bloody stools +).
• Paraparesis after Sx : D/t artery of Adamkiewicz.
(Supplies anterior spinal artery).
• Mortality : 2-3%.

Thoraco- abdominal aortic aneurysms :

Classification system : Crawford classification.
Crawford type II : Left subclavian to aortic bifurcation (most extensive type).

Popliteal aneurysm :
• M/c peripheral vessel aneurysm and B/L in 50% of the cases.
• C/F : Pulsatile swelling behind knee, loss of contour, pain, emboli.
• Indications for intervention : All symptomatic & asymptomatic > 2 cm.

Aortic dissection :
• M/c in males in the 5th decade.
• M/c site : Lateral wall of ascending thoracic aorta.
• Important risk factor : Hypertension.
• Common C/F : Chest pain which radiates to the back.
• Can give rise to coronary insufficiency.
Classification :
DeBakey Extent Stanford
I (M/C) Ascending + Descending
A
II Only ascending
III Only descending B

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

- IOC in stable pt : CT angiography (False lumen seen).
- IOC in unstable pt : Trans esophageal ECHO.
- X ray : widening of mediastinum.

False lumen

widened mediastinum False lumen (CT angio)

Management :
- Esmolol : Permissive hypotension.
- Types 1 & 2 : Graft repair.
- Type 3 : Monitoring (If progressive : Sx).

Raynaud’s phenomena : 00:36:28

Etiology :
Common in patients working in the drilling industry, occurs due to vasospasm.
C/F:
• Hand pain.
• Colour change of hand from white → Blue → Red.

Primary & Secondary Raynaud :

Feature Primary Raynaud Secondary Raynaud
Prevalence Common Rare
Association with collagen
No Yes
vascular diseases and ANA
Complications No (rarely) Yes
DOC : Ca2+ channel
Pharmacological Rx No (Occasionally)
blockers

Subclavian steal syndrome :

• Etiology : Stenosis in 1st part of subclavian artery.
• C/F : Syncopal attacks due to retrograde flow
during exercise.
• IOC : CT angiography.
• Mx : Angioplasty.

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

Carotid artery stenosis :
• M/c site : Bifurcation.
• M/c cause : Atherosclerosis.
• C/F : Asymptomatic or symptomatic.
• Mx : Carotid endarterectomy.
• Indications for carotid endarterectomy :
Symptomatic patients:
- I/L amaurosis fugax or monocular blindness.
- C/L facial paralysis.
- Arm/ leg paralysis.
- Hemianopia.
- Dysphasia.
Asymptomatic patients with ≥70% stenosis.

Thoracic outlet syndrome :

Symptoms :
• Arterial : Emboli/thrombus → gangrene/claudication.
• Venous : Subclavian vein thrombosis.
• Neurological symptoms : Brachial plexus compression mainly on ulnar distribution.

Clinical tests : Adson test, Roos test/Elevated arm stress test (EAST).
IOC : CT angiography.
Mx : Treat underlying cause/angioplasty of narrowed vessel.

Cirsoid aneurysm :
AV malformation a/w superficial temporal vessels (Pulsatile).

AV fistulae : Cirsoid aneurysm

Causes :
• Iatrogenic (M/c) : Cimino fistula (radiocephalic).
Allens test should be done before doing Cimino fistula
to check radioulnar patency. Positive test
• Traumatic.
• Congenital.

Modified Allen's test

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

• Pulsatile swelling.
• In congenital fistulae : Hypertrophy of limb or high output cardiac failure.
• Nicoladoni/ Branham sign : On pressing feeding vessel, size↓, pulse↓, bruit↓,
but systolic BP↑.
IOC : MR/ CT angiography.
Mx : Embolization of AV fistula (If infected : Open Sx).

Venous Disorders 00:44:52

Venous thrombosis :
Risk factors :
Virchow's triad : (Endothelial injury + stasis + hypercoagulability) predisposes to
venous thrombosis, Obesity, immobility, pregnancy, estrogen therapy, cancer,
previous h/o DVT.
Clinical features :
• Pain & swelling.
• Constant sign : Limb edema.
• Majority are U/L.
• Homan’s & Moses sign : (High risk of Pulmonary Embolism (PE), if performed).
- Moses sign : On Squeezing calf → Pain.
- Homan’s sign : Dorsiflexion of foot → Resistance in calf.
• Phlegmasia cerulea dolens & Phlegmasia alba dolens :
Phlegmasia cerulea dolens Phlegmasia alba dolens
Painful blue limb. Painful white limb.
D/t thrombosis of major axial veins along Develop during pregnancy.
with collaterals D/t thrombosis of major axial veins.

Well’s criteria for predicting DVT :

Probability Score
Low -2 - 0
Moderate 1-2
High ≥2

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

Investigations :
• IOC : Duplex scan/Doppler.
• If suspecting pulmonary embolism (PE) : CT angiography.

Note : M/c veins affected in DVT : Calf/soleal veins.

More proximal the vein involved → greater the risk for PE.
Management :
1. Anticoagulants :
• First 5 days : LMWH + Warfarin.
• After 5 days : Only warfarin.
• Target INR : 2 - 3.
• Pregnant patients : LMWH is continued (As oral agents can be teratogenic).
• If sensitive to Heparin :
1. Fondaparinux (Factor Xa inhibitor).
2. Bivalirudin (Direct thrombin inhibitor).
3. Novel anticoagulants (NOAC) : Rivaroxaban, Apixaban.
2. Direct thrombolysis :
• Catheter induced dissolution.
• Early thrombolysis leads to incidence of post thrombotic limb.
• ATTRACT trial.
3. IVC filter : k/a Greenfield filter.
Indications :
- Recurrent thromboembolism despite adequate anticoagulation.
- DVT in a patient with contraindications to anticoagulation.
- Chronic pulmonary embolism and resultant pulmonary HTN.

Post thrombotic leg :

• Seen in 2/3 rd patients with DVT.
• Features : D/t deep vein blockade, leading to
chronic venous HTN, varicose veins,
pigmentation, and lipodermatosclerosis.

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Risk stratification : Low, Moderate, High. ----- Active space -----

High risk :
• Major orthopaedic surgery.
• Major abdominal/pelvic surgery for cancer.
• Major surgery, trauma, medical illness in patient with
• DVT, PE or thrombophilia.
• Lower limb paralysis (e.g. stroke, paraplegia).
• Major lower limb amputation.
Mx : Dual prophylaxis (both mechanical & pharmacological).

Prophylaxis :
• Pharmacological (LMWH) > Mechanical.
• Mechanical : Pneumatic compression
- Early ambulation. stockings
- Pneumatic compression stockings (Intermittently inflates).

Varicose veins : 00:55:33

Anatomy :

Deep veins Great saphenous vein Small saphenous vein

• Great saphenous vein (GSV) : Starts from medial end of dorsal venous arch
& drains at the saphenofemoral junction (constant location : 4 cm below &
lateral to pubic tubercle). Below knee, GSV is a/w saphenous nerve.
• Short saphenous vein (SSV) : Travels posteriorly & drains at the
saphenopopliteal junction (variable location). Throughout its course, SSV is
a/w sural nerve.
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----- Active space -----

Perforators :
There are at least 100 - 150 perforators. Few of them are named :
• Thigh perforator : Hunterian.
• Above knee : Dodd.
• Below knee : Boyd.
• Ankle : 3 Cockett perforators → 5, 10 & 15 cm above the medial malleolus.
• Heel : May/Kuster.
Varicose veins : Dilated tortuous veins with defective valves.
Clinical features :
• Dilated veins (M/c).
a. >3 mm : Varicose veins.
b. 1-3 mm : Reticular veins.
c. <1 mm : Dermal flares/ Varicose veins Thread veins Ulceration
thread veins/telangectasias.
• Dull aching pain.
• Pigmentation.
• Venous ulcers in Gaiter's zone.
• Corona phlebectatica or malleolar flare : Fan shaped pattern of
telangectasia on the ankle or foot.
• Atrophie blanche : Pale white area surrounded by varicose veins.
• Lipodermatosclerosis : D/t obliteration of fat → Shiny skin → Leg appears
like inverted champagne bottle.

Corona phlebectaticia Atrophie blanche Lipodermatosclerosis

Early signs of advanced venous disease

Summary of clinical tests :

For SJF incompetence For perforator incompetence For DVT
• Trendelenburg test. • Trendelenburg test. • Modified perthe’s test.
• Morrisey cough impulse. • Multiple tourniquet test.
• Schwartz test. • Fegan’s method.

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

IOC : Doppler/Duplex scan.
• It tells about flow, direction of
flow (away from heart : red),
reflux.
• Mickey mouse sign : Formed by
GSV, femoral vein, common femoral artery.
Note : Mickey mouse sign is also seen in the liver.

CEAP classification :
Grade Clinical features
Co No visible or palpable signs of venous disease
C1 Telangiectasias or reticular veins
C2 Varicose veins (>3 mm)
C2r Recurrent varicose veins
C3 Edema
C4 Changes in skin and subcutaneous tissue secondary to chronic venous disease
C4a Pigmentation or eczema
C4b Lipodermatosclerosis or atrophie blanche
C4c Corona phlebectatica
C5 Healed
C6 Active venous ulcer
C6r Recurrent active venous ulcer

Management :
1. Adjuncts to Sx : Compression garments → Class III (25-35 mm Hg).
Drawback → Poor compliance.
2. Surgery :
• Traditional Sx : Trendelenberg procedure (Flush ligation of SFJ).
Tributaries to be ligated are :
- Medial : Superficial external pudendal, Deep external pudendal.
- Distal : Accessory anterior saphenous vein, Posterior medial thigh vein.
- Lateral : Superficial epigastric vein, Superficial circumflex iliac vein.
Note : Stripping veins is not a part of Trendelenburg procedure. Stripping is
done only till the knee to prevent saphenous nerve injury.
• Latest treatment options :
- Endovenous laser therapy (EVLT).
- Radiofrequency ablation (RFA).
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----- Active space -----

• Foam sclerotherapy : Tessari technique :
Air : Sclerosant :: 3 : 1 or 4: 1.
Used in dermal flares/thread veins (< 1 mm).
Sclerosant : Sodium tetradecyl sulphate.

Trendelenburg procedure Tessari technoque

Complications :
Complications of varicose vein surgery : Complications of varicose veins :
• Injury to nerves (m/c) : Saphenous nerve, • Bleeding.
sural nerve. • Calcification.
• Wound infection. • Superficial thrombophlebitis.
• Bruising. • Pigmentation.
• Recurrence (SSV > GSV). • Lipodermatosclerosis.
• Bleeding. • Ulceration.
• Injury to vessels.

Varicose ulcer (venous ulcer) :

• M/c site : Medial malleolus/Gaiter area.
• Features of ulcer : Shallow ulcer, sloping edges,
pale granulation tissue, pigmented margins.
• Differential → Arterial ulcer : Can also occur on the lateral Venous ulcer
aspect with shiny skin, loss of hair and muscle, and punched out edges.
• Mx : Bisgard regimen.
- Education.
- Elevation of limb.
- Elastic compression stockings (of class III).
- Dressings.
- Surgery. Marjolin ulcer
- Pentoxifylline (Only approved drug) : Increased microvascular perfusion.
• Long standing venous ulcer (Or burns scar) can change into Marjolin's ulcer.
- Marjolin's ulcer is a SCC with raised, everted margins.
- Mx : Excision.

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Klippel Trenaunay syndrome : ----- Active space -----

• Mesodermal abnormality. • Absent deep veins.
• Non familial syndrome. • Cutaneous naevus.
• Vestigeal veins. • Soft tissue & bone hypertrophy.
• Varicose veins.
Note : Varicose vein Sx not done (d/t absent deep veins).
Parkes Weber syndrome :
• Multiple AV fistulae. • High output failure.

Lymphatic System 01:12:24

Cystic hygroma :
• Sequestered lymphatic tissue.
• M/c site : Posterior triangle of neck.
• C/F : Fluctuant swelling, brilliantly transilluminant,
partly compressible.
• Mx : Aspiration f/b surgery.
• Nerve at risk during Sx : Spinal accessory nerve.

Acute lymphangitis :
• Organisms : Streptococcus/Staphylococcus.
• C/F : Pain, reddish streaks seen.
• Mx : Limb elevation, broad spectrum antibiotics.

Lymphedema :
• Definition : Excessive interstitial fluid.
• Classified as primary & secondary.
Lymphedema

Primary Secondary

Lymphedema Lymphedema Lymphedema

congenita praecox : M/C tarda : >35 yrs

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

Primary Lymphedema :
Lymphedema congenita Lymphedema praecox (M/c)
0-2 yrs 2-35 yrs
M>F F>M
Can involve multiple limbs, face & genitalia Usually U/L till kee
Familial : Noone Milroy syndrome (FLT-4 gene) Familial : Meig’s disease (GJC gene)

Secondary Lymphedema :
• M/c cause of upper limb lymphedema : Post mastectomy lymphedema.
• M/c cause of lower limb lymphedema : Filariasis.

Post mastectomy lymphedema Filariasis

Clinical classification of subclinical lymphedema : Brunner’s classification.

Grade Clinical feature
↑ interstitial fluid & histological
abnormalities in lymphatics and lymph
0
nodes.
No clinically apparent lymphedema
Pitting edema, Swelling disappears on Grade 0 Grade 1
I
elevation or bed rest.

Non pitting edema. Swelling persists

II
despite elevation.

III Edema + Irreversible skin changes. Grade II Grade IV

Complications :
• Infection.
• Skin changes : Buffalo hump (Loss of ankle contour),
squaring of the toes, Stemmer’s sign (Inability to pinch
skin over the toes).
• Cancers : Stewart Treve’s syndrome
Stewart Treves syndrome : Development of angiosarcoma in long standing
lymphedema (8 - 10 yrs). Presents as bluish/reddish nodules.
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Investigations : ----- Active space -----

Limb volume measurement by Water plethysmography (gold standard).
B/o water displacement,
• Mild : < 20%
• Moderate : 20-40%
• Severe > 40%.

Management :
• Pain relief.
• Skin care :
- Protect hands when washing up or gardening.
- Never walk barefoot; wear protective footwear.
- Never let the skin become macerated.
- Treat cuts and grazes promptly.
- Use insect repellent sprays.
• Control of swelling : Decongestive lymphedema therapy.
1st phase : Short phase of intensive supervised therapy.
- Manual lymphatic drainage (MLD).
- Multilayer lymphedema bandaging (MLLB).
2 phase : maintenance phase – self care regimen.
nd

• Exercises : Vigorous & anaerobic isometric exercise → worsen lymphedema.

Slow rhythmic isotonic movement (Swimming) → useful.
• Surgery :
1. Homan's procedure : Wedge of skin and
subcutaneous tissue is removed.
M/c complication : Skin necrosis.
2. Thompson's procedure : Buried dermal flap is
sutured to deep fascia.
3. Charles’ procedure : Entire tissue removed and
split thickness skin grafting is done. Worst cosmetic
outcome.

Homan's procedure Charles' procedure Thompson's reduction Sx

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----- Active space ----- HERNIA, THORAX, AND SKIN

Hernia 00:02:00

Definition : Protrusion of a viscus or a part of viscus through the wall containing

it.
Types Reducibility Cough impulse Blood supply
Uncomplicated + + +
Obstructed - - +
Strangulated - - -

Strangulated hernia with skin changes

Note : Forceful reduction is not attempted in obstructed/strangulated hernias,

d/t risk of reduction en masse.

Reduction en masse
Types Omentocele Enterocele
Content Omentum Bowel
Peristalsis - +
Consistency Doughy
Reduction of first part Easy Difficult
Percussion Dull Tympanic
Amayand hernia : Appendix is the content.
Littre’s hernia : Meckel’s diverticulum is the content.

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Surgical methods : ----- Active space -----

1. Herniotomy :
Open sac→ Reduce contents → Close the sac.
↑sed risk of recurrence.
It is the TOC for :
• Congenital inguinal hernia. → →

• Inguinal hernia in children.

• Congenital hydrocele. Open sac Reduce contents Close sac

2. Herniorrhaphy : 3. Hernioplasty :
Suture 2 edges of defect together. Mesh is placed over the defect.
Done in cases of strangulation. ↓sed risk of recurrence.
Mesh :
Best mesh : Low weight, thin fibres, large pores
(Large bundles of fibrous tissue).
Ideal overlap of mesh : 2-5cm beyond the defect.

Mesh materials Synthetic Biological

Infection/strangulation Not used Can be Used (expensive)
1. Prolene.
1. Acellular human dermis
(Alloderm).

Examples

2. Vipro : Vicry| + prolene.

2. Acellular porcine der-
3. PTFE mesh : Poly tetra
mis.
fluoro ethylene mesh.
Plug mesh :
↑ed risk of collagenoma (Meshoma).

Inguinal hernia 00:09:37

Indirect inguinal hernia : M/c hernia in males & females.

Single best clinical test : Deep ring occlusion test.
20% patient’s have occult contralateral inguinal hernia.

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

Types of indirect inguinal hernia :

Bubonocele : Sac crosses Funicular : Sac crosses Inguinoscrotal : Sac

deep ring superficial ring reaches base of scro-
tum

Inguinal hernia anatomy :

Hesselbach’s triangle :
Boundaries :
• Medial : Outer border of rectus.
• Inferior : Inguinal ligament.
• Superior : Inferior epigastric vessels.
Hernia lateral to the triangle : Indirect.
Hernia through the triangle : Direct.

Myopectineal orifice of Fruchaud :

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Boundaries : ----- Active space -----

• Superior : Arching fibers of internal oblique.
• Medial : Outer border of rectus.
• Lateral : Tendon of iliopsoas.
• Inferior : Pectineal/cooper’s ligament.

Myopectineal orifice covers the defect of 3 hernias :

• Inguinal
• Femoral.
• Obturator.

Aim of laparoscopic repair recently is to cover the entire myopectineal orifice

with a mesh.
Complications of open inguinal hernia surgery/Lichtenstein tension free mesh
hernioplasty :
• Hemorrhage.
• Injury to vas/cord structures.
• Mc nerve injured : Ilioinguinal nerve (while cutting superficial ring).
• Mc nerve entrapped beneath the mesh : Iliohypogastric nerve, leads to
chronic inguinal pain.
• Recurrence.
• Wound infection.
Laparoscopic inguinal hernia surgery :
TEP (Total Extraperitoneal Repair) :
• Technically challenging.
• Better procedure (not breaching the peritoneum).
TAPP (Transabdominal Preperitoneal Repair) :
• Surgery is done beneath the peritoneum & hence breached.

TEP TAPP

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----- Active space ----- Important anatomical locations :

Triangle of doom :
Boundaries :
• Medially : Vas deferens.
• Laterally : Testicular vessels.
• Inferiorly : Peritoneal reflection.
Contents :
• External iliac artery & vein.
• Genital branch of Genito femoral nerve.
Stapler, tacker or a suture in the triangle of doom → Injury of the vessels →
Severe bleeding.

Triangle of pain :
Boundaries :
• Superiorly : Iliopubic tract/Inguinal ligament.
• Medially : Testicular vessels.
• Laterally : Peritoneal reflection.
Contents :
• Lateral cutaneous nerve of thigh.
• Femoral nerve.
• Femoral branch of genitofemoral nerve.
Stapler, tacker or a suture in the triangle of pain → Pain d/t entrapment of
nerves.
M/c nerve entrapped : Lateral cutaneous nerve of thigh
(Meralgia paresthetica).
Triangle of pain is aka Electrical hazard zone (Electrical cautery must be avoided).
Trapezoid of Disaster = Triangle of Doom (Medial) + Triangle of pain (Lateral).

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Corona Mortis/circle of death : ----- Active space -----

Abnormal communication b/w obturator & iliac vessels.
If injured during laparoscopic surgery → Torrential haemorrhage.
Named Hernias
Sliding hernia : Sportsman hernia :
• Aka Hernia en glissade. • Aka Gilmore’s groin/athlete’s groin.
• Common in elderly males. • Seen in athletes.
• Posterior boundary of sac is formed by • Usually due to tear in posterior
a visceral structure → Risk of injury to wall muscle.
that structure while removing the sac. • C/o inguinal pain.
• Left > right. • IOC : MRI.
• M/c structure : Sigmoid colon > bladder. • Mx : Laparoscopic repair.
Classification of Hernia 00:19:11

European Hernia Society (EHS) Classification:

Inguinal hernia :
Location/Type Finger Breadth (FB)
Primary Recurrent
0 1 2 3 X
(No hernia (One FB ) (Two FB) (More than (Not
detected) two FB) investigated)
L (Lateral/Indirect) L2
M (Medial/Direct)
F (Femoral) FX
Example 1 : Lateral hernia that is 2 finger breadth or recurrent → L2
Example 2: Femoral Hernia not investogated for finger breadth → FX
Ventral hernia classification :
Hernia Characteristics Term
Subxiphoid M1
Epigastric M2
Medial Umbilical M3
Infraumbilical M4
Suprapubic M5
Subcostal L1
Femoral L2
Lateral
Iliac L3
Lumbar L4

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

Nyhus Classification for Inguinal and Femoral Hernia:
Type Description
Indirect inguinal hernia with a normal ring.
Type 1
Sac in the canal.
Indirect hernia with an enlarged internal ring but the
Type 2 posterior wall is intact; inferior deep epigastric vessels
not displaced, sac not in scrotum.
Type 3a Direct hernia with a posterior floor defect only.
Indirect hernia with enlargement of internal ring and
Type 3b
posterior floor defect
Type 3c Femoral hernia
Recurrent hernia
A : Direct
Type 4 B : Indirect
C : Femoral
D : Combinations of A-B-C.
Note : If Aggravating factors are present, local or systemic : upstage type by 1.

Other Hernias 00:20:36

Femoral Hernia :
F>M
Boundaries of femoral ring :
• Medially : Lacunar ligament.
• Superiorly : Inguinal ligament/iliopubic tract.
• Laterally : Septum which separates it from the veins (iliac/femoral veins).
• Inferiorly : Pectineal/cooper’s ligament.
As the ring is surrounded by ligamentous structures, it cannot dilate →
Strangulation is more common.
Mx : Laparoscopic mesh repair. Differential diagnosis of femoral hernia :
1. Inguinal hernia.
Note : 2. Psoas abscess.
Femoral hernia : Below the pubic tubercle. 3. Inguinal lymph node.
Inguinal hernia : Above the pubic tubercle. 4. Saphena varix.

Ventral/ Abdominal Wall Hernias :

• Epigastric. • Spigelian.
• Umbilical. • Lumbar.
• Paraumbilical. • Parastoma.
• Traumatic. • Incisional (M/c).

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Surgery for ventral hernia : ----- Active space -----

• Onlay :
Mesh on top of the rectus sheath.
• Inlay :
Mesh at the level of rectus sheath.
• Retromuscular :
Mesh behind the rectus muscle.
• Preperitoneal/sublay repair :
Mesh between peritoneum & rectus sheath.
• Intraperitoneal :
Called as IPOM (Intraperitoneal placement of mesh).
Incisional hernia :
30-50% open abdominal surgeries.
1-5% laparoscopic surgeries.
Repair :
• Tissue repairs like Keel & Da silva are not preferred these days.
• Ramirez component separation technique done if incisional hernia volume is
>25% of abdominal volume (releasing incisions are given).
• Laparoscopic hernia repair.
Hernia Epigastric hernia Umbilical hernia Paraumbilical hernia
Location Xiphisternum till umbilicus Through Adjacent to umbilicus
umbilicus
Chances of
↓ ↓ ↑
strangulation
• Aka Fatty hernia of linea alba.
• M>F. • Umbilicus forms one of
• Young, fit males. Umbilicus is the boundaries of the
Unique • Between xiphisternum & everted; defect.
features umbilicus. Common in • It is a narrow defect
• Single/multiple defects. newborn. → High rate of stran-
• Structure that herniates out : gulation.
Pre peritoneal fat.
Conservative
management All patients require
Management Laparoscopic repair
till 2-3 years surgery
old

Epigastric hernia Umbilical Hernia Paraumbilical hernia

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----- Active space ----- Omphalocele vs. Gastrochisis :

Omphalocele Gastrochisis
Defect through the umbilicus in which
Defect adjacent to umbilicus.
bowel fails to return inside.
Covered with peritoneum. Bowel not covered with peritoneum.
Large defects; Liver can also herniate. Bowel exposed.
Associated with other congenital
Less congenital anomalies.
anomalies.
Associated with Beckwith Weidemann
Atresia & perforation common.
syndrome ; Trisomy 13, 18, 21.

Omphalocele

Gastroschisis

Lumbar triangles :
1. Inferior lumbar triangle of Petit :
Inferiorly : Iliac crest.
Laterally : External oblique.
Medially : Latissimus dorsii.
2. Superior lumbar triangle of Grynfelt :
Superiorly : 12th rib.
Laterally : Internal oblique.
Medially : sacrospinalis.
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Lumbar hernia : ----- Active space -----

Inferior > superior.
Secondary > primary.

Spigelian hernia :
Aka intraparietal hernia.
Sac lies in between muscle layers.
Hence detected late.
Diagnosed when strangulation occurs.
Seen along outer border of rectus, �bove the
arcuate line (Midpoint between umbilicus and
pubic symphysis).

Obturator hernia :
Aka Little old lady’s hernia.
Common in the elderly, multiparous women, and
people with short stature.
Narrow defect (High rate of strangulation).
Clinical features :
Bowel obstruction.
Pain.
Howship Romberg sign : Shooting pain along obturator nerve on flexion & internal
rotation.
Hannington Kiff sign : Absent adductor reflex in the presence of a positive
patellar reflex because of obturator nerve compression.

Richter’s hernia :
Seen in paraumbilical, obturator, femoral hernias.
There is a very narrow defect → Herniation of
only a portion of bowel wall → Strangulation →
Diarrhoea, gastroenteritis
Strangulation can be missed.
Maydl’s hernia :
Wide defect.
Aka W shaped hernia.
>1 bowel loop can herniate through.
Strangulation occurs at the junction joining 2 loops
(Intraperitoneal).
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----- Active space -----

Congenital diaphragmatic hernia 00:35:59

Bochdalek Hernia Morgagni Hernia

M/c
Left postero lateral Right antero medial
Defective development of
Defective central tendon
pleuroperitoneal canal
of diaphragm
membrane
Contents : Stomach, spleen,
Transverse colon
Bowel in thoracic cavity Bochdalek hernia transverse colon
Clinical features :
Scaphoid abdomen.
Respiratory distress.
Pulmonary hypoplasia/non development of lung : M/c cause of death.
Pulmonary hypertension : 2nd m/c cause of death.
Management :
Bag & mask ventilation is contraindicated.
Best : Intermittent Positive Pressure Ventilation (IPPV).
Surgery : Circular incision made over the diaphragm & repair with mesh.

Thorax 00:39:15

Thoracoscore :
Predicts mortality after thoracic surgery.
1. Sex.
2. ASA classification (≤2, ≥3).
3. Performance status according to Zubrod scale (≤2, ≥3).
4. Severity of dyspnea according to medical research council scale (≤2, ≥3).
5. Priority of surgery Elective, urgent/emergency).
6. Extent of resection (Pneumonectomy, other).
7. Diagnosis (Malignant, benign).
8. Comorbidity score.
Spontaneous pneumothorax :
Primary spontaneous Secondary spontaneous
pneumothorax pneumothorax
Young tall people. Older individuals.
Males > Females.
Secondary to underlying lung
Family history +
disease : TB, tumors, emphysema.
Leak from blebs : Upper lobe.
Tolerated better. Not tolerated well.
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Clinical features : ----- Active space -----

• Sharp pleuritic pain.
• Partial or complete collapse.
• Hyper resonant note on percussion.
Risk of recurrent pneumothorax :
One episode : About 1/3rd experience recurrence.
Two episodes : Half develop recurrence.
Three episodes : All will develop future episodes.
Indications for surgical intervention :
• Secondary ipsilateral pneumothorax.
• First contralateral pneumothorax.
• Bilateral spontaneous pneumothorax.
• Pneumothorax fails to settle despite chest drainage.
• Spontaneous hemothorax : at-risk professions such as pilots and divers.
• Pregnancy.
Treatment : Spontaneous pneumothorax
If bilateral/hemodynamically unstable, proceed to chest drain

Age >50 and significant smoking history

Evidence of underlying lung disease on exam or X-ray
No Yes
Primary pneumothorax Secondary pneumothorax

Size >2 cm Size >2 cm

and/or breathless Yes and/or breathless
Yes No
No
Size 1-2 cm
Yes
Aspirate No
Aspirate
16-18G cannula
16-18G cannula
Aspirate <2.5L
Aspirate <2.5L

Success (<2 cm No Yes

Consider Yes Success
discharge & breathing No (size now <1cm)
review in OPD in improved) Admit
2-4 week High flow Oxygen
Chest drain (Unless suspected oxygen sensitive)
size 8-14 Fr Observe for 24 hours
Note: In some patients having large pneumothorax but with minimal symptoms,
conservative management may be appropriate.

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

Video assisted thoracoscopic surgery (VATS) :
Double lumen endotracheal tube inserted →
Lung is collapsed → Creates space to move
instruments.

Empyema :
Collection of pus in pleural space.

Causes
Aspiration of Extrapulmonary Bone
Pulmonary infection Trauma
pleural effusion sources infections
Unresolved pneumonia.
Bronchiectasis. Penetrating injury. Osteomyelitis
Tuberculosis. Any etiology. Surgery. Subphrenic abscess of ribs or
Fungal infections. Esophageal perforation. vertebrae.
Lung abscess.

Lung Cancer 00:45:58

Risk factors :
• Smoking.
• Pollution.
• Exposures : Asbestos.
Feature SCC Adeno ca Small cell ca Large cell ca
Incidence M>F F>M M>F M>F
Location Central Peripheral Central Peripheral
Smoking association + - +++ +
Paraneoplastic Migratory throm- Cushing’s syn-
Hypercalcemia Gynecomastia
syndromes bophlebitis drome, SIADH
Pathogenesis p53 K RAS, EGFR, ALK L-myc
Small cells, salt &
Keratin pearls, Glands lined by pepper chromatin, Large pleomor-
HPE
desmosomes. pleomorphic cells. nuclear moulding, phic cells.
azzopardi effect.
NSE, chromogranin,
IHC CK, p63, p40 TTF1, NAPSIN A
synaptophysin
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Small cell (Oat cell) carcinoma : ----- Active space -----

Strongest association with smoking.
Males > females.
Poor prognosis.
Highly chemosensitive.
Maximum number of paraneoplastic syndromes.
Paraneoplastic syndrome Hormone/antibody
Endocrine
Cushing's disease Adrenocorticotropic hormone
SIADH Antidiuretic hormone
Acromegaly Growth hormone-related peptide
Neurologic
Lambert-Eaton syndrome ANti-VGCC
Encephalitis Anti-GAD65, CRMPS
Cerebellar degeneration Anti-HuD, Anti-Yo
Stiff-person syndrome
Retinal blindness
Opsoclonus/myoclonus

SVC syndrome :
• A/w central tumors (Small cell cancer & SCC),
which blocks SVC.
• Patient presents with facial/cranial edema.
• Collaterals develop in later stages.
• It is an oncological emergency → Treated
with chemotherapy/radiotherapy.
Histopathology : Azzopardi effect,
Non small cell lung cancers : salt & pepper chromatin.
1. SCC (Squamous cell ca) of lung :
Centrally placed.
Strong association with smoking.
M/C lung cancer in smokers.
Can lead to hypercalcemia of malignancy.

Pancoast tumor :
Apical central tumors which compresses
sympathetic chain → Horner’s syndrome:
• Ptosis
• miosis
• Enophthalmos
Pancoast tumor
• Anhydrosis
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2. Adenocarcinoma : 3. Bronchoalveolar carcinoma :
Females > Males. Multifocal in nature.
m/c lung cancer overall. Usually resectable.
Peripherally placed. Spreads along bronchoalveolar lining : Lepidic pattern.
Slow growing.
Early metastasis.
Markers : NAPSIN 4.
Mutations : ALK, RAS.

Lung cancer staging :

Stage Description
TX Tumor in sputum/bronchial washings but not be assessed in
imaging or bronchoscopy.
To No evidence of tumor.
Tis Carcinoma in situ
T1 ≤ 3 cm surrounded by lung/visceral pleura, not involving main
bronchus.
Tia (mi) Minimally invasive carcinoma.
> 3 to <5 cm or involvement of main bronchus without carina,
T2 regardless of distance from carina or invasion of visceral pleura or
atelectasis or post obstructive pneumonitis extending to hilum.
>5 to ≤7 cm in greatest dimension or tumor of any size that involves
T3 chest wall, pericardium, phrenic nerve, or satellite nodules in the
same lobe.
> 7 cm in greatest dimension or any tumor with invasion of the
mediastinum, diaphragm, heart, great vessels, recurrent laryngeal
T4
nerve, carina, trachea, esophagus, spine or separate tumor in
different lobe of ipsilateral lung.
Diagnosis : Endobronchial ultrasound guided FNAC (EBUS FNAC).
Complications of lung resection :
• Bleeding.
• Respiratory infection.
• Persistent air leak.
• Bronchopleural fistula.
Hamartoma :
M/C benign lung tumor.
Asymptomatic/cough/hemoptysis. Coin shaped
Management : Excision using VATS. lesion
Hamartoma

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Mediastinal tumors 00:54:20 ----- Active space -----

Thymoma :
• M/c overall.
• It can be a/w myasthenia gravis.
Neurogenic :
• M/C in children,
• M/C posterior mediastinal tumor.
Thymoma staging :
Masaoka thymoma staging system.
Stage Description
1 Macroscopically completely encapsulated
Microscopically no capsular invasion
11 Macroscopic invasion into surrounding fatty tissue or mediastinal pleura
Microscopic invasion into the capsule
111 Macroscopic invasion into neighboring organs (Pericardium, great vessels, lungs)
IVA Pleural or pericardial dissemination
IVB Lymphogenous or hematogenous metastasis

Skin 00:57:29

Types of Ulcers :

Basal cell carcinoma :

Rodent ulcer.
Locally invasive.
Lymph nodes and distant metastasis absent.
M/C site : Face (above line joining angle of
mouth to ear lobule).

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

Risk factors :
White population.
UV rays.
Gorlin syndrome : Chromosome 9. Palisading
pattern
Pathology : “Palisading pattern”

High risk features :

• >2 cm in size.
• Sites where infiltration can lead to cranial extension.
• Recurrent lesions.
• After immunosuppression.
Rx :
1. Rhomboid/Limberg flap : BCC

2. Bilobed flap : Tip of nose.

Note : Bipedicled flap : Eyelid reconstruction.

3. Moh’s micrographic surgery :

• Cosmetic way.
• Less tissue removed.
• More time consuming.

Malignant melanoma :
Risk factors :
UV radiation.
White population.
Familial atypical mole melanoma syndrome.
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Types : ----- Active space -----

1. Superficial spreading : 4. Nodular :
M/C type. Most aggressive.
Seen in young. Worst prognosis.
Sun exposed areas. Rapid vertical phase of growth.
M/C melanoma in a pre existing mole. Variant : Amelanotic melanoma.

2. Lentigo maligna :
In situ melanoma.
Elderly patient.
Best prognosis.

3. Acral :
Subungual melanoma
M/C in dark skinned patients. ‘Hutchinson sign’
Seen in palm,sole.

For detection of melanoma :

A → Asymmetry
B → Borders which are uneven
C → Change in colour
D → Increase in diameter >6mm

IHC Markers :
• S -100.
• HMB 45.
• Melan A.

Clarke & Breslow staging :

Based on the depth of invasion.

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----- Active space ----- Rx :

Wide local excision.
If LN not enlarged → SLNB is done.

Most important prognostic factor : LN status.

Marjolin’s ulcer :
Long standing burns/venous ulcers → SCC.

Soft Tissue Sarcomas 01:06:12

Sarcomas usually spread via hematogenous route.

Sarcomas which spread to lymph nodes :

“MARCES”
Clinical features : Lump/mass.
• Malignant fibrous histiocytoma.
• Angiosarcoma.
Investigations :
• Rhabdomyosarcoma.
IOC : Tru cut biopsy.
• Clear cell.
Staging : MRI.
• Epithelial.
Distant metastasis : PET-CT.
• Synovial sarcoma.

Rx :
Wide local excision (WLE).
Chemotherapy : MAID regime.
Radiotherapy : To reduce locoregional recurrence.
For lymph node spread : Lymph node clearance.

Desmoid tumor :
Seen over anterior abdominal wall.
Lump/mass.
Locally invasive.
Diagnosis : Biopsy.
Mx : WLE.

Sarcoma over anterior abdominal wall

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UROLOGY 1 ----- Active space -----

Kidney 00:00:54

Duplication of ureteric system :

Wiegert meyer rule : Ureter draining upper part opens more distally & medially
& at an ectopic location (in females opens into vagina & males into urethra).

Duplication of ureteric system Duplication with malrotated

pelvis : Dropping lily sign.
Polycystic kidney disease (PCKD) :
Drooping lily sign

Infantile PCKD AR Adult PCKD AD

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.
Death due to hepatic fibrosis. Hypertension in third decade
of life (M/C feature),
abdominal mass, hematuria.
Extra renal manifestations OF PCKD :
a. Most common : Hepatic cysts.
b. Cysts in spleen, pancreas, lungs.
c. Colonic diverticulosis.
d. Mitral valve prolapse.
e. Berry aneurysms in circle of Willis.
USG : Multiple cysts in the kidney.
Prenatal scan findings for diagnosis :
• ≥3 cysts (unilateral or bilateral).
• ≥2 bilaterally. Rx - Dialysis or Transplant

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Polycystic kidney disease Horse shoe kidney

Horseshoe kidney :
• Fused lower end of kidney (at level of L3).
• Ascent restricted by Inferior mesenteric arteries.
• Adrenals : Normal position.
• Don’t cut fused portion (can devascularise lower ends of both kidneys)..
• Intravenous urogram : Flower vase sign/hand shake sign.
• Usually asymptomatic sometimes present with lumps, stone, hydronephrosis.
• If malrotated pelvis : Pyeloplasty done.
renal

Hydronephrosis :
Aseptic dilatation of pelvi-calyceal system due to intermittent partial/complete
blockade to flow of urine.
Unilateral hydronephrosis causes :
1. Intra-luminal causes :
• M/c cause of acquired hydronephrosis : Stone disease.
• Sloughed papillae.
2. Intra-mural causes :
• M/c cause of congenital hydronephrosis : PUJ (pelvi ureteric junction)
obstruction (adynamic). Mx : Anderson Hynes pyeloplasty.
• Ureterocele : Lower end of ureter is dilated (Cobra head/ Adder head sign).
• Transitional cell carcinoma of pelvis (goblet sign).
3. Extra-luminal causes :
a. Aberrant renal vessels : Usually unilateral, never cut. Mx : Pyeloplasty.
b. Advanced cancers : Ca colon, cervix, Uterus, soft tissue sarcoma.
c. Retroperitoneal fibrosis (Ormond’s disease) : Causes can be Idiopathic, drug
induced (Methysergide), IgG4 mediated, post radiotherapy.
• First structure to be affected : Ureters.
• IVU : Maiden’s waist deformity .
• Mx : Steroids & DJ stenting (Maintain potency).
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----- Active space -----

TCC
Ureter/
Pelvis

Cobra head sign Goblet sign PUJ obstruction

Ureters
fibrosed
together

Maidens waist deformity DJ stent Double J stents

Bilateral hydronephrosis causes :

• Any unilateral cause of both sides.
• BPH.
• Bladder outlet obstruction.
• Posterior urethral valves.
• Phimosis.
• Meatal stenosis.
DMSA scan : Best for structural abnormalities.
DTPA Scan : For function.
with Lt. and Rt. parts
MAG 3 scan : Best for function (Differential functioning).

Renal stones :
1. Calcium oxalate stone (m/C) :
• Acidic urine.
• Radio-opaque.
Two types :
a. Monohydrate stones : Dumb bell shaped crystals
(hard stones), spiculated margins (Mulberry stones).
b. Dihydrate stones : Envelope shaped crystals.
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Dietary advise in recurrent calcium oxalate stones :
• Decrease fat content.
• Increase calcium intake in diet.
• Large doses of pyridoxine.
• Cholestyramine : Binds oxalate in gut.

2. Triple phosphate/Calcium ammonium magnesium phosphate/struvite/

staghorn stones :
• Formed in alkaline /infected urine (Proteus).
• Radio opaque.
• Crystal : Coffin lid appearance.

3. Cystine stones : HARDEST, CRYSTALLINE LATTICE

• Acidic urine.
• Radio-opaque stones. Cystine
• Very hard : Crystalline lattice
stones

(difficult to break by ESWL).

• Seen in cystinuria.
• D-penicillamine used in Mx.

4. Uric acid stones : URIC

• M/c radiolucent stones. ACID
STONES
• Acidic urine.
• Crystals : Glass shards.
• Seen in gout & tumor lysis syndrome.
• Medical therapy : Allopurinol.

5. Ammonium urate crystals :

• Radiolucent.
• Associated with laxative abuse. and INFLAMMATORY
BOWEL DISEASE

Presentation :
• Pain (M/C) : Colicky or fixed at renal angle.
• Haematuria.
• Dietl’s crisis : Pain & palpable mass followed by passage of large quantities
of diluted urine (when stone shifts).

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

• Investigation of choice : NCCT Scan (Also for head injury).

Management :
• < 5 mm : No active intervention.
• > 5-6 mm ; symptomatic : First line of treatment → ESWL (Extra corporeal
Shock Wave Lithotripsy).
• Medical management of stones : Tamsulosin used (causes smooth muscle
alpha blocker (FOR STONES LARGER THAN 5 MM)
relaxation of distal ureteric muscles).

Complications of ESWL :
• Pain.
• Hematuria.
• Stone street (Steinstrasse) : Stone fragments block the ureter.
• Urinary tract infection.

Contraindications of ESWL :
• Pregnancy.
• Uncontrolled bleeding disorder.
• Cardiac pace-maker.
• Stone > 1.5 cm size.
• Children.
• Obese.
• Very hard stones (cysteine > calcium oxalate monohydrate).
• Obstructed system.
• Lower calyx stone.

PCNL (percutaneous nephrolithotomy) : PCNL - Works better in

Indications : Stone >2cm, Lower pole stones with anatomy unfavourable for hydronephrotic and obstructed
calyces as they are dilated
ESWL, failed SWL or RIRS for renal calculi, staghorn calculi. Mini-PCNL - <22 F tracks useful in
children and those with smaller
disease burden

RIRS (retrograde intrarenal surgery) :

Indications : Stone < 2cm, lower pole, obesity, musculo skeletal deformity.

URS (Ureteroscopic removal of stones) :

• Dornia basket.
• HoYaAG laser.

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

Summary :
<5 mm : Observation.
>5 mm : Try medical MX Fails ESWL
If C/I or fails

PCNL RIRS/ URS

Prevention of recurrent stone disease :

• Fluid intake more than 2.5 L.
• Dietary calcium should not be restricted.
• Reduce intake of animal protein and salt.

Bladder stones : 00:26:30

• Most common : Mixed urate.
• First line of management : Per urethral
cystolithotomy.
• If contraindicated : Supra pubic cystolithotomy.
• Contraindications :
- Urethral stricture.
- Stone in diverticula.
Bladder stones
reflux
Vesicoureteral reflex : 00:27:44

• Grade 1 : Reflux into non dilated ureter.

C/F recurrent UTIs
recurrent infection • Grade 2 : Reflux into pelvis but no distension.
Rx Prophylactic Antibiotics
• Grade 3 : Reflux with mild distension.
Prophylactic Abs
If they don't respond
• Grade 4 : Blunting of calyces/ tortuous ureter.
then Interventions • Grade 5 : Severe distension of ureter along with
loss of papillary impressions.

IOC : MCU (Micturating cystourethrogram). VUR

Management :
• Grade 1-3 : Prophylactic antibiotics.
• Grade 4, 5 : Prophylactic antibiotics No response Surgery.
• STING Procedure (sub ureteric teflon injection) : Done in VUR.

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Renal trauma 00:30:33 ----- Active space -----

Renal injury grading :

Grade Description Of Injury

1 Contusion : Microscopic/gross hematuria, urological studies normal.
Sub-capsular hematoma, non-expanding without parenchyma laceration.
2 Hematoma : Non-expanding perirenal hematoma confined to renal retroperitoneum. no urine
extravasation
Laceration <1.0 cm parenchymal depth of renal cortex without urinary extravasation.
3 Laceration >1.0 cm parenchymal depth of renal cortex, without collecting system
rupture or urinary extravasation
4 Parenchymal laceration extending through the renal cortex, medulla & collecting
system (OR)
Main renal artery/vein injury with contained haemorrhage.
5 Completely shattered kidney (OR)
Vascular avulsion of renal hilum which devascularizes kidney.
*Advance one grade for multiple injuries to same organ

• No urine extravasation in grade 1 to 3 and is managed conservatively.

• IOC : CECT (stable patient), single shot IVU (unstable patient).
• Grade 4 :
If urinary leak +nt : Urinoma

Sterile Infected

DJ stent Pigtail catheter

• If vascular injury, try to repair it, but in grade 5 injuries a partial or

complete nephrectomy is often needed.

Complications :
• Hematuria.
• Urinoma.
• AV fistula.
• Renal artery thrombosis : Renal infarct.
• Meteorism : Colonic distension developing after retroperitoneal hematoma..
• Hypertension.

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Renal infections 00:34:18

Renal TB :
• Usually secondary infection. fibrosis, calcification -> pseudo
calculi
• First lesion : Papillary ulcer. destroy calyx -> ghost calyx
track out to form perinephric

• Putty kidney : Nephrectomy done.

abscess

• Opening of ureteric orifice remains dilated :

Golf hole orifice.
• C/f : Pain, hematuria.
• Urine examination : Sterile pyuria
(pus cells +, but -ve culture).
• IOC : CT urography.
• Boari flap repair : Mx of shortened /
strictured ureter.
NON FUNCTIONING KIDNEY

Ulcers → Necrosis → Pus filled (Putty) → Calcification (Cement kidney)

Perinephric
abscess

Ghost calyx Kerr's kink

Pseudo calculi

Papillary ulcer
(Earliest)

Putty kidney.
Mx : Nephrectomy + ATT.
Stricture
Remain open Shortening of ureter
(Golf hole
ureteric orifice

Heal with fibrosis

(Thimble Bladder)

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Emphysematous cholecystitis caused by Clostridium

Emphysematous pyelonephritis : ----- Active space -----

• Caused by E. coli.
• Seen in immunocompromised, diabetic
patients.
• Clinical features : Fever, pain.
• IOC : CECT (gas in and around kidney).
• Management :
Antibiotics, Drainage.
If it fails : Nephrectomy.
Note : Emphysematous cholecystitis is caused by Clostridium.

Xanthogranulomatous pyelonephritis :
• Causative organism : Proteus.
• Seen more commonly in Middle aged
perimenopausal females.
• Common in diabetic patients.
• Clinical features : Flank pain, pyrexia & abdominal
mass.
• IOC : CECT Scan : Non functioning kidney, low
density mass, staghorn calculi.
• Management : Subcapsular nephrectomy.

Renal tumours 00:40:32

Angiomyolipoma :
• Benign.
• Arises from perivascular epitheloid cells (PEC).
• 5-6th decade of life.
• Clinical features : Usually asymptomatic.
a. Massive retroperitoneal hemorrhage MX:
(Wunderlich syndrome). <4 cm and asymp OBSERVE
>4 cm and symp PARTIAL
b. Lenk triad : Mass (no hematuria), NEPHRECTOMY OR
NEPHRON SPARING SX
hypotension, flank pain. If it is Bleeding then first
ANGIOEMBOLIZATION and
• IOC : CECT Scan. then PARTIAL
NEPHRECTOMY
• Multiple angiomyolipoma : Seen in tuberous
sclerosis.

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

Bosniak classification of renal cysts :
Class Description Features Workup Risk of
malignancy

1 Simple cyst Anechoic, imperceptible wall, round Nil 0%

2 Minimally complex Single thin septation, thin calcification Nil 0%
2F Minimally complex Thin septation, thick calcification, USG or CT 5%
(need follow up) hyperdense on CT follow-up
3 Indeterminate Thick or multiple septation, mural Partial 50 %
nodule nephrectomy
4 Clearly malignant Solid mass with cystic spaces Partial/Total 100 %
nephrectomy

Oncocytoma :
• M/c benign tumor.
• Histopathology :
a. Tan/Mahogany cut surface.
b. Cytokeratin absent (Helps in differentiating between chromophobe
RCC).
• Types : Sporadic > familial. Familial seen in Birt Hogg Dube syndrome
(Oncocytomas, Chromophobe RCC, Fibrofolliculomas, Trichodiscomas).
• Clinical features : Usually asymptomatic.
• IOC : CECT Scan : Central stellate scar.
• Partial Nephrectomy done if Oncocytoma > 4cm. BOSNIAK 3 because can be confused
with chromophobe RCC

Cells rich in mitochondria

00:44:05
Renal cell carcinoma :
Risk factors :
• Diabetes mellitus.
• Hypertension.
• Tobacco intake.
• Thorotrast exposure. Also in HCC
• Increased protein intake.
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Types of RCC : ----- Active space -----

Renal cancer Clear cell (M/c) Papillary Chromophobe Collecting duct

Prognosis Best Worst
Proximal PCT > DCT
convoluted (Distal
Arises from
tubule (PCT) convoluted
tubule)
Clear cells (Rich Psammoma Plant like cells/ Bellini cancer
in glycogen) bodies. Resin like nucleus
Key feature
Seen in long
term dialysis.
as well

1. Clear cell carcinoma :

• Genetics : Deletion of 3p & 6p.
• Associated with Von Hippel Lindau syndrome.
2. Papillary RCC :
• Hereditary papillary RCC syndrome.
• CMET mutation.
3. Chromophobe RCC :
• Loss of multiple chromosomes (1, 2, 6, 10, 13). Papillary RCC
• Seen in Birt Hogg Dube syndrome.
• Cytokeratin positive (differentiates b/w
oncocytoma).
RCC a/w sickle cell anemia : Medullary type.

Clinical features :
• Haematuria : Most common.
• Pain.
Chromophobe RCC
• Mass.
• Paraneoplastic syndromes : Raised ESR (M/C).
• Can spread along renal vein (not considered mets) & can be surgically removed.
Paraneoplastic Syndromes in Renal Cell Carcinoma :
Endocrine Nonendocrine
• Hypercalcemia. • Amyloidosis.
• Hypertension. • Anemia.
• Polycythemia. Mediated by IL-6 and causes deranged LFTs • Vasculopathy.
• Nonmetastatic hepatic dysfunction : Stauffer syndrome. • Coagulopathy.
• Galactorrhea.
• Cushing's syndrome.

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

Seen at poles

RCC
Staging of RCC :
Stage Definition Subdivision
Tumor stage
TO No evidence of primary tumor
T1 < 7 cm in greatest dimension, 1a: <4 cm.
confined to the kidney 1b: > 4 cm and < 7 cm
T2 > 7 cm in greatest dimension, 2a : ≥ 7 cm and < 10 cm
confined to the kidney 2b : > 10 cm
T3 Extends into major veins or perinephric 3a : Tumor extends into renal vein
tissues but not into the ipsilateral branches, or invades perirenal and/or
adrenal gland or beyond Gerota fascia. renal sinus fat.
3b : Tumor extends into the
subdiaphragmatic inferior vena cava.
3c : Tumor extends into the
supradiaphragmatic inferior vena cava.
T4 Tumor invades beyond the Gerota
fascia and/or contiguous extension into
the ipsilateral adrenal gland.
Regional lymph nodes
N0 No regional lymph node metastasis
N1 Metastasis to regional lymph nodes paraaortic LNs
Distant metastasis
M0 No distant metastasis M/C Lungs
• RCC is both chemo and radio resistant. Surgery is treatment of choice.
Indications for partial nephrectomy :
• T1 tumors (<7 cm).
• Restricted to poles.
• Bilateral RCC.
• RCC in a solitary functioning kidney.
Relative indications for partial nephrectomy :
• RCC in a kidney where other kidney is affected by hydronephrosis/stones.
If partial nephrectomy is not feasible then radical nephrectomy is done.

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Cryoablation for renal tumors : Rapid freezing to -20 degrees Celsius and gradual thawing ----- Active space -----
• Indications :
a. T1a RCC in patients where surgery cannot be performed (elderly patients).
b. Advanced/ metastatic tumors, where cryoablation of the renal tumor
can be done as a palliative measure.
• Immunotherapy used in RCC : Sunitinib/Sorafenib.

Pathological staging : Best prognostic factor (Robson staging is another tool used).
Fuhrmann grading is used in RCC.

Wilms tumor :
• M/C paediatric renal malignancy.
• 2nd most common abdominal malignancy in children. M/C NEUROBLASTOMA
• C/f : Mass (rarely cross midline), hematuria.
shows CHROMOGRANIN
helps in differentiating the 2 conditions
• IOC : CECT.
• A/w Beckwith weidman syndrome, Denys drash syndrome & WAGR syndrome
(Wilms tumor, aniridia, genitourinary malformations, mental retardation) and
is usually bilateral (stage 5 tumor).
• Wilms tumor is chemo & radio sensitive and principles of surgery is similar to RCC.
• Most important prognostic factor : Histology of tumor.

Prostate 00:55:41

Zones of prostate :
• Transitional zone : M/c zone involved in BPH.
• Peripheral zone : M/c zone involved in cancer.

Corpora Amylacea :
• Lamellated bodies.
• Precursor for prostatic stones.
• Calcium phosphate stones formed.
C/F : Lower urinary tract symptoms (LUTS) (voiding & storage symptoms) :

Voiding Storage
• Hesitancy. • Frequency. Earliest and M/C
• Poor flow. • Nocturia.
• Intermittent stream. • Urgency.
• Dribbling : Including, after micturition. • Urge incontinence.
• Sensation of poor bladder emptying. • Nocturnal incontinence (enuresis).
• Episodes of near retention.

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

Work-up :
• DRE (rubbery feel in BPH & hard feel in cancer).
• USG KUB : Prostatic volume, upper urinary changes, residual urine.
• Prostate specific antigen (PSA).
• Uroflowmetry. Helps in differentiating BPH and
Bladder Outlet Obstruction with
neurogenic bladder
PSA values (50-69 years) :
• 0-3 ng/ml : normal, BPH.
• > 3-4 ng/ml : BPH, cancer, prostatitis.
• >20ng/ml : metastatic cancer.
Corpora amylacea
Do TRUS (Trans rectal USG) Guided tru cut Biopsy : Minimum 12 cores are taken.
Trans perineal biopsy (done under GA) useful for taking anterior lobe biopsy.

Benign prostatic hypertrophy (BPH) : 01:01:18

↑ size of prostate compresses on urethra giving rise to LUTS.

Medical Mx :
• Alpha blockers : Faster acting(reduce smooth muscle tone eg: Tamsulosin.)
• 5 alpha reductase inhibitors : Slow acting, more sustained effect
(eg: Finasteride), reduces size of gland by acting on the stroma.
Surgical management :
• TURP : Transurethral resection of prostate.
• TULIP : Transurethral laser incision of prostate.
• ND YAG laser : Most commonly used.
• KTPA laser : Best laser.

Indications for surgery : Failed medical Mx, Hydronephrosis, recurrent UTI,

Hematuria, Decreased flow and increased residual urine, retention +.
• TURP distal limit : Veru montanum. If we go distal → Incontinence.

Irrigation fluids :
• 5 % dextrose. Hypotonic
• Distilled water.
• Isotonic glycine. ISOTONIC PREFERED
• Normal saline (only with bipolar TURP). to prevent water intoxication

Complications of TURP :
• M/C complication : Retrograde ejaculation.
• Hemorrhage : Badenoch arteries (M/c).
• Clot retention (irrigate with three way Foley’s).
• Incontinence.

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Water intoxication/Dilutional hyponatremia/TURP syndrome : ----- Active space -----

• More with distilled water/ 5 % dextrose.
• Incidence has reduced with Isotonic glycine. and lasers as they reduce the duration of surgery
• Symptoms : Altered sensorium few hours after Sx, nausea, vomiting.
• Management :
a. Mild (Na+ >120meq/L) : Water restriction.
b. Severe (Na+ <120meq/L): 3 % hypertonic saline (not more than 8-10
meq/L correction each day : Central pontine demyelinosis).

Prostate cancer : 01:08:38

Risk factors :
• Increasing age.
• Increased testosterone.
• African American.
• BRCA 2 > BRCA 1.
• Obesity.
IOC : Trus guided biopsy.
Spread :
• Local.
• Lymphatic (obturator nodes).
• Distant mets : Bones (Vetebrae) → Osteoblastic > osteolytic (Batson’s plexus
responsible for spread).
Bone scan done if : WORKUP : PSMA PET / MRI of the vertebral column

• PSA > 10 ng/ml.

• Gleason > 7.
• Symptomatic. Score from 1 to 5 (1 being well differentiated and 5 being poorly differentiated)

Gleasons score : Score of M/c gland type + 2nd M/c gland type.
Risk Group ISUP Grade Group Gleason Score
Low 1 ≤6
Intermediate (Favourable) 2 7 (3+4) Better Prognosis
Intermediate (Unfavourable) 3 7 (4+3)
High 4 8
High 5 9-10

Management :
• <70 years Radical prostatectomy :
• > 10 years expected life span • Prostate
• G3, G4 tumours • Iliac + Obturator LN
T1, T2A • Seminal vesicles
• >70 years
• < 10 years expected life span Observation/surveillance
• G1, G2 tumours
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----- Active space ----- Locally advanced prostatic cancer

T2B, T3, T4 Tumor

<70 years >70 years

> 10 years expected life span < 10 years expected life span
G3, G4 tumours G1, G2 tumours

Androgen
Brachytherapy Brachytherapy ± ADT Deprivation
Therapy
I 125 or Palladium103

No residual disease & Residual disease +

↓ PSA & ↑ PSA
↓ ↓
Surveillance Radical prostatectomy

Brachytherapy
Metastatic

First line : ADT

Surgical : Medical :
B/L orchidectomy LHRH agonists (Goserelin, Buserelin)
+
Anti-androgens (Flutamide, Abiretarone)

Hormone resistant disease :

1. Chemotherapy : Cabazitaxel, Paclitaxel.
2. Sipleucel T : T cell vaccine (Provenge).
3. Hormone resistant bony metastasis : Radium223 → Acts via a rays.
4. Radiotherapy.

Most important prognostic factor : Stage of disease.

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UROLOGY 2 ----- Active space -----

Urinary bladder 00:00:50

Foleys Catheter :
Size : Measured in French (Fr) - 2πr (Outer Circumference).
Color coding :
GFour • Green : 14 Fr

O6 • Orange : 16 Fr
R8 • Red : 18 Fr
3 Way Foleys
3 Way Foleys : Used in clot retention (1 channel is used for irrigation).
Stuck Foleys : USG Guided suprapubic puncture of balloon to be done.
Types of foleys :
• Rubber foleys : Used for 28 days.
• Silicone foleys : Used for 90 days.

Bladder trauma :
Extraperitoneal rupture M/C Intraperotoneal rupture
2 to blunt/ penetrating trauma in a
o
2o to pelvic fracture
patient with full bladder.
• A/w proximal urethral injury &
deep perineal hematoma A/w peritonitis
• Inability to pass urine
IOC

Unstable : MCU (Micturating Stable : CT Urography

Cystourethrogram)
Mx : Laparotomy + Bladder repair in 2
Mx : Foleys/ SPC x 7 days
layers + SPC/ Foleys

Intraperitoneal
leak of contrast

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----- Active space ----- Bladder carcinoma : TSA 00:04:09

Types of Carcinoma :
1. Transitional cell 2. Squamous cell 3. Adenocarcinoma
carcinoma : TCC carcinoma : SCC

M/c worldwide M/c in Africa Develops near

Etiology : Etiology Trigone /persistent
• chemicals • Smoking urachus
• cigarette • Schistosomiasis
• cyclophosphamide

C/f : Gross painless hematuria

Investigations :
Carcinoma bladder
1. USG KUB : 2. Urine Cytology : look for 3. Cystoscopic Biopsy : IOC
clots/ growth malignant cells
inside bladder (Low sensitivity)

Bladder tumor confirmed MRI : Staging

Note : 1 Lymph node to drain from bladder cancer : Obturator Lymph nodes.
st

Ta: Non invasive papillary carcinoma

TNM staging Tis: Carcinoma in situ
T1: Invades subepithelial tissue (Above muscle layer)
Management :
TURBT (Trans Urethral Resection of Bladder Tumor)

Muscle invasive Non muscle invasive

T2: Surgery T3,T4 : Chemo →Surgery

pTa pT1s pT1

Observation/single dose of Intravesical BCG Intravesical
intravesical chemotherapy (Immunotherapy) chemotherapy/BCG
• Mitomycin
• Adriamycin
Check cystoscopy every 3 months : to look for recurrence
NMP URINARY MARKER
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Surgery ----- Active space -----

Radical Cystectomy Partial cystectomy

Bladder + Iliac + Obturator Small tumor at the dome of
Lymph nodes + bladder and not involving
(In females : urethra + TAH) the ureteric orifice
+
Urinary Diversion

Continent Non continent

Neobladder (Ileum) 1. Ureterosigmoid • Risk of cancer by 100 times.
anastomosis • Recurrent UTI
2. Ileal conduit • Hyperchloremic Hypokalemic
(M/c used) metabolic acidosis
Urethra & Penis 00:09:43

Urethra :
• Anatomy
Female : 3-4 cm • Longest portion : Penile
• Shortest portion : Membranous
• Narrowest : External urethral
Male : 18-21 cm
meatus
• Most distensible : Prostatic
Prostatic Membranous Bulbar Penile • Least distensible : Membranous

Prostatic urethra
Membranous urethra
Bulbar urethra
Penile urethra

Phimosis : Parts of urethra

Inability to retract the foreskin.
Symptomatic phimosis :
• Balooning of for foreskin.
• Balanoposthitis.
• Recurrent UTI. Phimosis
Mx : Circumcision (In Symptomatic phimosis/Religious reasons).
Plastibel (latest technique). Stapler device
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----- Active space -----

Paraphimosis :
Foreskin forms constriction ring around the penis.
Mx : Conservative reduction
If fails : Dorsal slit is performed.
Paraphimosis
Hypospadias : 00:12:29
ventrally placed urethral opening.
M/c congenital urogenital anomaly (1 : 450 live births).
A/w micropenis & undescended testis.
C/f :
Downward directed stream of urine. Note : More proximal the
Chordee : Downward bending of penis. hypospadias more
Infertility. severe is chordee
Types of Hypospadias :

M/C

Most Severe Hypospadias : opening

M/c type : Glanular ventrally placed
Most severe type : Perineal

Mx : Sx usually done at 6-12 months (Best time).

Principles of correction :
Orthoplasty Urethroplasty Glanuloplasty Skin cover

Chordee correction Placement of

urethral opening
at normal
position
Note : Circumcision should be avoided : Skin needed for reconstruction.

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Distal Hypospadias Mustardee, Mahiteu ----- Active space -----

Surgeries Mid Hypospadias Snodgrass, TIP

Proximal Hypospadias Theirsch duplay, Dennis brown

( 2 Staged procedure)
Ectopia vesicae :
Anterior abdominal wall & anterior wall of bladder deficient below umbilicus.
C/f :
• Urine dribbling from bladder.
• Pubic diastasis.
• Undescended testis in males.
• Bifid clitoris in females.
• Ingunial hernia. Ectopia vesicae

Urethral trauma : BLOOD AT THE TIP OF MEATUS 00:16:29

Anterior Urethral injury Posterior urethral injury

Injury to penile/bulbar urethra Injury to membranous/prostatic urethra
Direct trauma/straddle injury Secondary to pelvis fracture
Superficial perineal hematoma Deep perineal hematoma
around penis/scrotum Vermooten sign → Floating prostate
sign on digital rectal examination.
C/f :
• Blood at tip of meatus.
• Inability to pass urine.
IOC : RCU (Retrograde cystourethrogram)
Mx :
Suspected urethral trauma

Bladder full Bladder not full

Suprapubic catheterization Wait for bladder to
MCU
fill give one trial of
Fails micturition
Note : Do not try passing Foley’s.
Complications :

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

Urethral stricture : Management

Short incomplete Short complete Long complete

stricture stricture stricture
Urethral stricture
Excision + End to Resection + Urethroplasty
end anastomosis with graft
(Spatulate ends) (Buccal mucosal graft)
VIV : Visual OIV : Optical
internal internal
urethrotomy urethrotomy
Fracture shaft of penis :
Tear in the corpora cavernosa usually of an erect penis.
C/f :
• Popping sound f/b pain.
• Egg plant deformity of the penis.
• usually occurs during sexual activity.
Rx : Clot removal and repair. Egg plant of penis
Posterior urethral valve : 00:21:13
Young’s classification

Type 1 MALES Type 2 Type 3

2 mucosal fold extend mucosal fold extend along Cobbs collar :
anteroinferiorly from bottom the posterior urethral wall circular diaphragm with
of verumontanum & fuse from ureteric orifice to central opening in mem-
anteriorly at lower level verumontanum branous urethra

C/f : Male child with recurrent UTI.

Investigation

USG : Key hole defect MCU : Micturating cystourethrogram

KEYHOLE
DEFECT

Mx of Posterior Urethral valve : Fulguration of the valve

BURN

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Peyronie’s disease : ----- Active space -----

Etiology : Calcific deposition in corpora cavernosa.
C/f :
• Penis bend towards side of plaque.
• Prominent in erect state.
Dx : Clinical examination + MRI Peyronie’s Disease
Mx : Intra lesional collagenase clostridium
histolyticum ( Xiaflex)
Fails
Nesbits technique or 16 dot technique
or
Incision of plaque and bovine pericardial patch
Priapism :
Prolonged erection : > 4 hours.
Erection last > 6 hours : Ischaemia/necrosis of the penis.
Types :
High flow priapism Low flow priapism
Etiology blood flow into penis venous obstruction : M/c cause
Secondary to Hypercoagulable states :
• Trauma. • Children
Causes
• Spinal injury. • Leukemia.
• Papaverine injection. • Sickle cell anemia.
Pain Painless Painful
Penile ABG oxygenated blood Deoxygenated blood
Angio - Angiogram : Block in veins
Mx : Sedation followed by Adrenaline injection
If priapism persist
Shunt surgery: Grey Hack shunt (Corporo saphenous shunt)
Penile cancer : 00:25:42
Squamous cell carcinoma.
Premalignant conditions :
• Bowens disease of the shaft.
• Erythroplasia of Queyart (Glans).
• Balanitis xerotica obliterans.
• Genital warts : HPV.
• Leukoplakia. Squamous cell carcinoma

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----- Active space ----- C/f :

• Growth over penis.
• Inguinal lymph nodes enlarged : 50 % cases may be due to infection.
Note : M/c cause of death : Erosion of femoral/iliac vessel due to involved
lymph nodes.
Dx : Bx of the lesion.

Staging : T1: Skin involved

T2: Corpora Involved

Jacksons Staging
T3 :Urethra involved

T4: Adjacent structures involved

Management :

In situ carcinoma Distally placed Proximally placed

Topical 5 - Fluorouracil Distal/ Partial Total amputation of

Penectomy : the penis & Urethral
Margin- 0.5cm opening in perineum

Positive Clearance/Radiotherapy
Sentinel Lymph node biopsy
Negative
Note : 5 FU is also used in Bowens disease & Erythroplasia of Queyart.

Testicular disorders 00:28:23

Undescended testis :
• Normal descent fails
• Inguinal canal : M/c site.
• Right > left.
• If Bilateral : Cryptorchidism.
• Normal Descend of testis :
Genital Ridge Iliac fossa Inguinal canal Superficial ring Scrotum
(3 months) (6 months) ( 7 month) ( 8 month) (9 months)

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Differential growth of the abdominal wall ----- Active space -----

Trigger factors for

Pull of Gubernaculum (Least)
descend of testis
Hormonal
Changes & Complications :
Changes Complications
• Decreased volume • T : Trauma
• Increased risk of intra tubular germ cell • E : Epididymoorchitis
neoplasm. • S : Sterility
• Sertoli cells : More affected • T : Torsion
(Spermatogenesis affected). • I : Indirect inguinal hernia
• Leydig cells : Less affected (Normal Sec-
(M/c)
ondary sexual character)
• S : Seminoma
• Higher the testis : More histological changes.
Men with undescended testis : Reduced fertility even after orchidopexy. Almost always infertile and
azoospermic
Note : Risk of malignancy → does not seem different when surgery done early
in infancy as compared to childhood.
• M/c carcinoma : Seminoma
Mx : Unilateral non palpable testis

Inguinal region Intra abdominal testis

Orchidopexy IOC : Laparoscopy

Blind ending vessels Vessels exiting Degenerative

intrauterine the internal ring
torsion

Monorchia Inguinal exploration Orchidectomy

Rx : Excision of remnant Rx : Orchidopexy
• Bilateral non palpable : Cryptorchidism

Give inj. hCG

Spontaneous descent occurs only till 5-6 months
of age after which surgery is essential

No response Testosterone
FSH Laparoscopy +/- Exploration
Anorchia
LH
• Surgery : Orchidopexy (Stephen Fowler technique) 2 staged technique
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----- Active space ----- Ectopic testis :

Testis deviated from normal path of descent.
M/c site : Superficial inguinal pouch.
Mx : Orchidopexy.
Retractile testis :
Normal variant.
Testis in scrotum but occasionally jump into inguinal canal.
Mx : Reassurance
Testicular torsion : 00:35:04

Risk factors :
• Testicular inversion.
• Torsion of cyst of Morgagni.
• Undescended testis.
• Bell Clapper testis (High attachment of tunica vaginalis).
C/f : Acute scrotal pain & swelling (Usually young male).
Differential Dx : Clinical signs & USG doppler are used to differentiate between
torsion & epididymo orchitis.
Tests/Signs Torsion testis Epididymo orchitis
Prehn sign : Lift the testis Pain Pain
Deming sign Testis at higher level -
Angel sign Testis is transversely placed -
• 720˚ twist : More rapid ischaemia compared to 360˚ twist.
Surgery done within <6 hrs : 100 %
• salvagability of testis
Surgery done after 24 hrs : 20 %
Mx :
• Surgery : 3 point fixation with non absorbable sutures.
• If orchidectomy/orchidopexy is done on one side : Prophylactic orchidopexy
done on the opposite side.

Hydrocele : 00:37:57

Accumulation of fluid in tunica vaginalis.

Types of Hydrocele :
1. Vaginal : M/c.
2. Infantile : Upto superficial ring.
3. Congenital : Communicate with peritoneal cavity.
4. Hydrocele of cord.

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Types of vaginal hydrocele : ----- Active space -----

Primary Secondary
Decreased Increased secretion d/t :
absorption • Epididymo orchitis
• Trauma
• Tumor Vaginal Hydrocele Infantile Hydrocele
M/c Less common
Tense swelling Lax swelling
Testis not palpable Testis palpable
separately separately
Transillumination + - Congenital Hydrocele Hydrocele of cord
Mx : Lords plication : Small sac
Surgery Eversion of sac : Large sac
Herniotomy : Congenital hydrocele

Note : Congenital hydrocele can be a/w hernia.

Spermatocele vs Epididymal cyst :

Spermatocele Epididymal cyst

Unilocular : Sperms present Multi-loculated : Bunch of grapes
appearance
Involves epididymal head Cystic degeneration of epididymis
Barley coloured fluid Crystal clear fluid
Transillumination - Transillumination +
Mx : Symptomatic- excision Mx : Symptomatic- Excision

Varicocele : 00:40:55

Dilated tortuous pampiniform plexus of veins.

Left testicular vein (LTV) longer.
• Left side > Right side LTV drains at right angle into left renal vein.
Sigmoid colon pressing on LTV.
C/f :
• majority : Asymptomatic.
• Common cause of infertility.
• Dull dragging pain : M/c symptom.
• O/e : Bag of worms consistency.
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----- Active space -----

IOC : Duplex scan
Mx : 1 st line : Percutaneous embolization of gonadal veins
Percutaneous intervention
not possible/recurrence
Surgical Ligation
• Microsurgical Varicocelectomy (Most effective method).
Fourniers gangrene : 00:42:30

Necrotizing fascitis of perineal region.

Mixed microbial infection : Aerobic + Anaerobic bacteria.
Diabetic
Common in immunocompromised patients. Alcoholic
Following trivial trauma

Meleneys gangrene : Founiers gangrene

extending into the abdominal wall.

• Testis usually spared : Dual blood supply of the testis.

Mx : Iv Fluid + IV Antibiotics (Aerobic + anerobic) + Aggressive debridement.
Testicular tumors :

Most commons
• Most common in children : Yolk sac
tumor
• most common overall : Seminoma
• Most common in elderly : Lymphoma
Cannon ball mets
Clinical features of Testicular tumours

Lung Mets : Abdominal lump Testicular Precocious Feminization &

Cannon ball Para aortic LN mass puberty : Leydig Gynaecomastia :
mets 1 draining LN
st
cell tumor Sertoli cell tumor

Left Right
Paraaortic/preaortic 1st Inter aortocaval

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Dx : Imaging USG/CT ----- Active space -----

Suspected case • Alpha fetoprotein

Tumor markers • beta hCG
• LDH
If high suspicion with negative imaging & tumor markers : Chivasu maneuver
(High inguinal orchidectomy + Frozen section)

• TNMS : Staging of testicular tumors where S is Value of tumor markers.

• Note : Never do a trans scrotal FNAC/Biopsy (Upstaging of the disease).
Mx : If scrotum becomes involved because of our mistake it becomes a T4 disease

Stage Seminoma Non seminomatous Non metastatic disease stage 1

(TESTIS)
Good prognosis Bad prognosis About 15% with stage 1
SEMINOMA will have
Retroperitoneal LND
I Adj chemo / Cycle of Chemo BEP ± RPLND subclinical metastatic disease

Observation
usually in the retroperitoneum
Carboplatin + RT Bleomycin Cisplatin and Etoposide ADJ RT reduces relapse to
1-3%

Previously : RT
II
Now : Chemo BEP
Chemo BEP
III & IV Chemo BEP + RT
Mets Chemo BEP
Good prognosis : Well differentiated & tumor markers not highly raised.
Bad prognosis : poorly differentiated & highly elevated tumor markers.
BEP : Bleomycin Etopaside Cisplatin
RT : Radiotherapy.
RPLND : Retroperitoneal LN dissection.

Lymphocytic
infiltration

Seminoma - gross Histopathology

Scrotal sebaceous cyst :

Multiple sebaceous
cyst : need excision

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----- Active space ----- TRANSPLANT, PLASTIC SURGERY AND ADRENAL

Transplant surgery Questions mainly asked from KIDNEY and LIVER 00:00:47

Types of grafts :
• Autograft : Graft from the same person (Eg : Skin graft).
• Isograft : Graft from identical twin (Eg : Kidney transplant).
• Allograft : Graft from same species.
• Xenograft : Graft from different species.

Masstricht classification :
Masstricht Presentation of DCD situation Organs procurable
Donation after
classification death circulatory death

I Dead on arrival Uncontrolled Tissue (Heart valves,

cornea
II Unsuccessful Uncontrolled Kidney, heart valves,
resuscitation cornea
III Anticipated cardi- Controlled All organs except heart
ac arrest
IV Cardiac arrest in Controlled All organs except heart
brain dead donor
V Unexpected Uncontrolled All organs except heart
cardiac arrest in a
hospital patient
DCD : Donation after Circulatory Death.
Organ to be transplanted is stored in University of Wisconsin (UW) solution stored
at 4°C (static cold storage) :
• Hydroxyethyl Starch (HES)
• Lactobionic Acid (as Lactone)
• Potassium Phosphate monobasic
• Magnesium Sulfate heptahydrate
• Raffinose Pentahydrate
• Adenosine
• Allopurinol
• Glutathione (reduced form)
Cold ischemia time :
Kidney can be stored for the longest time , for up to 36 hours.
Heart and lung have the least cold ischemia time of <3 hours.
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Flushing of UW solution : ----- Active space -----

UW solution flushed through aorta and portal vein of donor.
Effects :
• It flushes out blood to prevent thrombosis.
• Cools organs so reduces oxygen requirements.
• Replaces normal extra cellular fluid with preservation fluid.

Normothermic machine perfusion :

• Heart, lung, liver and kidney preservation.
• Provides more physiological environment.
• Restores function ex vivo and replenishes depleted ATP’s.
• Leads to increased utility of marginal organs.
• Leads to early allograft function.
Hypothermic organ may show delayed graft function.

Renal transplant :
Most common indication in adults : Diabetic nephropathy.
Most common indication in children : Glomerulonephritis.
Dual kidney transplant :
• Involves transplantation of a pair of marginal quality kidneys from the same
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.

Extended donor criteria for renal transplant : 00:05:34

• Fit patient more than 60 years (OR)
• More than 50 with two or more of the following :
a. Death due to stroke.
b. History of HTN.
c. Serum creatinine > 1.5 mg/dl.
Deceased and live donor transplant :
Deceased donor Live donor
Patch of aorta taken along with renal artery Patch of aorta not taken
End to side anastomosis with external iliac End to end anastomosis with internal iliac artery
artery and Ext. iliac vein and end to side anastamosis with Ext. iliac vein

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

Causes of early graft dysfunction :
Any rise in serum creatinine >10% of baseline or ≥20μmol/L should be considered
as acute allograft dysfunction that requires investigation. Possible causes are :
• Acute rejection (Antibody mediated or cell mediated).
• Calcineurin inhibitor toxicity.
• Dehydration.
• Urinary tract infection or pyelonephritis.
• Any other source of sepsis.
• Renal vein or renal artery thrombosis.
• Ureteric obstruction or urine leak.

Complications of renal transplant : 00:08:56

Rejection

Hyperacute Acute Chronic

rejection rejection rejection
Occurs on table Due to immunological m/c type of rejection
Due to preformed antibodies causes > 6 months after transplant
Anti-HLA antibodies Reduced due to effec- Type 1V (Delayed) hypersensitivity
Type II Hypersensitivity tive immunosuppression On HPE : glomerular sclerosis
On HPE : Intravascular throm- >90% 1 year graft surviv-
bosis al rate

Intravascular thrombosis Glomerular sclerosis

Other complications of renal transplant :
• Infection : Maximum incidence in first 6 months.
a. First month : Bacterial infections.
b. Overall : Viral infections.
c. M/c virus : CMV.
5 yr graft survival in a live donor is 90% and deceased
• Malignancy : M/C : Skin cancers ( SCC). donor is 85%

• PTLD : Post Transplant Lymphoproliferative Disorder :

a. EBV ( B cell mediated).
• M/c vascular complication : Renal vein thrombosis.

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Liver transplant : 00:11:26

----- Active space -----
• m/c indication in adults : Cirrhosis.
• M/c common in children : Extrahepatic biliary atresia .
• HLA matching not important as hyperacute rejection does not occur in liver
transplants.
Types of liver transplant :
Based on type of allograft.
• DDLT (Deceased donor Liver Transplant).
• LDLT (Live Donor Liver Transplant).
• Split and reduced-size Liver Transplant :
a. Segment 2,3 donated to child.
b. Segment 4,5,6,7,8 donated to adult. Split liver transplant
• Auxiliary LT : Donor liver is transplanted and deceased liver is not removed.
The donor liver piggybacks the existing liver (done in metabolic diseases).
• Domino LT : Liver is taken from a patient who is suffering from a systemic disease.
• Paired-exchange programme.

Sequence of anastomosis in liver transplantation :

1. Suprahepatic IVC.
2. Infra hepatic IVC.
3. Portal vein.
4. Hepatic artery.
5. Bile duct.

Extended donor criteria for liver :

• Advanced donor age.
• Macrovesicular steatosis.
Liver transplant after
• Donation after circulatory death organs. completed anastomosis
• Mild organ dysfunction at procurement.
• Cause of death : Anoxia, cerebrovascular accident.
• Patients with systemic diseases for domino transplant.
• Cold ischemia time >12 hours .
Strategies to overcome shortages of livers for liver transplantation :
• Increase donor pool by using marginal livers.
• Increase split liver transplants.
• Increase HCV positive donor grafts.
• Improve preservation of grafts.

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

Complications of liver transplant
Rejection : No hyperacute rejection.
Chronic rejection : Vanishing duct syndrome (Type IV
hypersensitivity).
Vascular complications : Hepatic artery thrombosis.
Infections ,PTLD & cancers following liver transplant
is same as in renal transplant.

Diseases that recur after liver transplant :

• Chronic hepatitis B and C.
• Primary Biliary Sclerosis.
• Primary Sclerosing Cholangitis.
• Autoimmune hepatitis.
• Alcoholic liver disease.
• Non Alcoholic Fatty Liver Disease (NAFLD).
• Budd-Chiari syndrome. Standard donor liver transplant
• Malignant tumors (HCC, hepatoblastoma). with a classical caval replace-
Liver transplant in acute liver failure is done based ment technique
on King’s College criteria which is different for acetaminophen induced and non
acetaminophen induced acute liver failure.

Liver transplant for hepatic malignancy :

• LT for hepatocellular carcinoma simultaneously treats the tumor and the
underlying disease.
• Milan criteria (allow selection of HCC patients for LT, with improved overall
and disease free survival) :
a. One lesion ≤ 5 cm.
b. less than three lesions ≤ 3cm.
c. No imaging evidence of vascular invasion.
d. No imaging evidence of extrahepatic metastatic disease .
• Other criteria: UCSF criteria, UKHCC criteria.

00:18:17
Heart and lung transplant :
Sequence of heart transplant :
1. Left Atrium. 3. Pulmonary Artery.
2. Right Atrium. 4. Aorta.

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Criteria for HT
Subendocardial biopsy is done to see rejection. Impaired LV systolic function ----- Active space -----
NYHA 3
Standard criteria for lung donors : Receiving Optimal Medical Therapy
Resynchronization
Investigations : Evidence of poor prognosis

• Clear chest radiograph.

• Negative gram stain of bronchial secretions or purulent secretions.
• Arterial oxygen tension >300 mmHg (inspires oxygen fraction of 100% and
PEEP 5cm H2O).
Pulmonary diseases requiring transplant :
• Cystic fibrosis.
• Interstitial lung disease.
• Emphysema/COPD.
• Pulmonary hypertension.
Intestinal transplant :
Done in short bowel syndrome <200cm.
Intestinal transplant can be only of bowel or can also be multivisceral transplant.

Plastic surgery 00:20:26

Skin grafts:
Split thickness skin graft (STSG) Full thickness skin graft (FTSG)
Donor site
a.k.a Thiersch graft THin a.k.a Wolfe graft thick
Epidermis & part of dermis taken. Epidermis & whole dermis taken .
m/c site : Post auricular skin.
m/c donor site : Anterolateral thigh, but-
Supra/infraclavicular fossa (never har-
tocks.
vested from axilla).
Only dressing done for donor site after Donor site sutured after harvesting
harvesting graft . graft.
Donor site can be reused. Donor site cannot be reused.
Recipient site
Secondary contracture : (More common Primary contracture : (More common
than primary in STSG) Occurs when graft than secondary in FTSG) Occurs imme-
has been placed on the recipient bed. diately after harvesting graft.
Secondary contracture is inversely pro-
portional to thickness.
Cosmetically better, more resistant to
Better take up/survival of graft.
trauma .

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

STSG FTSG

Punctate bleeding points in donor area

denote that graft of right thickness Humby’s knife STSG
has been harvested.

Meshing in STSG
• Increases surface area of graft.
• Prevents contracture.
• Prevents seroma formation.
Graft survival :
• Imbibition : 24 to 48 hours.
• Inosculation: 2-4 days (Graft draws out nu-
trients by giving out buds).
• Neovascularisation : >4days (Anastomosis of graft and recipient vessels).
Causes of graft failure :
• M/c cause : Seroma or hematoma formation beneath
graft.
• Infection.
• Movement/shearing force.
• Poor recipient bed :
a. Lacks periosteum.
b. Has excessive granulation tissue. Graft failure

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Flaps: 00:26:00 ----- Active space -----

A flap has its own blood supply

Random flaps : VY plasty and Z plasty
• Based on un named/ random blood vessels.
• Used for elongation.
• Used in post burn contractures.
• Flap angle of 60° confers an increase 1.75 times in length of flap.
Eg :
1. Rhomboid flap : Z plasty
used in pilonidal sinus excision and basal cell carcinoma (BCC).

Rhomboid flaps
2. Bilobed flap : Used for BCC of tip nose.

Bilobed flaps
3. Bipedicled flap taken from eye lid region.
Axial flap :
rotated on named blood supply
Robust blood supply → better survival of graft

H&N

Pectoralis Major Myocutaneous flap (PMMC) : Deltopectoral flap

m/c used flap used by head and neck surgeon

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

H&N

Lattismus Dorsi flap :

Abbe Estlander flap :
based on labial vessels. used based on thoracodorsal
for angle of mouth & lips recon- pedicle
struction

TRAM : Transversus Rectus Abdominis myocu- DIEP : Deep inferior epigastric artery perfo-
taneous flap. rator flap.
Skin, fat, muscle taken → Risk of abdominal Best flap for breast reconstruction.
wall weakness & incisional hernia. Only skin & fat taken → no muscle weakness.

H&N H&N

Radial artery forearm flap : Used for Free fibular flap : Based on
head and neck reconstruction, based on peroneal vessels. Best flap for
radial artery & cephalic vein. mandibular reconstruction.

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mathes and Nahai classification for axial flaps : ----- Active space -----

Type Pedicles Examples

IV multiple minor pedicles Sartorius
1 Dominant pedicle, multi- Pectoralis major
V
ple minor pedicles Latissimus Dorsi
Flap failure :
Arterial flap Venous flap
Temperature Cold warm
Color Pale Congested
Capillary refill Reduced Quick
Pin prick Reduced Increased
blood flow blood flow
Bed sores/pressure sores : Flap failure
Occurs when there is a constant pressure of >30mmHg at one site.
Staging of pressure sores :
Stage Description
1 Non blanchable erythema without a breach in epidermis.
2 Partial thickness skin loss involving epidermis and dermis.
Full thickness skin loss extending into the subcutaneous tissue but
3
not through underlying fascia.
Full thickness skin loss through fascia with extensive tissue destruc-
4
tion, maybe involving muscle, bone, tendon or joint.
M/C site : Ischium > Greater trochanter.
Risk factors :
• Prolonged immobilisation.
• Malnutrition.
• Maceration of area.

To prevent bed sores :

• Adequate nutrition.
• Frequent change in position : Bed bound patient needs to be turned for 10
minutes every 2 hours .
• Air/water mattress : For offloading & to facilitate constant change in position
• keep area dry, no wrinkles in bedsheets.

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

Stage I : Keep dry + offloading.
Stage II and III: Debridement + VAC.
Stage IV : Debridement + flap(VAC can also be done).

Vacuum Assisted Closure (VAC) : Uses of VAC :

aka negative pressure dressing. • Chronic non healing wounds
Hastens healing process. • Venous ulcer without slough
VAC unit pressure = -120mmHg. • Burns wound without eschar
• Bed sores after debridement
• Diabetic ulcer without osteomyelitis
Wound Healing :
Phases of wound healing :
• Hemostasis : immediate
• Inflammatory : 0-5 days
• Proliferative : 3- 13 days
• Remodeling : goes upto many months
Wound strength :
After 1 week : approximately 10% of normal strength. VAC dressing
After 3 months ( 12 weeks) : 70-80% of initial strength
(max strength).
Wound never regains its original strength.
Initially, type 3 collagen is found in wounds.
In remodelling, type 1 collagen replaces type 3 by 4:1
ratio. Grade 4 bed sore
• Healing by primary intention : Sutured wound, gives good scar.
• Healing by secondary intention : Open wound, heals by contracture.
Increase in granulation tissue → bad scar/keloid.
• Healing by tertiary intention : Aka delayed primary healing, wound left open
& sutured after few days.

Keloid vs. Hypertrophic scar :

Keloid Hypertrophic scar
m/c site : Sternum, shoulder region m/c site : extensor surface
Racial predisposition for dark skinned people More common in children
Grows beyond the boundary of scar Remains in the boundaries of scar
Doesn’t subside with time & pressure Subsides with time & pressure
Intralesional triamcinolone Silicone pads/gel

Keloid Hypertrophic scar

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Cleft lip and palate : 00:40:00 ----- Active space -----

Seen in 1 in 600 live births.
Males > females.
M/C defect : Combined lip plus palate.

Documentation : LAHSAL
Capital letters (Eg : “L” ) for complete involvement.
Small letters (Eg : “l”) for partial involvement.
L : Lip
A : Alveolus
H : Hard palate
S : Soft palate
A : Alveolus
L : Lip
Management :
Cleft lip Cleft soft palate Cleft hard palate
Surgery done in Surgery done at 12
Surgery done in 5 to 6 months .
5 to 6 months. to 15 months.
m/c repair done : Millard repair. Wardkill- kilner repair or
other : Tennison repair. V-Y plasty .

Adrenal Gland 00:41:58

Adrenal Incidentaloma :
Incidental adrenal mass discovered during workup for another disease.
Most are non functioning tumors.
If functioning, d/t cushing’s syndrome or metastasis.

Workup : to rule out functional tumor

• Serum cortisol
• Plasma free metanephrines
• Serum DHEA
• Dexamethasone suppression test
• Urinary cortisol

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

Unilateral adrenal mass

Radiological suspicion of malignancy

No
Yes

Functioning tumor? Local invasion?

No Yes No Yes
No surgery if Laparoscopic Diameter Open
< 4cm adrenalectomy <6cm adrenalectomy
No
Individualized
surgical
Surgery is indicated if : approach
• Tumor of >6cm with no local invasion.
• >4cm non functioning tumor. >4-6 cm or there is an increase in size on followup
scans then CARRY OUT SURGERY
• Increase in size on follow up scans
Radiological features suspicious of adrenal malignancy
• Diameter > 40 mm and >10 HU density.
• Contrast-enhanced washout CT.
• FDG-PET: positive uptake.
Pheochromocytoma :
Tumor of adrenal medulla.
Extra adrenal tumor : Paraganglionoma (M/c in
organ of Zucker kandl).
HPE : Zellballen pattern.
Associated syndromes :
• MEN2.
• Neurofibromatosis 1.
• Von hippel lindau.
• Familial paraganglionoma syndrome.
Compounds released :
• Adrenal : Noradrenaline > adrenaline.
• Paraganglionoma : Noradrenaline.
• Malignant : Dopamine.

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

• Headache.
• Sweating.
• Episodic hypertension,especially suspect when hypertension seen in a young
patient.

Work up :
Screening test : Urinary catecholamines/
Vanillyl mandelic acid (VMA).
IOC : Plasma free metanephrines.
Imaging IOC : MRI → Light bulb sign. Light bulb sign
IOC for extra adrenal pheochromocytomas : Gallium DOTATATE scan.

Management :
• Pharmacological management :
α blockade by phenoxybenzamine followed by β blockade
(unopposed α action leads to hypertensive crisis).
• Surgical management : Laparoscopic adrenalectomy.
Adrenocortical carcinoma :
Bimodal distribution : seen in children and in 4-5th decade.
Non functional tumor more than functional tumor.
Clinical Features :
• Lump
• Cushing syndrome
McFarlane classification used to stage adrenocortical carcinoma.
Mx : Open adrenalectomy.
Neuroblastoma :
m/c abdominal tumor in child.
N-myc amplification seen.
Occurs in adrenal medulla> sympathetic chain. Blueberry muffin lesion
Clinical features :
• Abdominal lump which crosses midline.
• Raccoon eyes.
• Blueberry muffin lesions.
Investigations : Racoon eyes
Intra abdominal calcification in CECT.
Elevated chromogranin levels in blood.
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----- Active space ----- Management : Chemotherapy with cisplatin and etoposide.
Surgery done even if metastasis is present d/t good survival rates.
Carcinoids :
These are neuroendocrine tumors.
Arises from argentaffin cells.
m/c site of origin : Appendix.
Foregut and bronchial carcinoids Midgut carcinoids Hindgut carcinoids
Site Stomach, duodenum Appendix, ileum Colon, rectum
Metastasis Bone Liver
Carcinoid Argentaffin - Normally they produce serotonin, but
syndrome Serotonin - liver metabolises them.
Do not produce carcinoid In case of liver metastasis →
syndrome. carcinoid syndrome is present
Chromogranin +

Clinical features : Workup :

• m/c : Cutaneous flushing. • Urine : 5 hydroxy Indole Acetic acid.
• Sweating. • Serum : Chromogranin A levels.
• Abdominal pain. • CECT to localize lesions.
• Carcinoid syndrome :
a. when serotonin leaks out into systemic circulation.
b. Occurs when liver metastasis is present causing bronchospasm
and right sided cardiac lesions (tricuspid valve m/c affected than
pulmomary valve).
Management
Appendicular
• If carcinoid :
a. <2cm/close to tip : Simple appendicectomy.
b. >2cm/close to base : Right hemicolectomy.
• If malignant (high ki67 index) → chemotherapy given.
Neurosurgery IMP STUFF COVERED IN HEAD TRAUMA 00:55:45

Berry Aneurysms :
• Occur in the circle of Willis.
• M/c site : junction of anterior communicating
with anterior cerebral artery. It is the M/c site
of intracranial aneurysms as well.
• M/c site of rupture : Apex of aneurysm.
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• If it ruptures : Can give rise to SAH. ----- Active space -----

• Clinical features : Thunderclap headache (Worst headache of their life).
• Diagnosis : NCCT.
• If delayed presentation, Xanthochromia is seen in CSF.
• Management :
c. Interventional radiology : Coiling.
d. Surgery : Clipping of aneurysm.
• Nimodipine to prevent vasospasm after intervention.

CNS tumors :
M/c primary brain tumor : Glioma > meningioma.
M/c primary brain tumor in children : Medulloblastoma.
M/c brain tumor : Metastasis.
Imaging IOC : MRI.
CT, PET-CT can miss lesions in the brain.
Treatment options : Surgery, Radiotherapy, Chemotherapy.
M/c cancer metastasizing to cerebrum : Lung cancer
(prophylactic CNS radiation used in certain stages of lung cancer).
M/c cancer metastasizing to leptomeninges : Breast cancer.
Surgery : Restricted to solitary metastasis.
Radiotherapy : Main treatment.
Chemotherapy : Intra thecal chemo for leptomeningeal disease.
Steroids are the drug of choice for vasogenic edema.

Management of brain metastasis :

• Radiotherapy.
• Steroids given if increase in intracranial tension is seen.

Astrocytoma :
Grade 1 : Pilocytic astrocytoma
(M/c astrocytoma in children).
Presents as mural nodule. EXCISION
Grade 4 : Glioblastoma multiforme.
Butterfly shaped tumor. Glioblastoma multiforme
Oral temozolamide used along with chemo and radiotherapy.
Despite everything, survival is 1-1.5 yrs
Oligodendroglioma :
On HPE :
Fried egg appearance.
Chicken wire vascularity.

Oligodendroglioma (HPE)
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----- Active space ----- ORAL CANCER & SALIVARY GLANDS

Oral Cancer 00:00:23

Features :
M/c site (Overall) : Lateral border of tongue.
M/c site (India) : Gingivo-buccal sulcus.
M/c gene mutation : p53.

HPE : SCC with keratin pearls.

Keratin pearls
Risk factors :
• Smoking.
• Alcohol.
• Betel quid consumption. SCC
• Immunosuppression.
• Chronic infection : 5% oral SCC
a. HPV : Associated with
50-70% oropharyngeal SCC Better prognosis
b. Sharp, ill-fitting dentures.
Note : EBV → A/w Nasopharyngeal cancer.

Pre-malignant conditions :
1. Leukopakia & 2. Erythroplakia

Leukoplakia Erythroplakia
White patch. Red patch.
↑ Risk of cancer by 3-5 times. ↑ Risk of cancer by 6-9 times.
Cannot be rubbed off (D/d : Most aggressive form : Speckled.
Candidiasis → Can be rubbed off).
Mx : Stop the risk factors.
If it persists → Biopsy.

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

3. Chronic submucous fibrosis :
• Hypersensitivity reaction to betel nuts.
• Fibrous deposition within oral cavity → Inadequate
mouth opening.
• Mx : Intra-lesional steroids. TRIAMCINOLONE
4. Chronic hyperplastic candidiasis. Chronic submucous
↑ Risk for malignant change in pre-existing dysplastic lesions : fibrosis
• Female sex.
• Size >200 mm2.
• Non-homogenous lesion.
• Non-smoker.
• Multiple lesions.
• Lesion at lateral border of tongue or floor of mouth.
Note :
Plummer Vinson syndrome/Paterson Kelly Brown syndrome/Sideropenic dysphagia :
• Seen in perimenopausal women.
• Features :
a. Iron deficiency anemia (Koilonychia seen).
b. Angular stomatitis.
c. Upper esophageal webs/post-cricoid webs.
• ↑ Risk of :
a. SCC of esophagus.
b. Hypopharyngeal cancer.

Pattern of invasion in oral cancers :

Tumor thickness (Includes the DOI)

Basement membrane
Mucosa DOI
Depth of invasion (DOI) is a prognostic factor in T stage.

Staging : ORAL CANCER AND BREAST CANCER STAGING IS EXTREMELY IMP FOR THE EXAM
T stage :
Stage Description
T1 Size ≤2 cm & DOI ≤5 mm.
T2 Size ≤2 cm & DOI 5-10 mm (OR) Size 2-4 cm & DOI ≤10 mm.
T3 Size >4 cm (or) DOI >10 mm.
T4 Invasion of adjacent structures.

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

N stage :
Stage Description
N0 No LN involved.
N1 Single I/L LN ≤3 cm size.
N2
N2a Single I/L LN 3-6 cm size.
N2b Multiple I/L LN, all ≤6 cm size.
N2c Any B/L (or) C/L LN, all ≤6 cm size.
N3
N3a Any LN >6 cm & ENE -ve.
N3b Any ENE +ve.
ENE : Extra-Nodal Extension (Matting, skin fixity).
Management :
1. Surgery (Followed by reconstruction) :
a. Wide local excision (0.5 mm margin).
b. Mandibular resection. Commando procedure.
c. Neck dissection.
2. Chemotherapy.
3. Radiotherapy.

Neck Dissection (ND) :

T1/T2 lesions → Prophylactic ND (Better prognosis).
N0 lesion

Sentinel lymph node biopsy (SLNB) Supra omohyoid ND (SOHND) :

Incision : Modified Schobinger’s incision. Level 1, 11, 111 removed

Types of neck dissection :

Radical ND Modified Radical ND (MRND) Selective ND
Given by Crile. Mod. Schobinger incision 1. Central ND : Level
Structures removed : Structures removed : 6/Delphian LN
1. Level I-V LN. 1. Levels I-V LN removed removed.
2. 3 extra-lymphatic structures : 2. At least 1 extra-lymphatic 2. SOHND (Level I, II, III
a. Sternocleidomastoid (SCM). structure saved. LN removed).
b. IJV. a. MRND I : SAN saved. 3. Extended SOHND
c. Spinal accessory nerve (SAN). b. MRND II : SAN & IJV saved. (Level I, II, III, IV LN
3. Submandibular gland. c. MRND III : All 3 saved. removed).
4. Tail of parotid. (MRND III is aka Functional ND).
3. Submandibular gland.
4. Tail of parotid.

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Complications of ND : ----- Active space -----

1. Haemorrhage.
2. Injury to nerves :
• M/C injured nerve : Marginal mandibular nerve (Ramus mandibularis)
→ Drooping of angle of mouth (Incision should be 2 finger breadth be-
low the mandible to avoid nerve injury).
• Nerve injury causing shoulder dysfunction → Spinal accessory nerve.
3. Carotid artery blowout → Maximum mortality.
Reconstruction :
1. Radial artery Forearm Flap (RFFF) : Most versatile flap used in head & neck.
2. Free fibular flap : Best for mandibular reconstruction (Based on peroneal
vessels).

RFFF Free fibular flap

3. Delto-pectoral flap.
4. Pectoralis Major Myocutaneous (PMMC) flap : M/C used by head & neck
surgeons (Based on pectoral branch of Thoracoacromial vessels).

Delto-pectoral flap PMMC flap

Adjuvant therapy :
Used in high risk features :
Major features Minor features
• ENE • Close margins
• Involved margins • Multiple LN involvement
• Largest LN >3 cm
• Lympho-vascular Invasion (LVI)
• Peri-neural Invasion (PNI)
• T3/T4

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

Radiotherapy indications : One major (or) two minor features. Cisplatin acts as a
radiosensitiser
Concurrent chemo-radiation : Cisplatin-based regimen in high risk patients.
Immunotherapy : PDL-1 inhibitors used in recurrent/metastatic SCC.
Note : Most important prognostic factor in oral cancers → LN status.

Benign conditions of salivary glands 00:16:49

Ranula : Marsupialization
Mucus extravasation cyst involving the sublingual salivary gland.
Site : Floor of the mouth.
C/f : Brilliantly transilluminant.
M/x :
• Marsupialization.
• Excision of cyst + Sublingual gland (TOC).
• Incision & drainage not done as it can cause recurrence. Ranula
Complications of excision :
• M/C injured structure : Submandibular duct.
• M/C injured nerve : Lingual nerve.
Note :
Plunging ranula :
• Mucus retention cyst.
• Site : Submandibular & sublingual glands.
• C/f : Swelling in oral cavity and neck.
• Mx : Excision of intra-oral swelling + Aspiration of neck swelling.

Stafne bone cyst :

Site : Mandible.
M/C site for ectopic salivary tissue.

Accessory parotid gland : Stafne bone cyst

Seen in 21-61%.
Removed during parotidectomy (To prevent sialocele → Fistula formation).

Parotid abscess :
Seen in immunocompromised individuals.
Presentation : Pain, redness,fluctuation (Late sign).
Mx :
• Incision & drainage. Parotid abscess
Incision (To avoid injury to facial nerve) : Acute necrotizing sialometaplasia
a. Skin : Vertical incision. On palate and affects minor salivary glands
b. Fascia : Transverse incision. Swelling then central crater with rolled out
margins
Mimics a malignant ulcer
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BIOPSY TO RULE OUT CANCER
Self-limiting lesion
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Recurrent parotitis in childhood : ----- Active space -----

C/f :
• Rapid swelling of one/both glands.
• Aggravated by chewing, eating.
• Symptoms last for a week followed by a quiescent phase.
• Age group : 3-6 years.
Imaging : Snowstorm appearance on USG.
Rx : Long course of antibiotics + Endoscopic washouts. Snowstorm appearance

Sialolithiasis :
MORE VISCOUS
ANTIGRAVITY Submandibular > Parotid gland.
DRAINAGE
Composition : CaPO4.
Investigation : NCCT.
M/x : Sialolithiasis
If fails
• Endoscopic management Duct slitting (Also used for larger lesions).
• Excision of gland : Last resort.

Salivary gland tumors 00:22:53

LARGER THE GLAND MORE PERCENTAGE OF BENIGN TUMORS AND SMALLER THE GLAND MORE MALIGNANT TUMORS

Gland Benign tumours Malignant tumours

Parotid 90% 10%
Submandibular 50% 50%
Sublingual 20% 80%
Minor 10% 90%

Milan system for reporting salivary gland cytopathology :

Group Diagnostic criteria Management
I Non-diagnostic Repeat FNAC
II Non-neoplastic Follow up
III AUS Repeat FNAC/surgery
IVA Benign neoplasm
IV Conservative surgery
IVB SUMP
V Suspicious of malignancy
Surgery
VI Malignant
AUS : Atypia of Undetermined Significance.
SUMP : Salivary gland neoplasm of Unknown Malignant Potential.

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Parotid tumors :
90% benign.
Presentation :
• Swelling on side of the face.
• Lifts ear lobule.
• Deep lobe involvement (Tonsillar fossa pushed medially).
M/C tumor : Pleomorphic adenoma.
M/C malignant tumor : Mucoepidermoid carcinoma.

Benign tumors :
1. Pleomorphic adenoma :
• C/f : Slow growing, benign.
PLAG-1 gene mutation seen.
• HPE : Triphasic tumour with epithelial components
in myoepithelial & myxoid backgrounds.
• Diagnosis : FNAC. Pleomorphic adenoma
• Mx : Superficial parotidectomy. Enucleation is C/I as it leads to high recurrence

2. Carcinoma ex pleomorphic adenoma/mixed malignant tumor :

• Malignant transformation of pleomorphic adenoma.
• Signs of malignant change :
a. Rapid ↑ in size.
b. Painless → Painful.
c. Ulceration.
d. Facial nerve involvement.
e. LN involvement.
• Management : Surgery followed by radiotherapy.

3. Warthin’s tumour :
• 2nd M/C parotid tumor.
• M/C B/L parotid tumor (10%).
• M > F.
• Benign.
• Diagnosis : FNAC. HPE of warthin’s tumor
• HPE :
a. Two layers of cells rich in mitochondria.
b. Lymphocytic infiltration.
• Mx : Superficial parotidectomy.
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Malignant tumors : ----- Active space -----

1. Mucoepidermoid carcinoma :
• M/C malignant tumor.
• Risk factor : Radiation exposure.
• CRTC1-MAML2 gene fusion.
2. Adenoid cystic carcinoma :
• 2nd M/C malignant tumor. Adenoid cystic carcinoma
• PNI +ve (Extremely painful). Perineural Invasion (Swiss cheese appearance)
• High recurrence rate.
• HPE : Swiss cheese appearance.
Imaging :
CT : Superior for differentiating inflammatory lesions from neoplasms.
MRI : Better differentiation b/w benign and malignant.
High resolution USG : For guided FNAC.

Treatment principles : Similar to ORAL CANER

Margin : 0.5 cm.
Elective SOHND for T3/T4 tumours & high grade tumours.
Adjuvant radiotherapy given if :
a. Stage 3 & 4.
b. High grade tumours.
c. Positive margins.
d. PNI/LVI.
e. ENE +ve.

Parotidectomy :
Incision : Lazy-S/Modified Blair incision.
Types :
1. Superficial.
2. Deep : Superficial + Deep lobes removed.
a. Conservative : Facial nerve is saved.
b. Radical : Facial nerve is sacrificed. Sural nerve : Best for cable graft.
Complications :
1. Haemorrhage.
2. Nerve injury :
a. Facial nerve.
b. Great auricular nerve : Anesthesia over beard region.
c. Ramus mandibularis : Drooping of angle of mouth.
3. Parotid fistula of :
a. Gland : Low output. Self-limiting.
b. Duct : High output. Mx : Surgery.

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

4. Frey’s syndrome :
• Sweating over parotid region after eating food.
• Auriculotemporal nerve (Post-ganglionic parasympathetic fibres).
• Investigation : Starch iodine test.
• Management :
1st line : Botox & anti-perspirants.
Definitive : Tympanic neurectomy.
• Prevention : SCM/digastric muscle flap to cover parotid bed.

Starch iodine test

Submandibular tumors :
Bimanual palpation :
• Done to differentiate b/w submandibular swelling & LN.
• Deep lobe of gland will be palpable but not LN.
M/C tumor : Pleomorphic adenoma.
M/C malignant tumor : Adenoid cystic carcinoma.
Diagnosis : FNAC.
Mx : Submandibular excision.

Bimanual palpation
Complications of submandibular surgery :
• Haemorrhage.
• Nerve injuries :
a. Marginal mandibular (M/C).
b. Lingual.
c. Hypoglossal.
• Injury to other structures :
a. Anterior facial vein.
b. Facial artery.

Sublingual gland tumors :

M/c : Adenoid cystic carcinoma.

Minor salivary gland tumors :

• M/c : Adenoid cystic carcinoma.
• M/c site : Hard palate.
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