Summary of

clinical surgery

edited and updated by: Aws Mohammed Majid

CLICK ON THE SUBJ ECT TO GO TO IT

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I V F L UID
 Common Types
of IV fluid

crystalloid colloid

Isotonic hypotonic hypertonic 25% Human

albumin

Normal saline 0.45% saline 3% saline 5% albumin in NS

0.9%

Lactate ringer
Hartmann's 5% saline Gelatin
solution

5% dextrose in 10% dextrose in dextran

water (D5W) water

5%dextrose in Total parentral

0.9%saline nutrition

50%dextrose Hydroxyethyl
water( injectable starch (HES)
) D50W

* note:-

• some resources consider plasma and

cryoprecipitate as colloid fluid .

• Osmolarity defer from tonicity

• E.g., NS is isotonic but hyperosmolarity

• 0.9% saline

• normal saline
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 Side effect and
Types of Fluid Uses ( indications )
cautions

1 hypovolemia ( dehydration due to _ fluid overload , be careful in pt.

vomiting ,diarrhea ) with HF
_ Ringers lactate contain
2 blood loss
potassium don’t use it in pt.
Isotonic fluid 3 DKA
with renal disease , Don’t
4 surgery ( intraoperative and post
use it in liver disease
operative maintenance fluid )
because lactate will not
5 Burn metabolize.
1-hyponatremia and cerebral
edema
2- decrease in circulatory
1-hyperosmolar hyperglycemic state
Hypotonic fluid volume , so don’t use it in
in pt. with type 2 DM
cases of trauma , burn
because of a risk of low blood
pressure
- Higher risk of fluid
1- hyponatremia and overload and
Hypertonic cerebral edema pulmonary edema .
fluid 2- Addison crisis - Its usually given in ICU
3-hypoglycemia ( 50%dextrose water) via central line with
caution
1-Fluid replacement prior to
blood arrival
Colloid 2- burns
solution 3-when there is excessive
crystalloid use
4- severe hypoglobulinemia

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 CRYSTALLOID COLLOID
• Few side-effects • Longer duration of action
• Low cost • Less fluid required to correct
Advantage
• Wide availability hypovolemia
• Efficacious • Less weighty and bulky
• No evidence that they are
• short duration of action
more clinically effective
• Required in large quantity
• Higher cost
Disadvantages • Lack of O₂ carrying capacity
• May cause volume overload
• May cause oedema
• May interfere with clotting
• Weighty and bulky
• Risk of anaphylactic reactions

RL
• Mainly used in hypovolemic shock
, it’s the 1st line Iv fluid for pt. with
hypovolemia and dehydration

• If you don’t have RL then give NS

as a 2nd line

Which one is better RL or NS , and why ?

Normal saline

RL because its more physiological &

contain more electrolytes like K , ca , that
are not found in NS , so RL is more
resembling the normal plasma .

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• It’s the faster one to be distributed , within
only few minutes , after giving 1 L , only

Dextrose 5%
100 ml will remain in intravascular
compartment ( only 10 % ( so its not used
in shock and fluid rescucitation )
• Its mainly used in post op. conditions
• Each pint contain 25 g glucose every 1
gram gives 4 Kcal energy
• So every pint gives you 100 kcal

Dextrose 2.5% + 0.45 sodium chloride

Half dextrose and half NS

▪ solution Used in :-
• pediatric
• elderly
• diabetic
• hypertensive patients

Urine. The normal urine output is approximately

1500mlday–1 and, provided that the kidneys are
healthy, the specific gravity of urine bears a direct
relationship to volume. A minimum urine output
of 400mlday–1 is required to excrete the end
products of protein metabolism.

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• Each 1 kg requires 1.5 ml per hr ,
• so the patient of 70 kg requires around 105 ml per hr
• So in 24 hrs the patient requires around 2500 ml
• If there is a loss due to diarrhea , vomiting , blood loss
due to fracture for ex then we have to add the lost
fluid to the daily requirement
• Femur fracture = 2L loss
• Pelvic fracture = 2L loss
• Humerous fracture = 500 ml loss
• In post op. patient who is fasting for around 20 to 24
hrs (nothing by mouth ) we have to give him 4 pints of
IV fluid ( 2L ) = ( 3 pints 5% glucose water and one pint
of normal saline because the daily requirement of
sodium is 1 meq for each 1 kg )
Baily & love

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 OTHER METHOD OF IV FLUID CALCULATION
( MAINLY USED FOR PEDIATRIC )

Micro drip MAcro drip

The micro drip

Macro drip chamber
chamber delivers
deliver 15 (10-20)
about 60 drops or
drops or gtt/ml.
gtt/ml.

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 Uses of microdropper :-
1 to give IV fluid for pediatric age group
2 to give chemotherapy
3 to give highly concentrated drugs like antibiotics

Microdropper Macrodropper
• Allows fast fluid infusion
• Easy to Titrate
Advantage • Allows fluid resuscitation
• Avoids fluid overload
• Allows fluid boluses

• Potential tot fluid overload • Does not allow resuscitation

Disadvantages
• Difficult to Titrate • Does not allow fluid boluses

Example

IF THE Patient 70 kg how many drops per min?

• 1kg need 1.5 cc/hr.
• 70 x 1.5 ≈ 100cc
• so, we need 100cc per hr.
• how many drops per min?
• in macrodropper
• 20/1cc x 100= 2000 drop per hr.
• per min = 2000/60 min = 30 drop/min

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HI STROY T A K ING
• Patient profile ( PP )
• Date of admission and surgery
• Chief complaint ( CC )
• History of present illness
• Review of systems
• Past medical Hx
• Past Surgical Hx
• Drug Hx
• Family Hx
• Social Hx

PATIENT PROFILE (PP)

Patients name , address , age , marital status,

blood group

CHIEF COMPLAIN (CC)

• The chief complaint is usually the reason for the

patient’s visit.
• It is stated in patient’s own words [No medical terms]
in chronological order of their appearance & their
severity. { Brief & Duration }
• Make clear – patient was free from any complaint
before the period mentioned.
• If the pt. came to the hospital for elective surgery ,
you have to say ‘ elective surgery for …… ‘ and then
you must start talking about the condition .
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 History of present illness (HPI)

• This should record the details of each problem, using

mainly the patient’s own words.
• Record as accurately as possible how long the
complaint has been present and include the sequence
of events in chronological order with dates (e.g. 1 year
ago, 1 month ago, yesterday).
• The presenting disorder is usually related to one
system, and questions referable to this – and any other
system involved in
• the presenting complaint – are delivered at this stage.
• Pain is one of the most common symptoms;
appropriate questions are memories in SOCRATES.
• Many of these questions can also be applied to other
symptoms.
• If the patient is a poor historian or is unable to give a
history, or you suspect them of giving unreliable
information, it may be helpful to talk to relatives or
witnesses.
• Record the source of this and all aspects of the history
that are not obtained directly from the patient.

SOCRATES • dull pain

• S: Site; • stabbing
• O: Onset; • burning
• C: Character; • squeezing
• R: Radiation; • crushing
• A: Associations;
• T: Timing;
• E: Exacerbating/relieving factors;
• S: Severity.
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 Previous History of Presenting Complaint(s)

• If the patient has had similar symptoms in the past,

obtain detailed information in chronological order,
including any treatment received and the results of any
investigations (if known).
• Report any past event with a clear bearing on the present
condition, such as operations, trauma, weight loss,
medication, contact with others with disease or any
recent travel abroad.

SOME NOTES YOU HAVE TO KNOW ABOUT

THE PAIN

RADIATED PAIN
• This is the extension of the pain to another site while the
initial pain persists.
SHIFTED PAIN
• A pain that occurs in one site and then disappears before
reappearing in another site is not radiation: it is a new
pain in another place
REFERRED PAIN
• This is pain that is felt at a distance from its source.
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 After analysis of the symptoms in the HPI you should
comment on the following in the HPI :-

• If the pt. was admitted to the emergency unit or surgical ward ?

• What are the Invest. Done to the Pt. in the hospital ,
• and you should ask about Nasogastric tube decompression use (
used in Intestinal obstruction) .
• If the surgery was done to the pt. , you should ask about :-
1. Type of Anesthesia ? ( General ? , Regional ? Spinal ? )
2. duration of operation ?
3. any complication during the operation like for e.x bleeding ?
( any need for blood transfusion ? )
4. post operative :- you should ask
A. at which day the pt. pass flatus ? ( because of the risk
of paralytic ileus )
B. you should ask if the pt. urinate after surgery ? (
because of the risk of urine retention)
C. at which day the pt. start walking ? ( we should
encourage Early mobilisation to prevent DVT )
D. at which time the pt start eating after the operation ? (
note :- the day of operation is Day 0 , 1 day after
operation is day 1 and so on …. )
E. is the condition improved after the operation or not ?
5. you should ask about symptoms of post _ operative
complications ( very important )

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 Post operative complications (Ws)

Wind (pulmonary)
• Atelectasis (usually within 24 hrs) , pneumonia (usually
within 48 hrs) ( so you should ask if the pt. developed SOB
? , Fever ? , productive cough ? , chest pain ? Post _
operatively
Water ( urinary tract )
• urinary tract infection (usually in Day 3 _ day 5) ( so you
should ask if the pt. develop dysuria , frequency ,urgency ,
fever ? ) , urine retention ( so you should ask about
urination after surgery ) .
Wound infection
Walk
• ( venous thromboembolism ) (usually in Day 5 _ day 7) , so
you should ask if the pt. developed leg Edema ? (DVT) , if
the pt. developed sudden dyspnoea , chest pain ,
hemoptysis ? ( pulmonary embolism )
Other complications include
MI ( so you should ask about past Hx of Ischemic heart
disease) , stroke , heart failure , hypotension , RF , post Op.
nausea and vomiting , paralytic ileus , thrombophlebitis
(Phlebitis may cause postoperative pyrexia and it is important
that intravenous cannula are regularly inspected for evidence
of redness, oedema and tenderness ) .

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• The commonest cause of postoperative dyspnea
(shortness of breath) and rapid shallow breathing is
alveolar collapse or atelectasis.
• The diagnosis is confirmed by clinical examination and
radiography .
• Atelectasis usually responds to chest physiotherapy.

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 Post operative hypotension

• The commonest cause of low blood pressure

postoperatively is hypovolemia,
• as a result of either bleeding or insufficient fluid
replacement ,
• other causes include :- myocardial infarction may also
present with hypotension, overdose of analgesics,
especially opioids.
• Specifically, epidural anesthesia may be complicated by
hypotension because of the vasodilatation of veins.
• Septic shock may also present in this way.
• Whatever the cause of hypotension,
• the emergency treatment requires an increase in the fluid
input with administration of high-flow oxygen.
• The patient should also be tilted head-down to maintain
cerebral perfusion

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 Post operative complications

POST OPERATIVE Renal Failure

• Oliguria may be defined as urine output less than the
minimum obligatory volume (0.5mlkg–1h–1).
• The commonest cause of oliguria postoperatively is reduced
renal perfusion ( pre renal cause) resulting from perioperative
hypotension or inadequate fluid replacement.
• If untreated, acute renal failure may develop.
• To ensure that fluid management is adequate, daily
input/output charting should be maintained.

POST OPERATIVE PARALYTIC ILEUS

• Paralytic ileus may present with nausea, vomiting, refusal to
eat , bowel distension and absence of flatus or bowel
movements.
• Abdominal radiography reveals a dilated bowel.
• Following laparotomy, gastrointestinal motility temporarily
decreases. Treatment is usually supportive with maintenance
of adequate hydration and electrolyte levels.

POST OP. URINE RETENTION

• particularly men who are bed-bound postoperatively.
• The inability to void after surgery is particularly common with
pelvic and perineal operations or after procedures performed
under spinal anaesthesia.
• The causes of retention are related to the interference of
neural mechanisms that are usually responsible for normal
bladder emptying and over-distension of the bladder.
• Retention may be confirmed by ultrasound and may require
catheterisation. Catheterisation should be performed
prophylactically when an operation is expected to last 3 hours
or longer or when large volumes of fluid are administered.
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 Paralytic ileus Radiology

Causes of paralytic ileus :-

1. surgery ( post operative )
2. Hypokalemia ( electrolytes
disturbance )
3. DKA , uremia, sepsis

POST OPERATIVE UTI

• This is the one of the most commonly acquired infections in the

postoperative period.
• Patients who are immunocompromised or diabetic, or who
have pre-existing urinary tract contamination, urinary retention
or a history or presence of catheterization, are known to be at
higher risk.
• In those patients who are catheterized for less than 48 hours,
Symptoms of urinary tract infection and cystitis include dysuria
and mild pyrexia; however, pyelonephritis may cause severe
flank tenderness in addition to high temperatures.
• Dx :- The diagnosis is confirmed by dip sticking the urine and
sending samples for culture and sensitivity
• TX :- Treatment involves adequate hydration and proper
bladder drainage together with the useof relevant antibiotics in
the light of laboratory sensitivities.

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Note :- The main complications to look out for in a
postoperative abdominal surgical patient are:
• anastomotic leakage;
• bleeding or abscess
• slow recovery of intestinal motor function (ileus).

DVT

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 Review of system

You should start with system that’s closely related to the pt

presenting symptoms to exclude some of DDx .
For e.x :- pt presented with right lower abdominal pain , you
put on the DDx , appendicitis which is the most common and
stone in the ureter and ovarian pathology, so you should ask
about urinary system in the review of system to exclude the
presence of uretric colic . And you should ask about
gynaecological problem to exclude the presence of ovarian
pathology .

Past medical Hx

• Diabetes ( pt. may presented with diabetic foot problem ,

abscess and increasing risk of post operative infections ,
Delay wound healing ) .
• hypertension
• Asthma
• Hx of ischemic heart disease , stroke
• HF
• Epilepsy
• Tuberculosis
• previous Hx of hospital admission and the cause for this
admission .
• For each condition, ask the
• When was it diagnosed?
• How was it diagnosed?
• How has it been treated?
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* Note :- pt. with DM should not take their medications prior
to the surgery because the pt. is fasting before the surgery ,
and if the pt. takes the medications , there is a risk of
hypoglycemia .

Why its important to ask about HT in the

past medical Hx ?

HYPERTENSION
• in the perioperative and postoperative period increases
cardiovascular events Like MI , cerebrovascular events,
bleeding, and mortality and should be controlled prior to
major elective surgery .
• Hypertension is the commonest avoidable medical reason for
postponing surgery .
• In the preoperative setting, most antihypertensive
medications should be continued until surgery. Except
ACE inhibitors and diuretics .
ANESTHESIA.
Undergoing anesthesia can influence blood pressure and
causing hypotension , Recovery from anesthesia can hit people
with high blood pressure harder as well.

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 PAST SURGICAL HX

• Its important to ask about previous Hx of surgery because

some presenting problem are related to previous surgery ,
for E.x :- pt. presented with intestinal obstruction by the
means of constipation , abd. Distention , the cause of
obstruction may be Adhesion from a previous surgery .
Other E.x pt . Presented with lump at the site of previous
surgical incision , this lump may be incisional hernia
• You should ask about the type of surgery , the date of
surgery , type of Anesthesia ? ,
• and if there was any complication during the surgery
• Previous Hx of blood transfusion and the indication for it
and the No. of pints
• Previous Hx of trauma

DRUG HX

• its important to ask about allergy to antibiotics because

any pt. will receive prophylactic antibiotics prior to the
surgery
• its important to ask about Anti_platelets drugs ( Aspirin ,
clopidogril , Dipyridamole ) because of the risk of bleeding
during the operation , so it should be stopped 7 days prior
to the surgery .
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• Its important to ask about Anticoagulant ( warfarin , heparin )
and theses should be also stopped prior to the surgery
because of the risk of bleeding during the surgery .
• NSAIDs because of antiplatelet effects and associated with
peptic ulceration and bleeding
• oral contraceptive pills increase Risk of DVT
• its important to ask about steroids intake whether its sex
steroids ( oral contraceptive pills, hormonal replacement
therapy in post menopause , androgen in body buildings ) or
glucocorticoids ( prednisolone , hydrocortisone ,
fludrocortisone ) because those pt. have already adrenal
suppression due to exogenous intake and the surgery is a
stress condition and more cortisol is needed so the pt. will
undergo acute adrenal insufficiency during the surgery , so in
those pt. you must double the dose of steroids prior to the
operation by giving IV hydrocortisone . And in the case of pt.
taking steroids , there will be delay wound healing .

medications that must be hold

or stop before surgery

At day of operation
• Diuretics (unless in sever heart failure or thiazide for
hypertension)
• Oral hypoglycaemic agents
• Vitamins and iron
• Angiotensin converting enzyme inhibitor or
angiotensin receptors blocker
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• 2 days before operation ( NSAIDs)
• 4 days before operation (warfarin and convert to
enoxaparin)
• 7 days before operation
• Clopidogrel (plavex)
• Aspirin
• Regarding tobacco smocking must be stopped 4 weeks
before the operation

Family Hx

Ask about Family Hx of colonic Ca ( may be sporadic in

elderly not familial ) , gall stones , breast tumor ,
appendicitis

Social Hx

• Ask about smoking :- smoking in pack yrs , 1 pack-year is

20 cigarettes (1 pack) per day for 1 year (e.g., 40/day for
1 year = 2 packyears; 10/day for 2 years = 1 pack-year).
• Ask about alcohol drinking
• living in Urban Vs Rural Area
• occupational Hx
• any contact with pets
• water supply ?
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28
G e neral
e x a mination
 THE EXAMINATION

General
look

Vital
signs

General
exam

Local
exam

PRINCPLES

• The examiner stands on the right side of the patient.

• It is usual to start the examination with the patient’s
hands and then to proceed methodically from head to
toe
• observe the exposed parts, particularly the hands, skin,
head and neck.

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 THE GENERAL LOOK

ABCOP S
A • AGE (young, middle age, elderly)

B • BODY built ( cachexic, under wight, over wight, obese.)

C • Conscious

O • Oriented (time, person, place)

P • Position (lie supine, setting, semi supine)

S • Surrounds (iv line, canula, catheter, drains)

GENERAL SIGNS

J ACOLD
• Jaundice
• Anemia
• Cyanosis
• Clubbing
• LAP (lymph adenopathy)
• Dehydration 31
 HAND, HEAD AND NECK

• HAND & FEET

• Skin
• Nail
• Muscle
• Oedema
• HEAD
• Skin
• Hair
• Orifices
• NECK
• Thyroid
• Tracheal deviation
• Neck veins
• Cervical LN

VITAL SIGNS

P U L S E R AT E
• the normal PR ( 60_100 Beats per min ) ,
• we count it from the radial A. by using 3 fingers ,
• the 1st for partial occlusion to get a high get of blood
• the 2nd to count
• the 3rs for the character .
• You have to count for 1 min.
• You have to present the finding in following manner for ex
:- the pulse is 90 BPM , which is regular of normal volume
and normal character .
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 VITAL SIGNS

BLOOD PRESSURE
• measured by the sphygmomanometer
• you have to put the cuff on the arm , and then start to
inflate the cuff for up to 200mmhg until the pulse
disappear and then put the stethoscope on the brachial A.
which is medial to biceps tendon and start to deflate the
cough ,
• the 1st sounds to be heard called the Korotkoffs sounds
which indicating the systolic BP ,
• and keep to deflate the cough when there is change in the
intensity and the character ( muffling of sound this is the
diastolic BP
R ES P I R ATO RY R AT E
• you have to divert the attention of the patient while you
are counting it
• for 1 min , in adults the N. resp. rate is 12 to 20 breaths per
min
T E M P E R AT U R E
• by using thermometer ,
• Sub lingual ( pre requests :- you have to ensure that its
sterile aseptic and you have to shake it and look at the
mercury line should be at zero level and then put it laterally
, why ? Bec. In anxious irritable pt , may crush it and the
midline there is a sublingual Artery )
• Axillary ( - 0.5 C ) and rectal ( + 0.5 C ) 33
 JAUNDICE

• is a yellow discoloration of the skin

• caused by an excess of bilirubin (bile pigment) , a serum
bilirubin level greater than 2.5 to 3 mg per dL . (at >35
μmol/L).

Pre hepatic

hepatocellular

Obstructive

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 JAUNDICE

• The Best site to look for jaundice is the upper Sclera

because its rich in elastin which is the most predictive Site
for bilirubin Deposition and its covered by the upper eye
lid so there will be no degradation of the bilirubin by the
sun light
• the Examination should be on the Day light .
• Other sites to look for jaundice
• Mucus membrane
• previous Scars and incisions
• Skin .
• The yellow color is first visible in the white background of
the sclerae
• With the onset of jaundice, white skin turns :-
• A PALE LEMON YELLOW
• Hemolysis ( pre hepatic jaundice )
• As the bilirubin level increases, the skin becomes YELLOW–
ORANGE
• hepatocellular jaundice
• The skin eventually turns, yellow– grey–green colour in
patients with
• primary biliary cirrhosis, obstructive ( Extra hepatic
jaundice )

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 PALLOR

The sites for looking

• lower conjunctiva
• mucus membrane
• nail beds
• palmar skin creases ( by comparing with your hand , don’t
let the pt. to know that you are comparing )
• The best site is the palmar creases , because lower
conjunctiva can be inflamed ( conjunctivitis ) and it will be
red despite the presence of Anemia , and the mucus
membrane is the same
• Facial pallor is often a sign of severe Anemia
• Causes of pallor
• Anemia
• Shock state
• hypothyroidism
• hypopituitarism
• thick skin .

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 CYANOSIS

• the Bluish discoloration of the skin and mucus membrane

• when the Deoxy Hb is more than 5 g per dl . Or less than
50%
• Central cyanosis
• It is most apparent in areas with thin skin and a rich
blood supply, such as the lips, tongue .
• Peripheral cyanosis , in the extremities ( fingers) .
• The cyanosis is central if it is caused by cardiopulmonary
disease, and the patient’s extremities are usually warm. It
is best appreciated by inspecting the inner aspect of the
lips
• When the cyanosis is caused by a peripheral abnormality,
the extremities such as the fingers, toes and nose are blue
and cold, but the central organs such as the lips and
tongue remain pink.
• In the case of severely Anemic pt. , there is no possibility of
development Cyanosis . Because of low Hb level .
• Central cyanosis + peripheral
• severe Elevation in the deoxy Hb
• Only peripheral cyanosis > peripheral vascular disease
• Common Causes of cyanosis :-
• Respiratory chronic obstructive disease ( Asthma ,
COPD ) and parenchymal lung diseases ,
• cardiac ( Left sided heart failure , cyanotic congenital
heart disease ) 37
 CYANOSIS

FINGER CLUBBING

• is painless soft tissue swelling of the terminal phalanges.

• it is an important sign of major diseases, although it may
be congenital .
• It usually takes weeks or months to develop, and may
disappear if the underlying condition is cured

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 FINGER CLUBBING

EDEMA

• Exam . By pressing on the shin of the Tibia about 10 cm

above the medial malleolus for 15_30 Sec to see it its
pitting or non pitting edema.
• There are two principal causes of generalized oedema :
• fluid overload
• hypoproteinemia.
• Distinguish them by assessing the jugular venous pressure
(The jugular venous pressure is usually elevated in fluid
overload but not in hypoproteinemia).

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40
A b d ominal
e x a minati on
 ABDOMINAL EXAMINATION

1. Introduce your self , take permission , explain what you

are going to do
2. Position
• the pt. should be in a Flat position or 1 to 2 pillow
under his \ her head ( 15 _ 20-degree elevation ) for
Relaxation of the anterior Abd. Muscles .
3. Exposure
• from the nipple to the mid thigh ( the cause ? )
I. The pathology that occur in abdomen may extent to
these areas
II. to do percussion for the upper border of the liver .
III. to look for spider nevi on the chest , Gynecomastia (
signs of chronic liver disease )
IV. to see if there is hyper inflated chest in COPD that
push the diaphragm downward resulting in apparent
hepatomegaly .
V. to look , if there is mastectomy due to breast Can
may have hepatomegaly due to distant metastasis .
VI. to Exam the hernial orifices & the genitalia and
finally doing PR .
4. Then start with the Exam. :- Inspection , Palpation ,
percussion , Auscultation .
• But recently it changed into visual inspection and
auscultation, followed by palpation and percussion.
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 ABDOMINAL EXAMINATION

1. ASK THE PATIENT TO COUGH TO LOOK FOR HERNIA

• 3 times
• one for any bulging ,
• one for pain
• other to look at the Genitalia for any swelling
2. We have 3 positions for inspection
• Birds' eyes
I. to look for the contour of the abdomen ( Flat ? ,
scaphoid ? , distended ? )
II. look for the umbilicus( flat ? , Everted ? , inverted ? )
III. look for surgical scars
IV. Abdominal striae
V. dilated veins
VI. bruises
VII. redness
• knelling position
I. to see the movement of the Abdomen with
respiration ,
II. ask the pt. to take a breath and hold it to look for
visible pulsation and visible peristalsis .
• End of the bed . , to look for any asymmetry .

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 ABDOMINAL INSPECTION

6 S 4P
Symmetrical and movement with the respiration .
Shape of the Abdomen ( Distended ? )
Shape of the umbilicus
Scar
Striae
Skin lesions
Prominent veins
Pulsation ( transmitted normally in thin or pathological due
to aortic aneurysm )
Peristalsis ( normal in thin pt, ,intestinal obstruction )
Pigmentations ( Cullen's sign , Grey turners sign)

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 CONTOUR OF THE ABDOMEN

A scaphoid ( concave)
abdomen may be present
in an emaciated patient
with a poor nutritional
status resulting from an
advanced malignancy or
inflammatory bowel
disease (IBD)

UMBILICUS

• The umbilicus is the scar that forms during closure of

the umbilical ring after the umbilical cord has
separated. is normally situated almost halfway
between the xiphoid process and the symphysis pubis
• Inadequate healing and closure of the umbilical ring
leads to hernia formation, which represents the most
common umbilical pathology ,
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 UMBILICUS

• Normally the umbilicus is inverted ,

• it will be flat in ascites ( to diff. ascites from fatty
abdomen ) , in very severe ascites it can be Everted
and in the umbilical hernia it will be Everted and
enlarged .
• You must see if the umbilicus
• is inverted ?
• Everted ?
• flat ?
• is there any discoloration
• any nodule ?

Everted umbilicus in pt. with severe Umbilical hernia

ascites

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 SURGICAL SCARS

For
cholecystectomy
And bile duct sx

( kocher's incision )

(laparotomy)

(Gridiron or Lanz incision)

(Pfannestiel incision)

DISCOLORATIONS

Bruising (ecchymosis) or hematomas of the abdominal wall

( rectus sheath hematoma ) develop due to trauma or the
use of prophylactic and therapeutic anticoagulation or illicit
drug injection or retroperitoneum hemorrhage ( ectopic
preg. , hemorrhagic pancreatitis , ruptured AAA ) that give
Umbilical hernia
Cullen's sign which is periumbilical bruising and grey turner
sign which is flank bruising
47
 STRIAE
Abdominal striae due to
Linea Nigra :- better
Cushings syndrome .
Pregnancy stretch known as pregnancy line,
is a dark vertical line that purplish in colour and
marks, also
appears on the abdomen fade with time to a
known as striae in about three quarters of whitish
gravidarum all pregnancies

48
 DILATED VEINS

• Place two fingers at one end of the vein and apply occlusive
pressure.
• Move one finger along the vein, emptying that section of
blood in a milking action.
• Release the pressure from one finger and watch for the
flow of blood back into the vein.
• Repeat, emptying blood in the other direction.
• Given the venous valves, you should be able to determine
the direction of blood flow in that vein.
• Inferior flow of blood suggests superior vena cava (SVC)
obstruction.
• Superior flow of blood suggests inferior vena cava (IVC)
obstruction.
➢ NOTE
• Flow radiating out from the umbilicus (caput
medusae) indicates portal vein hypertension , the
blood flow is directed into the normally obliterated
umbilical vein, leading to a radial engorgement of the
periumbilical venous plexus (caput medusae).

49
 DILATED VEINS

Patient with superior vena caval

obstruction demonstrates facial,
neck, arm and chest edema

caput medusa due to portal hypertension in case of liver cirrhosis .

PALPATION

• Before you palpate you must ask the patient , if he has any pain
in his abdomen , because if he has pain you must palpate the
area of pain lastly and gently .
• The classical way is to start from the left iliac fossa and move
anti clock wise toward the umbilicus .

50
 PALPATION

• When , you palpate you must put your eyes on your patients
face ( Observe the patient’s face for any sign of discomfort
throughout the examination).

SUPERFICIAL & DEEP PALPATION

Guarding

Rigidity

PALPABLE MASS
TENDERNESS

Consider the patient’s If you detect a mass ,

level of anxiety when you must Describe
assessing the severity its site, size, surface,
of pain and tenderness shape and consistency,
elicited. and note whether it
Tenderness in several moves on respiration. Is
areas on minimal the mass fixed or
pressure may be due to mobile? , is it pulsatile
generalised peritonitis or not ? Is it tender ? ,
but is more often due to fluctuant ?
anxiety .

51
 RIGIDITY & GARDING

1. ‘Voluntary guarding’ denotes purposeful contractions of abd.

Muscles initiated by the patient, usually in response to fear .
2. ‘involuntary guarding’ reflects reflexive contractions upon
palpation that are more indicative of peritoneal irritation
• Use clinical judgement to distinguish between the two.
3. ‘Rigidity’ describes diffuse board-like guarding of the
abdominal wall due to inflammation of the parietal
peritoneum.
4. Rebound tenderness :pained expressions or involuntary
guarding upon release of the examiner’s hands
• 2 , 3 ,4 are signs of peritonitis
• When these signs are limited to one quadrant, they reflect
localized peritonitis, as in
• Cases of uncomplicated appendicitis or diverticulitis.
• When these signs are elicited over the whole anterior
abdominal wall, diffuse peritonitis is present.

PALPABLE MASS

• Most benign lesions (inclusion cysts, lipomas, fibromas) are

subcutaneous and are easily mobile.
• Benign subfascial masses on the other hand, and locally
aggressive neoplasms such as sarcomas or desmoid
tumours, can be suspected based on their lack of
mobility relative to the surrounding tissues
52
 PALPABLE MASS

Pain of Abd. Wall

Q\A site of maximum tenderness on palpation , how you can

differentiate this pain is of Abd. Wall origin (musculoskeletal)
Or internal visceral origin?
BY DOING CARNETS TEST

53
 CARNETS TEST

▪ origin of chronic abdominal pain.

▪ Ask the patient to tense their
abdominal muscles (either by lifting
their head and shoulders, or by raising
both their legs with straight knees
from the examination table).
▪ A positive test (no change or an
increase in pain) suggests that the
abdominal wall is the origin of the
pain,
▪ for example, from a rectus sheath
haematoma, muscle strain or tumour,
pathology of the sensory nerves or an
abdominal wall hernia.
▪ A negative test (a decrease in
abdominal pain) indicates intra-
abdominal pathology ( visceral )
▪ Note :- peritonitis may give false-
positive results, so Carnett’s sign is
more helpful in the differential
diagnosis of chronic abdominal pain.
54
ENLARGE ORGNAS

LIVER

Causes of enlargement

55
 LIVER

LIVER PALPATION

Surface markings for the liver :-

▪ Upper border: fifth right intercostal space on full expiration
▪ Lower border: at the costal margin in the mid-clavicular line
on full inspiration

To palpate the inferior edge of the liver,

▪ place your examining hand first in the RLQ, lateral to the
rectus sheath,
▪ the fingers pointing towards the left axilla.
▪ Ask the patient inhales deeply, the edge of an enlarged
liver will move down to touch the examining hand.
▪ Repeat the manoeuvre, progressing up to the costal
margin.
❖ normal-sized liver will usually not move below the right
costal margin on inspiration.
❖ In late cirrhosis, the liver is shrunken and not palpable
❖ The liver may be enlarged or displaced downwards by
hyperinflated lungs

56
 LIVER

LIVER PALPATION

❖ so we must measure the liver span ( the upper edge

determined by percussion and the lower edge determined
by palpation and percussion )
❖ Upper edge :- to detect you should start from the 4th
intercostal space and descend .
❖ The normal liver span :- 12 cm +- 4 cm

When you feel the edge, you should comment on the

following :-
❖ size
❖ surface: smooth or irregular ( nodular )
❖ edge: smooth or irregular
❖ consistency: soft or hard
❖ tenderness
❖ whether it is pulsatile.
➢ Absence of liver dullness indicate pneumoperitoneum (
perforated viscus )

57
 LIVER

LIVER PALPATION

GALL BLADDER

MURPHY'S SIGN
▪ is elicited in patients with acute cholecystitis by
▪ asking the patient to take in and hold a deep breath while
palpating the right subcostal area.
▪ If pain occurs on inspiration, when the inflamed gallbladder
comes into contact with the examiner's hand, Murphy's sign
is positive.
COURVOISIER’S SIGN
▪ presence of jaundice, a palpable, distended gallbladder
▪ is suggestive of periampullary malignancy
58
SPLEEN

59
 SPLEEN

• The spleen and kidneys are normally palpable only when

pathologically enlarged.
• The normal site of the spleen :-
• Underlies left ribs 9–11, posterior to the mid-axillary
line
• To feel the spleen
1. place the fingertips of your right hand on the right iliac
fossa just below the umbilicus .
2. Keep your hand stationary and ask the patient to breathe
in deeply through the mouth.
3. Feel for the splenic edge as it descends on inspiration .
4. Move your hand diagonally upwards towards the left
hypochondrium 1cm at a time between each breath the
patient takes.
5. If you cannot feel the splenic edge, ask the patient to roll
towards you and on to his right side and repeat the above.
6. Palpate with your right hand, placing your left hand behind
the patient’s left lower ribs, pulling the ribcage forward

60
 SPLEEN

HOOKING METHOD Examining for the spleen from

behind the patient, in the right lateral position. In this
case, the fingers are "hooked" over the costal margin.

• The spleen must increase in size three-fold before it

becomes palpable, so a palpable spleen always
indicates splenomegaly.
• The normal spleen lies beneath the ninth and 11th ribs
in the left mid-axillary line.
• It enlarges from under the left costal margin down and
medially towards the umbilicus .
61
 KIDNEY

1. Use the fingers of your right hand. Start in the right lower
quadrant and palpate each area systematically
2. place your left hand behind the patient’s back below
the lower ribs and your right hand anteriorly over the
upper quadrant just lateral to the rectus muscle
3. push your hands together as the patient breathes out.
4. Ask the patient to breathe in deeply; feel for the lower pole
of the kidney moving down between your hands.
5. If this happens, gently push the kidney back and
forwards between your two hands to demonstrate its
mobility. This is balloting and confirms that this structure
is the kidney .
Note :-
• Percussion of the kidneys is unhelpful.
• The kidneys are normally mobile and move as much as 3 cm
inferiorly during inspiration.
• The spleen and kidneys are normally palpable only when
pathologically enlarged. In thin patients, the inferior pole of
the right kidney is sometimes palpable using the
ballottement method
62
 KIDNEY

PERCUSSION

• Percussion should be for the 4 quadrants ( whole

abdomen ) , its a useful tool to detect the presence of :

• Air absence of liver dullness ( indicating pneumopritoneum

, perforated viscus ) , and hyper resonant abd. , it’s a late
sign of perforation .

• fluid ( shifting dullness and transmitted thrill )

• solid organs ( upper border of the liver , spleen , bladder )

• to identify areas of tenderness (Patients with peritonitis

may not tolerate percussion; gentle percussion is one
way to elicit peritoneal signs )

• Detect mass :- a dull area may draw your attention to a

missed mass during palpation

63
 BLADDER

• Percuss for the bladder over a resonant area in the

upper abdomen in the midline and then down
towards the symphysis pubis.

• A change to a dull percussion note indicates the upper

border of the bladder.

• Abnormal finding is the distended bladder due to urine

retention .

• Or you may do palpation of the bladder by the radial

side of yout hand like palpation of the uterus

64
 GASTRIC OUTLET OBSTRUCTION

• Shaking the pt . And put your stethoscope in the

epigastric region

• Splashing sounds – A succussion splash – indicate that

there is distended stomach with a mixture of fluid and
gas. ( the pt. should be fasting for 8 hrs )

65
 AUSCULTATION

1. put the bell of the stethoscope on the McBurney's point that

is one-third of the distance from the anterior superior iliac
spine to the umbilicus ( site of ileocecal valve to listen for
bowel sounds ) ,

• normal bowel sounds :- low pitched gurgles noises occurs

every few sec .

• Normal bowel sounds freq :- 5-30 per minute

• Abnormalities of the bowel sounds :-

• Increased in bowel sounds and high pitched Amorphic

sounds mechanical bowel Obst.

• A paucity ( absence ) of bowel sounds for 30 sec. post op.

is typical of paralytic ileus.

• A patient who presents with new, severe abdominal pain

( acute abdomen ) and a truly silent abdomen in which
no sounds are heard over 10 minutes raises concerns of a
surgical emergency such as a perforated viscus.

2. put it above the umbilicus ( midway between the umbilicus

and the xiphoid process to listen for bruit of AAA

3. put it 2 inches above and lateral to the umbilicus to listen for

renal A. bruit ( renal A. stenosis )
66
 FINISHING OF THE ABDOMINAL EXAM

1. Renal angle tenderness

2. Examination of the inguinal lymph nodes (Normal lymph nodes

are no larger than1.5 cm, mobile, soft and non-tender )

3. Examine the supraclavicular lymph nodes ( left enlarged

supraclavicular node )

4. Checking the Femoral pulse

5. Perianal and PR exam.

Causes of inguinal lymphdenopathy

When its clearly

visible its called
Troisiers sign

67
 INGUINAL LN SWELLING

• An assessment of inguinal lymphadenopathy must include a

review of constitutional symptoms and examination of the
drainage sites of the inguinal lymph nodes (lower torso, lower
extremity, perineum, anus, external genitalia) as well as other
lymph node groups (neck, axillae).

• in cases of bacterial lymphadenitis may result in the formation

of an abscess. Signs of a purulent lymphadenitis are erythema,
oedema, tenderness and, if superficially located, fluctuation

RENAL ANGLE SWELLING

When it presents , indicating

pyelonephritis , one of the DDx
of abdominal pain that should
be excluded

68
DDX OF ABDOMINAL PAIN

69
 DDX OF ABDOMINAL PAIN

• Pain in the LUQ is rare and usually reflects splenic

pathology.
• The physical examination of patients with LUQ pain
should focus on identifying splenomegaly and
excluding extra- abdominal signs of systemic disease.
• Although ultrasound may be helpful when the
spleen is grossly enlarged, CT scanning is the primary
diagnostic modality for pathology in this region

70
DDX OF ABDOMINAL PAIN

71
DDX OF ABDOMINAL PAIN

72
Ascites
 ASCITES

Ascites is defined as an accumulation of excess serous fluid

within the peritoneal cavity.

• Ascites can usually be recognized clinically only when the

amount of fluid present exceeds 1.5 L depending on body
habitus:

• in obese individuals a greater quantity than this is necessary

• The abdomen is distended evenly with fullness of the flanks,

which are dull to percussion.

• Usually, shifting dullness is present but, when there is a very

large accumulation of fluid, this sign is absent.
74
 History

Age :-

• Children most likely cause :- intra Abd . Infection Tb ,

Nephrotic syndrome

• Middle age :- liver cirrhosis

• Elderly :- intra abd. Malignancy

• Gender :-

• in female the cause may be pelvic or ovarian tumor

• Onset , pattern of progression ( order of development ) ,

severity ( interfere with breathing )

• , associated symptoms ( fever , night sweating ? )

• Imp. To ask about RF of hepatitis :- IV drug misuse , Hx of

blood transfusion , Tattoing

• Past medical :- DM , HT ( both controlled or not ) , hx of any

chronic liver dis.

• Past surgical :- any previous abd Sx

• Social alcoholism ?

75
 Examination

firstly by inspection we will see a flank is filled and then we will

do:- shifting dullness & transmitted thrill .

Shifting dullness
1. With the patient supine, percuss from the midline out to the
flanks Note any change from resonant to dull, along with
areas of dullness and resonance .

2. Keep your finger on the site of dullness in the flank and

ask the patient to turn on to his opposite side

3. Pause for 10 seconds to allow any ascites to gravitate, then

percuss again. If the area of dullness is now resonant,
shifting dullness is present, indicating ascites

76
 Examination

Transmitted thrill
1. Place the palm of your left hand flat against the left side of
the patient’s abdomen and flick a finger of your right hand
against the right side of the abdomen.

2. If you feel a ripple against your left hand, ask an assistant

or the patient to place the edge of his hand on the
midline of the abdomen This prevents transmission of
the impulse via the skin rather than through the ascites. If
you still feel a ripple against your left hand, a fluid thrill is
present (only detected in gross ascites).

77
 Examination

Color
• Congestive heart failure

• The ascitic fluid is light yellow and of low specific

gravity, about 1.010, with a low protein concentration
(<25 g/L).

• peritoneal metastases is caused by excessive exudation of

fluid and lymphatic blockage

• fluid is dark yellow and frequently blood stained. The

specific gravity, ≥1.020, and the protein content (>25
g/L) are high.

INVESTIGATION

• liver function tests (LFTs),

• cardiac function,

• ultrasonography and/or CT scanning

• puncture of the peritoneum or peritoneal drain may be

inserted. and Fluid is sent for microscopy/cytology, culture,
including mycobacteria, and analysis of protein content and
amylase. 78
 TREATMENT

• Treatment of the specific cause is undertaken whenever

possible

• Dietary sodium restriction to 200 mg/day may be helpful,

but diuretics are usually required (combination of
spironolactone and furosemide).

• For patients failing to respond to such measures,

therapeutic needle paracentesis can be performed.

CHYLOUS ASCITES

• In some patients the ascitic fluid appears milky because of

an excess of chylomicrons (triglycerides).

• Most cases are associated with malignancy, usually

lymphomas

• other causes are cirrhosis, TB, filariasis, nephrotic

syndrome, abdominal trauma (including surgery),
constrictive pericarditis, sarcoidosis

• and congenital lymphatic abnormality.

• The prognosis is poor unless the underlying condition can

be cured.

79
 CHYLOUS ASCITES

• In addition to other measures

used to treat ascites, patients
should be placed on a fat-free
diet with medium-chain
triglyceride supplements.

80
Appendicitis
 SURFACE ANATOMY

ON THE EXTERNAL SURFACE

• The bowel, the base of the appendix is found at the point of

convergence of the three taeniae coli of the caecum.

ON THE SURFACE OF THE ABDOMEN

• This point lies one-third of the way along a line drawn

between the right anterior superior iliac spine and the
umbilicus. (McBurney’s point)

ETIOLOGY of appendicitis

1. A faecolith

2. foreign body

3. A fibrotic stricture of the appendix

4. Obstruction of the appendiceal orifice by tumour,

5. Intestinal parasites, particularly Oxyuris vermicularis

(pinworm).
82
 Complications

1. Appendicular mass

2. Appendicular abscess

3. gangrene

4. perforation

PERFORATION

SYMPTOMS

83
 CLINICAL SIGNS

1. The patient is then asked to point to where the pain began

and where it moved (the pointing sign).

2. Deep palpation of the left iliac fossa may cause pain in the
right iliac fossa, Rovsing’s sign, which is helpful in
supporting a clinical diagnosis of appendicitis.

3. Occasionally, an inflamed appendix lies on the psoas

muscle, and the patient, often a young adult, will lie with
the right hip flexed for pain relief (the psoas sign).

4. Spasm of the obturator internus is sometimes demonstrable

when the hip is flexed and internally rotated. If an inflamed
appendix is in contact with the obturator internus, this
maneuver will cause pain in the hypogastrium (the
obturator test; Zachary Cope)
84
 Rovsing’s sign

PRESENTATION ACCORDING TO SITE

Retrocaecal
• Rigidity is often absent, and even application of deep pressure may
fail to elicit tenderness (silent appendix),

• the reason being that the caecum, distended with gas, prevents the
pressure exerted by the hand from reaching the inflamed structure.

Pelvic
• diarrhea results from an inflamed appendix being in contact with
the rectum.
• When the appendix lies entirely within the pelvis completely
• absence of abdominal rigidity
• tenderness over McBurney’s point is also lacking.
• An inflamed appendix in contact with the bladder may cause
frequency of micturition. This is more common in children.

Postileal
• pain may not shift,
• diarrhea is a feature and marked retching may occur.

85
 PRESENTATION ACCORDING TO AGE
Infants
• for obvious reasons, the patient is unable to give a history.
• Because of this, diagnosis is often delayed, and thus the
incidence of perforation and postoperative morbidity is
considerably higher than in older children.
• Diffuse peritonitis can develop rapidly because of the
underdeveloped greater omentum, which is unable to give
much assistance in localizing the infection.
Children
• It is rare to find a child with appendicitis who has not vomited.
• complete aversion to food.
The elderly
• Gangrene and perforation occur much more frequently in
Elderly patients with a lax abdominal wall or obesity may
harbour a gangrenous appendix with little evidence of it, and
the clinical picture may simulate subacute intestinal
obstruction.
The obese
• Obesity can obscure and diminish all the local signs of acute
appendicitis and the clinician may have to rely on imaging to
establish the diagnosis.
Pregnancy
• pain in the right lower quadrant of the abdomen remains the
cardinal feature of appendicitis in pregnancy.
86
 DEFERENTIAL DIAGNOSIS

TREATMENT

• Emergency appendicectomy ( lap. Or open) is the treatment of

choice.
• Conservative management: appendix mass should be treated
non-operatively with antibiotics and intravenous fluids.
• Appendicular abscess: It should be drained either under
radiological guidance or surgically.
87
 Gridiron & Lanz

POST OP. COMPLICATIONS

1. Wound infection
2. Intra-abdominal abscess
3. Ileus
4. Respiratory
5. Venous thrombosis and embolism
6. Portal pyaemia (pylephlebitis)
7. Faecal fistula
8. Adhesive intestinal obstruction

88
89
HERNIA
 Abdominal Hernia

• A hernia is the bulging of part of the contents through a

weakness or defect in the wall

• Component

1. defect

2. Sac:

• A peritoneal pouch that bulges out through

abdominal wall defect

• It has neck , body and fundus

• The neck has the clinically significant

• Determine the obstruction

• Determine the surgical incision

• If it narrow the incision will be at neck

• The free part is neck

3. Coverings:

• Structures that are stretched over the sac

4. Contents: ( any abdominal viscus except pancreas )

• Usually intestine ( enterocele)

• omentum (omentocele) or both

91
 Causes Hernia

• that hernia is no more common in Olympic weight lifters

than the general population, suggesting that high pressure
is not a major factor in causing a hernia.

• A recent Swedish report has shown that inguinal hernia is

less common in obese patients, with hernia risk being
negatively related to body mass index (BMI), contrary to
widespread belief.

• Hernia is more common in smokers.

92
 TYPES

Special content hernias

• Richter's hernia

• Content part of bowel

• Littre's hernia

• Content Meckel's diverticulum

• Maydl's (W) hernia

• Content 2 loop of bowel

• Amyand hernia

• Content appendix

• Pantaloon hernia

• Inguinal hernia that surrounding the inferior epigastric

vessels

93
 HISTORY

Age

• for ex femoral hernia rarely presents before the age of 50

yrs ( browses 5th edition )

• While the umbilical hernia most commonly in children due

to cong.

• Umbilical defect, paraumbilical hernia mostly in middle age

and old and associated with parity and obesity

Gender

• femoral hernia and paraumbilical hernia more common in

females

Occupation

• those are associated with heavy weight lifting and requires

excessive physical activity .

Chief complain

• most common symptomless swelling

• painful swelling in the begging then become painless

• pain in the groin and the hernia discovered by the doctor

• altered bowel motion and symptoms of intestinal

obstruction .
94
 HISTORY
EMERGENCY PRESENTATION: strangulated hernia , the pt. is
presented with acute abdomen and acute bowel
obstruction and shock state .

present illness

▪ parity

▪ ask if the swelling disappears on lying supine and rest ,

▪ is it bulging during crying in children or during exercise ,

▪ is it enlarging in size ,

▪ Ask about change in colour of the swelling ,

▪ ask about the bowel habits ,

▪ Ask about previous hernia in the same site ( may be

recurrent )

In past medical

▪ ask about asthma , chronic bronchitis ( chronic cough ) ,

chronic urine retention like ( BPH ) , chronic constipation

In the past surgical

▪ ask about previous surgery , may be its incisional hernia , or

may be predispose for hernia , for e.x There is an increased
incidence of direct right inguinal hernia in patients who
have had an appendicectomy through a right iliac fossa
incision because this incision weakens the adjacent muscles
95
 HISTORY

Social

▪ ask about smoking ( causing acquired collagen deficiency )

Drug hx

▪ ACE inhibitors causing chronic cough , Steroids ( inhibit

collagen synthesis )
Examination

1. Don’t forget introduce your self , take permission , explain

what s you are going to do

2. Began with general examination

3. Position :- standing position then supine

4. Exposure :- from nipple to mid thigh

5. Inspection

6. Palpation

7. auscultation :- hearing bowel sounds ( the content is bowel )

, absence of bowel sounds on the hernia in pt. with IO , one
of sign of strangulation

8. The most important signs to confirm dx of hernia :- Expansile

cough impulse ( visible and palpable ) , reducibility , carnetts
test

96
 EXAMINATION

• Before doing any thing ask the patient if

• its tender
• painful
• you can reduce it
• if not do funneling

Ask the pt. to look at the ceiling &

cough to elicit visible cough impulse
Inspection & carnetts test may be useful

Any dilated veins ?

Goes with saphenous
varix , one of DDx of
groin hernia
5 S of any mass exam .
Site :- for ex inguinoscrotal Any previous
hernia scar (
recurrence ) , any
Size :- 5 * 5 measured by tape measure surgical scar (
incisional hernia )
Shape :- for e.x indirect hernia piriform in
shape
Redness in inflamed hernia
Surface ( the skin )

Surrounding , Dusky in strangulated hernia

any surrounding cellulitis

97
 Description :- there is inguinoscrotal
swelling , approx. 10 by 5 , piriform in
shape , with normal overlying skin
Q\ whats next to do to make sure this
swelling is hernia ?
1. reducibility ,
2. Expansile cough impulse ( visible
and palpable ) ,
3. carnetts test

Palpation
• R T T P ZC
consistency

Ziemans test
reducibility
Palpable cough
Testis
impulse
palpation

Tenderness and
temp.

98
 Examination

REDUCIBILITY

• Ask the patient to lie down to look if its reducible or not , if

not ask the pt. to reduce it by himself .

TESTIS

• in a male, simultaneously palpate the spermatic cords,

epididymites and testes bilaterally to assess these structures
for symmetry, masses, tenderness and varicosities.

• If you can circumferentially palpate the spermatic cord

above the scrotal mass ( can get above it ), it is not an
inguinal hernia In this case, suspect a testicular tumor or
non-communicating hydrocele.

• and in children , its important to palpate the testis to look for

undescended testis which is one of DDx of hernia.

• And to look for associated hydrocele ( DDx of indirect

inguinal and can be associated with it )

• Tenderness it’s a sign of strangulation

TEMP.

• hotness indicating inflamed or strangulated hernia

PALPABLE COUGH IMPULSE

ZIEMANS TEST ( 3 finger test )

99
 Examination

CONSISTENCY

• Doughy ( the content is Omentum )

• Tense ( sign of strangulation )

• soft ( the content is bowel )

ZIEMAN’S TEST
• Palpation of the groin with the
patient in an upright position.
• Position the index finger over the
expected projection of an indirect
hernia
• the middle finger over an
expected direct hernia
• the ring finger over an expected
femoral hernia
• ask the patient to cough.

• Alternatively, hold the fingers together and palpate one location

at a time.
• The deep inguinal ring (site of indirect hernia ) located at 1.25
cm above the mid inguinal point
• Superficial inguinal ring ( site of direct hernia ) located above and
medial to the pubic tubercle
• Femoral canal ( site of femoral hernia ) below and lateral to the
pubic tubercle
100
 Sign of strangulation

• irreducible

• The swelling is tender and hot

• Cough impulse becomes negative

• Consistency The swelling is very tense

• the swelling enlarging , & the skin overlying becomes dusky

and the patient in a shock state

Hydrocele vs indirect

INDIRECT INGUINAL HERNIA HYDROCELE

by hx : the family reports a swelling

by hx : the family reports a swelling
that bulging in crying and disappear is constant
on lying supine
the swelling is reducible usually and the swelling is not reducible usually
cough impulse + and cough impulse is neg

you can not get above it usually ( you can get above it usually ( neck
neck scrotal test ) scrotal test )

transillumination ( negative )
transillumination ( + )
opaque
the testis is not included in the the testis is included in the swelling
swelling and can be palpated and can not be palpated

the swelling is not flactuant the swelling is flactuant

the penis is deviated the penis is not deviated

101
DDX

102
DDX

103
 HERNIA IN CHILDREN

• Groin hernias in infants and children are virtually always

indirect inguinal hernias.

• Most patients are boys , in some cases we can see umbilical

hernia ( which usually resolve spontaneously with in 2 in
95% of cases, if not reduced after that we have to do Sx “
herniorrhaphy” )

The family usually report in the hx :-

• typical episodes of bulging of the groin during crying or

physical activity that disappear spontaneously or with
manipulation.

• In children , there may be no swelling in exam. ( the child can

not do cough impulse ) , so we have to Encourage older
children to run around or jump up and down in order to
allow descent of the hernia , if the swelling still not obvious
we have to do Gornalls' test

• A small hydrocele with the hernia may indicate the existence

of a patent processus vaginalis
• Remember :- you have to Gently palpate the cord just
outside the external ring between the index finger and
thumb, and compare its thickness with that of the opposite
side , A thickened cord indicates the presence of a hernial
sac even if it is empty. Remember to examine both sides
since 15 per cent of cases are bilateral.
104
 TREATMENT

CONSERVATIVE IN
• umbilical hernia below 2 yrs
• small asymptomatic hernia in elderly with medical
comorbidities
• Conservative measures These are indicated only in infants.
The child is given analgesics and placed in gallow’s traction
(the judgement of Solomon position). In 75% of cases
reduction is effected

105
 IRREDUCIBLE HERNIA
• Adhesion between the sac and the contents

• Narrow neck with rigid surroundings ( as femoral hernia that

carry the highest risk of strangulation and sx should be done as
early as possible after dx )

• Massive hernia ( large sized contents )

• Complicated hernia ( obstructed , strangulated , incarcerated )

NORMAL VARIANTS

(Malgaigne’s bulge)

• An elongated bilateral muscular bulge along the inguinal

ligament (Malgaigne’s bulge) can be seen in thin individuals
during straining and is not a hernia

Divarication of the recti

• ( confused with paraumbilical ) is separation of the rectus

abdominis muscles with extenuation of the linea alba, from
the xiphisternum to umbilicus , seen in adults, in females
during and immediately after childbirth ( may be permenant in
multiple pregnancy) , iatrogenic divarication may follow
repeated surgery through a long midline incision , also seen in
children if first few yrs.

• Divarication is best observed with the patient lying supine. If

asked to raise the head and legs together. ( carnets test )
106
 (b) Malgaigne’s
bulges

Divarication of the recti

107
M a ss
e x a minati on
 IMPORTANT POINTS IN HISTORY

• Duration of the mass

• How the mass had been discovered
• Is it found all the time or disappear
• Progression of the mass ? Is it enlarging
• Is it painful
• Is it single or multiple
• Is there any discharge or change in color
• Any associated systemic manifestation
• Exacerbating and relieving factors
• Hx of previous same mass

109
 IMPORTANT POINTS IN examination

• Introduce your self , Take permission , Explain the procedure

• Position :- for e.x in abdomen , the pt. is supine , in thyroid
should be sitting on the chair
• Exposure
• Inspection
• Palpation
• Auscultation :- diagnostic signs.
Examples include bowel sounds
in a hernia, bruits over vascular
lesions, crepitus over a joint
and friction rubs over pleuritic
and pericardial surfaces. The
bruits of vascular lesions
include the machinery
murmurs of an arteriovenous
fistula and also masses, such
as an enlarged toxic thyroid
gland, that may have an
audible blood supply.
• Examine the draining LN & vascular structures

110
 IMPORTANT POINTS IN examination

• The location of a lump must be described in

SITE exact anatomical terms, using distances
measured from bony points.
• Do not guess distances; use a tape measure.

SIZE • Take 2 dimentions , each one perpendicular to

each other , its important for progression of
the lump When a lump is rapidly changing in
size
• solid objects have at least three dimensions:
width, length and height or depth.
INSPECTION

SHAPE • oval, flattened, triangular, rectangular, square,

irregular

• Any dilated veins ? , any discharge ?When the

SURFACE
skin over a cystic lesion breaks down, the
contents may be discharged onto the surface;
this is a common feature of sebaceous cysts
and abscesses
• Any pit or punctum with waxy discharge (
feaures of sebaceous cyst )
• Any ulcer due to malignant invasion ( SCC,BCC )
• pigmentation :- Any redness ( in abscess ) , it
may be the brown melanin of a malignant
melanoma ,Xanthelasmas are the yellowish
colour

SURROUNDING • to see the degree of redness ( cellulitis ) in

abscess , any enlarged nodes , tethering ?

111
 IMPORTANT POINTS IN examination
PALPATION

• 1st Ask the patient if he has a pain , don’t forget to exam the LN
near the mass after finishing palpation

• Tenderness
• may accompany trauma, inflammation and malignant
lumps that are expanding rapidly, degenerating or
invasion of nervous tissue
• Surface
• smooth , lobulated , irregular
• Temp.
• hotness , indicating inflammation like in abscess
• Consistency
• cystic or solid , if its solid ( can be soft , firm , hard , stony
hard )
• Flactuation
• to differentiate cystic ( fluid filled lump ) from solid lesion
should be done in 2 directions to said its +
• Fixation
• to the skin ( by pinching the skin & to the underlying
structures by moving the base of the lump
• Pulsation
• the lump can be pulsated by it self or its located on a
vessel ( transmitted pulse ) , you have to differentiate
between the 2 ( see the next slide )
112
 IMPORTANT POINTS IN examination
PALPATION

• Emptying (compressibility )
• Lumps are termed compressible when they can be
emptied by squeezing but reappear on release. These
features are characteristic of blood-filled lesions, such as a
cavernous haemangioma
• Transillumination
• Cough impulse
• Reducibility
• A lump can be emptied by squeezing but does not return
spontaneously – this requires an additional force,
• Such as a cough or the effect of gravity. A classic example
is an inguinal hernia
• Slip sign
• A lipoma, for example, is one of the more common
subcutaneous lumps, and if its edge is pressed the
swelling slips from under the finger, producing a
characteristic ‘slip sign’.
• Indentation
• This can be well demonstrated by compressing the faeces
in the palpable sigmoid colon in the left iliac fossa. It may
also be possible to demonstrate this sign in a lax
sebaceous cyst and in large dermoid cysts

113
 IMPORTANT POINTS IN examination
PALPATION

• PULSATION
• This transmitted pulsation may be demonstrable in a
pancreatic mass situated in front of the abdominal aorta.
• While e.x for pulsatile mass is the carotid aneurysm (
vascular malformation ) , AAA
• This can be demonstrated by gently pressing a finger of
each hand on either side of the mass, in pulsatile mass the
fingers then being moved outwards away from each other,
whereas in transmitted pulsation they both move in the
same direction

LIPOMA

• Definition
• It’s the most common benign fatty subcutaneous mass , its
asymptomatic painless slowly growing swelling can reach
the max. size of 2 _3 cm , the main complain of the pt . Is
usually cosmetic

114
 LIPOMA

• Lipomas have characteristic signs.

• They are smooth, soft and slightly lobulated due to thin
fibrous septa.
• The edge slips away from the examining finger — the 'slip
sign'.
• They transilluminate and fluctuate, and are mobile with no
attachments to the skin or deep fascia.
• They are non-tender and non-reducible, and there is no
associated lymphadenopathy.
• The overlying skin is generally normal, but there may be
stretch marks, thinning or prominent veins with large
lesions.
• DDx
• sebaceous cyst ( epidermoid cyst ) , cold abcess ,
liposarcoma , hematoma , erythema nodosum , hernia
• Indications of surgical removal
1. compression symptoms and restrict movement
2. risk of malignant transform. ( scapular , supraclavicular ,
thigh )
3. progressive enlargement in size
4. cosmetic

115
 SEBACEOUS CYST | EPIDERMAL CYSTS
• DEF .
• Is a benign tumor that’s derived from hair follicles and are
usually filled with altered keratin , so they are more
appropriately called epidermal cysts .
• ( when an opening of one of the sebaceous gland becomes
blocked , it distends with its own secretions and ultimately
becomes sebaceous cyst ) .
• SITE
• They are often multiple and occur at any hair-bearing site on
the body, commonly the trunk, face and neck, and particularly
the scalp and scrotum; they do not occur on the palms and
soles.
• Sebaceous cysts most frequently arise on the scalp, and the
most common complaint is of a painless lump that gets
scratched when the patient is combing their hair.
• Such scratches may get infected, and when infection develops
in a cyst, it enlarges rapidly and becomes acutely painful with A
slow discharge of sebum from a punctum .
• Shape and size
• Most sebaceous cysts are tense and spherical. Even on the
scalp, where there is the unyielding skull beneath them,
they remain spherical by bulging outwards and stretching
the overlying skin
• They can vary from a few millimetres to 4-5 cm in
diameter, but most patients seek advice before they
become very large.
116
 SEBACEOUS CYST | EPIDERMAL CYSTS

• Surface
• The surface of a sebaceous cyst is smooth.
• Edge
• The edge is well defined and easy to feel, as it is usually
lying in subcutaneous fat.
• Colour
• The skin over the cyst is usually normal, although a
`punctum' or pit may be visible as a dark spot
• Tenderness Uncomplicated sebaceous cysts are not tender.
• Pain and tenderness indicate infection.
• Temperature
• The temperature of the skin over a cyst is normal except
when the cyst is infected.
• Composition Most sebaceous cysts feel hard and solid.
• They are occasionally so tense that it is not possible to elicit
fluctuation, especially if there is no firm underlying tissue to
press them against.
• On the scalp, the resistance of the underlying skull aids
detection of fluctuation.

117
T h yroid
 ANATOMY

• The normal thyroid gland weighs 20–25 g.

• The functioning unit is the lobule supplied by a single arteriole
and consists of 24–40 follicles lined with cuboidal epithelium.
• The follicle contains colloid in which thyroglobulin is stored
• Blood supply:
• Superior thyroid artery: arises from the external carotid
artery
• Inferior thyroid artery: arises from the thyrocervical trunk
• Thyroid -ima artery: arises from the innominate artery or
directly from the aorta
• - Venous drainage:
• Superior thyroid vein accompanies the same artery and
drains into the internal jugular vein
• Middle thyroid vein drains into the internal jugular vein
• Inferior thyroid vein drains into the brachiocephalic vein
• Lymphatic drainage: There is an extensive lymphatic network
within and around the gland.
• the subcapsular plexus drains principally to the central
compartment juxtathyroid – ‘Delphian’ and paratracheal
nodes and nodes on the superior and inferior thyroid veins
(level VI), and from there to the deep cervical (levels II, III,
IV and V) and mediastinal groups of nodes (level VII).

119
120
 HISTORY

• Symptoms of hyperthyroidism \ hypothyroidism

• Compression symptoms ( dyspnea , difficulty in swallowing ,
dilated neck veins & engorged face )
• Symptoms goes with malignancy ( the most important
Hoarseness of the voice ) ‘caused by a paralysis of one of the
recurrent laryngeal nerves, which means that the lump is likely
to be malignant and infiltrating the nerve ‘ .
• Past medical :- diabetes ( insulin dependent ) ,
• past surgical hx ( thyroidectomy ) ,
• Drug hx ( for e.x amiodarone is associated with a number of
side effects, including thyroid dysfunction (both hypo- and
hyperthyroidism) , previous hx of head & neck radiation tx
increase the risk of papillary and follicular thyroid cancers , any
antithyroid medications ? Such as Carbimazole and
propylthiouracil
• family Hx : most important for medullary thyroid Ca . in 20% are
hereditary
• The sudden enlargement of a lump caused by haemorrhage is
usually painful, whereas a fast-growing anaplastic carcinoma
is not usually painful until it invades nearby structures.

121
 THE EXAMINATION

General look :-
• is the patient agitated & nervous with starry eyes (
hyperthyroidism ) , or he \ she is depressed with slow
movements ( hypothyroidism ) ,
• Are they thin or fat? What is the distribution of any wasting or
fattening? Patients with thyrotoxicosis have a generalized loss
of weight, especially about the face
General examination :
• face :- looking for hair loss , eye brow ( loss of lateral third in
the hypothyroidism , eye signs of hyperthyroidism
• Hand :- Feel the pulse. Tachycardia suggests thyrotoxicosis
(hyperthyroidism); bradycardia suggests myxoedema
122
 THE EXAMINATION

In middle-aged and elderly patients, thyrotoxicosis may cause

atrial fibrillation , sweating , fine tremor ( more accurate by putting
a paper on the patient hands ) , thyroid Acropachy ( finger
clubbing ) .
• Legs :- to look for pretibial myxedema , also known as Graves'
dermopathy
Eye signs in thyrotoxicosis ( hyperthyroidisms )
1- Exopthalmous :- (If the eyeball is pushed forwards by an
increase in retro- orbital fat, oedema and cellular infiltration) ,
stand behind the pt. ant do neck extention , normally , the the
cheeks is first seen and then the eye brows and lastly the eyes
2- lid retraction ( caused by sympathetic overactivity of the
involuntary (smooth muscle) part of the levator palpebrae
superioris muscle. , normally the upper lid cover the limbus by 2
mm and the lower lid is at the level of the limbus
3- lid lag (When the upper lid does not keep pace with the eyeball
as it follows a finger moving from above downwards, the patient
has lid lag. )
4- Opthalmoplegia ( limitation of the upword and outword eye
movement , there will be difficulty in convergence , when the pt
asked to look for near object )
5- chemosis A thickened, crinkled, oedematous and slightly
opaque conjunctiva

123
124
 THE EXAMINATION
Local examination of the thyroid
• Introduce your self , take permission , explain ….
• Position :- sitting on a chair
• Exposure :- from the chin down to the nipple
• Inspection
• Palpation
• Percussion
• Auscultation
INSPECTION
• Looks for any obvious swelling ( full description 5 S ) , normally
the thyroid is not visible
• except the isthmus in very thin people
• In obese pt . You can see the thyroid swelling easier by doing by
Pizillo’s manoeuvre in which the patient’s hands are placed
behind their occiput and the head is pushed backwards against
the clasped hands
• Looks for scar of previous thyroidectomy ( may be recurrent
goiter )
• Looks for dilated veins , indicating retrosternal goiter and SVC
compression
Ask the patient to do 3 things :-
1. swallow :- The hallmark of a thyroid swelling is that the
swelling moves on deglutition
2. protrude the tongue :- for thyroglossal cyst
3. raising the arms above the shoulder may aggravate the
125
 THE EXAMINATION
prominent veins and induce facial flushing and stridor
(Pemberton’s sign) ( which is due to compression on the veins in
the thoracic inlet )

(Pemberton’s sign)

PA L PAT I O N
1. While you are doing inspection in front of the patient start to
do palpation for the trachea to look for any tracheal deviation
and then standing behind the patient :-
2. Place your thumbs on the ligamentum nuchae and tilt the
patient’s head slightly forwards to relax the anterior neck
muscles. Let the palmar surface of your fingers rest on each
side of the neck;.
3. At the end of palpation, you should know the following facts
about the gland and/or the lump: tenderness ( pain may occur
126
 THE EXAMINATION
in cases of acute and subacute thyroisitis & Anaplastic carcinoma
can cause local pain and pain referred to the ear if it infiltrates
surrounding structures.) , shape, size, surface ( nodular , smooth ,
diffuse hyperplastic ) and consistency (A hard consistency in a
nodule is not pathognomonic of malignancy as it may also arise
from calcification in a longstanding multinodular goitre) , fixation .
With a retrosternal extension of the thyroid, it is important to
assess whether you can feel the lower border of the gland on
swallowing or whether there is still a significant extension
lying behind the sternum.
3. A normal thyroid gland is not palpable.
4. Palpate the whole of the neck for any cervical and
supraclavicular lymphadenopathy.

PERCUSSION
Percussion is used to define the lower extent of a swelling that
extends below the suprasternal notch by percussing along the
clavicles and over the sternum and upper chest wall , to look for
retrosternal extentsion ( dullness on percussion )

AU S C U LTAT I O N
Listen over the swelling. Thyrotoxic ( graves disease ) and highly
vascular glands ( thyroid Ca ) may have a systolic bruit.

127
THYROID SWELLING

128
 THYROID SWELLING
1. solitary thyroid nodule
2. Multinodular goitres result from fluctuating levels of thyroid-
stimulating hormone (TSH) as a consequence of
I. iodine deficiency,
II. Goitrogens or dyshormonogenesis ,
III. secondary hyperthyroidism ( plummer syndrome ) .
Note :- The incidence of malignancy in a multinodular goitre
is lower than in a solitary thyroid nodule in endemic areas.
3. Diffuse enlargement of the thyroid gland occurring
I. at puberty is referred to as a physiological or simple
goitre. These are usually not associated with hypo- or
hyperfunctioning of the gland but are a response to
increased metabolic demands.
II. A similar enlargement may be seen in women during
pregnancy.
III. Diffuse goitre in a middle-aged woman may be due to
thyroiditis, most commonly chronic lymphocytic
(Hashimoto’s) thyroiditis. The gland may initially
hyperfunction, but the process eventually leads to
hypothyroidism. Hashimoto’s thyroiditis can occasionally
undergo malignant transformation into a lymphoma
4. primary hyperthyroidism ( Graves disease )

129
 THYROGLOSSAL CYST
• It is a midline tubulo dermoid cyst arising in thyroglossal duct
remnant.
• The thyroglossal duct has a variable relationship with the hyoid
bone
• They are commonly found in two sites: between the isthmus of
the thyroid gland and the hyoid bone( sub hyoid ), and just
above the hyoid bone ( suprahyoid ) .
CLINICAL FUTURES
• The cyst may present at any age, most common in childhood.
• Painless cystic swelling moving up and down on swallowing &
on protrusion of the tongue (due to its relation to hyoid bone).
• There may be a palpable track. Extending from the hyoid bone
upwards towards the tongue.
• The wall of the cyst is rich in lymphatics which may
communicate with the cervical lymph nodes, so infection may
be the presenting symptom and may even lead to fistula
formation when an infected thyroglossal cyst ruptures or is
incised.
T R EAT M E N T
• Surgical excision of the cyst and its associated tract then
removal of the middle third of the body of the hyoid bone
(Sistrunk. Operation).
• If the excision is incomplete, recurrence in the form of
thyroglossal cyst or fistula may result.
• In patients presenting by an infected cyst, treatment is by
antibiotics and drainage of the abscess
130
 THYROIDEOCTOMY
I N D I C AT I O N S
1. Risk of malignancy: FNAC positive thy3–5, clinical suspicion
(age, male sex, hard texture, fixity, recurrent laryngeal nerve
palsy, lymphadenopathy, recurrent cyst)
2. Toxic adenoma
3. Compression symptoms
4. Patient’s wish
5. Recurrent cyst
P R E PA R AT I O N I N A T H Y R O T O X I C PAT I E N T :
1. Carbimazole 30-40 mg divided into three doses until becoming
euthyroid, after 8-12 weeks of being euthyroid the dose
becomes 5 mg every 8 hours.
2. Beta blockers are given to reduce the symptoms of
hyperthyroidism related to sympathetic overstimulation and to
inhibit the peripheral conversion of T4 to T3. Thyroid
hormones will remain elevated but the effect on target organs
is blocked. Rapid symptomatic relief is achieved with beta
blockers
3. Iodine with carbimazole for 10 days preoperatively to reduce
the vascularity of the gland and may induce remission.
4. Informed consent
131
 THYROIDEOCTOMY

Position of the patient

• Supine on the operating table with the neck extended and in a
reverse trendelenburg’s position.
Incision
• Cervical collar incision
OPTIONS
1. Total lobectomy: Total lobectomy + isthmusectomy
2. Total thyroidectomy: 2x total lobectomy+ isthmusectomy
3. Near total thyroidectomy: One total lobectomy+
isthmusectomy+ One subtotal lobectomy
4. Subtotal thyroidectomy: 2x subtotal lobectomy+
isthmusectomy
• The selection is done based on surgeon’s experience, the
indication of surgery, patient’s age, likelihood for recurrence
and anticipation of thyroid or parathyroid insufficiency
postoperatively
CO M P L I C AT I O N S
1. Hemorrhage: Life threatening and may obstruct the airway.
Usually, it is presented in the first 24 hours (reactionary).
Presented as tension hematoma with stridor and airway
obstruction. It should be avoided by maintaining strict
hemostasis intraoperatively
2. Recurrent laryngeal nerve injury and voice changes: Either
unilateral or bilateral, transient or permanent. RLN should be
identified during operation and avoided. Vocal cord function

132
 THYROIDEOCTOMY

should be checked postoperatively by laryngoscopy.

3. Thyroid insufficiency: especially who underwent total
thyroidectomy. They need life-long replacement of Thyroxine.
4. Parathyroid insufficiency: only occurs in total thyroidectomy.
Either due to inadvertent removal of the parathyroid glands or
due to parathyroid ischemia. It is manifested as hypocalcemia
2-5 days postoperatively
5. Thyrotoxic crisis: due to inadequate preoperative preparation
in a thyrotoxic patient.
6. Wound infection
7. Keloid scar
8. Stich granuloma
P O STO P E R AT I V E C A R E
1. Regular inspection of wound for signs of hematoma formation
2. Serial calcium measurement and awareness of hypocalcemia
symptoms
3. Thyroxine replacement for patients with total thyroidectomy.
4. Clinic visit: review histology, inspect the wound, perform
laryngoscopy, check thyroid function test and serum calcium
level

133
 HYPOCALCIUM

• This occurs primarily as a result of surgical trauma or

inadvertent excision following thyroid surgery, and presents
with the signs and symptoms of hypocalcaemia
SYMPTOMS
• circumoral tingling, numbness, paraesthesias, carpopedal
spasm, laryngeal stridor, respiratory muscle spasm,
arrhythmias, convulsions and blurred vision..
Hypocalcaemia is clinically diagnosed by: ( signs )
• Chvostek’s sign: twitching of the facial muscle on stimulating
the facial nerve in front of the tragus ;
• Trousseau’s sign: inflation of a sphygmomanometer above
systolic blood pressure for 5 minutes induces carpal spasm,
that is, muscular contraction with flexion of the wrist and
metacarpophalangeal joints, hyperextension of the fingers and
flexion of the thumb onto the palm (also known as
obstetrician’s hand)

134
 EMERGENCY OF THYROID DIS.

MYXOEDEMA COMA
• is now uncommon but can result from prolonged, untreated
hypothyroidism. It is usually precipitated by triggering factors
such as hypothermia or infection. Patients present with
hypothermia, hypotension, hyponatremia, hypoventilation,
hypoglycemia, bradycardia, an altered sensorium, lethargy,
stupor and delirium that progresses to coma.
THYROID CRISIS OR THYROID STORM
• is caused by an excessive release of thyroid hormones into the
circulation. It manifests clinically with hyperpyrexia,
tachycardia and hypertension that progresses to cardiac
failure. It is commonly associated with neurological and
gastrointestinal symptoms. It was formerly seen in patients
inadequately prepared for surgery
• Tx of thyroid storm :- Specific treatment :-
• is with carbimazole 10–20mg 6-hourly,
• Propranolol intravenously (1–2mg) or orally (40mg 6-hourly)
• sodium iodide 1g intravenously .
• Iv hydrocortisone can be given

135
N E CK SWE L LING
• Swellings in the neck are a common surgical problem.
• As more than half the body’s lymph nodes are in this area
• nodal enlargement is the most common pathology
encountered in clinical practice.
• In addition, the neck contains many important anatomical
structures and undergoes a complex embryological
development, adding to the variety of swellings that may
occur.
The ‘rule of 80’ for neck swellings

• 80 per cent of neck swellings are lateral;

• 80 per cent of lateral neck swellings are nodal;
• 80 per cent of swellings in those less than 40 years of age
are inflammatory or congenital
• 80 per cent of swellings in those over 40 years of age are
malignant;
• 80 per cent of malignant swellings are squamous carcinoma

The ‘rule of 80’ for neck swellings

• Nodes over 1 cm in size warrant investigation.

• Nodes smaller than this are rarely a cause for concern and
are not investigated unless there is a high index of suspicion
of pathology.
• The exception to this rule is supraclavicular nodes, which
are investigated irrespective of size.
• In addition, the cut-off of size for jugulodigastric lymph
nodes requiring evaluation is 1.5 cm.

137
• The human tubercle bacillus can enter
the body via the tonsils, and from
there move to the cervical lymph
glands. The upper deep cervical
glands are most often affected ,
Tuberculosis is the most common cause of
chronic lymphadenopath
• The most common cause in
children is tonsillitis ,sore throat ,
recurrent upper resp. infections ,
Lymph from the tonsils drains to
the upper deep cervical lymph
glands. The gland just below and
deep to the angle of the mandible
is often called the tonsillar gland
(jugulodigastric node). This gland
and those just below it are likely
to be enlarged

Dx of LN swelling
• The clinical history plays an important role in the diagnosis of
neck swellings.
• A history of addiction to tobacco or alcohol suggests a
malignancy of the upper aerodigestive tract.
• Constitutional symptoms are usually associated with chronic
infections and lymphomas.
• The consistency of the node aids in diagnosis.
• Inflammatory nodes are firm,
• malignant nodes are hard,
• lymphomatous nodes are rubbery,
• cystic nodes are associated with caseation (tuberculosis,
when the classical signs of inflammation are lacking) or
abscess formation. Exceptions to this are large malignant
nodes (secondary to necrosis), human papillomavirus-
associated malignancies, and occasionally papillary thyroid.

138
• Regional adenopathy (the involvement of a single anatomical
area) is usually seen with localized pathologies, and
generalized adenopathy (the involvement of three or more
non-contiguous lymph node areas) is seen in chronic
infections and reticuloendothelial malignancies

139
 DDX

Don’t forget , salivary

gland swelling (
submandibular mainly
) lipoma , demoid
cyst . As a causes of
neck swelling

BRANCHIAL CYST

• A branchial cyst is a remnant of a branchial cleft, usually the second cleft,

and often appears from beneath the upper third of the sternomastoid
muscle . It is lined with squamous epithelium, but there are often
patches of lymphoid tissue in the wall that are connected with the other
lymph tissue in the neck and can become infected.

• Although these cysts are present at birth, they may not distend and
cause symptoms until adult life. The majority present between the ages
of 15 and 25 years, but they can present in childhood .

• The common presenting complaint is a painless swelling in the upper

lateral part of the neck. The lump may be painful when it first appears,
and later attacks of pain may be associated with an increase in size,
usually caused by infection in the lymphoid tissue in the cyst wall
140
 cystic hygroma (congenital lymphangioma)

• A cystic hygroma is a congenital collection of lymphatic

sacs that contain clear, colourless lymph. They are
probably derived from clusters of lymph channels that
failed, during intrauterine development, to connect with
and become normal lymphatic pathways. Located are
commonly found around the base of the neck ,usually in
the posterior triangle .
• The majority of cystic hygromas present at birth or within
the first few years of life , but they occasionally stay empty
until infection or trauma in adult life causes them to fill up
and become visible
• The main symptoms is the disfiguring lump
• Cystic hygromas are soft and dull to percussion. They
fluctuate easily,and compressible but their distinctive
physical sign is a brilliant translucence

Salivary gland enlargement

• Inflammation and neoplasms of the submandibular gland may

present as neck swellings
• The most common surgical conditions affecting the salivary
glands are:
• infection and calculus formation in the submandibular
gland;
• tumours of the parotid gland ( the most common one is
pleomorphic adenoma ).
• Mumps is the most common medical disease
141
142
T HE B R E A S T

Two station in final exam

one for history and one
for examination
 IMPORTANT POINTS IN THE HX

• AGE
• young females rarely have Ca , but over the age of 70
yrs. must of breast lumps are Ca ,
• Benign breast disease is a common entity in women
aged 20–40 and covers a wide spectrum of
conditions.
• Now the age without significant it can be occur in any
age
• Address :- the recent and the previous one ( to look for any
risk of radiation )
• Job :- the recent and previous ( any risk of Radiation ? )

COMPLAIN

• Painless lump ( most common cause Ca , cyst ,

fibroadenoma )
• Painful lump ( periductal mastitis , abscess “ bacterial
mastitis “ , fibrocystic dis.)
• Breast pain ( cyclical breast pain most common cause )
• Nipple discharge ( many causes )
• Skin changes ( eczema & pagets diseases )
• changes in nipple and areola ( Ca , duct ectasia )
• All these + duration is important

144
 Notes

• Pain and tenderness are more common with benign

problems but are also seen with breast cancer.
• May be there is double complain so, you should ask about
which one began first.
• Date of admission we mention it in pre op only

History of present illness

• Pain
• Precyclic
• First day of cycle is first drop of blood not when
she became clean from blood
• Continuous or intermittent
• Pain can be precipitated by
• Anxiety
• Heavy wight lifting
• Time of the pain
• September and march for seasonal cleaning so she will
do a heavy work
• Size increase or decrease
• Nipple discharge
• We are looking for color
• Don’t say bloody we say red color
• How many drops
• Bra wetting

Review of systems

• No need
145
 GYNECOLOGICAL HIS.

• Previous pregnancies and apportions

• How many children has the patient had? Were the children
breast-fed and, if so, for how long?
Parity and breast-feeding reduce the incidence of breast cancer:
a mother of five breast-fed children is less likely to have breast
cancer than a nulliparous woman of the same age.
• Cycle
• Regular or not
• Days
• 10 days after cycle is the best time for examination

Pat medical and surgical

• Thyroid
• DM
• Cough
• Surgeries for
• Thyroid
• Breast
• Ovaries
• Uterus
• Suprarenal gland
146
 Drugs History

• oral contraceptive pills

• Oral contraceptives reduce the severity of cyclical
change in the breasts.
• radiotherapy
• chemotherapy
• Hormone replacement therapy taken by menopausal and
postmenopausal patients extends the age at which they are
likely to suffer from benign conditions such as breast cysts.
• Steroid
• can cause a gynecomastia in male and then end with
pendules breast
• DM drugs
• Prostate drugs
• Which can use in beauty care centers to use their side
effect(gynecomastia) to enlarge breast and lead
pendules

SOCIAL AND FAMILY HIS.

• History of relative breast problems

• History of alcohol and smoking past and present

147
148
 THE EXAMINATION

1. Don’t forget introduce your self , take permission , explain

what s you are going to do
2. Position
• Standing : for well developed
• Supine: for small breast
• Setting
• Semi setting: 45 degree for elderly
3. Exposure
• the patient should be undressed from suprasternal
notch to the umbilicus and bilateral breast should be
exposed
• Should be gentle exposure not intense because if there
is a fibro adenoma can be move and will miss the
diagnosis
4. Take care to ensure that the examining room is warm,
comfortable and private with good light

149
 INSPECTION

• For 6th grade student exam, the just pathological one

• Looking for
• Asymmetry
• Skin changes
• Nipple and areola
• Asymmetry
• The lift breast normally more pendules than right to
prevent crush trauma
• Skin change
• Visible mass
• Skin ulcer
• Orifice
• Scar
• Dilated vein
• Redness and edema
• peau de orange appearance (results from
subcutaneous oedema goes with ca , is due to
lymphatic obstruction )
• Pickering

150
 INSPECTION

• Areola
• Pale: young
• Brown: pregnancy
• Dark brown: lactating
• Nipple

• Normal hire around the areola

• Small nodule around areola (Montgomery nodule) if it
become large called tubercle
• Then ask the patient to raise the arms above her head to
look for axilla and tethering of the skin

PALPATION

There are 2 ways of palpation :-

• Tips of the fingers and the thumb in well developed breast
• And flat fingers in small breast ( pt. is supine and against
chest wall )
▪ Using Rt. hand for the Rt. breast and vice versa …. ,
▪ start with the normal breast
▪ May be there is 2 masses so do not left your hand if feel a
mass and complete your examination
151
 PALPATION

• ask patient to push against wall by two her hands to

identify if the mass related to pectoralis fascia or not
• its less mobile horizontally and more mobile vertically

• ask patient to put her hand on her hip ( thumb

anteriorly and fingers posterior) to identify if the mass
related to serratus ant muscle
• its less mobile horizontally and more mobile vertically

152
 LYMPH NODES

• While the woman is still sitting up with her hands on her

hips,feel the axillae for lumps. Have her relax her muscles.
• Lymph nodes associated with breast cancer are divided into
three levels
▪ LEVEL I
• nodes lie along the chest wall lateral to the pectoralis
minor muscle
▪ LEVEL II
• nodes lie under the pectoralis minor muscle
▪ LEVEL III
• nodes lie high at the apex of the axilla medial to
pectoralis minor.
• Level I and II nodes are most easily felt by examining both
sides simultaneously, placing a hand high up on each lateral
chest wall and then sliding the fingers down.
• Small mobile nodes are often felt bilaterally in slender young
women but the presence of unilateral enlarged nodes
suggests underlying malignancy.
• Note the size, mobility and texture of any nodes.
• Similarly, feel the supraclavicular fossae for nodes, generally a
sign of more advanced malignancy

153
 LYMPH NODES LEVELS

NIPPLE & AREOLA

• If there is nipple inversion, it may be possible to evert it by

gentle squeezing its base or by asking the patient do it for
you.
• Nipple inversion that is easily everted is not an abnormality. If
the nipple will not evert, there is likely to be underlying
disease.
• Unilateral inversion is more significant than bilateral
inversion.
• If there is said to be a discharge, it may be possible to express
it by gently pressing the areola around the base of the nipple
and observing whether any fluid comes from one or many
duct orifices.
• The character of the fluid should be noted.
• Nipple discharges may be red, white, creamy yellow or watery

154
Nipple Retraction

155
 ECZEMA VS PAGET

• But the most PATHOGNOMONIC FEATURE to differentiate.

between the 2 , Paget's disease , will not respond to the
topical steroids use
Q\What the type of Ca that associated with the pagets dis.? Ca
in situ and then invasive ductal Ca

156
 GENERAL EXAMINATION

• General examination A full general examination is essential to

detect the presence of metastases, which commonly occur at
the following sites.
• The skeleton – especially the lumbar spine, causing back pain
and reduced spinal movements, and pathological fractures in
long bones. There may even be paraplegia from cord
compression
• The lungs – causing pleural effusions. Lung parenchymal
involvement, in the form of diffuse lymphatic involvement
known as lymphangitis carcinomatosa, may cause severe
dyspnea.
• The liver – making it palpable and causing jaundice and
ascites.
• The skin – producing multiple hard nodules within the skin.
These are usually in the skin of the breast containing the
cancer, but may be seen in the neck, trunk and further away.
• The brain – producing any variety of neurological symptoms
and signs.

157
 DISCHARGE

TRIPLE ASSESSMENT

158
 MASTECTOMY type

• SIMPLE OR TOTAL MASTECTOMY

• is the removal of the breast tissue with its skin and the
nipple But without Lymph nodes dissection
• THE RADICAL HALSTED MASTECTOMY
• which included excision of the breast, axillary lymph
nodes and pectoralis major and minor muscles, is no
longer indicated as it causes excessive morbidity with no
survival benefit
• (MODIFIED RADICAL ) PATEY MASTECTOMY
• The breast and associated structures are dissected
• ENBLOC and the excised mass is composed of :
• the whole breast;
• a large portion of skin, the center of which overlies the
tumor but which always includes the nipple; all of the
fat, fascia and lymph nodes of the axilla.

159
 MASTECTOMY indications

1. Large tumor in relation to the breast size

2. Central Tumor beneath or involving the nipple
3. Multifocal disease
4. Local recurrence
5. Patient preference
6. persistent + pathological margin
7. previous high dose chest radiotherapy

MASTECTOMY complications

1. seroma and hematoma collections

2. nerve injury :-
I. long thoracic N. ( supplying serratous anterior ) winging
of the scapula
II. Injury to the thoracodorsal nerve is one of the
complications related to the axillary dissection. The
thoracodorsal nerve innervates the latissimus dorsi
muscle
III. intercostal brachial N. injury post mastectomy pain
syndrome
3. movement problems ( due to N. injury and pectoralis minor
m. division or retraction) , sensation changes post Op.
160
 MASTECTOMY complications

4. vascular :- injury and thrombosis of the axillary vein

5. wound infection
6. lymphedema
7. psychological impacts :-over 30% of women develop
significant anxiety and depression following both radical and
conservative surgery

R I S K F A C T O R S for cancer

• Age
• Carcinoma of the breast is extremely rare below the age
of 20 years but, thereafter, the incidence steadily rises
so that by the age of 90 years nearly 20% of women are
affected
• Gender
• Less than 0.5% of patients with breast cancer are male
• Genetic
• It occurs more commonly in women with a family
history of breast cancer than in the general population.
Breast cancer related to a specific mutation accounts for
about 5% of breast cancers .

161
 R I S K F A C T O R S for cancer

• Diet
• A high intake of alcohol is associated with an increased
risk of developing breast cancer.
• Endocrine
• Breast cancer is more common in nulliparous women
and breastfeeding in particular appears to be
protective.
• Also protective is having a first child at an early age,
especially if associated with late menarche and early
menopause.
• It is known that in postmenopausal women, breast
cancer is more common in the obese. This is thought to
be because of an increased conversion of steroid
hormones to estradiol in the body fat.
• Previous radiation :- a real problem in women who have
been treated with mantle radiotherapy as part of the
management of Hodgkin’s disease, in which significant doses
of radiation to the breast are received . The risk appears
about a decade after treatment and is higher if radiotherapy
occurred during breast development.

162
Upper outer quadrant the most common site of
breast ca

163
164
UCLER
 ULCER

• Def. :- An ulcer is a persistent discontinuity of an epithelial

surface that can occur in the skin or in the mucosa of the
alimentary and respiratory passages.
Causes of leg ulcer :- DDx
• Vascular → venous , arterial , mixed
• Neuropathic → DM
• Trauma → pressure , injury , burn
• Tumor → squamous cell Ca
• Metabolic → DM , gout
• Infection → necrotizing fasciitis
• Pyoderma gangrenosum → inflammatory bowel dis.
• Hypertensive ulcers
• Hematological → sickle cell disease

ULCER examination

• Exam. Of the ulcer :- inspection , palpation , exam of others

• Ulcer examination : site, size , shape , edge, base and surrounding tissues
(‘3SEBS’)
Site :-
• Venous ulcers are sited just above the malleolus. They are
usually medial .
166
 ULCER examination

• Arterial ulcers are situated distally, that is, over the tips of
the toes and between the toes. lowest, and over the
malleoli and heels where minor pressure such as lying in a
bed .
• Neuropathic ulcer usually at the pressure site like the sole
of the foot
• The most common site for a diabetic neuropathic ulcer is
therefore over the heads of the first and second
metatarsals.
• Malignant ulcers can also occur in typical locations; for
example, rodent ulcers (basal cell carcinomas) occur on
the upper part of the face
• Decubitus ulcers ( pressure sore – bed sore ) in the sacral
area in the lower back)

167
 ULCER examination

Edges :-
• Flat sloping– venous or septic, often with a transparent
healing edge along part of its circumference.
• Punched-out – biopsy , Sx , syphilitic, trophic, diabetic,
ischaemic , leprosy.
• Undermined – tuberculosis, pressure necrosis; particularly
over the buttocks, carbuncles.
• Raised – rodent ulcer often with a slightly rolled
appearance.
• Raised and everted – carcinoma .

168
 ULCER examination

The Base
• (The base provides an indication of the ulcer’s progress)
• In the base, note the depth, the covering (the floor) and
any discharge.
The floor may be :-
• With ischaemic ulcers, it is not uncommon to see fascia,
tendons, bones and joints in their base.
• Initially, there is an inflammatory response with the
production of slough a yellowish, adherent surface made
up of dead tissue and inflammatory cells stimulated by
trauma and subsequent infection.
• Signs of a healing in an ulcer occur when the slough is
replaced by granulation tissue and the skin creeps in over
the granulating surface. Granulation is usually pink with
red dots at the site of the capillary loops

169
 ULCER examination

Surroundings :-
• Induration of the surrounding tissues is seen particularly
in the inflammatory response to infection, trauma and
malignancy, or it may be from direct invasion in a
malignant process
• Pigmentation is common around a venous ulcer, and the
surrounding skin may be scarred from previous ulceration
• If the prime aetiology of the ulcer is neuropathic, there is
sensory loss over the adjacent skin, and reduced sweating
in an autonomic neuropathy.
Palpation of the ulcer :-
Tenderness , Temperature , fixation
Lastly :-
Examination of the region involved (e.g. lower limb ),
examination of the vascular system ( arterial and venous) ,
neurological examination ( motor and sensory )and
examination of lymph node basin.

170
 ULCER

I N V EST I G AT I O N S
• Biochemical: Complete blood count , Fasting blood sugar,
renal function test.
• Microbiological : culture and sensitivity from the
discharge.
• Histopathological : exclude malignancy by biopsy
• Radiological : X ray of the involved part ( to exclude
osteomyelitis), chest X ray ( TB )…etc.
• T R EAT M E N T I N G E N E R A L :
• Treat and control underlying cause
• Exclude malignancy.
• Regular dressing and hygiene.
• Skin grafting if needed

171
Diabetic foot
 MAIN CAUSES
1. Angiopathy (Vasculo-pathy)(ischemic)
A. Macro-angiopathy
• atherosclerosis (PAD).
B. Micro-angiopathy
• decreased nutrient & oxygen exchange with resultant
tissue ischemia.
• Thickening of the capillary BM.
• Increased platelet aggregation & adhesion with micro-thrombi
formation
• this will reduce the blood flow and thus a minor wound will be
difficult to heal and resulting in ischemic pain at rest . This will
increase the Risk of infection also of anaerobic micro-
organisms .
• Vasa nervosa ischemia
• the blood supplying the nerves will be diminished
2. Neuropathy:
A. Sensory:
• Radicular pain.
• Paresthesia & anaesthesia.
• Loss of vibration & position sense.
B. Motor
• muscle weakness with resultant foot deformities (hammered
toes & claw toes).
C. Autonomic:
• Impaired vascular tone (altered blood flow regulation,
abnormal vaso-dilatation).
• Anhydrosis (dry skin with cracking & fissuring).
173
 MAIN CAUSES
2. Neuropathy:
• loss of pain perception
• the small injuries will go unnoticed , this is with ischemia
are the most important factors in the development of
foot problems
• Paralysis of the small M. of the foot
• leading to Clawing of the toes and decrease effective load
bearing area for the foot
• Autonomic neuropathy
• failure of reflex dilation in response to local injury ,
Abnormal vasoconstriction in response to cold , loss of
sweating that make the skin thin and dry
3. Immunopathy
• impaired cellular & humeral immunity with hyperglycemia
• due to impaired immunity , more than 70 % infection are multi
microbial Gram + & Gram - & anaerobes
• Usually, the cause of diabetic foot trophic ulcer is combination
of these 3

174
 CLINICAL PRESENTATION

• The neuropathic foot:

• Warm with palpable pulses.
• Dry.
• Calluses & painless ulcers at pressure points.
• Charcot’s joints (in severe cases).
• Sensory loss & diminished deep tendon reflexes.
• The Ischaemic foot:
• Claudication and rest pain.
• Cold with absent pulses.
• Calluses & painful ulcers.
• Normal sensory & motor functions.
• Combined neuro-ischemic foot.

COMPLICATIONS

1. Skin changes (dryness, calluses, cracks & fissures).

2. Foot ulcers & infection.
3. Diabetic gangrene.
4. Charcot’s foot (neuro-arthropathy).
5. Amputation.

175
 HISTORY

GENERAL & MEDICAL HISTORY

• Details of DM: Duration, type & control.
• Diabetic complications: CVS, ophthalmic, renal.
• Past Medical & Surgical history
• Past medical :- important to ask about previous
hospital admission for ischemic heart disease ? ,
stroke ? , any complication of DM like DKA ,
hypoglycemia .
• Past surgical :- any previous toe , limb amputation ?
• Drug history & drug allergy.
• Social history: smoking, alcohol & occupation.
• You should almost always start the History of present illness
as for e.x a 35 yrs old female with a known hx of dm ,
diagnosed before 5 yrs by the HBA1C measurement

• SPECIFIC FOOT HISTORY

• Skin & nail problems: sweaty feet / fungal infections / skin
disease / blisters.
• Neuropathy and ischemic symptoms.
• Callus formation.
• Deformities and previous foot surgery.
• Daily activity & current foot status

176
 EXAMINATION

INSPECTION: Look
• Skin: discoloration, hair, calluses, infection, ulcers.
• any black , bluish toes ( Don’t say gangrenous be. Most of
the patients are familiar with these words ) , any clawing
of the toes which indicating neuropathy
Soft tissue: swelling.
Bone: deformities (hammered toes, claw toes, Charcot’s foot, loss
of arch).
Examination of the ulcer
• (to determine whether it’s predominantly ischemic (critical
limbischemia*), neuropathic or combined
• check between the digits , and the pressure area for any ulcers
( Describe the ulcers ‘ ulcer exam. ‘ )
PALPATION: feel
1. Temperature.
2. Tenderness.
3. Capillary re-filling.
4. Pulses.
5. Neurological examination:
• Monofilament sensory examination: big toe, first & fifth
metatarsal heads.
• start to prick the chest to make the patient know the
sensation and then do it for the lower limbs
• Tuning fork (128 Hz): for proprioception.
MOVE
• ask the patient to stand from squatting position this will
just give you some idea about the motor function

177
 INVESTAGATION

GENERAL INVESTIGATIONS INCLUDING

ESR , CBC , Renal function tests , Liver function test , ECG
SPECIFIC INVESTIGATIONS
• Random
• fasting blood glucose
• post prandial 2 hrs
• HBA1C
• Swab for culture and sensitivity
IMAGING :-
• Plain radiograph , it may show deformity , osteomyelitis ,
osteoporosis and I can see gas shadow in gas gangrene
and atherosclerotic changes in the form of calcified vessels
• Doppler US :- to see the blood flow in the lower limbs and
we can do Ankle brachial pressure index if it is less than
0.5 arterial reconstruction or Amputation
• If the decision of Op. and imputation is taken we should do
Arteriography

178
 MANAGEMENT

1. Admission to the hospital

2. correct the hyperglycemic state
• by putting the patient on a sliding scale on soluble
insulin , 4 times checking per day every 6 hrs and each
time checking the blood sugar , you give Tx accordingly
until end up with controlled blood G level
3. start parental empirical antibiotics until the result of culture
and sensitivity to reduce the spread of the infection , to
treat cellulitis surrounding the lesion , to prevent
development of infection after Sx ( amputation if needed )
,3rd generation Cephalosporin for gram + , Metronidazole
for gram – and anaerobes
4. Correct Anemia to enhance healing
5. Rest and avoid any mechanical trauma to facilitate healing
6. conservative Tx which include
• cleansing the wound twice daily with normal saline &
• excision of the thickened dead skin to induce healing
and then dressing with povidone iodine
7. if abscess is present , it should be drained and left open for
daily dressing .
8. excision of any gangrenous tissues until reaching a healthy
margin
9. Amputation if there is any indication for that

179
 WAGNERS CLASSIFICATION

• Grade 0
• no open lesion , just deformity of the foot can be seen like
clawing of the toes , hallux valgus
• Grade 1
• skin lesion of either full or partial thickness but superficial
• Grade 2
• the open lesion penetrates to the M. , tendon , Lig. and
bone
• Grade 3
• there is osteomyelitis , plantar space abscess , joint sepsis
• Grade 4
• gangrene in some part of the toe or forefoot & there may
be surrounding cellulitis
• Grade 5
• gangrene involves the whole foot or such percentage
that’s no clinical procedure is helpful and a higher
amputation is necessary .

180
Sinus and
fistula
 SINUS
• Sinus :- Blind-ending tract that connects a cavity lined with
granulation tissue (often an abscess cavity) with an epithelial
surface.
Classification of sinuses:
• Congenital: failure of obliteration of embryonic ducts during
development.
• Acquired sinuses : causes
1-inadequate drainage of an abscess.
2- Chronic infection , like The tuberculous, syphilitic and
leprosy bacteria, the fungal infection
actinomycosis .
3- A foreign body in an abscess cavity stimulates a prolonged
inflammatory response and recurrent infection. A foreign
body may gain access through injury, as with clothing
material, or at operation, such as with a non-absorbable
suture
4- crohns disease
5- intra Abd. Malignancy
• Clinical presentation :- A sinus can give symptoms through
recurrent discharge and recurrent bouts of acute infection of
the abscess cavity.
• Treatment of the sinus :
• Treat underlying cause.
• Biopsy should be taken to exclude malignancy.
• Surgical treatment of the sinus according to the cause.
182
 FISTULA
• Def :- Abnormal communication between two epithelial lined
surfaces . the communication maybe lined by granulation
tissue or epithelium in chronic cases.
• Classification of fistulae:
• Congenital : Tracheoesophageal fistulae, branchial fistulae.
• Acquired:
• in Crohn’s disease :- Enterocutaneous fistulae , between
loops of gut (entero-enteric fistulas) ,
• Between the gut and the bladder (entero-vesicular
fistulas) in diverticulitis or malignant disease of either
organ.
• postoperative anastomotic complications
• fistula in ano, Perianal abscesses may communicate with
the rectum and the anal canal, and in these cases surgical
drainage produces a fistula that may persist with
continued discharge .
• traumatic AV fistulae,
• iatrogenic.
• Causes of non- healing fistulae: (FRIEND mnemonic)
• Foreign body
• Radiation
• Infection
• Epithelialization
• Neoplasm
• Distal obstruction
183
 FISTULA

• Treatment:
• Exclude malignancy
• Treat the underlying cause.
• Surgical resection according to the cause

184
Anorectal
Diseases
 RECTUM
A N ATO M Y O F T H E R EC T U M
• The rectum measures approximately 15 cm in length
• It is divided into lower, middle and upper thirds
• The blood supply consists of superior, middle and inferior rectal
vessels
• The superior rectal artery is the direct continuation of the
inferior mesenteric artery and is the main arterial supply
of the rectum.
• The middle rectal artery arises on each side from the
internal iliac artery
• The inferior rectal artery arises on each side from the
internal pudendal artery
• The lymphatic drainage follows the blood supply. The principal
route of drainage is upwards along the superior rectal vessels
to the para-aortic nodes, although the lower rectum can drain
to lymphatics along the lateral pelvic side walls
M A I N S Y M P T O M S O F R E C TA L D I S E A S E
• Fresh bleeding per rectum
• Altered bowel habit with loose stool
• Mucus discharge
• Tenesmus
• Prolapse
• Proctalgia (pain)

186
 ANUS

A N A L C A N A L A N ATO M Y
• The internal sphincter is composed of circular, non-striated
involuntary muscle supplied by autonomic nerves
• The external sphincter is composed of striated voluntary
muscle supplied by the pudendal nerve
• Extensions from the longitudinal muscle layer support the
sphincter complex
• The space between sphincters is known as the intersphincteric
plane
• The superior part of the external sphincter fuses with the
puborectalis muscle, which is essential for maintaining the
anorectal angle, necessary for continence
• The lower part of the anal canal is lined by sensitive squamous
epithelium
• Blood supply to the anal canal is via superior, middle and
inferior rectal vessels
• Lymphatic drainage of the
lower half of the anal canal
goes to inguinal lymph
nodes
• Lymphatic drainage of the
upper half to the para
aortic lymph nodes

187
 AUNORECTAL EXAMINATION

1) introduce your self , take permission , explain , Privacy ,

equipment ( you need gloves , surgical lubricant or Xylocaine ,
good lighting , Tissue to clean the area after completing the
procedure
2) positions :- we have 4 positions to do PR
I. knee elbow (genucubital) position mainly for males
II. Left lateral (Sims) maily for females
III. Dorsal for elderly
IV. Lithiotomy for PR under GA which is done in patient with
anal fissures
3) exposure from the lower back to mid thigh
4) inspection
5) digital per rectal exam.
6) proctoscopy & sigmoidoscopy

188
 INSPECTION

1) If you see the sulcus only , try to pull the buttocks away to see
clearly the anal verge and margins , Look for:
I. skin rashes and excoriation,
II. faecal soiling, blood or mucus,
III. scarring, or the opening of a fistula,
IV. lumps and bumps (e.g. polyps, papillomata,
condylomata, a peri-anal haematoma, prolapsed piles, or
even a carcinoma),
V. ulcers, especially fissures.
2) You have to localize the site of the lesion as a face of the clock
3) Then ask the patient to strain to look for :- rectal prolapse ,
hemorrhoids prolapse , bulging mass , discharge coming out
on straining , incontinence and ask if the straining is painful

• Anal fissure :- causing ulcers most commonly on the

posterior part 90% why ? Bec . The distal part ( 3 rd part of
the rectum) is very curved and any accumulation of feces in
this part will cause pressure necrosis to the area ,
• While Ant, ulcers which accounts about 5% are caused by
Preg. , Crhons disease , Anal sex .
• Lateral ulcers are non specific

189
 DIGITAL PER RECTAL EXAM.

1. First take a drop of lubricant with the index only and put it
around the anal Verge and then press on the anus and
remove your finger ( this to induce relaxation of the anal
sphincter
2. Then introduce your finger with rotating hand
3. Look for abnormality
A. Intraluminal ( you can get around the lesion ‘ separating
the lesions from the walls ‘ ) :- normally there is feces ,
abnormally when there are FB , Polyp
B. Intramural :- hemorrhoids ( soft , gelly like structures ) ,
hard goes with CA , and ask the patient to strain to assess
the tone of the sphincter
C. Extramural :- you have to know the relation to the rectum
I. Start Ant. prostate in male , cervix in female
II. Left lateral :- empty area
III. Posteriorly in male there is coccyx bone ( Bec its
curved in male while straight in females )
IV. Right lateral empty area
4. After finishing the procedure withdraw the index in rotation
and clean the anus Area with Tissues and cover the patient
and thank the patient (there is a point in exam for this so you
should do it)

190
191
What are the causes of anal pain ?
Main causes :-
• anal fissures mainly on defecation
• Perianal abscesses
• perianal hematomas
• complicated hemorrhoids
• Rectal ca can cause pain by
following mech.

192
 ANAL FISSURES

Def. :- is a longitudinal split in the anoderm of the distal anal canal

, which extends from the anal verge proximally towards, but not
beyond, the dentate line.
Causes :-
1. Mainly occurs on the posterior wall& midline ( ischemic
fissures due to pressure necrosis ), acute anal fissures arise
from the trauma caused by the strained evacuation of a hard
stool ( patient with chronic constipation ) , less commonly,
from the repeated passage of diarrhoea.
2. When it occurs in the anterior wall which is most commonly in
females , the causes are :- Vaginal delivery , pregnancy ,
Crhons disease , Anal sex , Anterior fissures account for about
10% of those encountered in women but only 1% in men.
3. Fissures at the lateral side with atypical features should raise
the suspicion of a specific aetiology, and failure of adequate
examination in the clinic should prompt early examination
under anaesthesia, with biopsy and culture to exclude Crohn’s
disease, tuberculosis, sexually transmitted or human
immunodeficiency virus (HIV)-related ulcers (syphilis,
Chlamydia, chancroid, lymphogranuloma venereum, HSV,
cytomegalovirus, Kaposi’s sarcoma, B-cell lymphoma) and
squamous cell carcinoma

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 ANAL FISSURES

C L I N I C A L F U T U R E S

which usually resolves

spontaneously after a
variable time only to recur
at the next evacuation

That may cause anal

itching

Chronic fissures are characterized by a

hypertrophied anal papilla internally and a
sentinel tag externally (both consequent upon
attempts at healing and breakdown)

When chronic, patients may also complain of

itching secondary to irritation from the
sentinel tag, discharge from the ulcer or
discharge from an associated inter sphincteric
fistula, which has arisen through infection
penetrating via the fissure base

T R E A T M E N T

Conservative :-
conservative management should result in the healing of almost
all acute and the majority of chronic fissures.
addition of fibres to the diet to bulk up the stool, stool softeners
and adequate water intake are simple and helpful measures.
Warm baths and topical local anesthetic agents relieve pain.
The mainstay of current conservative management is the topical
application of pharmacological agents that relax the internal
sphincter, most commonly nitric oxide donors (Scholefield); by
194
 ANAL FISSURES

reducing spasm, pain is relieved, and increased vascular perfusion

promotes healing. , Such agents include glyceryl trinitrate (GTN)
0.2% applied four times per day to the anal margin (although this
may cause headaches) and diltiazem 2% applied twice daily
Operative :-
• surgery if above fails, that consisting of lateral internal
sphincterotomy ir anal advancement flab
• In this operation, the internal sphincter is divided away from
the fissure itself
• Early complications of sphincterotomy include
• haemorrhage, haematoma, bruising, perianal abscess and
fistula.
• Despite low recurrence rates the most important complication
is incontinence of a variable nature and severity, which may
affect up to 30% of patients, particularly women, who have
weaker, shorter sphincter complexes

195
 HAEMORRHOIDS

Def. :-
• Internal haemorrhoids are symptomatic anal cushions and
characteristically lie in the 3, 7 and 11 o’clock positions (with
the patient in the lithotomy position). ,
• External haemorrhoids relate to venous channels of the
inferior haemorrhoidal plexus deep in the skin surrounding the
anal verge and are not true haemorrhoids; they are usually
only recognised as a result of a complication, which is most
typically a painful solitary acute thrombosis.
• The primary hemorrhoids , there are many theories regarding
that suggests the causes
• The hemorrhoids may be secondary to some conditions :-
• The most important causeis carcinoma of the anorectum
• local, e.g. anorectal deformity, hypotonic anal
sphincter;
• abdominal, e.g. ascites;
• pelvic, e.g. gravid uterus, uterine neoplasm (fibroid,
carcinoma of the uterus or cervix), ovarian neoplasm,
bladder carcinoma;
• neurological, e.g. paraplegia, multiple sclerosis.

196
 HAEMORRHOIDS

C L I N I C A L F U T U R E S

is the principal and earliest symptom.

Patients may complain of true ‘piles’, lumps that appear

at the anal orifice during defaecation and which return
spontaneously afterwards (second-degree )

patients may complain of anal irritation, which may occur as a

result of mucus secretion

True strangulated haemorrhoids usually

present as an emergency.
They are associated with severe, constant,
unremitting pain. On examination, large pile
masses are seen to be protruding from the
anal orifice, with gross oedema and later
ulceration

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 HAEMORRHOIDS

• Strangulation, thrombosis and gangrene In these cases it was

formerly believed that surgery would promote portal
pyaemia. However, if adequate antibiotic cover is given from
the start, this is not found to be so, and immediate surgery
can be justified in many patients . Besides adequate pain
relief, bed rest with frequent hot baths and warm or cold
saline compresses with firm pressure usually cause the pile
mass to shrink considerably in 3–4 days.

T R E A T M E N T

Exclusion of other causes of rectal bleeding, especially

colorectal malignancy, is the first priority.

the submucosal injection of 5% phenol in arachis oil or almond oil, at the

apex of pile . The aim is to create fibrosis, cause obliteration of the vascular
channels and hitch up the anorectal mucosa. With the awake patient in the
left lateral position and under direct vision with a proctoscope, about 5ml of
sclerosant is injected

Pre op. preparation :-It is usual for the patient to have been
1-taking stool softeners in the days before surgery and a
2-preoperative enema to empty the rectum is administered.
3-The perianal skin is shaved and a formal examination performed.
Haemorrhoidectomy can be performed using an open or a closed technique
the submucosal injection of 5% phenol in arachis oil or almond oil,

198
 HAEMORRHOIDS

other strong indication for surgery is

haemorrhoidal bleeding sufficient to cause
anaemia

PERIANAL HEMATOMA
A perianal haematoma (thrombosed external haemorrhoid) is a 5–
10 mm thrombosed vein in the subcutaneous perianal venous
plexus. The lesion is usually of sudden onset and exquisitely
painful. The lump is blue and tender, and visible at the anal verge.
The pain takes 4–5 days to resolve and the lesion slowly fibroses,
often leaving a palpable, persistent nodule .
199
 Pilonidal sinus (PNS)
Def :-
• pilonidal sinus describes a condition found in the natal cleft
overlying the coccyx, consisting of one or more, usually
noninfected, midline openings, which communicate with a
fibrous track lined by granulation tissue and containing hair
lying loosely within the lumen.
• Hair follicles have almost never been demonstrated in the walls
of the sinus.
• The hairs projecting from the sinus are dead hairs, with their
pointed ends directed towards the blind end of the sinus.
Other possible sites ?
• Interdigital in the hairdressers and the umbilicus
CF :-
• (82% occur between the ages of 20 and 29 years) , The disease
mostly affects men, in particular hairy men. and is
characteristically seen in dark-haired individuals rather than
those with softer blond hair ,
• Recurrence is common, even though adequate excision of the
track is carried out.
• Patients complain of intermittent pain, swelling and discharge
at the base of the spine but little in the way of constitutional
symptoms.
• There is often a history of repeated abscesses that have burst
spontaneously, or which have been incised, usually away from
the midline
200
 Pilonidal sinus (PNS)

• Starting with conservative :- , simple cleaning out of the tracks and

removal of all hair, with regular shaving of the area and strict hygiene,
may be recommended.

• If an abscess develop ? → baths, local antiseptic dressings and

the administration of a broad-spectrum antibiotic

• If it fails ? → the abscess should be drained through a small

longitudinal incision made over the abscess and off the midline,
with thorough curettage of granulation tissue and hair.

• Treatment of a chronic PNS is Sx , one of the Sx that can be done is

Bascom’s procedure involves an incision lateral to the midline to gain
access to the sinus cavity, which is rid of hair and granulation tissue
and excision and closure of the midline pits .The lateral wound is left
open .

• postoperative wound care is important and centres around

elimination of hair (ingrown, local or other) from the wound.

The primary sinus may have one or many openings, all

of which are strictly in the midline between the level of
the sacrococcygeal joint and the tip of the coccyx.

201
 ANO RECTAL ABSCESS
Causes :-
1. Infection of the anal gland and there will be pus in the intersphincteric space ,
pus may travels along the path of least resistance, may spread
• caudally to present as a perianal abscess, the most common 60%
• laterally across the external sphincter to form an ischiorectal abscess the
2nd most common 30%
• or, rarely, superiorly above the anorectal junction to form a supralevator
intermuscular or pararectal abscess
2. submucosal abscess (following haemorrhoidal sclerotherapy, which usually
resolve spontaneously),
3. mucocutaneous or marginal abscess (infected haematoma)
4. ischiorectal abscess (foreign body, trauma, deep skin-related infection)
5. pelvirectal supralevator sepsis originating in pelvic disease.
6. Underlying rectal disease, such as neoplasm and particularly Crohn’s disease,
may be the cause. Similarly, patients with generalised disorders, such as
diabetes and acquired immunodeficiency syndrome (AIDS), may present with
an anorectal abscess; in these patients, abscesses may run an aggressive
course.
C L I N I C A L F E AT U R E S : -
• Perianal abscess
1. a short (2–3 day) history of increasingly severe, well-localised pain and a
palpable tender lump at the anal margin.
2. Fever and rigor and night sweating
3. Examination reveals an indurated hot tender perianal swelling. the affected
buttock is diffusely swollen with deep tenderness
• Patients with infection in the larger fatty-filled ischiorectal space, in which
tissue tension is much lower, usually present later, with less well localised
symptoms but more constitutional upset and fever
• If sepsis is higher like supra levator , pelvirectal .. deep rectal pain, fever and
sometimes disturbed micturition may be the only features, with nothing
evident on external examination but tender supralevator induration palpable
on digital examination above the anorectal junction.
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 ANO RECTAL ABSCESS

Treatment :- for perianal and ischiorectal which are the most common
• Drianage together with antibiotic cove :- drainage is through the perineal skin,
usually through a cruciate incision over the most fluctuant point, with excision
of the skin edges to de- roof the abscess.
• Pus is sent for microbiological culture (Grace) and tissue from the wall is sent
for histological appraisal to exclude specific causes.
• With a finger in the anorectum to avoid creation of a false opening,
• A gentle search may be made for an underlying fistula if the surgeon is
experienced, and, if obvious, a loose draining seton may be passed

203
 FISTULA IN ANO
Def. :-
• A fistula-in-ano, or anal fistula, is a chronic abnormal communication, usually
lined to some degree by granulation tissue, which runs outwards from the
anorectal lumen (the internal opening) to an external opening on the skin of
the perineum or buttock (or rarely, in women, to the vagina main cause
Obstetric injury).
C A U S E S : -
• Majority non specific ( idiopathic )
• The remaining due to :- such as Crohn’s disease, tuberculosis, lymphogranuloma
venereum, actinomycosis, rectal duplication, foreign body and malignancy
(which may also very rarely arise within a longstanding fistula), Abscess .
C F : -
• those men in their third, fourth and fifth decades of life are most commonly
affected. Patients usually complain of intermittent purulent discharge (which
may be bloody) and pain (which increases until temporary relief occurs when
the pus discharges). There is often, but not invariably, a previous episode of
acute anorectal sepsis that settled (incompletely) spontaneously or with
antibiotics, or which was surgically drained.
I N V E S T I G AT I O N S : -
• By the exam. :- the most imp. Is to identify the external opening and the
primary track and the internal opening and presence of secondary extension
• External opening is seen by inspection
• The site of the internal opening may be felt as a point of induration or seen as
an enlarged papilla By PR
• Palpable induration between external opening and anal margin suggests a
relatively superficial track .
• Exam. Under anesthesia with Dilute hydrogen peroxide, instilled via the
external opening, is a very useful way of demonstrating the site of the internal
opening, or retrograde probing

204
 FISTULA IN ANO
W H AT S T H E G O L D S TA N D A R D I X ?
• Magnetic resonance imaging (MRI) is acknowledged to be the ‘gold standard’
for fistula imaging but it is limited by availability and cost and is usually
reserved for difficult recurrent cases. The great advantage of MRI is its ability to
demonstrate secondary extensions, which may be missed at surgery and which
are the cause of persistence .
W H AT S T H E G O O D S A L L’ S R U L E . ?
• Goodsall’s rule , used to indicate the likely position of the internal opening
according to the position of the external opening(s),
Tx :- is Surgery (Fistulotomy )

PA R K S C L A S S I F I C AT I O N

According to the relationship of the primary track to the anal sphincters .

1. Intersphincteric fistulae (45%) do not cross the external sphincter .
2. Trans-sphincteric fistulae (40%) have a primary track that crosses both internal
and external sphincters
3. suprasphincteric fistulae are very rare, are thought by some to be iatrogenic
and are difficult to distinguish from high-level trans sphincteric tracks .
4. Extrasphincteric fistulae run without specific relation to the sphincters and
usually result from pelvic disease or trauma.

205
 RECTAL PROLAPSE

DDx :-
*In the case of a child with abdominal pain, prolapse of the rectum must be
distinguished from ileocaecal intussusception protruding from the anus. &
rectosigmoid intussusception in the adult, there is a deep groove (5cm or more)
between the emerging protruding mass and the margin of the anus, into which the
finger can be placed , in cases of intussusception
C A U S E S O F R E C TA L P R O L A P S E ( M U C O S A L )

How clinically you can diff , between mucosal and full thickness prolapse
• It is more than 4cm and commonly as much as 10–15cm in length .
• On palpation between the finger and thumb, the prolapse feels much thicker
than a mucosal prolapse, and obviously consists of a double thickness of the
entire wall of the rectum.

206
 RECTAL PROLAPSE

T R E AT M E N T

Mucosal Full thickness

RECTAL POLYP

207
drains
 NASOGASTRIC TUBE

I N D I C AT I O N S : -
• Therapeutic
1. Gastric decompression in cases of Bowel obstruction
2. Enteral feeding
3. Gastric lavage in case of drug overdose toxicity or poisoning
4. Administration of drugs in patient unable to swallow
• Diagnostic indication :-
1. to detect the presence of bleeding and monitor it
2. administration of the Contrast material
3. To take a gastric fluid sample
4. Identification of the esophagus and stomach ( in TEF where
will be coiling of the tube and itsnot reaching to the stomach )
C O N T R A I N D I C AT I O N S : -
• Absolute
1. Severe Maxillo facial Trauma ( fracture ) & Basal skull fracture
2. Recent nasal surgery
• Relative :-
1. Coagulation disorder
2. Pt. with a known hx of chronic liver dis. And esophageal
varices
3. Recent esophageal Sx
4. Esophageal stricture or alkaline ingestion injury

209
 NASOGASTRIC TUBE

C O M P L I C AT I O N S : -
1. epistaxis due to trauma to the nasal mucosa
2. can induce gagging or vomiting,
3. Aspiration due to regurgitation or wrong placement .
4. wrong placement ( pulmonary )
5. esophageal perforation
6. Blockage of the tube by the feeding particles
7. dislodgement

210
 SURGICAL DRAINS

• Drains are inserted to allow fluid or air that might collect at an

operation site or in a wound to drain freely to the surface.
• INDICATIONS FOR THEM
• To help eliminate dead space .
• To evacuate existing accumulation of fluid , to remove
pus, blood , serous exudates , chyle or bile.
• To prevent the potential accumulation of fluid .
• Decrease infection rate.

Indications
AHMED AZBAR for Surgical Drains
INDECTIONS

Therapeutic Prophylactic
• Tension pneumothorax • Cardiothoracic procedures
• Pleural fluid • Esophageal resection
• Abscess cavity • Duodenal stump following
• Seroma gastrectomy
• Acute urinary retention • Post thyroidectomy
• Acute suppurative arthritis • Thoracotomy
• Infected cyst • cholecystectomy
• Splenectomy
Palliative • Pancreatectomy
• Advanced Ca esophagus • post chest trauma
• Hydrocephalus Monitoring
• Gastrointestinal bleeding
Diagnostic • Urethral catheterizations
• Biliary fistula
• T-tube cholangiogram for retained gall
stones in common bile duct

211
 SURGICAL DRAINS

How can you classify the surgical Drains ?

• Open drainage system Vs Closed Drainage system

• Passive drainage system Vs Active drainage system

OPEN DRAINS
• Include corrugated rubber or plastic sheets .
• Drain fluid collects in gauze pad or stoma bag .
• They increase the risk of infection.
• E.g. Penrose drain.
CLOSED DRAINS
• Consist of tubes draining into a bag or bottle.
• They include chest and abdominal drains.
• The risk of infection is reduced.
• E.g. Jackson-pratt drain.
ACTIVE DRAINS
• Active drains are maintained under suction .
• They can be under low or high pressure.
• Closed ( Jackson- Pratt , hemovac drain )
• Open (sump drain ).
Disadvantages
1. high negative pressure may injure tissue .
2. Drain clogged by tissue .

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 SURGICAL DRAINS

Advantages of active drains

1. Keep wound dry , efficient fluid removal .
2. Can be placed anywhere .
3. Prevent bacterial ascension.
4. Allows evaluation of volume and nature of fluid.

PASSIVE DRAINS :
• Passive drains have no suction.
• Drains by means of pressure differentials, overflow, and
gravity between body cavities and the exterior.
• Closed ( NGT, Foleys catheter, T-Tube)
• Open ( Penrose drain, corrugated drain )
DISADVANTAGES
1. Gravity dependent affects location of drain.
2. Drain easily cogged.
ADVANTAGES
1. Allow evaluation of volume and nature of fluid.
2. Prevent bacterial ascension.
3. Eliminate dead space.

213
 SURGICAL DRAINS
WHEN TO DISCONTINUOUS A SURGICAL DRAIN.
► ONCE THE DRAINAGE HAS STOPED.
► ITS OUT PUT HAS BECOME <25-50 ML/DAY.
► THE DRAIN HAS STOPPED SERVING THE DESIRED FUNCTION.
► Drains put in to cover perioperative bleeding may usually be
removed after 24 hours, e.g. thyroidectomy.
► Drains put in to drain serous collections usually can be
removed after 5 days, e.g. mastectomy.
► Drains put in because of infection should be left until the
infection is subsiding or the drainage is minimal.
► Drains put in to cover colorectal anastomoses should be
removed at about 5–7 days.
► Common bile duct T-tubes should remain in for 10 days.
CO M P L I C AT I O N S .
IMMEDIATE.
► PAIN
► IRRITATION
► BLEEDING
► PERFORATTION OR INJURY TO ADJACENT STRUCTURES.
EARLY.
► OCCLUSION
► LEAKING AROUND DRAIN
► DISPLACEMENT
► INFECTION
► LOSS OF FLUID,ELECTROLYTES AND PROTEIN
214
 SURGICAL DRAINS

CO M P L I C AT I O N S .
LATE.
► PRESSURE/SUCTION NECROSIS OF BOWL OR VESSEL.
► FISTULA.
► SCAR.
► HERNIA.
COMPLICATIONS DURING REMOVAL.
► PAIN
► INFECTION(CELLULITIS/ABSCESS)
► INJURY TO ADJACENT STRUCTURES.
► RETAINED OR FRAGMENTATION OF TUBE.

SURGICAL DRAIN

• ( the most commonly used in our hospital is the Tube drain =

NG tube + urine bag )
• Which is closed passive Drain

JACKSON-PRATT DRAIN

• Jackson-Pratt drain, JP drain, or Bulb drain,

• is a drainage device used to pull excess fluid from the body by
constant suction.
• The device consists of a flexible plastic bulb that connects to
an internal plastic drainage tube.

215
 JAC KS O N - P R AT T D R A I N

Penrose drain (open drain)

► Penrose drain is a surgical device placed in a wound to drain

fluid.
► It consists of a soft rubber tube placed in a wound area, to
prevent the build up of fluid.

Corrugated Rubber Drain (an open drain)

► Rubber causes a tissue reaction and the drain track caused by
this material persists longer than when inert materials arc
used.
► The drain is fixed by a suture at the end of the wound

216
 Corrugated Rubber Drain (an open drain)

• a safety pin must he placed through the end to prevent the

drain slipping inwards.
• Corrugated rubber drains can be used either for the wound or
for deep drainage

Redivac Drain (a close drain)

• This is a fine tube. with many holes at the end, which is

attached to an evacuated plastic bottle providing suction.
• It is used to drain blood beneath the skin, e.g. after
mastectomy or thyroidectomy, or from deep spaces, e.g.
around a vascular anastomosis.

217
 T tube

• Kehr's T tube : a tube consisting of a stem and a cross head

(thus shaped like a T ).
• The cross head is placed into the common bile duct while the
stem is connected to a small pouch (i.e. bile bag).
• It is used as a temporary post-operative drainage of common
bile duct.
• Sometimes its used in ureteric problems too

Chest Tube (close drain)

• Open (incisional) vs. close ( traocar use),
• open is preferred (less risk in term of intranl organ
penetration by strong trocar inserion).
• Used as closed system under water seal.
• Used to drain; haemothorax, pneumothorax, chylothorax,
pleural effusion and epyema.
• Put in the pleural space in the 4 th intercostal space (mid
axillary or ant. Axillary or between them for better mobility of
the patient ) above the upper border of the rib bellow ( VAN
structure)

218
219
THE STOMA
 T H E D E F I N IT IO N

• Colostomy is an artificial opening made in the large bowel to divert faces

and flatus to the exterior, where it can be collected in an external
appliance. Depending on the purpose for which the diversion has been
necessary, a colostomy may be temporary or permanent.

T H E P RO PE R S I T E

• The point at which the colon is brought to the surface must be carefully
selected to allow a colostomy bag to be applied without impinging on
the bony prominence of the antero_superior_iliac spine. The best site is
usually through the lateral edge of the rectus sheath, 6cm above and
medial to the bony prominence

THE TYPES
• LOOP COLOSTOMY
• END COLOSTOMY

THE CLASSIFICATION
• According to period
• Temporary
• Permanent

• According to site
• the colostomy is done to the transvers sigmoid, ileum, and caecum, the latter is used since it
is wide and behind the skin immediately.

221
 PERMANENT & TEMPORARY
• PERMANENT :-This is usually formed after excision of the rectum for a

carcinoma by the abdominoperineal technique

• END COLOSTOMY

• It is formed by bringing the distal end (end-colostomy) of the divided colon to the surface in the left iliac

fossa, where it is sutured in place, joining the colonic margin to the surrounding skin.

• HARTMANSPROCEDURE
• is the surgical resection of the rectosigmoid colon with closure of the anorectal stump and formation of

an end colostomy. It was used to treat colon cancer or inflammation (proctosigmoiditis, proctitis,

diverticulitis,

222
 PERMANENT & TEMPORARY
• T E M P O R A R Y, : -
• LOOP TRANSVERSE COLOSTOMY
• in the past been most used to defunction an anastomosis after an anterior resection , but now the loop ileostomy is
preferred

• A LOOP LEFT ILIAC FOSSA COLOSTOMY

• sometimes used to prevent faecal peritonitis developing following traumatic injury to the rectum, to facilitate the operative
treatment of a high fistulain-anoand incontinence.

• DOUBLE-BARRELLED COLOSTOMY :-It is rarely used now .

• LOOP ILEOSTOMY
• An ileostomy is now often used as an alternative to colostomy, particularly for defunctioning a low rectal anastomosis , The
advantages of a loop ileostomy over a loop colostomy are the ease with which the bowel can be brought to the surface and
the absence of odor.

INDICATIONS FOR TEMPORARY COLOSTOMY

1. Distal Obstruction.

2. Defunction a low rectal anastomosis after Anterior resection of the rectum.

3. Following traumatic injury to the rectum or colon.

4. During operative treatment of a high fistula in ano.

5. Fulminant Colitis (IBD).

6. Complicated Diverticular disease.

INDICATIONS FOR PERMANENT COLOSTOMY

1. After rectal excision and abdominoperineal resection.
2. In the cancer of the colon, rectosigmoid, sigmoid tumor, tumor of the anus, and
crush injury of the pelvis.

3. Toxic megacolon.

223
 PREPARATION FOR
THE CLOSURE OF COLOSTOMY
1. Admission of the patient to the hospital 5 days before the operation.

2. Giving purgatives like castor oil until the patient gets diarrhea.

3. After that the purgatives must be stopped and starting fluid diet for 3 days before the operation.

4. At day 1, it must be giving one enema at night, stout fluid diet, and vitamins.

5. At day zero, at the night the enema must be giving and before the operation another enema must be giving by
500 cc normal saline.

6. Bacterial preparation:
1. From day 5 before operation, Metronidazole tab 400 mg and Neomycin 250 mg or Ampicillin till day zero.

2. At day zero, at the night, Gentamycin 80 mg in addition to Metronidazole.

3. 2 hrs before the operation, Metronidazole 400 mg and Gentamycin 80 mg to be given.

CLOSURE OF COLOSTOMY
• The closure is usually done after 4-6 wks or may extend to 2 months, the types of the
closure are:

1. Internal closure, by opening the abdomen and closing the colostomy.

2. External closure, without opening the abdomen, it is dangerous and not used
nowadays.

3. Before the closure, the physician must be sure about:

1. No distal obstruction, by doing Barium enema and sigmoidoscopy.
2. The general condition of the patient must be fit for operation.

TIME OF CLOSURE OF COLOSTOMY

• This depends on the case:

1. When the patient has positive nitrogen balance (defecation is positive).

2. When there is no sepsis.

3. When there is no distal obstruction.

224
 COMPLICATIONS OF COLOSTOMY
1. Prolapse of the intestinal mucosa through the wide opening of the colostomy.

2. Retraction of the mucosa down to the abdomen.

3. Bleeding from the edges.

4. Gangrene at the colostomy site due to decrease in the blood supply.

5. Stenosis of the colostomy orifice if the skin and muscle of the abdominal wall are too small.

6. Herniation of the viscera through the colostomy site.

7. Diarrhea due to infective enteritis.

8. Peritonitis.

Ischemia

Retraction

225
 COMPLICATIONS AFTER THE CLOSURE
OF COLOSTOMY
1. Failure of the closure, as there is a leak causing peritonitis or fecal fistula.
• The leak is due to inspissated fecal material or spastic anus. The patient is in the bed and not passing stool for 3-6 months, so anal dilatation prior
to colostomy is important.

2. Recurrence of the same lesion.

3. Ischemia of the bowel.

4. Closure colostomy diarrhea, as the colon was in rest sudden passing of the feces will cause intestinal hurry which leads to
diarrhea.

5. Adhesions and intestinal obstruction.

6. Incisional hernia, due to the infection and poor closure.

7. Stenosis at the site of the anastomosis with the features of intestinal fistula, so end-to-end intraperitoneal closure to
decrease the risk of stenosis is indicated.

8. If not well cleaned, so there may be abscess and skin excoriation.

226
THE EXAMINATION

227
Surgical
instruments

–
–
–
229
230
231
232
233
 CANULA

• The color is not a stander

Method of canula insertions

Before the procedure

• Introduce yourself to the patient.
• Explain the procedure to the patient and gain informed consent
to continue
• Make sure there is adequate light and that the room is warm
enough to encourage vasodilation
• Make sure the patient is in a comfortable position and place a
pillow or a rolled towel under the patient’s extended arm
• The patient’s skin should be washed with soap and water if
visibly dirty
234
 Method of canula insertions

• If difficulty is encountered in finding an appropriate vein, one

of the following techniques may be used:
• Inspection of the opposite extremity
• Opening and closing the fist
• Using gravity (holding the arm down)
• Gentle tapping or stroking of the site
• Applying heat (warm towel/pack)
TECHNIQUE
• Apply tourniquet and select the appropriate vein
• Apply an antiseptic solution with friction for seconds, allow to
air dry for up. Once cleaned, do not touch or re-palpate the
skin
• Remove the cannula from its packaging and remove the needle
cover ensuring not to touch the needle
• Stretch the skin distally and tell the patient to expect a sharp
scratch
• Insert the needle, bevel upwards at about 30 degrees
• Advance the needle until a flashback of blood is seen in the
hub at the back of the cannula
• Once this is seen, progress the entire cannula a further 2mm,
then fix the needle, advancing the rest of the cannula into the
vein

235
 Method of canula insertions

• Release the tourniquet, apply pressure to the vein at the tip of

the cannula and remove the needle fully
• Remove the cap from the needle and put this on the end of the
cannula
• Carefully dispose of the needle into the sharps box
• Check function by flushing with saline. If there is any
resistance, if it causes any pain, or you notice any localized
tissue swelling; immediately stop flushing, remove the cannula
and start again
• Apply the plaster to the cannula to fix it in place
• Finally, ensure that the patient is comfortable and thank them
COMPLICATIONS

• Pain
• Failure to access the vein
• Blood stops flowing into the flashback chamber
• Arterial puncture
• Thrombophlebitis
• Hypersensitivity reaction
• Peripheral nerve palsy
• Skin and soft tissue necrosis When some irritant solutions leak
into the tissue e.g. chemotherapeutic agents More safely
infused into a central vein

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 YOUTUBE VIDEO

https://youtu.be/vE99rZ7JT3Q

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 NEEDLES

• the smallest one is the orange one

that use for insulin injection
• Blue one for IM injection if the drug is
watery
• If it oily drug use green one
• Use green for blood test because blue
can cause hemolysis
• Pink one for
• Fine needle aspiration
• Biopsy
• Atrial blood sample

IV set

• One for blood and another for fluid

• The deferent between them in blood there is
Blood Fluid iv set
There is a filter No filter
There is a bulb No bulb
The iv chamber does not
There is cup
have a cup
Pink needle come with it Green needle

• The bulb to clear clots in canula

• The cup to relive the negative pressure that can occur in glass
pint

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 IV set

BLOOD FLUID

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 Some drugs

- betadine (povidone - iodine): standard of care, 10%

concentration. Can be diluted to 7.5%, but do not dilute below
that because it will lose its effect. It is slow acting. For gram +ve
and -ve monilia and pseudomonas.
- chlorhexidine: comes with 50% concentration and must be
diluted before using it because it will cause chemical burn. It is
usually diluted to 1%. It acts on gram +ve mainly. So use alcohol
with it to cover gram -ve. It is long acting.
- savlon: yellow in color, acts as surfactant for washing dirty
surgical site along with disinfecting it. It is used for washing
diabetic foot for a patient before amputation.
- local anesthetics: xylocaine, esters and amide. Mostly we use
xylocaine and amide.
Xylocain: starts acting within 15 mins and continues for 2 hours.
Comes in form of 50cc containers or single dose of 2cc.
Sometimes we use ampoule of 1cc contains 10% concentration
given iv in CCU as stabilizer for cardiac muscle. Concentrations of
1-2% are NOT given iv and iv xylocaine is given iv only in CCU.
When you inject xylocaine, make sure it is not inside an artery or
vein ‫نتأكد من هالشي من نسحب بالسرنجة ومتسحب دم‬

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 Some drugs

- concentrations of xylocaine mean amount of drug in 1cc. 1%

means 10mg in 1ml, and there is 2% concentration. It is useful to
know the maximal safe dose. To know it, we have to know
whether it is combined with adrenaline or not. Why adrenaline?
To cause vasoconstriction to reduce drugs absorption, therefore
decreasing systemic toxicity. If there is adrenaline, the patient
can withstand high dose, 7mg/kg. If no adrenaline, highest dose
is 4mg/kg.
If the patient is 70kg, and the drug is combined with adrenaline,
then maximal
dose is: 7 × 70 = 490mg. How many mls? 1% means 1ml=10mg,
so it is 49ml.
The drug with no adrenaline, you can use anywhere in the body.
If it is combined with adrenaline, it is contraindicated in:
1- hypertension
2- ischemic heart disease
3- in hand fingers, penis, periauricular injection and tip of the
nose.
Bupivacaine: acts after 1-2h and continues for 12h.
Sometimes we do combination, like in case of nerve block for
post op. analgesia.
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