GENERAL SURGERY

Dr ROHAN KHANDELWAL

WHO Checklist

Me cause of wrong site surgery

1
communication errors

I
M.c cause of Missmatched Blood transfusion

surgery safety checkliston

J
signing ITImeautJ
I
outy
Isign
SOTT
Iward Before skin incision Attime of
Skinclosure
confirm identity
consent written
surgeon lN4mJ
I
count gauzyEquipment
IsitemarkingJ surgery
Anticipated surgeon
Allergies
Bloodloss Actual surgery
serology
viralmarkers Anesthetist Any concern
I Anesthetist
Anyconcern
prophylacticAby Actual Blood loss
 protective zone Cleazzone
change Rooms 7 connect protective zone

Transfers Bay to asepticzone

pre postoprooms Equipment storeroom

ICU PAW maintainance Room

Asepticzone L
y Disposal zone
OT waste

Me complication I V line 8 Superficialthrombophisis

of

t L
Thickest thinnest
Maxflowrate Least flow rate
 commerisal procedure
I supine E Abdominal s Breast
Thyroid

2 Lithotomy
Gyrelobs Haemonoids cystoscopy TURP
MC Ingyred in the Lithotomy positions

commenpermealNernec3
for Lateral kidney and thoracotomy
I
in this Sx overabduction can causes Brachial plexus
of arm
injury

4 Jacknife position Easier Used for Haemossoia

t
but Now a days Not used 7 due to POSITIONAL ASPHAXIA

5 prone position spinal surgery

FOWLER's position Best for CNS surgery

sitting
9 Risk of Air embolism
 for Lap cholecystectomy µ
I
ReverseTrandelenburg
Head
up foot 10W
F
sideup

gasused coz
GAS Beneath dome
of diaphragm
I
irritated
I
shoulder tip pain

CM c complication of LAP CHOLAE

surgicalBlade

No 11 stab blade Used for

No 12 curved 2 for suture

Removal

all others for incision

OO
Energy source

Safe closed to vital

structure

I
for aThyroid
parathyroid

Egrlobule
penile
safe in pacemakers pins
suture and surgical knot 3

insecureknot Slipknot

surgeon's knot
 subcuticularsuturing
1
3 O monocryl suture

if the depth

Distgne b w two suture is

 Needle Holding procedure 8

do
143rd
g

Kody

SUTURE

L J
Natural synth moreinert
1 most inert
More Infection Is Synthetic Non Absorbable

S4t

Monofilament Multifilament

Higherwound Refection Rate B

e.g catgut Fg fgfg
proline they are easier to handle knot
monocryl
eg cotton vinyl
Nylon
silk
Ethiloy
 sutured

IABSORBAB.LI INM
ABSORBABLEJ

Natural synthetic
t
I IMONOCRH.fi

Catgut 1VICR polyglactin dissolve in 60 90 days

I 1
Uses BOWEL BLADDER CBD
fromsheep
submutosa polyDTaxon monofilament
180days
L
TensileStrength Absorptiontime same uses as VICRYL
I
duration for Wich
com bold tissue
3 5days

Non Absorbable

Natural synthetic
silk Cpzoline
Skin Hernia mesh
2ndLayer ofBOWEL vascular Repair
Fix drains Close the Recture sheath
4times length of wound
 EthimJ
NY1m
Skin
uses
Tendon
Nerve fix drain

Sutenefemoval

Neck 5 7 days
Thorax 10 12days
Abdomen 12 14
days
Perinium 12 14

circularg for Heznorroids

Linear Dohrmann CZEIKER diverticulum

2 Sleeve gastrectomy
 causes of Post Op feverg
t
Post day 1 MC C Atelectasis
t
incentive spirometer
chest physiotherapy

Post Cop Day 02 03 Me cause of HAI

pneumonia

supthrombophlebitis
Post op Day 05 Me cause of HAI
in a surgical patient
Surgicalsify
1
any wound infection within days of surgery B
if an implant 2 year

DVI PostOp 5thday

I
pharmacological LMWH
Lowmolecularweight
Mechanical Heparin

Stockings TO prevents Dvi

PostOp day of

sign8 SALMON FLUID

sign or
SERUS FLUID SIGN

Mx emergency Mx
I
UROBAG LAPROSTOMY

unbag lapostony I
definativeRx thesuture
of
Rectus sheath
suture f prolineused

postop days 07 Beyond8

intra abdominal collection Abscess

m
i t
Ambulatory
overran supine
He
I µ
pelvis or Morison's fffyweisordouglasJq
pouch ofdoughs pouch

Ioc CECT 0
drain wig
pigtail
catheter
 Types of wound

class EXAMPLES SSI

I Clean 3 Cleanincised wound L 2

Thyroid
Breast
Uncomplicated inguinal
knee Replacement

CABG

II Clean Enter GILGu system when 2 20

contaminated
inflammation
when Bowel is Repaired
Elective Cholycystectomy
Appendectomy

Lscs
Hysterectomy

IT contaminated 8
GIIGUsystem when Non purulent 10 2040
inflammation is
Bowel prepared

II Dirty 3 or pus Abscess 20

peritonitis
 Neglected traumatic wound 6HRS

6HRS Golden peroid for traumatic wound

Clean CASES Are done 1st in elective OT list

Ans

How to prevent SSI

MII factor in preventing SSI

Handwashing
Min 2 min Handwash
Hands UP Elbowdown

thumb
prophylactic Abx
I
Best time 30 Min 1 Hour before surgery

in a prolonged s When do we Repeat dose

AFTER 4 HRS

Best way to Remove HAIR

Clipping of Hair Just before surgery
SHAVING 99 SSI Rate

Cleaning of part by Alcob0I

IBetadi.me

In
Abdominal Surgery

to
I
Nipples to mid Kuframammary fold to
thigh midthigh
Cleanfrom Lateral to medial

Temp of OT I 18 22 C prevent Hypothermia

A sterile less sterile

Adequate Haemosiasia
0 inhalation in the immediate post op period It
 SURGICAL NUTRITION 8
T
Entree Parentral
GUT Itv
1
Best route
1
oral Route
1
if not possible
I
s3w
C 3weeks µ
I feedinggastrostomy feeding Jgyrostomy
we use it
NGTube morephysiological
Ryle'sTube but HigherRateof
Aspiration
How to measure
Lenghth
Tip ofNose to Eatlobule
I
xiphisternum

Bestposition sitting
NeckSlightly Flexed

How to checkposition
gastricAspirate
otherwisepush air and
Auscultate in epigastrium
 Complication of entral Nutrition 8
Tube Related Mrcfeeding Regime complicating
14 I
M C Overall Osmoticdiarrhea

PARAENTRAL
TRITIONII.ru
Routes

BestRoute piceeine Leastprep

I I
4
peripherally inserted
I centralline penopharal I
µ central catheter lines
Mrc line for Tpm is subclavian
B
overall M c central line or ITV

complication of Tpm 8

central line feeding Regime

pneumothorax me overall Hyperglycemia

Air embolism CHOLESTASIS

Thrombosis
Refeeding sylidionre Large Quantity is
a

Arrhythmia givento severe chronically malnourished Pt

M C Central line problem a
HypoKt Hypomg Hypoca Hypopost
41
is catheterinduced sepsis CHF Anythemia
Fluidoverload
 How to prevent R FS
1 gradually A dose
2 THAI MIE Suppiimentation
3 Strict monitoring of electrolytes

SIRS g Systemic inflammatory Response

syndrome

Body's Response to inflammation

Mediated by ILI IL 6 TNFL

WBC L 4000 Comm or 12,0001COMM or 104 BAND FORMS in

patients

Iii
mn

PR 901min
Any 2 parameters SIRI
SIRS t known foci Sep
of infection
sepsis Wich causes Hypotension Septfc8h
failure of 2 or more organ system M
1
Multiple organ dysfunctional syndrome
 O

Hypovolemic Shock
www mu

e.g Blood Decompensated

donation compensated
Phase
I 2
Phase 3 4
Yo B volume lost 0 15 15 30 30 40 40
Amount 400 500Cc Hr 1.5 Its Zits

pp A Ap
SBP Normal

DBP
Fput Normal I
NM
RR Normal 9 Recordable

BASE
Deficit
2 to 6 Gto 10 v

MentalStatus Thirsty Anxious confused coma

I voystalloids Iv crystalloid Massive
Mx OralLiquid CNG RL
IV conoid oozy Bloodtransfusion

pulse pressure Narrow Narrow

when Blood loss Adrenaline Earliest
sympathetic Change
systemstimulated Noradrenaline
Hpp

A peripheral
co ShuntBlood C Vasoconstriction
to Extra vital cold
SBP
organs PPUR T DBP
compensated

Massive Blood transfusion

v if we transfuse
10 Units 24HRS 447175in entheBlood volume in
one HR 44HRS

complication 5 Hypothermia

Hypocot Ccitrate chelatescadt

Hyper letFIB Hypo K

Transfusion Associated Cardiac overload

ofEdemaf puffiness
Breathlessness

enter by diuretics
prev CHISIX
TRALI Transfusion Associates Acute14mg Ryung
HLA
ARDS

Coagulopathy is leading causes of mortality in

Massivetransfusions
 PRBC FFP Platelets
Packed freshfrozen
RBC plasma
1 I o
I

Q
Bestindicator to determine Amount of Fluid Required in Shock
Pcwp pulmonary capillary wedge pressure Cup central venous
patients

Best indicator
of Fluid Resusitation in shock
Urineoutput

New Endpoints pesucitation

MVOS
of mixed venous 02 saturating

shock index
I j Rope
modifiedshock Rateover pressure
differentite
different
3p
HR
Mostsensative
Hyperdynamic
Bradycardia Circulation
Hypovol Cardiogenic Neurogenic Anaphylactic septic
shock f l
2 Hypotension warm cod
PR R Rfd L T A
SBp I d t T
f
co L d L L T
VR T T t I I
Jrp j T I I
 I

µI inthe Late phase

Bacterial Toxins
1 I ofsepsis
myocardium
CO I cold
Iv
TIPU
SBP
4JVP
Anaphylactic shock
Mistched Blood transfusing
a
Histamine Released
Vasodilation

warm Ct PVR
11
Pooling of Blood 1 VenousReturn
He
1 Jvp Ico Is Bp

Distributive warmO obstructive

septic cardiogenic
Neurogenic

Anaphylactic
 TRAUMA
Trimodal distribution of mortality

MassiveHead ingysy
Atimpact Aortictransecting
mortality

IEighoisintmainminny's
Pneumothorax
I
Jing Tensing

ia
a
im n
eariEeam
Time
within
if proper intervention done in IHR then mortality can be
prevented So 1 HOUR is Trauma is Golden HOUR

or Advanced trauma Life supports BLS

Trauma cardiac
A c
Airway
B A
Breathing
C circulating B
D disability

Isurvey 20survey
t 1
Detailed survey in Wich all other
ABCD 1 Life instries are searched
thretening injury
 LOGROLL
11
Examine Back of a trauma PEN
Min No of people

Airway
Cervicalspi Followed by Airway
t
a Dangersign of
Pf cervical spine Kyung is airwaycompsomice
Suspected
I I
we immobilized c spine 1 Unable to speak
Using a HARD PHILADELPHIA COLLAR21 2 Gc
do Imaging
3 comatose

Tt
securethe airway using
Orotracheal intubation

t it ta
y Is
emergency M DefinitiveMx
Needle Tracheostomy
Crieothyroidotomy

circulation
I A
lines Em 188
Insert 2 LargeBone Ifr
 v

Ff Iv line insertion is Not possible

L y
Emergency intervention
Definative
a
centralline
Intraosseous venous cutdown Mc lI
infusion
a
Just below
Tibialtuberosity greatsaphanay
vein

Earlier 2 Its fluid B Now

of
was given 2 Liter

GLASSGOW COMA SCALE f

pupil Reactivity score

intubated

O
O
8
 t He
Eg

Non testable
EzVNTM3
5

min Gcs 03
Max 15
mild Head Kyung 13 15
Mod i 09 15
severe i Ii 8

O
 ABDOMINAL TRAUMA f

Mfc organInvolved
overall spleen
Blunt spleen
penetrating liver spleen
GSW Cgunshotwound SI
Seat Beatt Sx Mesentery

Deceleron Puppy D J flexure

Blunt Abdominal trauma or

At

L
Hemodyanmically Unstable
Stable
First FAST FAST
I OC CEI FAST If FAST
I
LAPAROTOMY
HOWFAST 3 5min midline

RtHQ
Minimum fluid detected on FAST Examination

E FAST8 Fast t thoracic cavity

I

penetrating
s ft perftBreach
if supto peritoneum peritonitis

Localexploration
FIB omentum is Hanging out
suturing Baestaining of Dressing
FIB I
C Do I LAPAROTOMY

splenictrauma
Isuspect
kH 2ign
if
splenic Rupture
I 9 11 Ribs on Leftside
if we Raise LL
Blood Acc Beneath
dome of diaphragm
I
left shouldertip pain
Grades

Non Expanding subcapsular Hematoma CLI0 Area

Laceration I cm in deapth

Non Expanding subcapsular Hematoma C10 504

Laceration I 3 cm in deapth
Hematoma wich is Expanding or 50 area
Laceration 3cm in depth
Kyung to splenic vessels
shattered spleen

Ioc vative Mx
conser
usually
stable CECT Monitor vitales
A serial 24 HR CECT
I t it grade of Kyung TT
ANGIOEYMBOLIZATION

u I
Ha
Unstable

f Usually Unstable
I O c FAST
surgtesy splenoRRAPHY

1 surgery
splenectomy
complication ofsplenectomyor

10Hemorrhage during surgery

Hemorrhage
Reactionary 4 24 HRS of surgery
Hemorrhage I
slippage of knot
Dislogment of clot

J 20Hemorrhage Fewdays
infection
pancreatic fistula

Mfc complecation f ATELECTASIS LeftLower Lung

Hematological change

L J
transient permanent
A WBC HOWEL JOLLY BODY
2W
BASOPHILIC STIPPLING

IfPRBf a RETICULOCYTES

HYPERSEGMENTED WBds

Opportunistic poet splenectomy infections8

M C organism ENCAPSULATED

pneumococcus
 H9ufMM2a

meningococcus
children Adults
Occurs in 1st After surgery
High mortality
Hematological condition 7 Trauma

prevents
t
vaccines

Eiece Emergency
Besttimef Hr
Hr P0
2 weeksbefore

Liver trauma 8 Mlc in penetrating Trauma

1
If We Explore a liver Trauma PTNs
d
scribe of Lives bleeding
1
Pringles maneyroe
I
compress Hepatic pedicle

HA CBD
Bleedingsstopsthey
PV continious dueto
or Hepaticvein
 Mesentric trauma Mc seatbelts

MY MY
Rx
In No Loss of vascularity Repair Anastomosis

Rx Repair tear

Damage control surgery ABBREVITED LAPROTOMY

lithal triad of trauma

Coagulopathy

Hypothermia Acidosis

phase phase

PHASE0 Pt M
identification E Laparotomy I Reexploration
t I cU
of P T Aim I 1
StopBleeding Aim Aim
L ER t I
prevent contamination correct correct
physiology Anatomy
 thoracic Trauma Rib simplest form
of thoracic
trauma
Mtx
Adequate Analgesia
is
strapping Gtd
if if
1StRib Occurs Lo 12thRib
Uncommon Gloating Rib
1 subclavian
canbe
damage

II g Spleen Liver

M C Ribs during CPR 3 5thRib

Mc c of mortality in thoracictrauma
6 4
Blunt penetrating

TracheoBronchial Kyung Haemothorax

flail chest 8 2 or more consecutive Ribs at 2

of or

More places

problems
I
paradoxicalchestwall movements
I
ft's leads to pulmonary contusion
M c cause of Death
 ME Adequate analgesia Oa
Ivdespite
Ff RR 20 Min

POI 60MmHg
1
IPPV

Tension pneumothorax 8

gf D

sucking wound Conewayvalue

1
Sameclinicalfeature

I in

TAMPONADE
t
 tension pneumothorax cardiac Tempondae
Clinically Hyperresonant percussion
Note
Absent Breathsound MuffledHeartSound
Investigation EFast EFast

L J
emergency Definative

Needlethoracocentesis d
Tube thoracocentesis
I b t
children Adults
incertion Ict intercostal tube
of
2nd 5th I c s in D of Safley
Mfcspace
midclavicularline midAxillaryline
and we cover sucking wound with
gauze and tape it on 3 side
Tx Haemothorax B
I
Accumulation
of Blood in
pleuralspace
source Intercostal Vesseles

My incestion ICT in Dcf safety

of

Indication of E thoracotomy in thoracic trauma Artery

7 I I 5 Itr of Blood on incertion of ICT
2001CclHR for 3 consecutive Hours

Tamponade

Thoracic aortic Myung

Tracheo Bronchial

esophageal Kyung

ICT Dt tube 5
of safety

Ant Ant Axillary fad

post post
Apex Axilla
5th
Base
Ifc space
 of Lower Rib
incertion chest tubes UpperBorder
of
Mx

in
EfX
Movement of water column indicate A Functioning
Tube

Cardiac Tamponade A Zeck's f Hypotension

d T JVP
Rapid Accumulation Blood in Muffled Heartsound
of
the pericardial space

FASTIEFASI

M
Emergency
I
Needle penocardiocentesis
insert a needle viasubxipodSpace
Under EcholUs guidence

Definative
emergency thoracotomy and Repair tear
 NeckTrauma 3
1
traumazone

Zone I 8 Thoracic to cricoid cartilage

zone 02 E osteoid cartilage to angle of mandible

to Base
zone 03 angle of mandible of Skull

Head trauma
I tissue
Fibrous
septate
scalp laceration
Bleed profusly

t
Wales
of vessels

o
que
wa ca
cut

suture
 curlingulcers stress ulcer Dz
Ioc M L
H Burns
Mx3 Raised ICT
sign punctate Hemorrhage
l Adequate 02 I Vfluids
At grey's a white matterjynetiq
Avoid dextrose containing fluids
worst prognosis
3 I v mannitol

3 BrainHemorrhage 8
contusion Intraparenchymal M C traumatic
D by Nat
SAH subarachnoid
Mx conservative
EbHCExt d
Traumais m.ccauseofs.AM

Tµ
Extractural s
t
seen in young Pat's Highlevel impact

Arterial Middlemeningeal

Lucid intervel
ye
N consciousness b w 2 episodeof Unconsioousness
Ioc NCCT
Mx Bursts Made on side of iyysy
Mic site ptenon temporal Region
t
H shaped Area in T R
so if Nat is unavalible then BurrHole on side of pupillary
dilatation

subdural Hamessohage
I
due to Bridgingvein
usually in elderlyPINS
after Trival trauma
Altered SensoriumAfterfewdays
Bleeding bw Dura and arachnoid

Mx Burrte

TX Byers ABCD
t Exposure Amountof Burns

severity of Burns

Airways Dangersign and symptoms of Airway Burns

Burnt sign Nasal hair If any danger sign

carbon deposit in sputum u

Burns 97 Closed Room they

Prophylactic intubation
Burns involved Face1Head Neck
 voice
Hoarseness
of

circulation 5 Burns pals are dehydrated

154 TBSA Burnt in Adults

Hypothermic shock
cheqdrey
lot

parkland's Formula

94
X BW X TBSA
Burnt
Amount of Fluid in in in the 1st
Kgs 24HRS
In
1stdegreeBurns are Next
Excluded
YzAmount 1 2 Amount

first 8HRs Next 16HRS

Eg 60kg man
lot 1st degreeBurn 4 60 20
toy 2nd a

toy 3rd degree

2
60kg man
zoy 2nddegreeBurn 4 60 20
4pm 6pm a
Amount of fluid till midnight
3 Dextrose containing maintanence fluid given to children in
Addition to parkland

Targeturineoutput
New ATLS formula
Adults 2X BWX TBSA 0.5mi 1kg1 HR

children 3XBWX t.BA lmiHR_

kg

Infants 3XBwX TBSA 1 t.sn kglHR

1 dextrose commanding
fluids

TBSA Burn 8
PALM 1
WALANCE RULE OF 9

t
perinium 2.1
 Best method for 4 total BSA of Burn
LUND and BROWDER CHARTS

Degrees of Burns

1stdegree only involve Epidermis Red Tender Blanching

I
Heals without scarring spontaneously in 3 5 days
e SUNBURN
g

2nd degree
L J
sup deep
I
Epidermis papillary dermis Epidermis Dermis
Red Tender Blanching Red lesstender some area
dn't Branch
Blisterformation less Blisterformation
Heals in 2 3 Weeks c out 41
scarring but Requirespecial material Tendency to form Hypertrophic
scar and keloids

Special materials

M c used silver sulfadiazine

causes metabolic acidosis Mafenide Acetate
Best Cerium Nitrate
 4thdegreef
30ddeg.ee Black CHARRED
I painless
S ctissue muscle Mx
early exscion followedby Thickws
Skin grafting

M.cc of death due to Burns E

I immediate Asphexia Neurogenicshock
2
Early l 3days Hypovolemicshock
3 Late C 3days septicshock
4 overall
septic
Mc organism pseudomonas

special situation

17 chemical Burns
Alkali Burns severe
Never
try Nutrilizatim
wash with water
2 Electrical Bums
m c c of death Anythemia
AfcBurns
I
induced
Tetany
I
Myoglobinuria
 E Burns are Highgrade Burns always LOOK
for entry and
Exit

3 Lightening injury

L J
Indirect
Direct
Highgradeelectricalinjury Lightening strikes and object
and sparks fly off
1
Superficial Burns on ExposedArea
I
FILIGRI BURNSo

plastic surgery e

C Autograft sameperson
2 Iso Identicaltwins
graft
3 Allograft samespecies
147 Xenograft Different is

graft
Does not Have own Bsupply
 Split thickness skin Fullthickness
StsG graft CFTSG

Thin Thick
THIERSCH o WOLFE's

I DONOR
Mrc Donor site
Thigh post Auricular skin
supraclavicular fossa
11
Kufra in

INIVERAXILLATE

Epidermis t parts of a ETD

epidermis

Reused for grafting onceft tx cannot be used

Heals

STIG 1RecipientJ FIG

thicker More Resistant to trauma

cosmetically Better colour

Better survival rate matching
syrui
imbibatim 24 48HRS
inosculation 2 413ays
Neovascularization
74dg
graftfailure
Mc collection b w benath graft Haematomafseroma

infection

FLAP8 they Have their own Blood supply

postburn
contractures

Rhomboid Limberg
forpilonidalSinusSx
Jeepdriver'sdiseases
 Rotated Named blood vessels
Axial flap9 they are

M.c Usedflap by Head12 Neck surgeon prime

pectoralismajormyocutaneous
flap

perforates of internal mammary

I pectoratzrofthoracoaoomial

ABBE ESTEnder's Labial Vessel

upper lip reconstruction

we use Latssimus
Dorsimuscle
flap for Breast
Reconstruction
M.c Used
flap for Breast Reconstruction 8 TramTransverse Rectus
cutaneous
Abdominusmyo
flays
Best flap DIEP 3 Deep inferior epigastric A perforatorflap

tree flap 3 free fibular flap Best for Mandibular

Reconstruction
 Bedsore
sum Mc site
Bedsore same as Burns
Staging of

prevention

frequent changes of position every 2 HRS

water airbed

VAC
ve pressure dressing 125MmHg

1
YES Chronic non Healing wound
Venous ulcer without Slough
Diabetic ulcer without osteomyelitis

Burns wound without Eschar

Bedsore

Healing by intention delayed primary closure

I
if wound is infected leave it open when granulation
tissue
I
suture after
 Hypertrophic scar keloid

Remain withinthe keloid grows beyond Boundy of

Limits of the scar the scar
settle with time I Don't settle with time
pressure pressure

geneticand Racial presentation

commen in dark patients
Mic site Sternum
shoulder
egolobule

IntraKismat Tnhmcinolone
Mx

BREAST Modified sweat gland

rn

J is 20 lactiferousgland

involved
a
Retraction
Pmajor
of
Nipple
LigamentofCooper
involved
Dimplicering
 Peau d
orange

t
O
due to subdermal blockage
of Lymphatics

TELUS Terminalduet lobule Unit All cancer's anise from

Here
Functional Unitof Breast

Lymphaticdrinage

e
n
Axillary L N 90 3 Internal mammary L N Cloy

P minor divide Axilla in 3parts

Es
press
Rotter's
LymphNode3 interpectorial N Bw pmajor and minor
Tx Pf Lady comes with Breast Lump

triple Assessment
L u
Histopathology
Historyandphysical Radiological
ExaminationTest Test I
IFNAI 23 30gauze
Needle
40412 740412

USG
t t
Mammogram
l
CBC2young pimps Have Drawbacks
Dencetissue mammogram Highfalse ve
Notsensetive it can Not diagnosed bw
in situ invasive cancer
I One forBreast lumps True
cut Biopsy CoreNeedleBiopsy
insicional Biopsy Technique

Exsicional Biopsy
GoldStandered investigation

Mammography on 0.2 0.2copy

C C coaniocaudal
2 views

Or
Mio Mediolateral oblique Show Max
tissue
 Latest BEST3
3D Mammo Tomosynthesis

mammography

a
Screening Diagnostic
I
Best screening modality 40yrs
start at 404 r

Imaging for Breast 8 BIEADS3 Breast investigation

Reporting and data system

v so
Best investigation To diff B w solid Uf cystic lump
in a pregnant Lady with Breast Lump

MRI for Breast implant

Bestinvestigation to detect multifocal and multicentric
Best for local scar Recurrence

screening modality for young 2 Higher Risk pads

I
StrongFamily History
BRCA mutation
 most sensethe DeutualcarcinomainsitucDCt

Pathology f Br cancer
1 is
sporadic got family lot

M.c Genemutated in BR cancer Ps3

I il l FAMILIAL BA ca's BRCA

BRCA mutation syndrome

d
HER Breast and ovarian cancer syndrome

1Brc YBR
179 139

Breast cancer S
ovarian ca
pancreatic

dialogism.me

nonaggressive
poor prognosis Basalsubtype
 4130 1stdegree
should be screened

1
BRCAmutation

t
Lifestyle changes
Wt loss
RegularExersice
Giveup smoking Alcohol

MRI screening

Risk Reduction Technique

I
BIL salpingoophrectory
TAMOXIFEN
SERM
13ft prophylactic Bso
mastectomy
t ovarian BR ca
I BRCANCER

M c Type Invasiveductal carcinoma Nos Nototherwise

specific

Hp E indian file pattern

cuistopatho
single n
Invasivelobular ca a
o

M c Quadrent affect f Upper outer Quaderent

 L c Quaderent affect 8 Lower inner Quadrent

IHC immunohistochemistry

f t ki
PRO HERai
proliferation
1 d index marker
Estrogen progesterone

Receptor Receptor

t t Low
luminal
Mrc
Bestprognosis

Luminal t t t LowlHigh
B
Basal
High
CthpleNegative
CTNBC d
worst
prognosis
mostaggressive

HER 2 High
ENRICHED
 TNM staging of Baca

Tuznor

To No tumor
Tis in situ 7 DCIS ductal Ca in situ
Lets Lobular 11 Now NO
Longer in situ
Paget'sdisease
it's Benign disease

Igf 2cm Ta 2cm but cm Tz 75cm

Ta
t t
t t
ChestWale Skin
Dimplingf A inflammatory
p Mayor C J Breast ca
minor C I RetractionC 3
worst prognosis
S anteriorCt ulcerationCt

IIcmuscle t p dorange Ct
RIBS Ct satellite t
Modules

No NO LN
N Mobile Axillary LN

Nz fixed Matted Axillary L N

Nz Infraclavicular supraclavicular L N
 Mo No distant Metastasis

My
M c site of distant metastasis BONET
I
Wich Bone Vertebral Column

Why Batsonpspiexusqvelns
wi.ch vertebrae Lumber Thoracic

what type of Bonymetastasis Osteolyticsosteoblastic

Q
MII
MII
USG
Tryout Biopsy
MRI

USG

I O C8 Try out Biopsy

11 for staging 18 FDG 42 110 MM
PE
Management surgery

Breast conservation surgy Mastectomy

BCS

overall same same

survival

LRR 4 I
local Regional
Recurrence
u

Radiotherapy is

mandatory

Bfs Lumpectomy

J
Oldmargin New Latest
ammo

CIIfogBcs f Technical
to Rt
pregnancy multifocal multicentric
SLE Rheumatoid Lobular cancer multicentric
PriorRT Exposure to Largetumor Breast Ratio
chest wall
 Mastectomy

S
Radical mastectomy Modified Radical
mastectomy

BREAST 1 NIPPLE AREOLA BREAST t NAC

COMPLEX

3 AXILLARY LEVEL 1,2 3 AXILLARY

LEVEL 1,2 LN LN

p Major t Pminor P facial p minor

Incision ELLIPTICAL
STEWART
e

simplemastectomy

BREAST 1 MAC
Pfacia
L.nl are not Removed

complication Hemorrhage
Pug to Nerve CM.CN My during MRM ICBM
He
Intercostal Brachial Nerve
I
sensory Nerve to Axilla
 I
Loss of sensation in Axilla

Longthoracic meme Puppy winging of scapula

of Bell Sant

Mc complication SERoMA_
prevent Drain
if it develops Aspirateunder Aseptic condition

Lymphedema

Post mastectomy Lymphedema is the Mfc cause ofthe

UIL lymphadenoma
Long standing Lymphedema can give Rise to
ANGIOSARCOMA
L
STEWART TREVI syndrome

Local Recurrence CANCEREN CURASSE

Extensive

Sentineal LymphNode Biopsy E

S LN first draining in LN from cancer

First cancer in with SLNB described a penile
Name CABANA
of surgeon
othercancer Breast
Malignantmelanoma
H ZNeck
vulvar cancer

in BRICANCERS indication LN are Not clinically palpable

TO Localize sentineal L N BLUE DYE technique

dye methylene blue Blue L N
are sentineal LymphNode

2ndTechnique for s Tcgg TAGGED

LN Radionuclide
colloid
I
see with gamma camera
14
HOTL N or Radioactive technique

I
show Sentineal L N

Best for dx is a combination of Bluedye 1 Radio

Nucleotide

M c Nerve Pyured in S L N
Biopsy f Intercostal Brachial
Nerve
chemotherapy f given it
LN
t.op.ee
HERZNew Paclitaxel
Y
d
we add TRASTOZUMAB
SIE Hemorrhagic cystitis
Also ACROLIN Causes Hemorrhagic
cystitis
preventive Agent

MESNATX
Radiotherapy5 given it Hormonal therapy

1 BCS done I
2 it LN onlyin t t

L S
premenopausal Postmenopausal
Tamoxifen Aromatase

Earlier it wasgiven 5 year Letrozole Anastrozole

Now 10 Year given 10year
M HOT flushes me e Osteoporosis
Ss

M Tmp prognostic factor L.nl tus

M 11 for metastasis Breast cancer ER.PL
 Ff localized Breast ca early
t
surgery is done first Chemo RT

Localised Advanced B12 cancer

Neo adjuvant chemo surgery Rt

Male BREAST CANCER incidence It

Female
Mx and prognosis same as BREASTCANCER

pregnancy Associated B CANCER8

R

Imaging of choice USG

Ma
syrgery chemo RT 2 HT

Bcs GI
L J
GItrimester
in 45 in All
Mastectomy go Trimester
Bcs RT is
GI

DCISoo ductal carcinoma in situ

Non invasive

Mic presentation Microcalcification on mammogram

My g 540guy
NO ROLE OF CHEMO
a HORMONAL T If ER PR
Lumpectomy simple
mastectomy
pet is done if Lumpectomy

Benigno
1 Breast Abscesse seen in lactating women
M.c organism Staph Aureus
Source oropharynx of child

Pain Fever swelling fluctuation is a latesign

or USG

I Abx of choice3 AMOXYCLAV or CLOXACILIN

2 Attempts
of Aspiration shouldbe done
1
if they fail incision and

drinage
11NOblade
 fibroadenoma Mfc cause of BREAST LUMP

15 25 YR
firm lobulated

Mobile lump BREASTMOUSE

by user If
if Mammogram popcorn
calcification
I
surgery
1
It Pt is symptomatic
5cm giantfibroadenoma
Family History of cancer

1
PAREAREOLAR incision C cosmetically better

TX MASIALGIA 3
L J
cyclical Non cyclical

Mic fibroadenosis fibrocystic Mondordisease

sup
disease
thrombophlebitis of chest Veins
25 YRS cord like structure below
cyclical pain is Max the Breast
 TIETZE syndrome Is
Before onset of peroids
costochondsitis

A
DX f USG t
MX I Intraleismal
Mx Lifestyle modification
Trigmcinolone
wt Reduction
Vit E 2 PRIMROSE Oil
capsule

Tf Not Respond
Lowdose Tamoxifen

Nippledischarge e

greenish Nippledischarge Mc c duetectasiaCdilated duet

I
mutipleduet
40412
Age
Doo USG
MX 0 ANTIBIOTICS
I
it PTH Does Not Respond surgery
 Headfields procedure
CONE EXCISION OF MULTIPLEDUCT

Bloody Nipple discharge

Single duct Multiple duct

Duct papilloma
t I
Me Cause Bloody Nipple
of cancer
discharge

toy are Associate with

DCI S

Mx surgery
Microdochectomy Removal
of a single duct and papilloma

PAGET'S DISEASE ECZYMA

Eczyma like
condition in NOdestruction
of NAC
Wichthere is destruction
of NAC B c
02 No Lump
70 With Patients Have
Underline Lump
Sometime
Mostly Deeg invasivecancer
B DxS punch Biopsy
1
Pagetcells in epidermis
ER PR 0
CEA

Mx Underlying disease Mx Steroids

phyllodestumor cystosarcoma phylodes

3rd 5thdecade
Rapidly enlarge Mass
Dilated veins
L N involvement is Uncommon
A Try out Biopsy

Mx L s
Lympectony simplemastectomy
 Gynecomastia enlopymet of male Breast

Physiological Pathological

NewBom Drug induced

pubertal D Digoxin
senile I IN H CBon9929d
S spironolactone steroid
C cimetidine ketoconazole
0 oestrogen

Klinefeltersyndrome
Cfoshosis

paraneoplastic syndrome
Hcc
Rcc
Testicular

DX 8 USG
Mx liposuction t Gland Excision
 ORALCANCER8
Mrc site

India world

gingivoBuccalsulcus Lat BorderofTongue

Pathology e

M.c Histology Scc

M c gene 1253

Riskfactor8
smoking TOBACCO chewing Alcohol
HPV EBUG SHARP ILL FITTINGE
DENTURE
Nasopharyngeal ca

condition
premaligned
Morecommon 3 5 time
Leukoplakia whitepath cannot be Rubbed off
Erythroplakia Red patch

more premaligned CG 9 time

chronic Hypoplastic candidiasis
oral lichen planks
20syphilis
chronic submucousfibrosis I Hypersensetivity Reaction to
Beetle Nut
My Intraleismatthamcinolme
fibrosis in oral cavity
 Plummer Vinson syndrome
syndquef person Kelly
Ass 2cancer

pharyngeal Sc c of esophagus
cancer

confirms by g Wedge Biopsy

done CE
Staging by

Me d X
chemo
RT
surgery
I 5 FU d Local
Recurrence
widelocal Exsicimof cisplatin
Ptumor
site Distantmetastasis
old New goprofft
Mfc of I
P
E Lungs
2cm 0.5cm

if mandible inv
2
Mandibular Resection
MII prognostic factor
Lonstat
3 it LN
Neck bisection

4 Reconstruction
 Upperdeep cervical we
Bymanual palpation
111 mid diff1 B w gland
IV Lower 11 L N enlargement

DigastrickufzignYigular
M.astoIDg

B Antdigastric
9
Oe j submental D
HYOID
level IA
Submental L.nl

L 5
3 supomohyoid
again Spats L N6 Central
levee compartment
P ipranihaenuirini

CLAYICLE
k
TufomohyaI
Iastinal L N
n Medi

Neckdissection
f b MRND modified Radical
Radicle Neck Incision 3 Modified SCHOEBINGER
dissection
CRILE LV l 5 LN
by
w 2 to 5 But we save at least one extra
3 ExtraLymphNode Lymphatic Structure
Structure
SCM o Ijv o
spinalA N
 complicationof N D

1 Hemorrhage

2 Injury to Marginal mandibular Nerve

Ramusmandibular is
Br offacial which supply angle of mouth
it figured Drooping
Hypoglossal
phrenic
vagus
3 Maxmortality E c

X X X X

Benign salivary gland conditions

RANILA8 Mucus ExtraVASATION

cyst inva sublingual salivary
gland 0
cystic swelling in azula
floor of mouth
Fluctuation
Transluminatim othercondition cystocele cysticHygoma
 of Ranma Iap is GI
Excision of cyst
or MARSUPIALIZATION
sublingual gland

Mtc structure Ayural during surgery submandibular

Nene n n n Lingual Nerve
a

TX PLUNGING RANULA f Mucus Retention cyst inv

sublingual 12 Submandibular gland
swelling is in oral cavity in the Neck

Mx Excision of intra oral swelling t sublingualgrand

Aspiration of Neck swelling

SIALOLITHIASIS 8 Stone in salivary gland

submandibular s popatoid

more viscusus secrating

antigravity damage

Mc composition E Calcium Phosphate

 post parandial painful Neck swelling

I O.c NCCT

Mx surgery

If stone is Distal to Lingus Nome Incisor

closed to thegland L
H Endoscopic removal
submandibular gland
Excision

M c structureinjured e Lingual Nerve

salivary gland tumor

p of Benign op of malignant

Paratoid 90 10

Submandibular 50 50

Sublingual 20 Soyo
minor 10 904
 PARAIOID
M c Benign tumor in paratoid pleomorphic Adenoma

MfcTumor overall

pleomorphic adenoma 2

slowgrowing paratoid tumor

Usually inv sup Lobe of paratoid

Dx by FN Ac
Histopatho Epithelial and mesenchymal component

Extent MRI CECT

My superficial parotidectomy

sometime mixed
malignant change malignat timer
signs Rapid Tin size
pain
Ulceration
fire of LN
investigating of facial N
Dx by E FNAC
Mx surgery followed by Radiotherapy
 Warthen's tumors

Adenoma Lymphomastum

2ndM c tumor in paratoid

10 f Canbe B L
M F

sup lobe of paraloid is inv

DX by FNAC

Extent MRI CT

Mx sup paratoidectomy

Me Malignut tumor parathyroid MUCOepidermoid

of carcinoma

2nd M c u m Adenoid
cystic
cancer

paroidectomy

Incision LAZY S Modified BLAIR

L J
Total pasotdeetomy
sup
sup deep lobes are Removed
sup lobe
 If deep Lobe involved them
clinically a
Toneinarfossapushed medially

complication
I Hemorrhage

2 Trying to Nerve
Marginal mandibular N
Facial N Involved
Greater Auricular Nerve
1
leads to Anesthesia over angleofmandible
3
freysyndrome gustatorysweating
11
sweating over paratoid Region when pints think
offood eatsfood

Nerve implicated Aysicotemporal parasympathetic

DX by s starch iodine test

Mxby E Antiperspirants
Botox
Tympanic Neurotomy

prevent 8 o Scm
M flap
Digastric
Me Tumor of submandibular gland pleomorphic
adenoma

a Malignant tumor of a Adenoid

cystic
cancer

Nerves Ryured in surgery marginalmandibular

Lingual
Hypoglossal
 Thyroid gland

Surgical Enatorye Butterfly shaped gland

sup thyroid A Br External Caratoid

of
Tuf u n thyrocervical think
ima A Direct Br
Thyroid of Arch of Aorta
30.1 pthls Have middlethyroid Vein First vessel ligated
during thyroid surgery

Tuf thyroid vein drain Bradriocephalic veins

Ext Laryngeal Nerve Associated With upperpole

supplyonly cricothyoidM

RLN Associated with lower pole supply all other mg

of larynx
sup thyroid Ligateclose to gland
Thf a
only ligate capsular Branches
main trunkof Pnfthyroid Never ligated bez
it's supply paratysoidgland

Investigation
1st investigation CTzftylTSH
 USG Neck
I O.c FNAc
I
Drawback can't d F b w follicular
Adenoma
v
follicular carcinoma
Normalthyroidscan
Thyroidscan
indication
1 Hyperthyrodism 2 LowTSH
2 Ectopic Aberrant thyroid tissue
DrugsFIBsurgery
Non Functional
Nodule

0 08
Plummer'sdisease
DJ
Rx DrugsFIB
RIA
00

G O
1
Hyperfunctional diffuseduptake
Nodule

cold Nodule Have Higherchance of Malignancy

Soy

Hot Nodule Have less 1204 chance

5 CECT Neck Thorax

Retrosternal goitre
 Thyroglossaf
cyst Remnant of tyroglossal tract

i tegmen

A
if tract persistthen thynglossal
Cystoccurs
M c location Subhyoid

Midline Neck Swelling

Cff moves with deglutition
n protrusion of
Tongue

in and drinage is DX by FNAC

MX by SISTRUNK's procedure
I Removal
of cyst tact till base of
it donebymistakethan tongue part of Hyoid Bone Is
Removed
thyroglossal fistula form
H
then myo SISTRUNK's procedure

Long standing thgoglossal cyst can develop papillarythyroid

carcinoma
 Thyroidcancer
I papillary thyroid cancer PTC

Mfcthyroid cancer overall

2nd to 4th decade F M

Radiation Exposure to Neck

Longstanding Thyroglossal cyst

Tends to be multifocal
s Hematogenous
Lymphatic
K H
Lov 6 of M C Lungs
Centralcompartment
indelphian

Lateral Aberrant thyroid

t
Level 6th LymphNode due to pic b thyroid glandis
Not enlarged

Dx by Oo FHAC

Histopatholy C intranuclear inclusion 3 Psammoma

Bodies
2 orphan annie eyednucleus
 O
O
I
PsammEmabodies

othercancer3 a PTC
psammomabodies
Meningioma
protection ma

Mesothelioma

papillaryRenal cell ca
adenoma
Serous cyst of ovary

D DXby FNAC

Mx by surgery
1
If PTNs is L 40 4 r C 2cm tumor Unifocal
Nocapsular invasion
1
them do HEMITHYROIDECTOMY

Others Totalthysoidectomy Ctt

if W G L N are enlarged than TT 1 centralNeck
dissection
CND
 It
if Lu 6 are enlarged than
other L N
TT 1 CND 1 Modified Radical N D
MRND

waitfor 4 6 Weeks
L
Wholebody Ia Scan
If Residualdisease Metastatic disease

S
0
Radioactive Ablation
followup
by I 1317 a 6months
prays the dogs
78
USG
sothyroglobwin
a
Tumormarker for differentiation
of
thyroid cancer

PTC Have good prognosis

Lindsey's tumor follicular variant of follicular ca

 2 follicularcarcinoma FTC
I
2Nd M c

Mic in iodine deficient Areas

Fs M

RIF 8 MultiNodular goiter longstanding

CIF E o
thyroid swelling
Hematogenous Lymphatics

Bony metastasis pulsatile in

Mc site Nature
I
also in Renalcell ca

FNAC Can't d F follicular Adenoma Is follicular

ca
He
follicular Neoplasm
I
MX f HEMITHYROIDECTOMY
frozensection
L ADENOMA
CANCER
I I
samesurgical principle No furthersurgery
95 PIC
I
postopand followup
same as p T c
 3 Hurthle cell carcinoma

Earlierthought to be a variant of FToc

More Aggressive than follicular cancer

4 ANAPLASTIC cancer
e

worst prognosis
in5th 16th decade
Rapidly growing thyroid swellings

Shows

Local features Distantmetastasis

RLN Involved
I
Hoarsnessof voice Mlc site Lungs
TRACHEA involved
I
stridor
HARD SWELLING

D by 8 FNAC
My8

c S

Pt Restricted to ft metastasis Advanced

thyroid a palliative Mx
I
Aggressivesurgery
I
Tf pressure over trachea
I
isthmustectomy

DABRAFINIBTIC

Medullary thyroid cancer MTC

11
arise from c cells Parafonicular cells

Neural crease Ultimobranchial bodies

calcitonin Tumor marker

MTC

Familial
sporadic
MEN 2 Syndrome

Most aggressive MEN 2B

Aggressive tumor
Multifocal
 Lymphatic Hematogens spread
M C site Lives

swelling
Diarrhea Serotonin
Flushing Histamine

mic

IT
Amyloid Rich Stroma
D by f FNAC

Mx Surgery one step ahed of tumor

ft Restrictedthyroid TT 1 CND

It thyroid 1 LN 6 TT t CND t MRND

t other L N
fx
there is NO ROLE Of Ig SCAN and Radioiodine
Ablation

VANTENIB CARBOZANTINIB Tyrosine kinase

 11

MEI syndrome
MEN 01 Wernersyndrome
chromosome Chr H

P pituitaryadenoma Mfc prolactinoma

PTN's
P parathyroid 95
p pancreatic endocrine Mrc in MEN IS
tumor GASTRINOMA

MEN 2 syndrome RET PROTOONCOGENE

Ch

L J
MTC
MEN2CA
only Sipplesyndrome
MedullaryThyroid ca CM
pheochromocytoma

parathyroid adenomas

02 B AK A MEN 3
MENI Syndrome

MTC
Mucosal Neuromas

MARFANOID HABITUS features

Medullated corneal Nerve fibers
 Thyroidsurgeries

IncisionUse COLLARI

position Ii I ROSEPOSITION2

Types
Hemithysoidectomy

Lobectomy
D fishmuseetony
D total

YOBBOS Yama
Near total
subtotal
HARTLEYDUNHILL
procedure

complication P Hemorrhage
Trying to External laryngeal N S RLN

4 Bc of B
I
t
f
Hoarsness
Litethreatning
Hoarsness
 3 Postop Respiraty distress due to
causes
Laryngealedema Mrc
Tension Hematoma Remove suture and
evacuate Hematoma
Layngeomalasia
131L Laryngeal N Ryung

Hypopartyrodism Late causes

48 72 HRS

U Hypoparathgrodism
vascularinsult to p gland

symptoms after 48 72 HRS

Easysymptoms periora numbness Paresthesiasis

Tetny
t
Respiratydistress
2
sign
I TrossAUSIGN8 carpopedal spasm or
obstretician Hand
deformity
2 CHOUSTEKSIGNS facial facial spasm

MX I L
if severesymptoms or
if minorsymp s can s
8mgIdl
S card S
8mgIdt I v calcium gluconate
oral ca 2 oral VitDg oral cat
oral Vit133
 Joli's thyroid Retractors

MIUAT minimally invasive videoassociate thyroid

surgery

intraoraltysodotomy

Hypethysodism I weightgain
constipation
coldintercourse Alopesia
Lethargy Menorrhagia

Bradycardia

I Tz Ty I TSH T

causess
m Iadeeficieng

In Western HASHIMOTOTHYRODITIS

wolf CHAIKOFF IzinducedHypothyndis

iatrogenic

dystormogenesis A Defect in Thyroid peroxidase

 HASHIMOTO's lymphocytic

Mc AutoAb against TPO

FSM thenglobulin
Autoimmune Thyroid receptor
Blocking Ab

I AutoAb Stimulate infiltrated gland

lymphocytes
1
destroy follicle
I
stored Hormone into
circulation
1
prolonged
destroy Initially HYPERTHYRODISM
follicle
HYPOTHYROIDISM Hashitoxicosis

Diffuse enlargement of gland

Dby Autoab level

Mx Thyroxine Replacement

Tf goitre surgery subtotal Near total

Long standing Hashimoto can Risk of thyroid

lymphoma
 Viralthyneditis DEQUEROAIN GRANULOMATOSIS

SUBACUTE THYROIDITIS

viral infection 4 6weeks Lymphocytes intogland

CURTI Later µ
destroyfollicle
I
FIB initially Hyper
Hypo

But it is a
self limiting condition
I
In a Few Months follicle Regenarate a
Euttyroid state

painful Neck swelling

supportive care

Reidatthyneditis 8 CFTbrosingthyroditis

t t
fibrous withingland vicinity of gland
t
RIN Hoarseness
Hardthyroidswelling
Trachea stridor

Anaplastic Ca Mx8 Steroids

 Hyperthyroidism
Wtloss ABMR

sweating Heat intolerance

THR irratibility
Diarrhea
OIg
A Tz Ty T TSH I

causes e Me Gravesdisease
2
solitary toxic Nodule
3 Toxic Modular goitre
4 TODBASDOW'S PHENOMENA
Iz induced Hyperthyroidism

5 Factitious Hyperthyroidism Exogenous steroid

6 Struma Overii
7 TSH secreting pituitary adenoma

t
Drugs Drugs fW
Drugsonly RIA
tfw surgery
f b
Carbimazole
PTU
Tafeiffegnency

Agranulocytosis
Drugs are given 6 8
Weeks before intervention
any
I continious 7
day after Sy to prevent
THYROID STORM
propanol01 also added
a

I vasculary
Shrinkthegland

MC
of Death in thyroid
causes
storms Arrythemia

GRAVEL diseases
M c causes of Hyperthyroidism
AI condition
AutoAb Against Thyroid Receptor
stimulatingAb
L Long Acting Thyroid Stimulating Ab

Diffuse Goitre

Eyesign

Exopthalmus so STEALWAG
signCPufrequent Blinking
Lid Retraction Lid Lagevon spasm of Muller
GRAFFE muscle
sign Autonomic componentor
Lps
 JOFFORYsign Absence
of Forbead Wrinkles on upward
gaze
Loss Accomodattoy
MOEBIUS sign of Reflux

pretibial myxedema
Thyroid Acropathy

DXby D AutoAb Leveles

Mx in child drugs only

Adult with out goitre Drugs f113 RIA

it with goitre Drugs FIB surgery
Elderlypals with Drugs F B RIA
comorbid condition
PTU propyl.thiouracil
pregnant

solitary thyroidmodule
M.c causes colloidAdenomae
2nd M c causes Follicular
1st investigation Thyroidfunctiontestct
Ioc FNAL
 Retrosternal goitre

mediastinal goitre 20Retrosternal goitre

10 3 90 3
Ectopicthyroid tissue in start in Neck
1
Mediastinum
plunge into
mediastinum
Cso Plunging goitre

swelling
dyspnea
Stridor
Lower limit can'tbe Reached
Pemberton's sign

IO C CECT

Mx sternal Goitre can be Removed

Majorityof Retro via
1
Neck only incision
 Parathyroid

Hyperparathyroidism

Bong Pathological
Browntumors Osteitisfibnosa cystica
Stones Renalstone I oc NcCT

Abdominal growns colicky

pancreatitis
psychiatric overtone

test8 SoPTH AT
S Cq y y
S phosphate it

L J
Adenoma Hyperplasia

Tagg
Sestamibi
scan L
1 surgery
surgery I
Removal of Remove342 Glands and we

singlegland Auto
transplantation
ofthe Remaining
Gland

If thereis Recurrencethan Brachiofadialis S Sternockido

mastoid
we can easily Removeit Non dominert
Hand
 I Hyperparathgrodism

vito
If Id condition
Ica 12 Absorption
16 Y'gyevegible
we correct CRF
Is.ca and give
11 ORAL Vit D3
PARATHYROID
HYPERPLASIA

30 Hyperparathyroidism
e

Longstanding CRF Adenoma

irreversible
good
condition

Mx I correction
of CRF
Removal of Gland

TX PseudoHyperzaralytodism
Hypercalcemia of malignancy
More PARANEOPLASTIC
syndrome
me cancer s c c lungs
 VASCULAR SURGERY

1 Deep vein thrombosis

Stasis
Ito Virchow

EnothelialKyung
Hypercoague
State

R previous 4 0 DVT
Trauma

pregnancy

protein Cas defi

Factor I leiden mutating
immobilization

I I
PainfulWhitelimb a painful bluelimb
thrombosisof majorAxialveins collatrels are spared
collatrols
 Me vein involved n
Mnc vein in Wich DVT give Rise to p.EE all
199

Femoraliy

me symptom pain
M c sign

Limbedematx
signs
1 Homan Painon doositlexiong foot
2 MOSES pain on squeezing calf
I O.c Duplexscan

Mx
First 5 days LMWHTWARFARIN2

After 5 days onlywARFARIN2

Monitor warfarinby I international Normalized

Ratio
Target INR in DVT a 3

First episode of DVT Anticoagulant for 3 months

Recurrent DVT for life long

 IVC filter
I
indication I
I
Anticoagulation YI i
if pummasy embolism
despite Anticoagulant

f limb
Venous
system of lower
b
sup Goy deep soy

l perforators

100 150 y
 VARICOSE VEINS e
mm mm

Venous Lower limb

systemof
k b
deep soy
sup 20
t t
greatsaphanousvein short saphenous vein
Medial end of dorsal I
Lateral end
t t
medial Malleolus
posteriorly
I I
medialAspectof knee S FT
I Csaphanopoplietal Junction
S FT
Variable location
saphanofemoral j
All along it's corpse
4cm belowandlateral
to pubictubercle 14
I syral Nerve
Below theknee GSU is I
associate with SO NOstripping should done
saphenousNerve
I
SO therefor NO
stripping of GSU below
knee
 perforator

1 saphanotemoral Junction MIM

Hunterian Thigh
3 Dodd's
Abovekneee
U Boyd Below knee

TX 3 COCKETT 5 CM
from m
to cm
15 CM

mayestKuster Heels

Dilated veins
of Varicose vein
Tortuous veins

pigmentation due to HAMESIDERN

Test
for is SFJ competent or Not
Trandelenburg's test
are perforator 1

multipletorniguert Test site of incompetent perforator

Fegan's methods
 Modified Perthes Test if Dvt or Not

DVT is for surgery

MORRISEY COUGH IMPULSE f SFJ Incompetence

I o C J Duplex scan

MX I Traditional
c u surgery
1 GSU SFI 2 SSU SPJ
incompetence DODD COCKETT
incompetence
procedure
Traditional surgery Traditionalsurgery
Ligation of
TRANDELENBURG FlushLigation of Perforators
SURGERY SPS
I cosmetically inferior
11
Flushligationof SFJ
Nostripping
stripping is
Additional µ seepsg
but only done Above Latest Subfacial Endoscope
the knee EULT Perforatorsurgery
RFA H
Latest Latest
I
l Endovenous lasertherapy EULT
RFA
Radiofrequency Ablation
TRIYAX Sfc Piuminator
I
we took out Vein and ligate

Foam feterotherapy I
3mm in diameter varicose Vein

f 3 MM i Reticular 4

L l MM 11 THREAD Vein DERMAL

FLARE

M c Eelenosing
Agent Nattetradecyl
f
sulphate

complication of surgery

M c Bruising
injury to Nerve
it 11 Femoral
11 11 11

complication of v.v surgery

1 Bleeding 3 pigmentation
2 Calcification 147 Lipodermosclerosis
 varicose Ulceron

o O
Theory Ambulatory venous HTN theory
features a shallow Ulcer
Sloping edges
pale granulation
oftissue
My BISGARDREGIME
l Education
of patients
elevation of limb
3 elastic compression stockings

4 Dressings
5 surgery Margolin's ulcer AA

BUMP scar
longstanding venous Ulcer

Margolin's ulcer
I
in squamous can ca
 Ulcer's

sloping edges Healing

venous

punched syphilis
Diabetic
Neuropathic Ulcer
Bedsore
Arterial

J underminded TB

Rolled out pearly white

Guy Rodent ulcer
Bcc

Globe Raised cauliflower

cc
like
 ARTERIAL SYSTEM

Acute Arterial occulasim

I to an embolus

source Heart
8 Eps p pain
p pallor
P paresis

P paresthesia

p poikilothermic

p pulselessness latefeatures

I o c Duplexscan

Mx I 4
Early late
II I
with in 6 steps gangrene
I
Embolectomy Amputating
1

by
Fogarty's
Ballon
catheters
 chronic Arterial occlusion g

E to thrombus collated
gradual phenomey f
Intermittent claudication

ERICHEsyndrome9 Aortokiac Bifurcation Block

Earliest off Gluteal claudication

I
Impotence in male
I O.c Duplex scan
 Ankle Brachial pressure index MaasystolfeBpa tankle
Il a Brachial

I 2 CKD DM

I I 2
0.9 intermittent claudication
Lo 3 critical limb ischemia CRestpain
co Rest pain

Burger'sdisease Atherosclerosis
oblitopigns
thromboIgitis
M F or
M F

smoking
or LL UL
LD UL 5th decade
3rddecade only involve

Artery Nerve Vein proximal to distal spread

involved vessels
Large to medium
Distal to proximal spread my Bypass grafting
small to mediumvessels
Mx Bypassgrafting Not suprainguinalgraft
1
Useful bc2 No DistalTarget Aortofemoral
Bestgraftmaterial DECRON
stop smoking
Lumber sympathectomy infrainguinal graft
I Ciliopoplietal
only done in Restpain
Best Best
it 131LLumber sympathectomy Material synthetic
I
Leave Lz Ganglion on side Reversed PTFE
Saphenous vein
lead to
damage
Impotence

ANEYRYSM

Mnc vessels c Aneurysm circleofwillis

M c Extracranial Ab Aorta CintoraReggata

M c peripheral popietal
Me visceral vessels splenic
M c vessels in mycotic Aneynysm Aorta
m c organism stgohaureus
 Raynaud's phenomena
1
Vasespasm
phase I phase 2 phase 3
Atv inspasm ARelex v inspasm A 1 V Both
Relax
white pale Blue pain Red

Do c card1 channel Blocker

AN fistulae causes
traumatic
congenital

Mfc Iatrogenic
dialysis
f
Radiocephalic
C Cimmino

pulsatile swelling
palpable thrill
it in a limb 2 Hypertrophy of limb
congenital fistula

BRANHAM NICOLADONI sign press feeding vessels

size PRISBp 1 Thrill I
I OC MRANGIOL

MX Ft symptomatic
Angloembolization

fails
Hypertrophy

surgical ligation
 HERNIA I
mm
protrusion of viscus or part of
viscus through Wale containing it

Uncomplicated Hernia 3 Reducibility

cough impulse

obstructed Hernia irreducible

cough impulse 0
B Blood supply to content is intact

Strangulated Hernia obstructed 1 compromised B supply

TA is a process to Reduction of Hernia

wld Not be done in obstructed or strangulated

Hernia

Based on content

difficult to Reduce 1stpart

Bowel enterocele 2nd n
easy to 1

omentum omentocele
easyto Reduce 1st part
difficult to Reduce 2ndpart
Meckell diverticulum Litters Hernia
Appendix Amayant
 Inguinal Hernia 8

indirect inguinal are theMlc Hernias in Both

of 07
But femoral is more common in IFSMT

HASSELBACH A

Medially outer Borderof Rectus

sup if epigastric
iwf inguinal ligament

L j
through Lat
direct indirect

Deep Ring occlusion test

Mx surgery

HERNIOTOMY

Ann
identyty and cutaccess
tax
Wedo nothing
opensact push sac close to defeet
contentsinside Sac 11
therewin Highest Recurrence
But it is T.o.ci inguinal Hernia in children

congenital Hydrocele

2 HernIorraphy
I 2 13J we suturedefect togather

in obstructed strangulation
He
Bez MESH can't Use in infection

Hernioplasty I 2 IMESHI
proline
Least Recurrence

complicating open inguinal six e

i 10 Hemorrhage

2
M c ihyural Nerve Pieoinguinal
3 MC ENTRAPTTED Nerve Pleohypogastric
Beneathmesh pain
4 Trying to UAS
 Special type of inguinal Hernias

1 sportsman's small inguinal through in post

I
fwaum usue
inguinalpain
Not palpable
Ioc MRI

2 Sliding's post Boundaries of sac is formed by

viceral Structure
I
seen in elderly PINS
site Lt
I
o m c structure figured sigmoid colon

Pantaloon Hernia Direct indirect

Gibbons inguinal t Hydrocele

Femoral Hernia
comes out from the femoral Ring

Narrow High Rate of strangulation

Richter'shernia

Clinically diff b w
Inguinal femoral

pubictubercle
L Belowand lateral
Aboveandmedial

s surgery

Low
High
Lockwood
Me Evedy
Strangulated uncomplicated

paritatHernia's Dincisional 6 spiglein

4 Umbilical
3 paraumblical
4 Epigastric
5 Lumber
 I incisional Mrc parietal Hernia
Mx
open Lap
Hernioplasty
2 Epigastric Fatty Hernia of Lima Alba
Midline
xiphisternum till Umblicus
Lamp
pain similar to peptic Ulcer

Open Lap
Hernioplasty

3 UMBLICAL 4 PARAUMBLICAL

through Umblicus Adjacent to Umb19cal

t
Evert 4Mblicus
Narrow defect
Largedefect I
strangulation
New Born Children
RichterHernia is common
In
conservative Mx
2 3 yrs
Mx Surgery
I
if it persiststhem
surgery
 5 spigenian intrapasital
I
Detected Late

Strangulation can occurs

Mesite outer Borderof Rectus at

level
of Arcuate line

Herniae
Maydal's O
Morethan one bowel loop
Hernia
W shape
it strangulation occurs it inv
the connecting portion 8 it can
be missed

Richter's Hernia

VeryNarrow defect
strangulation is commey But to

initial feature of Gastroenteritis

Femoral
popraumblical

obturator