Index

Sl.No. Topic Pg.No.

1 Shock and Transfusion 09

2 Wounds, Healing and Tissue repair 14
3 Surgical infection 19
4 Basic surgical skills and anastomoses 21
5 Pre and Post operative care 26
6 Trauma 28
7 Head and Neck 44
8 Skin And Subcutaneous Tissue 50
9 Breast 58
10 Hernia 69
11 The peritoneum And Retroperitoneal space 80
12 Endocrine 93
13 Bariatric and Metabolic surgery 122
14 Vascular Disorders 127
15 Cardiothoracic 143
16 GIT 150
17 Genitourinary 211
 Traditional classification of haemorrhagic shock.
Class
1 2 3 4
Blood volume lost as
<15% 15–30% 30–40% >40%
percentage of total

TRANSFUSION
Whole blood

:
Packed red cells
- Each unit is approximately 330 mL and has a haematocrit of 50–70%.
- are stored in a SAGM solution (saline–adenine–glucose–mannitol) to increase shelf
life to 5 weeks at 2–6°C.
Fresh-frozen plasma
- rich in coagulation factors and is removed from fresh blood and stored at −40 to
−50°C with a 2year shelf life.
- first line therapy in the treatment of coagulopathic haemorrhage
- Rhesus Dpositive FFP may be given to a rhesus Dnegative
Cryoprecipitate
- supernatant precipitate of FFP.
Q
- rich in factor VIII and fibrinogen.
- stored at −30°C with a 2 yr shelf life. -

- given in low fibrinogen states or factor VIII deficiency.

• Platelets
9
- supplied as a pooled platelet concentrate and contain about 250 × 10/L.
- Platelets are stored on a special agitator at 20–24°C.
- have a shelf life of only 5 days.
- given to patients with thrombocytopenia or with platelet dysfunction who are
bleeding or undergoing surgery.
•
Prothrombin complex concentrates
- are highly purified concentrates prepared from pooled plasma.
- They contain factors II, IX and X.
- Factor VII may be included or produced separately.
- Indicated for the emergency reversal of anti coagulant (warfarin) therapy in
uncontrolled haemorrhage.
 Wounds, Healing and Tissue repair
•
Phases of normal wound healing :
1. The inflammatory phase
- begins immediately after wound and lasts 2–3 days.
2. The proliferative phase
- lasts from the third day to the third week, consisting mainly of fibroblast activity
with the production of collagen and ground substance, the growth of new blood
vessels as capillary loops (angioneogenesis) and the reepithelialisation of the
wound surface.
- in the early part - granulation tissue.
- in the latter - increase in the tensile strength of the wound due to increased
Q
collagen(consists of type III collagen.)
3. The remodelling phase (maturing phase) :
- maturation of collagen (type I replacing type III until a ratio of 4:1 is achieved).
- maturation of collagen leads to increased tensile strength in the wound which is
maximal at the 12th week post injury and represents approximately 80% of the
uninjured skin strength.
•
The phases of healing.
(a) Early inflammatory phase with platelet-enriched
blood clot and dilated vessels.
Q

(b) Late inflammatory phase with increased

vascularity and increase in polymorphonuclear
leukocytes and lymphocytes (round cells).
(c) Proliferative phase with capillary buds and
fibroblasts.
(d) Mature contracted scar.

Classification of wound closure and healing

•
Primary intention
- Wound edges opposed
- Normal healing
- Minimal scar

Reference :
Bailey and Love’s Short Practice of Surgery 27th Ed Pg: 24
 The ASEPSIS wound score
ASEPSIS wound scoring takes all of
the following into consideration
except ? '

18
MEET

SSI rates relating to wound contamination with and without using antibiotic
prophylaxis

Definitions of systemic inflammatory response syndrome (SIRS) and sepsis.

The principles of safe laparoscopic surgery
•
The umbilicus is preferred for primary trocar insertion
•
An open or semi-open technique is prefered by most surgeons
•
Open insertion away from the umbilicus is safer if there is a midline scar
• Secondary trocars should be inserted and removed under direct vision
All trocars should be placed perpendicular to the abdominal wall
: All trocar sites above 5 mm in length should undergo closure of the fascial layer
A- 1114119
Image Based Question

Trocar and canula

Suture techniques
Interrupted suture technique. Continuous suture technique.

The siting of sutures. As a rule of thumb, the distance of insertion from the edge of the
wound should correspond to the thickness of the tissue being sutured (X).
Each successive suture should be placed at twice this distance apart (2X).
 Related clinical question
A previously healthy, 25-year-old man is brought to the casualty after falling from a height,
landing on his left side.There was no loss of consciousness.The patient has left shoulder and
left-sided chest pain, as well as abdominal pain.Blood pressure is 114/72 mm Hg and pulse is
116/min.Physical examination shows bruising to the left side of the chest wall and
abdomen.Heart sounds are normal.There is sharp, left-sided chest pain with deep inspiration
but equal breath sounds on both sides.The left costal margin and the left upper quadrant of
the abdomen are tender to palpation.Range of motion of the left shoulder is normal.Portable
chest x-ray is normal.  Focused Assessment with Sonography for Trauma shows no
pericardial effusion or significant intraperitoneal free fluid.Which of the following is the best
next step in management of this patient?
A.Monitor with serial physical examinations
B.Obtain CT scan of the abdomen
C.Obtain dedicated radiographs of the ribs
D.Obtain plain radiographs of the left shoulder
E.Perform exploratory laparotomy

Related clinical question

A 34-year-old man is brought to the casualty after a head-on motor vehicle collision.On
arrival, blood pressure is 78/40 mm Hg and pulse is 134/min.On physical examination, the
patient is alert but intoxicated.Pupils are equal and reactive to light.Ecchymosis in the
distribution of a seat belt is present over the chest and abdominal wall.The left chest wall is
tender to palpation.Breath sounds are equal bilaterally.Heart sounds are normal.The
abdomen is distended and diffusely tender.Portable chest x-ray reveals multiple left rib
fractures without pneumothorax or effusion.Cervical spine and pelvic radiographs are
negative for fractures and dislocations.Focused Assessment with Sonography for Trauma is
negative for pericardial effusion but positive for free intraperitoneal fluid.After rapid
infusion of 2 L of intravenous crystalloid, blood pressure is 80/50 mm Hg and pulse is 118/
min.Transfusion of uncrossmatched blood is pending.Which of the following is the best next
step in management of this patient?
A.Abdominal CT scan
B.Contrast angiography
C.Diagnostic peritoneal lavage
D.Emergent laparotomy
E.Vasopressor therapy
Treatment
no alternative to surgery for femoral hernia

:
There are three open approaches and appropriate cases can be managed laparoscopically.
1.Low Approach (LOCKWOOD)
- simplest operation
- suitable only when there is no risk of bowel resection.
- easily performed under LA
2.The Inguinal Approach (LOTHEISSEN)
3.High Approach (McEVEDY)
- ideal in the emergency situa- tion where the risk of bowel strangulation is high.
- requires Regional or General Anesthesia
Laparoscopic Approach
Both the TEP and TAPP approaches can be used for a femoral hernia and a standard
mesh inserted.
Ideal for reducible femoral hernias presenting electively, but not for emergency cases
or irreducible hernia.
Related Clinical Question
A 68-year-old woman comes to the Surgery OPD due to a groin bulge.  She first noticed it 2
months ago and says that it gets larger with prolonged standing and shrinks with lying
down, but it is not painful.  There has been no trauma to the area.  The patient has had no
fever, nausea, anorexia, weight loss, abdominal pain, or urinary symptoms.  She has a
history of obstructive pulmonary disease with occasional exacerbations and hypertension. 
The patient has smoked a pack of cigarettes daily for 45 years.Temperature is 36.9 C (98.4
F), blood pressure is 140/80 mm Hg, pulse is 78/min, and respirations are 16/min.  BMI is
34 kg/m2.  Oxygen saturation is 95% on room air.  Cardiopulmonary examination shows
mildly decreased breath sounds bilaterally.  The abdomen is soft and nontender; bowel
sounds are normal.There is a 2-cm groin mass below the right inguinal ligament, which is
medial to the right femoral artery; no tenderness, pulsations, or overlying erythema is
present.The mass is tympanitic to percussion.Which of the following is the best next step
in management of this patient?
 A.CT angiogram of the lower extremities
B.Elective surgical repair
C.Needle aspiration of the mass
D.Oral antibiotics and reevaluation in 2 weeks
E.Reassurance and observation
Clinial Formula
FEmORAL HERNIA
hernia appears no specific investigations no alternative to surgery
below and lateral to are required. Low Approach (LOCKWOOD)
the pubic tubercle Ultrasonography or CT The Inguinal Approach (LOTHEISSEN)
and lies in the High Approach (McEVEDY)
upper leg Laparoscopic Approach

VENTRAL HERNIA
•refers to hernias of the anterior abdominal wall.
- Umbilical - Spigelian
- Paraumbilical - Lumbar
- Epigastric - Traumatic
- Incisional
- Parastomal
Umbilical hernia
develops due to either absence of umbilical fascia

i
or incomplete closure of umbilical defect.
can be congenital in newborn and infants (common
in males) or acquired in adults (common in
females).
Obstruction and/ or strangulation is extremely
uncommon below the age of 3 years.
Umbilical hernia in a male child and adult.
Often it can attain a large size.
Clinical Features
•
In Children :
- Presents with a swelling in the umbilical region within first few months after birth,
the size increases during crying.
- It is hemispherical in shape.
- Defect can be felt with finger during crying.
•In Adults :
- commonly overweight with a thinned and attenuated midline raphe.
- The bulge is typically slightly to one side of the umbilical depression,
creating a crescent-shaped appearance to the umbilicus.
- Common in females more than men