Anesthesia and preperations before surgery

Q. Calculate the maximum dose of the drug?

Q. Safe dose of Xylocaine?
Q. Spinal anesthesia?
Q. Tests before surgery? PT APTT INR CBC LFT RFT Serum electrolytes Surface antigen and
anti HCV CXR and ECG TFT (if thyroid patient)

Counselling
Q. Counsel the patient about appendectomy?
Q. Counsel the patient about breast cancer? (Also do staging, nottingham prognostic index, tx,
and categories of mammography and difference between benign and malignant lumps)
Q. Counsel the patient about a subaceous cyst?
Q. Counsel the patient about a colostomy bag?

Radiographs
Q. X-ray supine for intestinal obstruction? (Air Fluid levels)
Q. T-tube cholangiogram?
Q. ERCP/MRCP? And it’s components
Q. Air Under diaphragm?

Causes:​ Perforated duodenal ulcer, Perforated ileum due to TB or Typhoid, Injury to the
intestine blunt or penetrating, Post laprotomy/laproscopy (persist up to 7 days). Always in erect
position because air moves under the diaphragm (upwards) occupies the space betweeen the
diaphragm and liver. It takes 3 - 4 hours after perforation for this air to appear (minimum amount
of air is 12cc that can be visualized)

Manage:​ Resucitation (Fluids, antibiotics, catheterization, NG aspiration, Ix). Open and

laproscopic repair.
Q. Radiograph of Hydatid cyst/Liver abscess?
Q. X ray of Hemopneumothorax/Pneumothorax?
Q. X ray of Pleural Effusion?
Q. X-ray of Plummer vinson? Esophageal CA?
Q. Osteosarcoma and it’s common site?

Sterilization
Q. Autoclave tape?
Q. How to sterlize a trochar

Sutures & Fluid resuscitation and ATLS

Q. Sutures? (Vicryl)
Q. Trimodal distribution of death, triangle of death, classification of shock
Q. Tension and spontaneous pneumothorax

Tension pneumothorax
Definitive treatment: Chest tube with an underwater seal in the triangle of safety. Base: formed
by the 5th intercostal space. Post: Posterior axillary line. Ant: Anterior axillary line. Exact
position: Upper border of the rib, in the 5th intercostal space, just anterior to the mid-axillary line.
You don’t insert the chest tube posteriorly, why? Because the lung parenchyma is displaced
backwards. There is serratus anterior along with it’s nerve (long thoracic nerve), if damaged, it
can cause winging of the scapula.

Q. Fresh Frozen Plasma (See picture)?

Q. Trosseu’s sign
Q. Chvostik sign
Q. Post operatively, how will you check if the patient is dehydrated? Urine output. Keep the
urine output of the patient at 0.5-1 ml/kg/hr.

Patient arrived in shock, what can you do to maintain an airway?

- Chin lift
- Jaw Thrust
- Finger sweep
- Suction
- Oropharyngeal airway
- Cricothyroidectomy
Patients in whom airway is difficult to insert: Burn patients (due to edema) and patients with
head injury (because the tongue falls back), so do: cricothyroidectomy or tracheostomy, if
edema is less than ETT can be inserted.

Maintain 2 wide bore IV lines, what is a wide bore? Anything that is less than 18G (orange, grey
and green) is a wide bore. Increasing FR means increasing diameter, increasing G means
decreasing diameter (bore gets slimmer). When you divide FR by 3, you get the diameter.
As the diameter increases, flow rate is increased in square root.
As length increases, flowrate is decreased in square root.

Will you insert a 16G branula or a CVP line in shock?

You will insert a branula because CVP line has more length and less flow rate.
While maintaining IV line, blood sampling should be done.
Two more lines? NG tube and Foley’s catheter.
In case of head injury (/unconscious/decreased GCS), you will not put a NG tube, insert an
orogastric tube, as you don’t know the cause of head injury; he might have a fracture of the
base of the skull.
To insert a NG tube, you take measurement from the ear till the xyphisternum.

Oropharyngeal airway
Insert the airway upside down with the tip facing the roof of the mouth (tongue will fold back if
placed the right side up) , when resistance is encountered, turn the airway 180 degrees so that
it comes to rest with the flange on the patient’s lips. You may also insert the airway right side up,
using a tongue depressor to press the tongue down. This is preferred in infants and children.

Burns
Q. Airway management in a burnt patient?
Q. Calculate TBSA in a burnt patient?

Arterial and Venous disorders

Q. Picture of a gangrenous toe?
Instruments
Q. Proctoscope?
Q. LP needle?
Q. Branulas?

Yellow is used in infants and toddlers.

Pink is used in IV infusion, blood transfusion and emergency management.
Q. ETT?
Q. NG Tube?
Q. Laproscopic port?
Q. Three ways Foley’s Catheter? Indication and Material

Q. How to sterlize the trochar?

Q. Mayo’s scissor (curved scissor) - Allows deep penetration into the wounds and often used in
cutting the fascia and is used to cut heavy tissue?
Q. Lahey’s Forcep?
Q. Airway?
Q. Deevor’s Retractor?
Q. Round body retractor?
Q. Langenbach?
Q. Needle holder?
Q. Babcock Forcep? Broad flared ends with smooth tip to grasp delicate tissue specially tubular
structures (Intestine, fallopian tube, ureter, appendix, lymphnodes)
Q. Sponge holding forceps
Q. Non-crushing forceps
Q. Monehan’s?
Q. Kellys (Rochester Pan)?
Q. Kockers (Ochsner) - to grasp heavy tissue, fascia or bone. It’s blades have transverse
serations?
Q. Allis - Has sharp teeth, used to grasp tissues but most are used on tissues that is about to be
removed. It also holds tissue edges to facilitate deeper exposure of the underlying organs or
tissues. Judd Allis (for intestinal tissue), heavy allis (for breast tissue, fascia and aponeurosis)?
Q. Towel Clamp
Q. Trocar with laproscopic port? Difference between trochar and canula?
Q. Intestine Forcep?
Q. Canula (Sizes and Guages)
GIT
Q. Appendectomy? Plus MANTRELS and DD, plus complications of appendectomy
Q. Anal fissure?
Q. Specimen of the appendix?
Q. Acute Pancreatitis: Ranson’s criteria and Glasgow scale?
Q. Differentiate between direct and indirect inguinal hernia?
Q. Treatment of ruptured spleen? Vaccines given before spleenectomy?
Q. Bilroth I and II?
Q. Dumping syndrome?
Urology
Q. Congenital Hydrocele/Hernias?
Head and Neck
Q. Picture of a parotid gland tumor? Scenario? Dx? Which structures to save? Best treatment?
Q. Differentials of swelling of neck? Front and side?
Thyroid
Q. Which test do we do before thyroidectomy? IDL
Q. Differentiate between hot and cold nodule?
Q. Differentials of a solitary nodule?
Breast
Q. Modified Radical Mastectomy (Which structures to save?)
Q. Why does lymphedema occur?
Q. It’s treatment? Increase movement of the limb/Physiotherapy/Exercise as if brushing hair.
Staging
Q. Breast
Q. Thyroid
Cancers
Q. Prostatic enlargement (Sx, Dx)
Q. Rectal CA (Presentation, Ix, staging)
Bone metastasis:
Sclerotic bone metastasis: ​Prostate, transitional cell CA, carcinoid, medulloblastoma, mucinous
adenoCA, lymphoma. ​Lytic: ​Thyroid, renal, hepatocellular, squamous cell of skin, uterine and
pheochromocytoma. ​Mixed: ​Breast CA 25% mixed, lung CA, 15% mixed. ​Cookie bite mets:
Bronchogenic.
Important Short cases
Paraumblical and Umblical Hernia
Thyroid
Varicose veins
Corrosive intake
Intestinal obstruction
Inguinal hernia

ERCP
Dilated pancreatic duct/Level of Confluence/Dilated CBD/Presence of gallbladder? Iodinated
contrast.
Endoscopic Retrograde Cholangiopancreaticography:
It is performed via an endoscope, it is passed via the oral cavity and reached up to the second
part of the duodenum. Through the scope the ampulla of vater is cannulated and dye is injected
through this cannula either into the pancreatic duct or into the CBD, then X ray of abdomen is
obtained. In this way we can visualize the pancreatic duct (Strictures, stones and CBD) and
biopsy can be taken for diagnostic purposes.
Therapeutic indications:
- Stones can be extracted from CBD through ERCP by using a dormia basket.
- If strictures of CBD are found, then it can be dilated by a balloon catheter, or stent can
be passed accross the stricture.
- Sphincterotomy can be performed through this approach to remove the stone from
ampulla or vater.
- Cells (Brush cytology) can be obtained from CBD or from pancreatic duct for histological
examination.
- Stent can also be passed in the pancreatic duct.

It can show filling defect in the CBD.

Complications:
- Bleeding
- Perforation of duodenum
- Pancreatitis
- Cholangitis

Treatment options for Stones in CBD

- Stone removal via ERCP
- Laproscopic or open choledocotomy
- Burhenne’s technique.
MRCP
Magnetic Resonance Cholangiopancreaticography
Magnetic resonance cholangiopancreatography (​MRCP​) is a technique for viewing the
bile ducts and the pancreatic duct. It can also ​show​ the pancreas, gallbladder and liver.
MRCP​ uses magnetic resonance imaging (MRI) to produce detailed pictures of these
ducts and organs.
MRCP​ is a special type of magnetic resonance imaging (MRI). It uses computer
software that specifically images pancreatic and bile ducts, which are often the site of
tumors. Fluid naturally present in the ducts serves as a contrast substance. ... An
MRCP​ can be ​done​ at the same time as an MRI.

T tube cholangiogram?
Performed to check the patency of CBD. A dye (urograffin) is injected into the long limb of T
tube and X ray of abdomen is taken
How is it performed?
Usually inserted during a cholecystectomy/totomy when there is possibility of residual gall
stones in the billiary tree.
Indications: Must have T tube in situ, residual small gall stones post cholecystectomy/totomy,
Obstructive Jaundice, Bile duct strictures, surgeon unable to explore the bile duct during
cholecystectomy.
Contraindications: Non consent, contrast or iodine allergy, pregnancy (pregnancy test required),
barium study within last three days.
Preparation
● patient identification (3 Cs- correct patient, correct side, correct procedure)
● Patient should be wearing a hospital gown
● consent form
● no diet restrictions (some centres suggest fast from solids for 4 hours prior to procedure)
● collect relevant previous imaging for ease of access prior to procedure prophylactic
dose of broad spectrum antibiotic prior to procedure (immunosuppressed patients)
● Some operators prefer the T-tube to be clamped prior to the procedure to allow the bile
duct to fill with bile. Air in the bile duct can give a false impression of a gallstone.
Procedure
● the patient is positioned supine on the X-ray table
● A slightly RPO position can help to ensure the CBD is not superimposed over the
patient's spine.
● a preliminary/scout image of the RUQ should be acquired.
● The tip of the T-tube is cleaned with antiseptic
● the T-tube should be raised and tapped to ensure there are no air bubbles lurking in the
tube.
● A butterfly needle should be inserted into the T-tube
● The syringe plunger is withdrawn to remove bile from within the duct. (optional)
● An early filling image should be obtained.
● The entire biliary tree should be imaged during injection of contrast medium.
● Injection should continue until the entire biliary tree is opacified and there is passage of
contrast into the deuodenum.
● If the intrahepatic ducts do not fill, the patient can be tilted trendelenburg and further
contrast injected into the T-tube.
● The patient may need to lie on their left hand side to fill the left hepatic duct.

Material used:
The T-tube is made of very flexible plastic. The flexibility of the plastic facilitates the
percutaneous remove of the T-tube without surgical intervention. T-tubes are usually sized
between 10 French (10F) and 16 French (16F).

Sterilized by: ​Gamma rays or ethylene oxide.

42 year old female Showing T tube in place, gallbladder present or not? Negative shadow or
filling defect? Miniscus sign? Complete cut off? Contrast going or not going in the deudenum?

PTC — Percutaneous Transhepatic Cholangiography and Biliary Drainage

What is PTC?
Percutaneous transhepatic cholangiography, or PTC, is a way of examining the bile duct system
in the liver. This procedure is done under local anesthesia by a radiologist. During the exam, a
thin needle is inserted through the skin (percutaneous) and through the liver (transhepatic) into
a bile duct. Then dye is injected, and the bile duct system is outlined on x-rays
(cholangiography). Iodinated contrast is used
42 year old female showing PTC catheter in situ, contrast is given showing dilated common
hepatic duct and dilated intra-hepatic biliary channels, confluence is intact, beyond that we can
see two clips, beyond that contrast is not freely flowing

Skin, deep tissue and liver capsule are infiltrated with a local anesthetic, under flouroscopic
guidance the cheba needle is introduced into the liver in suspented respiration, when correctly
positioned the patient is permitted to breathe gently. The stillete is withdrawn from the needle
and a syringe containing contrast media attached, contrast media is injected under flouroscopic
guidance as the needle is slowly withdrawn for analysis and then contrast media is injected to fill
the ductal system and identify the level of obstruction. Following the initial injection of contrast
into the bile duct during a PTC, a small guide wire is passed through the needle, into the ducts
and across the site of blockage while watching the wire and ducts on x ray. Over this wire, a
small catheter is then inserted to allow the bile to be drained from the liver and thus relieving the
jaundice caused by blocking of the duct.

Findings: PTC can show dilated intrahepatic and part of extrahepatic system
If there’s an obstruction at any level, the part distil to the obstruction will not be outlined.
Differential Dx: CBD Stricture, Cholangiocarcinoma.

Choledochotomy w/ T tube insertion

If ERCP fails, the CBD can be explored laproscopically or by open surgery. The aim of surgery
is to drainthe CBD and remove stones by a longitudinal incision on the duct. After removing the
stones, a T tube is placed in the CBD and the duct is closed. The long limb of the T tubeis
brought out on the right side of the abdomen and bile is allowed to drain externally. When the
patient recovers and the bile is cleared. T tube cholangiogram is performed after 7 - 10 days of
surgery. If there is no distil obstruction, the T tube is removed but if any residual stones are
found in CBD then T tube is left there for 6 weeks so that the tract gets matured. The retained
stones are then removed by various techniques including Choledocoscopy via T tube (Burhenne
Technique)

Barium Swallow/Meal?
Barium swallow or meal of patient aged 19 year old showing two strictures, first stricture is
opposite to C2 extending upto C3. Second
Stricture in esophagus?
Contrast is flowing into stomach? Stomach is deformed? Contrast flowing into deodenum or
not?

Surgical jaundice?
Causes, presentation, Ix