SURGERY LONG CASE

VIVA QUESTIONS

Authored by
The Department of Surgery
And
The Students of IGMC&RI
 SURGERY LONG CASE VIVA
QUESTIONS
Contents:
1. Thyroid - 2
2. Breast - 11
3. Varicose Veins – 22
4. Hernia – 32
5. Peripheral Vascular Disease – 42
6. Hydrocele – 52
 THYROID
1. What is the Significance of age in
thyroid swellings?
a) Young age:
Deficiency goitre
Dyshormonogenetic
Papillary carcinoma
b) Middle age:
Solitary nodule
MNG
Colloid goitre
Hashimoto’s
Follicular carcinoma
Anaplastic carcinoma
C)Old age:
Anaplastic Carcinoma
2. What is the significance of
Geographical Location?
High altitudes
are deficient in iodine content in
water as well as soil.
Hyperhydrosis
Nervousness
Insomnia, Tremor
Muscle weakness
Palpitation
Diarrhoea
Hypomenorrhea
6.Pathophysiology of hyperthyroidism
The action of thyroid hormone on body is
stimulatory resulting in hypermetabolism
Increased sympathetic nervous system
activity
Excessive thyroid hormone stimulates
cardiac system and increases the
adrenergic receptors
Tachycardia, increased cardiac output,
stroke volume and peripheral blood flow

3. Name the Pressure effects and 7.Primary vs Secondary

its cause: Hyperthyroidism
-Dyspnea/Stridor (Trachea)
-Dysphagia (Esophagus)
-Hoarseness of voice (RLN) Primary Secondary
-Syncope (Carotid artery) hyperthyroidism hyperthyroidism
-Horner’s syndrome (Sympathetic Symptoms appear Swelling appears
chain) first then thyroid first
swelling
4. Symptoms of Hypothyroidism:
Goitre is diffuse, Swelling is large,
Weight gain smooth, firm or nodular
soft. Both lobes
Cold intolerance are involved with
thrill and bruit
Skin dryness
Eye signs and Eye signs not
Depression exophthalmos are common
common
Muscle cramps and myalgia
Bradycardia Younger age Adult and elderly
group individual
Constipation
Entire gland is Internodal tissue is
Menorrhagia overactive overactive
5. Symptoms of Hyperthyroidism: Neurologic Cardiac features
Weight loss features are more are more common
common
Heat intolerance
8. Past history of radiation
significance
Papillary or mixed papillary & follicular
carcinoma are common in patients who
have received low dose radiation
9. Pulse abnormality in hyperthyroidism
-In hyperthyroidism, pulse rate is always
high
-Irregularly irregular rhythm
- High volume
10. Pedal edema causes
- Pretibial myxoedema - due to deposition
of mucin- like material in the subcutaneous
tissue.
- High output cardiac failure can cause
pedal edema
11. Pathophysiology of eye signs
Von graefe’s sign – Lid lag (Muller’s
muscle contraction)
Stellwag’s sign – Characteristic stare and
infrequent blinking
Moebius sign – Loss of convergence (Due
to ophthalmoplegia)
Joffroy’s sign – Absent creases on the
forehead
Dalrymple’s sign –lid retraction with
widened palpebral fissure
12. Signs of retrosternal extension
- Lower border of thyroid is not visible
-Any dilated vein over the neck & chest wall
Pemberton's sign - Ask the patient to raise
both upper limbs above the head & keep it
– for 2-3 min. If retrosternal prolongation is
there patient will have congestion &
puffiness in the face with respiratory
distress. The Pemberton's sign is positive.
Percussion over the manubrium sternum –
Dull note
13. Significance of tracheal deviation:
- Enlarged thyroid may compress on the
trachea or deviate it to one side or the other
to cause dyspnoea.
-Difficult to intubate the patient
-Carotid sheath is pushed back by benign
swellings where carotid pulsations are felt.
14. Carotid pulse-significance:
-Carotid sheath is pushed back by benign
swellings where carotid pulsations are felt.
-Berry’s sign- malignant thyroid engulfs the
carotid sheath completely hence pulsations
are not felt.
15. Lymph node involvement in thyroid
swellings
-In malignant carcinoma of thyroid
lymphatic metastasis can occur. most
commonly in papillary carcinoma of thyroid
followed by medullary carcinoma
-Lateral aberrant thyroid: metastatic node
from non-palpable papillary cancer.
16. Name the swellings that move with
deglutition:
Thyroid
Thyroglossal cyst
Subhyoid bursitis
Nodes attached to larynx and trachea
Normally it moves because of pre tracheal
fascia (enclosing the gland is attached to
hyoid), Ligament of berry (thickened form nodule. Many nodules form
pretracheal fascia which is attached to multinodular goitre.
cricoid cartilage)
21.Primary vs Secondary
Limited movements- fixed by inflammation, Thyrotoxicosis
malignant infiltration

Feature PRIMARY(G SECONDAR

17. Differential diagnosis of midline rave’s) Y(Toxic
neck swellings: MNG)
Age 20-40 YRS 30-50YRS
-Enlarged thyroid Sympto Appear Long duration
-Sub hyoid bursitis ms and simultaneous of swelling
-Thyroglossal cyst signs ly and short duration
Pre laryngeal and pre tracheal lymph nodes duration is of signs
short
18. Name the Triangles of neck: Predomi CNS CVS
nant
-Submental triangle sympto
-Submandibular triangle ms
-Carotid triangle Pretibial Seen in 1- Never seen
-Muscular triangle myxoed 2% of
-Posterior triangle ema patients
Swelling Diffuse Nodular
enlargement
19. Causes of solitary nodule of Surface Smooth Nodular
thyroid: Soft Firm
Consist
Adenoma thyroid ency
Auscult Bruit is Uncommon
Dominant nodule of MNG ation common
Eye Commonly Rarely found
Cyst signs found
Thyroid neoplasm
Lymphoma
Thyroiditis- Hasimoto’s, Reidel’s, de 22. Classification of thyroid tumors
quervain’s a.BENIGN-follicular adenoma
b.MALIGNANT (Primary)
20. Pathophysiology of multinodular i. Follicular epithelium - Follicular and
goitre: papillary carcinoma"
STAGES: ii. Follicular epithelium undifferentiated -
Stage 1 - diffuse hypertrophy and Anaplastic carcinoma
hyperplasia" iii. Parafollicular cells - Medullary
Stage 2 - due to fluctuating levels of TSH, carcinoma
some areas in thyroid are overstimulated iv.Lymphatic cells - Lymphoma
and converted to follicles
c. SECONDARY (Metastatic) - Renal cell
Stage 3- active follicle undergoes necrosis carcinoma, Breast carcinoma, Malignant
and many such necrosed follicles join to melanoma
INVESTIGATIONS-
1.Thyroid profile(TSH,T3,T4)"
2.Ultrasonography
3.USG guided FNAC
23. Investigations of solitary thyroid
nodule:
a.Ultrasonography-features suggestive
of malignancy
i. Sonolucent unilocular lesion"
ii. Cyst larger than 3-4cm
iii. Rich in microcalcifiation
iv. Can detect jugular lymphadenopathy
b. FNAC
c. Thyroid profile-TSH,T3,T4
24. Investigation of toxic diffuse goitre
-Thyroid stimulating hormone
-T3, T4
-TSH receptor antibodies
-Thyroid peroxidase antibodies
-FNAC should not be done
25. Uses of USG:
a. To identify nodules, numbers, size,
vascularity,
b. To do USG guided FNAC
c. To identify neck lymph nodes
d. To find out solid or cystic nature
e. Relation of the mass to the neck
vessels
26. Uses of FNAC.
a. To rule out malignancy (papillary
carcinoma, medullary carcinoma,
anaplastic carcinoma)
b. To diagnose colloid nodule, thyroiditis
c. FNAC not reliable in follicular carcinoma
d. Therapeutic aspiration of cyst
27. Uses of radio iodine scan.
a. Doubtful toxicity
b. Ectopic thyroid
c. Autonomous toxic nodule >45 years of
age
d. To find secondaries in follicular
carcinoma after thyroidectomy
e. Retrosternal thyroid
28. Modes of spread of thyroid tumor:
- Papillary carcinoma – lymphatics
-Follicular carcinoma – blood
-Anaplastic carcinoma – lymphatics, blood
and direct invasion
29. Features of papillary carcinoma:
-Contains brownish black fluid.
-Often discrete lymph nodes in the neck
(40%) are palpable.
-Slowly progressive and less aggressive
tumor.
-Commonly multicentric
-Spreads to cervical lymph nodes.
30. FNAC features of papillary
carcinoma:
-Branching papillae having a
fibrovasccular stalk covered by cuboidal
cells
-Nucleus- Optically clear/ ground-glass
appearance/ Orphan-Annie nucleus
-Intranuclear inclusion or intranuclear
grooves
-Psammoma bodies
-Variants of papillary carcinoma –
Follicular, Tall-cell, Diffuse sclerosing,
Papillary microcarcinoma
31. Features of follicular carcinoma:
e. Thyrotrophin
34. FNAC findings of colloid goitre /
thyroid tumors
FNAC is reliable in identifying papillary
thyroid cancer but cannot distinguish
between a benign follicular adenoma and
follicular carcinoma, as this distinction is
dependent not on cytology but on
histological criteria, which include capsular
and vascular invasion.

- Well localised, non-mobile, soft,

fluctuant (because of colloid content) and 35. MACIS scoring for prognosis:
pulsatile (as both inner and outer tables of
skull bone are disrupted allowing brain Metastasis
pulsation to transmit) secondaries in the
Patient Age
skull.
Completeness of resection
-Present with distant metastasis
Local Invasion

32. FNAC features of follicular Tumor Size

carcinoma:

-Uniform cells forming small follicles 36. AGES scoring:

containing colloid
-Follicular differentiation is less apparent
-Nets or sheets of cells without colloid
Age less than 40 years got better
prognosis
Pathologic Grade of the tumor
Extent of the primary tumor

-Nuclei lack the features typical of Size ( <4cm got better prognosis)
papillary carcinoma
-There is no reliable cytologic difference 37. Surgeries in thyroid swelling:
between follicular adenoma and follicular
carcinoma
a. Total thyroidectomy
b. Hemi thyroidectomy
33. Tumor markers:
c. Near total thyroidectomy
a. Thyroglobulin (Non medullar thyroid
carcinoma) d. Subtotal thyroidectomy

b. Carcinoembryonic antigen
c, β-2-microglobulin
d. Calcitonin (Medullary carcinoma of
thyroid)
38. Near total thyroidectomy:
Removal of almost whole of thyroid gland
leaving behind a rim of thyroid tissue in
each lobe to avoid injury to the recurrent
laryngeal nerve and the parathyroid
glands.
39. Hemi thyroidectomy:
Removal of one complete lobe with the
isthmus of the thyroid gland
40. Total thyroidectomy:
Complete removal of both the lobes and
the isthmus of the thyroid gland
41. Subtotal Thyroidectomy:
An amount of thyroid tissue filling the
tracheo–esophageal fistula is left behind
while doing subtotal thyroidectomy.
42. Symptoms of hypoparathyroidism:
-Weakness
-Tetany
-Muscle twitching and cramping
-Carpopedal spasm
-Convulsion
43. Complications of thyroidectomy:
-Haemorrhage
-Respiratory obstruction
-Recurrent laryngeal nerve palsy
-Thyroid insufficiency
-Parathyroid insufficiency
44. Treatment of hypocalcaemia:
-Calcium gluconate – 10ml of a 10%
solution is 90 mg of elemental calcium
-Calcium chloride - 10ml of a 10%
solution is 270mg of elemental calcium
45. Treatment of nodes in papillary
carcinoma:
-Thyroxine 300 micrograms to supress
TSH
-Thyroglobulin measurement –
Measurement of thyroglobulin is useful in
follow up and detection of metastatic
disease
-Radio-iodine therapy – I131whole body
scan to detect residual normal thyroid
tissue and metastatic tissue
-Radio ablation of metastasis
-Total Thyroidectomy
46. Treatment options in Grave’s
disease:
-Anti-thyroid drug – Decreases hormone
synthesis
-Carbimazole – 5-20mg daily
-Propylthiouracil – 200mg 8 hourly
-Beta blocker – inhibits peripheral
conversion
-Propranolol – 10 mg TDS"
-Surgery – Total/subtotal thyroidectomy
-Radio-iodine therapy – Destroy thyroid
cells and control thyrotoxicosis
47. MEN 1 (Wermer’s syndrome)
Pituitary adenoma, Parathyroid
hyperplasia, Pancreatic tumor
52. Synthesis of Thyroid Hormones

48. MEN 2A (Sipple’s syndrome)

Parathyroid hyperplasia, medullary
carcinoma of thyroid, Pheochromocytoma.
49. MEN 2B:
-Marfanoid body habitus/mucosal -
neuroma,
-Medullary carcinoma of thyroid,
-Pheochromocytoma
*Iodide trapping
*Conversion of iodide into iodine
*Thyroglobulin synthesis
*The coupling reaction
*Proteolyosis of thyroglobulin
*Secretion of thyroid hormones

50. Treatment of medullary 53. Treatment of Multinodular

carcinoma: goitre:
-Total thyroidectomy with bilateral Early cases, asymptomatic cases:
central node dissection
-levothyroxine 0.15-0.2 mg daily
-No role for suppressive hormone
-Observe and follow up for 6 months
therapy or radioactive iodine therapy

-External beam radiotherapy for Surgery(when indicated) :

residual tumor disease
51. Retrosternal Goitre
Defined as having >50% goitre below
the suprasternal notch.
Types:Substernal,plunging,intrathoraci
c
Features:dyspnoea,cough,stridor,dysp
hagia,engorgement of neck veins
Lower border not seen on inspection
and not felt on palpation
Pembertom sign positive,dull note
over sternum on percussion.
Total/Subtotal/Near total
Thyroidectomy
54. Pathophysiology of multinodular
goitre:
STAGES:
Stage 1 - diffuse hypertrophy and
hyperplasia
Stage 2 - due to fluctuating levels of
TSH, some areas in thyroid are
overstimulated and converted to
follicles
Stage 3- active follicle undergoes
necrosis and many such necrosed
follicles join to form nodule. Many
nodules form multinodular goitre.
55. Mechanism of drugs given in
multinodullar goitre:
 L-thyroxine: Decrease TSH
activity by negative feedback
mechanism
 Thioamides :
1. Inhibit thyroid peroxidase
enzyme which converts Iodide
to Iodine
2. Inhibit iodination of tyrosine
residue in thyroglobulin
3. Inhibit coupling of
iodotyrosines(MIT & DIT)
4. Propylthiouracil also inhibit
peripheral conversion of T4 to
T3, while others don’t have this
action
 Radioactive Iodine :
emits x-rays & beta particles
which destroys the thyroid
tissue Thyroid follicular cells
undergo pyknosis, necrosis
followed by fibrosis
56. ENT examination in
tracheomalacia:
Post Thyroidectomy
tracheomalacia is one of the
important cause for respiratory
distress in post Operative
thyroid patients with the history
of huge thyroid.
So it is important to examine the
thyroid to rule out these
potential causes.
57. Types of Goitre:
1. Simple non toxic:
A. Diffuse hyperplastic
* Physiological (Puberty,
Pregnancy)
*Primary Iodine Deficiency
*Secondary Iodine
Deficiency (Goitrogens,
Drugs, Excess Flouride)
B. Colloid Goitre
C. Nodular Goitre
D. Solitary nontoxic nodule
E. Recurrent nontoxic nodule
2.Toxic
A. Diffuse (primary) - Graves'
Disease
B. Multinodular (Secondary) –
Plummer's Disease
C. Toxic Nodule (Solitary)
(Tertiary)
3. Neoplastic:
A. Benign – Adenomas:
Follicular, Hurthle cell
B. Malignant – Carcinomas
(Papillary, follicular,
medullary, anaplastic),
lymphomas
4.Thyroiditis
A. Hashimoto's Autoimmune
Thyroiditis
B. de-Quervain's Autoimmune
Thyroiditis
C. Riedel's Thyroiditis
5. Rare: Bacterial
(Suppurative), Amyloid
58. USG in Thyroid case:
•To detect number , size ,
nature of the nodules
(cystic/solid/complex)
(Complex means cystic and
solid together -more suspicious
of carcinoma)
6. Indirect laryngoscopy :
patient is asked to tell ‘E' to
check the abduction of vocal
cord
7. Serum calcium estimation
8. T3,T4,TSH

•Size up to 2mm can be 9. Thyroid scan

detected
10. USG NECK
•US guided FNAC is very useful
11. FNAC
•US at regular intervals is
advisable to observe a small 12. XRAY NECK AP/lateral
nodule in thyroid view

•To detect recurrent nodule

60. Grading of
•To find out the Hypothyroidism:
invasion/spread/vascularity/stat
us of carotid artery and internal TSH FT4 FT3
jugular vein GRADE Increased Normal Normal
1A (>4.0 to
•To find out enlarged lymph <10
node in neck mU/I)
GRADE Increased Normal Normal
1B
59. Preoperative Evaluation in GRADE Increased Decreased Normal
Thyroidectomy: 2
GRADE Increased Decreased Normal
1. Blood grouping and cross 3
matching .keep the required
blood ready
61. Toxic Adenoma(Toxic
2. Complete blood count Nodule):

3. Urine albumin, sugar or •It is a benign functioning

deposits
4. Blood urea, glucose
5. ECG and cardiac fitness
especially in toxic goitre
monoclonal thyroid tumor,
usually more than 3cm in size.
•Usually presents as functioning
(toxic) solitary nodule of thyroid.
•It is autonomous functioning
tumor, Not TSH responding,
commonly shows higher T3
levels than T4.

•No eye signs and other

features of graves disease.

•INVESTIGATIONS- US Neck
,T3,T4,TSH and Radioisotope
scan.

•TREATMENT-
- Initially- Antithyroid drugs
Later-Hemithyroidectomy,
done after 6 weeks

- Radioactive iodine therapy

62. What happens when both

the recurrent laryngeal
nerves are injured?

Vocal Cords get stuck in

meidan/paramedian position,
leading to:
1. Dyspnea
2. Stridor (biphasic)
3. Aspiration
4. Phonation may be preserved

- Treatment:
1. Permanent tracheostomy
with speaking valve
2. Lateralisation of the vocal
cords

63.Scales used in
hypothyroidism:
 BREAST

1. Significance of age in breast

lump:

d. Nulliparity
a. Fibroadenoma : 15-25 yrs
e. Absent breastfeeding
b. Phyllodes tumor : 30-50 yrs f. Hormone replacement
therapy
c. Carcinoma breast : Common in
g. Family H/o breast carcinoma
Middle age anytime after 20.(median
h. H/o irradiation
age – 47 yrs)

2. Causes of recent onset nipple

retraction: 5. Genes involved in breast
carcinoma:
a. Circumferential – Carcinoma a. BRAC 1 and BRAC 2
breast b. HER 2/ neu
b. Slit Like – Mammary duct
Ectasia with periductal
mastitis 6. Features of malignant breast
c. Traumatic fat necrosis swelling:
d. Tuberculosis a. Ill defined margins.
e. Previous surgery in breast b. Hard in consistency.
c. Uneven surface
d. Fixed to skin
3. Types of nipple discharge and e. Peau d ' orange appearance
causes: f. No Intra mammary mobility

a. Blood – Duct papilloma

carcinoma breast 7. Causes of nipple retraction:
b. Milk – Lactation, galactocele,
mammary fistula Involvement of lactiferous duts
c. Pus – Breast abscess
d. Serous/Greenish – duct
ectasia 8. Causes of skin tethering/
Dimpling:

4. Risk factors of CA breast: Involvement of coopers ligament

a. Early menarche
b. Late menopause
c. Late childbirth 9. PEAU ‘D orange appearance:
 a. Tumour cells involve and Level 3 - Apical
block subdermal lymphatic
and causes cutaneous 14. Examination of internal
lymphatic edema. mammary node:

b. Skin areas tethered to sweat Percussion over Parasternal

ducts cannot swell remains
dimpled in between areas of
cutaneous lymphatic edema
giving peau d orange
appearance.
region 2ndand 3rdspace
15. Investigations for a breast
lump:

10. Skin involvement: I. Specific investigations:

a. FNAC
a. STAGING T4 b b. Trucut biopsy
b. Peau d orange appearance c. Incision biopsy- for large lump
c. En cuirasse d. Excision biopsy- for small
d. Ulceration of skin of breast lump
e. Satellite nodules e. Wedge biopsy- for ulcerated
lump
f. Ultrasound
11. Chest wall involvement:

STAGING T4 a
II. Staging investigations:
Chest wall includes:
a. Ribs a. X ray chest- pleural effusion
b. Intercoastal muscles b. Skeletal bone survey- to
c. Serratus anterior but not look for osteolytic lesions in
pectoral muscles ribs, pelvis, spine.

12. Significance of leaning

III. Investigations for secondary
forward:
a. USG abdomen - for liver
Normal breast falls more forward secondaries, krukenberg tumour
than the diseased breast and malignant ascites.
suggesting fixity of the lump to b. Liver function test
chest wall or pectoralis muscle. c. CT chest – for mediastinal
nodes
d. Mammogram of opposite breast
13. Groups of axillary lymph e. FNAC of opposite axillary nodes
nods: f. Tumour markers : CA-15-3,
CEA.
Level 1 - Pectoral ,Brachial g. PET CT SCAN-recent trend to
,Subscapular look for metastasis based on
Level 2 - central group concept of increased uptake of
 fluorodeoxy glucose by the
tumour cells.
h. Routine investigations:
urine, blood, blood grouping/
typing, chest x-ray, ECG
16. Indications of mammogram:
a. Screening mammography (
more than 40 years with
family history )
b. Obese patients
c. Whenever conservative
surgeries are planned
19. Investigation for metastasis:
d. To detect spread or de novo
tumor in the opposite breast
e. Mammography guided
biopsy
f. Evaluation and follow up in
breast disease with
malignant potential
g. Follow up mammography
after conservative surgery
h. Mastalgias
17. Uses of trucut biopsy:
a. Differentiate between
carcinoma in situ and
malignancy
b. Confirms DCIS ( FNAC does
not confirm DCIS)
c. Receptor status of the tumor
18. Hormone status how it is
done :
a. They are estrogen sensitive
receptor present in the
breast and tumor tissue
b. Tissue for receptor study is
sent at low temperature in
ice flasks
c. Assessed by quantitative
analysis
d. >10U/g of tissue ( ER
positive )
e. <10U/g of tissue ( ER
negative)
f. ER positive ( prognosis
good, hormone therapy
beneficial, respond to
treatment is better )
g. ER negative ( poor
prognosis, hormone therapy
not very beneficial, respond
to treatment is not good )
a. Mammography - opposite
breast
b. Chest X Ray - pleural
effusion, cannon ball
secondaries, mediastinal
lymph node, secondaries in
rib
c. CT chest - lung secondaries
d. USG abdomen - liver
secondaries, ascites,
krukenberg tumor
e. X Ray spine - osteolytic
secondaries
f. MRI spine/pelvis - bone
secondaries in vertebrae,
pelvic bones.
g. Radioisotope bone scan
h. PET scan
i. Sentinel lymph node
biopsy
j. Axillary sampling
 of the skin, which do not
meet the criteria for
20. TNM staging of breast inflammatory carcinoma.
carcinoma: T4c – T4a, and T4b.
T4d – Inflammatory
Tx Primary tumour carcinoma.
cannot be assessed Nx– Regional nodes
(already treated cannot be assessed
elsewhere without N0– No regional nodes
documentation). involved
T0 – No evidence of N1– Metastases to
primary mobile ipsilateral level 1
Tis – Carcinoma in and 2 axillary nodes
situ.Tis (DCIS) Ductal
carcinoma in situ.Tis N2
(LSCIS) Lobular N2a – Metastases in
carcinoma in situ.Tis ipsilateral level 1 and 2
(Paget’s) – Paget’s axillary nodes, which are
disease of the nipple not fixed to one another
associated with invasive (matted), or other
carcinoma or with structures.
DCIS/LCIS in the N2b – Metastases only in
parenchyma clinically detected
T1 – Tumour less than 2 ipsilateral internal
cm (20 mm)T1 mi – mammary nodes and in
Micro invasion 1 mm or the absence of clinically
less in greatest evident level1 and 2
dimensionT1a – 1 – 5 axillary nodes
mmT1b – 5 – 10 mmT1c N3
– 10 – 20 mm N3a – Metastases to
T2 – 20 – 50 mm in ipsilateral infraclavicular
greatest dimension lymph nodes (level III
T3 – >50 mm in greatest axillary) with or without
dimension level 1 and 2 axillary
T4 – Any size with direct lymph node involvement.
extension to the chest N3b – Metastases to
wall or skin or both. ipsilateral internal
T4a – Tumour of any size mammary lymph nodes
extending into the chest with clinically evident
wall, not including only level 1 and 2 axillary
pectoralis muscle lymph nodes
invasion/adhesion (chest involvement.
wall means ribs, N3c – Metastases to
intercostal muscles and ipsilateral supraclavicular
serratus anterior but not lymph nodes with or
pectoral muscles). without axillary or internal
T4b – Ulceration or mammary lymph node
ipsilateral satellite involvement.
nodules and/or oedema
including peaud’orange
 M0—No clinical or
radiological evidence of
distant metastases
M0(i+)–No clinical or
radiological evidence of
distant spread
metastases but deposits
of molecularly or
microscopically detected
tumour cells in circulating
blood, bone marrow or
other non-regional nodal
tissue that are no larger
than 0.2 mm in a patient
without symptoms or
signs of metastases.
21. Various treatment options for
breast carcinoma
A. SURGERIES:-
a.Total (simple) mastectomy
b. Total mastectomy with axillary
clearance:
c. Modified radical mastectomy [MRM]:
--Patey’s operation
--Scanlon’s operation
--Auchincloss modified radical
mastectomy
B. Conservative breast surgeries:
a. Wide local excision Quadrantectomy
b. Toilet mastectomy
c. Extended radical mastectomies
d. Skin sparing mastectomy (Key hole
mastectomy)
e. Lumpectomy( wide local excision)
C. External radiotherapy
Total dosage 5000 cGY units 200-cGY
units daily 5 days a week for 6 weeks
D. Hormone therapy:
a. Tamoxifen - 20mg
b. Medroxyprogesteron - 400mg
c. Aminoglutethimide - 250mg
d. Arimidex , Letrozol, Zoladex,
Diethylstilbestrone, Fluoxymestron
E. Chemotherapy:
1st line – Anthracyclines
2nd line-Taxanes
3rd line- Gemcitabine
22. Indications for hormone
therapy:
a. ER/PR positive patients in
all age group
b. For prophylaxis against
carcinoma of opposite
breast
c. Metastatic breast carcinoma
23. Modified radical mastectomy
structures removed:
a. Tumour, entire breast,
nipple, areola, skin over the
tumour with margin.
b. Pectoralis minor muscles.
c. Fat, fascia, lymph nodes of
axilla
 d. Few digitations of serratus
anterior.
24. Indication for breast
conservation surgery:
a. Lump <4 cm
b. Mammographically detected
lesion
c. Clinically negative axillary
nodes
d. Well-differentiated tumour
with low S phase.
e. Adequate sized breast to
allow proper RT to breast
f. Feasibility of axillary
dissection and radiotherapy
to intact breast
25. Contraindications for BCS:
a. Tumour >4 cm
b. Positive axillary nodes >N1
c. Tumour margin is not free of
tumour after breast
conservation surgery needs
MRM.
d. Poorly differentiated tumour
e. Multicentric tumour
f. Earlier breast irradiation
g. Tumour/breast size ratio is
more (central tumour)
h. Tumour beneath the nipple
i. Extensive intraductal
carcinoma
j. Pregnancy
26. Indication for neo adjuvant
chemotherapy:
In large operable primary tumor
to make it amenable for
conservative breast surgeries.
27. Indication for chemotherapy:
a. All nodes positive patients
b. Primary tumor more than 1
cm in size.
c. Presence of poor prognostic
signs like vascular and
lymphatic invasion.
d. In advanced carcinoma
breast as a palliative
procedure.
28. Drugs used in
chemotherapy:
a. CMF regime
(Cyclophosphamide/Methotr
exate/ 5-flourouracil)
Every 21 days for a total of 6
cycles
b. CAF regime
(Cyclophosphamide/Adriamy
cin/ 5-flourouracil)
6 cycles
c. TAC (Taxanes/ Adriamycin/
cyclophosphamide)
29. Side effects of chemotherapy:
a. Nausea and vomiting
b. Alopecia
c. Myelosuppression
d. Megaloblastic anemia
e. Cardiac toxicity (Adriamycin)
f. Cystitis(cyclophosphamide)
30. Indications of radiotherapy:
a. Breast conservation surgery
b. Extensive in situ carcinoma
c. More than 4 positive nodes
in the axilla or extranodal
spread
d. Pectoral fascia involvement
31. Side effects of radiotherapy:
34. Fibroadenoma:
a. Skin changes – Redness,
irritation
b. Axillary hair loss
c. Breast – Mild throbbing pain
and swelling
d. Tightness in the chest/arm
e. Arm edema
32. Turn around time for Breast
CA:
Time interval between
screening and
treatment of breast cancer.
35. Complications of Breast
Calculated in days by adding
time intervals:
-From abnormal screening
mammogram to
diagnostic mammogram,
-From diagnostic mammogram
to biopsy
-From biopsy to MRI
-From MRI to surgery
33. Breast mouse:
A fibroadenoma (Breast mouse)
is a well defined, firm lump in
the breast.
They are often very mobile,
hence the name called breast
mouse.
It is a benign encapsulated
tumour.
Presently it is considered as the
hyperplasia of single lobule of
the breast.
Commonly occurs in young
females of 15 – 25years.
It does not turn into
malignancies.
surgery (MRM):
a. Pain and numbness
b. Seroma
c. Injury of axillary vein
d. Flap necrosis
e. Lymphoedema
f. Shoulder dysfunction
g. Axillary hyperasthesia
h. Winged scapula
i. Numbness over medial
upper part of arm
j. Pectoral muscle atrophy
k. Weakening of internal
rotation and abduction of
shoulder
l. Phantom breast syndrome
 36. Stewart-Treve’s syndrome: non tender, nonprogressive,
nonregressive"
Lymphangiosarcoma of upper
limb which can develop in •FNAC- Chalky fluid
patients who have had Mammography"
lymphedema after mastectomy
with axillary clearance. Treatment- Excision

They require amputation.

39. Radical Mastectomy Vs MRM
37. Syndromes associated with
carcinoma breast: Radical Mastectomy MRM
Structures removed: Structures removed:
a. Li- Fraumen's syndrome: •Tumour •Tumour
-Autosomal dominant
condition, with breast cancer •Entire breast,nipple, •Removal of all breast
inheritance (90%) along with areola,skin over the tissue, nipple-areolar
sarcoma, Leukaemia, Brain tumour with margin complex, skin
tumours
•Pectoralis major & minor •Pectoralis minor
-Due to mutation of TP53 gene muscles muscle

•Fat, fascia, lymph nodes •Level I,II,III nodes

b. Cowden's syndrome: of axilla
-Autosomal dominant condition,
with cutaneous facial lesion •Few digitations of
characterized by non- Serratus anterior
cancerous, tumour like growths Structures preserved : Structures preserved:
called Hamartomas, bilateral •Axillary vein •Axillary vein
breast lesion, thyroid tumours. •Bell’s nerve •Bell’s nerve
•Cephalic vein •Cephalic vein
•Nerve to Lattisimus
dorsi
38. Traumatic fat necrosis:
•Intercostobrachial
nerve
Due to either direct or indirect •Pectoralis major
trauma. muscle
Halsted’s radical Patey’s operation-
Capillary ooze cause triglyceride mastectomy enblock dissection
in fat to dissociate into fatty acids of breast & axilla
combines with calcium in blood
resulting in saponification
leading to inflammation.

•Painless swelling in
breast,smooth,hard,
40. Arterial supply of Breast: 42. CA Breast vs Lipoma:
Features CA Breast Lipoma
a.Axillary artery:
GENERAL Malignant tumor Benign
-Lateral thoracic Artery(30%) of breast tissue neoplasm
arising from
-Superior thoracic Artery yellow fat
NATURE Can be Universal tumor
-Acromiothoracic Artery Ductal/Lobular, In (occur anywhere
situ/invasive except brain)
occur only in
breast
b.Internal thoracic Artery(60%): (unless
metastasized)
-perforating branches to 2,3 and Upper outer Trunk, nape of
COMMONEST
4th Intercostal space SITE quadrant of breast neck, limbs
CAPSULE Not Encapsulated
encapsulated
c.Intercostal Artery: CLINICAL Tender or non- Non-tender
FEATURES tender (unless nerve
-Lateral branches of 2,3 and 4th involved/
compressed)
arteries
Lobular or uneven Lobular swelling
swelling
Fluctuant or hard Fluctuant like
41. Venous Drainage of Breast: feel
Mobile (unless Mobile
A. Axillary Vein fixed)
B. Internal Thoracic Vein Skin may or may Skin is free
C. Posterior Intercostal Veins not be fixed
Other features None present
may be present except
Eg. Dimpling, ulceration
peau d’ orange, (due to friction)
Nipple retraction, in very few
nipple discharge cases
Lymph nodes are Lymph nodes
involved, not involved,
metastasizes Doesn’t
metastasize
TREATMENT Extensive Excision under
treatment- CT, anaesthesia
RT, Surgery
43. Phyllodes tumour:

•Also called cystosarcoma

phyllodes or serocystic disease
of Broadie

•They show wide spectrum of

activity -may be benign (85%)
or metastatic tumour (15%)

•Depending upon the mitotic

index and degree of
pleomorphism they are graded
as low grade to high grade
tumour.

-They present as a large,

sometimes massive,
tumour with an unevenly
bosselated surface.

-Occasionally, ulceration of
overlying skin occurs because
of pressure necrosis

44. Triple assessment for Ca

breast:
a.Clinical examination

b.Radiological imaging
-USG (young female)
-Mammography(old age)
c.Pathological examination
 VARICOSE VEINS
1. Types of presentation:
-Swelling along the vein
-Pain
-Pigmentation
-Ulcer
2.Primary varicose vein:
-Congenital incompetence of valve
-Absence of valve
-Defective connective tissue in vein
wall
3.Secondary varicose vein:
-Deep vein thrombosis
-AV malformation
-Pelvic/Abdominal mass
-Pregnancy
-Inferior venacava thrombosis
4. Venous pain:
-Aching, cramping pain at the end of
the day
-Elevating the feet relieves pain
5. Arterial pain:
-Cramping pain worsens with walking.
-Lowering feet may relieve pain
6. Neurogenic pain:
-Pain at specific postures
-Gets relief after taking few steps and
on assuming some posture so as to
relieve nerve compression
7. Symptoms of chronic venous
disease:
-Postural discomfort
-Dilated and tortuous veins
-Edematous
-Pigmentation, induration, dermatitis
-Lipodermatosclerosis
-Ulceration
8. Anatomy of superficial veins:
A. Great saphenous vein starts from
medial side of dorsal venous arch runs
in front of medial malleolus ascends up
to posteromedial aspect of knee joint
and then ascends upward in the thigh
towards saphenous opening
B. Short saphenous vein starts from
behind the lateral side of the dorsal
venous arch joined by lateral marginal
vein of foot and ascends in the leg
behind the latera malleolus and runs in
the posterior aspect of the leg between
the two gastrocnemii and ends in
popliteal vein.
9. Anatomy of deep veins:
-Venae commitantes of anterior and
posterior tibial artery join to form
popliteal vein
-It continues up as femoral vein and
drain into external iliac vein and then
into IVC
10. Anatomy of perforator veins:
-Saphenofemoral junction
-Hunterian perforator
-Above the knee (Dodd’s perforator)
-Below the knee (Boyd’s perforator)
-Medial ankle perforator at 5cm,
10cm and 15 cm
11. Varicosities location and their
significance:
Medial side of leg (in front of medial
malleolus to medial side of knee &
along medial side of thigh upwards to
the saphenous opening)-LONG
SAPHENOUS VEIN VARICOSITY
Varicosity from behind lateral
malleolus upwards in posterior aspect
of the leg and ending in popliteal
fossa- SHORT SAPHENOUS VEIN
VARICOSITY
12. Skin changes and their
pathophysiology:
Local redness- superficial
thrombophlebitis
Phlegmasia alba dolens(white leg)-
excessive edema / lymphatic
obstruction
Plegmasia cerulea dolens- deep vein
thrombosis
Pigmentation-due to release of
hemosiderin from lysed RBC’s when
they enter into tissue planes following
defective micro circulation resulting
from CHRONIC AMBULATORY
VENOUS HYPERTENSION
Dermatitis- released hemosiderin
stimulate mast cell to cause histamine
release
Ulceration-severe anoxia resulting
from capillary endothelial damage
13. Lipodermatosclerosis-definition:
Progressive sclerosis of of the skin
and sub cutaneous tissue due to fibrin
deposition, tissue death and scarring
due to chronic venous hypertension.
14. Features of a classic venous
ulcer:
Site- lower one third of medial side of
leg(GAITER’S ZONE)
Size- variable
Shape- oval to circular
Margin- well defined
Edge- sloping edge(healing)
Floor- Granulation tissue
Surrounding skin- pigmentation,
eczema, varicosity
Base- May extend up to periosteum
Deformity- talipes equino varus(due to
shortening of achiles tendon)
15. Trendelenberg test and their
significance:
Step 1: Patient in recumbent
position legs are raised to empty the
vein, may be hastened by milking
the veins
Step 2: Tourniquet is applied below
sapheno femoral junction(thumb
may be used to occlude the SF
junction)
Test 1: Pressure is released at the
SF junction. Varices fill very quickly
from above.
Test 1 is positive- SAPHENO
FEMORAL VALVE
INCOMPETENCE
Test 2:- Do not release the pressure
for one minute. Gradual filling of
veins occur in the lower limb.
Test 2 is positive – PERFORATOR
INCOMPETENCE.
16. Multiple tourniquet test:
a.veins are emptied
b.tourniquets are tied above and
below the perforators to be tested
c.patient is asked to stand, segment of
veins between two tourniquets will
become varicose if particular
perforator is incompetent.
TORNIQUETS LOCATION:
1. Just below SFJ
2. Just below mid thigh
3. Just below knee
17. Test for deep veins:
A.MODIFIED PERTHES TEST-
a. Tourniquet tied below saphenous
opening with veins being full. Ask the
patient to walk for 3-5min.
b. If deep veins are patent dilated
sup.veins will collapse
c. If deep veins occluded by thrombus
,sup,veins more distended amd patient
will complain of bursting Pain in
leg(positive).
B.HOMAN SIGN-Passive dorsiflexion
of foot elicit tenderness in calf
C.MOSES SIGN-Squeezing of relaxed
calf muscles will be painful.
18. Other test:
A.FEGAN’S TEST-
-In standing posture,excessive bulges
within varicosities are marked.
-Patient now lies down,empty the veins
-Palpate along the marked varicosities
-Sites where perforators are
incompetent and dilated,gap or pit may
be felt in deep fascia.
B.SCHWARTZ TEST-
-Patient is asked to stand.
-Keep one finger at saphenous
opening and tap dilated vein down in
the leg
-Test is positive when impulse is
palpable at saphenous opening on
tapping the vein at lower level
-Seen in gross varicosities of veins.
 -Recurrent thrombophlebitis
19. Examination:
OTHER LIMB -Examined for presence 22. CEAP classification:
of varicose veins
CLINICAL SEVERITY OF
REGIONAL LYMPH NODES-Enlarged DISEASE:
if venous ulcer gets infected
C0-no apparent disease
LIMB GIRTH-Measure both limbs
C1-Telengiectasia or reticular veins
circumference above or below a fixed
bony point to detect any swelling of C2-Varicose veins
affected limb
C3-Presence of edema
ARTERIAL PULSATIONS-to rule out
arterial causes of ulcer. C4-Skin changes
C4a pigmentation/eczema

20. Varicose Veins Definition: C4b lipodermatosclerosis

Varicose veins are abnormally dilated C5-Healed ulcer

tortuous veins in the subcutaneous C6-Active venous ulcer
tissue of >=3mm in diameter, in the
standing position ETIOLOGY:
Ec-congenital

21. Syndromes associated with Ep-primary

varicose veins: Es-secondary
-Kippel trenaunay syndrome ANATOMY:
-Parkes weber syndrome As-superficial veins
22. Complication of venous Ad-deep veins
insufficiency:
Ap-perforators
-Haemorrhage
PATHOPHYSIOLOGY:
-Pigmentation, eczema, dermatitis
PR-due to reflux
-Venous ulcer
PO-due to obstruction
-Lipodermatosclerosis
PRO-combination of reflux and
-Cellulitis obstruction
-Marjolin’s ulcer
-Ankylosis
-Talipes equinovarus
-Deep vein thrombosis

23. Venography:
X-ray of vein is taken after injection of
special dye into the vein.
Types:
a.Ascending venography– A
tourniquet tied above the ankle. A
superficial vein on the dorsum of foot
is cannulated and dye is injected.
Dye passes to deep vein. Deep vein
thrombosis can be diagnosed.
b.Descending venography– A
cannula is inserted into the femoral
vein with patient in standing position
and dye is injected.
To rule out marjolin ulcer
26. Conservative management of
varicose veins:
Elevating the legs
Wearing of compression stockings with
variable pressure gradients
27. Bissgard’s regimen:
4 layered bandage, changed once a
week
Education, Elevation and exercise.
Dressing
Antibiotics(if required)
Surgery

This is done to identify valvular

incompetence.
24. Venous duplex ultrasound:
It is the combined study of veins with
B-mode ultrasonography coupled with
Doppler flow study.
Advantage:
Noninvasive, Dynamic flow patterns
can be seen.
Disadvantage:
User dependent
Details to be looked for:
-Reflux at SF junction on valsalva
-Perforator reflux
-Compressibility of deep veins
28. Indications of conservative
treatment:
Asymptomatic cases.
C1 – C3(CEAP Grading)
Secondary varicose veins:
Pregnancy
Deep vein thrombosis
29. Role of compression in varicose
veins:
-It reduces the venous wall tension.
-Diverts the blood towards deep veins
through perforator veins.
-It reduces the oedema and improves
the venous and lymphatic drainage.

-Phasic variation with respiration

25. Wound swab c/s Ulcer edge

biopsy:
30. Pressure and modes of GSV – Saphenous Nerve(if ligated
compression: below knee)
-30-40 mmHg. SSV – Sural nerve(throughout the
course of the vein)
-Elastic crepe bandage.
-Elevation of the limb
36. Injection sclerotherapy - agents
-Unna boots.
used:
-Pneumatic compression method.
By injecting sclerosants into the
vein,complete sclerosis of the venous
walls can be achieved.
32. Indications for surgery:
Agents used :
-Cosmetic.
-Sodium tetradecyl sulphate 3%
-Varicose ulcers. (STDS)
-C4-C6.(CEAP Grading) -Sodium morrhuate
-Ethanolamine oleate
33. Basic steps of SFJ ligation and -Polidocanol
GSV removal:

37. Complications of varicose vein

Trendelenburg operation surgery:
(Crossectomy):
-Infection—10%
It is juxtafemoral flush ligation of long
saphenous vein (i.e. flush with femoral -Haematoma
vein), after ligating named (superficial
-FormationDVT—0.01%
circumflex, superficial external
pudendal, superficial epigastric vein), -Saphenous neuralgia, sural nerve
deep external pudendal vein and injury
unnamed tributaries.
-Recurrence

34. Minimally invasive procedures:

-Radio frequency ablation(RFA)
-Endovenous laser ablation(EVLA)
-Subfascial endoscopic perforator
ligation surgery(SEPS)
35. Nerves injured during ligation:
38. Recognizing acute DVT:
Clinical features:
Pain and swelling in calf,local warmth,
low grade fever
Clinical signs:
Homan’s sign, moses sign, perthes
test(not done as they might dislodge
the thrombus)
Investigaions: -Other Systemic Symptoms
D-dimer measurement, duplex ultra 42. Newer Methods of Treatment of
sound. Varicose Veins:
-VenaSeal(cyanoacrylate) : latest
treatment for varicose veins that
39. Factors pre disposing to DVT:
doesn’t require anaesthesia.
-Old age
-Obesity
-Immobilization
-Endovenous laser treatment :
-Pregnancy performed under local anaesthesia
and laser energy is delivered into vein
-Puerperium to obliterate it.
-Estrogen therapy -Radiofrequency Ablation
-Thrombophilia
-Surgeries (pelvis and hip surgery) 43. Are clinical dvt tests performed
-Malignancy nowadays?
It is not performed nowadays because
it is unreliable,carries risk of
40. Steps in management of DVT: dislodgement of thrombus which can
Rest, elevation of limb, crepe lead to pulmonary embolism.
bandage.
Anti coagulants: heparin/LMW heparin, 44. DVT definition
warfarin for six months
DVT is the formation of a semi-solid
Target INR 2.0 coagulum within the venous system
which has got high tendency to
develop into an emboli.
41. Negative history to be asked in a
case of Varicose Veins: (AKA Phleothrombosis)

-Pain
-Ulcer 45. Perforators Vs Tributaries:

-Itching Peforators:

-Change in skin colour -Connects superficial to deep veins.

-Pain in abdomen -They have valves, which allows blood

to flow only from superficial to the
-Lump in lower abdomen deep direction.
-Bladder Habits:any Obstruction
-Constipation
 47. Theories of varicose venous
ulcer:
Tributaries:
A.Fibrin cuff theory
-Connects only one system (i.e.
Superficial to superficial OR deep to Incompetence of venous valves
deep)
↓
Stasis of blood
46. Differntial Diagnosis for
↓
Varicose veins:
Chronic ambulatory venous
-Lymphoedema
hypertension
-AV malformation
↓
-Orthostatic oedema
Defective microcirculation
-Renal and cardiac disease
↓
-Hepatic causes
RBC diffuses into tissue planes
-Vasculitis
↓
-Metabolic diseases like gout,
Lysis of RBC’s
myxoedema, and morbid obesity
↓
-Chronic infections like tuberculosis,
syphilis Release of haemosiderin
↓ Pigmentation
↓ Dermatitis
↓
Capillary endothelial damage
↓
Prevention of diffusion and exchange
of nutrients
↓
Severe anoxia
↓
Chronic venous ulceration
B.White cell trapping theory:
Inappropriate activation of trapped
leucocytes release proteolytic
enzymes, which cause cell destruction
and ulceration.
Fibrin deposition, tissue death,
scarring occurs together, called as
lipodermatosclerosis.

48.Procedure for Varicose Veins:

•Mark the varicose trunk and
incompetent perforators
•Anaesthesia
•Flush ligation i.e., trendlenburg’s
operation is performed.
•Oblique incision below inguinal
ligament at the level of femoral artery
and extends 4cms medially
•Long saphenous , superficial and
common femoral veins exposed
•Tributaries of saphenous veins ( sup.
Circumflex iliac, sup. External
pudendal) are dissected and ligated
individually

• The GSV is ligated and divided flush

with the femoral vein.
•Stripping of dilated segments or small
varicosities below the ligated vessel is
done if present.
 HERNIA
4. What are the Causes of inguinal
swelling:
1. Predisposing factors of a Hernia: -Bubonocele
-Chronic constipation -Lymph node enlargement
-Chronic cough
-Straining at Micturation
-BPH, Stricture urethra -Ectopic testis
-Pregnancy -Undescended testis
-Smoking -Aneurysm of external iliac artery
-Familial collagen disorder – Prune -Lipoma
Belly Syndrome
-Appendicectomy
5. Symptoms of obstructed hernia:
-Colicky abdominal Pain
2. What are the Complications of a
-Obstipation
Hernia:
-Abdominal distension
-Irreducibility
-Vomiting
-Obstruction
-Step ladder peristalsis
-Strangulation

6. Symptoms of strangulated
3. What are the Causes of inguino-
hernia:
scrotal swelling:
-Severe pain over pre-existing hernia
-Complete Inguinal hernia
-Persistent vomiting
-Encysted hydrocele of the cord
-Tachycardia
-Varicocele
-Hypotension
-Lymph varix
-Abdominal distension
-Diffuse lipoma of the cord
-Dehydration ,toxicity
-Malignant extension from the testis
-Local raise of temperature
 -Redness Reducibility Can be Cannot be
reduced reduced
-Hernia is tense, tender, irreducible
completely completely
and without expansile impulse on
coughing. Cough Present Often absent
impulse
-Electrolyte imbalance

9. Difference between Direct and

7. Differentiate Hernia from
Indirect hernia:
Hydrocele:
Features Direct Indirect
Hernia Hydrocele
Hernia Hernia
Cough impulse is Cough impulse is
Age Elderly All age
present. absent.
groups
Reducible Irreducible
Etiology Weakness of Preformed
We cannot get We can get above posterior wall sac
above the swelling the swelling of inguinal
canal
Fluctuation test is Fluctuation test is
negative. positive. Laterality Bilateral Unilateral
Transillumination is Trans-illumination Direction of Comes out of Comes out of
negative test is positive sac hasselbach’s deep inguinal
triangle ring
Obstruction Rare Common
and
8. Difference between Inguinal and strangulation
Femoral hernia:
Deep ring Negative Positive
occlusion
test
Features Inguinal Femoral
hernia hernia Zeimann’s Impulse on Impulse on
test middle finger index finger
Swelling Globular Retort
Site Above and Below and
medial to lateral to 10. What is Taxis ?
pubic pubic tubercle
-Used in irreducible or partially
tubercle
reducible hernia.
Groin Above the Below the
-Reduction is tried by flexing ,medially
crease of crease of
rotating and adducting the hip
groin groin
(superficial inguinal ring will be wide -If swelling does not appear and on
open). releasing the thumb, swelling appears
during coughing, then it is an indirect
It is dangerous in:
hernia.
-Obstructed hernia
-Maydl’s hernia
-No role in femoral and strangulated
hernia

13. Contents of inguinal canal:

11. Difference between Enterocele &
Omentocele: -Spermatic cord in male
ENTEROCELE OMENTOCELE -Round ligament in female
-Ilioinguinal nerve
First part is First part is
difficult to easier to reduce
reduce but last but last part is 14. What is Mid inguinal point what
part is easier. difficult. Has a is its significance:
There will be doughy feeling.
gurgling sound Point midway between anterior
on reduction. superior iliac spine and pubic
symphysis
Resonant Dull
Significance: Deep ring lies 1.25 cm
Peristalsis No peristalsis above it
Bowel sound Bowel sound not
heard. heard.
15. Boundaries of inguinal canal:
Anterior wall: Skin. Superficial fascia
(camper’s and scarpa’s) External
12. Describe Deep ring occlusion oblique aponeurosis
test: Posterior wall:Fascia transversalies
-Internal ring is located half inch above Roof:Lower arched fibers of internal
the mid-inguinal point (center point oblique and transverse abdominal
between anterosuperior iliac spine and muscle.
pubic symphysis).
Floor:inguinal ligament
-After reducing the contents, internal
ring is occluded using the thumb.
-Patient is asked to cough in standing
position.
-If a swelling appears medial to the
thumb, then it is a direct hernia.
16. What is Midpoint of inguinal
ligament what is its significance:
Point midway between anterior
superior iliac spine and pubic tubercle.
The femoral artery lies beneath this
point.
17. What are the boundaries of
Hesselbach's triangle and what is
its significance:
Medial:lower 5cm of lateral border of
rectus abdominis muscle
Lateral:Inferior epigastric artery
(branch of external iliac artery)
Inferior:Medial half of inguinal
ligament.
Direct hernia occurs through this
triangle.
18. Pubic tubercle-significance:
-Medial attachment of inguinal
ligament
-Landmark for superficial ring
-Landmark for saphenous opening
-Hernia surgery-First bite of hernia
repair
-Varicose vein surgery-landmark for
sapheno-femoral junction
19. Describe the anatomy of
Femoral canal:
Small compartment in medial part of
femoral sheath
Borders-
Lateral - femoral vein
Medial – Lacunar ligament
Anterior – Inguinal ligament
Posterior – Pectineal ligament
Contents-lymphatic vessels,deep
lymph node(cloquet)
20. Name some rare hernias and
describe them:
Sliding hernia (Slipping of posterior
peritoneum with retroperitoneal viscus)
Pantaloons hernia (Two sacs – Direct
and indirect)
Littre’s hernia (Hernia containing
Meckel’s diverticulum)
Maydl’s hernia (hernia, intra-
abdominal loop gangrene)
Richter’s hernia (Part of
circumference of bowel strangulated)
21. Describe Herniotomy:
-Ligation of hernia sac at the level of
deep inguinal ring
-Material used – absorbable
-Suture Tecnique– transfixation suture
-Landmark for deep ring during
surgery: Pre-peritoneal fat
22. Describe Hernioraphy:
Herniotomy plus repair of posterior
wall of inguinal canal with native
tissue.
Two technique
1. Bassini’s technique -
approximation of conjoint tendon with
inguinal ligament.
2.shouldice technique
23. Describe Hernioplasty:
Herniotomy plus reinforcement of
posterior wall of inguinal canal with
prosthetic material
Lichtenstein tension free onlay mesh
repair
Polypropylene mesh is used
24. Treatment of Strangulated
Hernia:
-The patient is resuscitated
-Ryle’s tube aspiration.
-Intravenous fluids to correct
dehydration and electrolyte imbalance.
-Antibiotics
-Catheterisation to monitor urine
output
-Taken for emergency surgery
-During surgery mesh is usually not
used (due to risk of infection)
25. Complications of hernia surgery:
-Wound infection
-Mesh Infection
-Seroma
-Scrotal collection
-Urinary retention
-Recurrence
26. Nyhus Classification:
Type I: Indirect hernia with normal
deep ring
Type II: Indirect hernia with dilated
deep ring
Type III: Posterior wall defect.
- Direct
- Pantaloon hernia
-Femoral hernia
Type IV: Recurrent hernia.
27.Gilbert Classification:
Type I: Hernia has got snug internal
ring through which a peritoneal sac
passes out as indirect sac.
Type II: Hernia has a moderately
enlarged internal ring which admits
one finger but lesser than two finger
breadth. Once reduced it protrude
during coughing or straining
Type III: Hernia has got large internal
ring with detect more than two finger
breadth.
Hernia descends into the scrotum or
with sliding hernia. Once reduced it
immediately protrudes out without any
straining.
Type IV: It is direct hernia with large
full blow out of the posterior wall of the
inguinal canal. The internal ring is
intact.
Type V: It is a direct hernia protruding 30. Intraoperative findings of direct
out through punched out hole/defect in and indirect inguinal hernia:
the transversalis fascia. The internal
Direct Hernia Indirect Hernia
ring is intact.
Sac is Sac is
posteromedial to anterolateral to
Type VI: Pantaloon/double hernia. cord cord
Sac is medial to Sac is lateral to
inferior epigastric inferior epigastric
Type VII: Femoral hernia
vessels vessels
Broad neck Narrow neck
Comes through Comes through
28. Giant hernia: hesselbach’s deep ring
triangle
It is inguinoscrotal hernia descending
below the midpoint of inner thigh when
patient is in standing position.

31. Sliding Hernia and its Surgical

29. Tension free meshplasty:
It is strengthening of posterior inguinal
wall in case of indirect hernia or in any
large hernia with weak abdominal wall
using a supportive material.
This allows and supports good
fibroblast proliferation which in turn
strengthens the weak posterior wall of
inguinal canal or abdominal wall
importance:
Hernia in which part of the posterior
wall is formed not only by the
peritoneum but also by part of
retroperitoneal structures.
Surgical Importance : Posterior wall
of the sac should not be separated
from large bowel or bladder , if tried
injury may result to these organs
leading to FAECAL or URINARY
FISTULAS.

32. Types Of Mesh:

Synthetic:
Prolene mesh(commonly used)
Vipro/ultrapro(nonabsorbable)
Dacronmesh, morilex mesh
Biological:
Tensor fascial lata
Temporal fascia
Skin (not well accepted as infection
is common)
33. Triangle of Pain:
Boundaries:
-Superomedial margin and inferolateral
margin of iliopubic tract
-Lateral margin of peritoneal fold and
testicular vessels
Contents:
-lateral femoral cutaneous nerve
-femoral nerve
-femoral branch of genitofemoral
nerve
Siginificance: After placing the mesh
the surgeon must avoid putting staples
to secure the mesh below iliopubic
tract or it can injure the nerves.
Hence the name Triangle of pain
34. Triangle of Doom:
Boundaries:
Laterally: spermatic cord vessels
Medially: vas deferens
Posteriorly: peritoneal edge
Contents:
-External iliac vessels
-Deep circumflex iliac vein
-Femoral nerve
-Genital branch of genitofemoral
nerve
Significance: During surgery
staplesshould be avoided in this region
to avoidinjury to external iliac vessels
and femoral nerve.
35. Vessels Ligated during
Herniorraphy:
-Superficial epigastric vein
-External pudendal vein
36. Vessels seen on opening of
superficial layer during hernia
surgery:
-Superficial epigastric artery & vein
Importance:Any damage to these
vessels may cause hematoma
formation.
37. Why is herniorraphy done
instead of hernioplasty in cases of
strangulated hernia?
In herniorrhaphy the defect is repaired
by stitching local body tissues while in
hernioplasty a remote tissue or
synthetic material like a mesh is
placed to cover the defect that caused
the hernia
In strangulated hernia, surgeons would
avoid placing synthetic mesh to reduce
the risk of seeding the mesh with
bacteria, especially when a bowel
resection was performed and to avoid
tension over the defect site.
38. Bubonocele:
It is a type of indirect inguinal hernia,in
which the hernia pouch descends only
as far as the groin, forming a swelling
there like a bubo.
Hernia is confined to the inguinal
canal.
39. Fruchard’s myopectineal orifice:
It is an osseo-myo-aponeurotic tunnel.
It is through this tunnel all groin
hernias occur.
It is the area between inguinal
ligament anteriorly and iliopubic tract
posteriorly.
40. Types of hernioplasty:
1. Onlay repair
2. Lichtenstein tension free onlay
mesh repair
3. Inlay mesh repair
4. Underlay mesh repair
5. Nyphus preperitoneal mesh repair
6. Modified Rives preperitoneal mesh
repair
7. Stoppa's gaint prosthesis
reinforcement of visceral sac(GPRVS)
8. Gilbert patch and plug repair/
Gilbert's PHS(Prolene Hernia System)
repair
9. Kugel groin hernia mesh repair
10. TAPP mesh repair
(Transabdominal preperitoneal
laparoscopic mesh repair)
11. TEP mesh repair (Totally extra
peritoneal laparoscopic mesh repair)
41. Examination of penis and
scrotum:
Inspection:
Note position and extent if:
-Swelling goes right down to bottom of
scrotum - Congenital inguinal hernia
-Swelling stops just above the testis-
Funicular and acquired types of
inguinal hernia
-Position of penis -Large inguinal
hernia in scrotum pushes the penis to
opposite side
On Palpation:
To get above the swelling:
Differentiates scrotal swelling and
inguinoscrotal swelling.In inguinal
hernia one cannot get above the
swelling.
In pure scrotal swelling one can feel
nothing between fingers expect the
spermatic cord structures
Relation of swelling to testis and 44. Management of Vas
spermatic cord: deferensinjury during hernia
surgery:
-Inguinal hernia remains in front and
sides of spermatic cord and testis Conventional ipsilateral and crossover
which remains incorporated in the vasovasostomies and
swelling. vasoepididymostomies
-In acquired or funicular variety testis
can be felt apart from hernia as the
45. Indications of Hernia surgery:
hernia stops just above the testis
HERNIOTOMY:
-Congential hernia
-Congential hydrocele
42. Complications of hernioplasty:
-All paediatric age group & young
-Infection
adults
-Mesh extrusion,
-Foreign body reaction,
HERNIORRHAPHY:
-Mesh inguinodynia (pain along the
-Young adults with good muscle tone
distribution of ilioinguinal or
iliohypogastric nerves), -Weak posterior wall
-Mesh erosion into bladder, bowel, or -Dilated internal ring
vessels (rarely).

HERNIOPLASTY:
-Old age with poor muscle tone
43. Recent advanced Hernia
surgeries: -Direct hernia

a. TEP: Totally Extraperitoneal -Huge indirect complete hernia

laparoscopic mesh repair
Indications are recurrent hernia, 46. Bassini Repair:
bilateral hernia indirect/direct femoral
hernia It is a surgical procedure done for
indirect inguinal hernia and small
direct hernia.
b. TAPP: Transabdominal
Preperitoneal Mesh Repair using
Laparoscope Procedure:

Indications are: Large indirect hernia -Opening the fascia tranversalis from
irreducible inguinal hernia. pubic tubercle to deep ring
-Approximation with interrupted suture
- Approximation of conjoint tendon with
inguinal ligament and lower leaf of
fascia transversalis.
Modified bassini:
Sutures are placed between the
conjoint tendon and inguinal ligament
below extending from pubic tubercle to
deep ring with prolene.
Specific-
-USG abdomen (non palpable mass,
occult inguinal hernia, abdominal
mass, ascites, BPH)
-Plain X-ray abdomen erect posture
(strangulated hernia)
50. Colour of mesh:
M/C used mesh: Prolene mesh –
white in colour

47. Complications of sportsman

51. Colour of suture material:
hernia:
Non-absorbable prolene monofilament
-Post herniorrhaphy pain syndrome
– blue (easy visibility against skin)
(inguinodynia)
-Hernia recurrence
-Wound Infection
-Ischemia
- Necrosis

48. Meshoma:

Meshoma is an inflammatory mass

with collagen and fibroblast resulting
from use of mesh.

49. Investigations for a case of

hernia:
Basic-
-CBC (Hb, BT, CT, Blood grouping and
typing, TLC, DLC ),
-Blood sugar
-Urine albumin and sugar
-Serum creatinine
-CXR.
PERIPHERAL VASCULAR DISEASE
HISTORY
1. Significance of age and gender:
a. Age:-
Young age : Raynaud’s phenomenon
Middle age: buerger's disease
(thromboangiitis obliterans)
Old age: Atherosclerosis
b.Gender:-
2. Risk factors:
a) Cigarette smoking
b) Hyperlipidemia
c) Hypertension
d) Diabetes mellitus
e) Lack of antioxidants: vitamin A, C, E
and beta-carotene
f) Coagulation factors: increased
fibrinogen, elevated factors 8, 13,
plasminogen and anti - plasmin
g) Others: sedentary life style,
Men > 45 years, women > 55 years,
premature Menopause with no
hormone replacement therapy
Buerger's disease seen in men
Raynaud’s disease in women
3. Intermittent claudication and
sites:
Crampy pain in muscles of lower limbs
due to excessive accumulation of P-
Substance and lactic acid causing
arterial
Sites of claudication pain:
a) Pain in foot - block in lower tibial
and plantar vessels
b) Pain in calf( most common) : block
in femoro-popliteal segment
c) Pain in thigh - block in superificial
femoral artery
d) Pain in thigh - block in common
illiac or aortoilliac artery
4. Boyds Classification of
Claudication:
Grade 1: patient experiences pain
after walking some distance and pain
disappears and patient continues to
walk (P- substances washes away).
Grade 2: pain persists and the patient
continues to walk with limp.
Grade 3: pain compels the patient to
take rest.
5. Rest pain:
-It is continuous pain in calf or feet or
toes or in the region even at rest
depend ending on site of obstruction.
-It is the cry of dying nerves due to
ischemia of the somatic nerves.
-Abdominal pain (mesenteric ischemia)
-Impotence (bilateral internal iliac
occlusion)
-Blurred vision (Ophthalmic vessels)
8. Difference between functional
and critical limb ischemia?
Functional Limb ischemia: Normal
blood flow at rest but cannot be
increased in response to exercise

-Rest pain increases on lying position,

Clinical features: pain in the muscle ,
movement of limbs, and elevation of
Pain increase on exercise , pain
foot and worsens during night so
relieved on rest
patient become sleepless.

-Rest pain relieved on hanging the foot Critical Limb ischemia : Recurrent
down, by holding the foot with hand, ischaemic pain at rest that persists for
which suppress the transmission of more than 2 weeks requires
pain. analgesics with an ankle systolic
pressure less than 50mmHg
It can lead to ulceration or gangrene
6. Differentiate Neurological
formation.
Claudication from Vascular
Claudication:
Pain due to some neurological causes
(eg: disk compression)
Neurological claudication will have
pain from the initial step, relieved only
by some posture, which relaxes the
nerve. It is not related to distance he
walks, all peripheral pulses are
palpable.

7. What are the history of involvement

of other vessels?
-Chest pain (Coronary artery
occlusion)
-Black outs (CVA)
 EXAMINATION
1. Signs of peripheral ischemia:
-Thinning of skin,
-diminished hair,
-loss of subcutaneous fat,
-loss of shine,
-trophic changes in nail: brittle nails,
transverse ridges develop
-minor ulcerations in pressure areas
2. Dry gangrene and wet gangrene
differentiation:
Dry gangrene has dry, shriveled,
mummified appearance, clear line of
demarcation present and localized.
Wet gangrene looks edematous with
putrefaction and infection, crepitus
may be present, line of demarcation
absent, spreads proximally and faster
3. Tests in inspection-buergers
postural test:
Patient lies on his back on the table.
He is asked to raise his legs one after
another keeping the knees straight.
Normal limb remains pink even if
raised to 90°.
However, in ischemic limb elevation to
certain degree cause marked pallor
and the veins will be empty and
guttered.
The angle at which the pallor appears
is buerger's angle.
After elevating the legs, patient is
asked to sit up and hang his leg down
by the side of the table.
Normal leg will remain pink as in
elevated position.
However, an ischemic limb first
becomes pale when elevated and
gradually becomes pink in horizontal
position.
The change of colour takes place
slowly. This is capillary refill time.
4. Capillary refilling time:
In severe ischemia, it takes 20-30 secs
to become pink.
5. Venous refilling time:
After keeping the limb elevated for a
while it is then laid flat on bed, there
will be normal refilling of veins within 5
secs. However, in ischemic limb it is
delayed.
6. Harvey’s sign:
To check venous refilling, the two
index fingers are placed side by side
on a vein.
The fingers are now pressed firmly and
the finger nearer the heart is moved
proximally keeping the steady
pressure on the vein to empty the
short length of vein between the two
fingers.
The distal finger is now released.
This will allow venous refilling to be
observed, this is poor in ischaemic
limb and is increased
in AV fistula. This is known as
Harvey’s sign.
7. Fuchsig’s test:
To detect popliteal pulsation.
Patient is asked to sit with legs
crossed one above another so
that the popliteal fossa lie against
knee of the other leg.
The crossed leg will show oscillatory
movements synchronously with the
pulse of the popliteal artery.
If the artery is blocked the movement
will be absent.
8. What is disappearing pulse?
An apparently normal pulse may
disappear after exercising the patient
to the point of claudication.
It is a sign of unmasking the
preliminary stage of arterial occlusion.
The disappearing pulse reappears
after a minute or two following
cessation of exercise.
9. What is Branham’s sign?
Also called nicoladonis sign, this is
performed when AV fistula is
suspected.
A pressure on the artery proximal to
fistula will cause reduction in size of
swelling, disappearance of bruit,
fall in pulse rate, and the pulse
pressure returns to normal.
10. Explain Allen’s test?
To know patency of radial and ulnar
arteries.
Patient asked to clench his wrist
tightly.
Surgeon presses on radial and ulnar
arteries, after one minute he is asked
to open the fist. Palm appears white.
Now pressure on radial artery is
removed and change in colour is
noted.
If the artery is blocked it remains white.
Now the test is repeated for ulnar
artery by releasing it and keeping
pressure on radial artery.
If ulnar artery is blocked, hand remains
white. If patent palm assumes normal
colour.
11. Palpation of peripheral pulses:
a) Abdominal aorta pulse
Palpate in the epigastric region
b) Carotid pulse
Chin of the patient is lifted to afloat
30°.
For palpation of right side, use left
thumb, vice versa.
Palpate near the medial border of
sternocleidomastoid at the level of
upper border of thyroid cartilage.
c) Subclavian pulse
Locate the midclavicular point. Take
fingers behind the clavicle and palpate
near midclavicular point.
Ask patient to lift shoulders to relax
deep cervical fascia for easy palpation.
d) Brachial pulse
It is palpated in front of elbow, medial
to tendon of biceps brachii.

e) Radial pulse
It is palpated near lateral border of
lower end of radius.

f) Ulnar pulse
It is palpated near the medial and
lower part of the wrist i.e. medial to
ulna bone.

g) Femoral pulse
It is palpated below inguinal ligament
present b/w ASIS to pubic tubercle.

h) Palpation of popliteal pulse

The knee is flexed to 40° with the heel
resting on bed, so that muscles around
popliteal fossa are relaxed.

The clinician places his fingers over

the lower part of popliteal fossa and
fingers are moved sideways to feel the
pulsation of popliteal artery against the
posterior aspect of tibial condyles.

i) Posterior tibial pulse

Plantar flexion of ankle.
Locate medial malleolus and palpate
posterior and slight superior to medial
malleolus

j) Dorsalis pedis pulse

Palpate in the proximal first
intermetatarsal space, lateral to
extensor hallucis longus muscle.

.
 INVESTIGATIONS

1. Gold standard method of 9. Duplex scan interpretation

investigation of PVD:
Digital subtraction angiography
2. Ankle brachial pressure index
Highest ankle pressure/ Highest
brachial pressure, normal: 0.9-1.2
3. Degree of ischemia based on
ABPI:
Mild: 0.5-0.9,
Moderate- 0.3-0.5,
Critical: <0.3
4. Significance of segmental
pressure
It is a systolic pressure measured in
thigh and calf, pressure drop
>20mmHg, is significant
For evaluation of arterial disease
Red – Blood towards the heart
Blue – Blood away from heart
Golden yellow/orange- turbulence
Allows subtraction of background data
prior to contrast with that of contrast
film.
(Done only when some intervention is
planned)
10. Significance of ECG
To measure left ventricle ejection
fraction

5. Significance of serum creatinine

To assess renal function

6. Invasive and non-invasive

assessment for PVD
Invasive- Catheter angiography (high
cost, longer duration, radiation and
contrast exposure),

Non-invasive - Continuous wave

Doppler, Pulsed wave Doppler, Duplex
Scan
(widely available, repeatable, safe)

7. Seldingers technique
Retrograde common femoral puncture

8. Digital subtraction angiography

 MANAGEMNET
1. What are the measures in
conservation treatment?
Modify the risk factors
-Smoking should be stopped, diabetes
should be in control,
hypertension and heart diseases
should be treated, weight reduction,
reduce hyperlipidaemia,
reduce hyperhomocysteinemia.
2. Indications for surgical
intervention:
-In critical limb ischemia
-Failure of non-surgical treatment in
the presence of disabling claudication
3. Grafts used in supra and infra
inguinal disease:
Suprainguinal disease - polytetra
fluoro ethylene or dacron materials
and
Infrainguinal diseases - saphenous
vein.
4. Surgical treatment of common
iliac occlusion , unilateral iliac
occlusion, aorta and bilateral
common iliac occlusion ? (or)
Surgical options for suprainguinal
diseases?
For common iliac occlusion -
aortofemoral bypass
For unilateral iliac occlusion- femoro
femoral bypass from opposite limb
For aorto and bilateral common iliac
occlusion- axillobifemoral bypass
5. Surgical options for infrainguinal
disease:
Occlusion Above popliteal artery-
femoropopliteal bypass
Occlusion Below popliteal artery-
femorotibial bypass
6. Medical drug therapy and their
mechanism of action:
Aspirin - it inhibits cyclo-oxegenase
enzyme
Clopidogrel - inhibits Gp2b3a
receptors
Dipyridamole,cilostazol- inhibit
phosphodiesterase 3 leading to
increase in cAMP levels
(improves walking distance)
7. Endovascular intervention:
1. Level of disease (suprainguinal
diseases are better than the
infrainguinal diseases)
2. Severity (stenosis better than
obstruction)
3. Quality of inflow
 QUESTIONS

1. 6P's Of Acute Limb Ischemia:

• Pain - continuous, severe, steady
and bursting.
• Pallor - distal part with extreme cold
3. Arterial vs Venous Ulcer:
limb
• Pulselessness – sudden loss of Features Arterial ulcer Venous
earlier palpable pulse Ulcer

• Paraesthesia - tingling, numbness or Etiology Insufficient Pooling of

complete loss of sensation. blood supply blood
causing causing
• Paresis - damage to motor nerve ischemia increased
and muscle leading into paralysis (late) pressure
• Poikilothermia on the
veins
Location Pressure Area
2. Leriche syndrome: points: toes between
It is a triad of Buttock Claudication, and feet, the lower
Impotence, and Absent Femoral lateral calf and
Pulses on both sides due to Aortoiliac malleolus and medial
obstruction. tibial areas malleolus

Predispos Diabetes, Varicose

ing hypertension, veins,
factors smoking, previous
previous DVT,
vascular obesity,
disease pregnancy
Ulcer Well defined Shallow
wound and flat
margin, margins,
punched out slopy 4. Bisgaard’s Regime:
edge, edges,
Bisgaaard’s Regim is as follows:
unhealthy moderate
bed with to heavy • 4 layered bandage, change once in a
necrotic exudates, week
tissue, slough at
• Massage of the indurated area and
minimal the base
whole calf
exudates if with
infected. granulatio • E-Elevation
n tissue.
• A-Antibiotics
Pain Painful with Painful • B-Bandages
intermittent
claudication. • C-Cleansing of ulcer
• D-Dressing with eusol
Surroundi Thin dry shiny Hemoside
ng skin and cool skin, rin • E-Exercise
reduced hair staining,
growth and thickening MNEMONIC - 4ME ABCD
pale or and
cyanotic. fibrosis,
itchy and 5. Findings in vessel wall:
edematou 1. Plaque formation
s,
indurated 2. Calcification
with 3. Aneurysm
dilated
veins. 4. Thrombus formation

Pulse Decreased or Normal 5. Lipohyalinosis

absent
Capillary Prolonged Normal 6. Signs of chronic Limb Ischemia:
refill
• Wasting of arm, forearm, and hand
Treatment Revasculariz Compress muscles.
ation, ion
antiplatelet therapy, • Ischemia changes in the skin,
drugs and leg tapering of fingertips.
management elevation • Drop in Systolic Pressure >
of risk factors. and 20mmHg.
surgical
managem • Proximal thrill or bruit.
ent.
• Mass in the neck, thrill and bruit in
the neck in Supraclavicular region.
• Adson test, Hyper abduction (Halsed)
test, Roos’ Test, Allen’s test are
important.

7. Procedure for Varicose Veins:

• Mark the varicose trunk and
incompetent perforators
• Anesthesia
• Flush ligation i.e., Trendelenburg’s
operation is performed.
• Oblique incision below inguinal
ligament at the level of femoral artery
and extends 4cms medially
• Long saphenous, superficial and
common femoral veins exposed
• Tributaries of saphenous veins (sup.
Circumflex iliac, sup. External
pudendal) are dissected and ligated
individually
• The GSV is ligated and divided flush
with the femoral vein.
• Stripping of dilated segments or small
varicosities below the ligated vessel is
done if present.
 HYDROCELE

1. Points in favour of Hydrocele? Get above the Get above the

swelling is absent. swelling is
-Testis not palpable present
Fluctuation test is Fluctuation test
-Fluctuant negative. is positive.
-Trans illuminant Transillumination is Trans-
negative illumination test
-Can get above the swelling is positive

-Cough impulse not present

-Not reducible 4. Differentiate between hydrocele
and varicocele:
Hydrocele Varicocele
2. Purely scrotal swellings:
Clear fluid in Engorgement of
-Varicocele tunica vaginalis pampiniforn
plexus
-Epididydimo orchitis
Consistency: Bag of worms
-Testicular tumor cystic
Painless swelling Dull aching
-Lymph varix swelling present
-Spermatocele on standing
Cough impulse is Increase in size
-Epididymal cyst absent with valsalva
,decrease on
-Elephantiasis of scrotum supine
Fluctuation fluctuation
positive negative
3. Differentiate Hernia from Hydrocele: Transillumination no
positive Transillumination
Hernia Hydrocele Idiopathic 2° to tumour,
trauma, filariasis
Cough impulse is Cough impulse Tense, painless, Small, lax,
present. is absent. large painful
Reducible Irreducible Middle/old age Young age
5. Types of Hydrocele:
a. Congenital
b. Acquired
- Primary vaginal hydrocele
- Infantile hydrocele
- Bilocular hydrocele
- Encysted hydrocele
- Hydrocele of hernial sac
placing a roll of paper of X-ray sheet
on opposite side(medially) "
Transilluminant: because of the clear
fluid
Non transilluminant : Because of
Thick dartos, thick sac, thick unclear
fluid, pyocele,chylocele.
Brilliantly Transilluminant: Vaginal
Hydrocele, Epididymal cyst, Ranula,
Meningocele, Cystic hygroma.

c. Secondary
- Infection ( Tuberculosis, 8. Diagnosis of Pyocele:
Syphilis)
-Fever
- Injury
-Toxicity
- Tumor
-Tender swelling in the Scrotum with
edema of scrotum
6. Layers of scrotum:
-Pus under tension causing infective
Skin
thrombosis of testicular vessels
Dartos muscle leading to gangrene.

External spermatic fascia -Transillumination test will be negative.

Cremastric fascia
9. Surgery for Hydrocele:

7. Transillumination: Congenital: Herniotomy

Method : It is done in a dark room with
a pen torch
Pen torch is placed laterally on the
Anterior part of scrotum, never place it
posteriorly as testis may interfere with
trans illumination.
Red glow of translucency seen in
scrotum which is better appreciated by
Infantile :sac is excised
Acquired:
1) Jaboulays procedure:
-Small & moderate Hydrocele
-Thin sac
- Eversion and placement of testis in
pouch prepared in fascial planes of
scrotum
 (hydrocele fluid coagulates if mixed
2) Excision of sac- with even a trace amount of blood that
hydrocelectomy: has been in contact with damaged
-Thick sac tissue).
-Long standing Hydrocele
-Haematocele 2) Excessive production of fluid within
-Infected sac tunica vaginalis.

3) Lords plication - sac with thin 3) Interference with drainage of fluid by

wall
-Small and medium size hydrocele
10. Principle of Surgery:
1) Jaboulay’s procedure :
lymphatics vessels of the cord.
4) Connection with peritoneal cavity
via a patent processus vaginalis
(congenital).

-Partial excision and eversion of the

sac

-On eversion of the sac, the secreting

surface of the testis becomes anterior
and secretions are absorbed by the
subcutaneous lymphatics.

2) Lord’s plication:

-The sac is opened and the cut edge

of sac is plicated to tunica albuginea.

-The redundant tunica vaginalis is

plicated by interrupted sutures.

-The sac gets crumpled up &

surrounds the testis

-The secretions get absorbed by the

lymphatics & venous system

11. Pathology of
Primary vaginal Hydrocele:

1) Defective absorption of hydrocele

fluid by tunica vaginalis -
Most common cause though the
reason is still obscure. Damage to
endothelial wall by low-grade infection
is the most probable explanation