Surgery

SURGERY
PREVIOUS YEARS’ Q&A
*COMPILED FROM BAILEY & LOVE 27E AND SRB 6E
- OM SUBHAM
PAPER-I
1. THYROID ................................................................................................... 1
2. BREAST ..................................................................................................... 7
3. LIVER ...................................................................................................... 18
4. GALLBLADDER ........................................................................................ 21
5. SPLEEN ................................................................................................... 29
6. PANCREAS .............................................................................................. 32
7. ESOPHAGUS ........................................................................................... 34
8. STOMACH ............................................................................................... 39
9. INTESTINE ............................................................................................... 47
10. INTESTINAL OBSTRUCTION ................................................................... 51
11. ABDOMINAL TUBERCULOSIS ................................................................. 55
12. MASS ABDOMEN ................................................................................... 56
13. APPENDIX .............................................................................................. 57
14. RECTUM AND ANAL CANAL ................................................................... 60
PAPER-II
1. HERNIA ................................................................................................... 67
2. KIDNEY AND URETER .............................................................................. 73
3. URINARY BLADDER ................................................................................. 83
4. PROSTATE .............................................................................................. 84
5. URETHRA ................................................................................................ 88
6. PENIS ...................................................................................................... 90
7. SCROTUM ............................................................................................... 93
8. TESTIS ..................................................................................................... 96
9. WOUNDS AND WOUND HEALING ........................................................ 100
10. ULCER .................................................................................................. 102
11. SINUS AND FISTULA ............................................................................ 104
12. INFECTIOUS DISEASES ......................................................................... 105
13. SWELLINGS .......................................................................................... 107
14. SHOCK ................................................................................................. 110
15. HEMORRHAGE AND BLOOD TRANSFUSION ........................................ 111
16. BURNS ................................................................................................. 113
17. TRAUMA .............................................................................................. 116
18. HAND AND FOOT ................................................................................ 117
19. ARTERIAL DISEASES ............................................................................. 118
20. VASCULAR LESIONS ............................................................................. 123
21. VENOUS DISEASES ............................................................................... 125
22. SKIN TUMORS ...................................................................................... 128
23. FACIOMAXILLARY DISEASES ................................................................ 130
24. ORAL CAVITY ....................................................................................... 132
25. SALIVARY GLANDS ............................................................................... 135
26. NECK .................................................................................................... 139
27. PERITONEUM ...................................................................................... 142
28. MESENTERY ......................................................................................... 144
29. RETROPERITONEAL SPACE .................................................................. 145
30. UMBILICUS .......................................................................................... 146
31. NEUROSURGERY ................................................................................. 147
32. THORAX ............................................................................................... 150
33. OPERATIVE SURGERY .......................................................................... 154
CLASSIFICATION OF GOITRE
A. Simple non-toxic
1) Diffuse hyperplastic
a) Physiological – puberty, pregnancy
b) Iodine deficiency
2) Colloid
3) Nodular
a) Solitary
b) Multinodular
B. Toxic
1) Diffuse (Graves’ disease)
2) Multinodular
3) Toxic adenoma
C. Neoplastic
1) Benign – Follicular adenoma
2) Malignant
a) Primary – Follicular, Papillary, Anaplastic, Medullary, Lymphoma
b) Secondary – metastatic, local infiltration
D. Inflammatory
1) Autoimmune
a) Chronic lymphocytic thyroiditis
b) Hashimoto’s disease
2) Granulomatous – De Quervain’s thyroiditis
3) Fibrosing – Riedel’s thyroiditis
4) Infective
a) Acute – bacterial, viral
b) Chronic – tuberculous, syphilitic
MULTINODULAR GOITRE
➢ C/F
• Multiple nodules of different sizes – firm, non-tender, moves with deglutition
• slowly progressive disease with many years of history
• Positive Kocher's test
➢ COMPLICATIONS
• Secondary thyrotoxicosis
• Follicular carcinoma
• Haemorrhage
• Tracheal obstruction
• Calcification
• Cosmetic problem
➢ INVESTIGATIONS
• T3, T4, TSH, free T4
• FNAC
• US neck, X-ray neck
• Routine blood investigations, serum calcium
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➢ TREATMENT: surgery – thyroidectomy
1) Total
2) Subtotal
3) Partial (Hartley Dunhill operation)
SOLITARY THYROID NODULE
➢ ETIOLOGY
• Adenomas – Follicular
• Carcinomas – Papillary, Follicular, Anaplastic
• Cysts
• Thyroiditis
➢ INVESTIGATIONS
• US neck
✓ shows size, number, echogenicity, consistency, vascularity, presence of significant lymph node
✓ TIRADS (Thyroid Imaging Reporting And Data System)
1 – Benign
2 – Not suspicious
3 – Mildly suspicious
4 – Moderately suspicious
5 – Highly suspicious
✓ features of malignancy – irregular nodule, microcalcifications
• FNAC – IOC
• T3, T4, TSH
• Radioisotope study
• Power doppler: resistive index > 0.7 → malignancy
• X-ray neck: ring/rim calcification
➢ TREATMENT
A. Benign nodule
• Nontoxic nodule: observation or hemithyroidectomy for cosmesis & compressive symptoms
• Solitary toxic nodule: antithyroid drugs → radioactive iodine therapy
• Colloid nodule: observation or hemithyroidectomy for cosmesis & compressive symptoms
• Nodule in the isthmus: isthmectomy + excision of part of adjacent lateral lobes
B. Malignant nodule
• Papillary carcinoma: total or near total thyroidectomy
• Follicular adenoma: hemithyroidectomy
• Follicular carcinoma: total thyroidectomy
• Medullary carcinoma: total thyroidectomy + B/L neck nodal dissection including central compartment
C. Indeterminate nodule
• FNAC shows follicular neoplasm → hemithyroidectomy → if biopsy shows carcinoma → completion
thyroidectomy
• FNAC shows suspicious variety → repeat FNAC also suspicious → hemithyroidectomy → if biopsy shows
papillary carcinoma → total thyroidectomy + I/L central node neck dissection
D. Non-diagnostic nodule
FNAC also non-diagnostic → repeat FNAC also non-diagnostic → hemithyroidectomy if size >4 cm
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THYROTOXICOSIS
➢ TYPES
1) Diffuse toxic goitre (Primary thyrotoxicosis)
2) Toxic multinodular goitre (Secondary thyrotoxicosis)
3) Toxic nodule
4) Thyrotoxicosis factitial
5) Hashitoxicosis or de Quervain's thyroiditis
6) Amiodarone-induced thyrotoxicosis
7) Trophoblastic thyrotoxicosis
8) Postpartum hyperthyroidism
9) Neonatal thyrotoxicosis
10) Struma ovarii
➢ C/F
A. Symptoms
• Gastrointestinal system: weight loss in spite of increased appetite; diarrhoea
• Cardiovascular system: palpitations; SOB; angina; irregularity in heart rate; CCF
• Neuromuscular system: fatigue and muscle weakness; fine tremor; ↑ creatinine level
• Skeletal system: ↑ linear growth in children
• Genitourinary system: oligo or amenorrhoea
• Psychiatry: irritability; nervousness; insomnia
• Sympathetic overactivity: dyspnea, palpitations, tiredness, heat intolerance, sweating, hyperactivity,
irritability, nervousness, increased appetite, decrease in weight
B. Signs
• Thyroid swelling
• Eye signs
1) Lid retraction: upper eyelid higher than normal
2) von Graefe's sign (lid lag sign): inability of upper eyelid to keep pace with eyeball when it looks
downwards
3) Dalrymple's sign: visibility of upper sclera
4) Stellwag's sign: staring look; 1st sign to appear
5) Joffroy's sign: absence of wrinkling on forehead while frowning
6) Moebius sign: lack of convergence of eyeball
7) Naffziger's sign: protruding eyeball
8) Jellinek's sign: ↑pigmentation of eyelid margins
9) Enroth sign: edema of eyelids and conjunctiva
10) Rosenbach's sign: tremor of closed eyelids
11) Gifford's sign: difficulty in everting upper eyelid
12) Loewi's sign: dilatation of pupil with weak adrenaline solution
13) Knie's sign: unequal pupillary dilatation
14) Cowen's sign: jerky pupillary contraction to consensual light
15) Kocher's sign: when clinician places his hands on patient's eyes and lifts it higher, patient's upper lid
springs up more quickly than eyebrows
16) Exophthalmos: proptosis of eye with lid spasm of upper eyelid
• Cardiac manifestations
1) Tachycardia: measured by sleeping pulse rate
2) Pulsus paradoxus
3) Wide pulse pressure
4) Atrial fibrillation
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• Myopathy: weakness of proximal muscles
• Pretibial myxedema: B/L, symmetrical, shiny, red thickened dry skin with coarse hair in feet and ankles
• Thyroid acropachy: clubbing of fingers and toes
• Palpation: thrill
• Auscultation: bruit
• Hepatosplenomegaly
➢ INVESTIGATIONS
• Thyroid function tests: Serum T3 and T4 levels very high; TSH very low or undetectable
• Radioisotope study: I-123
• TRH estimation
• ECG
• TLC
• Thyroid antibodies estimation
➢ TREATMENT
A. Drugs
1) Anti-thyroid drugs: carbimazole, methimazole, propylthiouracil
2) Beta adrenergic blocking drugs: propranolol
3) Lugol's iodine
B. Surgery
1) Subtotal thyroidectomy
2) Total thyroidectomy: in Graves’ disease
3) Hemithyroidectomy: in autonomous nodule
C. Radioiodine therapy: I-131
PAPILLARY CARCINOMA OF THYROID
➢ ETIOLOGY
• Radiation
• Pre-existing MNG
• Hashimoto's thyroiditis
• Familial
• Elevated TSH
➢ MICROSCOPY
• cystic spaces
• papillary projections
• psammoma bodies
• Orphan Annie eye nuclei (intranuclear cytoplasmic inclusions)
• nuclear groove
• nuclear pseudoinclusions
➢ C/F
• thyroid swelling
• palpable discrete neck lymph nodes
➢ INVESTIGATIONS
• FNAC of thyroid nodule and lymph node
• Radioisotope scan: cold nodule
• Serum TSH level: high
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• Plain X-ray neck: fine calcification
• US neck
➢ TREATMENT
1) Total or near total thyroidectomy with central node compartment dissection
2) Lateral cervical/neck node dissection (LCND) or Modified radical neck dissection (MRND)
3) Suppressive dose of L-thyroxine 0.3 mg OD life long
4) Radioactive iodine therapy
LINGUAL THYROID
➢ DEFINITION: thyroid tissue in the midline posterior third of the tongue at the foramen caecum
➢ CAUSE: embryonic failure of normal thyroid tissue to descend from the foramen caecum area of the tongue base
through the lower neck
➢ PRESENTATION
• pink rounded strawberry-like mass
• hypothyroidism
• dysphagia, pain, speech impairment, stomatolalia, FB sensation, cough, snoring, sleep apnea
➢ INVESTIGATIONS: radioisotope study, US neck, MRI, thyroid function tests
➢ TREATMENT
1) L-thyroxine: daily orally
2) Surgical excision: transoral approach
3) Radioisotope therapy for ablation
THYROGLOSSAL FISTULA
➢ acquired
➢ CAUSES:
• following infection of thyroglossal cyst
• after inadequate removal of cyst
➢ lined by columnar epithelium
➢ secretes mucus discharge
➢ seat of recurrent inflammation
➢ Hood sign: opening of fistula indrawn and overlaid by a fold of skin
➢ Semilunar sign: peculiar crescentic appearance
➢ SITE: just below the hyoid bone
➢ INVESTIGATIONS: radioisotope study and fistulogram
➢ TREATMENT: Sistrunk operation
LATERAL ABERRANT THYROID
➢ DEFINITION: a mass of tissue having the structure of a normal or pathological thyroid gland, but situated lateral
to the jugular vein
➢ MCC: metastatic deposit from papillary thyroid carcinoma
➢ INVESTIGATION: FNAC
➢ TREATMENT: treated like metastatic papillary carcinoma thyroid
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THYROID FUNCTION TESTS
1) Serum T3
2) Serum T4
3) TSH
4) Free T3
5) Free T4
6) PBI (Protein-bound iodide)
7) RA I-123 scan
8) TRH stimulation test for hypothalamic-pituitary axis
9) Thyroid autoantibodies
10) Werner's T3 suppression test
11) Thyroglobulin estimation
RIEDEL'S THYROIDITIS
➢ DEFINITION: benign entity wherein thyroid tissue is replaced by fibrous tissue which infiltrates the capsule into
surrounding structures
➢ ASSOCIATIONS
• retroperitoneal and mediastinal fibrosis
• sclerosing cholangitis
➢ C/F
• small goitre: swelling with irregular surface, stony hard consistency
• stridor
• positive Berry's sign: absent/impalpable carotid pulsation
➢ D/D: Anaplastic carcinoma of thyroid
➢ INVESTIGATIONS
• T3, T4: low
• Radioisotope scan: no uptake
• FNAC
➢ TREATMENT
1) Isthmectomy
2) L-thyroxine replacement
3) High dose of steroids
4) Tamoxifen
OTHER IMPORTANT TOPICS
➢ Thyroglossal Cyst
➢ Retrosternal Goitre
➢ Follicular Carcinoma
➢ Anaplastic Carcinoma
➢ Hashimoto's Thyroiditis
➢ Thyroidectomy
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LYMPHATIC DRAINAGE OF THE BREAST
1) Axillary lymph nodes

Level I: Below and lateral to the pectoralis minor muscle – anterior, lateral, posterior
Level II: Behind the pectoralis minor muscle – central, interpectoral
Level III: Above and medial to pectoralis minor muscle – apical
2) Supraclavicular lymph nodes
3) Internal mammary nodes
4) Subclavicular nodes
MAMMOGRAPHY
➢ DEFINITION: a plain X-ray of soft tissue of breast using low voltage and high amperage
➢ 2 FILMS-
1) Craniocaudal: from above downward
2) Mediolateral: from side to side
➢ DOSE OF RADIATION: 0.1 Gy
➢ FINDINGS
• Microcalcifications – malignancy
• Soft tissue shadow: smooth – benign; irregular – malignancy
• Spiculations, duct distortion – malignancy
• Margin: circumscribed – benign
➢ BREAST IMAGING REPORTING AND DATA SYSTEM (BIRADS)
Grade 0: Need further imaging
Grade 1: Negative
Grade 2: Benign-repeat mammography 1 year
Grade 3: Probably benign-mammography after 6 months
Grade 4: Suspicious of carcinoma-biopsy
Grade 5: Highly suggestive of carcinoma-biopsy
Grade 6: Known carcinoma
➢ INDICATIONS
• Screening: after 40 years
• Diagnostic: evaluation and follow-up in benign breast disease
• Follow-up after conservative breast surgery
• For guided biopsy
• Mastalgias
• In obese patients
CLASSIFICATION OF BENIGN BREAST DISORDERS
A. Congenital disorders
✓ Inverted nipple
✓ Supernumerary breasts/nipples
✓ Non-breast disorders including Tietze’s disease
✓ Sebaceous cysts and other skin conditions
B. Injury
C. Inflammation/infection
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• ANDI
✓ Cyclical nodularity and mastalgia
✓ Cysts
✓ Fibroadenoma
✓ Duct ectasia/periductal mastitis
• Pregnancy-related
✓ Galactocele
✓ Lactational abscess
ABERRATION OF NORMAL DEVELOPMENT AND INVOLUTION (ANDI)
➢ includes variety of benign breast disorders occurring at different reproductive periods in females
➢ based on change in normal three phases of physiology of breast
1) Lobular development
2) Cyclical hormonal modifications
3) Involution
➢ ABERRATIONS-
A. In early reproductive age group (15-25 years)
1) Lobule: fibroadenoma
2) Stroma: juvenile hypertrophy
B. In mature reproductive age group (25-40 years)
1) Hormones: enlargement → fibrocystadenosis
C. Involution age group (40-55 years)
1) Lobule: macrocysts, cystic diseases
2) Duct: ductal dilatation, nipple discharge → periductal mastitis, breast abscess, mammary duct fistula
3) Epithelium: epithelial hyperplasia and atypia
FIBROADENOMA
➢ DEFINITION: hyperplasia of a single lobule of the breast (benign encapsulated tumour)

➢ mc in young females of 15-25 years age group
➢ Giant fibroadenoma: size >5 cm
➢ C/F: painless swelling in one of the quadrants – smooth, firm, non-tender, well-localised and moves freely within
the breast tissue (mouse in the breast)
➢ INVESTIGATIONS
• Mammography: well-localised smooth regular shadow, popcorn calcification
• FNAC or core biopsy
• USG
➢ TREATMENT
1) Excision – through a circumareolar incision (Webster) or submammary incision (Gaillard Thomas)
Indications-
• Size >3 cm
• Recurrence
• Multiple
• Cosmesis
• Complex type
2) Enucleation
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3) Cryoablation
4) Echotherapy
5) Removal with a large core vacuum biopsy system
FIBROCYSTADENOSIS / MAMMARY FIBROCYSTIC DYSPLASIA / CYCLICAL MASTALGIA WITH NODULARITY
➢ mc breast disease
➢ mc site: upper and outer quadrant
➢ estrogen-dependent
➢ CLASSIFICATION
A. Non-proliferative
B. Proliferative
1) Without atypia
2) With atypia
a) Ductal
b) Lobular
➢ STAGES
I: Hyperplasia
II: Adenosis
III: Cyst formation
➢ MICROSCOPIC CHANGES
• Stromal fibrosis
• Microcyst formation
• Adenosis
• Epitheliosis
• Papillomatosis
➢ C/F
• Swelling: B/L, painful, diffuse, granular, tender, better felt with palpating fingers
• Cyclical mastalgia: pain and tenderness more just prior to menstruation
➢ INVESTIGATIONS
• FNAC
• USG, Mammography
➢ TREATMENT
A. Conservative management – preferred
1) Reassurance, avoid caffeine, chocolate, salt
2) An appropriately fitting and supportive bra worn throughout the day and a soft bra worn at night
3) Drugs
a) Oil of evening primrose: DOC
b) Danazol (GnRH inhibitor): most effective drug; 2nd DOC
c) Bromocriptine
d) Tamoxifen
e) Goserelin (LHRH agonist)
f) Vitamin E and B6
g) NSAIDs
B. Surgery
1) Subcutaneous mastectomy with prosthesis placement: removal of entire breast with retaining skin over
the breast, areola and nipple through a submammary Gaillard Thomas incision
2) Excision of the cyst or localised excision of the diseased tissue
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PHYLLOIDES TUMOUR / CYSTOSARCOMA PHYLLOIDES / SEROCYSTIC DISEASE OF BRODIE
➢ mc non-epithelial neoplasm of the breast

➢ TYPES
1) Benign
2) Borderline
3) Malignant: sarcoma
➢ PATHOLOGY
• Gross
✓ large capsulated area with cystic spaces
✓ C/S – soft, brownish, cystic areas
• Microscopy
✓ contains cystic spaces with leaf-like projections
✓ hypercellularity and pleomorphism
➢ C/F
• Swelling: U/L, rapidly growing, smooth, non-tender, soft, fluctuant
• Skin over the breast: bosselated, stretched, red, pressure necrosis over the summit, with dilated veins
➢ D/D
• fibroadenoma
• angiosarcoma
• breast abscess
• carcinoma breast
➢ INVESTIGATIONS
• USG; mammography
• FNAC, core biopsy
• CXR, CT chest: in malignancy
➢ TREATMENT
1) Enucleation
2) Wide local excision with 1 cm margin
3) If malignant: total mastectomy + adjuvant chemotherapy
BREAST ABSCESS
A. Lactational
➢ PRECIPITATING FACTORS
• Cracked nipple
• Retracted nipple
• Improper cleaning of the nipple
• Milk stasis
• Infection from the mouth of the baby
• Haematoma getting infected
➢ mc bacteria: S. aureus
➢ C/F
• Continuous throbbing pain in the breast
• Diffuse redness, tenderness, warmness and brawny induration in the breast
• Purulent discharge from the nipple
• High-grade fever
➢ D/D: Inflammatory carcinoma of breast
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➢ INVESTIGATIONS
• TLC, DLC
• USG
➢ TREATMENT
1) Antibiotics
2) Repeated US guided aspirations
3) Drainage under GA: indications-
• Mastitis not resolving with antibiotics in 48 hours
• Persistent fever and progression of mastitis
• Brawny induration
➢ COMPLICATIONS
• Antibioma
• Sinus, fistula, skin necrosis
• Recurrent infection, bacteremia, septicemia
B. Non-lactational
➢ mc in duct ectasia and periareolar infections
➢ commonly recurrent with tender swelling under the areola
➢ TREATMENT
1) Antibiotics
2) Repeated aspirations
3) Drainage → cone excision of the duct
ANTIBIOMA
➢ intramammary mastitis treated by antibiotics but not drained → pus localises and becomes sterile with a thick
fibrous tissue cover
➢ C/F
• Previous h/o mastitis treated with antibiotics
• Swelling: painless, smooth, non-tender, hard, fixed to breast tissue
➢ D/D: Scirrhous carcinoma breast
➢ INVESTIGATIONS: FNAC; mammography; USG
➢ TREATMENT: excision – submammary incision → antibiotics
DUCT ECTASIA / PLASMA CELL MASTITIS
➢ DEFINITION: dilatation of lactiferous ducts due to myoepithelial relaxation of duct wall with periductal mastitis
➢ C/F
• Greenish nipple discharge from the nipple
• Tender, indurated mass under the areola
• Nipple retraction
➢ D/D: Carcinoma breast
➢ INVESTIGATIONS
➢ TREATMENT
1) Stop smoking
2) Cone excision of involved major ducts (Adair-Hadfield operation)
3) Antibiotics
4) Melhem Novel modified breast ductal system excision
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CYSTIC SWELLINGS OF THE BREAST
➢ Breast cysts
➢ Bloodgood cyst
➢ Hydatid cyst
➢ Phylloides tumour
➢ Cystic necrosis in carcinoma breast
➢ Breast abscess
➢ Hematoma
➢ Galactocele
➢ Lymph cyst
GYNECOMASTIA
➢ DEFINITION: hypertrophy of male breast more than usual due to increase in ductal (epithelial) and connective
tissue (stromal) elements
➢ ETIOLOGY
• Estrogen excess: testicular tumours; hyperthyroidism, liver diseases, estrogen therapy
• Androgen deficiency: aging, Klinefelter's/ Kallmann syndromes, eunuch, ACTH deficiency
• Secondary testicular failure: cryptorchidism, orchitis, trauma, CRF
• Drugs: digitalis, anabolic steroid, reserpine, theophylline, frusemide, cimetidine, phenytoin, spironolactone
➢ PRESENTATIONS
1) Diffuse enlargement of breast occupying all quadrants
2) Well-localised, painful, tender, small nodule under the areola
➢ INVESTIGATIONS: LFT, DNA study, hormone assay, FNAC, USG breast
➢ TREATMENT
1) Stop causative drugs
2) Well-localised type: surgical excision using circumareolar incision
3) Diffuse type: excision by Gaillard Thomas submammary incision
4) Hypogonadism: testosterone
5) Cosmesis: endoscopic-assisted subcutaneous mastectomy
6) Reduction mammoplasty; nipple reduction surgeries
7) Drugs: tamoxifen, clomiphene, androgens, danazol, aromatase inhibitors – 6 months
CARCINOMA BREAST
➢ TYPES
1) Scirrhous carcinoma
2) Medullary carcinoma
3) Inflammatory carcinoma / Lactating carcinoma / Mastitis carcinomatosis
4) Colloid carcinoma
5) Paget's disease of the nipple
6) Tubular, papillary, cribriform types of duct carcinomas
7) Atrophic scirrhous carcinoma
8) Lobular carcinoma in situ
9) Disease of Reclus
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➢ C/F
• Lump in the breast: hard, painless (mc site: upper outer quadrant)
• Cutaneous manifestations
✓ Peau d'orange
✓ Dimpling of skin
✓ Retraction of nipple
✓ Ulceration, discharge from the nipple and areola
✓ Skin ulceration and fungation
✓ Cancer-en-cuirasse
✓ Tethering to skin
• Axillary (mc involved: anterior, central groups) & supraclavicular lymph node enlargement
Effects of lymphatic obstruction
✓ Peau d'orange
✓ Brawny edema of arm
✓ Cancer-en-cuirasse
✓ Elephantiasis chirurgens
✓ Lymphangiosarcoma
• Chest pain and hemoptysis
• Hematogenous spread
✓ Bone (mc): pain, tenderness, swelling, pathological fracture
✓ Lungs: malignant pleural effusion and cannon ball secondaries
✓ Liver: ascites, secondaries
✓ Brain: ↑ICP, coning
✓ Secondary ovarian tumour
➢ 8 AJCC TNM STAGING
TH
• Primary Tumour (T)

Tx: Primary tumour cannot be assessed
T0: No evidence of primary
Tis: Carcinoma in situ
T1: Tumour < 20 mm in greatest dimension
-T1 mi: Microinvasion < 1 mm in greatest dimension
T2: 20-50 mm in greatest dimension
T3: >50 mm in greatest dimension
T4: Any size with direct extension to the chest wall or skin or both
-T4a: Tumour of any size extending into the chest wall
-T4b: Ulceration or ipsilateral satellite nodules and/or edema
-T4c: T4a and T4b
-T4d: Inflammatory carcinoma
• Regional Lymph Nodes (N)
Nx: Regional nodes cannot be assessed
N0: No regional nodes involved
N1: Metastases to mobile ipsilateral level 1 & 2 axillary LN
-N1 mi: 0.2-2 mm in greatest dimension
N2-
-N2a: Metastases in I/L fixed level 1 and 2 axillary LN
-N2b: Metastases only in clinically detected ipsilateral internal mammary LN
N3-
-N3a: Metastases to I/L infraclavicular lymph nodes
-N3b: Metastases to I/L internal mammary lymph nodes + clinically evident level 1 & 2 axillary LN
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-N3c: Metastases to I/L supraclavicular LN
• Distant Metastases (M)
M0: No clinical or radiological evidence of distant metastases
M1: Distant detectable metastases
• Stage Groups
Stage 0: Tis N0 M0
Stage IA: T1/1 mi N0 M0
Stage IB: T0/1/1 mi N1 mi M0
Stage IIA: T0/1 N1 M0; T2 N0 M0
Stage IIB: T2 N1 M0; T3 N0 M0
Stage IIIA: T0/1/2 N2 MO; T3 N1/2 M0
Stage IIIB: T4 N0/1/2 M0
Stage IIIC: T any N3 M0
Stage IV: T any N any M1
➢ INVESTIGATIONS
• Mammography
✓ for screening in elderly females
✓ irregular soft tissue shadow, microcalcifications, spiculations
• US breast
✓ preferred method of screening in young females
✓ irregular margin, irregular internal echoes, irregular posterior shadowing, non-compressibility, ratio
between anteroposterior to width dimensions >1
• FNAC
✓ done with 23-gauge needle using aspiration gun
✓ minimum six aspirations
✓ difficult to differentiate between in situ and invasive breast cancer
• Biopsy
✓ for confirmation of diagnosis
✓ done under LA
✓ method of choice: core needle biopsy
• Receptor study
1) Estrogen receptor
2) Progesterone receptor
3) Her-2/Neu receptor
• Nipple discharge study
• Sentinel lymph node biopsy
• Axillary sampling
• MRI breast: method of choice of imaging breasts in pregnancy
• Tumour markers: CA 15/3
• Ductography: contrast study of ducts of breast in case of unilateral nipple discharge
• Breast ductal endoscopy: for direct visualisation of tumour in DCIS and invasive ductal carcinomas
• For metastases
✓ MRI spine/pelvis
✓ Radioisotope bone scan
✓ PET scan
✓ CT scan chest, abdomen and brain
✓ X-ray chest, spine
✓ US abdomen
• CBC, LFT
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➢ TREATMENT OPTIONS
A. Surgery
1) Total mastectomy: removal of tumour, entire breast, areola, nipple, skin over the breast, pectoral fascia
2) Modified radical mastectomy (MRM)
a) Patey's operation: total mastectomy + axillary LN clearance + removal of pectoralis minor
b) Scanlon's operation: modified Patey's operation (instead of removing pectoralis minor, it is incised)
c) Auchincloss operation: total mastectomy + axillary LN levels I & II clearance
3) Conservative surgery / Wide local excision / Lumpectomy / Partial mastectomy: removal of unicentric
tumour with 1 cm clearance margin + axillary dissection + RT to breast and chest wall in low-grade <4
cm-sized tumor with negative axillary nodes
4) Skin sparing mastectomy / Key hole mastectomy: excision of nipple-areola complex with very limited
skin removal + marginal skin excision over tumour site + total glandular mastectomy + axillary dissection
5) Toilet mastectomy: removal of tumour with breast tissue after giving chemotherapy in LABC
6) Halsted radical mastectomy (RM): removal of tumour with entire breast, nipple, areola, skin over the
tumour with margin, pectoralis major and minor muscles, fat, fascia, axillary LN & serratus anterior
7) Extended radical mastectomy (ERM): RM + removal of internal mammary LN
B. Radiotherapy
• indications-
✓ after conservative breast surgery
✓ after total mastectomy
✓ invasive carcinoma
✓ extensive in situ carcinoma
✓ patients <35 years
✓ with multifocal disease
✓ with bone secondaries
✓ inflammatory carcinoma
✓ pre-operative: to reduce the tumour size
✓ curative: atrophic scirrhous carcinoma
• types-
1) Whole breast radiotherapy
2) Accelerated Partial Breast Irradiation
C. Hormone therapy
• indication: ER/PR positive patients
• advantages
✓ gives prophylaxis against carcinoma of opposite breast
✓ useful in metastatic breast carcinoma
✓ reduces recurrence rate
• includes
1) Tamoxifen
2) Letrozole
3) Trastuzumab, Lapatinib
4) Adrenalectomy by mitotane
5) Oophorectomy by surgery/radiation/Goserelin
6) Progestogens: MPA
7) Progesterone receptor antagonist
8) Androgens
D. Chemotherapy
• Types
1) Adjuvant
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2) Neoadjuvant
3) Palliative
• Indications
✓ All node positive patients
✓ Primary tumour > 1 cm in size
✓ Presence of poor prognostic signs
✓ Advanced carcinoma breast as a palliative procedure.
✓ After simple mastectomy in stage III carcinoma breast with fixed axillary nodes
✓ Inflammatory carcinoma of breast
✓ Stage IV carcinoma breast with secondaries in bone, lungs, liver
✓ In premenopausal age group with poorly differentiated tumours
• Regimes
1) CAF: cyclophosphamide + adriamycin + 5-FU
2) CEF: cyclophosphamide + epirubicin + 5-FU
3) CMF: cyclophosphamide + methotrexate + 5-FU
4) TAC: taxane + adriamycin + cyclophosphamide
➢ TREATMENT STRATEGY
• Stage 0
✓ <4 cm: wide local excision; RT; HT
✓ >4cm: total mastectomy + axillary dissection (if SLNB +ve); HT
• Stage I & II: BCS + RT + axillary dissection (if SLNB +ve) + CT (if tumour > 1 cm, +ve axillary nodes, high nuclear
grade, vascular/lymphatic invasion, ER/PR -ve with over expression Her-2/Neu)
• Stage III: NACT + MRM + RT + CT + HT
• Stage IV: HT + CT + palliative mastectomy
➢ EARLY CARCINOMA BREAST
• Stage I; IIA; IIB T2N1M0
• Diagnosis: mammography, core needle biopsy, MRI, CXR, USG abdomen, CT chest & abdomen, CBC, LFT
• T/t approaches
A. Surgery
1) BCS: wide local excision with a clearance margin of 1 cm + axillary dissection through a separate
incision in the axilla + RT to breast and chest wall
2) TM: indications – tumor >4cm or multicentric or poorly differentiated
3) MRM (Auchincloss or Patey's)
4) SSM + axillary dissection
B. Adjuvant therapy
1) Postop RT
2) CT: CMF, CAF
3) HT: tamoxifen, letrozole, goserelin
➢ LOCALLY ADVANCED CARCINOMA BREAST
• Stage IIB T3N0M0; III
• Diagnosis: B/L mammography, FNAC of tumor and axillary node, core needle biopsy, receptor study, CT chest
& abdomen, bone scan, MRI, LFT
• T/t approach: NACT (3 cycles) → RT (if non-responder) → TM/MRM → CT (remaining cycles) → HT (5 years)
➢ METASTATIC CARCINOMA BREAST
• Stage IV
• Diagnosis: FNAC, biopsy, receptor study, US abdomen, bone scan, CT chest, brain & abdomen
• T/t approaches
1) CT: CMF, CAF, TAC
2) RT: in bone metastasis
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3) HT: tamoxifen, trastuzumab, androgens, progestogens, mitotane
4) Palliative toilet/total mastectomy
PAGET’S DISEASE OF THE NIPPLE
➢ DEFINITION: superficial manifestation of an intraductal carcinoma

➢ C/F: a hard nodule just underneath the areola → ulceration → destruction of nipple
➢ HISTOLOGY: Paget's hyperchromatic cells containing intracellular mucopolysaccharides
➢ D/D: eczema of nipple and areola
➢ T/T: MRM
SENTINEL LYMPH NODE BIOPSY
➢ DEFINITION: biopsy of the first axillary LN draining the breast to check for involvement by tumor cells
➢ INDICATION: done in all cases of early breast cancers without clinically palpable node
➢ PROCEDURE: sentinel LN localised by preoperative/perioperative injection of patent blue or 99m Tc
radioisotope-labelled albumin in peritumour area or into subdermal plexus around the nipple → biopsied with a
small incision made directly over it
➢ SLNB +ve → axillary dissection
➢ COMPLICATIONS
• blue tattooing of skin
• blue-green urine and stool
• allergic reactions, anaphylaxis
• seroma formation
➢ C/I
• allergy to vital blue dye or radio-colloid
• pregnancy
• inflammatory carcinoma of breast
➢ OTHER INDICATIONS
1) Carcinoma penis
2) Malignant melanoma
NIPPLE RETRACTION
➢ 75% U/L; 25% B/L

➢ Congenital nipple retraction: simple nipple inversion
causes problems in breastfeeding, recurrent infection, collection of secretions
➢ Slit-like retraction: due to duct ectasia and periductal mastitis.
➢ Circumferential retraction: due to carcinoma
➢ Inflammatory carcinoma of breast

➢ Triple assessment
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HYDATID CYST
➢ C/F
• Three-finger test: asymptomatic palpable liver with classical thrill (hydatid thrill)
• Gradually enlarging painful mass in RUQ
• Jaundice
• Features of anaphylaxis (emergency presentation)
• Weight loss; fatigue; vomiting; dyspepsia
➢ INVESTIGATIONS
• USG: rosettes of daughter cysts, double contoured membrane of cyst, calcification of cyst wall
Hassen Gharbi’s US-based classification
Type 1 - Pure fluid collection
Type 2 - Fluid collection with split wall
Type 3 - Fluid collection with septa
Type 4 - Heterogeneous appearance
Type 5 - Calcified thick walls
• X-ray; MRI
• CT scan: a smooth space-occupying lesion with several septa
• ERCP – to check cystobiliary communications
• Serological tests
✓ ELISA
✓ immunoelectrophoresis: detection of precipitation line (arc 5)
• LFT
• Casoni's intradermal test
➢ TREATMENT
A. Drugs
1) Albendazole: 10 mg/kg → 4-week cycles with 2 weeks drug free interval → 3 such cycles
2) Praziquantel: 60 mg/kg for 2 weeks
B. PAIR (Puncture-Aspiration-lnjection-Reaspiration)
cyst punctured percutaneously using a cholangiography 22-gauge needle under LA under US/CT guidance →
50% fluid aspirated → scolicidal agents injected (15% hypertonic saline) → reaspiration after 20 mins →
sclerosant injected
C. Surgery
Asymptomatic inactive cysts: left alone → size monitored by US
1) Conservative
a) Laparotomy → cyst evacuation → omentoplasty/marsupialization/capitonage
b) Partial pericystectomy
2) Radical
a) Pericystectomy
b) Liver resection
D. Detection of cystobiliary communications and correction
AMOEBIC LIVER ABSCESS
➢ mc extraintestinal presentation of amoebiasis

➢ mc site: right lobe over posterosuperior surface → single large abscess with chocolate-coloured pus: anchovy
sauce – contains dead liver cells, RBCs, necrotic material
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➢ C/F
• fever, loss of weight, chills and rigors, non-productive cough, shoulder pain
• pain in the right hypochondrium
• soft, tender, smooth, liver with increased span
• intercostal tenderness
➢ INVESTIGATIONS
• TLC ↑, Hb% ↓
• LFT
• PT: widened
• US abdomen: altered echogenicity
• CXR: tenting diaphragm
• CECT: raised diaphragm
• Indirect hemagglutination test, ELISA and gel diffusion precipitative test
➢ TREATMENT
A. Drugs
1) Amoebicides
a) Tissue – dihydroemetine, chloroquine
b) Luminal – diloxanide furoate, paromomycin
c) Mixed – metronidazole, tinidazole, ornidazole
2) IV or oral antibiotics
B. US-guided wide bore needle aspiration
C. US-guided percutaneous drainage
D. Surgery: abscess area opened through transperitoneal approach → pus evacuated → Malecot's catheter
placed in situ
indications-
a) Recurrence after repeated aspirations
b) Left/caudate lobe abscess
c) Multiple/multiloculated abscess
d) Ruptured abscess
e) Thick pus
HEPATOCELLULAR CARCINOMA (HEPATOMA)
➢ mc site: right lobe

➢ ETIOLOGY
• Aflatoxin B1
• Hepatitis B and hepatitis C virus infection
• Alcoholic cirrhosis
• Clonorchis sinensis infestation
• Smoking
• Haemochromatosis
• α1 antitrypsin deficiency
• Hepatic adenoma
• Environment related chemicals
• Anabolic steroids
• NAFLD
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• Diabetes and obesity
• Primary biliary cirrhosis
• Wilson's disease
➢ C/F
• Painless mass in right hypochondriac region
• Loss of appetite and weight
• Jaundice
• Ascites
• Hepatic thrill and bruit
• Fever
• Hepatic failure
➢ INVESTIGATIONS
• US abdomen
• CECT
• AFP
• CT angiography
• LFT
➢ TREATMENT
A. Definitive t/t
1) Hemi-hepatectomy – in non-cirrhotic patients
2) Total hepatectomy with orthotopic liver transplantation – in cirrhotic patients
B. Adjuvant therapy
1) Sorafenib, levatinib
2) Systemic chemotherapy – adriamycin, cisplatin, carboplatin, mitomycin C, 5-FU
3) Octreotide
C. Palliative t/t
1) Radiofrequency ablation
2) Percutaneous ethanol or acetic acid injection
3) Targeted radiotherapy using Iodine-131 with lipiodol injection into hepatic artery
➢ Pyogenic liver abscess

➢ Portal hypertension
➢ Esophageal varices
➢ Ascites
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GALLSTONES
➢ ETIOPATHOGENESIS
1) Altered GB function
• Bile stasis - estrogen therapy, pregnancy, vagotomy
• Poor emptying
• Poor absorption
2) Supersaturated bile
• Female
• Fertile
• Fat
• Forty
• High calorie diet
3) Cholesterol nucleating factors
• Old age
• Obesity
• OCP
• Octreotide
• Clofibrate
• Infection
4) Altered enterohepatic circulation
• Ileal resection
• Ileal diseases
• Altered bowel transit time
• Altered bowel flora
• Cholestyramine
• Deoxycholate
5) Infections and infestations
• Bacteria - E. coli, Salmonella
• Parasites - Clonorchis sinensis, Ascaris lumbricoides
6) Increased bilirubin production
• Hemolytic diseases
➢ C/F
• Biliary colic
▪ sudden, severe spasmodic pain in RUQ which ebbs & flows
▪ radiates to chest, upper back and shoulder
▪ self-limiting; recurs unpredictably
▪ often precipitated by a fatty meal & supine position; starts during night and wakes the patient
▪ a/w nausea, vomiting, tachycardia and restlessness
• Dyspepsia
• Flatulence
• Fat intolerance
• Altered bowel habits
➢ COMPLICATIONS
A. In GB
1) Biliary colic
2) Acute cholecystitis
3) Chronic cholecystitis
4) Empyema GB
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5) Perforation → biliary peritonitis or pericholecystitic abscess
6) Mucocele GB
7) Ca GB
B. In CBD
1) Secondary CBD stones → biliary obstruction
2) Cholangitis
3) Pancreatitis
4) Mirizzi syndrome
C. In intestine
1) Cholecystoduodenal fistula → gallstone ileus
➢ INVESTIGATIONS
• History
• Physical examination: Murphy’s sign – RUQ tenderness exacerbated during inspiration by right subcostal
palpation
• US abdomen (initial imaging modality of choice): stone with posterior acoustic shadowing
• Plain X-ray abdomen
1) Radiolucent stones – 90%
2) Radiopaque stones – 10% → Mercedes Benz sign or sea-gull sign
• LFT
• TLC
• CT scan abdomen
➢ TREATMENT: cholecystectomy
1) Open – right subcostal Kocher's incision
2) Laparoscopic
ACUTE CHOLECYSTITIS
impacted stone → obstruction at Hartmann's pouch or in cystic duct → stasis, edema of wall, bacterial
infection → acute cholecystitis
➢ C/F
• sudden onset of pain in right hypochondrium, with tenderness, guarding, and rigidity.
• palpable, tender, smooth, soft GB
• Boa’s sign - area of hyperaesthesia between 9th and 11th ribs posteriorly on the right side
• Jaundice
• Fever, nausea
• Tachycardia and toxic features
• Murphy's sign
➢ D/D
• Duodenal ulcer perforation
• Acute pancreatitis
• Acute appendicitis
• Acute pyelonephritis
• Lobar pneumonia
• Myocardial infarction
• Ruptured ectopic pregnancy
➢ COMPLICATIONS
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• Perforation → cholecystoduodenal or cholecystobiliary fistula, Mirizzi syndrome, peritonitis; pericholecystitic
abscess
• Cholangitis and septicaemia
• Empyema GB; gangrenous GB
➢ INVESTIGATIONS
• US abdomen
• HIDA scan: non-visualisation of GB
• TLC: neutrophilia
• LFT
➢ TREATMENT
A. Hospitalisation
B. Conservative treatment
1) Nasogastric aspiration
2) NPO, IV fluids
3) Analgesics and antispasmodics.
4) Broad spectrum antibiotics
5) Observation
6) Follow-up US scan
C. Elective interval cholecystectomy: after 3-6 weeks
D. Emergency cholecystectomy or cholecystostomy → pus drainage by a Foley’s or Malecot’s catheter →
elective cholecystectomy after 3 weeks
indications-
1) Empyema GB
2) Persisting symptoms or failure of medication
3) Emphysematous cholecystitis
4) Perforation/peritonitis
EMPYEMA GALLBLADDER
➢ DEFINITION: a type of acute cholecystitis wherein GB is filled with pus

➢ C/F
• pain and tenderness in right hypochondrium
• tender, smooth, globular GB palpable in right hypochondrium
• fever, toxicity
➢ COMPLICATIONS:
• septicaemia
• rupture, peritonitis
➢ INVESTIGATIONS
• US abdomen
• TLC
• Hematocrit
• LFT
• PT-INR
➢ TREATMENT
1) Antibiotics
2) Emergency cholecystectomy
3) Cholecystostomy → Foley's or Malecot's catheter kept in situ → after 3- 6 weeks, cholecystectomy
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MUCOCELE OF THE GALLBLADDER
➢ DEFINITION: non-inflammatory overdistension of GB containing mucoid or clear fluid

➢ ETIOLOGY: cystic duct obstruction
• impacted stone
• polyp
• carcinoma
• extrinsic compression
• congenital narrowing of cystic duct
• parasitic block
• prolonged TPN
➢ C/F
• dyspepsia
• painless swelling in right hypochondrium
• non-tender, smooth, soft, globular, palpable GB reaching down up to pelvis
➢ D/D
• choledochal cyst
• mesenteric cyst
• hydatid cyst
• pseudocyst of pancreas
➢ COMPLICATIONS
• empyema GB
• perforation, rupture, peritonitis
➢ INVESTIGATIONS
• US abdomen
• LFT
• CT scan
• MRCP
➢ TREATMENT: cholecystectomy
CHRONIC CHOLECYSTITIS
➢ ETIOLOGY
• Gallstones
• Cholecystoses
• Chronic acalculous cholecystitis
➢ C/F
• Pain in right hypochondrium
• Positive Murphy's sign, Moynihan's sign
• Flatulent dyspepsia; intolerance to fatty meals; biliary dyspepsia
➢ INVESTIGATIONS
• US abdomen
• HIDA scan
• LFT
• TLC
• ERCP
• CT scan
➢ TREATMENT: Cholecystectomy
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GALLSTONE ILEUS
➢ DEFINITION: a type of acute intestinal obstruction d/t blockage by a bolus or mass of gallstones which enter
intestine through cholecystoduodenal (mc) or cholecystointestinal or gastric fistulas
➢ C/F
• features of intestinal obstruction
• recurrent episodic obstruction (tumbling obstruction)
➢ INVESTIGATIONS
• Plain X-ray abdomen in erect posture: pneumobilia, multiple air fluid levels
• US abdomen
• CT scan
➢ TREATMENT
1) Laparotomy, enterotomy, removal of gallstones and closure of enterotomy
2) Cholecystectomy, correction of fistula with T-tube drainage – done after 12 weeks
CHOLEDOCHOLITHIASIS
➢ C/F
• Pain
• Jaundice (mc clinical manifestation)
• Fever with chills and rigors
• Tenderness in epigastrium and right hypochondrium.
• Steatorrhea and darkening of urine; pruritus
➢ Charcot’s triad: intermittent pain, intermittent fever, intermittent jaundice
➢ Reynold’s pentad: persistent pain, persistent fever, persistent jaundice, shock, altered mental status
➢ D/D
• Ca head of pancreas
• Ca periampullary region
• Ca biliary tree
• Biliary stricture
• Viral hepatitis
➢ INVESTIGATIONS
• US abdomen
• CT scan: most sensitive
• MRCP, ERCP, PTC
• Blood tests: TLC, LFT, PT INR, platelet count
➢ TREATMENT
A. General measures
1) Injection Vit. K or FFP infusion
2) IV antibiotics
3) Correction of dehydration
4) IV mannitol
B. Secondary CBD stones
1) ERCP (endoscopic sphincterotomy and stone extraction through Dormia basket or balloon catheter) →
laparoscopic cholecystectomy
2) Open cholecystectomy → on table cholangiogram → choledochotomy → CBD stone removal using Des
Jardin's choledocholithotomy forceps → confirmation of patency using Bake's CBD dilator → placement
of Kehr’s T-tube in CBD for 14 days → postoperative T-tube cholangiogram → T-tube removed
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C. Primary CBD stones
1) Open transduodenal sphincteroplasty
2) Open side-to-side choledochoduodenostomy
3) Open Roux-en-Y choledochojejunostomy
OBSTRUCTIVE JAUNDICE
• intrahepatic/extrahepatic biliary outflow obstruction → cholestasis → conjugated hyperbilirubinemia
• impaired bile acid secretion into the gut → defective absorption of fat and fat-soluble vitamins →
steatorrhea; deficiencies of vitamins A, D, E, K
• severe biliary obstruction → secondary biliary cirrhosis, acute cholangitis
➢ CAUSES
1) Congenital: Biliary atresia, choledochal cyst
2) Inflammatory: Ascending cholangitis, sclerosing cholangitis
3) Obstructive: CBD stones, biliary stricture, parasitic infestation
4) Neoplastic: Ca head or periampullary region of pancreas, cholangiocarcinomas, Klatskin tumour
5) Extrinsic compression of CBD by lymph nodes or tumours
➢ C/F
• severe jaundice, pruritus
• loss of weight & appetite
• pain in right hypochondrium, palpable GB
• hydrohepatotic palpable, smooth, soft, non-tender liver
• steatorrhea
➢ INVESTIGATIONS
• LFT: direct bilirubin increased
• PT INR, TLC
• US abdomen, CT/MRI
• ERCP, MRCP, PTC
• Urine tests
➢ TREATMENT
A. Pre-operative preparation
1) Inj. vitamin K IM or FFP infusion
2) IV antibiotics
3) Adequate hydration
4) IV mannitol
5) Calcium supplements
6) Repeated monitoring of PT, electrolytes
7) Correction of coagulopathy
B. T/t of cause
1) CBD stones – ERCP stone removal, choledocholithotomy, transduodenal sphincteroplasty,
choledochojejunostomy/choledochoduodenostomy
2) Ca periampullary or head of pancreas – Whipple's operation or triple bypass or ERCP stenting
3) Biliary stricture – stenting, choledochojejunostomy, Roux-en-Y hepaticojejunostomy
4) Klatskin tumour – radical resection or palliative stenting
5) Biliary atresia – Kasai's operation or liver transplantation
6) Choledochal cyst – excision, hepaticojejunostomy, mucosal resection
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7) Pruritus – cholestyramine, rifampin, ondansetron, gabapentin, sertraline, ursodeoxycholic acid,
antioxidants, phototherapy, plasmapheresis
CARCINOMA GALLBLADDER
➢ ETIOLOGY
• Gallstones (mcc)
• Choledochal cyst
• Anomalous pancreaticobiliary duct junction
• GB cholesteroses
• GB polyp
• Chronic typhoid carriers
• Carcinogens
• IBD
• Hepatitis B and hepatitis C virus infection
• Porcelain GB
• Nitrosamines
• Xanthogranulomatous cholecystitis
➢ C/F
• pain in right hypochondrium
• hard and nontender mass in RUQ
• jaundice
• significant weight loss in short duration, anorexia
• acute presentation of cholecystitis
• palpable nodular liver secondaries, ascites
• more common in females
➢ 8TH AJCC TNM STAGING
• Tumour (T)
Tx: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ
T1: Tumor invades lamina propria or muscular layer
T2a: Tumor invades perimuscular connective tissue on peritoneal side without involving serosa
T2b: Tumor invades perimuscular connective tissue on peritoneal side without involving liver
T3: Tumor perforates serosa +/- directly invades liver +/- one other adjacent organ/structure
T4: Tumor invades main portal vein or hepatic artery or invades >1 extrahepatic organs/structures
• Nodes (N)
Nx: Regional lymph nodes cannot be assessed
N0: Regional lymph node metastasis
N1: Metastases to 1-3 lymph nodes
N2: Metastases to >3 lymph nodes
• Metastases (M)
M0: No distant spread
M1: Distant spread
• Staging
Stage 0: Tis, N0, M0
Stage I: T1, N0, M0
Stage IIA: T2a, N0, M0
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Stage IIB: T2b, NO, M0
Stage IIIA: T3, NO, M0
Stage IIIB: T1-3, N1, M0
Stage IVA: T4, N0/1, M0
Stage IVB: T any, N2, M0; T any, N any, M1
➢ INVESTIGATIONS
• US/CT abdomen
• US-guided FNAC
• LFT
• MRCP
• Laparoscopy
• CA 19-9
➢ TREATMENT: extended cholecystectomy + resection of liver segments IV and V + perihepatic nodal clearance
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)
➢ PROCEDURE: gastroduodenoscope passed → sphincter identified and cannulated → iodine contrast injected into
bile duct and pancreatic duct → visualised → if cannula goes upwards beside vertebra it is in bile duct; if cannula
goes across the vertebra, it is in pancreatic duct
➢ INDICATIONS
• Malignancy: irregular filling defect
• Chronic pancreatitis: chain-of-lakes appearance
• Congenital anomalies
• Stones
• Stricture of biliary tree
• Choledochal cyst
• For sampling of biliary and pancreatic juices for analysis and cytology
• Brush biopsy from tumour site
➢ THERAPEUTIC USES
• Extraction of stone from biliary duct
• Nasobiliary drainage
• Stenting of tumour in the CBD or in the pancreas
• Dilatation of the biliary stricture
• Endoscopic papillotomy
➢ COMPLICATIONS
• Pancreatitis; Cholangitis
• Duodenal injury, perforation
• Sphincter stenosis
• Bleeding from pancreaticoduodenal artery
➢ Courvoisier’s law
➢ Mirizzi syndrome
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SPLENUNCULI
➢ DEFINITION: single or multiple accessory spleens

➢ SITES
• hilum of spleen (mc)
• near splenic vessels
• behind tail of pancreas
• splenic ligaments
• mesocolon
• greater omentum
➢ failure to identify and remove these at the time of splenectomy gives rise to persistent disease
SPLENIC INJURY
➢ CAUSES
1) Traumatic – RTA, blunt injury, penetrating/stab injuries
2) Atraumatic – malaria, tropical splenomegaly, infectious mononucleosis
3) Spontaneous – idiopathic
➢ TYPES
1) Subcapsular haematoma
2) Incised wound
3) Lacerated wound
4) Hilar injury
➢ C/F
• features of shock
• pain, tenderness and abdominal rigidity in LUQ
• abdominal distension d/t hemoperitoneum
• dullness without shifting (Ballance's sign)
• referred pain in left shoulder (Kehr's sign)
➢ INVESTIGATIONS
• US abdomen: IOC
• Hb%, PCV, blood grouping and cross-matching
• CT scan
• Plain X-ray
• Diagnostic peritoneal lavage
• Angiogram
➢ COMPLICATIONS
• Blood loss
• DIC
• Sepsis
• Splenic artery pseudoaneurysm
• Splenic AV fistula
➢ TREATMENT
A. Initial management
1) ABCD
2) Resuscitation: crystalloids – RL/NS
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3) BT, FFP, platelets in 1:1:1 ratio
4) Central venous line for perfusion and monitoring
5) Catheterisation
6) Nasogastric tube aspiration
7) ICU care
8) Antibiotics
B. Conservative management: indications – only splenic injury, hemodynamically stable patient
1) Absolute bed rest
2) Sedation
3) Antibiotics
4) Close observation, serial haematocrit evaluation and serial CT/US abdomen at regular intervals
5) Angiographic selective embolisation
C. Surgery
1) Emergency splenectomy – through midline/left subcostal incision
2) Partial splenectomy
3) Splenorrhaphy – in clean incised wound
4) Splenic mesh wrap – in stellate and multiple lacerations
SPLENOMEGALY
➢ CAUSES
1) Infective: TB, splenic abscess, infectious mononucleosis, malaria, typhoid, kala azar
2) Blood diseases: CML, myelofibrosis, polycythaemia, hereditary spherocytosis, hemolytic anaemia, ITP
3) Metabolic: Gaucher's disease, amyloidosis, porphyrias
4) Portal hypertension
5) Collagen diseases
6) Malignancy: Hodgkin's lymphoma, splenic sarcomas
➢ C/F
• mass in left hypochondrium
• moves with respiration
• dull to percuss
• directed towards RIF
• Hook sign
SPLENECTOMY
➢ INDICATIONS
• Splenic injury
• Hemolytic anemias
• ITP
• Splenic cysts
• Splenic tumours
• Hypersplenism
• Portal hypertension
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• Tropical splenomegaly
• Felty's syndrome
• TB spleen
• In radical gastrectomy
➢ PROCEDURE
left paramedian, midline or left subcostal incision → lienorenal ligament, short gastric vessels ligated → splenic
vessels ligated at hilum of spleen → spleen removed → abdomen closed
➢ COMPLICATIONS
• Haemorrhage
• Gastric dilatation
• Haematemesis
• Left sided pleural effusion and left basal atelectasis
• Left subphrenic abscess
• Pancreatitis, pancreatic fistula
• Haematologic changes: rise in WBC, platelet count, abnormal RBCs and RBC bodies
• Gastric fistulas
• Left sided colonic injury
• Infection
• Portal vein thrombosis
• DVT
HYPERSPLENISM
➢ DEFINITION: overactivity of spleen causing pancytopenia with hypercellular BM

➢ CAUSES
• Primary hypersplenism
• Portal hypertension
• Malaria, kala-azar, schistosomiasis, TB
• Myeloproliferative disorders
➢ INVESTIGATIONS
• PBS
• CBC
• BM aspiration
• US abdomen
• LFT
➢ TREATMENT
1) Splenectomy
2) Splenectomy + proximal splenorenal shunt: in portal hypertension
3) Total splenic artery embolization
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PSEUDOCYST OF PANCREAS
➢ DEFINITION: a localized collection of sequestered amylase-rich pancreatic fluid enclosed in a well-defined wall of
fibrous/granulation tissue, 4 weeks or more from the onset of acute pancreatitis
➢ mc site: lesser sac
➢ contains typically brownish fluid with sludge like necrotic material
➢ TYPES
A. Based on communication with pancreatic duct
1) Communicating
2) Non-communicating
B. Based on onset
1) Acute
2) Chronic
➢ C/F
• Swelling in epigastric region: hemispherical, smooth, soft, not moving with respiration, not mobile, upper
margin diffuse but lower margin well-defined, resonant on percussion, with transmitted pulsation confirmed
by knee-elbow position
• Baid test: Ryle’s tube passed is felt per abdominally
➢ D/D
• Aortic aneurysm
• Retroperitoneal cyst/tumour
• Cystadenocarcinoma of pancreas
• Mesenteric cyst
• Hydatid cyst
➢ COMPLICATIONS
• Infection → abscess
• Rupture → GI bleeding, fistula, peritonitis
• Enlargement → pain, obstructive jaundice, bowel obstruction
• Erosion into a vessel → hemoperitoneum
➢ INVESTIGATIONS
• US abdomen
• CT scan: IOC
• MRCP
• ERCP
• LFT, serum amylase, platelet count, PT-INR
• EUS-guided aspiration and analysis of fluid for amylase and CEA
• Percutaneous FNA
➢ TREATMENT
A. Conservative: 50% show spontaneous resolution
1) Observation
2) Regular follow-up using repeat USG
B. Interventional
1) Transpapillary/transmural endoscopic drainage
2) US-guided aspiration or percutaneous drainage
C. Surgical drainage
D. Surgery
1) Cystogastrostomy (Jurasz operation)
2) Cystoduodenostomy
3) Cystojejunostomy: in large/recurrent cyst
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ZOLLINGER-ELLISON SYNDROME
➢ DEFINITION: a condition that includes-

1) fulminating ulcer diathesis in the stomach, duodenum or atypical sites
2) recurrent ulceration despite adequate therapy
3) non-beta islet cell tumours of the pancreas (gastrinoma)
➢ mc site: Gastrinoma/Passaro’s triangle
superiorly: junction of cystic duct and common bile duct
inferiorly: junction of second and third parts of duodenum
medially: junction of neck and body of pancreas
➢ C/F
1) Abdominal pain: from PUD/GERD
2) Diarrhea
➢ DIAGNOSIS
1) Gastric pH < 2.5
2) Serum gastrin concentration > 1000 pg/ml
3) Positive secretin test
4) CT/MRI/EUS
5) Somatostatin receptor scintigraphy – for staging
➢ D/D
• idiopathic PUD
• chronic idiopathic diarrhea
• GERD
• chronic atrophic gastritis
• GOO
➢ TREATMENT
A. Medical
1) PPI
2) Octreotide
3) Systemic chemotherapy: streptozotocin + 5-FU/doxorubicin
B. Surgical
1) Enucleation of tumor + peripancreatic lymph node dissection
2) Pancreaticoduodenectomy
➢ Acute pancreatitis
➢ Chronic pancreatitis
➢ Pancreatic carcinoma
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CARCINOMA ESOPHAGUS
➢ ETIOLOGY
• Diet, deficiencies (vit. A, C, riboflavin)
• Mycotoxin
• Alcohol and tobacco
• Fungal contamination of food
• HPV 16, 18
• Achalasia cardia
• Esophageal webs
• Barrett's oesophagus
• Plummer-Vinson's syndrome
• Corrosive strictures
• Tylosis
• Nitrosamines
• Age >45 years
• M>F
• Mc in China
• In India, mc in Odisha and Karnataka
➢ C/F
• Recent onset dysphagia: mc feature
• Regurgitation
• Anorexia, loss of weight, cachexia
• Pain – substernal/abdominal
• Bronchopneumonia, melaena
• Palpable left supraclavicular lymph nodes
• Hoarseness, hiccough, back pain
• Liver secondaries, ascites
• T status – Tumour
Tx: Tumour cannot be assessed
T0: No primary tumour
Tis: High-grade dysplasia
T1: Invasion into the lamina propria, muscularis mucosae or submucosa
T2: Invasion into muscularis propria
T3: Invasion of paraesophageal tissues without adjacent structure spread
T4: Invades adjacent structures
• N status – Nodes
Nx: Regional nodes cannot be assessed
N0: No regional lymph node metastases
N1: 1-2 positive regional lymph nodes
N2: 3-6 positive regional lymph nodes
N3: 7 or more positive regional lymph nodes
• M status – Metastasis
M0: No distant metastases
M1: Distant metastases present
• Clinical staging
Stage 0: Tis N0 M0
Stage I: T1 N0-1 M0
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Stage II: T2 N0-1 M0; T3 N0 M0
Stage Ill: T3 N1 MO; T1-3 N2 M0
Stage IVA: T4 N0-2 M0; T any N3 M0
Stage IVB: T any N any M1
➢ INVESTIGATIONS
• Barium swallow: Shouldering sign, irregular filling defect, rat tail lesion
• Esophagoscopy
• Biopsy
• CXR
• CT scan
• Bronchoscopy
• Esophageal endosonography
• US abdomen
• Blood tests: Haematocrit; ESR; LFT
• Laparoscopy
• PET scan using 18-FDG
• Endoscopic mucosal resection (EMR)
➢ TREATMENT
A. Curative treatment
1) Post-cricoid tumour (SCC)
• Radical radiotherapy
• Pharyngolaryngectomy + gastric/colonic transposition
2) Upper third growth (SCC)
• Radiotherapy
• McKeown three-phased esophagectomy + anastomosis in neck
3) Middle third growth (SCC)
• Ivor Lewis operation (Lewis-Tanner two-phased esophagectomy): partial esophagectomy +
esophagogastric anastomosis
4) Lower third growth (SCC + AC)
• Orringer approach: transhiatal blind total esophagectomy + anastomosis in left side of neck
• Sweet approach
• Thoracoscopic-laparoscopic esophagectomy
B. Lymphadenectomy
1) Standard
2) Extended/three-field/ultraradical
C. Palliative treatment
1) Radiotherapy
a) External RT
b) lntraluminal RT (Brachytherapy)
2) Chemotherapy
3) Intubation
a) Atkinson tube
b) Celestin tube
c) Souttar tube
d) Mousseau-Barbin tube
4) Endoscopic therapy
a) Self-expanding metal stents (SEMS)
b) Laser
c) Bipolar diathermy
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d) Photodynamic therapy (PDT)
5) Surgery
a) Transhiatal Orringer's blind esophagectomy
b) Kirschner palliative gastric bypass
HIATUS HERNIA
➢ TYPES
Type I: Sliding hernia
Type II: Rolling hernia
Type III: combined
Type IV: hernia containing other abdominal viscera
➢ SAINT’S TRIAD: hiatus hernia, diverticulosis, gallstones
➢ C/F
• abdominal pain, chest pain
• hiccough, early satiety
• regurgitation, postprandial bloating
• dysphagia, dyspnea
• cardiac arrhythmia
➢ INVESTIGATIONS
• Plain X-ray: retrocardiac air-fluid level
• Barium meal study
• CT scan
➢ TREATMENT
1) Excision of sac and repair of the defect
2) If gangrenous → gastrectomy
REFLUX ESOPHAGITIS
➢ TYPES & ETIOLOGY

1) Acute - burns, trauma, infection, PUD
2) Chronic - sliding hernia, after gastric surgery
➢ GRADING
1) Mucosal erythema
2) Mucosal erythema + superficial ulceration
3) Mucosal erythema + superficial ulceration + submucosal fibrosis
4) Mucosal erythema + extensive ulceration + paramural fibrosis
➢ SAVARY-MILLER CLASSIFICATION
1) Single/isolated erosive lesion
2) Multiple erosive lesions
3) Circumferential erosive lesions
4) Chronic lesions
5) Columnar epithelium
➢ LOS ANGELES CLASSIFICATION
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1) < 5 mm long
2) > 5 mm long
3) < 75% of the circumference
4) > 75% of the circumference
➢ C/F
• Pain and burning sensation in retrosternal area
• Dysphagia
➢ INVESTIGATIONS
• Barium meal X-ray
• Gastroscopy and biopsy
➢ TREATMENT
1) Antacids; H2 blockers; PPI, prokinetic drugs
2) T/t of GERD
3) Resection – severe cases
ACHALASIA CARDIA / CARDIOSPASM
➢ DEFINITION: failure of relaxation of cardia (esophagogastric junction) d/t disorganised esophageal peristalsis, as
a result of failure of integration of parasympathetic impulses causing functional obstruction
➢ ETIOLOGY: absence/less-numbered ganglions in Auerbach’s myenteric plexus-
• Idiopathic degeneration (mc)
• Stress
• Vitamin B1 deficiency
• Chagas disease
• Diffuse esophageal spasm (corkscrew esophagus)
➢ C/F
• Chest pain
• Progressive dysphagia: more for liquid than to solid food
• Regurgitation and recurrent aspiration pneumonia
• Odynophagia and weight loss
• Malnutrition and general ill health
➢ STAGING/GRADING
I: dilatation <4 cm
II: dilatation 4-6 cm
III: dilatation >6 cm
IV: sigmoid dilatation
➢ INVESTIGATIONS
• Barium swallow
▪ Bird beak appearance
▪ Cucumber esophagus
▪ absence of fundic gas bubble
• CXR lateral view
▪ double mediastinal strip of dilated esophagus
▪ air fluid level in posterior mediastinum
• Esophageal manometry - unrelaxed LES with high resting pressure (gold standard)
• Esophagoscopy & biopsy – totally closed LES
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➢ TREATMENT
A. Surgery
1) Modified Heller's cardiomyotomy with Toupet's / Dor's fundoplication
2) Resection of esophagogastric junction or transhiatal total esophagectomy with gastric pull up and
esophagogastric anastomosis in the neck
B. POEM (Per Oral Endoscopic Myotomy)
C. Forcible dilatation
1) Plummer's pneumatic dilatation
2) Negus hydrostatic balloon dilatation
3) Self-expanding metal stents (SEMS)
D. Drugs
1) Botulinum toxin
2) CCB, NTG
3) Sildenafil
MALLORY-WEISS SYNDROME
➢ DEFINITION: longitudinal tear in mucosa of stomach at and just below cardia (mc: 1 o'clock position)
➢ C/F
• severe vomiting
• haematemesis
• features of shock
➢ INVESTIGATIONS
• Gastroscopy
• Hb%, PCV, Blood grouping
➢ D/D
1) Bleeding PUD
2) Esophageal varices
3) Erosive gastritis
4) Ca stomach
➢ TREATMENT: conservative
1) Blood transfusion
2) IV fluids
3) Sedation
4) Haemostatic agents – vasopressin
5) Endoscopic injection therapy
➢ GERD
➢ Barrett’s esophagus
➢ Boerhaave’s syndrome
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DUODENAL ULCER
➢ ETIOLOGY
• Blood group O +ve
• Stress, anxiety
• Helicobacter pylori infection
• NSAIDs, steroids
• ZE syndrome, MEN syndrome, hyperparathyroidism.
• Alcohol, smoking, vitamin deficiency
• Type A personality
• M>F
➢ C/F
• Pain (hunger pain): more before food, in early morning and decreases after taking food
• Periodicity
• Water-brash, heart burn, vomiting
• Melaena, haematemesis
• Appetite good, gain in weight
➢ COMPLICATIONS
• Pyloric stenosis
• Bleeding
• Perforation: anterior ulcers
• Residual abscess
• Penetration to pancreas
• Intractability
➢ INVESTIGATIONS
• Barium meal X-ray: deformed/absent duodenal cap, trifoliate duodenum
• Gastroscopy + biopsy
• Estimation of serum gastrin level, serum calcium level
➢ TREATMENT
A. General measures
1) Avoid alcohol, NSAIDs, smoking, spicy foods
2) Have more frequent food
B. Drugs
1) H2 Blockers
2) PPI
3) Antacids
4) Sucralfate
5) Colloid bismuth sulphate
6) Misoprostol
7) Anti-Helicobacter pylori regime (Triple regime)
a) Clarithromycin/Amoxycillin/Tetracycline
b) Metronidazole/Tinidazole
c) Omeprazole/Lansoprazole/Pantoprazole
C. Surgery
Indications – (a) intractable DU, (b) repeated recurrences
1) Highly selective vagotomy (HSV)
2) Selective vagotomy + pyloroplasty
3) Truncal vagotomy + gastrojejunostomy
4) Posterior truncal vagotomy + anterior seromyotomy (Taylor's operation)
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5) Vagotomy + antrectomy
6) Posterior truncal vagotomy + HSV (Kim’s procedure)
7) Linear gastrectomy + posterior truncal vagotomy
PYLORIC STENOSIS
➢ C/F
• Pain - severe, persistent, in epigastric region, with feeling of fullness
• Vomiting - large quantity, foul smelling, frothy, vomitus contains partially-digested/undigested food
• Loss of periodicity
• Visible gastric peristalsis (VGP)
• Positive succussion splash
• Auscultopercussion test: dilated stomach
• Confused status
• Electrolyte changes: hypochloremic, hyponatremic, hypokalemic, hypocalcemic, hypomagnesemic alkalosis
→ paradoxical aciduria
• Goldstein saline load test – half hour after instillation of 750 ml saline, if volume remained >250 ml →
obstruction
➢ INVESTIGATIONS
▪ Absence of duodenal cap
▪ Dilated stomach, greater curvature below the level of iliac crest
▪ Mottled stomach
▪ Barium does not pass into duodenum
• Gastroscopy
• Electrolyte study
➢ TREATMENT
A. IV fluids
B. TPN support
C. Stomach wash
D. Surgery
1) HSV + gastrojejunostomy
2) Truncal vagotomy + gastrojejunostomy of Mayo
3) Vagotomy + antrectomy + Billroth I anastomosis + feeding jejunostomy
PEPTIC PERFORATION
➢ C/F
• Pain
▪ sudden severe persistent
▪ epigastrium → right side abdomen (right paracolic gutter) → generalised
▪ radiates to right scapular region
▪ becomes more on movements
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• Tenderness and rebound tenderness (Blumberg sign) all over the abdomen
• Fever, vomiting, dehydration, oliguria
• Patient is toxic, with tachycardia, hypotension, tachypnoea
• Abdominal distension
• Guarding and rigidity
• Dullness over the flank
• Obliteration of liver dullness
• Silent abdomen with absence of bowel sounds
• Tenderness felt on PR examination
➢ INVESTIGATIONS
• Chest X-ray with abdomen in erect posture: gas under diaphragm
• US abdomen: free fluid and gas
• Blood urea, serum creatinine, TLC, electrolytes
• CT scan abdomen
➢ TREATMENT
A. Admission
B. IV fluids
C. Antibiotics – Cefotaxime, metronidazole, amikacin
D. Catheterisation; Ryle's tube aspiration
E. Surgery:
• Emergency laparotomy through upper midline incision
• All infected fluid sucked out
• Perforation closed with interrupted horizontal sutures and omental patch
1) Cellar Jones technique: omental patch → suturing
2) Rosoe Graham's patch: omental plug → suturing
3) Modified Graham's technique: primary closure with pedicled omental patch
• Peritoneal toilet
F. Follow-up gastroscopy after 12 weeks
CARCINOMA STOMACH
➢ ETIOLOGY
• Familial
• HNPCC, Li-Fraumen syndrome
• Blood group A
• Pernicious anemia
• High salt diet, nitrosamines, smoked salmon fish, red meat, less vegetables
• Smoking, alcohol, obesity
• Agammaglobulinemia
• Epstein-Barr virus, radiation exposure
• Zinc, lead, talc, asbestos
• Precursor lesions-
▪ Chronic atrophic gastritis
▪ Adenomatous gastric polyps
▪ Intestinal metaplasia
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▪ Gastric dysplasia
▪ Menetrier's disease
▪ Benign gastric ulcer
▪ Stomach remnant (stump carcinoma)
➢ C/F
• Recent onset of loss of appetite and weight, early satiety, fatigue
• Hematemesis, melena, microcytic, hypochromic anaemia (IDA)
• Upper abdominal pain
• Vomiting with features of GOO
• Mass abdomen: lies above the umbilicus, nodular, hard, with impaired resonance, mobile
• Dysphagia
• Ascites
• +ve Troisier's sign
• +ve Trousseau sign
• Sister Joseph's nodules
• Krukenberg’s tumours
• Tumour – T
Tx - tumour cannot be assessed
T0 - no evidence of tumour
Tis - intraepithelial tumour without invasion of lamina propria, high grade dysplasia
T1 - invades lamina propria or muscularis mucosa or submucosa
T2 - invades muscularis propria
T3 - invades subserosa
T4a - invades serosa/visceral peritoneum
T4b - invades adjacent structures
• Nodes – N
Nx - cannot be assessed
N0 - no nodal spread
N1 - 1-2 regional nodes
N2 - 3-6 regional nodes
N3 - 7 or more regional nodes
• Metastases – M
M0 - No distant metastases
M1 - Distant metastases present
• Staging
Stage 0 - Tis N0 M0
Stage I - T1 N0 M0; T2 N0 M0
Stage IIA - T1/T2 N1-3 M0
Stage IIB - T3/T4a N0 M0
Stage Ill - T3/T4a N1-3 M0
Stage IVA - T4b N any M0
Stage IVB - T any N any M1
➢ INVESTIGATIONS
• Hb%, haematocrit
• Barium meal
▪ irregular filling defect
▪ loss of rugosity
▪ delayed emptying
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▪ dilatation of stomach
▪ Carmann’s meniscus sign
• Contrast barium studies
• Gastroscopy with biopsy - 10 targeted biopsies
• Endosonography
• CT scan abdomen and thorax
• Ultrasound abdomen
• Liver function tests and prothrombin time
• FNAC from left supraclavicular lymph node
• Laparoscopy – for staging
• Combined PET-CT scan
• Sentinel node biopsy
➢ TREATMENT
A. Surgery
1) Growth in OG junction or upper part of stomach: upper radical gastrectomy + removal of spleen, both
omentum, lymph nodes → esophagogastric anastomosis
2) Growth in body: total radical gastrectomy → esophagojejunal anastomosis
3) Growth in pylorus: lower radical gastrectomy with proximal 5 cm clearance (subtotal gastrectomy) +
removal of both omentum, all lymph nodes, spleen, tail of pancreas → Billroth II anastomosis
4) Endoscopic mucosal resection (EMR)
5) Photodynamic therapy
B. LN dissection
1) N0 → D1
2) N1 → D2
3) N2 → D3
C. Adjuvant therapy
1) Chemotherapy: ECF (Epirubicin, Cisplatin, 5-FU)
2) Chemoradiotherapy
D. Palliative treatment
1) Partial/total gastrectomy
2) Gastric exclusion and esophagojejunostomy (Devine’s procedure)
3) Intubation and stenting
HELICOBACTER PYLORI
➢ gram -ve spiral-like flagellated organism

➢ mc bacterial infection in the world
➢ It can survive only in gastric epithelium
➢ Involvement-
• PUD
• Gastritis
• Gastric carcinoma
• Gastric MALToma
➢ Enzymes & toxins released-
• Urease
• Dehydrogenase
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• Cytotoxins – VacA, CagA
• Endopeptidase
• Hemolysin
➢ Pathogenesis: urease → hydrolyses urea → releases ammonia → increases gastrin release from G-cells
➢ Identification
• Rapid urease test (cod liver oil test)
• C13-C14 breath tests
• Biopsy → Warthin's starry silver stain
• ELISA
➢ Treatment: Triple regime for 7-14 days → PPI for 6-12 weeks
INFANTILE HYPERTROPHIC PYLORIC STENOSIS
➢ DEFINITION: hypertrophy of musculature of pyloric antrum causing primary failure of pylorus to relax
➢ familial
➢ seen between 3rd-6th weeks of age
➢ C/F
• Vomiting: forcible, projectile and non-bilious
• VGP
• Palpable lump of hypertrophied pylorus
• Constipation
• Dehydration and loss of weight
• hypokalemic metabolic alkalosis
➢ DIAGNOSIS
• Clinical examination
• USG abdomen: doughnut sign
• Barium meal: string sign or railroad track sign or double track sign
➢ D/D
• Duodenal atresia
• Volvulus neonatorum
• ICH
➢ TREATMENT
1) Correction of dehydration and electrolyte imbalance
2) Ramstedt's operation – pyloromyotomy
GASTRIC ULCER
➢ ETIOLOGY
• Atrophic gastritis, duodenogastric bile reflux, gastric stasis, abnormalities in acid and pepsin secretion
• Smoking, alcohol, NSAIDs, steroids
• Altered mucosal barrier mechanism
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• Lower socioeconomic group
➢ C/F
• Pain: in epigastric region after taking food; vomiting relieves pain
• Hematemesis and melaena
• Periodicity
• appetite decreases
➢ TYPES
➢ INVESTIGATIONS
• Barium meal X-ray
▪ Niche on the lesser curve with notch on the greater curvature
▪ Stomach spoke wheel pattern
• Gastroscopy and biopsy (10 biopsies)
➢ TREATMENT
A. Drugs: H2 blockers, PPI, carbenoxolone
B. Surgery:
1) Partial gastrectomy and Billroth I gastroduodenal anastomosis
2) de Miguel's antrectomy
3) Maki's pylorus preserving gastrectomy – for type I
4) HSV with excision of ulcer
5) For type IV-
a) Pauchet's procedure
b) Kelling Madlener procedure
c) Csendes procedure
➢ COMPLICATIONS
1) Hour glass contracture
• exclusively in women
• due to cicatricial contracture of lesser curve ulcer
• stomach is divided into 2 compartments
• C/f:
▪ Loss of periodicity
▪ Persistent pain
▪ Vomiting
▪ Loss of appetite and weight
• Diagnosis:
▪ Barium meal
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▪ Gastroscopy
• Treatment: Partial gastrectomy and Billroth I anastomosis
2) Tea-pot deformity (Hand-bag stomach)
• due to cicatrisation and shortening of the lesser curvature
• present with features of pyloric stenosis
• Treatment: partial gastrectomy with Billroth I anastomosis
3) Perforation
4) Bleeding
5) Penetration
6) Malignancy
LINITIS PLASTICA
➢ an aggressive diffuse type of carcinoma stomach → enormous proliferation of fibrous tissue involving
submucosa of stomach which is thickened (mother of pearl appearance) but mucosa is normal
➢ Type IV gastric carcinoma
➢ C/F
• Palpable mass
➢ INVESTIGATIONS
• Endosonography
➢ TREATMENT: Total gastrectomy with esophagojejunal anastomosis
➢ Bleeding peptic ulcer

➢ Hematemesis
➢ Dumping syndrome
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MECKEL'S DIVERTICULUM
➢ DEFINITION: a persistent remnant of proximal portion of vitellointestinal duct

➢ FEATURES:
• mc congenital anomaly of small intestine
• arises from anti-mesenteric border of ileum containing all three layers of bowel with independent blood
supply
• occurs in 2% of population
• 2 inches long
• 2 feet from the ileocecal valve
• 20% of cases have heterotopic epithelium
• 2:1 female preponderance
➢ PRESENTATIONS:
• Hemorrhage
• Diverticulitis
• Intussusception
• Chronic ulceration
• Intestinal obstruction
• Perforation
• Littre’s hernia
➢ INVESTIGATIONS:
• Technetium (Tc99) radioisotope scan
• Laparoscopy
➢ T/T:
1) Meckel’s diverticulectomy with closure of enterotomy
2) Resection of a short segment of ileum containing Meckel's diverticulum and end-to-end anastomosis
CROHN'S DISEASE / REGIONAL ENTERITIS
➢ DEFINITION: a chronic, transmural, non-caseating granulomatous inflammatory disease involving any area of GIT
➢ ETIOPATHOGENESIS: bacterial dysbiosis with aggressive T-cell immune response to specific components of
intestinal microbes with genetic susceptibility
➢ It is precancerous condition
➢ PRESENTATIONS & C/F:
A. Acute – severe diarrhea & peritonitis; mimics acute appendicitis
B. Chronic
1) 1st stage – diarrhea, colicky pain, fever, anemia, mass RIF, recurrent perianal abscess
2) 2nd stage – intestinal obstruction
3) 3rd stage – fistula formation
➢ INVESTIGATIONS:
• Plain X-ray & US abdomen
• Barium meal follow through or small bowel enema
✓ straightening of valvulae conniventes
✓ multiple defects (cobblestone appearance)
✓ cicatrisation of ileum (string sign of Kantor)
✓ rose-thorn appearance of the bowel wall
• CT scan and CT fistulogram
• Colonoscopy
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• Blood tests
• Capsule endoscopy
• MRI
• Serum markers: ASCA (anti-saccharomyces cerevisiae antibody) positive
➢ T/T:
A. Medical
1) Cessation of smoking
2) Bed rest, protein and vitamin supplementations, TPN
3) Steroids – prednisolone, methylprednisolone, budesonide (to induce remission)
4) Immunomodulators - azathioprine, 6-mercaptopurine, cyclosporine, tacrolimus (maintenance therapy)
5) Mesalamine (1st line), 5-aminosalicylic acid (5-ASA), sulfasalazine
6) Monoclonal antibody – infliximab
7) Antibiotics – metronidazole, ciprofloxacin
B. Surgery
1) Conservative – segmental resection
2) Ileocecal resection
3) Total colectomy and ileorectal anastomosis
4) Stricturoplasty
5) Temporary ileostomy
6) Corrective surgery for anal diseases – abscess drainage, fistulectomy
CARCINOID TUMOUR
➢ DEFINITION: neuroendocrine tumours arising from enterochromaffin cells

➢ MC SITES: appendix > ileum > rectum
➢ TYPES:
1) Foregut carcinoids – bronchial, thymic, gastroduodenal, pancreatic
2) Midgut carcinoids – jejunal, ileal, appendiceal, right colic
3) Hindgut carcinoids – distal colon, rectum
➢ C/F:
• Abdominal pain, intestinal obstruction, diarrhea
• Hindgut carcinoids – constipation, bleeding PR, rectal tenesmus
• Liver secondaries → Carcinoid syndrome – flushing, diarrhea, hepatomegaly, right-sided cardiac lesions (PS,
TS, TR), bronchospasm
➢ INVESTIGATIONS:
• Serum chromogranin A ↑
• Urine 5-hydroxyindoleacetic acid (5-HIAA) ↑
• CT scan
• MIBG scan
• PET scan
➢ T/T:
A. Medical
1) Somatostatin analogue – octreotide, pasireotide
2) Serotonin antagonists – ketanserin, cyproheptadine, ondansetron
3) Antihistamines, α-methyl dopa, 5-fluorouracil
B. Surgery
1) Appendix
a) Tip or lesion <2 cm but not involving base – appendicectomy
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b) Lesion >2 cm or involving base – right hemicolectomy
2) Gastroduodenum
a) <1 cm – endoscopic resection
b) >1 cm – subtotal gastrectomy or pancreaticoduodenectomy
3) Small bowel lesion
a) <1 cm – segmental resection
b) >1 cm – radical resection with adjacent mesentery
c) Terminal ileum – right hemicolectomy
4) Rectal lesion
a) <1 cm – endoscopic resection
b) 1 cm invasive – wide excision
c) >1 cm – anterior resection
5) Liver secondaries – surgical debulking, hepatic resection, embolisation
AMOEBOMA
➢ DEFINITION: a chronic granuloma arising in the large bowel (mc site – cecum) occurring in long-standing
intestinal amoebiasis that has been treated intermittently with drugs without completion of a full course
➢ C/F: pain, tenderness & mass in RIF with a h/o blood-stained mucoid diarrhea
➢ D/D: appendicular mass, ileocecal TB, carcinoma colon, retroperitoneal tumor, LN mass
➢ INVESTIGATIONS: colonoscopy and biopsy
➢ T/T:
A. Drugs
1) Metronidazole, tinidazole
2) Diloxanide furoate, paromomycin
B. Surgery – colonic resection
CARCINOMA CAECUM
➢ ETIOPATHOGENESIS: adenoma–carcinoma sequence

arises from adenomatous polyps after a sequence of genetic mutations (APC, k-RAS, p53) influenced by
environmental factors
➢ PATHOLOGY: columnar cell adenocarcinoma
4 varieties – (1) annular, (2) tubular, (3) ulcerative, (4) cauliflower-like (proliferative)
➢ TNM STAGING:
• Tumour stage
T1 - into submucosa
T2 - into muscularis propria
T3 - into pericolic fat or subserosa but not breaching serosa
T4 - breaches serosa or directly involving another organ
• Nodal stage
N0 - No nodes involved
N1 - 1-3 nodes involved
N2 - >3 nodes involved
• Metastases
M0 - No metastases
M1 - Metastases
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➢ C/F:
• after 50 years of age
• loss of appetite and weight, IDA, altered bowel habits, abdominal pain
• palpable mass RIF - not moving with respiration, mobile, non-tender, hard, well-localised with impaired
resonant note
• pericolic abscess, intestinal obstruction
• palpable LN, liver secondaries
➢ INVESTIGATIONS:
• Fecal occult blood test (screening)
• Colonoscopy (IOC)
• Double-contrast barium enema
• CEA (carcinoembryonic antigen)
• Spiral CT chest, abdomen and pelvis; CXR; US abdomen
• Hb%, PCV, hematocrit, ESR, LFT
➢ T/T:
1) Early growth – right radical hemicolectomy with ileo-transverse anastomosis
Structures removed → terminal 6 cm of ileum, cecum, appendix, ascending colon, 1/3 transverse colon, LN
2) Inoperable growth – ileo-transverse anastomosis
➢ Hirschsprung’s disease
➢ Ulcerative colitis
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INTESTINAL OBSTRUCTION
➢ CLASSIFICATION
A. Based on etiopathology-
1) Dynamic
a) Intraluminal
• Fecal impaction
• Foreign bodies
• Bezoars
• Gallstones
b) Intramural
• Stricture
• Malignancy
• Intussusception
• Volvulus
c) Extramural
• Bands/adhesions
• Hernia
2) Adynamic
• Paralytic ileus
• Pseudo-obstruction
B. Based on site of obstruction
1) Small bowel obstruction
a) High
b) Low
2) Large bowel obstruction
C. Based on nature of obstruction
1) Complete
2) Incomplete
D. Based on onset of obstruction
1) Acute
2) Chronic
3) Acute on chronic
E. Based on nature of obstruction
1) Simple
2) Strangulated
➢ C/F
1) Abdominal pain
• first symptom
• sudden onset
• coincides with increased peristaltic activity
• colicky intermittent (obstruction) → diffuse severe persistent (strangulation)
• site: umbilicus (small bowel) or lower abdomen (large bowel)
• absent in paralytic ileus
• SBO: crampy recurrent paroxysms
• LBO: longer episodes
2) Distension
• greater the more distal the lesion
• visible intestinal peristalsis (step ladder peristalsis)
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3) Vomiting
• SBO: early
• LBO: late
4) Absolute constipation
• neither feces nor flatus is passed
5) Dehydration
6) Hypokalemia
7) Pyrexia
8) Abdominal tenderness
9) High-pitched bowel sounds
➢ INVESTIGATIONS
✓ Dilated small bowel loops >3 cm
✓ Multiple air fluid levels
✓ Paucity of air in the colon
✓ Jejunum: concertina/ladder effect
✓ Ileum: featureless
✓ Cecum: round gas shadow in RIF
✓ Large bowel: haustrations
• CT scan
• Hematocrit, blood urea, serum creatinine; ABG analysis, LFT, platelet count
• Serum electrolytes estimation – hypokalemia
• TLC ↑
• US abdomen
➢ TREATMENT
A. Supportive management
1) Nasogastric decompression
• by passage of a non-vented (Ryle) or vented (Salem) tube
• free drainage with 4-hourly aspiration
2) Fluid and electrolyte replacement – Hartmann’s solution or NS
3) Broad-spectrum antibiotics
B. Surgery
• no evidence of intestinal ischemia → defer surgery until patient adequately resuscitated
• obstruction secondary to adhesions → conservative management continued for up to 72 hours
• Indications for early surgical intervention
✓ Obstructed external hernia
✓ Clinical features suspicious of intestinal strangulation
✓ Obstruction in a virgin abdomen
• Immediate laparotomy
• first manoeuvre – deliver the distended small bowel into the wound
• Operative decompression – insert a large-bore orogastric tube and milk the small bowel contents in a
retrograde manner to the stomach for aspiration
• Assess bowel viability
✓ Peristalsis
✓ Pulsation
✓ Bleeding
✓ Friability
✓ Lustre
• Bowel not viable → resection and anastomosis
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✓ right-sided colonic obstruction → right hemicolectomy + ileocolic anastomosis
✓ left-sided colonic obstruction → left hemicolectomy + colocolic anastomosis
✓ obstruction due to rectosigmoid growth → Hartmann's operation
INTUSSUSCEPTION
➢ DEFINITION: invagination of one segment of bowel into the adjacent segment

➢ ETIOLOGY
• Idiopathic
• Change in diet during weaning
• URTI
• Intestinal polyps
• Submucous lipoma
• Leiomyoma of intestine
• Meckel's diverticulum
• Carcinoma
• Purpuric submucosal hemorrhages
➢ C/F
• mcc of intestinal obstruction in infancy
• colicky abdominal pain: episodes of screaming and drawing up of legs
• passage of red-currant-jelly stool
• progressive distension of the abdomen, vomiting
• empty RIF - Sign of Dance
• O/E - sausage-shaped lump: with concavity towards umbilicus, smooth, firm, resonant, not moving with
respiration, mobile, contracts under the palpating fingers; appears and disappears
➢ INVESTIGATIONS
• plain X-ray abdomen: multiple air fluid levels
• barium enema: claw sign or coiled spring sign
• abdominal USG: doughnut appearance of concentric rings or target sign or pseudokidney sign or bull's eye
sign
• CT scan: target/sausage-shaped soft-tissue mass with a layering effect; mesenteric vessels within the bowel
lumen
➢ TREATMENT
A. Conservative management
1) IV fluids
2) broad-spectrum antibiotics
3) nasogastric drainage
4) catheterisation
5) non-operative reduction using air/barium enema
B. Surgery
• Indications
a) intussusception >48 hours
b) features of perforation, strangulation, peritonitis
c) recurrent intussusception
• Cope’s method
✓ transverse right-sided abdominal incision
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✓ reduction by gently milking the most distal part of intussusception towards its origin using warm
packs
• irreducible intussusception or complicated by infarction or a pathological lead point → resection and
primary anastomosis
SIGMOID VOLVULUS
➢ DEFINITION: anticlockwise twisting or axial rotation of sigmoid about its mesentery

➢ ETIOLOGY
• Adhesions; Peridiverticulitis
• Overloaded redundant pelvic colon
• Long pelvic mesocolon
• Narrow attachment of sigmoid mesocolon
• High fibre diet
• Chronic constipation with laxative abuse
➢ C/F
• Pain in the abdomen: left-sided → diffuse
• Absolute constipation (obstipation): early and progressive
• Enormous distension of abdomen (tympanic abdomen)
• Tyre-like feel of the abdomen
• Late vomiting → dehydration
• Features of peritonitis
• Hiccough and retching
➢ INVESTIGATIONS
• Plain X-ray: Ω sign (omega sign) or Coffee-bean sign or Bent-inner tube sign
• Contrast enema: Bird’s beak sign (ace of spades appearance)
• CT scan: whirl pattern
• Hematocrit, RFT, serum electrolytes
➢ TREATMENT
• Conservative management
▪ Ryle’s tube aspiration
▪ IV fluids
▪ Catheterisation
▪ Antibiotics
• Derotation
▪ Insertion of a flatus tube or sigmoidoscope
▪ Laparotomy through midline incision → manual derotation
• Assess viability
▪ Viable → sigmoidopexy
▪ Gangrenous →
1) Paul-Mikulicz operation
2) Hartmann's operation
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ABDOMINAL TUBERCULOSIS
➢ CLASSIFICATION:
A. Intestinal
1) Ileocecal
a) Ulcerative
b) Hyperplastic
c) Ulcero-hyperplastic
2) Ileal
B. Peritoneal
1) Acute
2) Chronic
a) Ascitic
b) Encysted (loculated)
c) Plastic (fibrous/adhesive)
d) Purulent
C. TB of mesentery and its lymph nodes.
D. Ano-recto-sigmoidal
E. TB of the omentum
F. Involvement of liver, spleen and other organs as a part of miliary TB
G. Rare types
1) Esophageal
2) Gastroduodenal
3) Retroperitoneal
ILEOCECAL TUBERCULOSIS
➢ INVESTIGATIONS:
• CXR
• Mantoux test, ELISA, ESR
• US abdomen - thickened bowel wall, loculated ascites, matted enlarged LN, pulled up cecum
• Plain X-ray abdomen – calcification, gas under diaphragm
• CECT abdomen – thickened bowel wall & ileocecal valve, adhesions, nodules, matted LN with cold abscess
• Colonoscopy
• FNAC of palpable mass
• Laparoscopy
• Ascitic tap fluid analysis
• Biochemical assay - proteins, ADA activity and interleukins
➢ T/T:
A. Drugs
1) ATT
2) TPN, blood transfusion, steroid
B. Surgery
1) Limited ileocecal resection with 5 cm margin
2) Stricturoplasty in single ileal stricture
3) Ileal resection and anastomosis in multiple strictures
4) Laparoscopic adhesiolysis in adhesive obstruction
5) Drainage of intra-abdominal abscess, perianal abscess and treatment for tuberculous fistula-in-ano
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MASS IN THE RIGHT ILIAC FOSSA
➢ DIFFERENTIAL DIAGNOSIS:
1) Appendicular mass: smooth, firm, tender, non-mobile, resonant, distinct borders
2) Appendicular abscess: smooth, soft, tender, dull, indistinct borders
3) Carcinoma cecum: nodular, hard, mobile, resonant
4) Ileocecal TB: smooth, hard, resonant, non-tender, restricted mobility
5) Ameboma: smooth, hard, well-defined, non-mobile
6) Psoas abscess: localised, smooth, soft, non-mobile
7) LN mass – mesenteric or external iliac
8) Bony swellings
9) Ectopic kidney
10) Undescended testis (abdominal)
11) Actinomycosis
12) Crohn's disease
13) Iliac artery aneurysm
14) Ovarian cyst
15) Tubo-ovarian mass
16) Uterine mass – pedunculated fibroid
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ACUTE APPENDIX
➢ C/F
• Pain: visceral pain around the umbilicus → somatic pain in RIF → diffuse
• Vomiting
• Fever, tachycardia, fetor oris
• Murphy’s triad: pain → vomiting → fever
• Constipation
• Urinary frequency
• Blumberg's sign: tenderness and rebound tenderness at McBurney's point in RIF
• Rovsing's sign: on pressing LIF, pain occurs in RIF
• Cope’s psoas test: hyperextension of right hip in retrocecal appendix causes pain in RIF
• Obturator test: internal rotation of right hip in pelvic appendix causes pain in RIF
• Baldwing's test: in retrocecal appendix, when legs are lifted off the bed with knee extended, the patient
complains of pain while pressing over the flanks
• PR examination: tenderness in right side of the rectum
• Hyperaesthesia in Sherren's triangle
➢ D/D
Children Adult Adult female Elderly
Gastroenteritis Regional enteritis Mittelschmerz Diverticulitis
Mesenteric lymphadenitis Right ureteric colic PID Intestinal obstruction
Meckel’s diverticulitis Perforated peptic ulcer Right-sided Colonic carcinoma
Intussusception Torsion of testis pyelonephritis Torsion appendix
Henoch–Schönlein Pancreatitis Ectopic pregnancy Mesenteric infarction
purpura Rectus sheath hematoma Torsion/rupture of Leaking aortic aneurysm
Lobar pneumonia Acute cholecystitis ovarian cyst
Worm infestation Acute severe orchitis Endometriosis
Salpingitis
➢ INVESTIGATIONS
• TLC ↑, CRP ↑
• CECT
▪ dilated non-compressible appendix, dilated lumen, thickened wall
▪ non-filling of the lumen by contrast/air
▪ periappendicular fluid collection
▪ dirty fat thickened mesoappendix
▪ appendicular phlegmon
▪ appendicular fecolith
▪ arrowhead sign
• USG
• Laparoscopy
• MRI
• Plain X-ray
➢ TREATMENT
Surgery: Appendicectomy
A. Open
1) Gridiron muscle-splitting incision
2) Lanz transverse skin crease incision
3) Rutherford Morison's muscle-cutting incision
4) Right lower paramedian incision/lower midline incision – when in doubt
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B. Laparoscopic
APPENDICULAR LUMP
➢ localisation of infection occurring 3 to 5 days after an attack of acute appendicitis

➢ inflamed appendix, greater omentum, edematous caecum, parietal peritoneum and dilated ileum form a mass in
the RIF
➢ O/E: mass is tender, smooth, firm, with well-defined borders, not moving with respiration, not mobile, resonant
on percussion
➢ INVESTIGATIONS
• TLC ↑
• USG
➢ TREATMENT
A. Conservative: Ochsner-Sherren Regimen
B. Interval appendicectomy: after 6 weeks
APPENDICULAR ABSCESS
➢ It occurs due to suppuration in an acute appendicitis or suppuration in an already formed appendicular mass
➢ C/F
• high fever
• features of toxicity
• tender, smooth, dull to percussion, soft swelling in RIF which lies towards right lateral and lower side with
clear upper margin but indistinct lower margin
➢ DIAGNOSIS: USG
➢ TREATMENT
A. Initial therapy
1) Antibiotics
2) CT-guided aspiration or catheter drainage
3) Pus drainage: GA → incision in lower lateral aspect of swelling → skin, external oblique muscle cut →
abscess cavity opened → pus drained extraperitoneally → wound closed → drain placed
B. Interval appendicectomy: after 3 months
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ALVARADO SCORING
➢ Symptoms
Migrating pain - 1
Anorexia - 1
Nausea and vomiting - 1
➢ Signs
Tenderness in RIF - 2
Rebound tenderness - 1
Elevated temperature - 1
➢ Laboratory
Leukocytosis >10,000 - 2
Shift to left with neutrophilia in peripheral smear – 1
➢ Total score: 10
Score <5: not sure
Score 5-6: equivocal
Score >6: strongly predictive
OCHSNER-SHERREN REGIMEN
➢ Conservative treatment
1) Observation: temp, BP, pulse, size of mass
2) Antibiotics
3) IV fluids
4) Analgesics
5) Nasogastric aspiration
➢ Patient usually shows response by 48-72 hours:
• mass reduces in size
• temperature and pulse become normal
• appetite regained
➢ Criteria to discontinue
• patient becomes more toxic
• persistent vomiting
• ↑ or spread of pain abdomen
• ↑ size of the mass
• abscess formation
➢ C/I
• diagnosis doubtful
• acute appendicitis in children and elderly
• burst, gangrenous appendicitis
• diffuse peritonitis
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CARCINOMA RECTUM
➢ mc site: rectum
➢ ETIOLOGY:
• Red meat and saturated fatty acids
• Low fibre diet
• Smoking
• Obesity
• Villous adenoma
• IBD – CD, UC
• HNPCC, Gardner syndrome, FAP
• Family history of rectal cancer
• Age >55 years
➢ C/F:
1) Bleeding PR
• earliest and mc symptom
• bright red in colour and painless
2) Tenesmus
• sense of incomplete evacuation
• spurious diarrhea
• bloody slime
3) Altered bowel habit
• Early morning bloody diarrhea
4) Pain
5) Weight loss, anemia, malnutrition, loss of appetite
6) Urinary symptoms
➢ STAGING
1) 8th AJCC TNM staging
Pretreatment MRI is the evaluation of choice
• Tx - Primary tumor cannot be assessed
T0 - No evidence of tumor
Tis - Carcinoma in situ-intraepithelial/invasion into lamina propria
T1 - Invasion into submucosa
T2 - Invasion into muscularis propria
T3 - Invasion into pericolorectal tissues/fat
T4a - Invasion into surface of the visceral peritoneum
T4b - Direct invasion or adherent to adjacent structures/organs
• Nx - Nodes cannot be assessed
N0 - No nodal spread
N1 - Regional nodes 1-3 involved
N2 - Regional nodes 4 or more involved
-N2a - 4-6 regional nodes
-N2b - 7 or more regional nodes
• M0 - no distant metastasis
M1 - distant metastasis
-M1a - metastasis confined to 1 organ/site
-M1b - metastases in >1 organ/site
-M1c - metastasis to peritoneum
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• 0 – Tis N0 M0
I – T1 N0 M0; T2 N0 M0
IIA – T3 N0 M0
IIB – T4a N0 M0
IIC – T4b N0 M0
IIIA – T1-2 N1 M0; T1 N2a M0
IIIB – T3-4a N1 M0; T2-3 N2a M0; T1-2 N2b M0
IIIC – T4a N2a M0; T3-4a N2b M0; T4b N1-2 M0
IVA – T any N any M1a
IVB – T any N any M1b
IVC – T any N any M1c
2) Modified Duke’s staging
A. Growth limited to rectal wall
B. Growth extending into extrarectal tissues but no lymph node spread
-B1: Invading muscularis mucosa
-B2: Invading into or through the serosa
C. Lymph node secondaries
D. Distant spread to liver, lungs, bone, brain
➢ MANAGEMENT
A. Investigations
• Abdominal examination
• Rectal examination
• Rigid sigmoidoscopy
• Colonoscopy
• Endoluminal US
• MRI – for staging
• CT chest, abdomen and pelvis; USG liver; CXR; PET scan – for metastasis
B. Preoperative preparation
• Counselling and siting of stomas
• Correction of anemia and electrolyte disturbance
• Group and save of blood
• Bowel preparation
• DVT prophylaxis
• Prophylactic antibiotics
• Foley's catheterisation and nasogastric tube
C. Neoadjuvant radiotherapy or chemoradiotherapy: folinic acid + 5-fluorouracil + oxaliplatin
D. Local transanal excision
E. Full-thickness excision of the cancer using TEMS (Transanal endoscopic microsurgery)
• organ-preserving surgery
F. Total mesorectal excision (TME)
• in all procedures
• sharp dissection of mesorectum in avascular areolar plane between fascia of rectum and parietal pelvic
wall fascia (Heald’s holy plane)
G. Abdominoperineal resection (APR)
• for tumours of the lower third of the rectum
• descending colon, sigmoid and upper rectum mobilised per abdominally → anal canal with perianal and
perirectal tissues dissected per anally → retained colon brought out as end colostomy in LIF
• Types-
a) Miles: abdomen first, perineum later
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b) Gabriel: perineum first, abdomen later
c) Lloyd-Davies: synchronised
H. Anterior resection
• sphincter-saving operation
• for tumours whose lower margin is ≥2 cm above the anorectal junction (upper and middle third rectal
growth)
• Types-
1) High anterior resection: resection of rectum above peritoneal reflection + colorectal anastomosis
2) Low anterior resection: resection of rectum below the peritoneal reflection along with sigmoid
colon + colorectal anastomosis
• Restoration of bowel continuity by-
a) double stapling technique
b) single stapled anastomosis
c) coloanal anastomosis
I. Transanal total mesorectal excision (taTME)
• total endoluminal excision of the rectum
J. Hartmann’s operation
• in elderly people not fit for major surgery and in locally advanced tumors
• rectal growth resected, upper end of rectum closed completely and proximal colon brought out as end
colostomy
K. Endoluminal stenting
• for obstructing carcinoma in rectosigmoid and upper rectum
L. Palliative colostomy
• in advanced unresectable growth with intestinal obstruction
M. Pelvic exenteration
• Removal of rectum with the tumour, all the lymph nodes, urinary bladder, fat, fascia, uterus, vagina,
with colostomy and urinary diversion
N. Liver resection – for liver metastases
✓ Recommended distal rectal margin clearance: 5 cm

✓ Circumferential resected margin clearance: 5 cm
✓ At least 12 lymph nodes' examination recommended
PILONIDAL SINUS
➢ DEFINITION: an epithelium-lined tract, situated behind the anus, containing hairs and unhealthy diseased
granulation tissue
➢ ETIOLOGY
• Jeep drivers
• Hair dressers
• mc in hairy men
• mc site: interbuttock sacral region
➢ C/F
• Discharge: serosanguinous/purulent
• Pain: throbbing and persistent
• Tender swelling
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1) Primary sinus - just above the coccyx in the midline
2) Secondary sinus - on either side of the midline
• Tuft of hairs: seen in the opening of the sinus
• H/o repeated abscesses
➢ TREATMENT
A. Conservative treatment
1) Regular shaving of natal cleft
2) Proper perineal hygiene
B. Acute exacerbation (abscess)
1) Rest
2) Baths
3) Local antiseptic dressings
4) Broad spectrum antibiotics
5) Abscess drainage: through a small longitudinal incision made over the abscess and off the midline +
thorough curettage of granulation tissue and hair
C. Surgery: jack knife position
1) Limberg procedure: excision with closure using rhomboid buttock flap
2) Excision with Z-plasty
3) Karydakis procedure: semilateral incision → lateralized suturing away from the midline
4) Bascom technique: excision through lateral approach
5) V-Y gluteal advancement flap
6) Buie's marsupialisation of the sinus track
7) Lord and Millar's limited excision of primary track
8) Excision and skin grafting
9) Laser pilonidoplasty
10) Injection phenol
ANAL FISSURE
➢ DEFINITION: an ulcer in the longitudinal axis of the lower anal canal

➢ mc site: midline posteriorly (males), midline anteriorly (females)
➢ ends above at the dentate line
➢ CAUSES
• hard stool
• diarrhea
• ↑ sphincter tone
• local ischemia
• trauma
• STDs
➢ TYPES
1) Acute
2) Chronic
➢ C/F
• pain
• constipation
• bleeding and discharge
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➢ T/T
A. General measures
1) Adequate fluid intake
2) Fibre rich diet
3) Bulk forming agents
4) Stool softeners – lactulose
5) LA – lignocaine 5%
6) Sitz bath
7) Avoid constipation
8) Regular anal dilatation
B. Acute case
1) Lord's dilatation under GA
2) Stretching of the anal sphincter using two fingers of each hand under anesthesia
3) Laxatives, xylocaine
4) Bed rest; 2% nifedipine ointment
C. Chronic case
1) Dorsal fissurectomy with sphincterotomy - internal sphincter divided in the floor of fissure
2) Lateral anal sphincterotomy - internal sphincter divided partially away from the fissure
3) Topical NTG 0.2%
4) Botulinum toxin 25 units injected into the internal sphincter
5) Diltiazem (2%), L-arginine
6) Regular anal dilatation
7) Anal advancement flap
ISCHIORECTAL ABSCESS
➢ CAUSES
• due to extension of low intermuscular anal abscess, laterally through external sphincter (mc)
• infection of fat in ischiorectal fossa
➢ C/F: tender, indurated, brawny swelling in the skin over the ischiorectal fossa with high fever
➢ TREATMENT: De-roofing and pus drainage
portion of skin excised through a cruciate incision under GA in lithotomy position
FISTULA-IN-ANO
➢ DEFINITION: a track lined by granulation tissue which connects perianal skin superficially to anal canal;
anorectum or rectum deeply
➢ usually occurs in a pre-existing anorectal abscess which bursts spontaneously
➢ CLASSIFICATION
A. Standard
1) Subcutaneous
2) Low anal
3) Submucous
4) High anal
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5) Pelvi-rectal
B. Park’s
1) lntersphincteric
2) Trans-sphincteric
3) Supralevator/suprasphincteric
4) Extrasphincteric
C. With respect to internal ring
1) High-level
2) Low-level
➢ C/F:
• seropurulent discharge
• skin irritation
• one or more external opening with induration of surrounding skin
• PR examination: indurated internal opening usually in the midline posteriorly
➢ Low-level fistulas
• INVESTIGATIONS
✓ Barium enema X-ray
✓ MRI fistulogram
✓ Endorectal US, Colonoscopy
✓ Discharge study, methylene blue dye study, biopsy
✓ CXR
✓ Blood tests
• TREATMENT
1) Fistulectomy
2) Fistulotomy
3) Mucosal flap procedure
4) Anal fistula plug repair
5) LIFT technique (Ligation of intersphincteric fistula track)
6) VAAFT procedure (Video assisted anal fistula track ligation)
7) Fistula clip closure
➢ High-level fistulas
• INVESTIGATIONS
✓ Barium enema X-ray
✓ Colonoscopy
✓ CXR
✓ Biopsy
• TREATMENT
1) initial colostomy → definitive procedure → closure of colostomy
2) Seton technique
a) Loose setons
b) Cutting setons
➢ Rectal prolapse
➢ Hemorrhoids
➢ Goodsall’s rule
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HERNIA
➢ ETIOLOGY
• Straining
• Lifting of heavy weight
• Chronic cough (tuberculosis, chronic bronchitis, bronchial asthma, emphysema)
• Chronic constipation (habitual, rectal stricture)
• Urinary causes (BPH, carcinoma prostate, stricture urethra, phimosis, meatal stenosis)
• Obesity
• Pregnancy
• Smoking
• Ascites
• Congenital
• Familial/acquired collagen disorders
➢ PARTS
1) Covering: layers of the abdominal wall through which the sac passes
2) Sac: a diverticulum of peritoneum with mouth, neck, body and fundus
Body of the sac – thin in infants, children and in indirect sac; thick in direct and long-standing hernia
3) Content
a) Omentocele: omentum
b) Enterocele: intestine
c) Richter's: a portion of circumference of bowel
d) Maydl’s: two small bowel loops
e) Cystocele: UB
f) Littre's: Meckel's diverticulum
g) Amyand's: appendix
h) Fluid
➢ CLASSIFICATION
• Clinical
1) Reducible
2) Irreducible
3) Obstructed
4) Inflamed
5) Strangulated
6) Infarcted
7) Occult
• Etiological
1) Congenital
2) Acquired
• Based on contents: see above
• Based on sites
1) Inguinal
2) Femoral
3) Obturator
4) Diaphragmatic
5) Lumbar
6) Spigelian
7) Umbilical
8) Epigastric
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INGUINAL HERNIA
➢ SURGICAL ANATOMY OF INGUINAL CANAL
• an oblique passage in lower part of abdominal wall, 4 cm long, situated above the medial ½ of inguinal
ligament, extending from deep inguinal ring to superficial inguinal ring
• Boundaries
✓ In front: external oblique aponeurosis and conjoint tendon laterally
✓ Behind: inferior epigastric artery, fascia transversalis and conjoint tendon medially
✓ Above: conjoint tendon
✓ Below: inguinal ligament
• Contents of inguinal canal
1) Spermatic cord in males; Round ligament in females
2) Ilioinguinal nerve
• Contents of spermatic cord
1) Vas deferens
2) Artery to vas
3) Testicular and cremasteric artery
4) Genital branch of genitofemoral nerve
5) Pampiniform plexus of veins
6) Remains of processus vaginalis
7) Sympathetic plexus around the artery to vas
➢ CLASSIFICATION
A. Anatomical
1) Indirect: through internal ring along with cord; lateral to inferior epigastric artery
2) Direct: through posterior wall of inguinal canal through Hesselbach's triangle; medial to inferior
epigastric artery
B. Based on extent
1) Incomplete
a) Bubonocele: sac confined to inguinal canal
b) Funicular: sac crosses superficial inguinal ring, but does not reach bottom of scrotum
2) Complete: sac descends to bottom of scrotum
C. Gilbert
Type I: snug internal ring
Type II: moderately enlarged internal ring which admits one finger but lesser than two finger breadth
Type III: large internal ring with defect more than two finger breadth
Type IV: direct hernia with large full blow out of posterior wall of inguinal canal
Type V: direct hernia protruding out through punched out defect in transversalis fascia
Type VI: Pantaloon hernia
Type VII: femoral hernia
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D. Nyhus
Type I: Indirect hernia with normal deep ring
Type II: Indirect hernia with dilated deep ring
Type III: posterior wall defect
a) Direct
b) Pantaloon hernia
c) Femoral hernia
Type IV: Recurrent hernia
➢ C/F
• dragging pain and swelling in the groin: better seen while coughing and standing with expansile impulse on
coughing
• features of intestinal obstruction: obstructed enterocele
• reddened skin over the swelling: strangulated
• palpation: doughy – omentocele; elastic – enterocele; cannot get above the swelling – complete; tender –
strangulated
• reducible: uncomplicated
• percussion: resonant – enterocele; dull – omentocele
• Internal ring occlusion test: reduction → internal ring occluded using thumb → patient asked to cough
• Ring invagination test: reduction → little/index finger invaginated from bottom of scrotum pushed up to
enter superficial inguinal ring → patient asked to cough
• Zieman's test: reduction → index finger on deep inguinal ring, middle finger on superficial inguinal ring, ring
finger over saphenous opening → patient asked to cough
• Head/leg rising test: Malgaigne bulgings – direct hernia
➢ D/D
• Hydrocele
• Undescended testis
• Femoral hernia
• Lipoma of cord
• Groin abscess
• Inguinal LN enlargement
• Saphena varix
➢ INVESTIGATIONS: CXR, US abdomen, laparoscopy
➢ TREATMENT
A. Herniotomy: skin incised ½ inch above and parallel to medial 2/3rds of inguinal ligament → outer Camper's
fascia and inner Scarpa's fascia incised → superficial pudendal and superficial epigastric vessels ligated →
external oblique aponeurosis incised along its long axis parallel to line of skin incision → iliohypogastric,
ilioinguinal & genital branch of genitofemoral nerve identified and safeguarded → cord structures dissected
→ sac identified & dissected starting from fundus and extending towards neck beyond deep ring → sac
opened at fundus, finger passed to release any adhesions, twisted, transfixed and excised
Sac not opened in direct hernia → inverted by taking purse-string sutures
B. Open suture repair (Herniorrhaphy = herniotomy + suture repair)
Indications – strangulated hernia, infected hernia
1) Modified Bassini's repair: conjoint tendon and inguinal ligament approximated using interrupted non-
absorbable monofilament sutures extending from pubic tubercle to deep inguinal ring
2) Shouldice repair: double-breasting of transversalis fascia → double-suturing of conjoint tendon with
inguinal ligament → double-breasting of external oblique aponeurosis
3) Desarda no mesh tension-free tissue repair: external oblique tissue flap reconstruction of posterior wall
4) Lytle’s repair: internal ring narrowed by interrupted sutures over medial side of ring to transversalis
fascia
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5) Halsted-Tanner slide operation: relaxing incision over lower rectus sheath
6) Abrahamson nylon darning: continuous intervening network of non-absorbable sutures between
conjoint tendon and inguinal ligament
7) McVay operation: interrupted sutures between edge of transversus abdominis to Copper's ligament
starting from pubic tubercle medially towards femoral sheath → suture repair between transversus
abdominis and iliopubic tract laterally up to entrance of cord
C. Mesh repair (Hernioplasty = herniotomy + mesh repair)
C/I – strangulated hernia, infected hernia
• Open
1) Lichtenstein tension-free onlay flat mesh repair: 15 x 8 cm sized mesh placed deep to cord
structures, sutured below to inguinal ligament → mesh spread laterally up to anterior superior iliac
spine and sutured till the level of internal ring → lateral part of mesh slit onto two tails (2/3rd upper
leaf and 1/3rd lower leaf) up to the internal ring; upper leaf overlapped onto lower leaf and sutured
to inguinal ligament → above & medially, mesh fixed to conjoint tendon → cord placed on the mesh
and external oblique sutured
2) Complex mesh repair
a) Plugs
b) Hernia systems
3) Preperitoneal mesh repair
a) Stoppa
b) Nyhus
c) Kugel
• Laparoscopic
1) Totally extraperitoneal (TEP)
2) Transabdominal preperitoneal (TAPP)
STRANGULATED INGUINAL HERNIA
➢ occurs when blood supply of contents of hernia is seriously impaired leading to formation of gangrene
➢ Indirect inguinal hernia more prone for strangulation than direct inguinal hernia
➢ CAUSES: narrow neck; adhesions; irreducibility; long-time
➢ PATHOLOGY: obstruction → venous return is impaired → congestion of bowel → dilatation of bowel (purple-
coloured) → fluid collects in sac → arterial blood supply impaired → bowel becomes dark, brownish black
coloured with flabby and friable wall → bacteria migrate transerosally and multiply in fluid of sac → perforation
occurs at site of constriction ring → peritonitis
➢ C/F
• sudden severe pain over a pre-existing hernia → generalised over the abdomen
• features of intestinal obstruction: persistent vomiting, constipation, abdominal distension
• hernia: tense, severely tender, irreducible and without any expansile impulse on coughing
• rebound tenderness with guarding and rigidity
• features of toxicity and dehydration; electrolyte imbalance; oliguria
➢ INVESTIGATIONS
• Plain X-ray abdomen in erect posture: multiple air-fluid levels
• Serum electrolytes; BUN, serum creatinine; TLC
• US abdomen
➢ TREATMENT
1) Admission; Ryle’s tube aspiration; IV fluids; antibiotics; catheterisation
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2) Emergency surgery: groin incision extending into the most prominent area of swelling → sac exposed →
constriction ring and superficial ring released → sac opened carefully without allowing the spillage of fluid →
fluid sucked with a suction apparatus → viability of bowel checked by colour, peristalsis, pulsation, bleeding
→ if gangrenous, resection and anastomosis → drain placed → Bassini's repair
SLIDING HERNIA
➢ an acquired hernia due to weakening of the abdominal wall but occurs at deep inguinal ring lateral to IE vessels
➢ sac forms secondarily: retroperitoneal fatty tissue pushed downwards along inguinal canal → peritoneum pulled
with it
➢ posterior wall of sac formed by parietal peritoneum, sigmoid colon with its mesentery on left side, caecum on
right side and bladder
➢ C/F: large globular swelling in inguinal region descending into scrotum
➢ TREATMENT: Hernioplasty
Posterior wall of sac should not be separated from large bowel or bladder
1) LaRoque repair
2) Modified Bevan technique: partial sac excision → reperitonealisation → Lichtenstein mesh repair
FEMORAL HERNIA
➢ hernial sac descends down through femoral canal vertically up to saphenous opening
➢ C/F
• a swelling in groin below and lateral to pubic tubercle
• impulse on coughing, reducibility, gurgling sound during reduction, dragging pain
• more prone for obstruction and strangulation: rapidly becomes irreducible and loses cough impulse
• features of intestinal obstruction: if obstructed
➢ D/D
• Direct inguinal hernia
• Lymph node
• Saphena varix
• Femoral artery aneurysm
• Psoas abscess
• Rupture of adductor longus with hematoma
➢ INVESTIGATION: CT scan
➢ TREATMENT
1) Low approach (Lockwood): sac approached below inguinal ligament through groin crease incision → inguinal
ligament sutured to Cooper's ligament
indication – when there is no risk of strangulation
2) Inguinal approach (Lotheissen): approach through inguinal canal → reduced by a combination of pulling
from above and pushing from below → conjoint tendon sutured to iliopectineal ligament
3) High approach (McEvedy): incision made over femoral canal → sac dissected from below, neck from above
→ assessment of bowel viability → bowel resection (if required) → repair done from above
indication – strangulated femoral hernia
4) AK Henry approach: repair of B/L femoral hernia through lower abdominal incision
5) Laparoscopic approach: TEP/TAPP
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EPIGASTRIC HERNIA
➢ occurs due to protrusion of extraperitoneal fat through an elliptical defect in the decussation of the fibres of
linea alba, anywhere between xiphoid process and umbilicus
➢ C/F: a soft, tender, irreducible, upper-midline swelling with an impulse on coughing
➢ sacless hernia
➢ common in muscular men, manual labourers
➢ D/D: PUD
➢ T/T: a vertical incision made over swelling down to linea alba → protruding extraperitoneal fat pushed back
through the defect or excised → defect closed with non-absorbable interrupted sutures → complete
reconstruction of linea alba from xiphisternum to umbilicus
➢ Triangle of doom
➢ Triangle of pain
➢ Incisional hernia
➢ Umbilical hernia
➢ Richter’s hernia
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PLAIN X-RAY KUB
➢ PROCEDURE: laxative given on previous day → patient asked to fast → high penetration X-ray taken in supine
position covering pubic symphysis and lower two ribs
➢ Look for-
1) Bony parts
2) Kidney shadow
3) Psoas shadow
4) Ureteric line
5) Bladder, prostate and urethral areas
INTRAVENOUS UROGRAM
➢ PROCEDURE: laxative given → overnight fasting for 8 hours → plain X-ray KUB taken → 1 ml test dose of
urograffin injected IV → if no adverse reaction, IV urograffin 1 ml/kg given
➢ INDICATIONS
1) Hydronephrosis: clubbing of calyces
2) Congenital anomalies
a) Horseshoe kidney: flower vase appearance
b) Duplex kidney and double ureter
c) Ureterocele: adder (cobra) head appearance
d) Polycystic kidney disease: spider leg appearance
e) Retrocaval ureter: reverse 'J' sign with hydronephrosis
3) RCC: irregular filling defect; spider leg appearance
4) B/L kidney diseases – stones, obstructive uropathy
5) After surgery for urinary diseases
6) Renal injury
➢ C/I
1) Iodine sensitivity
2) Multiple myeloma and hypergammaglobulinemias
3) Toxic thyroid
CYSTOSCOPY
➢ TYPES – (1) Rigid, (2) Flexible

➢ PROCEDURE: patient in lithotomy position → cystoscope passed through urethra using continuous glycine
irrigation → urethra, bladder, ureteric orifices visualised
➢ INDICATIONS
1) To examine urethra, bladder, ureteric orifice for any pathology
2) To treat-
a) Urethrotomy in stricture urethra
b) TURP for BPH and carcinoma prostate
c) Bladder tumour resection
d) Bladder stone removal
e) Ureteric catheterisation
f) Fulguration of posterior urethral valve
➢ C/I: Acute cystitis and prostatitis
➢ COMPLICATIONS: Urethral injury; Bleeding; Water intoxication
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HEMATURIA
➢ CAUSES
• Renal injury
• Urinary stones
• Wilm's tumour, RCC
• Renal TB
• Cystitis
• Bladder tumor
• Urinary bilharziasis
• BPH, carcinoma prostate
• Renal infarct
• Glomerulonephritis
• Blood dyscrasias
➢ INVESTIGATIONS
• Urine culture and sensitivity
• USG: stone/tumor
• Cystourethroscopy: bladder/urethral pathology
• IVU: kidney function
• Urinary cytology: urothelial malignancy
• Bleeding time; clotting time; prothrombin time; platelet count: bleeding diathesis
• CT abdomen
• RFT – BUN, serum creatinine
➢ TREATMENT
1) Blood transfusion
2) Antibiotics
3) Treat cause
a) RCC: Nephroureterectomy
b) Removal of stone from kidney, ureter, urinary bladder
c) Bladder tumour: cystoscopic resection; intravesical & systemic chemotherapy; radiotherapy
d) Treatment of medical causes like glomerulonephritis
e) Correction of BPH
f) Correction of bleeding diathesis
HYDRONEPHROSIS
➢ DEFINITION: an aseptic dilatation of pelvicalyceal system due to partial/intermittent obstruction to the outflow
of urine
➢ ETIOLOGY (SRB)
A. U/L
1) Extramural
a) Aberrant renal vessels
b) Compression by growth – carcinoma cervix/rectum
c) Retroperitoneal fibrosis.
d) Retrocaval ureter
2) Intramural
a) Congenital PUJ obstruction (mcc)
b) Ureterocele
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c) Neoplasm of ureter
d) Narrow ureteric orifice
e) Stricture ureter
3) Intraluminal
a) Stone in the renal pelvis or ureter
b) Sloughed papilla in papillary necrosis
B. B/L
1) Congenital
a) Stricture of external urethral meatus, pin-hole meatus
b) Posterior urethral valve
2) Acquired
a) BPH
b) Carcinoma prostate/bladder/cervix
c) Postoperative bladder neck scarring
d) Inflammatory/traumatic urethral stricture
e) Phimosis
➢ ETIOLOGY (Bailey & Love)
A. Upper urinary tract obstruction
1) Intrinsic causes
a) Intraluminal
• Intratubular deposition of crystals
• Stones
• Papillary tissue
• Blood clots
• Fungal ball
b) Intramural
• Functional: pelviureteral or vesicoureteral junction dysfunction
• Anatomic: tumours
• Infections, granulomas, strictures
2) Extrinsic causes
a) Reproductive system
• Cervix: carcinoma
• Uterus: pregnancy, tumours, prolapse, endometriosis, PID
• Ovary: tumour, cysts
• Prostate: carcinoma
b) Vascular system
• Aneurysms
• Aberrant arteries
• Ovarian veins, retrocaval ureter
c) GIT
• Crohn’s disease
• Pancreatitis
• Appendicitis
• Diverticulitis
• Tumours
d) Retroperitoneal space
• Lymph nodes
• Fibrosis
• Tumours
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• Hematomas
• Radiation therapy
• Surgical disruption or ureteral ligation
B. Lower urinary tract obstruction
1) Urethral anatomic causes
• Urethral strictures: trauma, post-instrumentation, infections
• Posterior urethral valves
• Stones
• Blood clots
• Periurethral abscess
• Phimosis
• Paraphimosis
• Meatal stenosis
2) Urethral functional causes
• Anticholinergic drugs
• Antidepressants
• levodopa
3) Prostate
• BPH
• Prostatic carcinoma
4) Bladder anatomic causes
• Bladder cancer
• Schistosomiasis
• Bladder calculi
• Bladder trauma, pelvic fracture
5) Bladder functional causes
• Neurogenic bladder
➢ PATHOLOGY: pressure burden taken up by pelvis; later calyces and renal parenchyma → parenchymal
destruction, thinning & dilation → compromised secretory function
➢ C/F
A. U/L
✓ Dull aching loin pain with dragging sensation or heaviness
✓ Mass in the loin: smooth, mobile, ballotable, moves with respiration with dullness in renal angle and a
band of colonic resonance in front
✓ Attacks of acute renal colic → Dietl's crisis
✓ Dysuria, haematuria
B. B/L
• Lower urinary tract obstruction
✓ Loin pain
✓ Features of bladder outlet obstruction – frequency, hesitancy, poor stream
✓ Kidneys not palpable
• Upper urinary tract obstruction
✓ Loin pain
✓ Mass in the loin
✓ Attacks of renal colic
✓ Features of renal failure – oliguria, edema, hiccough
➢ COMPLICATIONS
• Pyonephrosis
• Perinephric abscess
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• Renal failure
➢ INVESTIGATIONS
• Blood urea and serum creatinine
• Urine for microscopy
• US abdomen: IOC
• IVU: pelvis dilated; minor calyces clubbed
• CT scan
• Isotope renography: DTPA scan (best test)
• Whitaker test
➢ TREATMENT
1) Treat cause
2) Anderson-Hyne's open dismembered pyeloplasty
In congenital PUJ obstruction: upper third of ureter and renal pelvis mobilised → ureter
dismembered from renal pelvis → spasmodic segment and redundant pelvis excised → a new PUJ created →
cut end of pelvis anastomosed to ureter
3) Davis T-tube ureterostomy
4) Foley's non-dismembered Y-V pyeloplasty
5) Laparoscopic or retroperitoneoscopic pyeloplasty
6) Endoscopic pyelolysis
PERINEPHRIC ABSCESS
➢ CAUSES
• Infection of a perinephric hematoma
• Perforation through renal capsule from pyonephrosis or renal carbuncle
• Tuberculous perinephric abscess
• Extension of cortical abscess
• Haematogenous spread
• Extension of appendicular abscess
• Periureteral lymphatic spread
➢ C/F
• High fever
• Fullness in the loin
• Tenderness and rigidity
• Scoliosis with concavity towards the side of abscess
➢ INVESTIGATIONS
• TLC ↑
• Plain X-ray KUB
• IVU: absence of downward displacement of kidney (Mathe’s sign)
• US abdomen; CT scan
➢ TREATMENT
• Antibiotics
• Pus drainage: lumbar incision through loin approach
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RENAL CALCULUS
➢ 90% radiopaque; 10% radiolucent

➢ ETIOLOGY (Bailey & Love)
A. idiopathic calcium urolithiasis
B. hypercalcemic disorders
1) primary hyperparathyroidism
2) prolonged immobilisation
3) milk-alkali syndrome
4) sarcoidosis
5) disseminated neoplastic disease, Cushing’s disease, hyperthyroidism
1) decreased urinary citrate level, hypomagnesuria
C. renal tubular syndromes
1) renal tubular acidosis: type I
2) cystinuria
D. uric acid lithiasis
E. enzyme disorders
1) primary hyperoxaluria
2) xanthinuria
3) 2, 8-dihydroadeninuria
F. secondary urolithiasis
1) secondary hyperoxaluria
2) dietary excess: spinach, tea, cocoa, chocolate and pepper
3) infection: urease-producing organisms
4) obstruction and stasis
5) medullary sponge kidney
6) urinary diversion
7) drugs: acetazolamide, allopurinol, thiazide diuretics
G. other factors
2) geography
3) hot environment
4) water intake
5) diet: VAD, hypervitaminosis D
6) sedentary jobs
7) myelomatosis, gout, neoplasms on treatment
➢ TYPES
1) Oxalate stones: calcium oxalate (mc) – dumbbell/envelope-shaped
2) Phosphate stones: calcium phosphate or calcium magnesium ammonium phosphate → staghorn calculus
3) Uric acid stones
4) Urate stones
5) Cystine stones – hexagonal
6) Xanthine stones
7) Indigo stones
8) Struvite stones – coffin-lid-shaped
➢ C/F
• Pain: located over renal angle, hypochondrium and lumbar region; severe; radiating to groin and testis; with
vomiting; worsens on movements
• Hematuria
• Pyuria
• Fever
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• Tenderness in renal angle
• Mass in the loin: moves with respiration, bimanually palpable, ballotable, smooth, soft
➢ INVESTIGATIONS
• Blood: ESR, serum calcium, phosphate, creatinine, urea, uric acid, PTH level
• Urine: calcium, urate, pH, specific gravity, urinalysis, C/S
• Plain X-ray KUB
• IVU
• US abdomen
• CT scan (best)
➢ TREATMENT
1) ESWL (Extracorporeal Shock Wave Lithotripsy)
• Procedure: stones located using fluoroscope/US → piezoceramic/electromagnetic shock waves
generated outside the body & passed to the stone → fragments (steinstrasse) flushed out
• Indication: stone size < 2.5 cm
• C/I: obesity, pregnancy, bleeding disorders, abdominal aneurysms, sepsis & renal failure
• Complications: renal hematoma, severe hematuria, injury to adjacent structures
2) PCNL (Percutaneous Nephrolithotomy)
• Procedure: needle puncture made in the loin percutaneously under guidance of fluoroscope/US → calyx
& pelvis approached through kidney → guidewire passed → dilators passed → nephroscope passed →
fragmentation → stone removal
• Indications: multiple stones; size > 2.5 cm; not responding to ESWL; obesity
• Complications: hemorrhage, perforation of collecting duct, injury to adjacent structures, retained stones
3) Conservative treatment
a) Flush therapy
b) IV fluids
c) Diuretics
d) NSAIDs and anti-spasmodic agents
4) Surgery
a) Pyelolithotomy: for stones in extrarenal pelvis – renal pelvis opened by posterior subcostal incision
b) Extended pyelolithotomy: for stones in intrarenal pelvis – incision done on hilum over the renal sinus
c) Nephrolithotomy – incision placed just behind the most convex surface
d) Nephropyelolithotomy: in staghorn calculi – incisions made both over the kidney and pelvis
e) Partial nephrectomy: for multiple stones occupying a pole
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URETERIC CALCULI
➢ SITES
➢ C/F
• Pain: colicky type; radiates from loin to groin (referred along the genitofemoral nerve); severe in intensity;
increases with exercise
D/D - appendicitis, cholecystitis, ovarian or tubal pathology
• Nausea, vomiting, sweating
• Hematuria, dysuria, frequency, strangury
• Tenderness in iliac fossa and renal angle
➢ COMPLICATIONS
• Obstruction
• Hydronephrosis
• Infection
• Impaction
• Ureteral stricture
➢ TREATMENT
1) Plenty of water orally
2) Diuretic: oral furosemide
3) Antibiotics
4) Antispasmodics
5) IV fluids fast infusion and inj. furosemide
6) Surgery
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WILMS' TUMOUR (NEPHROBLASTOMA)
➢ ORIGIN: arises from embryonic connective tissue containing epithelial and connective tissue elements
➢ SITE: located in one of the poles of the kidney
➢ SPREAD: hematogenous
➢ C/F
• Mass abdomen: smooth, mobile, firm/hard, lobular, located in the loin, moves with respiration, bimanually
palpable, ballotable, with dullness in renal angle, with resonant band in front; does not cross the midline
• Fever
• Hematuria
• Hypertension
➢ D/D
• Adrenal tumor
• Retroperitoneal tumor
• Renal cyst
• Polycystic kidney disease
➢ INVESTIGATIONS
• US abdomen, CT scan abdomen, IVU
• Renal angiography
• X-ray abdomen: eggshell peripheral calcification
• MRI
➢ TREATMENT
1) U/L: Nephrectomy → radiotherapy
2) B/L: bilateral partial nephrectomy or nephrectomy on one side with partial nephrectomy on the other side
3) Chemotherapy: Actinomycin D, vincristine, doxorubicin
RENAL CELL CARCINOMA (RCC)
➢ TYPES
1) Clear cell carcinoma
2) Papillary carcinoma
3) Chromophobe carcinoma
4) Collecting duct of Bellini carcinoma
➢ C/F
A. Typical presentations
• Pain
• Hematuria
• Dragging discomfort in the loin
• Mass in the loin: moves with respiration, mobile, nodular, hard, with dull renal angle and resonant band
in front
• Left-sided varicocele: irreducible
B. Atypical presentations
• Pathological fractures
• Persistent cough and hemoptysis
• PUO
• Constitutional symptoms: Malaise, lethargy and severe anemia
• Polycythemia
• Hypercalcaemia
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• Hypertension
• Nephrotic syndrome
• Cushing's syndrome
• Leukemoid reaction
• Secondary amyloidosis
➢ INVESTIGATIONS
• Urine microscopy for RBCs
• IVU: mass lesion and irregular filling defect.
• US abdomen
• CECT scan: IOC
• CT chest
• Renal angiogram through Seldinger technique via transfemoral route
• CXR: cannon ball secondaries
• Bone scan
• Peripheral smear, serum calcium, haematocrit and ESR
• Inferior vena cavagram
• MRI
➢ TREATMENT
1) Nephron sparing nephrectomy
ureteric catheter placed using cystoscopy → kidney approached through rib cutting loin incision (11th rib) →
vascular control by Satinsky clamps → resection → bleeders ligated → renal capsule approximated →
vascular clamps released → renal surface hemostasis → drain placed and wound closed
2) Radical nephrectomy: transperitoneal approach
Structures removed-
• Entire kidney along with tumour
• Perinephric tissue
• Ipsilateral adrenal gland
• Proximal 2/3rd ureter
• Lymph nodes from crus of diaphragm to aorta bifurcation with renal hilar nodes
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VESICAL CALCULUS
➢ TYPES
1) Primary: occurs in sterile urine
2) Secondary: occurs in the presence of infection
➢ ETIOLOGY
• Infection
• Hypercalciuria
• Hyperoxaluria
• Cystinuria
• Gout and other hyperuricemic patients
• Bed ridden and paraplegic patients
• Diverticula bladder
• Neurogenic bladder
• Obstruction to urine flow by BPH, urethral stricture, bladder neck obstruction
• Schistosomiasis
• Foreign body in bladder
➢ C/F
• Pain: more during day, referred to the tip of penis or labia, increases during jolting movements
• Haematuria: terminal
• Interruption of urinary stream and acute urinary retention
• Features of cystitis: Burning micturition, fever, pain
➢ INVESTIGATIONS
• Urine microscopy: envelope crystals in oxalate stone, hexagonal type in cystine stone
• Urine C/S
• Blood urea, serum creatinine, serum calcium, inorganic phosphate, uric acid
• Plain X-ray KUB
• IVU
• US abdomen
• Cystoscopy
➢ TREATMENT
1) Cystoscopic litholapaxy: cystoscope passed → stone visualised → fragmentation by lithotripsy → bladder
flushed
2) Suprapubic open cystolithotomy: bladder approached extraperitoneally through Pfannenstiel incision →
bladder opened near the fundus → stone removed → bladder closed
3) Suprapubic percutaneous litholapaxy: bladder approached suprapubically → a track created through a
needle, guidewire and dilators → nephroscope passed → fragmentation → stone removed
➢ Bladder carcinoma
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SURGICAL ANATOMY OF PROSTATE
➢ 5 Lobes – anterior, posterior, lateral (2), middle/median

➢ McNeal zonal classification
1) Peripheral zone: lies posteriorly; site of carcinoma

2) Central zone: lies posterior to urethral lumen and above the ejaculatory ducts
3) Transitional zone: peri-urethral; site of BPH
➢ Sphincters
1) Proximal smooth muscle sphincter: in the upper part of the prostate and bladder neck
2) Distal striated sphincter: at the junction of prostate and membranous urethra
➢ Ducts of glands of the peripheral zone open into posterolateral grooves on either side of the verumontanum
➢ Outer true fibrous anatomical capsule → prostatic venous plexus → peri-prostatic sheath of endopelvic fascia
BENIGN PROSTATIC HYPERPLASIA
➢ C/F
A. Lower urinary tract symptoms
1) Symptoms of voiding
a) hesitancy
b) poor flow (unimproved by straining)
c) intermittent stream
d) dribbling (during and after micturition)
e) sensation of poor bladder emptying
f) episodes of near retention
2) Symptoms of storage
a) frequency
b) nocturia
c) urgency
d) urge incontinence
e) nocturnal incontinence (enuresis)
B. Bladder outflow obstruction
1) Decreased urinary flow rates
for a voided volume >200 mL, peak flow rate – normal: >15 mL/s; equivocal: 10–15 mL/s; low: <10 mL/s
2) Increased voiding pressures
voiding pressures – normal: <60 cm H2O; equivocal: 60-80 cm H2O; high: >80 cm H2O
3) Decompensated bladder with inefficient detrusor contraction and residual urine
4) Irritable bladder with decreased functional capacity
5) Pain
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➢ COMPLICATIONS
• Acute retention of urine
• Chronic retention of urine
• Impaired bladder emptying
• Hematuria
• UTI
• Hydronephrosis
• Renal failure
• Stones
➢ INVESTIGATIONS
• Urine: microscopy and C/S
• BUN and serum creatinine
• US abdomen
• Urodynamic studies: urinary flow rate, voiding pressure
• Cystoscopy
• TRUS
• Acid phosphatase
• PSA
• IVU
• Serum electrolytes
➢ TREATMENT
A. Conservative management: for mild symptoms
1) Observation and repeat assessment
2) Limiting fluid intake at night
3) Propantheline
B. Urethral catheterisation or suprapubic cystostomy: for acute retention, uremia
C. Correction of electrolyte disturbances
D. Drugs
1) α1 adrenergic blocking agents
a) Short-acting: prazosin, indoramin
b) Long-acting: terazosin, doxazosin
c) Selective α1A adrenergic blocking agent: tamsulosin
2) 5α-reductase inhibitors: finasteride 5 mg daily
E. Surgery: Prostatectomy
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1) Transurethral resection of prostate (TURP)
• Procedure: strips of tissue cut from bladder neck down to the level of the verumontanum by a high-
frequency diathermy current applied across a loop with a hand control → chips of prostate removed
from bladder using Ellik evacuator
• Types
a) Monopolar: glycine used as irrigant; duration of resection limited to 1 hour
b) Bipolar: NS used as irrigant; for resection of large prostates
2) Millin's retropubic prostatectomy
3) Freyer's suprapubic transvesical prostatectomy
4) Young's perineal prostatectomy
5) Laser treatment
a) KTP (green light) laser: hemostatic vaporisation
b) HOLEP: enucleation
F. After surgery: continuous bladder irrigation with NS using three-way Foley's catheter for 24 hours
➢ POST-OPERATIVE COMPLICATIONS
• Hemorrhage
• Perforation of the bladder or the prostatic capsule
• Sepsis
• Incontinence
• Retrograde ejaculation and impotence
• Urethral stricture
• Bladder neck contracture
• Recurrence
• Water intoxication (TURP syndrome)
CARCINOMA PROSTATE
➢ C/F
• BOO → retention of urine
• Frequency
• Pelvic pain
• Hematuria
• PR examination: irregular stony hard induration of prostate with obliteration of median sulcus
• Features of metastasis: bone pain, malaise, arthritic pain in sacroiliac joint, anemia, pancytopenia
• Features of renal failure
➢ GLEASON GRADE
1) Small uniform glands
2) More stroma between glands
3) Distinctly infiltrative margins
4) Irregular masses of neoplastic glands
5) Only occasional gland formation (undifferentiated)
➢ GLEASON SCORE: Gleason grade of most frequent field type + that of second most frequent
score <7: good prognosis; score 7 or more: poor prognosis
➢ INVESTIGATIONS
• Prostate-specific antigen: >10 ng/ml – suggestive, >35 ng/ml – diagnostic
• Transrectal/transperineal prostatic biopsy
• Blood urea, serum creatinine, LFT, Hb%, PBS
• Prostatic fraction of serum acid phosphatase increased
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• multiparametric-MRI (most accurate for staging)
• TRUS
• Plain X-ray KUB: dense coarse sclerotic metastases in lumbar vertebra and pelvic bones
• Bone scan: technetium-99m
➢ TREATMENT OPTIONS
1) Conservative treatment: active surveillance
3- to 6-monthly DRE & PSA measurement and repeated prostate biopsy
2) Radical prostatectomy: removal of prostate, seminal vesicles & distal sphincter + reconstruction of urethra
3) Radical radiotherapy
a) External beam radiotherapy (EBRT)
b) Brachytherapy: iodine-125, palladium-103
4) Androgen ablation
a) B/L orchidectomy
b) Medical castration
• LHRH agonists: leuprolide, goserelin
• Anti-androgens: flutamide, bicalutamide, enzalutamide
• LHRH antagonist: degarelix
• Cyproterone acetate, abiraterone acetate
• Phosphorylated diethylstilbestrol (DES)
5) Palliative radiotherapy: strontium-89
6) Chemotherapy: docetaxel, cabazitaxel
7) Tumor vaccines: Sepuleucel-T
➢ TREATMENT STRATEGY
A. Low risk disease
1) Age >70 years: conservative treatment
2) Age <70 years: radical prostatectomy
B. Intermediate risk disease
1) Age >70 years: TURP + androgen ablation
2) Age <70 years: radical prostatectomy or radical radiotherapy
C. High risk disease: androgen ablation + radical radiotherapy + radical prostatectomy
D. Metastatic disease
1) Symptomatic: androgen ablation
2) Asymptomatic: chemotherapy
E. Castrate-resistant prostate cancer: abiraterone + prednisolone
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STRICTURE URETHRA
➢ ETIOLOGY
1) Congenital/idiopathic
2) Inflammatory: urethritis (post-gonococcal, tuberculous) and balanitis xerotica obliterans
3) Traumatic: bulbar urethral injury, pelvic fracture urethral disruption injury
4) Iatrogenic
a) Post-instrumentation: catheter, dilator, cystoscope
b) Post-operative: prostatectomy, urethrostomy
➢ C/F
• Hesitancy of micturition, straining to void, poor urinary stream
• Narrow stream → prolonged micturition → post-micturition dribbling
• Incomplete emptying
• Forking and spraying of the stream
• Frequency, dysuria
• Retention and overflow
• Pain, burning micturition, suprapubic tenderness
• Thickening and button-like feeling in bulbar urethra
➢ mc complication: UTI
➢ INVESTIGATIONS
• Urine microscopy and culture
• Blood urea and serum creatinine
• IVU
• US abdomen
• X-ray pelvis
• Ascending urethrogram
• Urodynamic studies: uroflowmetry
• Urethroscopy
➢ TREATMENT
1) Intermittent dilatation
• once a week for one month, once a month for one year, and later once a year
• Dilators used
a) Lister's dilator
b) Clutton's dilator
c) Filiform bougies
2) Visual internal cystoscopic urethrotomy/stricturotomy
3) Johanson's urethroplasty
4) External urethrotomy
HYPOSPADIAS
➢ mc congenital malformation of urethra

➢ TYPES
1) Glanular
2) Coronal
3) Penile
4) Penoscrotal
5) Perineal
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➢ C/F
• External meatus opens on the underside of penis
• Absence of urethra and corpus spongiosum distal to abnormal urethral orifice
• Chordee: bowing/bending of penis distal to abnormal urethral opening
• Hooded prepuce: poorly developed prepuce over inferior aspect
• Urine soakage over the scrotum with dermatitis and infection
➢ TREATMENT
1) Surgical correction of chordee: at the age of 1.5 years
2) Urethral reconstruction using preputial skin: at the age of 5-7 years – for proximal hypospadias
3) Tubularised incised plate urethroplasty – for distal hypospadias
4) MAGPI repair (meatal advancement glanuloplasty) – for glanular hypospadias
ACUTE RETENTION OF URINE
➢ CAUSES
A. Male
• Bladder outlet obstruction (mcc)
• Urethral stricture
• Acute urethritis or prostatitis
• Phimosis
B. Female
• Retroverted gravid uterus
• Bladder neck obstruction
C. Both
• Blood clot
• Urethral calculus
• Rupture of the urethra
• Neurogenic: injury or disease of the spinal cord
• Smooth muscle cell dysfunction a/w ageing
• Fecal impaction
• Hemorrhoidectomy
• Intensive postoperative analgesic treatment
• Drugs: anti-histamines, anti-cholinergics, anti-hypertensives, tricyclic anti-depressants
• Spinal anesthesia
➢ C/F
• Painful swelling in suprapubic region: bladder visible, palpable, tender, dull to percussion
• Inability to pass urine
➢ INVESTIGATIONS
• US abdomen
• Blood urea, serum creatinine
• Urine microscopy
➢ TREATMENT
1) Urinary catheterisation using Foley's catheter
2) Suprapubic cystostomy using Malecot's catheter
3) Treat cause
4) Intermittent catheterisation: for neurogenic bladder
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PHIMOSIS
➢ DEFINITION: inability to retract the prepuce over the glans

➢ CAUSES
• Congenital
• Balanitis and balanoposthitis
➢ C/F
• pinhole meatus
• ballooning of the prepuce during urination
➢ COMPLICATIONS
• Recurrent balanoposthitis
• Paraphimosis
• Preputial calculi formation
• Retention of urine
• Carcinoma of penis
➢ TREATMENT
1) Preputioplasty: in mild cases with minimal scarring
2) Circumcision
PARAPHIMOSIS
➢ DEFINITION: inability to place back the retracted preputial skin over the glans
➢ causes ring-like constriction proximal to the corona and preputial skin
➢ precipitated after sexual intercourse or iatrogenically after urethral catheterisation
➢ C/F: glans swollen, edematous with severe pain and tenderness
➢ TREATMENT
1) Manual reduction of preputial skin
2) Antibiotics and analgesics
3) Hyaluronidase injection in 10 ml saline into the constriction ring
4) Dorsal slit → circumcision (after 3 weeks)
CIRCUMCISION
➢ INDICATIONS
• Religious
• Phimosis
• Paraphimosis
• Balanitis and balanoposthitis
• Early carcinoma of prepuce or glans penis
• STDs – herpes infection
➢ PROCEDURE: inj. 1% lignocaine circumferentially near root of penis → dorsal skin cut up to corona and later
circumferentially and ventrally → skin cut with inner layer → frenular artery transfixed and ligated ventrally →
skin apposed to cut edge of corona using interrupted sutures
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➢ COMPLICATIONS
• Reactionary hemorrhage
• Infection
• Stricture urethra
• Chordee
PEYRONIE'S DISEASE
➢ DEFINITION: development of fibrous tissue plaque on the covering of corpus cavernosum and later involving its
full extent resulting in induration of corpus
➢ a/w Dupuytren’s contracture
➢ C/F
• penile deformity (mc: dorsal)
• palpable penile plaques within the penis
• erectile dysfunction
• pain on erection
➢ TREATMENT
A. Drugs
1) Steroids
2) Vitamin E
3) Potassium amino benzoate
4) Tamoxifen: 20 mg daily
5) Terfenadine and fexofenadine
6) Colchicine
7) Intralesional inj. verapamil: 10 mg once in 2 weeks – 12 injections
B. Surgery
1) Nesbitt procedure: plication of convex side of deformity
2) Fitzpatric operation: excision and plication to opposite side
3) Gelhard's operation: multiple incisions over fibrous plaque and temporal fascia bridging
4) Excision of fibrous plaque and corporotomy covered with overlay flap – tunica vaginalis flap, dermal flap
5) lntracorporeal penile prosthesis placement
CARCINOMA PENIS
➢ ETIOLOGY
• Chronic balanoposthitis
• Phimosis
• STDs
• Smoking
• Leukoplakia of glans
• Penile intraepithelial neoplasia
• Genital warts
• Paget's disease of penis
• Erythroplasia of Querat
• Condyloma acuminata
• Balanitis xerotica obliterans
• Infection: HIV; HPV types 16, 18
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➢ SPREAD
• spreads proximally to the body of penis, urethral meatus
• through lymphatics: inguinal LN, external iliac LN, Cloquet LN
Fixed LN status indicates advancement of disease
➢ C/F
• Painless → painful (due to secondary infection) accompanied by edema, tenderness, redness, discharge –
foul smelling, purulent, irritating
• Altered urinary stream
• Fungation and induration, everted edge
• Palpable hard, nodular inguinal LN on both sides
➢ INVESTIGATIONS
• Wedge biopsy from the lesion: squamous cell carcinoma with epithelial pearls
• FNAC of LN
• US abdomen
• Cabana SLNB: located above and medial to the junction of saphenous and femoral vein
➢ TREATMENT
1) Partial penectomy – if tumor involves glans without extending into proximal part of shaft of penis
2 cm clearance from proximal extended part of tumor
Young's operation: partial amputation of penis + B/L ilioinguinal LN block dissection
2) Total penectomy + perineal urethrostomy: if tumor involves proximal part of body of penis or if it is
anaplastic/poorly differentiated tumor
Sir Piersey Gold operation: total amputation of the penis + total scrotectomy + orchidectomy
3) Circumcision + curative RT to penis: in case of carcinoma in situ, T1 lesion of glans penis or well-
differentiated tumour in young individual
4) B/L ilioinguinal LN block dissection: when LN are involved and are mobile
5) Post-operative RT to inguinal region
6) Palliative external RT: in advanced fixed inguinal nodes
7) Chemotherapy: 5-FU (in carcinoma in situ); methotrexate, bleomycin, cisplatin, vincristine (MBP/VBM)
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HYDROCELE
➢ DEFINITION: an abnormal collection of serous fluid b/w the two layers of tunica vaginalis of testis
➢ ETIOLOGY
1) By connection with the peritoneal cavity via a patent processus vaginalis: congenital hydrocele
2) By excessive production of fluid within the sac: secondary hydrocoele
3) By defective absorption of fluid: primary hydrocoele
4) By interference with lymphatic drainage of scrotal structures
➢ CLASSIFICATION
1) Congenital
2) Acquired
a) Primary
b) Secondary
• Infection: epididymo-orchitis, filariasis, TB epididymis
• Injury: trauma, testicular torsion, post-herniorrhaphy
• Tumors
➢ C/F
1) Primary vaginal hydrocele

• attains a large size; testis not palpable
• fluctuant
• initially transilluminant → non-transilluminant
• can get above the swelling
• testicular sensation can be elicited
2) Infantile hydrocele
• tunica and processus vaginalis distended up to internal ring; but do not communicate with the
peritoneal cavity
3) Congenital hydrocele
• processus vaginalis communicates with the peritoneal cavity
• while lying down, fluid disappears gradually and while standing fluid recollects
4) Encysted hydrocele of the cord
• fluid collection in a portion of patent funicular process part of tunica vaginalis; but closed above & below
• fluctuant and transilluminant
• can get above the swelling
• traction test: swelling becomes less mobile on gentle traction to testis
5) Hydrocele-en-bisac (bilocular hydrocele)
• two intercommunicating sacs, one above and one below the neck of scrotum
• cross-fluctuant
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6) Hydrocele of the hernial sac
• due to adhesions of the content of hernial sac
• fluid secreted collects in the hernial sac and forms hydrocele
➢ COMPLICATIONS
• Infection → pyocele
• Hematocele
• Infertility
• Hernia of hydrocele sac
• Atrophy of testis
• Rupture: either traumatic or spontaneous
• Calcification of the sac wall
➢ D/D: inguinal hernia, epididymal cyst, spermatocele, testicular tumor, scrotal edema
➢ TREATMENT
1) Herniotomy: if congenital hydrocele doesn’t resolve spontaneously
2) Lord's plication: if sac is small, thin and contains clear fluid
3) Evacuation and eversion of sac behind the testis: if sac is small, thin and contains clear fluid
4) Subtotal excision of sac: if sac is thick, in large hydrocele and chylocele
5) Jaboulay's operation: partial excision of sac and eversion
6) Sharma and Jhawer's technique: evacuation and placement of sac with testis in a newly created pocket
between the fascial layers of scrotum
HEMATOCELE
A. Recent hematocele
➢ due to rupture of one of the vessels in the tunica causing bleeding into the sac
➢ C/F: sudden onset of pain and swelling after a h/o trauma; tender, warm, fluctuant, but non-transilluminant
➢ COMPLICATIONS: chronic hematocele; infection → pyocele
➢ INVESTIGATION: US scrotum
➢ TREATMENT: scrotum explored under GA → clot evacuated → wound closed with a drain
B. Chronic/old clotted hematocele
➢ due to slow, spontaneous haemorrhage into the tunica vaginalis, without any h/o trauma
➢ C/F: painless, hard, non-tender, non-fluctuant, calcified swelling, with loss of testicular sensation
➢ INVESTIGATION: US scrotum
➢ TREATMENT: low orchidectomy through scrotal approach
PYOCELE
➢ DEFINITION: collection of pus in the layers of tunica vaginalis

➢ C/F
• fever, toxicity, tender swelling in the scrotum, with scrotal wall edema
• pus under tension → infective thrombosis of testicular vessels → testicular gangrene
➢ TREATMENT
1) Antibiotics
2) Scrotum explored immediately → pus evacuated → viability of testis checked
a) if viable: pus sent for C/S → wound closed with a drain
b) if not viable: orchidectomy
c) if doubtful: leave testis in place and observe → if no sign of viability: orchidectomy
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VARICOCELE
➢ DEFINITION: dilatation and tortuosity of the pampiniform plexus of veins and the testicular veins
➢ more common on the left side in tall, thin young men
➢ TYPES
1) Primary: idiopathic – 95%
2) Secondary: due to specific cause – left-sided RCC
➢ C/F
• Swelling in the root of the scrotum
• Dragging pain in the groin and scrotum
• Bag of worms feeling
• Impulse on coughing
• Reducible on lying down (except in RCC)
• Bow sign: patient asked to bow after holding the varicocele between thumb and fingers → varicocele gets
reduced in size
• Increased temperature in the scrotum → depresses spermatogenesis → infertility
➢ D/D: Hydrocele, Inguinal hernia, Lymph varix, Lipoma of the cord
➢ INVESTIGATIONS
• Venous doppler of the scrotum and groin.
• US abdomen
• Semen analysis
➢ TREATMENT: Surgery – extraperitoneal ligation of the testicular vein
Indications: pain; oligospermia
1) Suprainguinal approach (Palomo's operation)
2) Inguinal approach (lvanissevich approach)
3) Subinguinal approach (Marc-Goldstein)
4) Scrotal approach
5) Laparoscopic approach
FOURNIER'S GANGRENE
➢ vascular gangrene of infective origin – haemolytic streptococci, microaerophilic streptococci, staphylococci, E.

coli, Cl. Welchii, Bacteroides fragilis
➢ fulminant inflammation of scrotal skin and subcutaneous tissues → obliterative arteritis of arterioles of scrotal
skin → cutaneous gangrene
➢ common in diabetics, old age, malnourished, immunosuppressed individuals
➢ C/F
• Sudden pain in the scrotum, fever, severe toxicity
• Very fast spreading cellulitis of scrotal skin, extending to groin and anterior abdominal wall
• Extensive skin sloughing → normal testis exposed
➢ TREATMENT
1) IV fluids and catheterisation
2) Antibiotics, blood transfusion
3) Nutritional support
4) Liberal excision of all slough
5) Once patient recovers and wound granulates well → skin grafting
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UNDESCENDED TESTIS
➢ results from arrest of descent of the testis in some part along its pathway to the scrotum
➢ Cryptorchidism: clinically impalpable B/L undescended testis
➢ ETIOLOGY
• Gubernacular dysfunction
• Lack of HCG
• Lack of Calcitonin Gene Related Peptide
• Prune-Belly syndrome
• Familial
• Retroperitoneal adhesions
• Short vas deferens or testicular vessels
• Altered hypothalpituitary-gonadal axis
• Testosterone deficiency
• Deficiency of Mullerian inhibiting substance
➢ POSITIONS
1) Intra-abdominal
2) Intracanalicular
3) Extracanalicular
➢ COMPLICATIONS
• Torsion
• Epididymo-orchitis
• Sterility
• Trauma
• Indirect inguinal hernia
• Seminoma
• Testicular atrophy
➢ INVESTIGATIONS
• US abdomen
• Assessment of FSH, HCG
• CT scan
• Gonadal venogram
• Laparoscopy
➢ TREATMENT: always surgery
1) Orchidopexy: steps-
• Incision over the deep inguinal ring → inguinal canal opened
• Mobilisation of testis & spermatic cord
• Lengthening of cord by-
a) ligation of inferior epigastric vessels
b) ligation of patent processus vaginalis
c) division of coverings of spermatic cord
d) division of lateral fibrous bands just inside the internal inguinal ring
e) mobilisation of vas and testicular vessels retroperitoneally
f) safe ligation of testicular artery
• Scrotum stretched using finger → testis placed in a pouch constructed b/w dartos muscle and skin →
fixation using non-absorbable interrupted sutures
2) Orchidectomy: if testis totally atrophied
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ECTOPIC TESTIS
➢ scrotal tail of gubernaculum weakens or ruptures → one of the other accessory tails acts and pulls the testis in
direction according to its site
➢ SITES
• Superficial inguinal pouch: space between external oblique and Scarpa's fascia
• Perineum
• Root of penis
• Femoral triangle
➢ D/D: undescended testis
on raising the legs, ectopic testis in superficial inguinal pouch becomes more prominent but not in case of
undescended testis located in inguinal canal
➢ TREATMENT: mobilisation and creation of a new scrotal pouch → placement and fixation
TORSION OF THE TESTIS
➢ an emergency condition of the testis, wherein the testis rotates in its axis compromising its blood supply
➢ right testis rotates in clockwise direction whereas left testis rotates in anticlockwise
➢ PREDISPOSING FACTORS
• Inversion of the testis
• High investment of the tunica vaginalis
• Presence of gap between the body of the testis and epididymis
• Heavy straining
➢ C/F
• Sudden onset of pain in the scrotum, groin and lower abdomen
• Vomiting
• Tenderness, redness and edema of the scrotal skin
• Deming's sign: affected testis is positioned high because of twisting of cord and spasm of cremaster muscle
• Angell's sign: opposite testis lies horizontally because of the presence of mesorchium
➢ D/D: acute epididymo-orchitis, strangulated inguinal hernia
➢ INVESTIGATIONS
• TLC
• Doppler study of scrotum
• US abdomen
➢ TREATMENT
1) Surgery done within 12-24 hours: emergency exploration of scrotum and untwisting of the torsion testis →
check viability → fix testis to scrotal sac using interrupted non-absorbable sutures
2) Delayed presentation: testicular gangrene → orchidectomy
ORCHITIS
➢ DEFINITION: inflammation of the testis

➢ a/w inflammation of the epididymis (epididymo-orchitis)
➢ CAUSES: mumps, filariasis, syphilis, leprosy, brucellosis, infectious mononucleosis
➢ C/F
• Pain and tenderness in the testis
• Fever
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• Secondary hydrocele
• UTI
➢ COMPLICATION: testicular atrophy → infertility
➢ TREATMENT
1) Antibiotics, analgesics, DEC
2) Treat the cause
EPIDIDYMITIS
➢ DEFINITION: inflammation of the epididymis

➢ a/w inflammation of the testis (epididymo-orchitis)
➢ CAUSES
• Mumps, filariasis, TB
• In young sexually active men: sexually transmitted genital infection (mcc – Chlamydia trachomatis)
• In older men: UTI, secondary to an indwelling catheter
➢ C/F
• Epididymis: painful (radiating to groin), swollen, tender, thickened
• Scrotal wall: red, edematous, shiny
• Beaded vas with craggy epididymis: in TB
➢ COMPLICATIONS: abscess formation, testicular infarction, testicular atrophy, chronic induration and
inflammation, infertility
➢ INVESTIGATIONS: urine culture, urethral swab, US scrotum
➢ TREATMENT
1) Antibiotics (doxycycline/quinolone), analgesics, DEC
2) Treat the cause
3) Drink plenty of fluids, scrotal support
4) Drainage: if suppuration occurs
TESTICULAR TUMOURS
➢ ETIOLOGY
• Cryptorchidism
• Klinefelter's syndrome
• Testicular atrophy
➢ CLASSIFICATION
A. Germ cell tumors
1) Seminoma
2) Non-seminomatous germ cell tumors
a) Embryonal carcinoma
b) Yolk sac tumor: secretes AFP
c) Choriocarcinoma: secretes hCG
d) Teratoma
B. Interstitial tumors
1) Leydig cell tumor: pre-pubertal, masculinising
2) Sertoli cell tumor: post-pubertal, feminising
C. Lymphoma
D. Other tumors
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SEMINOMA TESTIS
➢ PATHOLOGY
• starts in the mediastinum of testis and lower pole
• c/s – lobulated, fleshy, homogeneous, pinkish cream in colour
• compresses adjacent testicular tissue
• consists of oval cells with clear cytoplasm and large rounded nuclei with prominent acidophilic nucleoli
• Histological types-
1) Typical/classic/syncytiotrophoblastic
2) Spermatocytic
3) Anaplastic
4) Atypical
➢ SPREAD
• through testicular lymphatics into para-aortic LN
• hematogenous spread: lungs > liver > brain > bone
➢ C/F
• Testis: enlarged, firm, heavy, with loss of testicular sensation
• Fullness and heaviness in the scrotum
• Secondary hydrocele
• Cremaster: hypertrophied and thickened
• Palpable para-aortic LN in epigastric region: hard, nodular, non-tender, non-mobile, vertically placed,
resonant mass, not moving with respiration
• Features of metastasis
➢ STAGING
Stage I: Tumour confined to testis and epididymis
Stage II: Nodal disease confined to below the diaphragm
Stage III: Nodal involvement present above the diaphragm
Stage IV: Non-lymphatic metastatic disease
➢ INVESTIGATIONS
• Frozen section biopsy
• Measurement of tumour markers
• US scrotum, abdomen
• CXR: cannon ball secondaries
• CT chest, abdomen, pelvis
➢ TREATMENT
A. Scrotal exploration and high orchidectomy via an inguinal incision (Chevassu maneuvre)
B. Adjuvant therapy
1) Stage I tumors
a) Radiotherapy
b) CT and tumour marker-based surveillance
c) BEP chemotherapy – for relapse
2) Stage II-IV tumors: BEP chemotherapy
a) Bleomycin
b) Etoposide
c) Cis-platinum
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WOUNDS
➢ CLASSIFICATION:
A. Rank and Wakefield classification
1) Tidy - surgical incisions and wounds caused by sharp objects
2) Untidy - crushing, tearing, avulsion, devitalised injury, vascular injury, burns
B. Based on the type of wound
1) Closed – contusion, abrasion, hematoma
2) Open – incision, laceration, crush injuries, penetrating
C. Based on involvement of structures
1) Simple – only skin involved
2) Complex – vessels, nerves, tendons or bones involved
D. Surgical wounds
1) Clean - hernioplasty, excisions, thyroidectomy, surgeries of brain, joints, heart and transplant
2) Clean contaminated - appendicectomy, gastrojejunostomy, pancreatic and biliary surgeries
3) Contaminated - acute abdominal conditions
4) Dirty - abscess, perforated viscous with peritonitis, fecal contamination
➢ PATHOPHYSIOLOGY:
A. Types of wound healing
1) Primary healing (first intention)
2) Secondary healing (second intention)
3) Tertiary healing (third intention or delayed primary closure)
B. Stages of wound healing
1) Stage of hematoma and inflammation
2) Stage of granulation tissue formation and organisation
3) Stage of epithelialisation
4) Stage of scar formation and resorption
5) Stage of maturation
C. Phases of wound healing
1) Inflammatory phase (lag or substrate or exudative phase) - begins immediately after formation and lasts
for 72 hours
2) Proliferative phase (collagen or fibroblastic phase) - begins from 3rd day and lasts for 3-6 weeks
3) Remodeling phase (maturation phase) - begins at 6 weeks and lasts for 6 months to 1 or 2 years
D. Factors affecting wound healing
1) Local factors – infection, blood supply, tissue tension, site, size, underlying disease, type of wound,
irradiation, presence of necrotic tissue or foreign body
2) General factors – age, obesity, smoking, alcohol, stress, malnutrition, vitamin deficiency, anemia,
hypoxia, malignancy, uremia, jaundice, metabolic disease, immunosuppression, neuropathy
➢ MANAGEMENT:
A. Assessment of the wound - detailed history and examination
B. Wound cleaning - irrigation with warm sterile isotonic NS
C. Specific treatment
1) Minor wounds – incision → primary suturing; laceration → primary suturing without tension
2) Hematoma – icepacks, compression bandage; elevation of the part; US and guided aspiration
3) Crushed/devitalised wound - wound excision/debridement → delayed primary suturing → secondary
suturing → SSG
4) Major wounds – maintenance of airway; control of bleeding; iv fluids; management in OT under GA;
suturing of major vessels and nerves; fasciotomy
5) Internal injuries – laparotomy / craniotomy / intercostal tube drainage
D. Other management - antibiotics, fluids, blood transfusion; electrolyte management; tetanus toxoid, ATG
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KELOID
➢ DEFINITION: excessive abnormally stretched type III thick collagen tissue bundles arranged with aligning in same
plane as the epidermis but extends beyond the original scar margin which continues to grow for long periods
➢ common in blacks, females
➢ genetically predisposed, often familial
➢ defect in maturation and stabilization of collagen fibrils
➢ C/F: brownish/pinkish black in colour, painful, tender; spreads and causes itching; vascular
➢ MC SITE: sternum
➢ D/D: hypertrophic scar
➢ Recurrence very high
➢ T/T:
1) Steroid injection – intra-keloidal triamcinolone
steroid injection → intralesional excision → steroid injection
2) Methotrexate, vitamin A and C therapy into the keloid
3) Silicone gel sheeting, topical retinoids
4) Nd-YAG laser therapy
5) Vitamin E or palm oil massage
HYPERTROPHIC SCAR
➢ DEFINITION: excessive formation of abnormal scar tissue containing type III thin collagen which is raised,
vascular but confined within the margin of the original wound; growth stops in 6 months and often regresses
spontaneously
➢ SITE: anywhere in the body
➢ not genetically predisposed; not familial
➢ C/F: pale brown in colour, not painful, non-tender; not vascular
➢ COMPLICATIONS:
1) scar breaks → infection, pain
2) Marjolin's ulcer
➢ T/T:
1) Pressure garments
2) Revision excision of scar and closure
3) Triamcinolone injection
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ULCER
➢ DEFINITION: a break in the continuity of the covering epithelium due to molecular death
➢ CLASSIFICATION:
A. Clinical
1) Spreading ulcer
2) Healing ulcer
3) Non-healing ulcer
4) Callous (stationary) ulcer
B. Based on duration
1) Acute ulcer - duration < 2 weeks
2) Chronic ulcer - duration > 2 weeks
➢ INVESTIGATIONS:
• Discharge study
• Wedge biopsy
• X-ray of the part
• FNAC of the LN
• Hb, ESR, TLC, serum albumin
➢ T/T:
1) Control of pain and infection
2) Rest, immobilization, elevation, avoidance of repeated trauma
3) Separation of slough and ulcer debridement
a) Mechanical – scissors
b) Chemical – H2O2, acriflavine, eusol, sodium hypochlorite, collagenase
4) Ulcer cleaning – NS
5) Ulcer dressing – cotton, paraffin, polyurethane, hydrogel, hydrocolloid
6) Removal of the exuberant granulation tissue
7) Vacuum assisted closure (VAC) therapy
8) Once ulcer granulates → defect closed with secondary suturing, skin graft/flaps
TROPHIC ULCER / PRESSURE SORE / DECUBITUS ULCER
➢ DEFINITION: tissue necrosis and ulceration due to prolonged pressure

➢ CAUSES:
1) impaired nutrition
2) defective blood supply
3) neurological deficit, pressure, anemia, injury, moisture
➢ SITES: over the ischial tuberosity; sacrum; heel; heads of metatarsals; buttocks; shoulder; occiput
➢ C/F: painless deep, non-mobile ulcer - punched out with base formed by bone
➢ INVESTIGATIONS: Study of discharge; blood sugar; wedge biopsy from the edge; X-ray of the part and spine
➢ T/T:
1) T/t of cause
2) Nutritional supplementation
3) Rest, antibiotics, slough excision, regular dressings
4) Vacuum-assisted closure (VAC)
5) Once ulcer granulates well → flap cover or skin grafting
6) Proper care
a) change in position once in 2 hours; lifting the limb upwards for 10 seconds once in 10 minutes
b) use of water bed / air bed / ripple bed / air-fluid flotation bed and pressure dispersion cushions
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c) urinary and fecal care; hygiene; psychological counselling
d) regular skin observation; keeping skin clean and dry
e) oil massaging of the skin and soft tissues; control and prevention of sepsis
RODENT ULCER
➢ DEFINITION: ulcerative form of BCC; locally malignant

➢ MC SITE: face
➢ C/F: ulcer shows central area of dry scab with peripheral raised active and beaded edge and pigmented floor
➢ INVESTIGATIONS: wedge biopsy, CT scan of the part
➢ T/T: wide excision
DIABETIC ULCER
➢ CAUSES:
• ↑glucose in the tissue
• Diabetic microangiopathy
• ↑glycosylated hemoglobin
• ↑ glycosylated tissue protein
• Diabetic neuropathy
➢ MC SITE: foot-plantar aspect
➢ C/F: ulcer – spreading and deep
➢ INVESTIGATIONS: blood sugar, urine ketone bodies, discharge study, X-ray of the part, arterial doppler of the
limb, HbA1c
➢ T/T:
1) Control of diabetes using insulin
2) Antibiotics
3) Nutritional supplements
4) Regular cleaning, debridement, dressing
5) Revascularization procedures – endarterectomy, thrombectomy, balloon angioplasty, arterial bypass graft
6) Amputation
7) MCR shoes
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SINUS AND FISTULA
➢ DEFINITION OF SINUS: a blind track lined by granulation tissue leading from an epithelial surface into the
surrounding tissues
➢ DEFINITION OF FISTULA: an abnormal communication between the lumen of one viscus to another or the body
surface or between the vessels
➢ CAUSES OF SINUS:
1) Congenital - preauricular sinus
2) Acquired - actinomycosis, TB, pilonidal sinus, chronic osteomyelitis, median mental sinus
➢ CAUSES OF FISTULA:
1) Congenital - branchial fistula; trachea-esophageal fistula; AV fistula; umbilical fistula
2) Acquired
a) Traumatic – following surgery, instrumental delivery or difficult labour
b) Inflammatory - actinomycosis, TB
c) Malignancy
➢ C/F:
• Discharge from the opening of sinus
• No floor, raised indurated edge, indurated base, non-mobile
• Sprouting granulation tissue over the sinus opening
• Induration (exception – TB)
• Enlargement of regional LN
➢ INVESTIIGATIONS:
• Fistulogram/sinusogram
• Discharge study
• Biopsy from the edge
• Chest X-ray; X-ray of the part; MRI of the part
• ESR
• Probing gently with care
➢ T/T:
1) T/t of cause
2) Excision of sinus or fistulas
3) Antibiotics, ATT, rest, drainage
PREAURICULAR SINUS
➢ DEFINITION: congenital entity occurring due to imperfect fusion of the six tubercles which form ear cartilage
➢ SITE: root of the helix or on the tragus
➢ C/F: swelling, pain and discharge
➢ D/D: cold abscess, sebaceous cyst
➢ INVESTIGATIONS: sinusogram, discharge study
➢ T/T: excision under GA with removal of entire track
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ERYSIPELAS
➢ DEFINITION: acute spreading inflammation of the upper dermis and superficial lymphatics
➢ CAUSE: acute infection by beta hemolytic Streptococcus pyogenes through a minor trauma
➢ C/F:
• Rose-pink skin rash – raised, well-demarcated, fast-spreading and blanches on pressure
• Serous discharge
• Cutaneous lymphangitis with lymphedema
• Toxaemia
• Severe edema in face and orbit
• Tender palpable regional LN
➢ T/T: antibiotics
PYEMIC ABSCESS
➢ spread from any infective focus → pyemic emboli → multiple abscesses in different places
➢ PRESENTATION: systemic features involving multiple organs with toxicity
➢ INVESTIGATIONS: evaluation for focus of infection, pus for culture, blood culture
➢ T/T: antibiotics, critical care, systemic therapy, drainage of surface abscesses
CARBUNCLE
➢ DEFINITION: infective gangrene of skin and subcutaneous tissue

➢ MCC: Staphylococcus aureus
➢ MC SITES: nape of the neck and back
➢ common in males, diabetics and after forty years of age
➢ infection → development of vesicles → red indurated skin with discharging pus → central necrotic ulcer with
peripheral vesicles → skin becomes black → disease spreads to adjacent skin
➢ cluster of furuncles connected subcutaneously → deeper suppuration and scarring
➢ T/T:
1) Control of diabetes
2) Antibiotics
3) Drainage by a cruciate incision and debridement of all dead tissues → excision
TETANUS
➢ DEFINITION: infective condition caused by Clostridium tetani leading to reflex muscle spasm a/w tonic clonic
convulsions
➢ ETIOLOGY:
• Absence of prior tetanus toxoid immunisation.
• Trauma
• Improper sterilisation
• Tattooing, rusted nails, ear lobe prick
➢ T/T:
A. Isolation in a dark quiet room
B. Eliminating the source of the toxin – DOC = metronidazole 500 mg iv 8th hourly for 10 days
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C. Neutralizing the unbound and circulating toxins – human tetanus immunoglobulin (ATG) 3000 units i.m.
D. Control of muscle spasms
1) Benzodiazepines – diazepam, lorazepam, midazolam
2) Therapeutic paralysis with a non-depolarising neuromuscular blocking agent - vecuronium & atracurium
3) Centrally acting drugs - methocarbamol, mephenesin, meprobamate
E. Control of autonomic dysfunction - fluid therapy (8 litres/day), morphine, phenothiazines, anticholinergics,
α-2 adrenergic agonists, magnesium sulphate
F. Managing respiratory system complications - ventilator support with endotracheal intubation; paralyzing the
patient; tracheostomy, regular suctioning, respiratory physiotherapy; regular monitoring
G. Active immunization - Tetanus toxoid (1st dose, 2nd dose after 1 month, 3rd dose after 6 months)
H. Wound management
1) wound debridement
2) drainage of pus
3) injection ATG 500 units into wound area
I. Management of complications
J. Good nursing care
GAS GANGRENE
➢ DEFINITION: infective gangrene caused by clostridial organisms (mc - Clostridium Welchii/perfringens) involving
mainly skeletal muscle as edematous myonecrosis
➢ ETIOLOGY:
1) Contaminated, manured or cultivated soil
2) Crush wounds, following RTA, after amputations, ischemic limb
➢ INVESTIGATIONS:
• LFT, blood urea, serum creatinine, TLC
• X-ray - gas in muscle plane or under the skin
• Gram's stain - Gram-positive bacilli
• RCM broth - meat turns pink with sour smell and acid reaction
• Culture media plate - Nagler reaction
➢ T/T:
1) Antibiotics - injection benzyl penicillin 20 lacs 4th hourly + injection metronidazole 500 mg 8th hourly +
injection aminoglycosides or third generation cephalosporins
2) Fresh blood transfusion
3) Polyvalent antiserum 25,000 units iv
4) Hyperbaric O2
5) Excision and debridement of dead tissues
6) Rehydration, electrolyte management, ventilator support
7) Guillotine amputation as a life-saving procedure
➢ Actinomycosis
➢ Surgical site infection
➢ AIDS
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LIPOMA
➢ DEFINITION: benign neoplasm arising from yellow fat composed of mature adipocytes
➢ mc benign tumor
➢ Universal tumour as it can occur anywhere in the body except brain (mc site = trunk > nape of neck > limbs)
➢ C/F: localised swelling – lobular, non-tender, non-transilluminant, mobile, slip sign +ve
➢ INVESTIGATIONS: US/CT/MRI, FNAC or incision biopsy in deep or large or intracavitary lipomas
➢ T/T: excision
DERMOID CYST
A. Sequestration dermoids
➢ occurs at the line of embryonic fusion due to inclusion of epithelium beneath the surface which later gets
sequestered forming a cystic swelling in the deeper plane
➢ congenital
➢ C/F:
• swelling – painless, smooth, soft, non-tender, fluctuant, non-transilluminant, free skin
• resorption and indentation of the bone beneath
➢ T/T: excision
B. Tubulodermoids
➢ arises from the embryonic tubular structures due to accumulation of secretions of the lining of the
unobliterated portion of congenital ectodermal tube/duct
➢ e.g. Thyroglossal cyst, Ependymal cyst, Post-anal dermoid, Urachal cyst
C. Implantation dermoids
➢ due to minor pricks or trauma, epidermis gets buried into the deeper subcutaneous tissue which causes
reaction and cyst formation
➢ acquired cyst
➢ C/F: swelling – painless, observed after minor trauma, slowly progressing in fingers or toes, smooth, soft,
mobile, tensely cystic, non-transilluminant, adherent to skin
➢ T/T: excision under LA
D. Teratomatous dermoids
➢ arises from all germinal layers
➢ occurs in ovary, testis, retroperitoneum, mediastinum
➢ contains hair, teeth, cartilage, sebum and muscle
SEBACEOUS CYST
➢ retention cyst
➢ due to blockage of the duct of sebaceous gland
➢ common in face, scalp, scrotum; not seen in palms and soles
➢ parasite in the wall of the sebaceous cyst - Demodex folliculorum
➢ C/F: swelling – painless, smooth, soft, non-tender, freely mobile, adherent to skin especially over the summit,
fluctuant (positive Paget's test), non-transilluminant with punctum over the summit, moulds on finger
indentation; unpleasant odour of sebum content
➢ COMPLICATIONS:
1) Infection and abscess formation
2) Cock's peculiar tumour
3) Sebaceous horn
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➢ T/T:
1) Dissection method - excision including skin adjacent to punctum using elliptical incision
2) Incision and avulsion of cyst wall
3) If abscess formed, drainage → excision
NEUROMA
➢ DEFINITION: swelling arising in relation to the nerve fibre

➢ TYPES:
A. True neuroma
• develops in relation to sympathetic nervous system
• T/T: complete excision
B. False neuroma
• occurs due to injury to nerve by trauma or during surgery
• arises from connective tissue of the nerve sheath
• Types-
1) End neuroma
✓ commonly seen in an amputation stump
✓ tender, localized, firm, swelling adherent to scar underneath
✓ prevented by cutting the nerve after pulling down for significant length during amputation so
that nerve end gets adequately retracted proximally
2) Lateral neuroma
✓ seen after traumatic partial nerve injury
✓ tender, firm swelling along the line of peripheral nerve
NEUROFIBROMA
➢ DEFINITION: benign tumour arising from connective tissue of the nerve containing ectodermal, neural and
mesodermal connective tissue components
➢ TYPES:
1) Nodular
2) Plexiform
3) Generalised
4) Elephantiasic
5) Cutaneous
➢ C/F: swelling along the nerves - moves perpendicular to the direction of the nerve; with smooth surface and firm
consistency; with tingling, numbness and paraesthesia along the distribution of nerve
➢ T/T: excision
VON RECKLINGHAUSEN’S DISEASE
➢ Generalised neurofibromatosis type 1

➢ Inherited autosomal dominant disease with mutated chromosome 17
➢ All layers of nerve with Schwann cells and fibroblasts show tumour proliferation
➢ C/F: multiple neurofibromas in the body
cafe-au-lait spots – coffee-coloured pigmented spots commonly seen on the back, abdomen, thigh
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LYMPHATIC CYST
➢ DEFINITION: acquired type of distension cyst wherein lymphatics form a localised swelling with capsule around it
➢ C/F: swelling in subcutaneous plane - smooth, soft, non-tender, mobile and brilliantly transilluminant, not
adherent to the skin
➢ MC SITES: neck and limbs
➢ D/D: Cold abscess, dermoid cyst
➢ T/T: excision
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SHOCK
➢ DEFINITION: a systemic state of low tissue perfusion that is inadequate for normal cellular respiration
a state of cellular and tissue hypoxia with either ↓O2 delivery or poor O2 utilization or ↑O2 consumption with
circulatory failure and poor perfusion
➢ CLASSIFICATION:
1) Hypovolemic
a) Hemorrhagic
b) Non-hemorrhagic - dehydration, vomiting, diarrhea, urinary loss, evaporation, third-spacing
2) Cardiogenic – MI, cardiac dysrhythmias, valvular heart disease, blunt myocardial injury, cardiomyopathy
3) Obstructive – cardiac tamponade, tension pneumothorax, massive pulmonary embolus or air embolus
4) Distributive – septic, anaphylactic, neurogenic
5) Endocrine – hypo- and hyperthyroidism and adrenal insufficiency
SEPTIC SHOCK
Toxins/endotoxins from organisms
↓
Inflammation, cellular activation of macrophages, neutrophils, monocytes
↓
Release of cytokines, free radicals
↓
Reversible hyperdynamic warm stage
↓
Irreversible hypodynamic cold stage
➢ C/F:
1) Hyperdynamic warm stage (reversible) - fever, tachycardia, tachypnea [SIRS]
2) Hypodynamic cold stage (irreversible) - anuria, cyanosis, jaundice, cardiac depression, pulmonary edema,
hypoxia, drowsiness [MODS]
➢ T/T:
1) Correction of fluid and electrolyte by crystalloids, blood transfusion
2) Pus/urine/discharge/bile/blood culture and sensitivity → antibiotics
3) Treat the cause or focus - drainage of abscess; laparotomy for peritonitis; resection of gangrenous bowel;
wound excision
4) Critical care, O2, ventilator support, inotropes
5) Monitoring the patient
6) Short-term high dose steroid therapy
SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS)
➢ DEFINITION: systemic manifestations of inflammation due to infection, pancreatitis, polytrauma, burns,

transfusion reaction, malignancy
➢ C/F:
• hyperthermia (>38°C) or hypothermia (<36°C)
• tachycardia (pulse >90/minute)
• tachypnea (>20/minute)
• TLC >12,000/cu mm or <4000/cu mm
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HEMORRHAGIC SHOCK
➢ PRIMARY HEMORRHAGE: occurs at the time of injury or operation

➢ REACTIONARY HEMORRHAGE: delayed (within 24 hours) due to dislodgement of a clot by resuscitation,
normalisation of blood pressure and vasodilatation
➢ SECONDARY HEMORRHAGE: occurs due to sloughing of the wall of a vessel 7–14 days after injury and
precipitated by infection, pressure necrosis or malignancy
➢ MANAGEMENT:
A. Identification of hemorrhage
Any shock should be assumed to be hypovolemic until proven otherwise
B. Immediate resuscitative maneuvers
1) Trendelenburg position
2) Direct pressure or packing over the site of external hemorrhage
3) Assess ABC
4) Large-bore iv access
5) Initially crystalloids (NS, RL) then colloids
6) Fresh warm whole blood transfusion or packed cell, FFP, platelet in 1:1:1 ratio
7) Catheterisation – urine output maintained >0.5 ml/kg/hour
8) Nasal O2 – 15 litres/min
9) Absolute rest, analgesics, morphine
10) Injection PPI
11) Local hemostatic agents – gelatin sponge, oxidized cellulose, collagen powder, topical EACA
C. Identification of site of hemorrhage
1) History - previous episodes, known aneurysm, NSAIDs
2) Examination - nature of blood, abdominal tenderness
3) Investigations - chest and pelvis x-ray, abdominal US, diagnostic peritoneal aspiration
Regular monitoring of BP, pulse, HR, RR, urine output, CVP, PCWP
CBC, ESR, ABG analysis, serum electrolyte, platelet count, serum lactate estimation
D. Damage control resuscitation
1) Anticipate and treat acute traumatic coagulopathy.
2) Permissive hypotension until haemorrhage control.
3) Limited crystalloid and colloid infusion to avoid dilutional coagulopathy.
4) Damage control surgery
a) Arrest haemorrhage - angioembolisation, endoscopic control
b) Control sepsis
c) Protect from further injury
BLOOD TRANSFUSION
➢ COMPLICATIONS:
1) Circulatory overload causing CHF
2) Incompatibility haemolytic transfusion reaction
3) Febrile transfusion reaction
4) Allergic reaction
5) Infections - bacterial, malaria, hepatitis, HIV
6) Air embolism thrombophlebitis
7) Coagulation failure
8) Iron overload → hemochromatosis
9) Citrate intoxication
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ARTIFICIAL BLOOD
A. Red cell substitutes

1) Stroma-free hemoglobin - biomimetic hemoglobin-based substitute
2) Perfluorocarbon - abiotic RBC substitute
3) Chelates
B. Plasma substitutes
1) Human albumin 4.5%
2) Dextrans
a) Low molecular weight dextran - Dextran 40
b) High molecular weight dextran - Dextran 110 and Dextran 70
3) Gelatin – Hemaccel
4) Hydroxyethyl starch
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BURNS
➢ ETIOLOGY:
• Thermal injury - scald, flame burns, flash burns
• Contact burns-contact with hot metals/objects/materials
• Electrical injury
• Chemical burns - acid/alkali
• Cold injury - frost bite
• Ionising radiation
• Sun burns
➢ CLASSIFICATION: Depending on thickness of skin involved
1) First degree – epidermis red and painful
2) Second degree – affected area mottled, red, painful, with blisters
3) Third degree – affected area charred, painless and insensitive, with thrombosis of superficial vessels
4) Fourth degree – involves underlying tissues
➢ ASSESSMENT:
1) Wallace's rule of nine
Adults Children Infants
Head and neck 9% 18% 20%
Front of chest and abdominal wall 9 x 2 = 18% 18% 20%
Back of chest and abdominal wall 9 x 2 = 18% 18% 20%
Lower limb 18 x 2 = 36% 13.5 x 2 = 27% 10 x 2 = 20%
Upper limb 9 x 2 = 18% 18% 10 x 2 = 20%
Perineum 1% 1%
2) Lund and Browder chart

3) Patient's entire hand area taken as 1% TBSA
Heat → coagulation necrosis of skin and subcutaneous tissue
↓
Release of vasoactive peptides → altered capillary permeability
↓
Loss of fluid → severe hypovolemia
↓
↓ CO
↓
↓ myocardial function
↓ renal blood flow → oliguria
Altered pulmonary resistance → pulmonary edema
↓
Infection → SIRS
↓
MODS
➢ COMPLICATIONS:
1) Shock
2) Renal failure
3) Pulmonary edema, respiratory infection, ARDS, respiratory failure
4) Infection (mc – beta hemolytic streptococci)
5) GIT - ischemia of mucosa, erosive gastritis, Curling's ulcer
Chemical injury causes erosions, perforation, stricture esophagus, pyloric stenosis, mediastinal injury
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6) Fluid and electrolyte imbalance
7) Immunosuppression → severe opportunistic infection.
8) Eschar formation
9) Electrical injuries cause fractures, major internal organ injury, convulsions
10) Development of contracture
11) DVT, pulmonary embolism, UTI, bed-sores, severe malnutrition
12) Hypertrophic scar, keloid formation
13) Toxic shock syndrome
➢ MANAGEMENT:
A. First aid
1) Stop the burning process and shift the patient away from the burning area
2) Cooling of the part by running water for 20 minutes
B. Definitive treatment
1) Patient admitted and placed in burns unit
2) Maintain ABC
3) Elevate
4) Assessment of percentage, degree and type of burn
5) Clothing removed
6) Cleaning the part
7) Tetanus toxoid; ATG; antibiotics
8) Sedation and analgesics
9) Urinary catheterization
10) Monitoring the patient - hourly pulse, BP, PO2, PCO2, electrolyte analysis, blood urea, nasal oxygen
11) IV ranitidine/PPI
12) Ryle's tube insertion
13) Culture of the discharge; TLC and platelet count at regular intervals
14) TPN
15) Intensive nursing care
C. Fluid resuscitation – indicated in children with burns > 10% TBSA and adults with burns > 15% TBSA
1) Parkland regime
• 4 ml x % burn x kg body weight for 24 hours
Half the volume given in first 8 hours; rest given in 16 hours
• First 24 hours only crystalloids should be given. Fluid of choice = RL
2) Muir and Burclay regime
• 0.5 ml x % burns x kg body weight = 1 ration
3 Rations given in first 12 hours
2 Rations in second 12 hours
1 Ration in third 12 hours
• After 24 hours, colloids should be given. Ideal colloid = human albumin
D. Local management and wound coverage
1) Dressing at regular intervals under GA
Synthetic dressings - Vaseline impregnated gauze dressing, Hydrocolloid dressing, Biobrane, Integra
Biologic dressings – autograft, allograft (cadaver skin), xenograft (pig skin)
2) Tangential excision of burn wound with skin grafting done within 48 hours in patients with < 25% burns
3) Regular slough excision, escharotomy
4) Cleaning with povidone iodine solution → silver sulfadiazine ointment
Other agents - mafenide acetate and silver nitrate
5) Once the area granulates well (3 weeks) → SSG (Thiersch graft), mesh SSG, full thickness graft (Wolfe
graft), cultured skin
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POST-BURN CONTRACTURE
➢ more common wherein flexibility and mobility present

➢ TYPES:
1) Intrinsic – by loss of tissue
2) Extrinsic – by pull during healing phase contraction
➢ COMPLICATIONS:
1) Disfigurement in face, microstomia, ectropion of eyelid
2) Restricted neck movements
3) Disability and nonfunctioning of joints
4) Hypertrophic scar and keloid formation
5) Repeated breaking of scar → infection, ulcer, cellulitis
6) Marjolin's ulcer
➢ T/T:
1) Release of contracture surgically and use of skin graft or Z-plasty
2) Proper physiotherapy and rehabilitation
3) Pressure garments
4) Management of itching in the scar – aloe vera, antihistamines and moisturizing creams
➢ PREVENTION:
1) Joint exercise in full range during recovery period of burns
2) Pressure garments for a long period
3) Topical silicon sheeting, saline expanders for scars
SKIN GRAFTING
➢ DEFINITION: transfer of skin from one area (donor area) to the required defective area (recipient area)
➢ STAGES OF GRAFT INTAKE:
1) Stage of plasmatic imbibition
2) Stage of inosculation
3) Stage of neovascularization
➢ TYPES:
A. Partial thickness graft / Split skin graft (SSG) / Thiersch graft
• removal of full epidermis + part of the dermis from the donor area
• C/I: not done over bone, tendon, cartilage, joint
• ADVANTAGE: easier; wide recipient area can be covered
• DISADVANTAGE: graft contracture
• TECHNIQUE:
✓ Donor area – thigh
✓ Knife – Humby's knife; Blade – Eschmann blade, Down's blade
✓ Donor area dressed and dressing opened after 10 days
✓ Recipient area scraped well and graft placed after making window cuts in the graft; graft fixed and
tie-over dressing placed
B. Full thickness graft / Wolfe graft
• removal of both epidermis + full dermis
• removed using scalpel blade
• Donor area – postauricular, groin crease, supraclavicular
• ADVANTAGE: no contracture; better functional and cosmesis results
• DISADVANTAGE: only for small areas
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ABDOMINAL COMPARTMENT SYNDROME
➢ DEFINITION: organ dysfunction caused by increased intra-abdominal pressure > 12 mmHg

➢ CAUSES:
• Major abdominal trauma, ruptured aortic aneurysm
• Post-operative haemorrhages, after damage control surgery with abdominal packings
• Closure of the abdomen under tension; forcible reduction of massive hernia
• Acute abdomen, acute gastric dilatation, paralytic ileus, gastroparesis, intestinal obstruction
• Laparoscopic procedures
• Morbid obesity, pregnancy, major burns
➢ EFFECTS:
• CVS: ↓VR, ↑PR, ↓RA pressure, ↓CO
• Respiratory system: ↑intrapleural pressure, upward displacement of the diaphragm, ↑ peak inspiratory
pressure, hypoxia, hypercapnia, acidosis
• Renal system: ↓renal blood flow and ↓GFR
• GIT: Mesenteric venous hypertension, bowel wall edema and ischemia
• CNS: Cerebral edema and hypoxia, unconsciousness
➢ C/F:
• tensely distended abdomen
• progressive oliguria, renal failure
• airway obstruction, respiratory failure
• occult blood loss, cardiac arrest
➢ INVESTIGATIONS:
• Measurement of IAP using a urinary catheter in the urinary bladder
• CXR, ECG monitoring, ICU care, electrolytes, haematocrit, serum creatinine, USG abdomen
➢ BURCH GRADING:
IAP grading in cm of H2O in mm Hg
I 10-15 12-15
II 15-25 15-20
III 25-35 20-25
IV >35 >25
➢ T/T:
1) Ryle’s tube aspiration, resuscitation, ICU care
2) Abdominal decompression is the only ideal treatment
3) Pressure free abdominal closure using non-absorbable sutures
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ACUTE PARONYCHIA
➢ mc hand infection
➢ SITE: occurs in subcuticular area under the eponychium
➢ MCC: minor injury to finger
➢ MC ORGANISMS: Staphylococcus aureus, Streptococcus pyogenes
➢ C/F: severe throbbing pain and tenderness with visible pus under the nail root
➢ pus tracks around the skin margin and spreads under the nail → hang nail or floating nail
➢ INVESTIGATION: pus for culture and sensitivity
➢ T/T:
1) Antibiotics
2) Pus drainage by making an incision over the eponychium
3) Floating nail → removed
CHRONIC PARONYCHIA
➢ MCC: fungal infection (candida)

➢ C/F:
• Nail diseased with ridges and pigmentation
• Itching in the nail bed
• Recurrent pain, discharge
➢ INVESTIGATION: Culture of scrapings
➢ T/T:
1) Long-term antifungal therapy
2) Antibiotics for secondary infection
3) Severe cases → removal of nail
FELON
➢ 2nd mc hand infection

➢ MC SITE: index and thumb
➢ MCC: minor injury
➢ MC ORGANISM: Staphylococcus
➢ C/F:
• Pain, tenderness, swelling in the terminal phalanx
• Fever, tender axillary LN
• Severe suppuration → collar stud abscess
➢ COMPLICATIONS:
• Osteomyelitis of the terminal phalanx
• Pyogenic arthritis of DIP and tenosynovitis of flexor sheath
• Septicemia
➢ INVESTIGATIONS: X-ray of the part, pus sent for culture and sensitivity
➢ T/T:
1) Antibiotics and analgesics
2) Drainage of terminal pulp space by an oblique deep incision
3) If osteomyelitis of the terminal phalanx → amputation
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INTERMITTENT CLAUDICATION
➢ DEFINITION: a crampy pain in the muscles of limbs

➢ Due to arterial occlusion, metabolites like lactic acid and substance P accumulate in the muscle and cause pain
➢ SITE OF PAIN:
• Foot – block in lower tibial and plantar vessels
• Calf – block in femoropopliteal segment
• Thigh – block in superficial femoral artery
• Buttock – block in common iliac or aortoiliac segment
➢ BOYD’S CLASSIFICATION:
• Grade I: Patient complains of pain after walking; pain subsides if patient continues to walk
• Grade II: Pain still persists on continuing walk; but can walk with effort
• Grade III: Patient has to take rest to relieve the pain
LIMB ISCHEMIA
➢ CAUSES:
• Atherosclerosis
• Embolism
• Arteriopathies – Buerger's disease, Raynaud's disease, Takayasu's disease
• Diabetes
• Scleroderma
• Physical agents – trauma, tourniquet, radiation injury
➢ FEATURES:
• marked pallor, purple blue cyanosed appearance
• thinning of skin, diminished hair
• loss of subcutaneous fat
• brittle nails with transverse ridges
• ulceration in digits
• wasting of muscles
• cold & tenderness
➢ ANKLE-BRACHIAL PRESSURE INDEX (ABPI):
• >0.9 → normal
• 0.7-0.9 → mild ischemia
• 0.5-0.7 → moderate ischemia
• <0.5 → severe ischemia
THROMBOANGIITIS OBLITERANS / BUERGER’S DISEASE
➢ DEFINITION: segmental, progressive, occlusive, nonatherosclerotic inflammatory disorder involving small- &
medium-sized distal vessels with cell mediated sensitivity to type I and type III collagen, recurrent migratory
superficial thrombophlebitis, neutrophil & giant cell infiltration and skip lesions
➢ PATHOGENESIS:
CO & nicotinic acid in smoke → carboxyhemoglobin → vasospasm and intimal hyperplasia → thrombosis and
obliteration of vessels → segmental panarteritis → neurovascular bundle involvement → rest pain → features of
limb ischemia → collaterals open up → compensatory peripheral vascular disease → continued smoking →
blockage of collaterals → decompensatory peripheral vascular disease (critical limb ischemia)
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➢ C/F:
• male smokers between 20-40 years of age
• intermittent claudication in foot and calf progressing to rest pain, ulceration, gangrene
• recurrent migratory superficial thrombophlebitis
• absent/feeble distal lower limb pulses
➢ INVESTIGATIONS:
• Hb%, blood sugar, ABPI
• Duplex scan (Doppler + B mode US)
• CT angiogram
• Transfemoral retrograde angiogram through Seldinger technique
✓ Cork screw appearance of the vessel
✓ Inverted tree/spider leg collaterals
✓ Corrugated/rippled artery
✓ Distal run off: good → compensated; poor → decompensated
• Transbrachial angiogram
• US abdomen
• Vein, artery, nerve biopsy
➢ T/T:
A. Stop smoking
B. Drugs
1) Analgesics, LDA, antiplatelet drugs – prostacyclin, clopidogrel, ticlopidine
2) Statin – atorvastatin
3) PDE inhibitor – cilostazole
4) Inj. xanthine nicotinate
5) Naftidrofuryl
6) Inj. VEGF i.m.
C. Care of the limbs
1) Buerger’s position
2) Buerger’s exercise
3) Chiropody
D. Chemical sympathectomy
1) LA – 1% xylocaine → temporary
2) 5 ml phenol in water → long-term
E. Surgery
1) Omentoplasty
2) Profundoplasty
3) Lumbar sympathectomy
4) Amputation
5) Ilzarov method of bone lengthening
RAYNAUD'S PHENOMENON
➢ DEFINITION: an episodic, localized, vasospasm of small vessels of hands and feet that leads into temperature and
well-demarcated reversible self-limiting colour changes with sequence of specific clinical features
➢ CAUSES:
• Raynaud's disease
• Working with vibrating tools
• Collagen vascular diseases – scleroderma, autoimmune diseases
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➢ TYPES:
1) Primary – vasospastic attacks precipitated by cold or emotional stress
2) Secondary – vasospasm due to some underlying cause
➢ C/F:
• females
• usually B/L
• normal peripheral pulses
• usually medial four digits and palm involved; thumb spared
• Raynaud’s syndrome – blanching (white) → cyanosis (blue) → flushing (red)
➢ INVESTIGATIONS:
• Duplex scan
• Assessment of segmental blood pressure gradient
• Nailfold capilloscopy
➢ T/T:
A. Treatment of cause
B. Avoid precipitating factors
C. Drugs
1) LDA, antiplatelet drugs
2) Vasodilators – pentoxiphylline, CCB, nitrates, bosentan, iloprost, misoprostol
3) Steroids for secondary Raynaud’s
D. Surgery – localized digital sympathectomy by resection of nerve of Henle
ANEURYSM
➢ DEFINITION: an abnormal permanent dilatation of localised segment of arterial system

➢ CLASSIFICATION:
A. Wall
1) True – contains all three layers of artery
2) False – contains single layer of fibrous tissue
B. Morphology
1) Fusiform – uniform dilatation of entire circumference of arterial wall
2) Saccular – dilatation of part of circumference of the arterial wall
3) Dissecting – through a tear in intima, blood dissects b/w inner and outer part of tunica media of artery
➢ CAUSES:
A. Acquired
1) Degenerative – atherosclerosis; mucoid degeneration
2) Traumatic
3) Infective – syphilis; mycotic; TB; arteritis; sepsis
4) Collagen diseases
B. Congenital – Berry aneurysm; cirsoid aneurysm; congenital AV fistula
➢ SITES: aorta; iliac; femoral; popliteal; subclavian; axillary; carotid; cerebral, mesenteric, renal, splenic arteries
➢ C/F:
• Swelling – pulsatile, smooth, soft, warm, compressible, thrill on palpation, bruit on auscultation, reduces in
size when pressed proximally
• Distal edema
• Altered sensation
• Erosion into bones, joints, trachea or oesophagus
➢ D/D: pyogenic abscess, vascular tumours, pulsating tumors, pseudocyst of pancreas, AV fistula
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➢ INVESTIGATIONS: doppler study, duplex scan, CT angiogram
➢ T/T:
1) Reconstruction of artery using arterial grafts
2) Matas arterial endoaneurysmorrhaphy
3) Therapeutic embolisation
4) Clipping the vessel under guidance
GANGRENE
➢ DEFINITION: macroscopic death of tissue in situ with putrefaction

➢ SITES: limbs; appendix; bowel; testes; GB
➢ CAUSES:
• Secondary to arterial occlusion – atherosclerosis, emboli, diabetes, TAO, Raynaud's disease, ergots
• Infective – boil, carbuncle, gas gangrene, Fournier's gangrene, cancrum oris
• Traumatic
• Physical – burns, scalds, frostbite, chemicals, irradiation, electrical
• Venous gangrene
➢ C/F:
• Colour changes – pallor, greyish, purple, brownish black
• Absence of pulse, loss of sensation, loss of function
• Line of demarcation between viable and dead tissue by a band of hyperemia and hyperaesthesia along with
development of a layer of granulation tissue
➢ TYPES:
1) Dry gangrene – separation occurs by aseptic ulceration
2) Wet gangrene – separation occurs by septic ulceration
➢ INVESTIGATIONS:
• Hb%, blood sugar
• Arterial doppler, angiogram (Seldinger technique), CT angiogram
• US abdomen
➢ TREATMENT:
A. Limb saving methods
1) Drugs – antibiotics, vasodilators, pentoxiphylline, praxilene, dipyridamole, LDA, ticlopidine
2) Care of feet and toes
• part to be kept dry
• injury to be avoided
• MCR footwear
• nutrition supplementation
• pus to be drained
3) Cause treated; diabetes controlled
4) Lumbar sympathectomy, omentoplasty
B. Life-saving procedures – amputations
1) Below-knee amputation
2) Above-knee amputation
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DRY GANGRENE WET GANGRENE
➢ Clear line of demarcation ➢ Line of demarcation vague
➢ Dry, shrivelled, mummified ➢ Edematous, putrefied, discoloured
➢ Slow, gradual loss of blood supply ➢ Sudden loss of blood supply
➢ Separation by aseptic ulceration ➢ Separation by septic ulceration
➢ Causes - atherosclerosis, TAO ➢ Causes - emboli, trauma
DIABETIC FOOT AND DIABETIC GANGRENE
➢ C/F:
• Pain in the foot
• Ulceration
• Absence of sensation
• Absence of pulsations in the foot
• Loss of joint movements
• Abscess formation
• Change in temperature and colour
➢ INVESTIGATIONS:
• Blood sugar, HbA1c, urine ketone bodies
• BUN and serum creatinine
• X-ray of part to look for osteomyelitis
• Pus for culture and sensitivity
• Doppler study of lower limb
• Angiogram
• US abdomen
➢ T/T:
1) Antibiotics
2) Regular dressing
3) Drugs – vasodilators, pentoxiphylline, dipyridamole, LDA
4) Diabetes controlled by insulin
5) Diet control, control of obesity
6) Surgical debridement of wound
7) Amputations of the gangrenous area
8) Care of feet
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HEMANGIOMA
➢ DEFINITION: benign tumour containing hyperplastic endothelium with cellular proliferation and ↑mast cells
➢ mc tumour in children
➢ MC SITE: head and neck
➢ TYPES:
A. Capillary hemangioma
• C/F:
✓ appears as red mark → rapidly increases in size in 3 months to form strawberry hemangioma
✓ clinically compressible, warm with bluish surface
• T/T:
1) Wait and watch policy - slowly begins to disappear after 1 year of age
2) Pulsed dye laser, surgical excision and reconstruction
3) Preoperative embolisation
4) Steroid therapy
B. Cavernous hemangioma
• C/F:
✓ present at birth and consists of multiple venous channels
✓ smooth, soft, well-localised, warm, fluctuant, compressible, non-pulsatile, non-tender swelling with
bluish surface
• INVESTIGATIONS: US, doppler; CT angiogram
• T/T:
1) Sclerosant therapy - sodium tetradecyl sulphate, hypertonic saline
2) Ligation of feeding artery
4) Excision
5) Laser ablation
CIRSOID ANEURYSM
➢ DEFINITION: congenital AVF of the scalp

➢ mc in superficial temporal artery
➢ C/F: pulsatile swelling - warm, compressible; with arterialisation of adjacent veins and bone thinning (pulsating
bag of worms)
➢ D/D: true aneurysm
➢ T/T:
1) Ligation of feeding artery and excision of lesion
2) Percutaneous direct puncture embolisation with trans-arterial embolisation
ARTERIOVENOUS FISTULA
➢ DEFINITION: abnormal communication between an artery and vein

➢ TYPES:
A. Congenital
• C/F:
✓ Structural changes
▪ Limb warm, lengthened, girth increased
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▪ Continuous thrill and continuous machinery murmur all over the lesion
▪ Dilated arterialised varicose veins
▪ Bone erosion
✓ Physiological change - ↑ cardiac output → CHF
• INVESTIGATIONS:
✓ MR angiogram
✓ Doppler study; X-ray of the part; ECG, echocardiography
• T/T:
1) Conservative - sclerotherapy, compression, avoiding injury
2) Surgical ligation of feeding vessels and complete excision of the lesion
B. Acquired
• CAUSES:
✓ Trauma
✓ Surgical intervention
✓ Therapeutic - for renal dialysis (Cimino fistula)
• C/F:
✓ Changes at the level of fistula
▪ aneurysmal sac - warm, pulsatile, smooth, soft, compressible swelling at the site
▪ continuous thrill and continuous machinery murmur
✓ Changes distal to the fistula
▪ distal part becomes ischemic
▪ varicose veins
✓ Changes proximal to the fistula
▪ Hyperdynamic circulation → CHF
▪ Nicoladoni's sign or Branham's sign - if pressure is applied to the artery proximal to the fistula,
swelling reduces in size, thrill and bruit disappear, pulse rate and pulse pressure become normal
• INVESTIGATIONS: doppler, CT angiogram; ECG, echocardiography
• T/T: excision of fistula and reconstruction of artery and vein with graft
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VARICOSE VEINS
➢ DEFINITION: permanently elongated, tortuous, dilated subcutaneous veins 3 mm or larger in diameter with
intermittent blowouts and presence of reflux causing pathological circulation
➢ ETIOLOGY:
• Congenital incompetence/absence of valves
• Muscle weakness/wasting
• Stretching of deep fascia
• Family history
• Occupational
• ↑ BMI & height
• Pregnancy
• AV malformations
• Iliac vein thrombosis
➢ SYMPTOMS:
• aching, heaviness, throbbing, burning or bursting over affected areas – typically increase throughout the day
or with prolonged standing and are relieved by elevation or compression hosiery
• night-time cramps
• itching
• swelling of the ankle
• discolouration/ulceration in the feet
• painful walk
➢ SIGNS:
• Visible tortuous dilated subcutaneous leg veins
✓ medial thigh and calf varicosities → GSV incompetence
✓ posterolateral calf varicosities → SSV incompetence
✓ anterolateral thigh and calf varicosities → ASV incompetence
• Pain, nocturnal cramps, pruritus
• Saphena varix – a large varicosity in the groin with positive cough impulse at the SFJ
➢ COMPLICATIONS:
• Hemorrhage
• Pigmentation, eczema and dermatitis
• Periostitis
• Venous ulcer
• Marjolin’s ulcer
• Lipodermatosclerosis
• Fibrous ankylosis
• Talipes equinovarus
• Calcification of the wall of varicose veins
• Recurrent thrombophlebitis
• DVT
➢ INVESTIGATIONS:
• Venous doppler
• Duplex scan
• Plethysmography
1) Photoplethysmography
2) Air plethysmography
• Ambulatory venous pressure
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• Arm-foot venous pressure
• Venography
• Varicography
➢ T/T:
A. Conservative
1) Compression hosiery – elastic crepe bandage application from below upwards or use of pressure
stockings to the limb
2) Elevation of the limb
3) Unna boots
4) Pneumatic compression method
B. Drugs
1) Calcium dobesilate 500 mg BD
2) Diosmin 450 mg + Hesperidin 50 mg
3) Troxerutin 500 mg BO
C. Sclerotherapy – mc sclerosant used: sodium tetradecyl sulphate
1) Macrosclerotherapy by Fegan’s technique
2) US-guided foam sclerotherapy by Tessari method
3) Microsclerotherapy
4) Echosclerotherapy
5) Catheter-directed sclerotherapy
D. Minimally invasive methods
1) Subfascial endoscopic perforator ligation surgery (SEPS)
2) Endothermal ablation
a) Endovenous laser ablation (EVLA)
b) Radiofrequency ablation (RFA)
3) Trivex method
4) Phlebectomy
5) Electrodissection
6) Endovenous glue
E. Surgery
1) Trendelenburg operation (Crossectomy) – juxtafemoral flush ligation of GSV after ligating all tributaries
2) Stripping of vein
a) Extraluminal collision technique using Myer's stripper
b) Invagination technique using Codman's stripper
3) SSV ligation at SPJ
4) Stab avulsion of varicose vein and perforators
VENOUS LEG ULCER
➢ PATHOPHYSIOLOGY: chronic ambulatory venous hypertension

➢ C/F:
• gently sloping edge and the floor contains granulation tissue covered by slough and exudate
• characteristically develops in the skin of the gaiter region
• majority develop on the medial side of the calf
• often develop in response to minor trauma
• surrounding hemosiderosis → dermatitis → lipodermatosclerosis → fibrosis
➢ D/D: arterial ischemic ulcers, vasculitic ulcers, traumatic ulcers, neuropathic ulcers, neoplastic ulcers,
rheumatoid ulcer, infections
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➢ INVESTIGATIONS:
• Duplex scan
• Collection of discharge for C&S
• CBC, blood glucose, ESR, CRP
• Wedge biopsy from ulcer edge
➢ T/T:
1) Bisgaard method
a) ↓ edema, ↑ venous drainage
b) elevation
c) massage of indurated area & calf
d) exercise – passive & active
2) Care of ulcer by regular cleaning and dressing
3) Compression by four-layer bandaging system (4LB)
a) orthopedic wool
b) cotton crepe
c) elastic bandage
d) cohesive bandage
4) Antibiotics
5) Pentoxiphylline
6) Split skin graft placement after ulcer bed granulates well
7) T/t of varicose veins
➢ Deep venous thrombosis (DVT)

➢ Thrombophlebitis
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DERMATOFIBROSARCOMA PROTUBERANS
➢ DEFINITION: low grade fibrosarcoma arising from dermal fibroblasts

➢ MC SITE: trunk
➢ C/F: multiple, nodular, hard swelling with involvement of LN
➢ D/D: SCC of skin
➢ INVESTIGATIONS: Biopsy of the lesion; CXR, CT scan; FNAC of LN
➢ T/T: wide excision
SQUAMOUS CELL CARCINOMA
➢ RISK FACTORS: exposure to UV-B rays, inheritance, HPV, premalignant conditions, ionising radiation,
carcinogens, chronic scar, immunosuppression, chemicals
➢ COMMON SITES: dorsum of hand, limbs, face and skin of abdominal wall
➢ C/F:
• Raised and everted edge; indurated base and edge; bloody discharge from the lesion
• Regional LN involved - hard, nodular
➢ INVESTIGATIONS: wedge biopsy from the edge, FNAC from LN, CT scan, MRI
➢ T/T:
1) Wide excision - 2 cm clearance → skin grafting or flaps
2) MOHS (Microscopically Oriented Histographic Surgery)
3) Amputation
4) Block dissection of the regional LN
5) Radiotherapy – curative or palliative
6) Chemotherapy – methotrexate, vincristine, bleomycin, cisplatin, carboplatin
MARJOLIN'S ULCER
➢ DEFINITION: well-differentiated SCC which occurs in chronic unstable scars; locally malignant
➢ C/F: indurated, painless, non-tender ulcer with raised and everted edge with scar in surrounding area and
marked fibrosis
➢ INVESTIGATIONS: Wedge biopsy from the edge, MRI of the part
➢ T/T: wide local excision; amputation - in large ulcers
BASAL CELL CARCINOMA
➢ DEFINITION: low grade, locally invasive carcinoma arising from basal layer of skin or mucocutaneous junction
➢ mc malignant skin tumour
➢ CAUSES: UV light, arsenics, coal tar, aromatic hydrocarbons, skin tumour syndromes, xeroderma pigmentosa,
albinism
➢ MC SITE: face - above the line drawn between angle of mouth and ear lobule (Onghren's line)
➢ C/F: ulcer on the face in a middle-aged man – non-tender, dry, slowly growing, non-mobile, with raised and
beaded edge with central scab, with central depression
➢ INVESTIGATIONS: Wedge biopsy, X-ray of the part, CT scan dermoscopy
➢ T/T:
1) Radiotherapy – not given, once it erodes cartilage or bone
2) Surgery
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a) Wide excision with skin grafting, primary suturing or flap (TOC)
b) Cryosurgery
c) MOHS
3) Laser surgery, photodynamic therapy, curettage and electrodesiccation, 5-fluorouracil local application,
topical 5% imiquimod, immunotherapy
MELANOMA
➢ DEFINITION: malignant tumour arising from epidermal melanocyte

➢ most aggressive cutaneous malignant tumour; neural crest (ectodermal) origin
➢ MC SITES: trunk (males), leg (females)
➢ RISK FACTORS: exposure to sunlight, ethnic factors, high socioeconomic status, lifestyle, climate, albinism,
xeroderma pigmentosa, family history, immunosuppressive drugs, NHL
➢ TYPES:
1) Superficial spreading (mc)
2) Nodular melanoma
3) Lentigo maligna melanoma
4) Acral lentiginous melanoma
➢ C/F:
• Pigmentation with irregular surface and margin with rapid growth
• Ulceration, bleeding, itching, change in the colour
• Ugly duckling rule (ABCDE)
✓ Asymmetry
✓ Border irregularity – coast of Marine sign
✓ Colour variation
✓ Diameter >6 mm
✓ Evolving
➢ INVESTIGATIONS:
• Excision biopsy of primary
• FNAC of LN; SLNB
• US abdomen; CXR; CT scan of head, chest, abdomen, pelvis; MRI; PET scan
• Tumour markers – LDH; Melan-A; S-100; tyrosinase; HMB 45
➢ T/T:
A. For primary
1) Handley's wide local excision with clearance of margin and depth
a) In situ and <1 mm (tumor thickness) – 0.5 to 1 cm (clearance margin)
b) 1 to 2 mm – 1 to 2 cm
c) > 2 mm – 2 cm
2) Amputation – if primary area wide and deep
3) Disarticulation – in fingers & toes
4) Enucleation – in eye
5) Termination of pregnancy
B. For LN secondaries
1) Regional block dissection – in case of spread
2) Chemotherapy – in a fixed LN
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CLEFT LIP
➢ ETIOLOGY:
• Familial
• Protein and vitamin deficiency
• Rubella infection
• Radiation
• Chromosomal abnormalities
• Maternal epilepsy and AED intake during pregnancy
➢ TYPES:
A. (1) Central (Hare lip) – between two median nasal processes
(2) Lateral
B. (1) Incomplete – does not extend into nose
(2) Complete – extends into nasal floor
➢ C/F:
• Altered dentition or supernumerary teeth
• Recurrent URTI, respiratory obstruction, CSOM
• Cosmetic problems, hypoplasia of the maxilla
➢ T/T:
Millard criteria (Rule of 10) – 10 pound in weight; 10 weeks old; 10 g% Hb
1) Millard cleft lip repair by rotating the local nasolabial flaps – 3-layer lip repair done (mucosa, muscle, skin)
2) Tenninson's Z-plasty
CLEFT PALATE
➢ CAUSE: defect in fusion of lines between premaxilla and palatine processes of maxilla
➢ CLASSIFICATION:
• Type I – complete
• Type II – incomplete
Type II a – bifid uvula
Type II b – bifid soft palate
Type II c – bifid soft palate and posterior part of hard palate
➢ C/F:
• Difficulty in sucking and swallowing, defective speech
• Small maxilla with crowded teeth, absent or poorly developed upper lateral incisors
• Recurrent URTI, CSOM
• Cosmetic problems
➢ T/T:
Criteria for surgery – 10 kg weight; 10 months old (10-18 months); 10 g% Hb
A. Palatoplasty – abnormal insertion of tensor palati released → mucoperiosteal flaps raised → palatal defect
closed using 3 layers → teeth extraction and alignment of dentition
B. Secondary management
1) Hearing aids, control of OM
2) Speech therapy, pharyngoplasty, veloplasty
3) Correction of dental problems
4) Orthodontic management
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EPULIS
➢ DEFINITION: swelling arising from the mucoperiosteum of gingiva

➢ TYPES:
1) Congenital – benign condition seen in a newborn arising from gum pads
2) Fibrous (mc) – fibroma arising from periodontal membrane
3) Granulomatous – mass of granulation tissue in the gum around a caries tooth
4) Pregnancy – occurs in pregnant women due to inflammatory gingivitis
5) Carcinomatous – SCC of alveolus and gum
6) Myelomatous – seen in leukemic patients
7) Fibrosarcomatous – fibrosarcoma arising from fibrous tissue of the gum
8) Epulis fissuratum: reactive lesion to chronic irritation due to ill-fitting dentures
9) Giant cell: occurs in osteoclastoma
AMELOBLASTOMA / ADAMANTINOMA
➢ arises from the dental epithelium

➢ SITES: mandible > maxilla
➢ locally malignant; neither spreads through LN nor through blood
➢ usually U/L multilocular cystic spaces
➢ C/F: swelling in the jaw – gradually progressive, painless, smooth and hard; enlarges externally
➢ INVESTIGATIONS: orthopantomogram, biopsy
➢ T/T:
1) Segmental resection of the mandible
2) Hemi-mandibulectomy with reconstruction of the mandible
DENTIGEROUS CYST / ODONTOME
➢ DEFINITION: unilocular cystic swelling arising in relation to the dental epithelium from an unerupted tooth
➢ SITE: occurs over the crown of unerupted tooth (premolars or molars)
➢ C/F: swelling in the jaw (lower > upper) – painless, smooth and hard
➢ COMPLICATION: adamantinoma
➢ INVESTIGATION: orthopantomogram
➢ T/T:
1) If small – excision of the cyst; if large – marsupialisation → excision
2) Extraction of unerupted tooth
DENTAL CYST
➢ SITE: occurs under the root of the chronically infected dead erupted tooth
➢ C/F: smooth, tender swelling in the jaw
➢ COMPLICATION: osteomyelitis of the jaw
➢ D/D: dentigerous cyst
➢ INVESTIGATION: orthopantomogram
➢ T/T:
1) Antibiotics
2) Drainage or excision of the cyst → extraction of the infected tooth
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RANULA
➢ DEFINITION: an extravasation pseudocyst arising from sublingual gland containing saliva

➢ C/F:
• Swelling in the lateral aspect of floor of mouth – bluish smooth, soft, fluctuant, brilliantly transilluminant
• Plunging ranula
✓ intra-oral ranula with cervical extension
✓ dumbbell-shaped swelling in the submandibular region
✓ cross fluctuant across mylohyoid
➢ INVESTIGATIONS: US neck, MRI neck and oral cavity
➢ T/T:
1) Marsupialisation → excision
If small – only excision
2) Excision of sublingual salivary gland
LEUKOPLAKIA
➢ DEFINITION: a white patch in the mucosa of the oral cavity that cannot be characterised clinically or
pathologically to any other disease; it is a premalignant condition
➢ ETIOLOGY:
• S’s - smoking, spirit, sepsis, superficial glossitis, syphilis, spices, sharp tooth
• Vitamin deficiencies
• Pan chewing using areca, tobacco, slaked lime
• Chronic hypertrophic candidiasis
➢ MC SITES: buccal mucosa and oral commissures
➢ C/F: white/greyish patch – well-localized, irreversible, hyperkeratotic, adherent, firm/hard/indurated
➢ INVESTIGATION: biopsy – parakeratosis with widening of rete pegs
➢ T/T:
1) Pan chewing and smoking to be stopped
2) Excision +/- skin grafting
3) Regular follow-up
4) Isotretinoin, β-carotene, tocoferol
PREMALIGNANT CONDITIONS OF ORAL CAVITY
A. High risks
1) Leukoplakia
2) Erythroplakia
3) Chronic hyperplastic candidiasis
B. Medium risks
1) Oral submucosal fibrosis
2) Syphilitic glossitis
3) Sideropenic dysphagia
C. Equivocal risks
1) Oral lichen planus
2) Dyskeratosis congenita
3) DLE
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CARCINOMA TONGUE
➢ ETIOLOGY:
• All S’s
• Premalignant conditions
➢ SITES:
1) Lateral margin (mc)
2) Posterior third
3) Dorsum
4) Ventral surface
5) Tip
➢ C/F:
• Painless ulcer/swelling in the tongue
• Excessive salivation – blood-stained
• Dysphagia
• Visible ulcer in anterior 2/3rd of tongue
• Ankyloglossia
• Movements of the tongue affected
• Inability to articulate
• Halitosis
• Change in voice
• Palpable LN in the neck
• Features of bronchopneumonia
➢ INVESTIGATIONS:
• Wedge biopsy; FNAC of lymph nodes.
• Indirect and direct laryngoscopy
• CT scan, MRI
• CXR
• Orthopantomogram
➢ T/T:
A. Surgery
1) Tumour < 1 cm or carcinoma in situ or involving tip – wide excision with 1 cm clearance in margin and
depth
2) Tumour 1-2 cm – partial glossectomy with 2 cm clearance from the margin with removal of 1/3rd of
anterior 2/3rd of tongue
3) Tumour > 2 cm – hemi-glossectomy with removal of anterior 2/3rd of tongue on one side up to sulcus
terminalis
4) Larger primary tumour – pre-operative radiotherapy → hemi-glossectomy
5) Same side palpable, mobile LN – RND
6) Bilateral mobile LN – one side RND and other side MRND
7) Posterior 1/3rd growth – total glossectomy using midline mandibulotomy incision (mandible split)
8) Mandible involved – hemi-mandibulectomy
9) Reconstruction of tongue
B. Radiotherapy
1) Curative – in small primary tumour
2) Pre-operative – in large primary tumour
3) Palliative – in advanced primary and neck secondaries
4) Post-operative – to reduce the chances of relapse in large tumour
C. Chemotherapy – Price-Hill regimen → methotrexate, vincristine, adriamycin, bleomycin and mercaptopurine
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TONGUE ULCERS
A. Dental ulcer
➢ common on sides of tongue due to sharp tooth, denture and broken tooth
➢ acute painful, self-limiting
➢ T/t: excision
B. Aphthous ulcer
1) Minor aphthous ulcer
➢ common in menstruating women
➢ painful, round, yellow-based with red margin
➢ regresses spontaneously in 2 weeks
2) Major aphthous ulcer
➢ large and deep
➢ T/t: Chlorhexidine gluconate, local application of triamcinolone acetate, choline salicylate gel
3) Behcet's syndrome
➢ genital ulcer, conjunctival ulcer and multiple oral ulcers
4) Reiter's syndrome
➢ urethritis, arthritis, periarteritis nodosa, conjunctivitis, and oral ulcers
5) Herpetiform aphthous ulcer
➢ small, 1-2 mm diameter ulcers in crops
C. Syphilitic ulcer (painless)
1) Primary syphilis
➢ extragenital chancre
2) Secondary syphilis
➢ multiple shallow snail track ulcers in the margins and undersurface
➢ mucous patches on the tongue and fauces
➢ Hutchinson's condyloma wart in midline
3) Tertiary syphilis
➢ gummatous ulcer in anterior 2/3rd
➢ interstitial glossitis with loss of papillae
D. Tuberculous ulcer
➢ undermined shallow, multiple, painful
E. Herpetic lingual ulcer
➢ acute lingual neuralgia with vesicles which form multiple superficial painful ulcers
F. Ulcers in lichen planus
➢ painless
G. Malignant ulcers
➢ painless
H. Smoker's ulcer
I. Ulcers due to vasculitis, eosinophilic granuloma
J. Post-pertussis ulcer
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SIALOLITHIASIS
➢ SITES:
1) 80% submandibular (radio-opaque) – (a) hilum of the gland, (b) near the punctum
2) 20% parotid (radiolucent)
➢ COMPOSITION: calcium phosphate, oxalate and carbonate
➢ single in 75% of cases
➢ C/F:
• Salivary colic – acute painful swelling
more during mastication due to stimulation; swelling decreases 2 hours after meal/stimulation
• Clinical examination – enlarged palpable firm/rubbery gland, tender on bimanual examination
• When stone is in the duct, it is palpable in floor of mouth as a tender swelling with features of inflammation
in the duct; pus exudes through the duct orifice
➢ INVESTIGATIONS:
• Intra-oral X-ray, USG
• FNAC of the gland
• TLC, ESR
➢ T/T:
1) US-guided removal using sialendoscopy under LA for stones <4 mm
2) Pneumatic lithotripter under sialendoscope guidance for larger stones
3) Removal by incising the duct longitudinally for stone in Wharton's duct in the floor of mouth anterior to the
crossing of lingual nerve
4) Removal using intra-oral approach under GA for stone in Wharton's duct behind the crossing of lingual nerve
5) Surgical excision for deep seated stones in the duct or stones in the submandibular salivary gland
PAROTITIS
➢ DEFINITION: acute ascending bacterial sialadenitis of the parotid gland

➢ CAUSES: Staphylococcus aureus (mc), Streptococcus viridans, gram-negative and anaerobic organisms
➢ C/F:
• Pyrexia, malaise, pain and trismus
• Swelling in the parotid region – red, tender, warm, well-localised, firm
• Pus or cloudy turbid saliva exuding from the parotid gland papilla
• Tender LN palpable in the neck
• Features of bacteremia in severe cases
➢ INVESTIGATIONS:
• US parotid region
• Culture and sensitivity of pus
• Needle aspiration from the abscess
➢ T/T:
1) Antibiotics
2) Incision and drainage under GA
Blair's incision – skin incised in front of the tragus vertically → parotid sheath opened horizontally
3) Proper hydration, mouth wash using povidone iodine or potassium permanganate solutions, nutrition
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PAROTID FISTULA
➢ arise from parotid gland or duct or ductules

➢ CAUSES:
• After superficial parotidectomy
• After drainage of parotid abscess, ruptured abscess
• After biopsy
• Trauma
• Recurrence of malignant tumour
➢ C/F:
• Discharging fistula in the parotid region of face; discharge more during eating
• Tenderness and induration; trismus
➢ INVESTIGATIONS:
• Sialography
• Fistulogram or CT fistulogram
• Discharge study
• MRI
➢ T/T:
1) Anticholinergics – hyoscine bromide
2) Radiotherapy
3) Exploration of fistula
4) Repair or re-insertion of the duct into the mucosa
5) Newman Seabrock's operation – removal of fistula tract and repair of duct
6) Denervation of the gland by cutting auriculotemporal nerve
7) Duct ligation
8) Total conservative parotidectomy
SALIVARY NEOPLASMS
➢ ETIOLOGY:
• Genetic – loss of alleles of chromosomes in 12q, 8q, 17q
• Infective – mumps, EBV, chronic sialadenitis
• Radiation
• Smoking
• Environment and diet
➢ CLASSIFICATION:
A. Epithelial (90%)
1) Adenoma
a) Pleomorphic adenoma
b) Monomorphic adenomas
• Adenolymphoma (Warthin's tumour)
• Oncocytoma (oxyphil adenoma)
• Basal cell adenoma
2) Carcinomas
a) Mucoepidermoid carcinoma (mc malignancy)
b) Adenoid cystic carcinoma
c) Acinic cell carcinoma
d) Adenocarcinoma
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e) SCC
f) Carcinoma in ex pleomorphic adenoma
g) Undifferentiated carcinoma
B. Non-epithelial
1) Hemangioma
2) Lymphangioma
3) Neurofibromas and neurilemmomas
C. Malignant lymphomas
1) Primary – NHL
2) Secondary – Sjögren’s syndrome
D. Secondary tumours
1) Local – tumours of the head and neck
2) Distant – skin and bronchus
E. Lymphoepithelial tumours
1) Benign – Godwin’s tumor
2) Malignant – Eskimoma
MANAGEMENT OF MALIGNANT SALIVARY TUMOURS
➢ INVESTIGATIONS: FNAC, CT scan, MRI, OPG

➢ T/T:
A. In parotid gland
1) Surgery
a) Total conservative parotidectomy
• indications – T1, T2, T3 tumours of low grade
b) Radical parotidectomy
• indications – T4 tumours, high grade tumours, SCC
• removal of both lobes of parotid, soft tissues, part of the mandible with facial nerve
2) Radiotherapy
a) Pre-operative – in large tumors to downstage the disease
b) Post-operative – in all carcinomas to reduce the chances of relapse
3) Chemotherapy – 5-FU, cisplatin, doxorubicin, epirubicin, cetuximab
4) Radical neck dissection – if LN involved
B. In submandibular gland
1) Wide excision with removal of mandible and soft tissues around
2) Block dissection of the neck – if LN involved
WARTHIN’S TUMOR / ADENOLYMPHOMA
➢ misnomer: not lymphoma, not malignant

➢ benign tumour that occurs only in parotid, usually in the superficial lobe of lower pole
➢ composed of double layer of columnar epithelium, with papillary projections into cystic spaces with lymphoid
tissues in the stroma
➢ C/F: swelling – slow growing, smooth, soft, cystic, fluctuant, non-tender, often bilateral
➢ INVESTIGATIONS: 99-Technetium pertechnetate scan (hotspot), FNAC
➢ T/T: superficial parotidectomy
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PLEOMORPHIC ADENOMA / MIXED SALIVARY TUMOUR
➢ mc salivary gland tumour in adult

➢ SITES: parotids (80%), submandibular, sublingual
➢ COMPOSITION: cartilages, cystic spaces, solid tissues
➢ In parotid, it involves superficial lobe or superficial and deep lobe together
➢ C/F:
• Swelling in front of the parotid – single or U/L, painless, smooth, firm, lobulated, mobile
• Positive curtain sign – cannot be moved above the zygomatic bone
• Obliteration of retromandibular groove
• Raised ear lobule
• Deviation of uvula and pharyngeal wall towards midline, dysphagia – in deep lobe tumors
➢ INVESTIGATIONS: FNAC, CT scan, MRI
➢ T/T: surgery
1) Superficial parotidectomy – if only superficial lobe involved
2) Total conservative parotidectomy – if both lobes involved
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BRANCHIAL CYST
➢ arises from the remnants of 2nd branchial cleft

➢ C/F: Swelling in the neck beneath the anterior border of upper third of the sternomastoid muscle – painless,
smooth, soft, fluctuant, transilluminant with a sensation of half-filled double hot water bottle
➢ COMPLICATION: recurrent infection
➢ INVESTIGATIONS: FNAC (cholesterol crystals), MRI
➢ T/T: excision under GA – step ladder approach using two parallel incisions
CYSTIC HYGROMA
➢ DEFINITION: a cystic swelling due to sequestration of a portion of jugular lymph sac from the lymphatic system,
during the developmental period in utero
➢ C/F:
• Swelling present at birth in the posterior triangle of neck – smooth, soft, fluctuant, partially compressible,
brilliantly transilluminant; causing obstructed labour; increases in size during crying
• Disfigurement of face
• Respiratory obstruction
➢ T/T:
1) Aspiration of contents → excision of sac
2) If it causes respiratory obstruction – aspiration and tracheostomy
3) If abscess formed – antibiotics → drainage → excision of sac
4) Pre-operative injection of sclerosants
LUDWIG'S ANGINA
➢ DEFINITION: an infective, acute inflammatory edema with cellulitis of submandibular region and floor of the
mouth due to streptococcal or staphylococcal infection
➢ contains gangrenous serosanguinous fluid which is spreading
➢ PRECIPITATING FACTORS:
• Caries teeth
• Malignancy, chemotherapy
• Sialadenitis
• Chronic diseases
➢ C/F:
• Brawny edema or diffuse swelling of submandibular and submental region; double chin appearance
• Intra-oral edema in floor of the mouth with putrid halitosis, drooling of saliva, earache
• Severe toxicity, fever, dyspnea, dysphagia
➢ INVESTIGATIONS:
• X-ray – thumb sign on epiglottis
• US neck, CXR
• TLC, blood sugar, serum creatinine
➢ T/T:
1) Airway maintenance – awake fibreoptic nasal intubation, tracheostomy
2) Antibiotics, hydration
3) Surgical decompression of the submandibular region – B/L deep transverse incisions → fluid collected for
culture → irrigation → penrose drains placed → delayed suturing
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CAROTID BODY TUMOUR
➢ DEFINITION: arises from the carotid body, which is located at the bifurcation of the common carotid artery
➢ C/F:
• U/L; middle age females
• Swelling in the carotid region of the neck – smooth, firm, pulsatile; moves only side to side (Fontaine sign)
• Headache, neck pain, dysphagia, syncope
• CN palsy
➢ INVESTIGATIONS:
• Arterial doppler
• Angiogram – tumour blush
• CT scan, MRI, MR angiography
• MIBG scan
➢ D/D:
• Carotid artery aneurysm
• Sarcoma
• LN enlargement
• Neurofibroma of the vagus nerve
➢ T/T: surgery
if small – excision; if large – complete excision → placement of a vascular graft
temporary shunt placed between common carotid below and internal carotid above during resection
TUBERCULOUS LYMPHADENITIS
➢ mc extrapulmonary TB
➢ CAUSE: Mycobacterium tuberculosis
➢ SITES: neck (upper deep cervical, posterior triangle), axillary, para-aortic, mesenteric, inguinal, mediastinal
➢ STAGES:
1) Stage of infection and lymphadenitis
2) Stage of periadenitis with matting
3) Stage of caseating necrosis and cold abscess formation
4) Stage of formation of collar stud abscess
5) Stage of formation of discharging sinus
➢ INVESTIGATIONS:
• Hematocrit, ESR, peripheral smear
• FNAC of LN and smear for AFB and culture in Lowenstein-Jensen media
• Open biopsy
• US neck, CXR, CT neck and chest, PCR
➢ T/T:
1) ATT
a) Rifampicin 450 mg OD
b) Isoniazid 300 mg OD
c) Ethambutol 800 mg OD
d) Pyrazinamide 1500 mg OD
2) Aspiration
3) Incision and drainage
4) Surgical removal
5) Excision of the sinus track
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COLD ABSCESS
➢ No evidence of signs of inflammation - not warm, no redness

➢ CAUSES:
1) TB LN (mcc) – anterior triangle
2) TB cervical spine – posterior triangle
3) Blastomycosis
4) Hyperimmunoglobulin E syndrome
➢ MC SITE: neck
➢ C/F:
• Swelling - smooth, non-tender, soft, fluctuant, non-transilluminant, not adherent to skin
• Neck pain, neck rigidity, restricted movements
• Evening fever, loss of weight and appetite, anemia
➢ INVESTIGATIONS:
• Hb, DC, TLC, ESR, Mantoux test
• CXR, US neck, MRI spine
• FNAC, ZN stain
➢ T/T:
1) ATT
2) Non-dependent aspiration or drainage of the cold abscess
3) Excision of the diseased neck nodes
4) Immobilization of cervical spine by plaster jacket/collar
5) Cervical spine fusion by open surgical method
CERVICAL LYMPHADENOPATHY
➢ CAUSES:
A. Inflammatory
1) Reactive hyperplasia
B. Infective
1) Viral - infectious mononucleosis, HIV
2) Bacterial - Streptococcus, Staphylococcus, actinomycosis, TB, brucellosis
3) Protozoan - toxoplasmosis
C. Neoplastic
1) Malignant – lymphoma, SCC
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ACUTE PERITONITIS
• DEFINITION: inflammation of the peritoneum

• TYPES
1) Primary: monomicrobial, extraperitoneal source, blood spread
2) Secondary (mc): polymicrobial, intra-peritoneal source
3) Tertiary: d/t superadded infection following treatment of secondary/primary peritonitis
• CAUSES
➢ Bacterial: gastrointestinal and non-gastrointestinal
➢ Chemical: bile, barium
➢ Allergic: starch peritonitis
➢ Traumatic: operative handling
➢ Ischemic: strangulated bowel, vascular occlusion
➢ Miscellaneous: familial Mediterranean fever
• MODES OF INFECTION
➢ GI perforation (mc): perforated ulcer, appendicitis, diverticulum
➢ Transmural translocation: pancreatitis, ischemic bowel, primary bacterial peritonitis
➢ Exogenous contamination: drains, open surgery, trauma, peritoneal dialysis
➢ Female genital tract infection: PID
➢ Hematogenous spread: septicemia
• MICRO-ORGANISMS
➢ Gastrointestinal sources: Escherichia coli, Streptococci, Enterococci, Bacteroides, Clostridium perfringens,
Klebsiella pneumoniae
➢ Non-gastrointestinal sources: Chlamydia trachomatis, Neisseria gonorrheae, Hemolytic streptococci,
Staphylococci, Streptococcus pneumoniae, Mycobacterium tuberculosis, Fungal infections
• C/F
➢ Abdominal pain: severe; sudden onset; worse on movement, coughing and deep respiration
➢ Constitutional: anorexia, malaise, fever, lassitude, nausea ± vomiting
➢ Pyrexia, raised pulse rate
➢ Tachycardia, tachypnea
➢ Abdominal tenderness ± guarding/rigidity/rebound tenderness
➢ Abdominal distension, dull flanks on percussion
➢ PR examination: tenderness
➢ Absent/reduced bowel sounds
➢ Hippocratic facies: circulatory failure, cold & clammy extremities, sunken eyes, dry fissured tongue, thready
irregular pulse, drawn and anxious face, blue lips
• INVESTIGATIONS
➢ CXR in standing position with abdomen: ground glass appearance of the abdomen with gas under diaphragm
➢ TLC: increased
➢ US abdomen: fluid in the abdominal cavity
➢ Electrolyte study, blood culture
➢ Blood urea, serum creatinine
➢ Four quadrant abdominal tap: pus or infected fluid
➢ Diagnostic peritoneal lavage: > 500 WBCs/ml
➢ Diagnostic laparoscopy
➢ CT scan
➢ MRI
• D/D: Pancreatitis, Intestinal obstruction, Ruptured ectopic pregnancy, Acute pyelonephritis, Acute mesenteric
ischemia, Diabetic acute abdomen, AMI
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• TREATMENT
A. General care of patient
1) IV fluids: NS/RL – 2 ml/kg/hour
2) Nasogastric tube aspiration
3) TPN, CVP monitoring, catheterisation
4) Antibiotics, analgesics
5) Sitting propped up position, early mobilisation, exercise, respiratory physiotherapy, prevention of DVT
using LMWH
6) Percutaneous drainage by Foley’s catheter
7) Dopamine, steroids and management of shock
8) ICU and ventilator support
B. Surgical treatment of cause
➢ Laparotomy: abdomen opened with midline incision extending both above and below the umbilicus →
pus removed using suction and collected for culture → abdominal cavity inspected thoroughly for site of
origin of sepsis
bowel perforation → perforation closure
intestinal obstruction → resection and anastomosis
appendicitis → appendicectomy
➢ Peritoneal lavage, drainage and wound closure with tension sutures
• COMPLICATIONS
➢ Abdominal: Paralytic ileus, Residual/recurrent abscess or inflammatory mass, Portal pyemia or liver abscess,
Adhesional small bowel obstruction
➢ Systemic: septic shock, SIRS, MODS, death
PSEUDOMYXOMA PERITONEI
• a rare malignant condition that develops due to ruptured malignant ovarian cyst or adenocarcinoma of appendix
• peritoneum coated with mucus-secreting tumour with tenacious gel-like mucus with cystic masses
• common in old aged females
• C/F: vague abdominal pain with distension and non-shifting dullness
• CT scan: bowel displacement with fluid content in the peritoneal cavity
• TREATMENT
➢ Laparotomy → masses of jelly scooped out
➢ Appendicectomy, oophorectomy
➢ Complete cytoreduction by Sugarbaker technique: removal of spleen, gall bladder, right hemicolectomy,
omentectomy, panhysterectomy + stripping of peritoneum from pelvis, diaphragm and surface of liver
➢ Heated intraoperative chemotherapy (HIPEC) using mitomycin C
➢ Intraperitoneal instillation of mucolytic agents – dextran, urokinase
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MESENTERIC CYSTS
• SITES: small intestine (60%); colon (40%)

• TYPES
1) Chylolymphatic (mc)
2) Enterogenous
3) Urogenital remnant
4) Dermoid
• PATHOLOGY
➢ Chylolymphatic
✓ arises from congenitally misplaced lymphatic tissue that has no efferent communication with the
lymphatic system (mc in the mesentery of the ileum)
✓ thin-walled cyst composed of connective tissue lined by flat endothelium
✓ independent blood supply
➢ Enterogenous
✓ derived either from a diverticulum of the mesenteric border of the intestine or from a duplication of the
adjacent bowel
✓ thick-walled cyst containing all layers of the bowel
✓ receives its blood supply from the adjacent bowel
• C/F: Tillaux triad
1) Painless soft smooth fluctuant swelling near the umbilicus
2) Swelling moves freely in a plane at right angles to the attachment of mesentery (Tillaux’s sign)
3) A zone of resonance around the cyst
• COMPLICATIONS:
➢ Torsion
➢ Rupture
➢ Hemorrhage
➢ infection
• INVESTIGATIONS: USG & CT scan abdomen
• D/D
➢ peritoneal inclusion cyst
➢ omental cyst
➢ serosanguineous cyst
➢ tuberculous abscess of the mesentery
➢ hydatid cyst of the mesentery
➢ hydronephrosis
• TREATMENT
➢ Chylolymphatic cyst: enucleation
➢ Enterogenous cyst: removal of cyst with resection of adjacent bowel
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PSOAS ABSCESS
➢ DEFINITION: abscess in the psoas region in the iliac fossa

➢ MCC: TB (spine, LN, retroperitoneal structures, lower intercostal region)
➢ C/F:
• Back pain, fever, spinal tenderness, paraspinal spasm, restricted spine movement
• Swelling in iliac fossa – smooth, non-tender, non-mobile, not moving with respiration.
• Cross fluctuant across the inguinal ligament
• Psoas muscle spasm – difficulty extending hip
➢ D/D:
• Iliac artery aneurysm
• Ovarian cyst
• Soft tissue tumours and cysts in the iliac region
• Hernia
➢ INVESTIGATIONS:
• X-ray spine and chest
• CT scan
• Mantoux test
• ESR
• Peripheral smear
• USG abdomen
➢ T/T:
1) ATT
2) GA → lateral loin incision → psoas region reached extraperitoneally → pus drained and collected for AFB,
culture and sensitivity
3) Anterolateral decompression with costotransversectomy with bone grafting
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UMBILICAL ADENOMA / RASPBERRY TUMOUR
➢ commonly seen in infants

➢ CAUSE: partially obliterated vitellointestinal duct towards umbilical end causing prolapse of the mucosa
➢ C/F: protrudes out as a red swelling – moist with mucus and tends to bleed on touch
➢ D/D: umbilical granuloma
➢ T/T:
• firm ligature tied around it → tumour falls off in few days
• if it reappears → umbilectomy
EXOMPHALOS / OMPHALOCELE
➢ DEFINITION: failure of all or a part of the gut to return to the celomic cavity during early fetal life
➢ Sac consists of 3 layers-
1) outer amniotic membrane
2) middle Wharton's jelly
3) inner peritoneal layer
➢ a/w congenital anomalies of cardiac and genitourinary system
➢ C/F:
1) Exomphalos minor
• small sac; defect < 5 cm
• umbilical cord attached to the summit
• content – small bowel
2) Exomphalos major
• large sac; defect > 5 cm
• umbilical cord attached to the inferior aspect of the sac
• content – small bowel, large bowel, liver
➢ INVESTIGATIONS:
• US
• Amniocentesis and chromosomal analysis
➢ T/T:
1) Vitamin K injection, TPN
2) Sepsis control with antibiotics
3) Evaluation for other anomalies
4) Application of 0.5% mercurochrome with 65% alcohol to promote granulation tissue formation
5) Prevention of aspiration and hypothermia
6) Correction of dehydration
7) Definitive surgical procedures-
a) Exomphalos minor – sac twisted to reduce the content to the peritoneal cavity through the umbilical
defect → abdomen strapped → defect closed
b) Exomphalos major – relaxing incisions placed over the lateral abdominal wall → gradual twisting of a
sterile polythene bag over the summit at regular intervals over 2-3 weeks → contents get reduced →
defect closed
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HEAD INJURIES
➢ MECHANISM:
• Distortion of the brain
✓ damage to neurons, supporting tissues and blood vessels → loss of consciousness, focal neurological
deficits
• Mobility of the brain in relation to the skull and membranes
✓ causes cerebral damage and bleeding in dural spaces
• Configuration of interior of skull
✓ damage is severe over the anterior cranial fossa, over the falx and over the tentorium
• Deceleration and acceleration injuries
✓ Deceleration injuries occur when moving head strikes an immovable object – RTA
✓ Acceleration injuries occur when stationary skull struck by a moving object – assault
• Cerebral concussion
✓ slight distortion → temporary physiological changes → transient loss of consciousness → complete
recovery
• Cerebral contusion
✓ more severe degree of damage → bruising and cerebral edema → diffuse/localised changes
• Cerebral laceration
✓ tearing of brain surface, collection of blood in different spaces, displacement of dural parts
➢ CLINICAL APPROACH:
• Detail h/o injury
• H/o alcohol intake
• Neurological assessment – level of consciousness, Glasgow coma scale, pupillary reaction, pulse, reflexes,
temp, BP, RR, limb movements
• Status and protection of airway
• General assessment and other injuries
• Fractures and bleeding
➢ INVESTIGATIONS:
• X-ray skull
• Serum electrolyte measurement
• Blood grouping and cross matching
• CT scan – plain
• Carotid arteriography
• US abdomen
• Monitoring of ICP
➢ T/T:
A. General
1) Protection of airway – mouth gag, endotracheal intubation or tracheostomy
2) Throat suction, bladder and bowel care and good nursing
3) Nasal oxygen, ventilator support
4) IV fluids → Ryle's tube feeding
5) Electrolyte maintenance
B. Drugs
1) Analgesics and anticonvulsants
2) Diuretics – mannitol 20% 200 ml IV 8 hourly or frusemide 40 mg IV 8 hourly
C/I – intracranial hematoma
3) Antibiotics
C. Surgery – craniotomy → cranial flap raised → clot evacuated → hitch stitches between dural layer and scalp
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EXTRADURAL HEMATOMA
➢ DEFINITION: collection of blood in the extradural space between the dura and skull
➢ MC SITE: temporoparietal region
➢ VESSELS INVOLVED: middle meningeal vessels
➢ C/F:
• H/o transient loss of consciousness following a h/o blow/fall
• Lucid interval – patient soon regains consciousness and again after 6-12 hour starts deteriorating
• Confusion, irritability, drowsiness, hemiparesis on same side of the injury, restlessness, headache, vomiting
• Hutchinsonian pupils – pupillary constriction → pupillary dilatation → totally unconscious
• Cushing's triad of raised ICP – bradycardia; systolic htn; respiratory irregularities (Cheyne Stokes ventilation)
• Wound and hematoma in the temporal region of scalp
➢ INVESTIGATIONS:
• X-ray skull – fracture of temporal bone
• Electrolyte estimation
• CT scan head – biconvex lesion
➢ T/T:
1) Immediate surgical intervention
craniotomy (5 cm vertical incision in parietal region above the zygoma) → cranial flaps raised → black
currant jelly clot evacuated → bleeding vessels cauterized → dura fixed to galea using hitch stitches
2) Post-operative antibiotics, analgesics and anti-convulsants
SUBDURAL HEMATOMA
➢ DEFINITION: collection of blood between the brain and dura

➢ Hematoma is extensive and diffuse with severe primary brain damage
➢ TYPES & C/F:
1) Acute
• Due to injury to the cortical veins and laceration of cortex of brain
• Loss of consciousness – occurs immediately after trauma; progressive
• Convulsions
• Features of raised ICP – high BP, bradycardia, vomiting
• Focal neurological deficits or hemiparesis
2) Chronic
• Due to rupture of veins between dura and brain causing gradual collection of blood in subdural space
• Common in old age, with h/o minor trauma
• Confusion, disorientation, altered level of consciousness and drowsiness
• Convulsions, features of raised ICP, features of coning
• Extensor plantar response and pupillary changes
➢ INVESTIGATIONS:
• CT scan head – concavo-convex lesion
• Electrolyte estimation
➢ T/T:
1) Surgical decompression by craniotomy & evacuation of clot
2) Antibiotics, anticonvulsants
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HYDROCEPHALUS
➢ DEFINITION: dilatation of ventricles due to blockage of CSF flow or ↑ secretion or defective absorption of CSF
➢ CLASSIFICATION:
1) Communicating type – ventricles communicate freely into the subarachnoid space
2) Non-communicating type – obstruction in the ventricle or its exit
➢ C/F:
• Obstructed labour, ↑ head circumference > 2 cm/month and craniofacial disproportion
• Bulging of anterior fontanelle; engorged scalp veins; scalp thin and shiny; suture line separation
• Sunsetting sign - ↓ upward gaze
• MacEwan’s sign - cracked pot sound on percussion
• Delayed milestones, mental retardation and difficulty in retaining feeds
• Features on raised ICP, lethargy, irritability, ataxia, papilledema, blindness and respiratory failure
➢ INVESTIGATIONS: CT scan; MRI brain, CT/air ventriculography
➢ T/T:
A. Drugs - acetazolamide, furosemide, isosorbide, glycerol
B. Surgery
1) Tapping of the lateral ventricles
2) Ventriculocisternostomy using polythene catheters (Torkildsen operation)
3) Ventriculoatrial or ventriculoperitoneal shunts
MENINGOCELE
➢ DEFINITION: herniation of meninges through a weak point of spine where bony fusion has not taken place
effectively
➢ C/F: swelling –
• covered with pia mater and arachnoid mater
• contains CSF
• present since birth
• soft, cystic, fluctuant with transillumination
• signs of compressibility
• expansile impulse
➢ SITES: lumbosacral > occipitocervical
➢ INVESTIGATIONS: CT scan head, MRI spine
➢ T/T:
1) Early excision
2) Transverse elliptical incision → closure of defect by plication → approximation of muscles
149 / 154
CHEST INJURIES
➢ INVESTIGATIONS:
• CXR – hemothorax, pneumothorax, fracture ribs
• Hb%, PCV, blood grouping and cross matching
• ABG analysis
• US abdomen, CT chest and abdomen
➢ T/T:
A. Initial first aid
1) Airway – prevention of aspiration, plastic airway, intubation, tracheostomy
2) Breathing – ICT placement, supportive measures
3) Circulation – fluid therapy, CVP line, blood transfusion
4) Look for disability
5) Expose the patient properly
B. Further treatment
1) Analgesics and rest
2) ICT drainage with underwater seal
3) Management of shock, blood transfusion
4) Antibiotics, bronchodilators, steroids
5) Nasal oxygen, throat suction
6) Ventilator support with IPPV
7) Tracheostomy/endotracheal intubation
8) Pulmonary physiotherapy, aspiration of secretions
9) Thoracotomy
FRACTURE RIBS
➢ CAUSES: RTA, chest injuries, direct trauma, blast injuries

➢ C/F:
• Difficulty and pain during breathing
• Tenderness over fracture site
• Spring test positive
• Features of haemothorax, lung injuries
• Features of abdominal injuries
➢ INVESTIGATIONS: CXR, CT chest/abdomen, ABG analysis
➢ T/T:
1) Control of pain
2) Prevention of infection
3) Respiratory physiotherapy
4) T/t for definitive conditions
FLAIL CHEST
➢ DEFINITION: fracture of two or more consecutive ribs, with each rib having 2 or more fracture sites
➢ PATHOPHYSIOLOGY: flail segment moves independent of the adjacent thoracic cage
➢ C/F:
• Paradoxical respiration → respiratory dysfunction
150 / 154
• Mediastinal flutter → kinking of great vessels and sudden cardiac arrest
• Pendular movement of air from one lung to other → respiratory failure
• Hemothorax, pneumothorax
• Hypoventilation – CO2 retention and respiratory failure
➢ INVESTIGATIONS: CXR, ABG analysis, blood grouping
➢ T/T:
1) First aid – prevention of paradoxical movement of flail segment by applying pressure over it
2) ICT drainage
3) Applying clips to fracture ribs and fixing above and below to normal ribs
4) Antibiotics, bronchodilators, steroids
5) Blood transfusion, IV fluids
6) Ventilator support with IPPV (TOC)
Tracheostomy – if ventilator support required for >10 days
7) Thoracotomy
TENSION PNEUMOTHORAX
➢ During inspiration, air is pumped into the pleural cavity through a valvular opening in the visceral pleura and
underlying injured lung → ↑ intrapleural pressure → lung collapses → mediastinum shifts towards the opposite
side → ↓ venous return, atrial filling, ventricular filling, cardiac output and cardiac function
➢ C/F:
• Tachypnea and tachycardia
• Decreased/absent breath sounds
• Resonant on percussion with severe mediastinal/tracheal shift
• Cyanosis and hypotension
• Chest pain, distended neck veins
➢ T/T:
1) Thoracocentesis - wide bore needle immediately placed in the 2nd ICS in MCL
2) Nasal oxygen
3) ICT placement
4) Antibiotic, analgesics
5) Ventilator support with IPPV – in severe cases
HEMOTHORAX
➢ DEFINITION: blood in pleural cavity

➢ CAUSES: trauma; post-operative; tumours of lung, mediastinum, pleura; leaking aneurysms; spontaneous
➢ C/F:
• Pain in the chest, tenderness
• Difficulty in breathing, dullness on percussion, diminished breath sounds
• Features of shock
➢ INVESTIGATIONS: CXR, CT chest, pleural tap
➢ T/T:
1) ICT placement in 6th ICS in the MAL
2) Antibiotics, bronchodilators
3) Thoracotomy
151 / 154
EMPYEMA THORACIS
➢ DEFINITION: collection of pus in pleural cavity

➢ CAUSES:
• From chest wall - wounds, osteomyelitis of ribs
• From lung - pneumonia, abscess, bronchiectasis, tuberculosis, growth
• Postoperative - after thoracotomy
• From oesophagus - perforations, carcinoma
• From below diaphragm - subphrenic abscess
➢ ORGANISMS: staphylococci, streptococci, pneumococci, E. coli, pseudomonas
➢ C/F:
• Pain in the chest, tenderness, fever
• Difficulty in breathing
• Features of toxicity in acute type
• Dullness on percussion, absence of breath sounds
• Decreased chest wall movement
➢ INVESTIGATIONS:
• CXR, ESR
• Peripheral smear
• Diagnostic aspiration
• Pus C/S, AFB
• Bronchoscopy
➢ T/T:
• Stage 1: Antibiotics; repeated aspirations; ICT drainage; ATT
• Stage 2: ICT drainage; rib resection (Eloiser's method); antibiotics, ATT; respiratory physiotherapy
• Stage 3: Decortication; lobectomy; physiotherapy, antibiotics, ATT
EMPYEMA NECESSITANS
➢ Empyema perforates through the chest wall presenting as subcutaneous collection of pus communicating with
the pleural cavity
➢ CAUSES:
• Neglected empyema
• Following incomplete aspiration of pus of empyema through a thin needle
➢ C/F: a diffuse, tender, smooth, soft, fluctuant swelling in the ICS having impulse on coughing
➢ INVESTIGATIONS: CXR, TLC, ESR
➢ T/T: antibiotics; ICT drainage; ATT; T/t of empyema
SURGICAL EMPHYSEMA
➢ DEFINITION: collection of gas/air in the subcutaneous or and fascial planes

➢ CAUSES: lung injury; tracheal injury; chest wall injury; after laparoscopic procedure
➢ C/F:
• Pain, diffuse swelling of the subcutaneous region
• Palpable crepitus
➢ INVESTIGATIONS: X-ray chest and neck
➢ T/T: T/t of cause; ICT placement
152 / 154
TRACHEOSTOMY
➢ TYPES:
1) Emergency
2) Elective
➢ TUBES:
1) Fuller's bivalved tracheostomy tube
2) Jackson's tracheostomy tube
➢ INDICATIONS:
• Head, neck and facial injuries
• Tetanus
• Tracheomalacia
• Laryngeal edema/spasm/surgeries
• Major head and neck surgeries
• ICU ventilation after 7 days
➢ TECHNIQUE:
neck hyperextended → vertical/horizontal incision made → deep fascia opened → strap muscles retracted
laterally → isthmus divided or retracted below → 2nd and 3rd tracheal rings opened and circular opening made
→ tracheostomy tube placed and tied around the neck
153 / 154
SURGICAL SUTURES
➢ FEATURES OF IDEAL SUTURE MATERIAL:

• Adequate tensile strength
• Good knot holding property
• Should be least reactive
• Easy handling property
• Should have less memory
• Should be easily available and cost effective
➢ CLASSIFICATION OF SUTURE MATERIALS:
A. Based on absorbability
1) Absorbable – Plain catgut, Chromic catgut, Vicryl, Dexon, Maxon, PDS, Monocryl, Biosyn
2) Non-absorbable – Silk, Polypropylene, Polyethylene, Cotton, Linen, Steel, Polyester, Polyamide, Nylon
B. Based on source
1) Natural - Catgut Silk, Cotton, Linen
2) Synthetic - Vicryl, Dexon, PDS, Maxon; Polypropylene, Polyethylene, Polyester, Polyamide
C. Based on filaments
1) Monofilament - Polyethylene, PDS, Catgut, Steel
2) Multifilament - Polyester, Polyamide, Vicryl, Dexon, Silk, Cotton
➢ USES:
A. Absorbable suture materials
1) bowel anastomosis - gastrojejunostomy, resection and anastomosis
2) cholecystojejunostomy, choledochojejunostomy, pancreaticojejunostomy
3) suturing muscle, fascia, peritoneum, subcutaneous tissue, mucosa
4) ligation of pedicles during hysterectomy
5) circumcision
B. Non-absorbable suture materials
1) herniorrhaphy
2) closure of abdomen after laparotomy
3) vascular anastomosis, nerve suturing, tendon suturing
4) tension suturing in the abdomen
5) suturing the skin
➢ TYPES OF SUTURING:
1) Continuous
2) Interrupted simple
3) Interrupted mattress
4) Subcuticular
5) Horizontal tension
6) Vertical tension
154 / 154

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Surgery

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SURGERY

PREVIOUS YEARS’ Q&A

*COMPILED FROM BAILEY & LOVE 27E AND SRB 6E

SOLITARY THYROID NODULE

PAPILLARY CARCINOMA OF THYROID

LATERAL ABERRANT THYROID

OTHER IMPORTANT TOPICS

1) Axillary lymph nodes

CLASSIFICATION OF BENIGN BREAST DISORDERS

ABERRATION OF NORMAL DEVELOPMENT AND INVOLUTION (ANDI)

➢ DEFINITION: hyperplasia of a single lobule of the breast (benign encapsulated tumour)

FIBROCYSTADENOSIS / MAMMARY FIBROCYSTIC DYSPLASIA / CYCLICAL MASTALGIA WITH NODULARITY

➢ mc non-epithelial neoplasm of the breast

DUCT ECTASIA / PLASMA CELL MASTITIS

• Primary Tumour (T)

PAGET’S DISEASE OF THE NIPPLE

➢ DEFINITION: superficial manifestation of an intraductal carcinoma

SENTINEL LYMPH NODE BIOPSY

➢ 75% U/L; 25% B/L

OTHER IMPORTANT TOPICS

➢ Inflammatory carcinoma of breast

AMOEBIC LIVER ABSCESS

➢ mc extraintestinal presentation of amoebiasis

HEPATOCELLULAR CARCINOMA (HEPATOMA)

➢ mc site: right lobe

OTHER IMPORTANT TOPICS

➢ Pyogenic liver abscess

➢ DEFINITION: a type of acute cholecystitis wherein GB is filled with pus

➢ DEFINITION: non-inflammatory overdistension of GB containing mucoid or clear fluid

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

OTHER IMPORTANT TOPICS

➢ DEFINITION: single or multiple accessory spleens

➢ DEFINITION: overactivity of spleen causing pancytopenia with hypercellular BM

➢ DEFINITION: a condition that includes-

OTHER IMPORTANT TOPICS

➢ TYPES & ETIOLOGY

ACHALASIA CARDIA / CARDIOSPASM

OTHER IMPORTANT TOPICS

➢ gram -ve spiral-like flagellated organism

INFANTILE HYPERTROPHIC PYLORIC STENOSIS

OTHER IMPORTANT TOPICS

➢ Bleeding peptic ulcer

➢ DEFINITION: a persistent remnant of proximal portion of vitellointestinal duct

CROHN'S DISEASE / REGIONAL ENTERITIS

➢ DEFINITION: neuroendocrine tumours arising from enterochromaffin cells

➢ ETIOPATHOGENESIS: adenoma–carcinoma sequence

OTHER IMPORTANT TOPICS

➢ DEFINITION: invagination of one segment of bowel into the adjacent segment

➢ DEFINITION: anticlockwise twisting or axial rotation of sigmoid about its mesentery

➢ localisation of infection occurring 3 to 5 days after an attack of acute appendicitis

✓ Recommended distal rectal margin clearance: 5 cm

➢ DEFINITION: an ulcer in the longitudinal axis of the lower anal canal

OTHER IMPORTANT TOPICS

➢ SURGICAL ANATOMY OF INGUINAL CANAL

STRANGULATED INGUINAL HERNIA

OTHER IMPORTANT TOPICS

➢ TYPES – (1) Rigid, (2) Flexible

➢ 90% radiopaque; 10% radiolucent

RENAL CELL CARCINOMA (RCC)

OTHER IMPORTANT TOPICS

➢ 5 Lobes – anterior, posterior, lateral (2), middle/median

1) Peripheral zone: lies posteriorly; site of carcinoma

BENIGN PROSTATIC HYPERPLASIA