Basic Surgery

Structured Online Medical Academy (SOMA) | Basic Surgery
Dr.Md.Sultanul Arephin
MBBS,BCS,MD(Resident),Cardiology
CEO,SOMA
Wound
What is wound?
Breaching in normal tissue continuity resulting various cellular and molecular sequel is called
so.
Viva
When deep structure is involved-Injury
When superficial structure is involved-Wound
Types-Acute and Chronic
Scar-Residual visible mark of wound
Penetrating wound-Wound caused by sharp cutting object(Nail ,ice peak) that passes
through skin into underlying structure
Perforating wound-The penetrating wound which extends into viscera/body cavity
What are the effects of wound on tissue?
Mechanical-Separation of functional structure(vessels ,tendon)
Biological-Inflammation
Secondary effects-Infection
Give the types of wound
 Broad classification-
1|Basic Surgery Special SOMA Edition

 Closed-Bruise ,hematoma
 Open-Puncture ,bites ,abrasion ,laceration
 Complex-Crush ,avulsion ,war wound ,gunshot wound
 Wound of special structures-Fat ,muscle ,bones ,nerve ,artery ,vein
 Chronic wound-Ulcer ,bed sore
Viva.
What is bedsore?-Ischemia and ulceration of tissue due to excess pressure is called bedsore
 Based on contamination-
 Tidy and untidy wound
Tidy wound Untidy wound

Incised Crushed
Clean Contaminated
Healthy tissue Devitalized tissue
Seldom tissue loss Often tissue loss occurs
 Surgical classification-
 Clean wound(No viscera opened)-1-2% infection
 Clean contaminated wound(Viscera opened with minimal spillage)-Less than 10%
infection
 Contaminated wound(Viscera opened with spillage or inflammation)-15-20%
infection
 Dirty wound(Incision through abcess ,pus/perforation)-Less than 40% infection
 Based on infection-
 Infected and non infected
State the management of acute wound
 Exploration
 Cleansing with
 H2O
 Soap
 Normal saline
 10% providone I2/most used
 Debridement
 Antibiotics ,analgesics ,tetanus prophylaxis
 Repair of structures if needed

Short note on lacerated wound
Not clean ,incised wound ,lacerated margin
Must not stitch immediately as some tissue may die and some may survive. So debridement
after 7-10 days(Delayed primary or secondary closure)
What are the factors influencing wound healing?
 Site of wound
 Structure involved
 Mechanism of wound
 Contamination-In explosion ,contamination may consist of tissue like bone from
another people
 (Incised wound takes least time to heal
 Contaminated wound takes most time to heal)
 Loss of tissue
 Other local factors-Vascularity , radiation ,pressure
What are the factors affecting wound healing?
 Malnutrition
 Diseases(DM)
 Medication(Steroid delays healing)
 Immune deficiency(Chemotherapy)
 Immune deficiency syndrome(AIDS)
 Smoking
Classification of wound closure and healing
 By primary intention
 Wound edge is apposed
 Normal healing time(7-10 days)
 Minimal scar
 Occurs in tiny wound or incised wound
 By secondary intention
 Wound is left opened
 Heals by Granulation ,contraction and re-epithelialisation
 Increased proliferation and inflammation
 Poor scar

 By tertiary intention(Delayed primary intention)

 Wound is left opened initially
 Edge is apposed when healing occurs
 Condition favorable
Wound closure techniques
 Primary closure(Within 6hours)

 Delayed primary closure(5-7 days)
 Secondary closure(10-14 days)
 Skin grafting(When granulation is formed)

Ulcer
What is ulcer?
Breach of epithelial surface due to sloughing out of inflammatory necrotic tissue is called
so.(It is a chronic wound)
Types of ulcer
 Etiologic type-
 Non specific ulcer(Trauma ,PUD)-
Due to infection ,physical or chemical agent
Due to interference with blood supply e.g. Varicose vein
Due to local irritation e.g. Dental ulcer
 Specific ulcer(TB ,leprosy ,syphilis)

 Malignant(Rodent ulcer)
 Clinical type-
 Healing ulcer(PUD)
 Non healing ulcer/Callous ulcer(TB)
 Special types-
 Trophic ulcer(Trophe means nutrition)
o Due to lack of nutrition which depends on nerve and blood
supply e.g. Buerger's disease ,Raynaud's phenomenon
around ankle or dorsum foot
o Ischaemia and anaesthesia will create such
o Chronic vasospsams and syringomyeli will create ulcer at
finger tip
 Neuropathic ulcer/perforating ulcer
o Around pressure area(most common is Great toe ,also in
heel of foot)
o Due to anaesthesia e.g. Diabetic neuritis ,Tabes
dorsalis(Dorsal root damage) ,spina bi fida ,leprosy
o Peripheral nerve injury is called perforating ulcer
 Decubitus ulcer/Pressure ulcer/Bed sores
o Lateral position pressure-Skin over the greater trochanter
,ischium ,malleolus

o Supine position-Sacrum
o Vulnerable patient-Old diabetic patient ,malignancy
Phages of ulcer
 Extension
 Transition
 Repair
Clinical examination of ulcer
 Site-Rodent ulcer on upper part of face ,primary chancre on upper lip

 Size-Carcinoma extends more rapidly
 Shape-
o Rodent ulcer is circular
o Artificial ulcer is square
 Edge-(Junction between margin and floor)
o Shelving edge-Healing ulcer ,non specific ulcer
o Rodent ulcer-Rolled out
o Malignant-Raised and everted
o Margin(Junction between healthy and unhealthy tissue)
 Floor(What we see)
o TB-Watery ,apple jelly like granulation tissue
o Gammatous-Washed lather slough granulation
 Base(What we feel)
o Indurated in carcinoma
o Attached to bone in venous ulcer
 Discharge-
o Purulent ulcer indicates active infection
o Blue green colour indicates pseudomonas infection
 Lymph node
o Involves in carcinoma
o Involvement in rodent ulcer in rare
Viva
Pain in ulcer
Non specific ulcer in extensive stage and transition stage-Painful
TB ulcer and of tongue-Very painful

Antiseptic solution in surgery
 10% providone I2
 Cetrimide solution
 Chlorohexide solution
 Alcohol
 Acetic acid and Honey(If granulation tissue stimulation is required)
 H2O2(Necrotic tissue)
Investigations of ulcer
 Fasting blood sugar(DM)

 CBC(Hb)
 Renal function test
 U/R/E
 To differentiate malignancy from inflammation-Biopsy from margin containing both
healthy and unhealthy tissue
Viva.
Why both healthy and unhealthy tissues are taken?-To see invasion of malignant cell into
healthy part
Closure of ulcer
 Usually secondary
 If small in size-Secondary closure
 If large size-Skin grafting
Criteria of healthy and unhealthy tissue
 Healthy-Pinkish , bleeds on touch ,granular surface ,no discharge , proliferative

fibroblast ,newly formed capillary
 Unhealthy-Pale ,not bleed on touch , pus present

Sinus , fistula & cyst

What is sinus?
It is a blind tract lined with granulation leading from epithelial surface into surrounding
Types of sinus
 Anatomical-Frontal sinus ,nasal sinus

 Pathological-Perianal sinus
 Congenital-Pre auricular sinus
 Acquired-Perianal sinus ,multiple sinus in osteomyelitis
(Perianal sinus-Opening end in anal canal ,blind end in anal gland)
(Fecal fistula-Between skin and intestine)
What is fistula?
It is an abnormal communication between the lumen/surface of an organ with the lumen

/surface of another organ ,or between 2 vessels(Mostly fistula connects epithelial lining)
Types of fistula
 Congenital-Branchial fistula ,tracehoesophageal fistula ,arteriovenous fistula

 Acquired-Fistula-in-anus ,arteriovenous fistula
Difference between sinus and fistula
Sinus Fistula
Definition Definition
Tract is closed Tract is opened
Opening is 1 Opening is 2
Always external External & Internal

Viva.
What is the most common fistula in surgery ward?-Most common fistula in surgery is fecal
fistula
Causes of persistence of sinus/fistula
 Presence of foreign body/necrotic tissue e.g. suture ,hair ,sequestrum ,faecolith

 In efficient drainage
 Unrelieved obstruction
 Absence of rest as in fistula-in-ano
 Types of infection-TB ,actinomycetes infection
 Persistent drainage
 Ischaemia
 Steroid
 Malnutrition
 Interference-Artifact
 Irradiation e.g. Rectovaginal fistula after Rx for ca cervix
What is cyst?
It is a swelling consisting of fluid in a sac lined by epi/endothelium
Viva.
True cyst-Lined by epi/endothelium e.g. ovarian cyst
False cyst-No epi/endothelium e.g.pseudocyst in pancreas
Classify cyst
 Congenital cyst-
 Sequestrum dermoid(Branchial cyst)

 Thyroglossal cyst
 Dermoid cyst
 Urachal cyst
 Cyst of embryonic ramnant
 Acquired cyst-
 Sebaceous cyst

 Ovarian cyst
 Retention cyst(Sebaceous cyst)
 Distension cyst(Thyroidal cyst)
 Exudation cyst(Hydrocele)
 Cystic tumor(Cystic teratoma)
 Parasitic cyst
 Hydatid cyst
 Cysticercosis
 Trichinosis
Cyst examination
 Inspection-Smooth ,shiny ,spherical

 Palpation-
o Flactuation depends on presence of fluid
o Tensed cyst feels like solid tumor
o Solid tumor is most hard at the centre but cyst is least hard at centre
o Flactuation positive means(Lipoma ,cold abcess)
o Aspiration
Viva.
Cold abcess-Can persist may days (1 month) ,where abcess does not persist that long .Occurs
in TB. Abcess without no rubor ,calor ,dolor is diagnostic.
Complication of abcess
 Infection
 Hemorrhage(Thyroglossal cyst)
 Torsion(Ovarian cyst)
 Calcification
 Obstruction
10 | B a s i c S u r g e r y S p e c i a l S O M A E d i t i o n
Positive transillumination test
 Hydrocele
 Meningocele
 Cystic hygroma
 Hernia
Criteria of malignant ulcer
 Covered by slough ,pus or exudate

 Base is Size usually larger(>2cm)
 Painful
 Floor hard and fixed
 Irregular margin
 Involves lymph node(Hard and non tender)
Viva.
In ulcer ,if you find lymphadenopathy with ulcer ,then if the teacher asks you for interference
, you need to say-
If lymph node is firm and painful-it should be inflammation
if lymph node is hard and painless-It would be malignant
Then what you'll do?-I will give broad spectrum antibiotics for 7-14 days ,if it is
inflammatory ,it should disappear ,and if it doesn't ,then take biopsy
DD of ulcer only by looking
 By edge-
 Slopping edge-Non specific/Trauma
 Undermined-TB
 Punched out-Trophic/Syphilitic
 Rolled and everted-Malignant(Squamous cell carcinoma)
 Raised and beaded-Basal cell carcinoma
Acid base balance

Viva.
Acidosis and alkalosis indicate a change in pH in particular direction
pH= -Log[H+]=Log. (1 / [H+])
H+ concentration is expressed as nanomol/L
What is acidosis and alkalosis
 Acidosis-Accumulation of acid ,loss of base leading to reduced pH

 Alkalosis-Opposite
Regulation of pH
 By buffering system consisting of weak acid and base(Blood)

 By removing CO2 in respiratory system
 By excretion of acid and base through renal system
 (HCO3 : H2CO3 = 20 : 1)
Metabolic alkalosis
 Condition of base excess or deficit of acid other than H2CO3

 Causes-
 Excess alkali ingestion
 Loss of acid from stomach by vomiting
 Cortisone excess
 C/F-Cheyne stroke breathing ,Tetani
 Rx-
 If associated with hypokalemia-Active Rx
 If without hypokalemia-Seldom Rx
(Subclinical alkalosis-Increased HCO3 and positive base excess)
Respiratory alkalosis
 Condition where CO2 in arterial blood is below 31-42mmHg

 Causes-
 Excess pulmonary ventilation in anasthesia
 Hyperventilation in high altitude

 Hyperpyrexia
 Hysteria
(During anasthesia ,alkalosis is associated with Pallor ,Fall of BP and in severe case
respiratory arrest)
 Rx-
 Respiratory suppression due to alkalosis
 Insufflation of CO2
Metabolic acidosis
 Condition where there is deficit of base or ,excess of acid other than H2CO3
 Causes-
 Excess acid due to-
o Ketoacidosis
o Starvation
o Cardiac arrest
o Lactic acidosis
 Loss of base due to-
o Sustained diarrhoea
o Ulcerative colitis
o Gastrocolic fistula
o High intestinal fistula
o Prolonged intestinal aspiration
 C/F-
 Rapid deep noisy breathing
 Strong acidic urine
 Base deficit
 Rx-
 Restoration of adequate tissue perfusion
 NaHCO3 should be given in severe form
Respiratory acidosis
 Condition where PCO2 is above normal range

 Causes-
 Impaired alveolar ventilation in anesthetic patient
 Incomplete reverse from anasthesia
 Operation done in pre existing lung disease
 Accentuated by thoracic and upper abdominal incision
Burn
What is burn?
Coagulative necrosis of tissue due to thermal application +etiologic agents
Viva.
Burn shock-Results from rapid plasma loss from damaged tissue causing hypovolaemia
When 25%/more surface area of body is burnt ,a generalized capillary leakage may occur
which result in such in 1st 24 hours
Layers of skin
 Epidermis-
 Carla-Stratum corneum
 Loves-Stratum lucidum
 German-Stratum granulosum
 Spinach-Stratum spinosum
 Stratum basale
 Dermis-
 Outer papillary layer

 Inner reticular layer
Classify burn
 Etiologic classification-
 Heat injury-
o Scalds(Most common burn ; due to hot liquid/H2O)
o Flame
o Electricity
 Cold injury-Frostbite
 Friction burn-Heat + abrasion
 Physical burn-Ionizing radiation
 Chemical burn-Acid/alkali(Alkaline burn is worse than acidic burn)
 Based on depth-
 Superficial partial thickness burn(1st degree)-Burn out epidermis
 Deep partial thickness burn(2nd degree)-Full epidermis + partial
dermis
 Deep burn(3rd degree)-Full thickness of skin burn
Area of burn
 Wallace's rule of 9(Patients's own hand=1%)

 Lund and Browder method
Rule of 9
 Head and neck=9%

 Back of trunk=18%
 Front of trunk=18%
 Both arms=18%
 Front of both legs=18%
 Back of both legs=18%
 Perineum=1%----------------Total 100%
Viva.
When I/V fluid is to be given after burn?
 To be hospitalized if-
Child burn area is >15% by rue of 9
Adult burn area is >25% by rule of 9
 Blood transfusion
Child burn area is >30% by rule of 9
Adult burn area is >30% by rule of 9
Effects of burn
 Local-Inflammation ,infection
 Regional-When whole circumference of skin is involved
 Systemic-Fluid loss , shock ,toxemia ,multi organ failure
Viva.
How to asses a burn wound?
By-area and depth
Different burn status
Depth Colour Blister Capillary Sensation Healing

refill
Epidermis Red(Masked) No Yes Yes Yes
Superficial Pale pink Small Yes Pain Yes
dermis
Deep dermis Blotchy red Yes/No No No No
Full White No No No No
thickness
Viva.
 How fluid is lost in burn?

o Cell injury causing persistent capillary opening
o Inflammation causing increased permeability
o Direct ICF loss
 Curling's ulcer-Burning patient receiving Rx for long time causing ulcer in stomach
 Cushing's ulcer-Ulcer after head injury
 C/F-Pain ,dehydration , shock ,coma
Treatment
 1st aid-Extinguished by wrapping with clothing

 1st Rx-(In hospital)-I/V fluid 3-4ml/kg/% burnt area-On 1st day within 6-8 hours
 2nd day-
 According to need
o Insensible loss + evaporation(25.% burnt.m2)
 Surgical Rx-
 Escharotomy
 Skin graft
 Reconstructive surgery
Viva.
Burn should be managed within 1st 24 hours
Burn shock-1st Neurogenic shock?2nd Hypovolaemic shock>3rd septic shock
Insensible loss-
Normal skin = 15ml/m2/hour
Burn skin = 300ml/m2/hour
ABCDEF management for any serious patient(Burn ,unconscious ,shock ,RTA ,poisoning)
Look Airway Breathing Circulation Disability Exposure Fluid

Do Ask name Ask name Stop To prevent Environmental
bleeding secondary condition
Collar band to prevent Check R.R injury
hyperextension/hyperflexion Check
O2 supply pulse ,BP LARPU-
Maintain patency
Endotracheal I/V fluid Light reflex
intubation
Alert-
Response to
vocal stimuli
Response to
painful
stimuli
Unresponsive
Viva.
Fluid requirement=3-4ml .(% TBSA) .(Weight in Kg)
50% fluid is to be given in 1st 8 hours
Next 50% in 2nd 16 hours
Note:
30 drops =1L=8 hours
Primary surgical management of burn
 Immediate-Escharotomy
 Delayed-
 Skin grafting from thigh
 Transitional skin grafting
 Pseudomonas infection(Greenish) common in burn
 Tropical antibacterial oinment-

 1% silver sulphadiazine cream(For pseudomonas and staphylococcus)
 0.5% silver nitrate solution
 Mafenide acetate cream
 Dressing-
 Vaseline impregnant gauze
 Paraffin soaked gauze(Sofra tuli)
 Hydrcolloid(Duoderm)-Change every 3-5 days
 Biological dressing-(No need to change , for superficial burn)
 Synthetic dressing-Biobrance
 Natural dressing-Amniotic membrane
 Exposure therapy-No dressing
Viva.
Tell the advantage and disadvantage of exposure therapy
Advantage-Decreased bacterial growth ,wound visible and readily accessible
Disadvantage-Increased pain , increased heat loss , chance of cross contamination
Importance of dressing
Decreases pain
Decreases topical moisture
Well wound healing
Tell the advantage and disadvantage of closed therapy
Advantage-Less pain ,less heat loss , less cross contamination
Disadvantage-Increases chance of infection
Haemorrhage
What is haemorrhage?
Extravasation of blood from closed CVS
Viva.
Amount of blood for adult-70cc/Kg
Amount of blood for neonate-80cc/Kg
Pathophysiology/physiological exhaustion/triad of death
 Lactic acidosis due to anaerobic metabolism

 Coagulopathy due to decreased function of coagulation protease
 Hypothermia due to underperfused muscle unable to produce heat
Classify
 According to time-
 Primary-Bleeding at the time of injury/surgery
 Reactionary-Bleeding within 24 hours e.g. Dislodgement of clot

,slippage of ligature , HTN ,reflex vasospasm
 Secondary-Bleeding occurs 7-14 days after injury
Factors-Infection ,pressure ,malignancy
E.g.Thyroidectomy ,hemorrhoidectomy , prostatectomy
 According to visibility-
 Revealed/external-Crush injury ,surgery
 Concealed/Internal-Cerebral hemorrhage ,long bone fracture ,
bluntoma abdomen/chest , PUD bleeding
 According to source-
 Arterial(Bright red ,spurting)
 Venous(Dark red , steady)
 Capillary(Reddish ,oozing) [Only 10-15% capillaries are functional

,rest are dormant]
 Other-
 Surgical-Those that can be stopped by surgical means
 On surgical-Those that cannot be stopped by surgical means e.g.
coagulopathy ,gum bleeding
Degree of hemorrhage
4 classes-
 Class-1 : Blood loss <15%(<75)cc)

 Class-2 : Blood loss about 15-30%(750-1500cc)
 Class-3 : Blood loss about 30-40%(1500-2000cc)
 Class-4 : Blood loss >40% (>2000cc)
Management of hemorrhage
 Indentify and stop bleeding by-

 Pressure ,packing ,positioning(Trendelenburg position-Feet tilted downwards)
,rest
 Surgically by suturing , ligation and coagulation by diatherming
 Open of large bore I/V channel and blood drawn for grouping and cross matching
 Others-Analgesic for pain and antibiotics(TT,TIG) for infection
Viva.
When there is blood loss-Give what?-Give Blood
15% blood loss is compensatory
30-40% blood loss initiated falling BP
Name some surgical emergencies
 Acute appendicitis
 Acute intestinal obstruction
 Perforation
(NOT ACUTE CHOLECYSTITIS)
Viva.
Some similar terms-
Haemostasis-Arrest of bleeding
Homeostasis-Maintenance of constant internal environment(Milieu interior)
Haematoma-Appreciable amount of extravasated blood which is clinically palpable
Purpura-Do by yourself
Hemartoma-Benign tumor of blood vessels/hemangioma
Shock
What is shock?
Widespread hypoperfusion of tissue due to reduction in blood volume/C.O/redistribution of

blood resulting in inadequate effective circulatory volume(ECV)
Classify shock-
 Hypovolaemic
 Cardiogenic
 Obstructive
 Distributive
 Endocrine
Mnemonics: HCODE
Another presentation-Hypovolaemic ,cardiogenic ,neurogenic and septic shock
Causes of shock
 Hypovolaemic due to-

 Decreased fluid intake(Dehydration)
 Increased fluid loss(Diarrhoea ,diabetes ,vomiting ,haemorrhage ,burn
,third spacing)
Viva.
But in ward we find hypovolaemic shock commonly due to intestinal obstruction and
perforation
Intestinal obstruction may occur from volvulus which is rotation of intestine around long axis
More than >60% blood is present in veins
 Cardiogenic due to-

 MI, cardiomyopathy , valvular heart disease
 Obstructive due to-

 Embolism
 Distributive due to-

 Sepsis ,spinal cord injury
 Endocrine due to-(H+C+D)

 Hypo/hyperthyroidism ,thyrotoxicosis ,adrenal insufficiency/addison's
disease
 Septic due to-

 Toxins by Gram negative bacteria causing endothelial injury
 Neurogenic due to-

 Anaesthesia ,spinal cord injury , autonomic blocking drugs
Viva.
Which shock is commonest in surgery ward?-Hypovolaemic(It is a component of other

shock types)
Which shock is commonest in gynae ward?-Septic
Which shock is commonest in O.T?-Neurogenic and hypovolaemic
1st affected area in shock-Extremity and kidney
What is third spacing?-Fluid loss into GIT and intestinal space
Compensated shock
 Decreased flow to non essential organ

 Increased flow to essential organ
 May be no sign-symptoms of hypovolaemia
Unresusitable shock
 Prolonged shock>ability of the body fails to compensate fluid loss

 Death is a must
Occult hypoperfusion
 High mortality rate

 Metabolic acidosis despite normal urine volume and normal Cardiorespiratory status
 Mechanism of shock
 Points from Definition of shock
Mechanism of spinal shock
 Spinal block>withdrawal of sympathetic activity>vasodilatation>peripheral pooling

of blood>decreased venous return>decreased C.O>decreased cerebral flow>shock
Mechanism of septic shock
 Endothelial injury>Extravasation of fluid>edema in pulmonary area ,brain +DIC
C/F of shock
 Signs-LUC.PRB
 L-Lactic acidosis
 U-Urine output
 C-Consciousness
 P-Pulse
 R-Respiratory rate
 B-BP
 Symptoms-
 Restlessness ,sweating ,cold clammy skin ,rapid swallow breathing
Compensated shock
 All C/F increases

 Lactic acidosis +
Severe shock
 Lactic acidosis +++

 Urine-Anuria
 Consciousness-Comatose
 Pulse-Tachycardia
 R.R-Laboured
 BP-Severe hypotension
Viva.
What will you give if a patient with severe bleeding comes to you?-Give blood
Why will you give blood?-As blood is the one and only substitute of blood
What will you do in the mean time before blood is available?-Stop bleeding and give volume
expander and send blood for grouping and cross matching
What will you do when a traumatic patient comes to you?-1st thing is to stop bleeding
Why not give blood 1st?-As the given blood will be ultimately lost if bleeding point is not
managed
Fluid management
 All shock-Give fluid(Wide bore catheter)

 Crystalloid fluid-Normal saline ,Hartman/s solution ,Ringer's lactate
 Colloidal fluid-Albumin
 (Crystalloid and colloidal do not carry O2)
 While awaiting for blood ,give crystalloid fluid
 Never give hypotonic solution like dextrose
Fluid response
250-500ml fluid bolus is given ,then-
 Responders-CVS status improves and persists

 Transient responders-CVS status improves and declines to previous state(Due to
moderate ongoing loss)
 Non responders-CVS status does not improves at all(Due to major ongoing loss)
Viva.
If hypovolaemic ,cardiogenic and distributive shock co exist, how will you differentiate?
By measuring preload ,C.O and systemic vascular resistance
Management of shock
 Resuscitation-ABC look and Do

 Prevent further loss-Pressure , packing , suture , ligation
 Analgesic and antibiotics(Morphine is not given in intestinal obstruction and
diarrhoea)
Types of hypovolaemic shock
 Mild(Covert compensated shock)

 <20% fluid loss
 No sign/symptoms
 Moderate(Overt compensated shock)
 20-40% fluid loss
 Restlessness
 Low volume and rapid pulse
 Severe(Decompensated shock)
 >40% fluid loss
 Lactic acidosis +++
 Urine-Anuria
 Consciousness-Comatose
 Pulse-Tachycardia
 R.R-Laboured
 BP-Severe hypotension
 Cold clammy skin
Complication of shock
 Heart-Hypotension ,low C.O , sub bacterial endocarditis

 Lung-ARDS ,pulmonary edema
 Multiple organ failure
 Kidney-Oliguria ,anuria ,acute renal shut down
 Liver-Central necrosis ,fatty change
Infection
What is infection?
Invasion of body tissue by pathogenic organism with multiplication producing sign

symptoms of disease in favorable condition is called so
Classify infection
 According to causative agent-

 Non specific-Abcess ,lymphangitis
 Specific-TB ,syphilis ,gas gangrene ,tetanus
 According to mode of transmission-

 Autoinfection(Infective agents is from same individual)-Scabies ,Mumps
 Cross infection(Agent is from other individual)-Syphilis ,Gonorrhoea
 Nosocomial infection(Infective agent is from hospital)-Staphylococcal
infection
 According to duration-
 Acute-Gas gangrene ,tetanus
 Chronic-TB ,syphilis
 Some special infections

 Tetanus ,warts ,AIDS ,candidiasis ,leprosy ,salmonellosis
How to prevent nosocomial infection?
 Rx of patient
 Isolation of septic patient
 Improve nutritional status
 Proper ventilation
 OT and ward sterilization
 OT skilled surgeon
Viva.
Nosocomial infection occurs 3/4days after admission and 5-7 days after leaving
Some terms
Invasion-Entry of organism
Septicaemia-Invasion with multiplication
Bacteremia-Presence of bacteria within blood
Pyemia-Presence of multiple foci of pus in blood
What is boil?
An acute staphylococcal infection of hair follicle with perifolliculitis which usually proceeds
to suppuration and central necrosis(Abcess)
What is blind boil?
Boil without any suppuration
Site-Back(Occipital region to coccyx) and neck
Complication of boil
 Cellulitis ,infection of lymph node , secondary boil

 Sinus and fistula(If Boil occurs in perianal region)
 Furunculosis-Boil on external auditory meatus
What is cellulitis?
Spreading and splitting inflammation of skin and subcutaneous tissue caused by

streptococcus pyogen(S.aureus , C.perfringens)
What are the commonest sites of cellulitis?
 Face
 Orbit
 Neck
Ludwig's angina>laryngeal edema
Respiratory distress>Asphyxia
 Hand(Contracture and stiffness)
Rx of cellulitis
 Antiseptic wash
 Antibiotic-Coxacillin
 Rx of underlying cause
Viva.
What is abcess?-Collection of pus in tissue /hollow viscus lined by pyogenic membrane
Symptoms-Rubor ,calor , dolor ,tumor ,functioleicha
Investigation- Blood sugar ,CBC
Rx-Incision and drainage(In most dependant part) ,antibiotics and analgesics
Cold abcess
 Abcess with pus but sign symptoms of inflammation are minimal

 Local examination-
 Redness , cystic swelling , positive flactuation test ,tenderness
 Site-Breast ,axilla ,appendix
 Complication-Burst ,persistent sinus /fistula(Fistula in ano) ,cavernous sinus
thrombosis ,bacteremia ,septicaemia ,pyemia
Viva.
Any pain-Means something due to inflammation
Fever >98/5 F; then pulse increases by 10 for 1 F
Abcess draining method(Hilton's method)
 Applied where large vessels and nerves are below abcess cavity
 Local injection at most fluctuating point
 Incision
 Drain(Sinus forceps)
 May contain multiple cavity ,so must be drained ,or ,discharging sinus may develop
later on
Carbuncle vs. boil
Carbuncle Boil
 Def: Infective gangrene in
subcutaneous tissue due to
staphylococcal infection
 Age>40 years ; old diabetic
 Sex: M>F
 Site: Usually nape of neck ,but can
occur anywhere
 Rx-Antiseptic wash ,antibiotics
Gangrene present Absent
Hair follicle not involved Yes
Multiple opening 1 or No
What is gangrene?
Macroscopic death of tissue with superadded putrefaction is called so.
What are the sites of gangrene?
 Distal part of limb

 Loops of intestine(Strangulated hernia-1st gangrene appear at deep ring)
 Appendix
 Testis
Viva.
Define necrosis
Slough-Dead soft tissue
Sequestrum-Dead and seperated piece of bone within living tissue that occurs in
osteomyelitis
Types of gangrene
 Based on etiology
 Secondary to arterial obstruction(Mnemonics: RESTED)-
 Reynaud's phenomenon
 Ergot poisoning
 Systemic sclerosis
 Thrombosis
 Embolism
 Diabetes
 Infective-
 Boil
 Carbuncle
 Gas gangrene
 Fournier's gangrene(Of scrotum)
 Traumatic-
 Direct-
Crush ,bedsore
 Indirect-
 Supracondylar fracture>Brachial arterial damage>Distal part
gangrene
 Cow attacks mostly inguinal region>Femoral arterial
damage>Distal part gangrene
 Physical-
 Burn ,frostbite ,electricity
Viva.
How venous gangrene is possible?
Continous pressure on sacral prominence>Possible
 Clinical type-
 Dry and moist gangrene
Dry gangrene (e.g.Burger's disease) Moist gangrene(e.g.Diabetic gangrene ,gas

gangrene)
Coagulative necrosis Liquefactive
Due to arterial obstruction Both arterial and venous obstruction
Dry in nature Moist in nature
No foul smell Foul smell is present
Line of demarcation of present Absent
Spreads slowly Rapidly
Non fatal Fatal
Usually on exposed part of limb Testes ,ovary ,intestinal
C/F of moist gangrene
 No pulse ,no venous return ,no colour return

 No sensation ,No temperature
 Black due to disintegration of Hb and FeS formation(Fe from Hb and S from protein
denaturation)
Viva.
Pain sensation-Spinothalamic tract
Position and vibration-Tract of Gall and Burdach
Necrosis-Single cell involves
Necrosis in large area-Slough
Slough with infection-Gangrene
Treatment
 Principle-
 Life saving amputation
 Limb saving attitude
 General Rx-
 1st improve general condition-
Correct anaemia
Improve nutrition
Control diabetes
 Antibiotics
 Analgesic
 Then>Debridement(Surgical toileting of wound)

 Or, Amputation(Purposeful severance of an organ/part of organ ,limb or
bone)
What is gas gangrene?
It is a special type of wound infection where anaerobic gas producing infection occurs
Viva.
By saccharolytic organisms-
 C.perfringens/welchi-80%(Found stool ,perineum ,occasionally in vagina)

 C.oedematiens/noveyi
 C.septicum
By proteolytic organisms-
 C.sporogens
 C.histolyticum
Susceptible wound for gas gangrene
 Surgery around hip joint

 Leg amputation(Upper thigh)
 War wound
Pathogenesis of gas gangrene
 Clostridium>Alpha toxin>whole length of muscle fibre is involved with further

septicaemia>(If occurs in liver ,called foaming of liver or frothy liver)
C/F of gas gangrene
 1-3 days after injury

 Autopsy room odour
 Discoloured skin(Khaki) due to hemolysis
 Cripitus
Rx of gas gangrene
 Max dose of penicillin upto 2g ,4 hourly OR, clindamycin with metronidazole

 Blood transfusion(Correct hemolysis)
 Exposure of affected muscle by long incision
 Removal of stitches and bandages
 Hyperbaric O2 therapy(O2+ H2O2--> To create aerobic condition)
 Prevention-[20% dies]
Early debridement
Open/light dressing
Viva.
Exotoxin-By living organism(Gram +ve)
Endotoxin-By dead organism(Gram -ve)
Body fluid
Daily water balance is /70Kg/temperate area
 Input-
 Beverage 1200ml
 Solid food 1000ml
 Oxidation 300ml---Total 2500ml
 Output-
 Urine 1500ml
 Insensible 900ml(Skin+lung)
 Stool 100ml----------Total 2500ml
Total Range 2500-3000ml
Why water requirement of children is more than adult?
 Larger surface area per unit of weight

 Increased metabolic activity for growth
 Poor concentrating power of immature kidney
Viva.
Takes 6 months to develope fully functional kidney)
Skin-->Visible and invisible perspiration
Minimum 600ml urine is required to excrete end products of protein
Liver store glycogen for 24 hours
Before1 week ,protein does not break
Water depletion
Causes-Decreased water intake for pain in mouth ,pharynx ,glossitis ,tonsilitis ,pharyngitis
C/F-Weakness ,intense thirst ,dehydration ,overt compensated hypovolaemia
Water intoxication
Reverse of water depletion
 Causes-
 Over prescribing I/V 5% DA in post operative patient
 Colorectal wash by plain H2O
 TURP
 Oat cell carcinoma of bronchus(Produce hormone that retains water)
 C/F-Weakness ,drowsiness ,convulsion(Shivering) ,coma , death

 Investigation-PCV reduced ,serum electrolytes reduced
 Rx-Stop intake ,ICU ,diuretics
Viva
If 24 hours urine output is normal ,then it is estimated that serum electrolyte levels are
normal also
Some routinely prescribed fluids
 5% DA(Blue)-Isotonic(Given in shock ,early post operative patient)

 0.9% NaCl solution(Yellow)-Isotonic(Post operative patient ,prostatectomy)
 5% DNS(Green)-Hypertonic(Given in hypovolaemic shock ,2nd and 3rd day for post
operative patient)
 Cholera saline(Red)-Isotonic
 Hartman's solution/Ringer's lactate-Isotonic(Given in Burn ,intestinal obstruction
,PUD ,perforation)
Viva.
5% DA-5 g dextrose in 100ml H2O
0.9% NaCl-0.9g NaCl in 100ml H2O
5% DNS-5g dextrose in 100ml of 0.9%NaCl solution
Actually 0.9% NaCl is not normal saline chemically ,but 5.85% NaCl is normal saline
according to chemistry
Isotonic-Tonicity equal to plasma
Hypotonic-Tonicity less than plasma
Hypertonic-Tonicity greater than plasma
Components of cholera saline-Na+ ,K+,Cl-,HCO3-
Components of Hartman' solution-Na+ ,K+ ,Cl-, lactate, Ca++
Fluid intake has 2 sources-
Endogenous : By oxidation 300ml
Exogenous : 2-3L/24 hours
H2O is 60% of TBW : 60% ICF and 40% ECF
Na+ is the golden ion for body
Total body Na+ is 5000mmol-44% in ECF ,9% in ICF ,47% in bones
Na+ conservator is aldosterone
Na+ intake varies as of food habit ,but on average 4mmol/Kg NaCl
Na excretion is shut down after trauma/surgery for 48 hours due to increased

ACTH(Metabolic response to trauma)
Total body K+ 4500mmol-98% in ICF ,2% in ECF ,3/4th(3500mmol) in skeletal muscle
Sources of K+ is fruits ,honey ,milk ,coconut juice
HypoNa+
 Causes-
 Small intestinal obstruction(Common)
 Duodenal fistula
 Pancreatic fistula
 Severe diarrhoea
 Ulcerative colitis
 Burn
 C/F-Signs of dehydration-
Restless
Sunken eye
Dry tongue
+ve skin pinch
Oliguria
Low BP,
Low volume rapid pulse
Hyper Na+
 Causes-
 Excess 0.9% NaCl intake
 Excess 5% DA
 Crohn's disease
 Oat cell carcinoma
 C/F-
 Puffiness of face
 Pitting edema(Clinically detected edema when >1500ml fluid collection)
 Increased weight
 Increased urination
HypoK+
 Causes-
 Trauma-Gradual loss of K+
 Surgery-Gradual loss of K+
 Insulin in diabetic coma-Sudden loss of K+
 C/F-

Asymptomatic

Cardiac arrest

Slurred speech

Decreased reflex

Paralytic ileus(abdominal distention) [It also occurs in spinal cord injury
,peritonitis ,uraemia)
 Rx-Cholera saline
(Excess K+-->cardiac arrest at diastolic phage)
Sterilization
What is sterilization?
Process of killing or freeing an article from microbial agents including spores
Classification of sterilization
 Physical-
 Heat-
Dry(Red heat ,flaming ,hot air oven)
Moist-
o Below 100 degree(Pasteurization)

o At 100 degree(Boiling ,steaming ,tyndalisation)
o Above 100 degree(Autoclave)
 Radiation(X ray ,gamma ray ,UV ray)
 Filtration(Berkfeld ,chamberland)
 Ultrasound
 Chemical-
 Phenol
 Dettol
 Cresol
 Formaldehyde
 Savlon
Viva.
Principle of autoclaving(Check from Microbiology)
Blood transfusion
What is infusion?
Administration of artificial fluid(Filter is absent and diseases transmission is less or absent)
What is transfusion?
Administration of natural fluid(Filter is present and diseases transmission occurs)
Filter usually filters large particle and prevent thrombus formation
Indication of transfusion/infusion
 To restore and maintain normal blood volume

 To correct severe anaemia(Wound of post operative anaemic patient will never heal
until anaemia is corrected)
 To correct bleeding and coagulation disorder
 Any surgery in anaemic patient
 Trauma
 Major surgery-Thyroidectomy ,prostatectomy ,spleenectomy
 Severe burn
 Haemorrhagic disorder
Complication of infusion
 Metabolic change-
HypoNa+
HyperNa+
Acidosis
Hypoglycaemia
 Local thrombophlebitis
 Sepsis
 Embolism
What are the tests before blood transfusion/precautions?
 Blood grouping and Rh typing

 Cross matching
 Screening test for- HBsAg(Hepatitis B) ,HIV(AIDS) ,PBF(Malaria) , VDRL(Syphilis)
Complication of blood transfusion
 Hemolytic reactions(Due to mismatched blood transfusion)

o Chest pain
o Abdominal pain
o Fever
o Rash
o Anuria
 Fever(Most common and immediate due t donor WBC)
 Allergic reaction
 Circulatory overload
 Disease transmission
 Ab formation
What are the blood components to be transfused?
 Whole blood-Severe blood loss ,major surgery

 Packed cell-Anaemia ,thalassemia ,CCF
 Platelets-ITP ,acute leukaemia ,aplastic anaemia
 Plasma-ITP ,DIC ,VIII ,IX deficiency
 Coagulation factors-
VIII and IX for hemophilia
Cryoprecipitate(VIII+ fibrinogen) for VWD
Viva.(Coagulation factors in serum are 1258)
 Blood substitute/plasma volume expanders
 Blood(Best)
Viva.
Artificial colloids-Dextran ,gellatin
Electrolyte solution-Balanced salt solution
Crystalloid <1 nm , differentiate from colloid
*WE usually use crystalloid in ward
Classify blood transfusion/BT
 Emergency transfusion-
RTA like severe blood loss
As early as possible
 Elective transfusion-
 Patient collects own blood and preserves it
Viva.
Auto transfusion-Transfusion of own blood
Intra operative autotransfusion-During operation blood is collected special device and

given to same person.It is only theoretical
Fresh blood vs.stored blood
Stored blood decreases life expectancy
Stored blood causes electrolyte imbalance
Stored blood causes coagulation problem
Viva.
Rate of infusion-
 3000ml/24hours
 1000ml/8 hours
 1500 drops/8hours
 31.25 drops/min(30 drops)
Rate of transfusion-
 500ml within 1.5-2 hours

 1ml=15 drops
 500ml= 500(15)=7500 drops
 Drops per minute= 7500/120= 60 drops
C/F of mismatched transfusion
Feeling of 8th wrong-
 Restlessness
 Pallor
 Raised temperature , pulse and low BP
 Pulmonary edema
 Anaemia
 Jaundice
 Cyanosis
Tumor
What is tumor?
According to Sir Ruport Willis , neoplasm is an abnormal mass of tissue growth of which
exceeds and is uncoordinated with that of the normal tissue and persist in same excessive
manner after the cessation of the stimulus that evoked the changes(WHO)
Difference between benign and malignant tumor
Traits Benign Malignant

Malignant tumor--- Slow Rapid
1.Rate of growth
2.Differentiation Well Well/moderate/poor/un

3.Invasiveness Grows by cohesive expansile Grows by invasion
manner
4.Metastasis(THE point) No Yes

Histogenic differentiation---
Morphology of single
malignant cell---
1.Cell Not pleomorphic Pleomorphic

2.Nucleus Not hyperchromatic Hyperchromatic(Increased
DNA synthesis)
3.Nucleus: Cytoplasm Not altered(1:8/10) Altered(May be 1:1)
4.Nucleolus Not prominent Prominent
5.Abnormal mitosis Not Yes
6.Capsule Usually present Absent
What are the routes of metastasis?
 Hematogenous-Sarcoma
 Lymphatics-Carcinoma
 Nerve sheath-Adenocarcinoma of pancreas
 Transcoelomic-Malignancy of stomach(It is commonest)
 Natural passage-Renal cell carcinoma to bladder carcinoma
 Surgical instrumentation-Tumor organ to incised margin by surgical instruments
Rx of malignant tumor
 Surgery
 Radiotherapy
 Chemotherapy
 Immunotherapy
 Hormone therapy
 Combined therapy
Anaesthesia
What is anaesthesia?
Stage of CNS depression where there is reversible and controllable loss of pain ,reflex
with/without loss of consciousness
Types
 General-Halothane
 Regional-
 Spinal
 Epidural block
 Subarachnoid block
 Local-
 Surface anasthesia-Xylocaine
 Infiltrative-Bupivacaine
 Nerve block-Pudendal block
Suture materials
What is suture materials?
Materials that are used in surgery to make an anastomosis ,repair ,closing wound or to ligate a
bleeding point
Property
 Good strength
 Minimum tissue reaction
 Good knotting capability
 Non thrombolytic
 Non carcinogenic
 Non electrolytic
Classify
 According to absorbance(In blood)-

 Absorbable-Catgut ,vicryl
 Non absorbable-Silk ,prolin
 According to source-
 Biological-Catgut ,silk
 Artificial-Vicryl ,prolin
 According to number of filament-

 Monofilament-Catgut ,prolin
 Multifilament-Silk ,vicryl
 Other-
 Coated-Prolin
 Uncoated-Catgut
Viva.
How they are absorbed?-Enzymatic digestion and Hydrolysis(Breakdown in presence of

H2O)
e.g. Catgut in 28 days ,polydihexon/PDS in 200 days ,polyester in 35 days ,polyamide in 35

days
Catgut is less strong ,but polydihexon is the most strong suture material
Complication of anastomosis
 Hemorrhage
 Stenosis
 Leakage
Tetanus
What is tetanus?
Special type of wound infection caused by C.tetani
Viva.
It is a Gram positive ,anaerobic ,small rod shaped drumstick like organism
Source-Manure ,soil(Market place and rose garden)
Wound prone to tetanus
 Contaminated wound
 Closed wound
 Perianal wound
 Penetrating wound from hoof of animal
 Thorn prick in well manured rose garden
Pathogenesis(I.P- 6-10 days)
Multiplication>Toxin production>(-)AchE locally at NMJ and blocks inhibitory NT

e.g.glycine>Goes to CNS via axons and continuous excitation of anterior horn
cell>Exaggerated action of LMN on muscle
Toxins in tetanus
Exotoxin-
Neurotoxin tetanolysin-Hemolysis in animal
Neurotoxin tetanospasmin-Produce C/F of the disease in human
C/F of tetanus
 Dysphagia
 Trismus(Lock jaw) due to masseter muscle spasm
 Sever pain in back of neck
 Tonic muscle spasm

 Sardonic smile/Devil's smile
Viva.
Status of tetanus is -
Decided by interval between 1st symptom and 1st reflex spasm
-If less than 48 hours-Death is likely
-If more short-Poorer prognosis
Rx of tetanus
 General-
 Isolation
 Dark room
 Debridement
 Antibiotic-Penicillin
 Metronidazole
 TIG ,I/M
Viva.
Special-
 Stage-1/mild case-
 Active immunization after recovery
 Barbiturates and diazepam 6 hourly
 Stage-2/Dysphasic and reflex spasm case-
 NG tube
 Sedation
 Tracheostomy
 Stage-3/Dangerous case
Curarisation-
D tubocurarine(1st I/V ,then I/M)
Intermittent positive pressure ventilation/IPPV
Prevention
 Toxoid immunization
 If not immunized and comes with wound prone to tetanus ,then-
In one hand-Give TIG
In other hand-Give Toxoid
 Keep wound opened
 Debridement
Viva.
Why Toxoid+TIG is given?
Toxoid acts 7 days later so ,TIG is also given along with it
Toxoid is given by 2 dose in 1 month interval

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Structured Online Medical Academy (SOMA) | Basic Surgery

When deep structure is involved-Injury

When superficial structure is involved-Wound

Types-Acute and Chronic

Scar-Residual visible mark of wound

Perforating wound-The penetrating wound which extends into viscera/body cavity

What are the effects of wound on tissue?

Mechanical-Separation of functional structure(vessels ,tendon)

Give the types of wound

1|Basic Surgery Special SOMA Edition

Tidy wound Untidy wound

State the management of acute wound

2|Basic Surgery Special SOMA Edition

Short note on lacerated wound

Not clean ,incised wound ,lacerated margin

What are the factors influencing wound healing?

What are the factors affecting wound healing?

Classification of wound closure and healing

3|Basic Surgery Special SOMA Edition

 By tertiary intention(Delayed primary intention)

Wound closure techniques

 Primary closure(Within 6hours)

4|Basic Surgery Special SOMA Edition

Due to infection ,physical or chemical agent

Due to interference with blood supply e.g. Varicose vein

Due to local irritation e.g. Dental ulcer

 Specific ulcer(TB ,leprosy ,syphilis)

5|Basic Surgery Special SOMA Edition

Clinical examination of ulcer

 Site-Rodent ulcer on upper part of face ,primary chancre on upper lip

Non specific ulcer in extensive stage and transition stage-Painful

TB ulcer and of tongue-Very painful

6|Basic Surgery Special SOMA Edition

Antiseptic solution in surgery

 Fasting blood sugar(DM)

Criteria of healthy and unhealthy tissue

 Healthy-Pinkish , bleeds on touch ,granular surface ,no discharge , proliferative

7|Basic Surgery Special SOMA Edition

Sinus , fistula & cyst

 Anatomical-Frontal sinus ,nasal sinus

(Perianal sinus-Opening end in anal canal ,blind end in anal gland)

(Fecal fistula-Between skin and intestine)

It is an abnormal communication between the lumen/surface of an organ with the lumen

 Congenital-Branchial fistula ,tracehoesophageal fistula ,arteriovenous fistula

Difference between sinus and fistula

8|Basic Surgery Special SOMA Edition

Causes of persistence of sinus/fistula

 Presence of foreign body/necrotic tissue e.g. suture ,hair ,sequestrum ,faecolith

It is a swelling consisting of fluid in a sac lined by epi/endothelium

True cyst-Lined by epi/endothelium e.g. ovarian cyst

False cyst-No epi/endothelium e.g.pseudocyst in pancreas

 Sequestrum dermoid(Branchial cyst)

9|Basic Surgery Special SOMA Edition

 Inspection-Smooth ,shiny ,spherical

Positive transillumination test

Criteria of malignant ulcer

 Covered by slough ,pus or exudate

If lymph node is firm and painful-it should be inflammation

if lymph node is hard and painless-It would be malignant

DD of ulcer only by looking

Acid base balance

Acidosis and alkalosis indicate a change in pH in particular direction

pH= -Log[H+]=Log. (1 / [H+])

H+ concentration is expressed as nanomol/L