Bedside Clinics in Surgery

Transcription

Bedside Clinics in Surgery
SURGERY
Bedside Clinics
in Surgery
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ditio
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Bedside Clinics
in Surgery
Long and Short Cases, Surgical Problems, X-rays,
Surgical Pathology, Preoperative Preparations,
Minor Surgical Procedures, Instruments,
Operative Surgery and Surgical Anatomy
Makhan Lal Saha
MBBS MS (Surgery) FMAS FAIS
Professor
Department of General Surgery
IPG E & R/SSKM Hospital, Kolkata, West Bengal, India
Formerly Associate Professor
Department of General Surgery, Calcutta Medical College
North Bengal Medical College
m
SURGERY
Se
Forewords
N Chintamani
Manoj Kumar Bhattacharya

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD
New Delhi • London • Philadelphia • Panama
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
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© 2013, Author
All rights reserved by the author. No part of this book may be reproduced in any form or by any means without the prior
permission of the author and publisher.
Inquiries for bulk sales may be solicited at: [email protected]ers.com
This book has been published in good faith that the contents provided by the author contained herein are original, and is
intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and
the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of
any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device.
Bedside Clinics in Surgery
First Edition: 2004
Second Edition: 2013
ISBN 978-93-5090-645-3
Printed at
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Dedicated to
My late parents Madhusudan Saha and Pushpa Rani Saha,
my revered uncle Shri Jadulal Saha
and my teachers
for whom what I am today.
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Foreword to the Second Edition
“He who loves his work never labors.”
—Jim Stovall
p
s
It gives me great pleasure and joy to write a foreword for this extraordinary book on Bedside clinics in urgery the 2nd edition by
Dr Makhan Lal Saha published by M/s Jaypee Brothers Medical
ublishers (P) Ltd, New Delhi, India. The book is a classic example of
how to make reading exhaustive yet lucid and enjoyable.
I have known the author for more than a decade and I can vouch for
his dedication and keen interest in the teaching of the science and art of
surgery. Having authored a few books myself, I am sure that any book
is a true reflection of the author’s love for the subject, his readers and
students and it is clearly palpable in this book. Dr Saha’s exceptional
way of narrating the text makes this book a masterpiece for bedside
learning of surgery.
Like in the first edition, the very simple way of teaching even the complex aspects of surgery has
its impact on the reader. The litmus test for any book on bedside clinics is the utility during various
undergraduate and postgraduate examinations. The book is surely going to pass that test with flying
colors as it is a wonderful blend of all the essential aspects of performance in the examinations and
in real-life scenario as a doctor.
The mandatory aspect of learning of surgery involves a thorough understanding of the surgical
anatomy. The addition of various essential aspects of surgical anatomy with very easily discernible
pictures adds tremendous value to this book. There are very limited texts available that address the
issue of surgical anatomy of relevant regions.
A picture is worth a thousand words and the presentation of various clinical scenarios with real-life
clinical pictures is truly remarkable. The demonstration of bedside physical signs and performance of
certain important procedures have been addressed using a very simple and understandable method.
The book is strongly recommended for all undergraduate, postgraduate trainees and trainers alike.
N Chintamani
MS FRCS (Ed) FRCS (Glas) FRCS (Irel)
FACS FICS (Surg Oncol) FIMSA
e
m
Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
Honorary Secretary—Association of Surgeons of India-2012
Governing Council ember—Association of Surgeons of India
President ( lect)—Association of Breast Surgeons of India
Editorial Secretary—Indian Association of Surgical Oncology
Controller of Examinations—College of Surgeons of India
Past President—Indian Society of Wound Management
Chief Editor—Surgical Clinics of India
Joint Editor—Indian Journal of Surgical Oncology
Associate Editor—Indian Journal of Surgery
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Foreword to the First Edition
C
It is my pleasure to write a foreword for Dr Makhan Lal Saha’s book,
Bedside linics in Surgery. I know him for more than a decade and
though he being a general surgeon worked under me in my neurosurgery
department for two years with keen interest and proved his worth.
I have gone through the proofs of his venture and I am sure his efforts
will prove results both to the undergraduate and postgraduate students
in surgery.
I am confident that his dedication to author this book for last five years
and practical experience will be very much useful to them for whom
he has written. I am sure his book will be highly appreciated, amply
rewarded and accepted by the entire medical students community.
HB 267 Salt Lake, Sector-3
26th January, 2004
Manoj Kumar Bhattacharya
MS MCh (Neurosurgery)
Former Dean
Faculty of Medicine
University of Calcutta
Kolkata, West Bengal, India
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Preface to the Second Edition
Bedside Clinics in Surgery released in the year 2004 was well accepted by both undergraduate and
postgraduate students. The book was also read by students of allied disciplines. Subsequently,
there have been repeated revised reprints. I worked on for last 9 years for necessary changes for
the second edition of the book. All the sections of the book have been thoroughly revised and
updated. All the recent guidelines for treatment have been incorporated in the book. In the first
edition, surgical anatomy and operative surgery was discussed along with the long and short
cases. In practical examination, emphasis is given on surgical anatomy and operative surgery.
Keeping in mind that, I have added two new sections in the second edition—a section on surgical
anatomy and another section on operative surgery. The section on surgical anatomy is not
exhaustive—the important topics required for undergraduate examination have been covered.
The operative section is little more elaborate and covers almost all common operations. The
topics required mainly for postgraduate students are in italics.
The first edition of the book contained black and white pictures except the surgical pathology
section. With the idea of publishing the book in a better way, the second edition is being
published and marketed by M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India.
I am grateful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director) and
Mr Tarun Duneja (Director-Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New
Delhi, India, for their interest in publishing the book.
My sincere thanks to editing team members of M/s Jaypee Brothers Medical Publishers
(P) Ltd at New Delhi—Ms Sunita Katla (Publishing Manager), Mr KK Raman (Production
Manager), Mr Rajesh Sharma (Production Coordinator), Ms Seema Dogra (Cover Designer),
Ms Geeta Srivastava, Mr Laxmidhar Padhiary, Mr Sarvesh Kumar Singh (Proof readers),
Mr Kapil Dev Sharma, Mr Kulwant Singh (DTP Operators) and Mr Sumit Kumar, Mr Rajesh
Ghurkundi (Graphic Designers), and at Kolkata Mr Sandip Gupta, Mr Sabyasachi Hazra and
Mr Suman Dutta for their dedicated and affectionate working in the second edition of the
book. I am sure the quality of the book in respect of paper, binding and design will be liked
by all the readers.
In this second edition, the book contains approximately 1,100 figures. Most of the pictures for
demonstration of clinical signs have been replaced by new color photographs. The schematic
diagrams in instrument section have been replaced by actual photographs. The instruments
required for laparoscopic surgery has been included. My postgraduate trainees Dr Subhamitra
Chowdhury, Dr Vivek Sharma, Dr Sidhartha Bhattacharya, Dr Sarvesh Gupta, Dr Asif Ayaz,
Dr Subhendu Majhi, Dr Kamal Singh Kanowar; my daughters Dr Priyanka Saha (Internee
at Medinipur Medical College) and Monica Saha (student at KPC Medical College), and my
friends Dr Kaushik Ghosh, Dr Partha Bhar and Dr Soumen Das has taken the new photographs
included in the second edition of the book. My colleagues at Institute of Postgraduate Medical
Education and Research (IPGME & R) Prof Bitan Kumar Chattopadhyay, Prof Amitava Sarkar,
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xii
Bedside Clinics in Surgery
Prof Prasanta Bhattacharya, Prof Diptendra Kumar Sarkar, Dr Shyamal Kumar Halder, Dr Anadi
Nath Acharya, Dr RS Moral, Dr Susnata De, Dr Subhasis Saha, Dr Subhra Ganguly, Dr Soumya
Mondal, Dr Saurav Das, Dr Prakash Kumar Bhagat, Dr Mainak Pal, Dr Partha Sarathi Dutta,
Dr Sunanda De were all helpful and provided many clinical photographs for inclusion in the
book. Some of the clinical photographs are also provided by my well-wishers Prof Sukumar
Maity, Prof Sasanka Sekhar Chatterjee, Prof Biswanath Mukhopadhyay, Dr Kalyani Saha Basu
and Dr Shamik Bandopadhyay. My wife Smt Priti Saha has also worked hard and helped me
during computer typing of different sections of the book.
My friend Prof Sekhar Mukhopadhyay, Bidhannagar Government College, West Bengal,
India, always encouraged and helped me with his artistic idea during the preparation of the
second edition of this book.
I received numerous suggestions from my colleagues and students and I have tried my best
to incorporate all these in the second edition of the book.
I thank all the students and faculty members for their applauding remarks about the book.
I am sure the students will be benefited by this book. However, I once again like to emphasize
that this book is not a substitute for a standard textbook of surgery, which every student should
read for acquiring a basic concept of surgery.
I am sure there is scope for further improvement in the next edition of the book. I would
request all the readers, my students and colleagues to give me their opinion and valuable
suggestion. The suggestion may please be sent to me in my e-mail address.
Makhan Lal Saha
E-mail: [email protected]
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Preface to the First Edition
Practical examination in surgery is exhaustive, encompassing long cases, short cases, surgical
problems, surgical pathology, radiology, surgical instruments, minor surgical procedures,
preoperative preparation and operative surgery. At present, there is no book available, which
covers all these aspects in a comprehensive manner, suitable for preparation in final MBBS
examination. The impetus for writing a book was primarily initiated by one of my favorite
students, Dr Shamik Nandy of Calcutta Medical College. This book, very different in its approach,
content and design, provides students of MBBS the basic and accurate knowledge of the practical
problems, which can be assimilated in a reasonable but short time. With six years of extensive
hard work, I have been able to present this book to the students of surgery.
This book covers discussions on almost all aspects of practical examinations. In long and
short cases, a sample summary is given and management is discussed based on that particular
case. The detailed discussion about that particular disease is presented afterward. The summary
described may not be reproducible in examination, but provides a valuable guideline as to how
to write a good summary of a particular case. Demonstration of physical signs with photographs
and schematic diagrams are also included in each section of the long and short cases. In long
and short case discussions, the students have to plan relevant management of the particular
clinical situation presented by him in the said examination. The section on surgical problems
covers both emergency and non-emergency conditions. A general outline for answer in such
a situation is presented. In X-rays section, representative plates are presented and discussion
is based on the findings of the particular X-rays. Discussions on the relevant clinical situation
are also covered. In surgical pathology section, a representative specimen is described and
this section mainly deals with the pathological aspects of the particular disease. For better
clarity and understanding, the surgical pathology specimens are printed in color. Preoperative
preparations for elective major surgery as well as those associated with common coexisting
medical diseases are discussed. The section on minor surgical procedures is not exhaustive and
only covers the important procedures commonly asked in examinations. Operative surgery is
not discussed in a separate section but important operations are discussed with long and short
cases and in other sections of the book. In instrument section, relevant points for identification
of the instrument are mentioned. While discussing the use of instruments, emphasis has
been given to mention the particular operations where the instrument is used. Sterilization
of instruments are discussed in detail. Every attempt has been made to create a condensation
of information by pointwise framing that will fulfil the students’ need during examination.
Throughout the text, emphasis has been given for methods of demonstration of clinical signs. An
attempt has been made to maximize the number of illustrations to complement the general text
materials. Photographs and schematic diagrams have been used for demonstration of clinical
signs and operative procedures. The book contains 485 illustrations, numerous photographs
and X-ray plates.
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Bedside Clinics in Surgery
This book, however, is not a textbook of surgery. I would recommend all the students to go
through standard textbooks of surgery for acquiring basic concepts. This book provides a very
simple, comprehensive, updated, and well-illustrated account, which may be used as a revision
book for preparation for practical examination in surgery. At places, the discussions are exhaustive
and may not be required for undergraduate students. These are indicated by italic fonts. I would
like to thank Dr Shamik Nandy, who has gone through the whole manuscript and suggested
important modifications to make the book suitable for undergraduate students. I would like to
thank Prof Biswanath Mukhopadhyay, Professor of Pediatric Surgery, Dr Anadinath Acharya,
Assistant Professor of Surgery, Dr Sasanka Sekhar Chatterji, Associate Professor of Plastic
Surgery and Dr Sukumar Maiti, Associate Professor of Surgery who have provided majority of
the clinical photographs included in the long and short case sections of the book. I would like
to thank all the faculty members of the Department of Surgery IPGME & R/SSKM Hospital,
Kolkata, West Bengal, India, namely Prof PK Gupta, Dr Sushma Banerji, Dr QM Rahaman,
Dr PK Sarkar, Dr Abhimanyu Basu, Dr PS Paul, Dr DK Sarkar, Dr S Das Chowdhury, and
Dr SK Halder for their constant help and encouragement while I was preparing this book. They
have also gone through the proof of the book. One of my postgraduate students, Dr Srinjoy Saha
spent lots of his time in taking different photographs included in this book. Dr Krishnendu Maity,
postgraduate student at Calcutta Medical College has also taken some photographs included in
this book. Dr Ranjit Das, Dr Kaushik Ghosh, Dr Budhadeb Saha for help in preparation of some
sections of this book. I thank my friend and well wisher Prof Sekhar Mukhopadhaya for his
constant encouragement while I was writing this book. He has also helped in designing the cover
page of this book. I would like to thank Dr Bansari Goswami, Professor and Head, Department
of Surgery, NRS Medical College, and Dr Mrityunjoy Mukherji, Professor and Head, Department
of Surgery, Calcutta National Medical College for allowing me to take the photographs of
surgical pathology specimens included in this book. Dr Sudip Chakraborty, Professor and head,
Department of urology, and Dr AG Ghosal, Professor and Head, Department of Chest Medicine,
IPGME & R, provided some X-ray plates for inclusion in this book. Dr Satinath Mukherji, Associate
Professor, Department of Endocrinology for help in writing the section on diabetes and surgery.
I would like to thank Mr Bimal Dhur and Sri Dipankar Dhur of Academic Publishers who
were always after me over these years and for their sincere efforts to publish this book in time.
Other members of staff of Academic Publishers Sri Abhijit Chakraborty, Sri Biswajit Seal and
Sri Swapan Dutta also worked hard for making this publication successful. I thank Mr Narayan
Sur and Mr Dilip Das who have drawn the different diagrams included in this book.
I am indebted to my wife Smt Priti Saha and my daughters Priyanka and Monica for their
wholehearted support in this endeavor. I will never forget their sacrifice of long hours of family
associations over these years while I was busy preparing this book.
My sincere thanks are due to my enthusiastic young students, friends, relatives and wellwishers for their constant support, encouragement and help.
In spite of all precautions, a good number of printing errors might have gone unnoticed. I would
request all the students to go through the corrigendum and correct the text to avoid confusion.
I hope this book will be beneficial to students of surgery and my efforts will be amply
rewarded only if this book is accepted by the students and teachers of surgery. I apologise for any
inadvertent mistakes, which might have been overlooked. I will be happy to receive comments,
criticisms and suggestions for the improvement of this book in future from my readers, which I
shall duly incorporate in the next edition of the book. The comments and the suggestions may
please be sent to me at my residential address or to my e-mail address.
Makhan Lal Saha
E-mail: [email protected]
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Acknowledgments
Prof Susanta Banerjee (Director of Medical Education), Prof Indrajit Saha (Joint Secretary,
Department of Health and Family Welfare), Swasthya Bhavan (Salt Lake City, Kolkata), for giving
me necessary permission for publishing this book.
My sincere thanks and gratitude to the following persons for their constant help and
encouragement during preparation of this book:
„„ Prof Pradip Kumar Mitra (Director, IPGME & R), Prof Tamal Kanti Ghosh (Vice-Principal and
Medical Superintendent), Dr Ajit Kumar Maity (Former Director), Dr DD Chattopadhyay
(Former Surgeon and Superintendent), Dr Arabinda Narayan Chowdhury (Ex-Professor
of Psychiatry and Superintendent, Institute of Psychiatry), Dr Nanda Dulal Chatterjee
(Ex-Professor and Head, Department of Orthopedics), Dr Anup Majumder (Professor and
Head, Department of Radiotherapy), Prof Rajen Pandey (Head, Department of Nephrology),
Dr Abhijit Tarafdar (Ex-Professor and Head, Department of Nephrology), Prof Pradip Kumar
Saha (Superintendent, Institute of Psychiatry), Dr Subhankar Chowdhury (Professor and
Head, Department of Endocrinology), Dr Parimal Tripathy (Professor and Head, Department
of Neurosurgery), Prof PK Ghosh (Ex-Professor and Head, Department of Forensic and
State Medicine), Dr Bijay Kumar Majumdar (Professor and Head, Department of Plastic
Surgery), Dr Alakendu Ghosh (Professor, Department of Medicine), Dr PK Mishra (Professor,
Department of Pediatric Surgery), Dr D Kar (Medical Officer, Department of Surgery),
Dr Abhijit Chowdhury (Professor of, Department Gastroenterology), Prof GK Dhali (IPGME
& R and SSKM Hospital), Prof Samarendranath Ghosh (Head, Department of Neurosurgery),
and all my postgraduate students, to name particularly—Dr Sarvesh Gupta, Dr Asif Ayaz,
Dr Sidhartha Bhattacharya, Dr Subhamitra Chowdhury, Dr Vivek Sharma, Dr Subhendu
Majhi, Dr Kamal Singh Kanwar, Dr Albinus Lakra, Dr Sanghamitra Sarkar, Dr Kallol Ray,
Dr Gopal Singh Yadav, Dr Suddha Swatya Sen, Dr Sohabrata Das, Dr Harbans Bansal,
Dr Puneet Goel, Dr Sushil Pandey, Dr Mala Mistry, Samir Saha, and Dr Rajan Tondon [MS
MCh (PDT)], Department of Plastic Surgery, Institute of Postgraduate Medical Education
and Research (IPGME & R), Kolkata, West Bengal, India.
„„ My teacher and well-wisher Dr Satyabrata Dasgupta, Ex-Professor and Head, Department
of Surgery, Calcutta Medical College, Kolkatta, West Bengal, India.
„„ Prof Bitan Kumar Chattopadhyay, Prof Amitava Sarkar, Prof Prasanta Bhattacharya, Prof
Diptendra Kumar Sarkar, Dr Shyamal Kumar Halder, Dr Anadi Nath Acharya, Dr Rajat Subhra
Moral, Dr Susnata De, Dr Subhra Ganguly, Dr Subhasis Saha, Dr Soumya Mondal, Dr Saurav
Das, Dr Partha Bhar, Dr Soumen Das, Dr Prakash Bhagat, Dr Mainak Pal, Dr Barun Kumar
Saha, Dr Partha Sarathi Dutta, Institute of Postgraduate Medical Education and Research,
Kolkata, West Bengal, India.
„„ Prof Kashinath Das, Prof Sukumar Maity, Prof Utpal De, Prof Debabrata Kundu, Prof Shibajyoti
Ghosh, Prof Gargi Banerjee, Prof Udipta Roy, Dr Shantanu Sinha, Dr Arijit Mukherjee and
other faculty members, Calcutta Medical College, Kolkata, West Bengal, India.
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Bedside Clinics in Surgery
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Prof Nemai Nath, Prof Sushil Ranjan Ghosal, Prof Sudev Saha, Prof Subodh Ranjan Saha,
Prof Nirjhar Bhattacharya, Prof Saugata Samanta, Prof TD Chattopadhyay and other faculty
members, Department of Surgery, Nil Ratan Sarkar Medical College and Hospital, Kolkata,
West Bengal, India.
Prof Saibal Mukherjee, Prof Manju Banerjee, Prof Subhabrata Das, Dr Ambar Ganguly,
Dr Subhasis Karmakar, Dr Nilanjan Panda, Dr Shamik Bandhopadhyay, Dr Ramanuj
Mukherjee and other faculty members, Department of Surgery, RG Kar Medical College and
Hospital, Kolkata, West Bengal, India.
Prof Debabrata Roy, Prof Hiranmoy Bhattacharya, Prof Ujjwal Bhattacharya, Dr Abhiram
Majhi, Dr Madhumita Mukhopadhyay and other faculty members, Department of Surgery,
Calcutta National Medical College, Kolkata, West Bengal, India.
Prof Mrityunjoy Mukherjee, Prof Manas Kumar Gumta and other faculty members,
Department of Surgery, Sagar Dutta Medical College, Kolkata, West Bengal, India
Prof Anil Kumar Saha, Dr Saugata Roy, Dr Amit Kumar Roy, Dr Mrityunjay Pal, Dr Mala
Mistri and other faculty members, Medinipur Medical College and Hospital, Medinipur,
West Bengal, India.
Prof Gautam Ghosh, Dr Ramkrishna Mondal, Dr Sukhendu Bikash Saha, Dr Sudangshu Sarkar
and other faculty members, Department of Surgery, Bankura Sammilani Medical College,
Bankura, West Bengal, India.
Prof Tomanosh Chowdhury, Prof RN Majumder, Prof Rabishankar Biswas, Dr Shamita
Chatterji and other faculty members, Department of Surgery, Burdwan Medical College,
Burdwan, West Bengal, India.
Prof Narendrananth Mukherjee, Prof Gautam Das, Prof SS Bhej, Prof Sudangshu Sekhar Bhoj,
Dr AN Sarkar, Dr JS Basunia and other faculty members, Department of Surgery, North Bengal
Medical College, Darjeeling, West Bengal, India.
Prof Abhimanyu Basu, Prof Manoranjan Kar, Dr Dushmanta Burman and other faculty
members, Department of Surgery, Malda Medical College, Malda, West Bengal, India.
Dr Tandra Mukherjee (Registrar), Dr G Dasgupta (Registrar), Dr S Das, Dr S Banerjee,
Dr KL Dey, Dr B Mukherjee (Medical Officer), PG Polyclinic, Kolkata, West Bengal, India.
My teachers and senior colleagues—Prof Manoj Kumar Bhattacharya (Former Dean of
Medical Faculty, University of Calcutta), Prof AP Majumder (Ex-President, AS1, WB Chapter),
Prof Urmila Khanna, Prof Sushila Sripad, Prof Purnima Mukherji, Prof Samar Pal, Prof
D Sarbapally, Prof Rita Sarkar, Dr RN Ghosh, Dr Gayatri Roy, Dr Chandreyi Gupta, Dr Collin Roy.
My friends and well-wishers—Pradip Kumar Gupta (MGM Medical College, Kishanganj,
Bihar, India), Dr Aniruddha Dasgupta, Dr SP Saha, Dr Samiran Saha, Dr KG Saha, Dr JN
Kabiraj, Dr S Babu Thakur, Dr SN Bhowmik, Dr PK Paul, Dr L Naha Biswas, Dr TK Paul,
Dr TN Sen, Dr SK Das, Dr Debjani Roy, Dr S Paul, Dr S Roy, Dr Tanusree Roy, Dr GD Mitra,
Dr S Purakayastha, Dr Manish Bose, Dr Om Tantia, Dr Shomnath Ghosh, Dr Aloke Kumar
Roy, Dr Manab Sarkar, Dr Sikha Adhikary, Dr Rama Das, Dr Sutapa Mondal, Dr Bhaswati
Basu, Dr Debashis Basu, Dr Dipak Pal, Dr Diptendu Bikash Sengupta, Miss Sikha Das, Sister
Moni Mandi, Sister Pronita Chakraborty, Sister Sumana and Sister Subhra.
Prof N Chintamani for his remarks in the foreword.
Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director) and Mr Tarun Duneja
(Director-Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India
My all relatives who have always stood beside me.
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Contents
Section 1 Surgical Long Cases 1.Introduction
1
• Outline for Writing a Surgical Long
Case 1
• Clinical Questions on General
Survey 9
• Outline for Writing a Case of
Swelling 25
• Clinical Questions on Swelling 27
• Outline for Writing a Case of
Ulcer 34
• Outline for Writing a Case of Sinus or
Fistula 35
2. Hernias
•
•
•
37
• Outline for Writing a Case of
Hernia 37
• Indirect Reducible Inguinal Hernia in
an Adult 41
• Inguinal Hernia with Features of
Prostatism 64
• Recurrent Inguinal Hernia 66
• Incisional Hernia 67
3. Abdomen
76
• Outline for Writing an Abdominal
Case 76
• Clinical Questions on Abdominal
Examination 81
• Cases Presenting with Gastric Outlet
Obstruction 94
−− Gastric Outlet Obstruction due to
Carcinoma of Stomach 94
•
−− Discussion on Gastric
Lymphoma 106
−− Discussion on Gastrointestinal
Stromal Tumor (Gist) 107
−− Gastric Outlet Obstruction due to
Complication of Chronic Duodenal
Ulcer 110
Peptic Ulcer Disease—Chronic
Gastric Ulcer and Chronic Duodenal
Ulcer 112
Case of Chronic Cholecystitis 124
Cases Presenting with Obstructive
Jaundice 132
−− Obstructive Jaundice due to
Periampullary Carcinoma or
Carcinoma of Head of
Pancreas 132
−− Obstructive Jaundice due to
Choledocholithiasis 146
−− Carcinoma of Gallbladder
(Presenting with or without
Obstructive Jaundice) 151
−− Discussion on
Cholangiocarcinoma 156
−− Obstructive Jaundice due to
Choledochal Cyst 158
Cases Presenting with Abdominal
Lump 162
−− Abdominal Lump due to Hydatid
Cyst of Liver 162
−− Pseudocyst of Pancreas 169
−− Carcinoma of Colon 175
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xviii
Bedside Clinics in Surgery
4. Urinary Cases
183
• Outline for Writing a Urinary
Case 183
• Hydronephrosis 188
• Carcinoma of Kidney 192
5. Breast
198
• Writing a Long Case of Carcinoma
of Breast 198
• Clinical Questions on Breast
Examination 201
• Early Carcinoma of Breast in a
Premenopausal Woman 210
• Locally Advanced Carcinoma of
Breast 221
• Management of Carcinoma of Breast
with Distant Metastasis 225
6.Thyroid
237
• Writing a Long Case of Thyroid
Disease 237
• Clinical Questions on Thyroid 241
• Nontoxic Multinodular Goiter or
Colloid Goiter 250
• Solitary Thyroid Nodule 255
• Primary Thyrotoxicosis (Graves
Disease) 259
• Carcinoma of Thyroid Gland 266
• Discussion on Anaplastic Thyroid
Carcinoma 272
• Discussion on Medullary Carcinoma of
Thyroid 274
7. Varicose Veins
278
• Outline for Writing a Long Case of
Varicose Vein 278
• Varicose Veins 280
8. Peripheral Vascular
Disease302
• Outline for Writing a Long Case
of Buerger’s Disease and
Atherosclerotic Peripheral
Vascular Disease 302
• Buerger’s Disease 306
Section 2 Surgical Short Cases 9. Skin and Subcutaneous
Tissue323
• Outline for Writing a Short
Case 323
• Dermoid Cyst 324
• Implantation Dermoid 328
• Submental Dermoid 329
• Sebaceous Cyst 330
• Lipoma 333
• Keloid 336
• Postburn Contracture 338
• Malignant Melanoma 341
• Malignant Melanoma with Lymph
Node Metastasis 345
• Benign Pigmented Nevus 353
•
•
•
•
Squamous Cell Carcinoma 355
Basal Cell Carcinoma 361
Marjolin’s Ulcer 364
Soft Tissue Sarcoma 366
10. Blood Vessels and Nerves 374
• Hemangioma 374
• Plexiform Hemangioma (Cirsoid
Aneurysm) 377
• Glomus Tumor 378
• Raynaud’s Disease/Raynaud’s
Syndrome 379
• Arteriovenous Fistula 384
• Neurofibroma 386
• Plexiform Neurofibromatosis
(Pachydermatocele) 388
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Contents
• Generalized Neurofibromatosis (Von
Recklinghausen’s Disease) 390
• Meningocele 391
• Meningomyelocele 394
• Nerve Injuries 395
−− Radial Nerve Injury 396
−− Ulnar Nerve Injury 406
−− Median Nerve Injury 410
11. Neck Swellings
•
•
•
•
•
•
•
•
•
•
•
•
417
Cystic Hygroma 417
Ranula 420
Thyroglossal Cyst 422
Thyroglossal Fistula 425
Branchial Cyst 427
Branchial Sinus (Fistula) 430
Tubercular Cervical
Lymphadenitis 433
Metastatic Cervical Lymph Node
Swelling with Unknown Primary 438
Malignant Lymphoma 441
Cervical Rib 445
Carotid Body Tumor 449
Pharyngeal Pouch 452
12. Salivary Gland
457
•
•
•
•
Mixed Parotid Tumor 458
Adenolymphoma 466
Carcinoma Parotid Gland 467
Chronic Sialoadenitis of Left
Submandibular Salivary
Gland due to Calculus in
Submandibular Duct 471
• Carcinoma of Submandibular
Salivary Gland 473
• Parotid Fistula 475
13. Mouth and Oral Cavity
•
•
•
•
•
Cleft Lip 478
Bilateral Cleft Lip 485
Cleft Palate 487
Oral Leucoplakia 492
Carcinoma of Tongue 494
• Carcinoma of Lip 502
• Carcinoma of Cheek 505
• Carcinoma of the Floor of
Mouth 507
• Carcinoma of Hard Palate and the
Upper Alveolus 508
• Dental Cyst 509
• Dentigerous Cyst 510
• Ameloblastoma or
Adamantinoma 511
• Osteomyelitis of Jaw 513
• Epulis 514
14. Breast, Hernias and
Abdominal Wall
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
516
Carcinoma in Male Breast 516
Bilateral Gynecomastia 518
Fibroadenoma Breast 520
Cystosarcoma Phylloides or Phylloides
Tumor in Breast 521
Congenital Hernia 522
Umbilical Hernia 524
Paraumbilical Hernia in Adults 526
Epigastric Hernia 528
Femoral Hernia 530
Lumbar Hernia 533
Persistent Vitellointestinal Duct 534
Umbilical Adenoma or Raspberry
Tumor 536
Urachal Fistula 536
Desmoid Tumor in the Lower
Abdominal Wall 538
15. Genitalia and Urethra
477
xix
539
Vaginal Hydrocele 539
Encysted Hydrocele of the Cord 545
Cyst of Epididymis 546
Varicocele 547
Undescended Testis 553
Filarial Scrotum and Ram’s Horn
Penis 561
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xx
Bedside Clinics in Surgery
• Phimosis 564
• Peyronie’s Diseases 567
• Carcinoma Penis 569
• Hypospadias 576
• Ectopia Vesicae 582
• Testicular Tumor 585
Section 3 Surgical Problems
16. Surgical Problems
591
•
•
•
•
•
•
•
•
•
•
•
Road Traffic Accident 591
Head Injury 597
Chest Injury 600
Abdominal Injury 606
Splenic Injury 609
Liver Injury 611
Pancreatic Injury 614
Renal Injury 616
Ruptured Urethra 619
Burn Injury 620
Acute Pain in Right Upper Quadrant
of Abdomen 625
• Acute Pain in Right Lower Quadrant of
Abdomen 629
• Lump in Right Iliac Fossa 631
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Acute Pancreatitis 634
Peptic Perforation 639
Intestinal Obstruction 640
Brust Abdomen 643
Postoperative Pyrexia 645
Acute Retention of Urine 647
Hematuria 650
Solitary Thyroid Nodule 652
Respiratory Distress Following
Thyroidectomy 654
Gangrene of Foot 655
Abnormal Nipple Discharge 658
Breast Lump 558
Deep Vein Thrombosis 660
Wound Infection 663
Section 4 X-rays
17. X-rays
669
• Straight X-ray of Chest/Abdomen with
Free Gas Under
Both Domes of Diaphragm 670
• Plain X-ray of Abdomen Multiple Air
Fluid Levels 675
• Sigmoid Volvulus 682
• Radiopaque Gallstone and Kidney
Stone 687
• Radiopaque Kidney Stones and
Bladder Stone 689
• Chest X-ray—Cannon Ball
Metastasis 692
• Chest X-ray—Subphrenic
Abscess 695
• Endoscopic Retrograde
Cholangiopancreatography (ERCP)—
Choledocholithiasis 698
• ERCP—Worm in Common Bile
Duct 700
• ERCP—Chronic Pancreatitis 702
• Paraumbilical Hernia in Adults 526
• T-tube Cholangiogram 705
• Barium Swallow X-ray of
Esophagus—Achalasia
Cardia 707
• Barium Swallow—Carcinoma of
Esophagus 710
• Barium Meal X-ray—Chronic
Duodenal Ulcer 713
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Contents
• Barium Meal X-ray—Benign
Gastric Ulcer 714
• Barium Meal X-ray—Carcinoma
Stomach 715
• Barium Meal X-ray—Gastric
Outlet Obstruction and Duodenal
Obstruction 717
• Barium Meal Follow Through—
Ileocecal Tuberculosis/
jejunal Sticture 720
xxi
• Barium Meal Follow Through—
Recurrent Appendicits 724
• Barium Enema—Carcinoma
Colon 727
• Intravenous Urography (IVU)—
Hydronephrosis 732
• Intravenous Urography—Carcinoma
Kidney 734
• X-ray Skull—Skull Bone Fracture 735
• Chest X-ray—Chest Injury 737
Section 5 Surgical Pathology
18. Surgical Pathology
•
•
•
•
•
•
•
•
•
•
•
•
741
Benign Gastric Ulcer 741
Perforated Benign Gastric Ulcer 745
Carcinoma of Stomach 746
Acute Appendicitis 752
Small gut Stricture 755
Intussusception 757
Meckel’s Diverticulum 760
Polyposis of Colon 762
Carcinoma of Colon 765
Carcinoma of Rectum 769
Ulcerative Colitis 772
Hydatid Cyst 775
•
•
•
•
•
•
•
•
•
•
•
•
Gallstone Disease 780
Cholesterolosis of Gallbladder 787
Carcinoma Gallbladder 788
Polycystic Kidney 790
Hydronephrosis 792
Carcinoma of Kidney
(Hypernephroma) 795
Tuberculosis of Kidney 798
Papillary Carcinoma of Urinary
Bladder 800
Benign Enlargement of Prostate 804
Testicular Tumors 807
Carcinoma Penis 811
Carcinoma of Breast 813
Section 6 Preoperative Preparations
19. Preoperative Preparations 819
• Preoperative Preparation for an
Elective Major Surgery 819
• Preoperative Preparation in a
Case of Toxic Goiter 822
• Preoperative Bowel Preparation for
Colorectal Surgery 823
• Preoperative Preparation in a Case of
Gastric Outlet Obstruction 824
• Preoperative Preparation in a
Case with Obstructive
Jaundice 825
• Preoperative Preparation of a
Patient with Diabetes
Mellitus 826
• Preoperative preparation of Patient
with Associated Heart Disease for
Surgery 829
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xxii
Bedside Clinics in Surgery
• Preoperative preparation of Patient
with Chronic Respiratory Disease for
Elective Major Surgery 831
• Preoperative Preparation of
Patient with Chronic Renal
Disease 832
Section 7 Minor Surgical Procedures
20. Minor Surgical Procedures 835
•
•
•
•
Insertion of a Nasogastric Tube 835
Starting an Intravenous Line 836
Arterial Blood Gas (ABG) 837
Establishing a Central Venous
Line by Subclavian Vein
Puncture 837
• Internal Jugular Vein
Cannulation 839
• Catheterization for Retention of
Urine 839
• Abscesses 840
−− Drainage of Peritonsillar
Abscess 841
−− Ludwig’s Angina 841
−− Parotid Abscess 842
−− Axillary Abscess 843
−− Perinephric Abscess 843
−− Anorectal Abscesses 843
−− Breast Abscess 845
−− Hand Infections 846
»» Acute Paronychia 846
»» Drainage of Pulp Space
Infection of Finger 847
»» Volar Space Infection 848
»» Web Space Infection 848
»» Infection of Middle Palmar
Space 849
»» Thenar Space Infection 849
»» Infection of Ulnar Bursa of the
Hand 850
»» Infection of the Radial
Bursa 851
»» Drainage of Infection in Space
of Parona 851
−−
−−
−−
−−
−−
−−
−−
−−
−−
−−
−−
−−
−−
−−
−−
−−
−−
−−
−−
−−
»» Infection of Flexor Tendon
Sheaths 851
Aspiration of Pleural Fluid
(Thoracocentesis) 852
Insertion of a Chest Drain 853
Pericardiocentesis 854
Peritoneal Fluid Tap 855
Cricothyrotomy 855
Sclerotherapy for Piles 856
Sclerotherapy for Ganglion 857
Lymph Node Biopsy 857
Excision of Sebaceous Cyst 858
Excision of Lipoma 858
Management of Ingrowing Toe
Nail 859
Dorsal Slit of Prepuce 859
Sclerotherapy for Varicose
Veins 859
Exposure and Ligature of External
Carotid Artery 860
Exposure of Subclavian Artery in
the Neck 861
Exposure and Ligature of the
Internal Iliac Artery 862
Exposure of the External Iliac
Artery 863
Exposure of the Femoral Artery
in the Thigh (in Adductor
Canal) 864
Exposure of the Popliteal
Artery 866
Peripheral Nerve Blocks 866
»» Digital Nerve Block 866
»» Median Nerve Block 867
»» Ulnar Nerve Block 867
»» Posterior Tibial Nerve
Block 868
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Contents
xxiii
Section 8 Instruments
21.Instruments
869
• Rampley’s Swab Holding
Forceps 872
• Towel Clips 873
• Bard Parker’s Handles 874
• Surgical Blades 875
• Hemostatic Forceps 877
• Kocher’s Hemostatic Forceps 881
• Mosquito Hemostatic Forceps 882
• Mayo’s Pedicle Clamp 883
• Lister’s Sinus Forceps 883
• Allis’ Tissue Forceps 884
• Babcock’s Tissue Forceps 885
• Lanes’ Tissue Forceps 885
• Plain Dissecting Forceps 886
• Toothed Dissecting Forceps 887
• Needle Holders 888
• Needles 889
• Skin Closure Clips and
Accessories 893
• Skin Staplers 894
• Mayo’s Scissors 894
• Mcindoe Scissors 895
• Metzenbaum Scissors 896
• Heath’s Suture Cutting Scissors 896
• Langenbach’s Retractor 897
• Czerney’s Retractor 897
• Morris’ Retractor 898
• Hook Retractors 898
• Cat’s Paw or Volkman’s Retractor 899
• Fisch Nerve Hook 899
• Deaver’s Retractor 900
• Self-retaining Abdominal Retractor
(Balfour’s Type) with Provision for
Attachment for Third Blade 900
• Millin’s Self-retaining Bladder
Retractor with a Provision for
Attachment of Third Blade 901
• Joll’s Thyroid Retractor 902
• Kocher’s Thyroid Dissector 903
• Cord Holding Forceps 903
• Malleable Olive Pointed Probe 904
• Olive Pointed Fistula Director with
Frenum Slit 907
• Piles Holding Forceps 907
• Right Angled Forceps (Lahey’s
Forceps) 910
• Cholecystectomy Forceps 911
• Desjardin’s Choledocholithotomy
Forceps 912
• Kehr’s T-tube 913
• Gastric Occlusion Clamps 914
• Lane’s Paired Gastrojejunostomy
Clamps 916
• Intestinal Occlusion Clamps 918
• Payrs’ Crushing Clamps 920
• Pyelolithotomy Forceps 923
• Suprapubic Cystolithotomy
Forceps 923
• Simple Rubber Catheter No. 10 924
• Foley’s Balloon Catheter 925
• Malaecot’s Catheter No. 30 Fr 926
• De Pezzer’s Catheter No. 24 Fr 927
• Catheter Introducer 927
• Metallic Bougie 928
• Female Metallic Catheter 930
• Male Metallic Catheter 930
• Volkman’s Spoon or Scoop 931
• Kelly’s Rectal Speculum
(Proctoscope) 932
• Flatus Tube 933
• Doyen’s Mouth Gag 934
• Airway Tubes 934
• Fuller’s Bivalved Metallic
Tracheostomy Tube 935
• Single-Bladed Blunt Hook 937
• Single-Bladed Sharp Hook 938
• Tracheal Dilator 938
• Corrugated Rubber
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xxiv
Bedside Clinics in Surgery
Sheet Drain 938
• Aneurysm Needle 939
• Suture Materials 942
• Instruments for Laparoscopic
Surgery 955
−− Telescope 955
−− Veress Needle 956
−− Trocar and Cannula 958
−− Maryland Dissector 959
−− Endograsping Forceps:
Toothed 960
−− Endograsping Forceps:
Non-toothed 960
−− Endoscissors: Curved Bladed/
−−
−−
−−
−−
−−
−−
−−
−−
−−
Straight Bladed 961
Suction Irrigation Cannula 961
Endoscopic Clip Applicator 962
Endoscopic Crocodile
Forceps 962
Endoscopic Spoon Forceps 963
Endoscopic Diathermy Hook 963
Endoscopic Diathermy
Spatula 964
Endo Needle Holder 964
Liga Clip—LT 300 965
Liga clip—LT 400 965
Section 9 Operative Surgery
22.Operative Surgery
967
• Lichtenstein Hernioplasty 967
• Steps of Herniotomy for
Congenital Hernia 968
• Steps of Tapp Operation 969
• Steps of Tep Operation for
Inguinal Hernia 972
• Anatomy of Abdominal
Incisions 973
• Steps of D2 Gastrectomy for
Gastric Cancer 976
• Steps of Truncal Vagotomy and
Gastrojejunostomy 978
• Steps of Repair of Peptic
Perforation 979
• Steps of Laparoscopic
Cholecystectomy 981
• Open Cholecystectomy 983
• Steps of Choledocholithotomy 985
• Steps of
Choledochoduodenostomy 986
• Steps of Whipple’s
Pancreaticoduodenectomy 987
• Steps of Lateral
Pancreaticojejunostomy 990
• Steps of Right Hemicolectomy 992
• Steps of Low Anterior Resection 993
• Steps of Abdominoperineal
Resection 996
• Steps of Transverse Colostomy 999
• Steps of Closure of Colostomy 1000
• Step of Appendicectomy 1000
• Splenectomy 1003
• Nephrectomy 1004
• Steps of Modified Radical
Mastectomy 1005
• Steps of Lumbar
Sympathectomy 1007
• Steps of Total Thyroidectomy 1008
• Steps of Left
Hemithyroidectomy 1010
• Steps of Superficial
Parotidectomy 1011
• Steps of Submandibular
Sialoadenectomy 1013
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Contents
• Steps of Type I Modified Radical
Neck Dissection 1014
• Venous Cut Down
(Venesection) 1016
•
•
•
•
xxv
Tracheostomy 1017
Gastrostomy 1018
Steps of Eversion of Sac 1020
Circumcision 1021
Section 10 Surgical Anatomy
23. Surgical Anatomy
1023
• Inguinal Canal 1023
−− Anatomical Concept in View
of Laparoscopic Repair of
Hernia 1029
• Anterior Abdominal Wall 1030
−− Rectus Sheath 1030
»» Esophagus 1034
»» Stomach 1036
»» Anatomy of Liver and
Extrahepatic Biliary
System 1044
-Appendix 1055
-abdominal aorta 1056
-inferior vena cava 1059
»»
»»
»»
»»
»»
»»
-portal vein 1060
-portacaval anastomosis 1061
-renal vein 1062
Autonomic Nervous
System 1063
Breast 1065
-boundaries of axilla 1066
- axillary artery 1068
Thyroid Gland 1076
-parathyroid glands 1079
Subclavian Artery 1080
-carotid artery 1081
Salivary Glands 1084
Anatomy of Testis, Blood Supply
and Lymphatic Drainage 1085
Index1091
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Surgery Curriculum for Mbbs Students
Clinical classes in surgery: Total 26 weeks
3rd Semester : 6 weeks
4th semester :Nil
5th Semester : 4 weeks
6th semester :Nil
7th semester : 4 weeks
8th semester : 6 weeks
9th semester : 6 weeks
Final MBBS surgery Examination: Marks distribution for Surgery
Theory: 2 Papers: 120 (60+ 60)
2½ hours duration in each paper
• Paper I:
−− Section 1: General surgery
−− Section 2: Orthopedic surgery
• Paper II:
−− General surgery
−− Anesthesiology
−− Dentistry
−− Radiotherapy
−− Radiology
„„ Oral: 20 marks
„„ Practical: 100 marks
• Internal assessment: 60 (Theory 30 + Practical 30)
• Total marks: 300 marks
• Pass criteria: 50% in aggregate.
−− Practical minimum 50%
−− Theory and oral minimum 50%.
Honours: 75% marks in the subject provided other subjects are cleared in one chance.
Surgery theory examination
• Paper I: 60 marks
Section I:
1. Long question type (compulsory) 10 + 5 = 15
»» General principle/Basic science.
2. Long question (1 out of 2) – 15
»» Gastrointestinal tract.
„„
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xxviii
Bedside Clinics in Surgery
3. Short answer type (5 out of 6) 2 × 5 = 10
»» General surgery.
Section II:
4. Short notes (5 out of 7) 4 × 5 = 20
»» Orthopedics.
• Paper II: 1. Long question (Compulsory) – 15
»» Endocrine and breast:
Thyroid
Parathyroid
Adrenal
Breast.
2. Long question (1 × 15 = 15) or Short notes (3 out of 5) 3 × 5 = 15
»» Genitourinary.
3. Short answer type (2 out of 3) 2 × 5 =10
»» Pediatric
»» Plastic
»» Neurosurgery
»» Cardiothoracic and vascular surgery.
4. Short notes (4 out of 5) 4 × 5 = 20
»» Anesthesiology
»» Radiology
»» Dental
»» Radiotherapy, etc.
Surgery practical examination
One long case (30 minutes) „„ History: 15 marks
„„ Clinical examination: 10 marks
„„ Discussion: 15 marks
60 marks
40 marks
Two short cases (5 × 2 = 10 minutes) – 20 × 2 = 40 marks
Discussion on clinical findings
„„ Clinical demonstration
„„ Management
„„
Operative: 20 marks
Operative steps: 10
„„ Surgical anatomy/Preoperative/Postoperative: 10
„„
Oral : 20 marks
X-ray/other imaging: 5 marks
„„ Instrument: 5
„„ Specimen: 5
„„ Problems and recent advances: 5
„„
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Section 1
Surgical Long cases
chapter
1
Introduction
Long case is an important part of practical examination. Separate marks are earmarked for
writing good history and recording the physical examination. There should be no spelling
mistakes while writing history and it should be written neatly and should include all the points.
There are two important parts for writing a surgical long case:
A. History and
B. Physical examination.
OUTLINE FOR WRITING A SURGICAL LONG CASE
A. HISTORY
1. Particulars of the Patient
„
„
„
„
„
„
„
„
„
name:
Age:
Sex:
Religion:
occupation:
Address:
Date of Admission:
Date of examination:
Bed no. (Bed number allotted in the examination hall):
2. Chief Complaint
if there are more than one chief complaint write as chief complaints
Write the presenting complaint in chronological order with duration
„ Do not write two symptoms in one sentence in chief complaint, e. g. pain in abdomen and
jaundice for 2 years.
„
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2
Section 1 Surgical Long Cases
Better write as
Pain in right upper half of abdomen for– 2 years.
„ Yellowish discoloration of eyes and urine for 2 years.
Do not write a long list of symptoms in chief complaint. Write up to 3–4 symptoms in chief
complaint.
„
3. History of Present Illness
„
„
„
„
„
Start with a comment that the patient was apparently well before this episode of illness which
started (months/years) back. Avoid writing that patient was absolutely well or perfectly
well—as patient may have some minor complaints earlier.
elaborate each chief complaint in one paragraph in history of present illness.
if patient’s chief complaints are pain, jaundice and vomiting, write details about pain, jaundice
and vomiting in three different paragraphs maintaining the chronological order.
once the chief complaints are elaborated then write about other relevant symptoms.
Symptoms pertaining to different systems should be asked and relevant symptoms are to
be written.
Gastrointestinal Symptoms
„
„
„
„
„
„
„
„
„
„
„
„
Pain
vomiting
Hematemesis
Heartburn
Acidity
flatulence
Sensation of fullness after meals
Any sensation of rolling mass in abdomen
jaundice
Appetite
Weight loss
Details of bowel habit—number of motions per day, consistency of stool, any change in bowel
habit, any history of passage of mucus with stool, melena, bleeding per rectum.
Urinary Symptoms
„
„
„
„
„
„
„
„
Any renal or ureteric colic
Pain in loin
Details of urinary habit
frequency, both diurnal and nocturnal
Hematuria
Pyuria
Difficulty in passing urine
Hesitancy and urgency.
Respiratory Symptoms
„
„
chest pain
cough
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Chapter 1
„
„
Introduction
3
Hemoptysis
fever
Breathlessness.
Cardiovascular Symptoms
„
„
„
„
„
chest pain
Palpitation
Breathlessness on exertion
Swelling of the face or feet
Any history of paroxysmal nocturnal breathlessness associated with expectoration of pink
frothy sputum.
Neurological Symptoms
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
Headache
History of loss of consciousness
History of convulsion
Any symptom pertaining to cranial nerve palsy
Any history of loss of smell sensation
Any difficulty in vision
Any difficulty in eye movement
Presence of squint
Double vision
Any difficulty in chewing
Any loss of sensation in face
Any loss of hearing
Any difficulty in speech
Any history of nasal regurgitation of food
Any alteration of voice
Any loss of taste sensation
Any difficulty in tongue movement and wasting of tongue
Any weakness in upper and lower limbs
Any sensory loss.
4. Past History
„
„
„
„
„
„
Do not write or say "nothing significant"
Mention about any major medical ailment in the past
Any history of operations. if so the type of operation, any postoperative complications. Any
complications of anesthesia
Any history of pulmonary tuberculosis (Koch's) in the past
Any history of diabetes or hypertension which may be present earlier to this period
Similar illness in the past. Particularly in disease characterized by relapse and remission.
5. Personal History
Write about the following points:
Marital status: Married or unmarried
„
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4
Section 1 Surgical Long Cases
„
„
„
„
„
„
„
number of children
Status of health of spouse and children
Dietary habit
Any addiction: cigarette, alcohol, beetel, tobacco chewing (addiction implies physical and
mental dependence on a particular substance or drug and if denied that particular substance
patient will have withdrawal symptoms.
otherwise mention these as habit of smoking or alcohol.
Sleep
Bowel habit/Bladder habit (to be mentioned here if not mentioned in the history of present
illness). in an abdominal case, usually bowel and bladder habits are mentioned in history
of present illness
Socioeconomic status: Poor/average income/high income group
In female patients:
Menstrual history
• Age of menarche
• cycle
• Duration of period
• Amount of blood loss (assessed by number of pads used or if there is history of passage of clots)
• Last menstrual period (mention the date)
• in postmenopausal woman mention the time (months/years) of menopause
„ obstetrical history
• number of pregnancies (Mention as P*+*)
• number of abortions
• number of live births: (i) Male and (ii) female
• Mode of delivery
• Last child birth
• Any complications following childbirth.
„
6. Family History
Do not write as “family history nothing significant”, instead write as:
Parents: if parents are alive, write their status of health. if parents are not alive, write when
they had died and what was the disease he/she died of.
„ Siblings: number of brothers and sisters, and their status of health.
„ in some hereditary diseases, e.g. carcinoma of breast, polyposis coli. take history of 2–3
generations for similar disease or related diseases.
„
7. Treatment History
„
„
treatment received so far for the present disease
Any other medications for other diseases.
8. Any History of Allergy to Drug or Food and Immunization History
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B. PHYSICAL EXAMINATION
in surgical long case, physical examination will be done under three headings:
1. General survey: Quick overview of patient from head to foot.
2. Local examination and
3. Systemic examination
1. General Survey
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Mental state: conscious, alert, cooperative
Performance status: Mention either in Karnofsky scale or ecoG scale
Built
facies
Gait
Decubitus
Hydration status
nutrition
Anemia
jaundice
cyanosis
clubbing
edema
neck veins
cervical lymph node
Pulse
Blood pressure
Respiration
temperature
Any obvious deformity
Any pigmentation
2. Local Examination
Mention the region that is to be examined in local examination, e. g.
Local examination of abdomen
„ Local examination of breasts
„ Local examination of inguinoscrotal region, etc.
„ Write details of local examination, which will vary according to region being examined.
„
examination headings are:
inspection
„ Palpation
„ Percussion (wherever applicable)
„ Auscultation (wherever applicable).
„
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3. Systemic Examination
This examination includes system other than that mentioned in local examination:
Do not write systemic examination as "no abnormality detected"
„ Better write in brief about each system.
„
1. Examination of Abdomen
A inspection:
• Shape of abdomen: normal/obese/scaphoid/distended
• Position of umbilicus: central/deviated/pushed up/pushed down
• Movements of abdomen: Respiratory/peristaltic/pulsatile
• Skin over the abdomen: Any scar/pigmentation/venous engorgements
• Any obvious swelling: Brief description of the swelling
• Hernial sites: Any expansile impulse on cough
• external genitalia
B. Palpation:
• Superficial palpation
− temperature
− tenderness
− Any muscle guard
− Any swelling
• Deep palpation
− Any tenderness in any of the deep tender spots
− Any other sites of tenderness
− Palpation of liver/spleen/kidneys
− Deep palpation of any swelling
− fluid thrill
c. Percussion:
• General note over abdomen
• Shifting dullness
• Upper border of liver dullness
• Upper border of splenic dullness
• Percuss over the renal angle area.
D. Auscultation:
• Bowel sounds
• Any added sound
e. Per-rectal examination :
f. Per-vaginal examination (if applicable):
2. Examination of Respiratory System
A. inspection:
• Respiratory rate
• Shape of chest
• Movement of chest
B. Palpation:
• Position of trachea
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• tenderness over the chest
• Movement of chest
• vocal fremitus
c. Percussion:
• note over chest
D. Auscultation:
• Breath sound
• Any added sound: crepitation/Rhonchi
• vocal resonance
3. Examination of Cardiovascular System
„
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inspection:
• Shape of precordium
• Apex beat
• Any pulsation
Palpation:
• Apex beat.
• Left parasternal heave
• Any thrill
Auscultation:
• 1st/2nd heart sound
• Any murmur
• Any gallop.
4. Examination of Nervous System
„
Higher functions:
• conscious, alert, cooperative
• Speech: normal/any special character
• cranial nerve: i to Xii. Any palsy
„
Motor system:
• tone, power, coordination of upper limb
• tone, power, coordination of lower limb
„
Sensory system:
• Superficial sensation: Pain, touch, temperature
− face, neck
− Upper limbs
− trunk
− Lower limbs
• Deep sensation
− joint sensation
− vibration sense
• Deep reflexes: jerks
• Superficial reflexes
− Abdominal reflex
− Plantar response
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• cerebellar sign: Absent
• Gait: normal
5. Examination of Cranium and Spine
normal
„
C. SUMMARY OF THE CASE
Write summary of the case of the patient in two paragraphs. in first paragraph, write in brief
about the history of the patient.
in second paragraph, write briefly about the examination such as important points from
general survey and local examination, including points from inspection, palpation, percussion,
auscultation, and positive findings on systemic examination.
D. PROVISIONAL DIAGNOSIS
try to give a complete diagnosis, such as:
This is a case of carcinoma of the left breast t2n1M0 (stage ii) in a premenopausal woman
„ This is a case of obstructive jaundice probably due to carcinoma of head of the pancreas.
„
E. INVESTIGATIONS SUGGESTED
investigations may be mentioned under the following headings:
investigations for confirmation of diagnosis
„ investigations to stage the disease (in case of a malignant disease)
„ investigations to assess fitness of patient for anesthesia and surgery.
investigations may also be mentioned under the following headings:
„ Base line investigations
• Blood for hemoglobin, total leukocyte count (tLc), differential leukocyte count (DLc)
and erythrocyte sedimentation rate (eSR)
• Blood for sugar, urea and creatinine
• Urine for routine examination
• Stool for routine examination for ova/parasite/cyst
• chest X-ray (posteroanterior view)
• 12-lead electrocardiogram.
„ Special investigations
• Depends on the provisional diagnosis.
„
F. DIFFERENTIAL DIAGNOSIS
Write few relevant differential diagnoses. in list of differential diagnosis the more probable
diagnosis should be written before the rare diagnosis.
in a long case examination: examiner usually asks what is your case?
Then you should mention the summary of the patient and end up by giving the provisional
diagnosis.
„
„
if the examiner asks you what is your diagnosis. Then straightway give a complete diagnosis.
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CLINICAL QUESTIONS ON GENERAL SURVEY
What are symptoms and signs?
Symptom is what the patient complains of and the sign is what the clinician elicits. Patient
complains of pain at one site. When the clinician presses the area and patient experiences pain,
this is tenderness. Pain is the symptom and tenderness is the sign.
How will you assess mental state?
While taking history try to make some initial assessment of the patient’s intelligence, mental
and emotional state. if the patient has been able to narrate the history well, cooperated with the
clinician for the clinical examination patient may be considered conscious, alert, cooperative
and oriented.
How will you assess performance status of the patient?
originally performance status was assessed for consideration of patient fitness for administration
of chemotherapy. This assessment of performance status may also be applied to surgical patient
for assessing fitness for surgery and also to assess the surgical outcome.
There are two different ways for assessing the performance status:„ The Eastern coopeartive oncology group (Ecog) performance status is as follows:
Performance scale:
• 0: fully active and is able to carryout normal activities without any restriction.
• 1: Symptoms restrict strenuous activity but is able to carryout light sedentary activities.
• 2: Ambulatory but unable to carryout normal activities.. Up and about >50% waking hours.
• 3: only limited self care. confined to bed for >50% of waking hours.
• 4: completely confined to bed , disabled, needs assistance.
So ecoG performance status is written as.. score of 0, 1, 2, 3 or 4.
„ Karnofsky scale for performance status is as follows:
• Able to carry on normal activity and to work; no special care needed (100–80).
− 100: normal no complaints; no evidence of disease.
− 90: Able to carry on normal activity; minor signs or symptoms of disease.
− 80: normal activity with effort; some signs or symptoms of disease.
• Unable to work; able to live at home and care for most personal needs; varying amount
of assistance needed (70–50).
− 70: cares for self; unable to carry on normal activity or to do active work.
− 60: Requires occasional assistance, but is able to care for most of his personal needs.
− 50: Requires considerable assistance and frequent medical care.
• Unable to care for self; requires equivalent of institutional or hospital care; disease
may be progressing rapidly (40–0).
− 40: Disabled; requires special care and assistance.
− 30: Severely disabled; hospital admission is indicated although death not imminent.
− 20: very sick; hospital admission necessary; active supportive treatment necessary.
− 10: Moribund; fatal processes progressing rapidly.
− 0: Dead
Karnofsky performance status expressed as... score of 100, 90.............
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How will you assess built or physique?
Built is the skeletal structure of an individual in relation to age and sex. Built may be described
as short (fig. 1.1), average or gigantism in comparison to a normal individual of the same age
and sex.
Figure 1.1: Short stature 20 years male patient.
Height 3ft 8 inches (courtesy: Prof Subhankar
Chowdhury, IPGME & R, Kolkata)
What is Facies?
observe the patient’s face. The facial expression particularly the eyes indicate the facies of
the patient. Some typical facies are thyrotoxic facies (fig. 1.2A), facies of myxedema, moon
facies of cushing’s syndrome (fig. 1.2B), acromegaly (fig. 1.2c), facies hippocratica, anxious
facies, etc.
Figure 1.2A: Facies of thyrotoxicosis (Note
the stare look, exophthalmos, visibility of both
upper and lower sclera) (courtesy: Prof Satinath
Mukhopadhyay, IPGME & R, Kolkata)
Figure 1.2B: Facies of Cushing syndrome (Note
the rounded face, hirsutism and facial acne)
(courtesy: Prof Abhimanyu Basu, Maldah Medical
College, West Bengal)
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Figure 1.2C: Facies of acromegaly (Note the enlarged
face, thick and enlarged lips, nose, pinna and forehead.
Note the enlarged hand and fingers—compare with
normal hand) (courtesy: Prof Subhankar Chowdhury,
IPGME & R, Kolkata)
How will you assess gait?
Gait is observed while the patient walks. Patient examined in the bed is asked to sit, stand and
then walk.
Decubitus or the Physical Attitude
Attitude of the patient in bed is called decubitus. Patient with abdominal pain due to peritonitis
may lie still, while patient with colic may be restless and even roll with an attempt to get relief.
various neurological diseases may have characteristics posture. When the patient is comfortable
in any position then the decubitus may be described as “decubitus of choice”.
How will you assess hydration status of the patient?
Assessment of the hydration status is important in surgical patient. Some diseases may cause
chronic dehydration either due to failure of intake (dysphagia due to carcinoma esophagus) or
excessive fluid loss due to vomiting (gastric outlet obstruction) or diarrhea (ulcerative colitis or
crohn’s disease). There may be evidence of fluid overload in patient with renal failure.
Hydration status is assessed by:
„ Look at tongue and oral mucosa—normally moist. in case of dehydration will appear dry.
„ Pull the skin and release. normal skin is elastic. in case of dehydration, the skin turgor will
get lost (figs 1.3A and B).
„ Patient will feel thirsty and urine output will also diminish.
Figure 1.3A: Pinch the skin up in between
fingers and then release
Figure 1.3B: Release the fingers- observe—in
dehydration the skin turgor will be lost
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How will you assess nutritional status of the patient?
nutritional status is assessed by:
calculating the body mass index.
„ Assessing the thickness of the subcutaneous fat in the arm, forearm or the back (fig. 1.4A)
„ Assessing the bulk of the muscle by measuring the mid upper arm circumference (figs 1.4B
and c)
„ Look for any evidence of vitamin deficiency: skin changes (dermatitis), stomatitis, glossitis
(fig. 1.4D), etc.
„
Figure 1.4A: Assessment of subcutaneous fat
by skinfold thickness
Figure 1.4B: Assessment of midarm circumference. Note the midarm circumference of a malnourished patient (18 cm)
Figure 1.4C: Assessment of midarm circumference. Note the midarm circumference of a
normal person (25 cm)
Figure 1.4D: Look at the tongue for evidence of
glossitis. Note the red and smooth tongue
What is body mass index?
Body mass index is calculated by:
Body mass index = Weight in kg/Height in sq meter.
• Body weight—60 kg, height—1.5 metre.
„
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• Body mass index (BMi) + 60/2. 25 = 26. 6
• Depending on the body mass index patient may be classified as:
− Underweight : BMi—<18. 5
− normal
: BMi—18. 5–24. 9
− overweight : BMi—25–29. 9
− obese
: BMi—30 or higher
nutritional state is described as poor, average or overnutrition.
in practical examination it may not be possible to measure BMi, unless you have a weighing
machine and a height scale.
How will you assess anemia?
Anemia is quantitative or qualitative reduction of hemoglobin or red blood cell (RBc) or both
in relation to standard age and sex.
Anemia is assessed by presence of pallor at the lower palpebral conjunctiva, tip and dorsum
of the tongue, soft palate, nail beds and the skin on the palm and sole and the general body
skin (figs 1.5A to D).
Figure 1.5A: Retract lower eyelids to look at the
lower palpebral conjunctiva for pallor
Figure 1.5B: Ask the patient to show the tongue
and look for pallor
Figure 1.5C: Look at the nail bed for pallor
Figure 1.5D: Look at the palm for pallor
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Depending on the degree of pallor anemia is described as mild, moderate and severe anemia.
Mild anemia: When the hemoglobin is 50–60% of the normal
„ Moderate anemia: When the hemoglobin is 40–50% of normal
„ Severe anemia: When the hemoglobin is less than 40% of normal.
„
How will you assess jaundice?
jaundice is defined as yellowish discoloration of skin, eyes and mucous membrane due
to excessive bilirubin in blood. jaundice is looked for in upper bulbar sclera, soft palate,
undersurface of tongue, palms, soles and general body skin (figs 1.6A to D).
Figure 1.6A: Retract the upper eyelid and ask
the patient to look downward and look at upper
bulbar sclera
Figure 1.6B: Ask the patient to open the mouth
and look at the soft palate
Figure 1.6C: Ask the patient to show the
undersurface of the tongue. Ask the patient to
lift the tongue and touch the roof of the mouth
with the tip of the tongue so that the under
surface of the tongue is visible
Figure 1.6D: Look at the palm and soles
„
in deep jaundice there is yellowish hue of general body skin surface. jaundice is also looked
in general body skin surface, palms and soles
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normal bilirubin: Serum bilirubin value of 0. 2–0. 8 mg%
Latent jaundice: Serum bilirubin between 1 mg% 1. 9 mg%
clinical jaundice is seen when the bilirubin level is more than 2 mg%.
What is cyanosis?
Bluish discoloration of the skin and mucous membrane due to excessive amount of reduced
hemoglobin in circulation, i.e. more than 5 gm% of reduced hemoglobin in circulation. The
cyanosis may be:
„ Peripheral cyanosis: Arterial oxygen saturation is normal but there is more oxygen
desaturation at the veno-capillary bed. This may be due to peripheral vasoconstriction or
sluggish circulation
„ central cyanosis: This is due to excessive oxygen desaturation of the arterial blood.
Where will you look for cyanosis?
Peripheral cyanosis is looked for at tip of nose,
ear lobule, tips of fingers and toes, and palms
and soles. central cyanosis is looked for in the
tongue, inner surface of the lips in addition to
the sites of peripheral cyanosis (fig. 1.7).
How will you assess for presence of
clubbing?
„
„
„
Look at the nail from the side to look for
increased curvature of the nail (fig. 1.8A)
and assessment of angle between the nail
and nail bed
Look for fluctutation at the base of the nail
with two index fingers (fig. 1.8B).
Look for Schamroth sign (fig. 1.8c).
Figure 1.8A: Look at the nail from the side
Figure 1.7: Central cyanosis. Note bluish discoloration of tongue, lips and tip of the nose (courtesy:
Prof Shankar Mondal, IPGME & R, Kolkata)
Figure 1.8B: Fluctuation at the base of the nail
with two index fingers
clubbing is characterized by increase in transverse and longitudinal curvature of the nail with
increase of the angle between the nail and the nail bed (Lovibond’s angle) (fig. 1.8D). This is
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also associated with bulbous changes and diffuse
enlargement of the terminal phalanges. These
changes are due to proliferation of subungual
connective tissues.
What is Schamroth’s sign?
When the nail of two normal fingers are apposed
there is a diamond shaped gap. in clubbing this
diamond shaped gap disappears. This is known
as Schamroth sign (fig. 1.8c).
What is Lovibond angle?
When the nail is viewed from the side, the skin fold
of the nail and the base of the nail makes an angle
known as Lovibond angle. normally this angle is
less than 165 degrees. in case of clubbing the angle
between the skin of the nail fold and the base of
the nail is more than 180 degrees (fig. 1.8D).
Figure 1.8C: Schamroth sign
What are the degrees of clubbing?
1st degree: There is only increased fluctuation
of the nail bed.
2nd degree: in addition to fluctuation, there
is increased anteroposterior and transverse
diameter of the nail.
3rd degree: Above changes with increased pulp
Figure 1.8D: Lovibond angle
tissue in the terminal phalanges.
4th degree: combination of above changes with
subperiosteal thickening of bones of wrist and ankle (hypertrophic osteoarthropathy).
Where will you look for presence of edema?
edema is defined as excessive accumulation of fluid in the extravascular compartment.
in ambulant patient, edema is looked for by pressing on the medial surface of the tibia about
2. 5 cm above the medial malleolus for about 5–10 seconds. if edema is present a dimple will
appear in the skin (figs 1.9A and B).
Figure 1.9A: Press on the medial aspect of the
leg 2.5 cm above the medial malleolus
Figure 1.9B: Note the pitting edema on release
of finger pressure
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in nonambulant patient, you should look for edema at the sacral region by pressing over the
sacrum for 5–10 seconds, a dimple appears if there is edema (figs 1.9c and D).
Figure 1.9C: Press against the sacrum
Figure 1.9D: Note the edema at the sacral region
How will you assess jugular venous pressure?
The jugular venous pressure reflects the hemodynamics of the right atrium. Patient is made
to lie supine with head end propped up to about 45° and the upper level of the jugular venous
pulsation is localized by the clinician looking from the side (fig. 1.10). The height of the upper
point of jugular venous pulsation measured from the level of the sternal angle in centimeter is
the jugular venous pressure (fig. 1.11).
Figure 1.10: Assessment of the upper level of
jugular venous pulsation. Look tangentially
from the side, keeping eye at the same level
Figure 1.11: Measurement of the height of
jugular venous pressure
in normal individuals, the jugular venous pressure does not exceed 2 cm vertically above the
sternal angle. The jugular venous pressure is elevated in patients with congestive heart failure
and in superior mediastinal syndrome.
What are the characteristics of jugular venous pulsation wave?
normal jugular venous pulse wave is characterised by both positive and negative waves. a, c,
and v are positive waves and x and y are negative waves (fig. 1.12).
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a wave: Due to right atrial contraction.
c wave: Due to impingement of carotid artery
into the jugular vein during systole.
x wave: Due to atrial diastole reulting in fall of
right atrial pressure.
v wave: Due to right atrial filling.
y wave: Due to opening of tricuspid valve
resulting in emptying of right atrium.
What are the different lymph node groups
in the neck?
Figure 1.12: Jugular venous pulse wave
Depending on the location of the lymph nodes in relation to the investing layer of deep cervical
fascia the cervical lymph nodes may be:
„ Superficial: Lymph nodes lying superficial to the investing layer of the deep cervical fascia
„ Deep: Lymph nodes lying deep to the investing layer of deep cervical fascia
„ These lymph nodes may further be subdivided into horizontal chain and vertical chain.
What are the different levels of lymph nodes in the neck?
There are six levels of lymph nodes in the neck
(fig. 1.13)
Level i: Submental lymph nodes lying in the
submental triangle (iA) and submandibular
lymph nodes situated in the submandibular
triangle (iB).
Level ii (Upper jugular Group): Lymph nodes
located around the upper third of the internal
jugular vein from the level of carotid bifurcation
to the base of the skull.
Level iii (Middle jugular Group): Lymph nodes
Figure 1.13: Levels of lymph nodes in the neck
located around the middle third of the internal
jugular vein extending from the carotid bifurcation
above to the cricothyroid membrane below.
Level iv (Lower jugular Group): Lymph nodes located around the lower third of the internal
jugular vein lying between the cricothyroid membrane above and the clavicle below.
Level v (Posterior triangle Group): Lymph nodes located in the posterior triangle extending
laterally up to the anterior border of the trapezius and medially up to the lateral border of
sternomastoid. The supraclavicular nodes are also included in this group.
Level vi (Anterior compartment Group): This includes the perilaryngeal, pericricoid and
peritracheal nodes lying above up to the hyoid bone, below up to the suprasternal notch, and
laterally extend up to the medial border of sternomastoid.
(Lymph nodes in the anterior mediastinum is included as level vii nodes).
What is Virchow’s gland?
The left supraclavicular lymph node lying between the two heads of sternocleidomastoid is called
the virchow’s lymph node. This lymph node may be involved by metastasis from carcinoma
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of stomach, testicular tumor, carcinoma of
esophagus and bronchogenic carcinoma (fig.
1.14).
How will you palpate the cervical lymph
nodes?
The cervical lymph nodes may be palpated both
from front and the back.
the clinician stands behind the patient.
the neck is slightly flexed and turned to the
side of examination. the different groups of
lymph nodes levels i to vi are then palpated
Figure 1.14: Enlarged Virchow’s lymph node
systematically with one hand.
„ Level iA lymph nodes are palpated at the
submental triangle with the pulp of the
fingers directed upwards with the neck slightly flex and turned to the same side (fig. 1.15A)
„ Similarly level iB nodes are palpated at the submandibular triangle (fig. 1.15B)
Figure 1.15A: Palpation of level IA (submental
group) lymph node
„
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„
„
Level ii, iii and iv nodes are palpated along
the line of internal jugular vein with the pulp
of the fingers (figs 1.15c to e)
Level v nodes are palpated at the posterior
triangle with the pulp of the fingers (figs
1.15f and G)
the supraclavicular nodes (Level v) are
palpated with the pulp of the fingers kept
at the supraclavicular fossa and asking the
patient to shrug the shoulder up (fig. 1.15H)
Level vi nodes are palpated at the pre- and
paralaryngeal and tracheal region.
Figure 1.15B: Palpation of level IB (submandibular group) lymph nodes
Figure 1.15C: Palpation of level II lymph nodes
(along the upper third of internal jugular vein)
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Section 1 Surgical Long Cases
Figure 1.15D: Palpation of level III lymph nodes
(Along the middle third of internal jugular vein)
Figure 1.15E: Palpation of level IV lymph nodes
(Along the lower third of internal jugular vein)
Figure 1.15F: Palpation of level V lymph nodes:
palpate along the posterior border of sternocleidomastoid muscle
Figure 1.15G: Palpation of level V lymph nodes
(Palpate along the anterior border of trapezius
muscle)
The number of lymph nodes, size, surface,
margins, consistency and fixity to the skin or
underlying structures are noted. if the lymph
nodes are enlarged the drainage area is to be
examined for any evidence of infection or any
malignant tumor.
How will you examine pulse?
Pulse is the lateral expansion of the arterial wall
due to a column of arterial blood forced into the
arteries by the contraction of the heart.
Figure 1.15H: Palpation of level V lymph nodes.
Palpate the supraclavicular fossa for supraclavicular lymph nodes
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Palpate the radial pulse just above the wrist
on the anterior aspect of the lower end of the
radius lateral to the tendon of the flexor carpi
radialis (fig. 1.16)
Look for rate, rhythm, volume, tension,
condition of arterial wall, equality of pulse with
the opposite radial and femoral pulses, any
special character of the pulse.
Regarding rate:
„ normal heart rate: it is 60–100 beats per
minute, average 72 beats per minute
Figure 1.16: Palpation of radial pulse
„ Bradycardia: Heart rate less than 60 beats
per minute
„ tachycardia: Heart rate more than 100 beats per minute
„ Relative bradycardia: When there is fever, there is rise of pulse rate. for each degree rise of
temperature and there is rise of 10 beats per minute. When with per degree rise of temperature,
the pulse rate increase is less than 10 beats per minute then it is called relative bradycardia,
e. g. enteric fever (1st week)
„ Relative tachycardia: With per degree rise of temperature, the pulse rate rise is more than 10
beats per minute, e. g. rheumatic carditis.
Regarding rhythm: Appearance of successive pulse waves with time:
„ normal rhythm: The successive pulse beats are appearing at definite intervals
„ irregular rhythm: The successive pulse beats are not appearing at definite interval. This may be
• irregularly irregular
• Successive beats are appearing at irregular intervals or the rhythm may be occasionally
interrupted by a slight irregularity coming at definite interval
• Regularly irregular.
How would you assess volume of pulse?
The amplitude of the pulse is defined as the pulse volume and is palpated with the fingers. This
may be normal, low volume or high volume depending on the amplitude of the pulse wave.
How will you assess tension of the pulse wave?
tension of pulse is defined as the pressure
required to obliterate the pulse wave.
How will assess the condition of the
arterial wall?
empty the segment of the artery by using two
middle fingers and then palpate with the two
fingers and try to roll the artery against the
bone. the arterial wall may be thickened in
atherosclerosis (figs 1.17A to c).
Figure 1.17A: Empty the artery by milking with
the middle finger of both hands
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Figure 1.17B: The segment of radial artery is
emptied
Figure 1.17C: The arterial wall is palpated with
the index finger of both hands
How will you measure blood pressure?
Blood pressure is measured by sphygmomanometer (fig. 1.18).
The patient lies supine in the bed. The blood
pressure cuff is wrapped around the arm firmly
and evenly around the arm one inch above
the elbow joint, with the middle of the rubber
bag lying over the brachial artery. the blood
pressure cuff is then inflated till the radial pulse
disappears. The diaphragm of the stethoscope is
placed over the brachial artery under the edge
of the sphygmomanometer cuff taking care not
Figure 1.18: Measurement of blood pressure
to press the diaphragm too heavily over the
brachial artery.
The blood pressure cuff is then deflated gradually and listen with the stethoscope when clear
tapping sound becomes first audible. This is the point which indicates systolic blood pressure.
The cuff is continually deflated. The character of the audible sounds changes and the sound
becomes muffled and then disappears. This is the point which indicates diastolic blood pressure.
The blood pressure may also be measured by palpatory method. The blood pressure cuff is
inflated till the radial pulse disappears. The cuff is then deflated slowly. The point at which the
radial pulse reappears is the systolic blood pressure. The cuff is then continually deflated and
the radial pulse assumes a water hammer character and then suddenly resumes the normal
character. The point at which pulse resumes normal character indicates diastolic blood pressure.
What is hypertension?
Persistent systolic blood pressure above 140 mm Hg and diastolic blood pressure above 90
mmHg is defined as hypertension.
What is hypotension?
Persistent systolic blood pressure below 90 mmHg is defined as hypotension.
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How will you assess respiration?
normal respiration is abdominothoracic and the normal rate is 18–20 breaths per minute. Allow
the patient to take normal breathing and observe the rate of respiration by noting the movement
of chest and abdomen in one minute. Look for rhythm of respiration and any special type of
respiration. note whether the respiration is thoracic, abdominal or abdominothoracic.
What is Cheyne-Stokes breathing?
This is a special type of respiration, when there is a period of hyperpnea followed by apnea. The
respiration becomes deeper and deeper until a peak is reached when there is apnea followed
by hyperpnea. The period of hyperpnea lasts for 1–3 minutes, whereas the period of apnea lasts
for 10–30 seconds.
This type of respiration is usually found in patients with increased intracranial pressure, renal
failure and morphine poisoning.
How will you measure temperature?
temperature is measured by clinical thermometer and is expressed in either fahrenheit or
centigrade scale. in surgical case, temperature is not recorded routinely.
„
„
normal body temperature: 98–99°f
Subnormal temperature: Below 98°f
Figure 1.19: Types of fever
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„
„
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Pyrexia: Above 99°f
Hyperpyrexia: Above 106°f
Hypothermia: Below 95°f.
types of fever (fig. 1.19):
continuous fever: The daily fluctuation of temperature is less than 1. 5°f and the temperature
does not touch the baseline. it is found in pneumococcal pneumonia, in second week of
enteric fever and rheumatic fever
„ Remittent fever: The daily fluctuation is more than 2°f and the temperature does not touch
the baseline. This is found in urinary tract infection and pulmonary tuberculosis
„ intermittent fever: fever continues for several hours and returns to normal during the day.
This may be:
• Quotidian: The paroxysm of intermittent fever occurs daily
• tertian: The paroxysm of intermittent fever occurs on alternate days
• Quartan: The paroxysm of intermittent fever occurs every three days
• Relapsing fever: There cyclic periods of fever and periods of apyrexia.
„
What is Pel-Ebstein fever?
This is a type of relapsing fever when there is fever for a period of 14 days and there is apyrexial
period of 14 days. found in Brucellosis and Hodgkin’s lymphoma.
What do you mean by pyrexia of unknown origin (PUO)?
When a fever of more than 101°f persists for more than 2 weeks with the cause remaining obscure
in spite of intensive investigations is called pyrexia of unknown origin.
Where do you look for pigmentation?
The usual sites to be looked for pigmentation are face, oral cavity, tongue, creases of palms
and soles and general body skin. Pigmentation may be seen in cushing’s syndrome, Addison’s
disease, Peutz-jeghers syndrome (figs 1.20A and B) and other dermatological diseases.
A
B
Figures 1.20A and B: Peutz Jegher’s syndrome. Note the pigmentation of oral mucosa, lips and
the fingers
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OUTLINE FOR WRITING A CASE OF SWELLING
A. HISTORY
Duration: How long is the swelling present?
Site: Where was the swelling first noticed?
„ Mode of onset: Whether swelling appeared following trauma, or developed spontaneously.
„ Progress of swelling:
• Static: Same as onset, no increase in size
• Slowly increasing in size since beginning (usually benign swelling)
• Rapidly increasing in size since beginning (usually malignant)
• initially slowly increasing in size, later (after a variable period) started rapidly increasing
in size (benign swelling showing malignant change)
• initially increasing size. Later the swelling regressed with time or treatment (inflammatory)
• Ask the patient what was the size of the swelling when he first noticed it. earlier this was
described as either pea, marble, lemon or orange shaped. it is better to describe the
approximate size of the swelling in cm at the onset. from patient description try to assess
the approximate size of the swelling at onset and describe as… the swelling was about
2 cm/3 cm/4 cm…. in size at the onset and then describe the progress of the swelling.
„ Pain over the swelling:
a. Duration of pain
b. Site of pain
c. character of pain
d. Any radiation of pain
e. Periodicity of pain
f. Relation of pain with the swelling
„ Any other swelling in the body
„ Any history of fever, loss of appetite, loss of weight
„ Any subsequent changes over the swelling, e. g. ulceration, satellite nodules. Ask when these
changes were first noticed
„ in a suspected malignant disease enquire about symptoms which will suggest metastasis,
chest pain, cough, hemoptysis, bone pain, headache, vomiting, loss of consciousness,
convulsion, pain abdomen, abdominal distension and jaundice
„ Any history of previous excision of the swelling and recurrence
„ History of similar swelling in the past
„ Any history of tuberculosis
Past History/Personal History/family History/treatment History/History of Allergy
„
„
B. PHYSICAL EXAMINATION
I. General Survey
II. Local Examination
Inspection (Fig. 1.21)
number
„ Site
„
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„
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extent
Shape
Size
Surface
Margin
Skin over the swelling
• Scar
• venous prominence
• Pigmentation
• Ulcer, any discharge
• Peau d’orange
• Satellite nodule
impulse on cough (for hernias and meningocele)
Any pressure effect
• Swelling of limbs
• Muscle wasting
Figure 1.21: Inspection of the swelling. Note
the site and extent, size and shape, surface and
margin and skin over the swelling
Palpation
temperature
„ tenderness
„ Site
„ extent
„ Shape
„ Size
„ Surface
„ Margin
„ consistency
„ fluctuation, if the swelling is cystic
„ transillumination, if swelling is cystic
„ Reducibility:
• Reducible or not
„ compressible or not
„ Palpable impulse on cough
„ fixity of the swelling to skin
„ fixity of the swelling to deeper structure
• Muscle: test mobility with muscle relaxed and contracted
• tendon: test mobility with tendon relaxed and after tendon is made taut with contraction
of muscle
• Bones: Swelling is fixed as such
• vessel compression effect: Absence of pulse distal to the swelling
• nerve compression effect: test for muscle power and sensation
„ Pulsation: if present, transmitted or expansile pulsation
„ Any thrill on palpation
Percussion
„ Auscultation
Movement of adjacent joint
Examination of regional lymph nodes
„
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CLINICAL QUESTIONS
How will you examine temperature over
the swelling?
The temperature of the swelling is ascertained
by palpation with the dorsum of the fingers.
compare the temperature over the swelling
with the temperature of the adjacent area or
corresponding area of the body (fig. 1.22).
How to ascertain tenderness over the
swelling?
Press the swelling with the pulp of the fingers and
look at the patient face. if the patient experiences
pain on pressure, tenderness is said to be present.
Figure 1.22: Ascertaining temperature over the
swelling
How will you measure the size of the swelling?
The size of the swelling on inspection is assessed approximately and expressed in centimeter.
During palpation the margins of the swelling are marked and the swelling is measured
with a tape. if the swelling is spherical the measurement of diameter is sufficient. in
other swelling measure the length and breadth of the swelling and express in centimeter
(fig. 1.23A to c). ideally the size of the swelling should be measured by using a vernier calliper.
Figure 1.23A: In globular swelling measurement
of diameter
B
C
Figures 1.23B and C: In elongated swelling measure the length and breadth of the swelling
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How will you examine the surface of the
swelling?
Palpate with the pulp of the finger over the surface
of the swelling. The surface of the swelling may be
smooth, irregular (The irregular surface may be
granular, nodular or lobulated) (fig. 1.24).
How will you assess the margin of the
swelling?
Palpate the periphery of the swelling with the
pulp of the finger (figs 1.25A and B).
The margin of the swelling may be well defined
Figure 1.24: Palpation of the surface of the
(When it can be palpated well) or illdefined when
swelling
the margins are not delineated well on palpation.
the margin of the swelling may be regular
(when it is uniform throughout) or irregular (when the periphery of the swelling is not uniform).
A
B
Figures 1.25A and B: Ascertaining the margin of the swelling
How will you assess underlying bony indentation?
Some swelling like long standing dermoid cyst
may show bony indentation.
Palpate at the periphery deep to the margin
of the swelling. if there is bony indentation the
raised bony margin can be felt deep to the margin
of the swelling (fig. 1.26).
How will you assess consistency of the
swelling?
Press the swelling with the pulp of the finger and
assess the feel (see fig. 1.24).
The consistency of the swelling may be:
„ Soft (feel of a relaxed muscle) or
Figure 1.26: Palpation for ascertaining underlying
bony indentation
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firm (feel of a contracted muscle).
Hard (feel of bone).
The consistency of a swelling may be described as variegated when the swelling has a variable
feel soft, firm or hard at different parts of the swelling.
How will you demonstrate fixity of the swelling to skin?
try to pick up the skin from the underlying
swelling (fig. 1.27). if the skin can be picked up
from the swelling, the swelling is not fixed to
skin. if the skin cannot be picked up from the
swelling, the swelling is said to be fixed to the
skin. The malignant swelling may infiltrate the
skin and the overlying skin may be fixed to the
swelling.
How will you ascertain relation of the
swelling with the underlying muscle?
A swelling may lie either superficial or deep to
Figure 1.27: Demonstration of skin fixity. The
the muscle or it may arise from the muscle itself.
skin can be picked up from the swelling
Ask the patient to contract the muscle. if the
swelling becomes more prominent, the swelling
lies superficial to the muscle (figs 1.28A and B). if the the swelling becomes less prominent, it
lies deep to the muscle. if the swelling remains same or becomes less prominent and becomes
immobile, it may arise from the muscle.
A
B
Figures 1.28A and B: Ascertaining relation of a chest wall swelling to the underlying pectoralis
major muscle. The swelling is first examined with the muscle relaxed. Patient is then asked to
contract the pectoralis major muscle—the swelling becomes more prominent with the muscle
contracted—suggesting that the swelling lies superficial to the pectoralis major muscle
How will you ascertain fixity of the swelling to the underlying muscle?
A swelling may become fixed to the underlying muscle or bone. Before testing for fixity of the
swelling to the muscle it is necessary to exclude whether swelling is fixed to the underlying
bone or not.
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Hold the swelling and try to move it with the underlying muscle relaxed both along and across
the axis of the muscle (figs 1.29A and B).
if the swelling is immobile with the muscle being relaxed, this indicates that the swelling is
fixed to the underlying bone. it is not necessary now to ask the patient to contract the muscle
and test for fixity of the swelling to the muscle. The swelling has to be fixed to the underlying
muscle as it fixed to the underlying bone.
if the swelling is mobile with the muscle relaxed , this indicates the swelling is not fixed to
the underlying bone.
Ask the patient to contract the muscle (confirmed by palpating the contracted muscle), and
try to move the swelling over the contracting muscle in both axes (fig. 1.29c).
if the swelling is freely mobile, this indicates that the swelling is not fixed to the underlying muscle.
Restriction of mobility of the swelling over the contracted muscle indicates fixity of the
swelling to the underlying mscle.
A
B
Figures 1.29A and B: Ascertaining fixity of the swelling with the underlying muscle. The swelling
is moved with the muscle relaxed. The swelling is mobile—suggesting that the swelling is not
fixed to the underlying bones and prevertebral fascia
Figure 1.29C: The right sternocleidomastoid
muscle is contracted by asking the patient to
look to the opposite side against resistance
and the mobility is tested again. If the mobility
remains same, then the swelling is not fixed to
the underlying sternocleidomastoid muscle, If
the mobility becomes restricted—the swelling
is fixed to the underlying muscle
How will you demonstrate fluctuation?
fluctuation means transmitted impulse in two planes at right angles to each other.
Depending on the size of the swelling one finger or two fingers of each hand is used to
demonstrate fluctuation. The finger which presses the swelling is called the displacing finger
while the static fingers, which appreciate the displacement is called the watching finger.
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Usually index and middle fingers straight with slight flexion at metacarpophalangeal
joint are placed over the swelling. The tip of the pulp of the left index middle finger is placed
halfway between the center and the periphery of the swelling. This is the watching finger
and is kept static throughout the procedure. The tip of the pulp of the right index and middle
finger is placed at similar point diagonally opposite the right index and middle finger. This is
the displacing finger.
The displacing fingers are pressed inward, if the watching fingers are displaced by this pressure
in both axes of the swelling then fluctuation is said to be positive (figs 1.30A and B).
in small swelling, the two fingers of the left hand are placed apart over the swelling and this
acts as the watching finger. The right index finger acting as the displacing finger exerts pressure
at the center of the swelling. if the watching finger is displaced in both axes of the swelling then
fluctuation is said to be positive (fig. 1.30c).
A
B
Figures 1.30A and B: Demonstration of fluctuation
Figure 1.30C: Demonstration of fluctuation in
small swelling
in small swelling the fluctuation may be demonstrated by Paget’s test. The swelling is fixed at
the periphery with two fingers and feel the swelling from centre to the periphery. The swelling
feels softer at the center than at the periphery.
in case of a mobile swelling, the swelling should be fixed by an assistant and the fluctuation
demonstrated by the above method.
if the swelling is very small (less than 2 cm), it is difficult to demonstrate fluctuation.
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How will you differentiate transmitted and expansile pulsation?
Place the index and middle finger over the swelling. if the pulsation is transmitted, the fingers
move up parallel to each other with each pulsation. if the pulsation is expansile, the fingers are
lifted up and also move apart with each pulsation (figs 1.31A to c).
The transmitted pulsation is present when there is a swelling in front of an artery. expansile
pulsation is present in cases of an aneurysm.
Figures 1.31A to C: (A) Demonstration of transmitted and expansile pulsation. (B) Both
the fingers are lifted up. (C) The fingers are both lifted up and moved apart
How will you demonstrate transillumination?
The transillumination is usually demonstrated by placing a torch over the swelling and usually
under the shade of a screen. The normal skin transillumination should be taken into account
before commenting that the swelling is transilluminant.
The important brilliantly transilluminant swelling includes:
vaginal hydrocele
„ cystic hygroma
„ encysted hydrocele of the cord
„ Hydrocele in the canal nuck
„ congenital hernia in infants may show positive transillumination.
„
How will you demonstrate that the swelling is compressible?
When the swelling is compressed with the fingers it diminishes in size and may disappear
completely and when the pressure is released, it reappears slowly (figs 1.32 and 1. 33).
Hemangiomas, lymphangiomas and meningocele or meningomyelocele are compressible.
Figures 1.32A to D: (A) Demonstration of compressibility of a swelling. (B) The swelling is
pressed with the fingers. (C) The swelling diminishes in size. (D) On release of compression
the swelling reappeared (D)
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B
A
C
Figures 1.33A to C: Demonstration of compressibility: (A) The swelling is compressed with the fingers;
(B) The swelling diminished in size; (C) On release of compression the swelling reappeared
What do you mean by indentation of a swelling?
Press the swelling for 15–30 seconds. if a dimple appears over the swelling then the swelling is
said to have shown the sign of indentation (figs 1.34A to D).
cysts containing pultaceous materials as in dermoid cyst or sebaceous cyst are said to be
indentable.
Figures 1.34A to D: (A) Demonstration of indentation. (B) The swelling is pressed with
the fingers. (C) An indentation appears on the surface of the swelling. (D) On release of
compression, the swelling refilled
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OUTLINE FOR WRITING A CASE OF ULCER
HISTORY
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Duration: for how long ulcer is present
Mode of onset: following trauma or spontaneously or following a swelling
Site: Where first noticed
Progress of the ulcer: change in size and shape
Any pain over the ulcer: Site of pain, any radiation, character of pain and severity.
Any discharge: Serous/purulent/hemorrhagic
Any associated disease: Diabetes/sickle cell anemia/pulmonary tuberculosis/varicose vein/
systemic malignancy/AiDS
Past history of similar ulcer, any history of tuberculosis in the past
Personal history: enquire about smoking, alcohol intake.
PHYSICAL EXAMINATION
General survey: A detail general survey.
Local Examination of Ulcer
Inspection
„
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number
Site: Describe in relation to the region or bony landmark.
extent
Shape: circular, oval, irregular or serpiginous
Size
Margin (fig. 1.35): This is the junction of normal
skin and the periphery of the edge of the ulcer.
edge of the ulcer: Area of the ulcer between
the floor and the margin. the edge may be
(fig. 1.36):
• Sloping
• Undermined
• Punched out
Figure 1.35: Various parts of ulcer
• Sloping
• Raised and rolled out
• Raised and beaded
floor of ulcer: exposed portion of the ulcer. floor may be covered by red granulation tissue/
pale granulation tissue/slough
Discharge character, amount, smell
Adjacent area:
• Any swelling
• Any skin change
• Any secondary changes, pigmentation, pallor.
• Any associated venous diseases
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Figure 1.36: Different types of edge of ulcers
Palpation
temperature: Palpate the area adjacent to the ulcer for any rise of local temperature
tenderness: over the ulcer and adjacent area
„ Size of the ulcer: Measure with a tape from one margin to the other.
„ Margin and edge of ulcer: type, any induration
„ Base: The area on which ulcer rests (fig. 1.36) (feel the base by picking up the ulcer in between
the thumb, index and middle finger)
„ test mobility of ulcer over the deeper structure
„ Any discharge during palpation: Bleeding or mucus discharge
Examination of regional lymph nodes
Examination of adjacent joints: Both active and passive movments
Examination for vascular disease
Examination for any nerve lesion
Examination of chest (in cases of tuberculous ulcer)
„
„
OUTLINE FOR WRITING A CASE OF SINUS OR FISTULA
Sinus is a blind tract having an opening on one side. Sinus is usually lined by granulation tissue
or sometimes may be epithelialized, e.g. preauricular sinus, submental sinus, pilonidal sinus, etc.
A fistula is a tract having opening at both ends of the tract. The fistula tract may communicate
a viscus to the external surface (enterocutaneous fistula, urethrocutaneous fistula), may
communicate two viscera (colovesical fistula communication between the colon and urinary
bladder. vesicovaginal fistula, communication between the vagina and urinary bladder).
A. HISTORY
Duration and onset: Mode of onset. Some sinuses or fistula may be congenital and may be
present since birth (branchial fistula).
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Some sinus or fistula may develop following incision and drainage of an abscess (perianal
fistula).
Some sinus or fistula may develop following incomplete excision of a congenital swelling
(thyroglossal fistula may develop following incomplete excision of a thyroglossal cyst).
„ Precceding history of swelling, pain and fever.
„ History of discharge:
• type of discharge(purulent, mucus, bilious, feculent or urine), any discharge of bony
spicules (may suggest underlying osteomyelitis)
• quantity of discharge, color and odour.
• Progress: Sometimes discharge may stop and opening may be blocked. Recollection occurs
in the tract and discharge comes out through the same or a different opening.
„ Any history of pain.
„ History of fever.
Past history: Any history of tuberculosis, actinomycosis or inflammatory bowel disease. Any
history of operation. Thyroglossal fistula may result following incomplete removal of thyroglossal
cyst. incision and drainage of perianal abscess may result in perianal fistula.
B. PHYSICAL EXAMINATION
I. General Survey
II. Local Examination
A. Inspection
„
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Site of fistula.
How many external openings: Single or multiple?
Appearance of external opening: Any presence of granulation tissue, margin of the opening.
Any discharge from the opening: character of discharge and the odour of discharge.
Appearance of the area adjacent to the external opening: Any swelling, any scar, pigmentation.
B. Palpation
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temperature of the local area.
tenderness around the site of external opening.
Palpate the wall of the tract: Any thickening.
Palpate for any swelling adjacent to the sinus/fistula.
Palpate for any bone thickening adjacent to the external opening (Bone thickening found
in osteomyelitis).
in case of perianal fistula—rectal examination to assess the presence of internal opening.
in case of vesicovaginal or rectovaginal fistula—Per vaginal examination.
C. Examination of Regional Lymph Nodes
III. Systemic Examination
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Hernias
OUTLINE FOR WRITING A CASE OF HERNIA
A. HISTORY
1. Particulars of the Patient (Same as mentioned in general scheme of case taking)
2. Chief Complaints
Usual chief complaints are:
Swelling in (right/left) groin for …………..… months/years
„ Swelling in (right/left) groin and scrotum for ………….. months/years
„ Pain over the swelling for ……….. months/years
„
3. History of Present Illness
Write in details about the swelling in first paragraph, details about the pain in the second
paragraph and in the next paragraph write about any straining factor and any systemic
symptoms
„ Patient was apparently well before he had noticed the swelling in groin … months/year back
„ Mode of onset—gradual or acute
„ How did the swelling appear first—following straining or spontaneously
„ Where did the swelling appear first—in the groin or in the scrotum
„ Progress of the swelling—size and extent of the swelling at onset—whether the swelling
descended from groin to the scrotum or from scrotum to the groin
„ What happens to the swelling when the patient stands up, walks about and strains
„ What happens to the swelling when the patient lies down
„ Any period of irreducibility of the swelling
„ Any inguinoscrotal swelling on the opposite side.
„
In the next paragraph write about the history of pain:
Site of pain in the groin or over the swelling
„ Any radiation of pain
„ Character of pain: usually dull aching. In case of obstructed hernia the pain may be colicky
„
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„
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Relation of pain with straining: usually pain increases with straining
How is the pain relieved: usually relieved on lying down.
In third paragraph write about any straining factor:
History of chronic cough, breathlessness, any history of chronic bronchial asthma
„ Bowel habits: whether normal or there is any history of constipation or straining at stools.
Write in details the usual bowel habit
„ Bladder habit: write in details about bladder habit to exclude any prostatic enlargement or
urethral stricture
• Any dysuria
• Hesitancy/urgency/precipitancy
• Narrowing of stream
• Frequency of micturition, during daytime and nocturnal (ask whether patient has to wake
up at night to micturate)
• Any history of acute retention of urine
„ Mention about any other important systemic symptom.
„
4. Past History: Any history of similar swelling in the same or opposite side. Any history of
operation.
5. Personal History
6. Family History
7. Treatment History
Whether using truss or not.
8. Any History of Allergy
B. PHYSICAL EXAMINATION
1. General Survey: Same as general scheme of case taking (see Page No. 5, Chapter 1).
2. Local Examination: Examination of both inguinoscrotal regions:
(In majority of hernia cases the swelling gets reduced partly or completely on lying down. So
description of details of the swelling in lying down position will be fallacious. Main part of
hernia examination will be in standing position and patient will lie down while doing some
special tests only.)
In standing position:
Inspection (Fig. 2.1):
• Side where the swelling is present—right/left
• Position and extent of the swelling:
− The swelling is seen in the inguinal region
− A swelling is seen in (right/left) inguinoscrotal region
− The swelling extends above upto the inguinal canal and below upto the bottom of
scrotum
• Size: mention approximate size of the swelling—longitudinal and transverse dimension
• Shape: pyriform or globular
• Surface: smooth/irregular
• Margin: rounded/ill-defined
„
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• Expansile impulse on cough over the
swelling
• Skin over the swelling: any scar/engorged
vein/pigmentation
• Any visible peristalsis over the swelling
• Position of penis: any deviation
• Testis: whether testis could be seen separately from the swelling or swelling is seen
all around the testis
„
Palpation
• Temperature over the swelling
• Tenderness over the swelling
• Whether it is possible to get above the
swelling (For an inguinoscrotal swelling it Figure 2.1: Inspection of both inguinoscrotal
region in standing position
is not possible to get above swelling)
• Position and extent of the swelling
• Si z e : l o n g i t u d i na l a n d t ra n s v e r s e
dimension, to be measured and mentioned, e.g. 5 cm × 4 cm
• Shape: a complete hernia is usually pyriform in shape. A direct hernia is globular in shape
• Surface
• Margin
• Consistency
− Soft and elastic (when content is intestine)
− Doughy (when content is omentum)
− Tense and tender (obstructed hernia)
• Relation of the swelling to pubic tubercle:
− The swelling is situated above and medial to pubic tubercle (inguinal hernia)
„
The swelling is situated below and lateral to the pubic tubercle (femoral hernia)
• Relation of swelling to testis: whether testis can be felt separately from the swelling or not.
• Reducibility (to test for reducibility patient has to lie down):
− Whether swelling reduces spontaneously on lying down, partially or completely
» If not reduced spontaneously—whether swelling can be reduced by manipulation
» Which part of the swelling is easy to reduce—first part or last part
- In omentocele, first part reduces easily, but last part is difficult to reduce
- In enterocele, first part is difficult to reduce, but last part reduces easily
• Invagination test:
− The invagination test is usually not done nowadays. The demonstration of this test is
painful.This is no longer necessary to mention about this test in routine examination
of hernia, unless examiner is specifically interested to know about the test.
− On invagination test, comment about the size of the superficial inguinal ring. Normally
the superficial ring does not admit the tip of index finger. When the hernia has reached
the scrotum, superficial inguinal ring becomes patulous
− Ask patient to cough and assess where the impulse is felt—pulp or tip
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„
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„
„
„
• Deep ring occlusion test:
− Hernia is reduced and the deep inguinal ring is occluded by the thumb and patient is
asked to cough. Test is positive when no impulse or hernial bulge is seen medial to the
deep inguinal ring on coughing after the deep ring is occluded, suggesting this to be
an indirect inguinal hernia
− Test is negative, i.e. an expansile impulse or hernia bulge is seen in inguinal canal medial
to the occluded deep ring suggesting this to be a direct inguinal hernia
• Palpation of testis epididymis and spermatic cord
Percussion
• Percuss over the hernial swelling keeping the content out in the hernial sac (Patient in
standing posture)
− Resonant note over the swelling suggests enterocele
− Dull note over the swelling suggests omentocele
Auscultation (Patient in standing posture)
• Bowel sound over the swelling suggests enterocele
Mention about normal side of inguinoscrotal region:
• No swelling in the opposite inguinoscrotal region
• No expansile impulse on cough
• Testis/epididymis and spermatic cord—normal
Examination of tone of abdominal muscles—good or poor with bulge in the flanks
Per-rectal examinations: it is important in a male patient with symptoms of prostatism.
3. Systemic Examination
Examination of abdomen
„ Examination of respiratory system (emphasize, if there is history of respiratory symptoms)
„ Examination of cardiovascular system
„ Examination of nervous system
„ Examination of spine and cranium.
„
C. SUMMARY OF THE CASE
D. PROVISIONAL DIAGNOSIS
Give a complete diagnosis mentioning:
Side: right or left
„ Inguinal or Femoral
„ Direct or Indirect
„ Complete or Incomplete
„ Reducible or Irreducible
„ Content: Intestine or omentum
„ Complicated or Uncomplicated
„
For example: This is a case of right-sided reducible complete indirect inguinal hernia containing
intestine without any features of complication at present.
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E. INVESTIGATIONS SUGGESTED
„
„
„
„
Baseline investigation to assess fitness of patient for surgery:
• Chest X-ray (posteroanterior view)
• Electrocardiography (ECG)
• Blood for Hb%, TLC, DLC and ESR
• Blood for sugar, urea and creatinine
• Urine for routine examination
If patient has urinary symptom:
• Ultrasonography (USG) of kidney, ureter and bladder (KUB) region.
If patient has chronic obstructive pulmonary disease: a pulmonary function test
If the patient has cardiac disease—Echocardiography/coronary angiography.
F. DIFFERENTIAL DIAGNOSIS
To be mentioned.
INDIRECT REDUCIBLE INGUINAL HERNIA IN AN ADULT
What is your case? (Summary of a case of inguinal hernia)
This 40 years male patient, a manual labourer
by occupation, presented with a swelling in his
right groin and scrotum for last 2 years and pain
over the swelling for last 6 months. The swelling
appeared insidiously, initially in the right groin
and gradually increased in size for last 2 years and
descended to the bottom of the right scrotum. The
swelling disappears completely when the patient
lies down, but the swelling reappears on standing
and increases in size as the patient walks, coughs
and strains at defecation. Patient complains of
a dull aching pain over the swelling for last 6
Figure 2.2: Right sided inguinal hernia
months. The pain increases with straining as the
swelling increases, but the pain subsides with
rest when the swelling gets reduced. Bladder and bowel habits are normal. No history of chronic
constipation, or difficulty in micturition. Patient complains of chronic cough and breathlessness
for last 3 years, which particularly aggravates during the winter season (Fig. 2.2).
On physical examination general survey is essentially normal. On local examination of
inguinoscrotal regions, on inspection, there is a swelling in right inguinoscrotal region extending
from the right inguinal canal to the bottom of the scrotum. The swelling is pyriform in shape.
Skin over the swelling is normal and there is visible peristalsis and expansile impulse over the
swelling. On palpation temperature is normal and there is no tenderness over the swelling.
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It is not possible to get above the swelling and there is palpable expansile impulse over the
swelling. The swelling extends above up to the deep inguinal ring and below upto the upper
pole of right testis. The swelling is soft and elastic in feel. The swelling lies above and medial to
the pubic tubercle. On lying down the swelling is easily reducible. The content of the swelling
reduces with a gurgling sound. The deep ring occlusion test is positive and on percussion the
swelling is resonant and bowel sounds are audible over the swelling on auscultation. The left
inguinoscrotal region is normal and the systemic examination is also normal.
What is your diagnosis?
This is a case of right sided, incomplete, reducible, indirect inguinal hernia containing intestine
without any complication at present.
Why do you say this is a case of hernia?
This 40 years male patient presented with a swelling which started in right groin and
subsequently increased in size and descended to the scrotum. The swelling increased in size
after walking and following strenuous activities. The swelling disappears (or reduces partially)
on lying down.
On examination of inguinoscrotal region there is a right sided inguinoscrotal swelling as it is
not possible to get above the swelling. There is expansile impulse on cough over the swelling.
On lying down swelling is reducible. So this is a hernia.
What is hernia?
Hernia is abnormal protrusion of a part or whole of a viscus through the wall of its containing
cavity.
Why do you say this is an inguinal hernia?
This patient presented with a swelling in the groin which subsequently descended to the scrotum.
This hernial swelling lies above and medial to the pubic tubercle. So this is an inguinal hernia.
In case of femoral hernia the hernial swelling lies below and lateral to the pubic tubercle.
Why do you say this is an indirect and not a direct hernia?
Indirect hernia is usually unilateral, more commonly complete and more commonly found in
young adults.
On inspection the swelling extends downward and forward from the inguinal canal upto the
bottom of the scrotum.
During reduction the hernial contents go upward and backward. The deep ring occlusion
test is positive. So this is an indirect inguinal hernia.
Why do you say this is a reducible hernia?
The content of the hernia can be reduced into the abdominal cavity, so this is a reducible hernia.
Why do you say this is an incomplete hernia?
The hernia has extended upto upper pole of the right testis. The testis and epididymis can be
palpated separately from the hernial swelling, so this is a incomplete hernia (Fig. 2.3C).
What do you mean by Bubonocele?
Bubonocele is an incomplete inguinal hernia where the hernial sac is confined to the inguinal
canal (Fig. 2.3B).
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A
B
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43
C
Figures 2.3A to C: Types of inguinal hernia. (A) Complete;
(B) Bubonocele (Incomplete); (C) Funicular (Incomplete)
What is funicular type of inguinal hernia?
In this type the hernial sac goes beyond the superficial inguinal ring and reaches upper pole
of testis. The testis and epididymis can be felt separately from the hernial contents (Fig. 2.3C).
What do you mean by complete hernia?
In complete hernia the hernial contents reaches up to the bottom of scrotum. Testis and
epididymis could not be felt seprately from the hernial swelling.
Why do you say this is an enterocele?
By definition, enterocele is one which contains intestine.
From history, patient says that while he lies down the hernial content reduces with a gurgling
sound.
„ On inspection there is visible peristalsis over the swelling.
„ On palpation the swelling is soft and elastic in feel. While attempting reduction, the first part
was difficult to reduce, but the last part reduces easily with a gurgling sound.
„ On percussion the swelling is resonant
„ On auscultation bowel sounds are audible over the swelling.
So this is an enterocele.
What are the differential diagnoses in this patient?
The important causes of inguinal or inguinoscrotal swellings are:
Indirect inguinal hernia
„ Direct inguinal hernia
„ Femoral hernia
„ Congenital hydrocele
„ Funicular type of hydrocele
„ Encysted hydrocele of the cord
„ Lipoma of the cord
„ Epididymal cyst
„ Varicocele.
„
Why hernia examination should be done in standing position?
In majority of patients with hernia the swelling reduces on lying down position. So in lying down
position the description of the swelling will be fallacious.
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How will you demonstrate the sign “to get above the swelling” ?
Start palpating the swelling from the bottom of the scrotum between the thumb in front and
index and middle fingers behind and gradually palpate upward toward the root of the scrotum.
In case of the inguinoscrotal swelling the thumb and other two fingers do not meet at the
root of the scrotum as the swelling continues in the groin. So it is not possible to get above the
swelling in case of inguinoscrotal swelling (Figs 2.4A and B).
In case of a scrotal swelling the thumb and other two fingers meet each other at the root of
the scrotum and only the spermatic cord is palpable inbetween the fingers; suggesting this to
be a scrotal swelling (Figs 2.5A and B).
Figure 2.4A: Start palpation at the scrotum
A
Figure 2.4B: Palpation at root of scrotum—the
swelling is still palpable—so it is not possible to
get above the swelling—inguinoscrotal swelling
B
Figures 2.5A and B: In scrotal swelling it is possible to get above the swelling. (A) Start palpation
at the scrotum; (B) At the root of scrotum swelling is not palpable—spermatic cord may be felt. It
is possible to get about the swelling—scrotal swelling
How will you demonstrate expansile impulse on coughing?
On inspection patient is asked to cough—the expansile impulse on cough may be seen over the
swelling. This is visible expansile impulse on cough.
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On palpation: keep thumb in front and index and middle fingers behind the swelling at the root
of the scrotum and ask the patient to cough. The expansile impulse can be appreciated by the
palpating finger as the thumb and other fingers get separated (Figs 2.6A and B).
A
B
Figures 2.6A and B: Palpate with the thumb infront and the index and middle finger behind
and ask the patient to cough. Expansile impulse may be appreciated by the palpating fingers
What other swellings show expansile impulse on cough?
Apart from hernia the following swellings may show expansile impulse on Cough:
Meningocele
„ Encephalocele
„ Laryngocele.
„ Empyema necessitates.
„
How will you do invagination test?
As discussed earlier the invagination test is no longer routinely done in hernia examination.The
method for demonstration invagination is however described. Patient is asked to lie down and the
hernial content is reduced. The scrotal skin is invaginated with the tip of the index finger from the
upper pole of the testis and the finger reaches upto the superficial inguinal ring (Figs 2.7A to C)
The finger first assesses the size of the superficial inguinal ring. Normally the superficial
inguinal ring does not admit the tip of index finger.
Once the size of the superficial inguinal ring is assessed and when it is patulous, the finger
is pushed further. The finger may go directly back into the inguinal canal suggesting this to be a
direct inguinal hernia or the finger may go upward and laterally suggesting this to be an indirect
inguinal hernia.
„ The finger is kept in the inguinal canal with the nail pointing towards the roof and patient is
asked to cough.
• If the impulse touches the pulp of the finger, it is likely to be a direct inguinal hernia.
• If the impulse touches the tip or dorsum of the index finger, it is likely to be an indirect
inguinal hernia.
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Figure 2.7A: Start invaginating the scrotal skin
with the index finger from the upper pole of
testis (Do not take the testis up)
Figure 2.7B: Push the index finger up to reach
the superficial inguinal ring
Figure 2.7C: Invagination test: The index
finger assess the superficial inguinal ring
How will you test for reducibility?
In some cases hernia gets reduced once the patient lies down. In majority of cases patient can
reduce the hernia better. Some cases require taxis for reduction of the hernia. However, forcible
taxis should not be done for reduction of hernia.
Patient lies down supine, leg flexed at the hip and knee, keep the thigh adducted. The fingers
of one hand surround the swelling near the superficial inguinal ring and guide the content
through the superficial inguinal ring into the inguinal canal. The other hand grasps the swelling
near the fundus. Gentle squeezing is carried out with one hand alternating with the other till
the hernia is reduced (Figs 2.8A and B).
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Figure 2.8A: Method for reduction of hernia:
Patient lies down and Flex the hip and knee
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47
Figure 2.8B: Keep fingers of one hand at the
superficial inguinal ring and the other hand at
the fundus of hernia sac and the hernia contents
are then pushed upwards from the scrotum.
The fingers in the superficial ring guides the
contents into the inguinal canal
How will you do deep ring occlusion test?
Patient is asked to lie down and the hernia is reduced. The position of deep inguinal ring is
marked out. The deep ring lies 1.25 cm above the mid inguinal point, which is situated at the
midpoint between anterior superior iliac spine and symphysis pubis.
The anterior superior iliac spine is marked by following the groin crease towards the lateral
side. The first bony point at the lateral end is the anterior superior iliac spine. If you follow the
iliac crest from back, the last bony point is the anterior superior iliac spine (Figs 2.9A and B).
Figure 2.9A: Finding the anterior superior iliac
spine—pass the finger along the groin crease
laterally
Figure 2.9B: The first bony point felt at the
lateral end of the groin crease is anterior superior
iliac spine
To find the pubic symphysis follow the midline from below the umbilicus. The first bony point
in the midline is the symphysis pubis (Figs 2.10A and B).
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A
B
Figures 2.10A and B: (A) Follow the midline below the umbilicus; (B) The first bony point in the
midline is the symphysis pubis
Measure the distance between the anterior superior iliac spine and the symphysis pubis
using a tape and take the midpoint at the inguinal ligament. This is midinguinal point which lies
over the inguinal ligament. The deep ring is located 1.25 cm above this point (Figs 2.11A to C).
A
B
Figures 2.11A and B: The midinguinal point is found out by measuring the distance between the
anterior superior iliac spine and the symphysis pubis
Figure 2.11C: The deep inguinal ring is marked
1.25 cm above the midinguinal point
The thumb is placed over the deep ring and patient is asked to cough. Look whether any cough
impulse is seen medial to the deep ring. If no expansile impulse is seen in lying down position
patient is asked to stand with the deep ring occluded and is asked to cough again. Again look
for any expansile impulse on cough medial to deep ring (Fig. 2.12).
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Figure 2.12: Occlude the deep inguinal ring by
pressing with the thumb
How to interpret deep ring-occlusion test?
On occlusion of deep ring and asking patient to cough—no expansile impulse on cough is seen
medial to deep ring, suggesting this to be an indirect inguinal hernia (Fig. 2.13). This is described
as deep ring occlusion test is positive.
On occlusion of the deep ring and asking patient to cough—expansile impulse on cough
is seen medial to the deep ring suggesting this to be direct inguinal hernia (Fig. 2.14). This is
described as deep ring occlusion test is negative.
Figure 2.13: On asking the patient to cough,
there is no expansile cough impulse medial to
the deep ring, suggesting this to be an indirect
inguinal hernia
Figure 2.14: On asking the patient to cough
with the deep ring occluded, there is expansile
cough impulse medial to the occluded deep ring,
suggesting this to be a direct inguinal hernia
What is Zieman’s test?
Hernia is reduced. Three fingers are placed—index finger over the deep ring, middle finger
over the superficial ring and ring finger over the femoral ring and the patient is asked to cough
„ If impulse touches the index finger—indirect inguinal hernia
„ If impulse touches the middle finger—direct hernia
„ If impulse touches the ring finger—femoral hernia
However it is difficult to appreciate the impulse with three fingers placed apart at three sites.
So Zieman’s test is not favoured by many at present (Figs 2.15A to C).
„
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Section 1 Surgical Long Cases
A
B
C
Figures 2.15A to C: Zieman’s test
How will you assess tone of abdominal muscles?
This is tested by rising test. Patient lies supine on the bed. He is asked either to lift the head and chest
or both the legs above the bed. If there is weakness of abdominal muscles, the flank will bulge out.
This is called Malgaigne’s bulging. The contracting muscle may be palpated with the hand placed
on the abdominal wall (Figs 2.15A to C).
Figure 2.16A: Ask the patient keep his hands over
the chest and lift the head above the level of bed
and look at the flanks for appearance of any bulging.
Appearance of bulging in the flanks suggest poor
abdominal muscle tone
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Figure 2.16B: Abdominal muscle tone and
appearance of bulging in the flanks may also be
observed by leg rising test
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51
Figure 2.16C: Patient is asked to lift the leg
above the bed ( leg rising) and the tone of
the abdominal muscles are assessed with the
palpating fingers
How will you differentiate inguinal and femoral hernia?
„
Relation with pubic tubercle: Inguinal hernia lies above and medial and the femoral hernia
lies below and lateral to the pubic tubercle (Figs 2.17A to C).
Figure 2.17A: The finger is placed in the pubic
tubercle. The hernial sac lies above and medial
to the pubic tubercle, suggesting this to be an
inguinal hernia
Figure 2.17B: Relation of pubic tubercle with inguinal
and femoral hernia
Figure 2.17C: Femoral hernia, the hernia sac lies below
and lateral to the pubic tubercle
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How would you find the pubic tubercle?
The patient is asked to adduct the thigh against
resistance. The tendon of the adductor longus is
palpated at the upper medial aspect of the thigh.
Trace the adductor longus tendon upwards, it
reaches up to a bony point, that is pubic tubercle
(Fig. 2.18).
How will you differentiate direct and
indirect inguinal hernia?
„
„
„
„
„
„
Direct hernia comes out through the
Hesselbach’s triangle, whereas the indirect Figure 2.18: Leg adducted against resistance,
follow adductor longus tendon. The bony point
inguinal hernia comes out through the deep
reached is the pubic tubercle
inguinal ring
Direct hernia is more commonly incomplete whereas indirect hernias are commonly
complete
Direct herniae are commonly bilateral whereas indirect herniae are commonly unilateral
On cough the direct hernia appears as a direct forward bulge, whereas the indirect hernia
comes out downward and forward
On invagination test, the palpating finger goes directly backward in direct hernia, whereas in
indirect hernia the finger goes upward and backward. The cough impulse will touch the tip
or dorsum of the finger in indirect hernia and pulp of the finger in direct hernia
Deep ring occulsion test is positive in indirect inguinal hernia.
How will you do percussion of hernia swelling?
This is to be done with the patient in standing
position, as the swelling may get reduced on lying
down (Fig. 2.19).
Dull percussion note—Suggest content is
omentum (omentocele).
Resonant percussion note—Suggest content
is intestine (enterocele).
How will you manage this patient?
This adult male patient presented with indirect
complete uncomplicated reducible inguinal
hernia. I will plan for surgical treatment after
Figure 2.19: Percussion over the hernia swelling
some routine investigations.
in standing position
I will suggest following investigations:
„ Blood for Hb%. Total count and differential
count (TLC–DC)
„ Blood for sugar, urea and creatinine
„ Urine for routine examination
„ Chest X-ray (posteroanterior view)
„ 12-lead-ECG
This patient complains of chronic cough and breathlessness. I will do a pulmonary function
test to exclude any obstructive or restrictive pulmonary disease.
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What operation will you do in this patient?
I will consider Lichtenstein tension free mesh hernioplasty in this patient under regional
anesthesia.
What anesthesia will you prefer for hernia surgery in adult?
„
„
„
Spinal and epidural anesthesia is excellent for hernia operation. Less postoperative pain
following regional anesthesia. In adult local infiltration anesthesia may be used for hernia
repair
General anesthesia is also used
Both surgeon and anesthetist should be flexible with regard to type of anesthesia to be used,
suiting to the general condition and preference of the patient.
Can this operation be done under local anesthesia?
Hernia operation can also be done under local anesthesia. In day care surgery units often the
hernia operations are done under local anesthesia and patient is discharged on the same day.
What is the technique of local infiltration for inguinal hernia surgery?
A large volume of local anesthetic is required so either lignocaine 0.5% with adrenaline or
without adrenaline is to be used. If used with adrenaline larger volume may be used. There are
two technique of local anaesthetic block:
Shouldice technique: This is a type of field block with local anesthetic. 1% lignocaine
hydrochloride is used as anesthetic (Fig. 2.20).
Here 4 cm wide area is infiltrated from anterior superior iliac spine to symphysis pubis. The
first layer of infiltration is subcutaneous tissue.
After skin and subcutaneous tissue are incised similar infiltration is done deep to external
oblique aponeurosis.
After external oblique aponeurosis is incised the inguinal canal is exposed. The hernial sac
is then infiltrated.
Figure 2.20: Shouldice technique for local anesthetic block
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Point Block (Fig. 2.21)
„ The mid inguinal point area is infiltrated with
10 ml of 0.5% lignocaine (1)
„ The pubic tubercle area is infiltrated with 10
ml of 0.5% of lignocaine (2)
„ A point below the inguinal ligament lateral
to femoral artery is infiltrated with 10 ml to
0.5% lignocaine (blocks genital branch of
genitofemoral nerve) (3)
„ A point 2 cm above and medial to anterior
superior iliac spine is infiltrated with 10 ml
of 0.5% lignocaine (blocks iliohypogastric
nerve) (4)
„ The line of skin incision is infiltrated with 10
ml of 0.5% of lignocaine (5)
„ During dissection of the hernial sac inject
10 ml of 0.5% of lignocaine into the neck of
the hernial sac.
Figure 2.21: Local anesthetic point block
for hernia repair
What is Lichtenstein tension free repair?
In 1993, Lichtenstein described a technique of
repair of both direct and indirect hernia by a
tension free technique without closing the defect
by direct suturing and by placement of a mesh in
the defect of inguinal canal (Fig. 2.22).
Procedure may be done under local anesthesia.
The hernial sac is dealt with by dissecting the sac
and invaginating it into the abdomen. In case of
large direct hernia this sac may be invaginated by
imbricating suture using an absorbable suture to
allow proper placement of the mesh.
Figure 2.22: Lichtenstein mesh repair
A mesh of size 11 cm × 6 cm is sutured along
the lower edge to pubic tubercle, the lacunar
ligament and the inguinal ligament to beyond
the deep ring with a continuous suture of 3-0
polypropylene. The medial edge of the mesh is sutured to the rectus sheath. The superior edge
is sutured to the conjoint tendon. The lateral edge of the mesh is split around the cord at the
deep inguinal ring. The two split arch of the mesh are then crossed over each other and sutured
down to the inguinal ligament to create a new deep ring. The external oblique aponeurosis is
sutured in front of the spermatic cord.
Describe the steps of Lichtenstein mesh hernioplasty.
See Operative Section, Page No. 967, Chapter 22.
What is modified Bassini’s repair?
„
There are various modifications of Bassini's repair.
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Lichtenstein modification of Bassini's repair
is as follows (Fig. 2.23):
• Herniotomy is done first. The lower edge
of the transversus abdominis aponeurosis
and the conjoint tendon with fascia
transversalis attached to it is apposed
to inguinal ligament with interrupted
non-absorbable suture. Tension may be
relieved by Tanner’s slide.
• The internal oblique muscle is bulky here
and does not hold suture well so it is not
included in suture in modified Bassini’s
repair.
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55
Figure 2.23: Modified Bassini’s repair: Conjoint
tendon apposed to inguinal ligament
What was original Bassini’s operation?
In 1884, Bassini first performed herniorrhaphy. He dissected the hernial sac upto the deep
inguinal ring and ligated the neck of the sac high up near the deep inguinal ring.
He reinforced the posterior wall of the inguinal canal by apposing internal oblique, transversus
abdominis and upper leaf of fascia transversalis to lower leaf of fascia transversalis, and inguinal
ligament using interrupted silk suture. The rectus sheath comes in the medial end of the repair.
The external oblique aponeurosis is sutured in front of the cord.
What is herniotomy?
Herniotomy involves dissection of the hernial sac and once the sac is dissected it is opened at
the fundus. The content of the sac is reduced and a sliding component is excluded. The hernial
sac is twisted and ligated at the neck and redundant part of the sac is excised.
While doing herniotomy where do you ligate the sac?
The sac is dissected all around the deep inguinal ring twisted and ligated in the neck of the sac.
However, the proximal end of the sac may not be ligated and simply inverted into the
peritoneal cavity. The defect closes rapidly within hours or days.
The pain in postoperative period is less when hernial sac is not ligated proximally.
How will you identify the neck of an indirect hernia sac?
The indirect hernial sac is dissected upto the neck of the sac. The neck of the indirect hernial
sac is identified by:
„ This is the most constricted part of the sac.
„ There is a collar of fat pad around the neck of the sac.
„ The inferior epigastric vessels crosses the neck of the sac from the medial side.
What is the standard skin incision for inguinal hernia repair?
For herniorrhaphy/hernioplasty in adult, the incision should be long, starting from the pubic
tubercle at the medial end and taken laterally along the inguinal canal beyond the deep inguinal
ring.
An adequate incision provides good exposure for dissection of the sac and repair of posterior
wall can be done easily.
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Why absorbable sutures are not used for hernia repair?
Following hernia repair, process of healing takes about 1 year. Eighty percent wound tensile
strength is achieved in 6 months. Absorbable suture like cat gut loses 50% of their tensile strength
within 1 week and gets absorbed within 6 weeks. So it is not an ideal suture for hernia repair.
Why braided silk is not preferred for hernia repair?
Silk sutures lose 40% of their tensile strength within 6 weeks. These sutures being braided
polyfilament suture causes more tissue reaction, may perpetuate infection once there is infection.
Which suture is ideal for hernia repair?
„
„
„
Monofilament nonabsorbable synthetic suture like polypropylene and polyamide sutures
are ideal for hernia repair
Even if there is infection these sutures need not be removed
Monofilament stainless steel sutures may also be used for hernia repair.
When can a patient return to normal activities after operation?
„
„
There is no advantage in limiting postoperative activities. Patient can return to normal
activities as soon as postoperative discomfort is over. There is no evidence that lengthy rest
reduces the chance of recurrence.
Recurrence rate depends on the technique used for hernia repair and does not depend on
postoperative activity of the patient.
What is Shouldice repair for inguinal hernia?
This is a multilayered repair of hernia first practiced at Shouldice clinic in Toronto.
Usually done under local anesthesia. Using stainless steel wire or polypropylene as suture
material
„ Skin incision in the groin from anterior superior iliac spine to the pubic tubercle. Cremaster
muscle is excised
„ Hernial sac is dissected and ligated at neck at the deep inguinal ring
„ Redundant transversalis fascia is excised from deep ring to pubic tubercle
„ The lower flap of fascia transversalis is sutured behind the upper flap of fascia transversalis
„ The upper flap of fascia transversalis is sutured to inguinal ligament from deep inguinal ring
to the pubic tubercle
This double breasting of fascia transversalis forms a new strong posterior wall of the inguinal
canal.
„ The posterior wall is further strengthened by double layer of suture apposing conjoint tendon
to the inguinal ligament starting from pubic tubercle and carrying laterally to deep ring and
back from deep inguinal ring to the pubic tubercle.
„ The cut margins of the external oblique aponeurosis are sutured in front of the cord in two layers.
„ Skin closure with interrupted 2-0 monofilament polyamide suture.
„ Recurrence rate following this type of repair is less than 1%.
„
What is modified Shouldice repair for inguinal hernia?
Berliner modified six layers repair of inguinal hernia. He initially started repair of posterior wall
in three layers and later modified it with repair in two layers. The fascia transversalis is split from
pubic tubercle to the deep inguinal ring. The upper leaf of fascia transversalis and transversus
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abdominis aponeurosis is apposed to lower leaf of fascia transversalis. The second layer of
continuous suture approximate the superior margin of fascia transversalis and transversus
abdominis aponeurosis to the inguinal ligament. The external oblique aponeurosis is sutured
in front of the spermatic cord in single layer.
What is Macvay repair for inguinal hernia?
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It is also known as Lothiessan's repair or Cooper's ligament repair.
Herniotomy is done. The Cooper's ligament is dissected by dividing the iliopubic tract.
Beginning at pubic tubercle a series of sutures are placed between the upper edge of the
fascia transversalis and aponeurosis of transversus abdominis and the Cooper's ligament
upto the medial margin of femoral vein.
Femoral ring is closed by interupted suture apposing the Cooper's ligament to anterior
femoral fascia and inguinal ligament.
In the lateral part the transversus aponeurosis and fascia transversalis is apposed to the
inguinal ligament with interrupted sutures.
The external oblique aponeurosis is sutured in front of the spermatic cord.
What are the important complications of herniorrhaphy/hernioplasty?
General complications:
Pulmonary: Atelactasis, pneumonia and pulmonary embolism.
„ Cardiac: Particularly in patient with overt cardiac diseases.
„ Urinary retention: Usually caused by overzealous fluid administration leading to diuresis
and atony of the overfilled bladder.
„
Local complications:
Hemorrhage
„ Urinary bladder or bowel injury during dissection and ligation of the sac
„ Injury to testicular vessels during dissection, leading to:
• Testicular swelling
• Testicular atrophy
„ Closing the superficial inguinal ring tightly may cause testicular swelling and subsequent
atrophy
„ Injury to vas deferens
„ Injury to nerve like iliohypogastric, ilioinguinal and genital branch of genitofemoral nerve
„ Wound infection
• Incidence 1–5%. Minor or major wound infection
„ Recurrence of hernia
„ Hydrocele or lymphocele
„ Edema of the penis due to injury to superficial external pudendal vein.
„
What are the parts of a hernia?
A hernia consists of:
Hernial sac
„ Contents in the sac
„ Coverings of the sac.
„
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What are the parts of hernial sac?
The hernial sac is the prolongation of the parietal peritoneum.
The hernial sac has following parts (Fig. 2.24):
„ Mouth of the sac: The opening into the peritoneal cavity (1)
„ Neck of the sac: The constricted part of the sac beyond the
mouth (2)
„ Body of the sac (3)
„ Fundus of the sac: The most distal closed part of the sac (4).
What may be the different contents of a hernia?
The hernia may contain different intra-abdominal structures
which includes:
„ Omentum: Omentocoele.
„ Intestine: Enterocoele.
„ A portion of the circumference of the bowel: Richter’s
hernia.
„ A portion of the urinary bladder.
„ Appendix.
„ Meckel’s diverticulum: Littre’s hernia.
„ Fallopian tubes.
„ Fluid: secondary to ascites.
Figure 2.24: Parts of a hernial sac
What are the coverings of complete inguinal hernia?
Apart from skin, subcutaneous tissue and Dartos, the coverings of hernia are:
External spermatic fascia derived from external oblique aponeurosis
„ Cremesteric muscle and fascia derived from internal oblique
„ Internal spermatic fascia derived from the fascia transversalis
„ Deep to this is hernial sac derived from the parietal peritoneum.
„
When the hernia sac is exposed at the inguinal canal the coverings include the cremesteric
muscle and fascia and the internal spermatic fascia.
What is Richter’s hernia?
When the hernial sac contains a portion of the
circumference of the bowel then it is called
Richter’s hernia (Fig. 2.25).
What is sliding hernia?
When the wall of the hernial sac (usually the
posterior wall) is formed by a viscus then it is
called a sliding hernia. On the right cecum or
urinary bladder may form the posterior wall of
the sac and on the left side sigmoid or urinary
bladder may form the posterior wall of the
hernial sac (Figs 2.26A and B).
Figure 2.25: Richter’s hernia (Circumference of
the colon lying in the hernial sac)
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B
Figures 2.26A and B: Sliding hernias: (A) Posterior wall of hernia sac formed by urinary bladder;
(B) Posterior wall of hernia sac formed by caecum
What is Littre’s hernia?
Hernial sac containing Meckel’s diverticulum as the content is called Littre’s hernia.
What do you mean by pantaloon (or saddle bag) hernia?
A pantaloon hernia is described as having both a direct and indirect inguinal hernial sac lying
on either side of inferior epigastric vessels. It is also known as dual hernia.
What is Cooper’s ligament?
It is the extension of the inguinal ligament, which is attached to the pecten pubis from pubic
tubercle and laterally extends upto the femoral ring. It is quite strong and forms the lower
boundary of the Fruchaud’s myopectineal orifice.
What are the different types of inguinal hernia depending on the distal extent of the
hernia?
The hernia may be:
Complete: When the hernial sac reaches upto the bottom of scrotum and the testis cannot
be felt separately (see Fig. 2.3A).
„ Incomplete hernia: When the hernial sac does not descend upto the bottom of the scrotum.
This can be:
„ Bubonocoele: When the hernial sac is confined to the inguinal canal and does not reach
beyond the superficial inguinal ring (see Fig. 2.3B).
„ Funicular: When hernial sac goes beyond the superficial inguinal ring and reaches upto the
upper pole of the testis (see Fig. 2.3C).
„
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What do you mean by hernioplasty?
When the repair of hernia is done by reinforcing the gap by placement of some prosthetic
materials like mesh or natural tissues like fascia lata.
What are the different techniques of hernioplasty?
Abrahamson nylon darn repair: The principle of this operation is to reinforce the posterior wall of
the inguinal canal with the muscle of the musculoaponeurotic arch along with a simple lattice of
monofilament suture under no tension on which fibrous tissue develops. The hernial sac is dealt
with. The repair begins by suturing the medial edge of rectus sheath and the musculoaponeurotic
arch (conjoint tendon) to the posterior portion of the inguinal ligament and to the iliopubic tract
with a continuous suture of 2-0 polypropylene. If the conjoined tendon and inguinal ligament
cannot be apposed without tension then approximation is not forced and a gap is left between
the inguinal ligament or the upper elements of repair. The gap is bridged by a number of layers
of the polypropylene suture.
The first bite is to take over the most medial fiber of inguinal ligament over the pubic tubercle
and then through the medial edge of the rectus sheath. The suture is then taken laterally taking
bites below to the inguinal ligament and above to rectus sheath medially and laterally to the
conjoint tendon and more laterally muscular part of transversus abdominis and internal oblique,
upto the deep inguinal ring. The suture is not tied tightly, but kept loose and the suture is then
continued medially taking bites of the same structures and ending up at the most medial end
of inguinal ligament and rectus sheath. A third layer of suture may be applied from lateral to
medial end thus providing a lattice of nylon suture in posterior wall of inguinal canal. External
oblique aponeurosis is sutured in front of the cord.
What is Rives prosthetic repair of inguinal hernia?
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„
Rives recommended placement of mesh in the preperitoneal space
The hernial sac is dealt with:
• The fascia transversalis is slit open and is dissected all around widely to create a
preperitoneal space.
• The lower margin of the mesh is folded over and stitched to the Cooper’s ligament and
fascia iliaca. The mesh is passed upward behind the cord, transversalis fascia, transversus
abdominis aponeurosis and rectus sheath into the preperitoneal space. The mesh is fixed
above by interrupted suture to the combined thickness of internal oblique, transversus
abdominis muscle and the edge of rectus sheath.
• The superolateral edge of the mesh is split to accommodate the cord and the tails of the
mesh are also fixed to the full thickness of internal oblique and transversus abdominis
muscle.
• The mesh is covered by suturing the musculoaponeurotic arch of the transversus abdominis
and internal oblique muscle and fascia transversalis above to the fascia transversalis and
inguinal ligament below. The external oblique is closed in front of the cord.
• Rives also uses a midline subumbilical abdominal approach with a preperitoneal
dissection to place a large sheet of mesh over the inguinal defect between the peritoneum
and the abdominal wall. This technique is recommended for difficult recurrent hernia
where Cooper’s ligament is already destroyed
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What is GPRVS?
This is called giant prosthetic reinforcement of visceral sac devised by Stoppa.
Where is the mesh placed in GPRVS?
A large sheet of mesh (mersilene, dacron or polypropylene) is placed between the peritoneum
and anterior, inferior, lateral abdominal wall. The mesh stretches in the lower abdomen and
pelvis from one end to the other enveloping the lower half of the parietal peritoneum with which
it gets incorporated by scar tissue.
What is the approach for placement of the mesh?
The mesh may be placed in the preperitoneal space by either a midline abdominal incision or
Pfannensteil incision. Unilateral mesh placement may also be done by an inguinal incision.
How do you measure the size of the mesh required for a bilateral giant mesh
placement?
The mesh is chevron-shaped and the width of the mesh is 2 cm less than the distance between
the two anterior superior iliac spines. The vertical dimension equals the distance between the
umbilicus and the symphysis pubis.
How is the mesh anchored in place?
When correctly placed, this large prosthesis does not require any anchoring suture. The
prosthesis may be fixed by a single suture to umbilical fascia only.
In which hernia repair GPRVS is more suitable?
This technique is particularly useful for:
Elderly patient with bilateral hernias
„ Large hernias
„ Recurrent hernias
„ Patient with collagen disease, Ehler’s Danlos syndrome or Marfan’s syndrome.
„
What is Lytle’s repair?
When the deep ring is patulous, the fascia
transversalis is plicated by suture narrowing the
deep ring. This is called Lytle’s repair (Fig. 2.27).
What is Nyhus classification for groin
hernia?
Depending on the anatomical defects in the
groin. Nyhus has classified groin hernias into
four types:
„ Type I: No defects in the deep inguinal ring
or the inguinal canal. There is presence of
persistent processus vaginalis, e.g. hernias in
newborn and infants.
„ Type II: Deep ring is patulous, but the inguinal
canal is intact. Small indirect inguinal hernias.
Figure 2.27: Lytle’s repair—Narrowing the deep
inguinal ring
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„
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Type III: Variable defect in the deep inguinal ring or the inguinal canal. This includes large
indirect inguinal hernias, sliding hernias, direct hernias and pantaloon hernias
Type IV: All recurrent hernias.
What is Gilbert’s classification for groin hernia?
Gilbert, in 1987, described an anatomical classification for hernia. However, it is not universally
accepted.
„ Type I: Patent processus vaginalis—Snug internal inguinal ring. Inguinal canal intact.
„ Type II:
• Moderately splayed deep inguinal ring
• Admits one finger
• Inguinal canal is otherwise intact
„ Type III:
• Large internal inguinal ring
• Admit two or more fingers
• Inguinal canal is weak
„ Type IV:
• Typical direct hernia
• Full blow out of the posterior wall of the inguinal canal
• Internal ring is intact
„ Type V:
• A type of direct hernia through a punched out hole in fascia transversalis
• Internal inguinal ring is intact.
What do you mean by groin hernia?
All the hernias occurring through the
myopectineal orifice at the groin are grouped
as groin hernias. These include the indirct
inguinal hernia, direct inguinal hernia and
the femoral hernia.
What is the boundary of Fruchauds
myopectineal orifice?
Fruchaud myopectineal orifice is an osseomyo-aponeurotic tunnel through which all the
groin hernia comes out (Fig. 2.28). This orifice
is bounded by:
„ Medially by the lateral border of the rectus
sheath (1)
„ Laterally by the iliopsoas muscle (2)
„ Below by the pecten pubis and fascia
covering it and the Cooper’s ligament (3)
„ Above by the arched fibres of internal
oblique, transversus abominis muscle and
the conjoint tendon (4).
Anatomy of inguinal canal (see Surgical
Anatomy Section, Page No. 1023, Chapter 23)
Figure 2.28: Schematic diagram of Fruchaud’s
myopectineal orifice
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What are the complications of hernia?
Untreated the hernias may lead to a number of complications.These includes:
Irreducible hernia
„ Obstructed hernia
„ Incarcerated hernia
„ Strangulated hernia
„ Inflamed hernia due to inflammation of the contents of hernia
„ Hydrocoele of the hernial sac.
„
What are the characteristics of irreducible hernias?
The contents of the hernial sac cannot be reduced inside the abdomen on lying down or after
manipulation. This is usually due to adhesion of the hernial contents. Apart from irreducibility
there are no symptoms and signs. However, irreducibility may lead to obstruction or
strangulation. So irreducible hernia should be operated early.
What do you mean by obstructed hernia?
Hernia containing intestine may lead to acute intestinal obstruction due to obstruction of the
lumen of the gut inside the hernia.
In addition to irreducibility patient complains of colicky pain initially over the hernia and
later on colicky abdominal pain. The hernia becomes tense and tender and there may be
visible peristalsis over the hernia. Unrelieved the patient may present with cardinal features
of acute intestinal obstruction—pain abdomen, vomiting, abdominal distension and absolute
constipation.
Unrelieved the obstruction may lead to impairment of blood supply to the gut causing
strangulation of the hernial contents.
What are the characteristics of strangulated hernia?
Due to impairment of blood supply there is ischaemic necrosis of the hernial contents.
The hernial swelling becomes irreducible, no cough impulse, tense, tender and there may
be rebound tenderness.
In strangulated omentocoele the symptoms and signs may be mild and if not relieved
ischemic necrosis of omentum may lead to bacterial invasion leading to a localised abscess.
In strangulated enterocoele symptoms and signs are more severe with features of acute
intestinal obstruction and if not treated patient condition will deteriorate rapidly. The
ischemic gut may perorate leading to initially localised and then generalised peritonitis
and septicemia.
What do you mean by inflamed hernia?
When the contents of the hernial sac get inflamed, this is known as inflamed hernia. Patient
complains of pain over the swelling and may be febrile. The hernia may become irreducible,
there may be localised tenderness over the hernia.
What do you mean by incarcerated hernia?
This is a type of obstructed hernia where the lumen of the colon is blocked with faecal matter.
The hernial contents may be indented with the finger.
The term incarcerated hernia is often used as an alternative to obstructed or strangulated
hernia.
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What are the aetiological factors for development of hernia?
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Chronic straining factors: Any chronic straining factors like chronic cough, lower urinary
tract obstruction, straining at defecation may increase the intraabdominal pressure which
may be one of the important precipitating factor for development of hernia.
Increased intraabdominal pressure due to an underlying intraabdominal malignancy or
ascites may result in an hernia.
Obesity: May cause stretching of muscles due to interposition of fat in between muscles
which makes the muscles weak. Fat may also weakens the fascia and aponeurosis and may
lead to hernias.
Smoking: Smoking may result in an acquired collagen deficiency and may result in hernia.
Chronic peritoneal dialysis may result in hernia either due to weakness of the abdominal
wall or enlargement of a persistent processus vaginalis.
What is herniography?
Radiographic contrast material is injected into peritoneal cavity and patient is turned to different
position. X-ray of local area will demonstrate contrast in the hernial sac, if hernia is present.
INGUINAL HERNIA WITH FEATURES OF PROSTATISM
What is your diagnosis?
A 60 years male patient with a right sided
incomplete, direct, reducible inguinal hernia
containing intestine with features of benign
prostatic enlargement.
(In this case a detailed history of bladder habit
needs to be taken along with mention of P/R
examination and comment on prostatic status)
(Fig. 2.29).
How will you manage this patient?
As this patient has chronic urinary obstruction
due to prostatic enlargement, I will do the
following special investigations in addition to
routine investigation.
„ Ultrasonography of kidney, ureter and bladder
(KUB) region to assess the size of the prostate,
amount of residual urine and back pressure
changes in the urinary tract
„ Uroflowmetry study to decide about the
necessity of operation for prostatic enlargement
„ Serum PSA level.
Figure 2.29: Direct inguinal hernia
If the patient has significant prostatic enlargement how will you treat this patient?
As the patient has significant prostatic enlargement, the patient should be treated by
prostatectomy and hernia repair in same sitting.
I will do transurethral resection of prostate and right-sided inguinal hernioplasty in same sitting.
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What is the role of medical treatment in benign prostatic hyperplasia?
See Page No. 806, Chapter 18.
Can you do open prostatectomy and hernia repair in same sitting?
Yes. This can also be done. A Pfannensteil incision extending slightly to the side of hernia is
suitable. A transvesical or retropubic prostatectomy and repair of hernia may be done in same
sitting.
What is direct inguinal hernia?
When the hernia occurs through Hessalbach’s traingle, it is called direct inguinal hernia.
What are the characteristics of direct inguinal hernia?
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Direct inguinal hernia is common in elderly male patient
The neck of the direct hernial sac is wide so the chance of strangulation is less
The direct hernia is usually incomplete
A direct hernia is always acquired. Smoking, strenuous activities, damage to ilioinguinal
nerve are predisposing factors.
What is funicular direct inguinal hernia?
This is a variety of direct inguinal hernia where a narrow necked sac descend through a small
defect in the most medial part of the Hesselbach’s triangle just above the pubic tubercle.
The chance of strangulation is high in this variety or direct inguinal hernia.
How will you tackle a direct hernial sac?
The neck of the sac is wide and hernia is usually incomplete. After dissection of the hernial sac
it may just be inverted into the peritoneal cavity. Excision of the sac is usually not required.
In case of a large hernial sac the fascia transversalis may be plicated to keep the sac reduced.
Only when direct hernial sac is like a diverticulum with a narrow neck, the sac is dissected,
ligated at neck and redundant sac is excised.
How will you differentiate a direct and indirect inguinal hernia at operation?
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The direct hernia is a bulge through the Hesselbach’s traingle, an indirect inguinal hernia
descends through the deep inguinal ring
The direct hernial sac lies posteromedial to the spermatic cord whereas an indirect hernial
sac lies anterolateral to the cord
The neck of direct hernial sac is wide and lies medial to inferior epigastric artery, whereas
the neck of indirect inguinal hernia is narrow and lies lateral to inferior epigastric artery
How will you repair a direct inguinal hernia?
In direct hernia there is usually a wide gap in the posterior wall of the inguinal canal so Iwill
consider Lichtenstein tension free mesh hernioplasty in this patient.
What are other techniques for repair of direct inguinal hernia?
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Shouldice repair
Cooper’s ligament repair
Rives preperitoneal mesh repair
Stoppa's GPRVS
Laparoscopic mesh repair (TAPP and TEP).
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RECURRENT INGUINAL HERNIA
What is your diagnosis?
This is a case of recurrent right sided complete, reducible indirect inguinal hernia containing
omentum (Fig. 2.30).
Figure 2.30: Right sided recurrent inguinal
hernia
What is the most important factor for development of recurrence after operation?
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The most important cause of early recurrence of hernia is due to technical reasons.
Late recurrences are due to tissue failure.
What are the important causes of recurrence of hernia?
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Repair under tension
Wound infection
• Fifty percent of recurrences are due to infection following repair
• Wound hematoma contribute to increased chance of infection
Use of absorbable suture
Size of the hernia:
• Larger the hernia, greater the chance of recurrence
Failure to identify and leaving behind a part of the sac
Missed hernial sac while repairing direct inguinal hernia, an indirect hernial sac may be
overlooked
Smoking
Ascites and other causes of increased intra-abdominal pressure
Surgeons expertise
Multiple recurrences of repeated repair may be due to disorder of collagen production,
maintenance and absorption
What is the incidence of recurrence of hernia after repair?
Varies between 1% and 3%.
What are the problems of surgery in recurrent hernia?
Because of previous repair, the anatomy of the inguinal canal is distorted. There is scarring of
tissues. The inguinal and Cooper’s ligaments are usually attenuated.
The hernia usually descends through a large defect in the inguinal canal.
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What investigations will you do in this patient?
I will do a routine workup to assess his fitness for surgery.
Other special investigations depending on any underlying disease:
„ If patient have urinary symptoms: ultarsonography of KUB region, uroflowmetry
„ If patient has obstructive air way disease: chest X-ray/pulmonary function test
What operation will you do in this patient?
As the patient has undergone an open operation earlier, it will be difficult to dissect the different
layers in the inguinal canal. It is preferable to do a laparoscopic mesh repair of hernia in this
patient.
What other operation may be suitable to this patient?
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An open preperitoneal approach for repair of this hernia may be undertaken and a mesh
may be placed in prepertioneal space to overlap the myopectineal orifice.
Stoppa's GPRVS (giant prosthetic reinforcement of visceral sac) for large multiple recurrent
hernia
If anatomy is not distorted too much, then either Cooper's ligament repair or Shouldice
repair may be attempted.
What is the indication of orchiectomy?
When in a recurrent hernia cord cannot be dissected free from the scar tissue then excision of
the cord and orchiectomy may be considered. Orchiectomy may also be required when cord
has been damaged during dissection or in repair of complicated recurrent hernia. Informed
consent is to be taken for orchiectomy.
What is the role of laparoscopic repair of inguinal hernia?
Advances in laparoscopic surgery made possible management of groin hernias with laparoscopy.
There are two techniques for laparoscopic groin hernia repair:
1. Transabdominal preperitoneal repair (TAPP repair)
2. Totally extraperitoneal repair (TEP repair):
Describe the steps of TAPP operation.
See Operative Surgery Section, Page No. 969, Chapter 22.
Describe the steps of TEP operation:
See Operartive Surgery Section, Page No. 972, Chapter 22.
INCISIONAL HERNIA
OUTLINE FOR WRITING A LONG CASE OF INCISIONAL HERNIA
A. HISTORY
1. Particulars of the Patient
2. Chief Complaints
„ Swelling in the abdomen for last .................... months/years
„ Pain over the swelling/abdomen for .......................................
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3. History of Present Illness
„ If the swelling started shortly after the operation then start writing history of present illness
with history of operation including details of postoperative course
„ If hernia developed after a long duration following operation then the operation history may
be described in past history
„ Detailed history about the swelling—mode of onset, progress of the swelling—size at the onset
and approximate present dimension. What happens to the swelling on standing, walking,
straining and lying down
„ Detail history about pain—Onset, duration, site, character, radiation. Relation of pain with
the swelling, any aggravating or relieving factor.
„ If operative history and appearance of the swelling is not a long gap (less than a year), then
details of the operation may be included in the history of present illness, otherwise the history
of operation may be written in past history. The operative history includes, type of operation,
emergency or elective, nature of operation, postoperative recovery, any history of cough or
abdominal distension in the postoperative period any wound infection, any wound gaping
or burst abdomen, whether required secondary suture, duration of hospital stay. Time gap
between the operation and appearance of swelling.
„ Any straining factors like chronic cough, constipation or difficulty in micturition.
„ Details of bowel and bladder habits.
„ Any other systemic symptoms—ask details about systemic symptoms.
4. Past History
Detail history about the operation, if not included in history of present illness.
5. Personal History
6. Family History
7. Treatment History
Whether using abdominal belt.
8. Any History of Allergy
B. PHYSICAL EXAMINATION
1. General Survey
2. Local Examination: Examination of abdomen
Detail abdomen examination: Inspection, palpation, percussion and auscultation
„ To comment about the hernial swelling site, extent, size, shape, surface, margin the patient
should be examined in standing as with lying down the swelling may disappear or may
reduce in size
„ For testing reducibility the patient should lie down and the clinician pushes the swelling
through the gap in the abdominal wall
„ The gap in the abdominal wall should be assessed
3. Systemic Examination
C. SUMMARY OF THE CASE
D. PROVISIONAL DIAGNOSIS
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E. INVESTIGATIONS SUGGESTED
What is your case?
This 40-year female patient developed gradual
onset of a swelling in lower abdomen since last
1 year. She underwent abdominal hysterectomy
through a midline incision for uterine-fibroid
1½ years back. Following hysterectomy patient
developed wound infection and the wound
required dressings for about 2 months for
healing. One year back the swelling appeared
at the site of abdominal wound, starting at the
lower end of the wound, gradually increased
in size over the last 1 year with occasional
episodes of pain, dull-aching in nature, which
Figure 2.31: Incisional hernia
aggravated when the swelling increases in size
and gets relieved on rest when the swelling
reduces in size. The swelling appears on standing and walking and gets aggravated on coughing
and other strenuous activities and disappears fully on lying down and manipulation by the
patient. There is no period of irreducibility. She is not a known diabetic and hypertensive
(Fig. 2.31).
On examination patient is obese. There is a wide-scar of lower-midline incision in right
abdomen. A swelling appears on coughing in lower-abdomen 8 cm × 7 cm in dimension,
reducing completely on lying down. The skin over the swelling is tense, thinned out with evident
visible-peristalsis. The gap in the abdomen is about 6 cm vertically and 4 cm horizontally in
diameter. No other organomegaly or lump abdomen detected. Chest is clear. Cardiovascular
system appears within normal limit.
What is your diagnosis?
This is a case of incisional hernia through lower midline incision following hysterectomy, content
of hernia being intestine and it is reducible.
What operative history is relevant in a case of incisional hernia?
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Type of operation.
Elective or emergency
• Postoperative complications more with emergency surgery.
Incision, suture material used, surgeon’s expertise, any intraoperative complication (If
information is available from the OT-note).
Postoperative period
• Wound infection/wound hematoma
• Gaping of wound/burst-abdomen
• Duration of postoperative stay
• Any history of postoperative cough, straining, abdominal distension
History of previous abdominal operations
Patient factors
• Systemic illness, e.g. hypertension, diabetes mellitus
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• Malnutrition
• Anemia
• Smoking
− Any straining factors- constipation, any history of chronic cough, any urinary problems.
• Prostatism.
How will you assess the gap in the abdominal wall?
The hernial content is reduced and the gap in the anterior abdominal wall may be felt with the
fingers. Patient is asked to lift both the legs with knee extended and with both arms folded over
chest. This causes contraction of muscle of abdominal wall and hernial gap may be felt distinctly.
In an irreducible hernia the gap cannot be felt properly.
What are the important causes for development of incisional hernias?
Many factors singly or in combination are responsible for development of incisional hernia.
1. Poor surgical technique:
a. Non-anatomic incision:
− Battle's pararectal incision damaging number of nerves has high incidence of incisional
hernia
− Vertical incision (midline or paramedian) has high chance of developing hernia than
the transverse incision
b. Method of closure: Layered closure has higher incidence of developing incisional hernia
than wound closed in single layer.
c. Inappropriate suture material: The wound gains about 85% of normal strength in 6 months.
Maximum strength is gained in 1 year. Sutures are responsible for maintaining wound
strength for 6 months. Wound closed with nonabsorbable suture material are followed by
a far lesser incidence of postoperative hernia than wound closed with absorbable suture.
d. Suturing technique: Closing abdominal incision with suturing under tension causes
pressure necrosis of intervening tissues and is an important cause for development of
incisional hernia.
e. Drainage tube: When drain tubes are brought out through the main wound the chance of
developing incisional hernia is increased.
2. Preoperative straining factors: Chronic cough, chronic constipation and urinary obstruction.
3. Postoperative complications: Abdominal distension, cough, respiratory distress due to
pneumonia or lung collapse, and postoperative wound infection.
4. General factors: Age (elderly patients), malnutrition, hypoproteinemia, jaundice, malignancy,
diabetes, chronic renal failure, steroid or immunosuppressive therapy and alcoholism.
5. Tissue failure: Late development of hernia after 5, 10 or more years after operation is usually
associated with tissue failure. Abnormal collagen production and maintenance has been
shown to be associated with increased incidence of incisional hernia.
When does majority of incisional hernia start?
Majority of incisional hernia starts in the immediate postoperative period due to partial
disruption of deep layers of the wound. As the skin remains intact the event may pass unnoticed
in immediate postoperative period.
What are the types of defects in incision line?
The hernial opening may vary in size. The whole of the incision line may have a long and wide
gap. A small area may have gap or there may be multiple gaps along the incision line.
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What is the role of rectus abdominis muscle in midline incisional hernia?
Due to gap in midline the rectus muscle is stretched and pushed laterally. Contraction of rectus
muscle now expels the abdominal contents out into the hernial sac rather than retaining them
into the abdominal cavity.
What are the problems with large incisional hernias?
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In large incisional hernia, large amount of omentum small gut and large gut may remain
outside the abdominal cavity into the hernial sac. If this continues for a long time the intraabdominal capacity is reduced. During operation, if such contents are reduced into abdominal
cavity forcibly under tension, it may cause compression of inferior vena cava and may also
cause splinting of diaphragm leading to respiratory distress (abdominal compartment
syndrome).
Large incisional hernia may cause reduction of intra-abdominal pressure and may cause
edema of the mesentery and stasis in IVC and splanchnic vascular bed. It may be difficult
to raise the intra-abdominal pressure leading to problems of micturition and defecation.
Lordosis may occur and back pain is a common complain.
The skin and subcutaneous tissue overlying a large incisional hernia are stretched and
damaged. Skin becomes atrophic devoid of subcutaneous fat and spontaneous ulceration
may develop in the skin.
Does all incisional hernia need operation?
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If the neck of the incisional hernia is wide, shows no signs of increase in size and patient has
no symptom, it may be observed
Symptomatic hernia, which is showing sign of increase needs repair
Large hernia with a small opening has high incidence of strangulation and need to be repaired
early. Attacks of subacute intestinal obstruction, irreducibility and strangulation are definite
indications for repair of incisional hernias.
How will you manage this patient?
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The patient has incisional hernia through lower midline incision. Patient does not have any
medical disease and there are no straining factors, I will prepare this patient for surgery
Associated cardiovascular disease, if any or hypertension needs to be treated
Associated respiratory disease, if any, needs treatment
If diabetic, needs good control before surgery
If obese, weight reduction before surgery is helpful
Intertrigo or any infected skin lesion overlying the hernia needs attention
Investigation for any intra-abdominal pathology—USG / Upper GI endoscopy.
What operation is preferable for this patient?
In this patient the hernial gap is about 6 cm × 4 cm, so I will consider mesh repair in this patient
Why do you like to do mesh repair?
In case of incisional hernia with a small gap (<2 cm) the tissue can be apposed without
tension.In those cases anatomical repair may be done. In this patient the gap is 6 cm × 4 cm
so an anatomical repair may cause tension in the suture line. So a mesh repair is preferable
in this patient.
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In case of midline incisional hernia what do you mean by anatomical repair?
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Anatomical repair involves apposition of the different layers of the abdomen to repair the
defect.
Either transverse or vertical elliptical incision. The skin flaps are raised.
The hernial sac is dissected upto the lateral edge of the gap and redundant sac excised.
The linea alba is apposed in the midline by continuous or interrupted polypropylene suture
taking heavy bite.
Skin apposed by interrupted suture using monofilament polyamide sutures.
What do you mean by anatomical repair in case of hernias through paramedian
incision?
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The hernial sac is dissected and the redundant sac is excised upto the lateral edge of the gap.
The medial edge of the defect will be the intact linea alba and remains of the rectus sheath
along it. The lateral edge will be composed of anterior and posterior rectus sheath and rectus
muscle between, then with all three layers fused by scar tissue.
The medial leaf is dissected separating the peritoneum with the posterior rectus sheath and
the anterior rectus sheath. The lateral edge is incised and the anterior and posterior rectus
sheath is dissected free.
The peritoneum with the posterior rectus sheath is approximated by continuous
polypropylene suture.
The anterior rectus sheath is apposed by continuous or interrupted polypropylene suture.
Alternatively: Mass approximation of the medial and lateral edge by continuous or interrupted
polypropylene suture taking good bite of tissue from the edge.
What is Shoelace darn technique for repair of incisional hernia?
„
This technique of repair restores the normal anatomy and function of abdominal wall. A new
strong linea alba is reconstructed and the new midline anchor allows the rectus muscle to
straighten and return to lie alongside the midline and also reconstruct the anterior rectus
sheath and fix them to the new linea alba (Figs 2.32A to D).
There are two steps of this operation:
• The first step is to reconstitute a strong new midline by suturing a strip of fascia from the
medial edge of each anterior rectus sheath. The second step is to restore the recti muscle to
their normal position by drawing together the lateral cut edges of the anterior rectus sheath.
• Either a vertical or transverse abdominal skin incision is made, and the redundant skin
and subcutaneous fat is excised.
• The skin flaps are dissected off the sac of the hernia and from anterior rectus sheath on
either side. The anterior rectus sheath is sufficiently exposed to allow for splitting of the
anterior rectus sheath. The sac is not opened and inverted into the abdominal cavity.
The sac is opened only when the operation is done for obstruction or strangulation. The
anterior rectus sheath around the hernial opening is defined. An incision is made over the
anterior rectus sheath 1–1.5 cm from the medial edge of the rectus sheath on either side.
The incision is extended up and down 2 cm beyond the gap on either side.
• The medial edge of the rectus sheath is sutured from above downward by a continuous
suture of polypropylene. This creates a new linea alba and return the unopened sac into
the peritoneal cavity.
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D
Figures 2.32A to D: Shoelace darn technique of repair. (A) Hernial sac dissected. (B) The linea alba incised
1cm from the margin. (C) The medial cut edge sutured by a running polypropylene suture. (D) A neo linea
alba created by running suture apposing the lateral cut edge and taking bites from the apposed medial
cut edge. (1) Margin of linea alba; (2) Hernial sac; (3) Medial cut margin of linea alba; (4) Lateral cut margin
of linea alba; (5) Medial cut margin suture; (6) Lateral cut margin suture
• The lateral edge of the anterior rectus sheath is situated at a gap from the newly constructed
linea alba. This gap is closed by a second suture running between the lateral edges of the
rectus sheath and while passing the midline it takes a bite through the newly constructed
linea alba. The sutures should be applied 5 mm apart and each suture passes through the
new midline. The second layer of suture begins at the top end of the incision in the rectus
sheath. In cases with large gap the to and fro shoelace suture across the fascial defect helps
in functionally substituting for the missing anterior rectus sheath.
How will you prepare an obese patient with incisional hernia for surgery?
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Obesity is associated with higher rate of recurrence following repair
Obese patient should lose weight.
What is the role of mesh repair in incisional hernia?
The mesh repair is an excellent method for repair of incisional hernia. It may be used for all types
of incisional hernias, for large incisional hernias with a wide gap, or when the aponeurotic gap
cannot be properly apposed or tissue is thinned out.
What is an ideal mesh?
Ideal mesh should be:
„ Cheap
„ Easy to handle
„ Can be cut to a desired shape
„ Flexible
„ Should be rapidly incorporated in tissues
„ Should be inert and should excite minimal tissue reaction
„ Should not be rejected in presence of infection
„ Should be noncarcinogenic
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What are the different types of mesh used for hernial repair?
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Polypropylene mesh
Vypro mesh (Polypropylene + Polyglycolic acid)
Dacron mesh
Polytetrafluroethylene (PTFE) mesh
Polyglycolic acid mesh (Vicryl mesh)
What are the different ways of mesh placement for repair of incisional hernia?
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Inlay graft: A sheet of mesh of the size of the defect is sutured to the margin of the defect,
the mesh bridging the hernial gap.
Onlay mesh: The hernial gap is apposed and a mesh is placed to reinforce the repaired defect.
The onlay mesh may be placed as:
• Underlay: The mesh is placed in the preperitoneal space after closure of the peritoneum
and the anterior sheath sutured in front of the mesh. The mesh is placed deep to the rectus
muscle.
• Overlay: The mesh may be placed as an onlay on the anterior surface of the rectus sheath
deep to the subcutaneous tissue after apposing the gap in the rectus sheath.
What is Rive Stoppa’s technique of mesh repair of incisional hernia?
The important steps in this technique of repair are:
The operation is done under general anesthesia
„ Old scar excised: Hernial sac dissected upto the margin of the myoaponeurotic edges of the
hernial opening
„ The sac is opened and its contents inspected. All bowel loops and omentum freed and
returned to the abdomen
„ The redundant sac is excised
„ The margin of the sac along with the peritoneum is closed with a running vicryl suture
„ A preperitoneal space is created between the rectus muscle anteriorly and the hernial sac
blended with the posterior rectus sheath posteriorly
„ A large mesh is placed in the preperitoneal space created extending 2–5 cm beyond the hernial
defect above, below and laterally upto the lateral edge of the rectus sheath
„ The prolene mesh is then fixed by polypropylene suture passing through full thickness of
abdominal wall and a stab wound is made in the skin and sutures are brought out and tied.
The mesh is thus fixed all around
„ The medial edge of the cut rectus sheath is sutured together by polypropylene suture
„ Excess skin is excised and skin closed by interrupted skin sutures keeping a suction drain in
preperitoneal space.
„
Can the mesh be placed in the preperitoneal space without fixation?
Yes. The mesh when placed in the preperitoneal space may be held in place by normal intraabdominal pressure and suture fixation may not be necessary.
What is Mayo’s repair?
Mayo’s repair involves tackling of hernial sac in the usual way. The repair is done by double
breasting of rectus sheath whereby one flap of rectus sheath overlaps the other.
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What is the drawback of Mayo’s repair?
Mayo’s repair with double breasting usually causes tension on the suture line and there is 50%
chance of recurrence following Mayo’s repair.
What are problems with intraperitoneal inlay mesh placement?
When mesh is placed intraperitoneally there is chance of adhesion and fistula formation.
How will you manage postoperatively?
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NG aspiration to prevent gastric distension
IV fluid till patient passes flatus
Urinary catheterization if there is difficulty in passing urine
Prophylactic antibiotics
Early ambulation is advisable.
What is the incidence of recurrence following repair of incisional hernia?
Most series incidence of recurrence following incisional hernia repair is 30–40%. With mesh
repair incidence of recurrence is less—about 10%.
What is the role of laparoscopic repair of incisional hernia?
Repair of incisional hernia has been tried laparoscopically. However, this is suitable only for
small reducible incisional hernias. The mesh is placed either in the preperitoneal space or
placed in the gap of hernia inside peritoneum. Intraperitoneal mesh placement is associated
with increased incidence of adhesion particularly if a polypropylene mesh is used. Placement
of polytetrafluoroethylene (PTFE) mesh cause least chance of adhesion.
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Abdomen
OUTLINE FOR WRITING AN ABDOMINAL CASE
A. HISTORY
1. Particulars of the Patient
2. Chief Complaints (with duration)
The usual chief complaints are:
• Pain abdomen
• Vomiting
• Sensation of fullness after meals
• Vomiting of blood
• Passage of black tarry stool
• Yellowish discoloration of eyes and urine
• Loss of appetite
• Weight loss
• Alteration of bowel habit
• Fever
• Swelling in abdomen.
3. History of Present Illness
• Detailed history about pain:
− Onset: Sudden/insidious
− Duration: Short-lived/persistent
− Initial site of pain
− Radiation/Shifting/Referral
− Character of pain: Dull-aching (chronic cholecystitis)/stabbing (pancreatitis)/colicky
(renal colic).
− Periodicity of pain: Appearance after a definite period of days/months
− Relation with food intake: before/after, i.e. on empty stomach or full stomach
− Relation with vomiting: Relief/aggravation
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− Aggravating and relieving factors: Food/vomiting/medicines
− Relation with defecation and micturition
Details of vomiting:
− Duration
− Frequency: The exact number
− Relationship with food intake
− Character of the act: Projectile or effortless
− Character of the vomitus
− Amount
− Color
− Taste
− Smell
− Contains any food taken more than 12 hours earlier
− Any blood in vomiting: Suggestive of upper gastrointestinal bleeding
− Any relation with pain
Details of blood vomiting (Hematemesis):
− Duration
− Number of bouts of blood vomiting
− Color
− Amount
− Whether associated with black tarry stool or not
Details of jaundice:
− Duration
− Onset
− Any prodromal symptom before onset of jaundice: Fever/arthralgia/generalized
weakness/loss of appetite/skin rash suggestive of viral-hepatitis
− Any history of biliary colic preceding the onset of jaundice
− Progress of jaundice
− Progressively increasing
− Diminishing after an initial deepening
− Waxing and waning
− Static
− Associated symptoms with jaundice:
» Pruritis: obstructive jaundice
» Clay colored stool: Obstructive jaundice
− History of fever with chill and rigor—cholangitis
− History of biliary colic
− History of black tarry stool with waxing and waning of jaundice
bowel habit
− What was the usual bowel habit before the illness started?
− What is the present bowel habit?
− What is the change in bowel habit?
− Any history of bleeding P/R or black tarry stool, passage of mucus in stool
− Any history of sensation of incomplete defecation
− Any history of tenesmus
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„
4.
5.
6.
7.
8.
Details of loss of weight and appetite: To mention exact figure of weight loss in kilogram and
the duration.
• Details of swelling in the abdomen
Duration
Site where first noticed
Size of of the swelling when first noticed
Progress of the swelling
• Details of urinary symptoms: Loin pain/mass in loin/frequency of micturition (diurnal
and nocturnal)/difficulty in passing urine/any burning during micturition/any urgency
or hesitancy/any history of passage of blood or pus in urine.
Past History
Personal History
Family History
Treatment History
Any History of Allergy
B. PHYSICAl ExAmInATIOn
1. General Survey
2. Local Examination of Abdomen
A. Inspection
(Patient supine with arms kept on sides and exposed from mid-chest to mid-thigh)
− Shape and contour of abdomen
» Normal/Scaphoid/Distended
− Umbilicus
» Position (normal position lies midway between the xiphisternum and the symphysis
pubis)
» Normally inverted/deeply inverted/flushed/everted.
− Skin over the abdomen
» Scar (If operative scar describe as upper midline/lower midline/upper paramedian/
right or left subcostal incision scar) (Fig. 3.1)
» Pigmentation
» Striae (white striae found in multiparous women is to be described as striae
albicans)
» Engorged vein (if engorgd veins are
present ascertain the direction of
blood flow in the engorged veins)
− Movements
» Respiratory movements whether all
region are moving normally with
respiration
» Visible peristalsis
» Pulsatile movements
Figure 3.1: Scars of different incision
− Visible swelling
» Site and extent
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» Size
» Shape
» Surface
» Margin
» Moving with respiration or not
» Rising test—whether swelling is parietal or intra-abdominal
− Hernial sites
» Any swelling
» Any expansile impulse on cough
− External genitalia
B. Palpation
• Superficial palpation:
» Temperature: Examine all the regions of the abdomen (Compare temperature of
abdomen with temperature of chest with the dorsum of finger)
» Any superficial tenderness.
» Feel of the abdomen:
- Soft and elastic feel is normal
- Muscle guard
- Rigidity
» Lump palpable: Details of the lump are to be described under deep palpation
• Deep palpation:
• Deep tender spots:Any tenderness over the following sites (Fig. 3.2):
1. Gastric point: A point in the midepigastrium.
2. Duodenal point: A point in the transpyloric plane
2. 5 cm to the right of midline.
3. Gallbladder point: A point at the junction of lateral
border of right rectus abdominis and the tip of
right 9th costal cartilage.
4. Mcburney’s point: A point in the right spinoumbilical line at the junction of medial two-thirds
and lateral one-third.
5. Amebic point: Point on left spinoumbilical line
corresponding to Mcburney’s point on right side.
6. Renal point: A point at the junction of lateral
border of erector spinae and the 12th rib (see Figs
4.2A and b, Page No. 187).
• Murphy’s sign:
− Found positive in patient with acute cholecystitis
− Usually not demonstrable in chronic cholecystitis.
Figure 3.2: Deep tender spots. For 1,
2, 3, 4, 5 see text
• Palpation of organs:
− Liver
− Spleen
− Kidneys
− Gallbladder is not normally palpable.
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• If gallbladder is distended or there is a mass in relation to gallbladder the gallbladder may,
be palpable—the detail of gallbladder examination is to be recorded
• Stomach is normally not palpable. In cases with gastric outlet obstruction, the distended
stomach may be palpable in epigastrium, which disappears with passage of peristaltic
waves from left to right
• Normal pancreas is also not palpable
• Palpation of any other lump:
− Position and extent in relation to abdominal regions
− Shape
− Size
− Surface
− Margin
− Consistency
− Mobility: with respiration
− Mobility from side to side, up and down
− Fixity to skin or underlying structure
− Rising test to confirm intra-abdominal or parietal swelling
− Knee elbow position and examine the swelling again to decide whether swelling is
intraperitoneal or retroperitoneal
• However, this position is very inconvenient for the patient, now this test is usually avoided.
• Hernial sites
• External genitalia.
C. Percussion
− Normal percussion note over the abdomen.
− Shifting dullness
− Fluid thrill
− Succusion splash over stomach
− Upper border of liver dullness
− Upper border of splenic dullness
− Percussion over any abdominal lump palpable.
D. Auscultation
− Peristaltic sound
− bruit
− Venous hum
− Any added sound.
E. Ausculto-Percussion
− In case of gastric outlet obstruction to delineate the greater curvature of the stomach.
F. Per Rectal Examination
G. Per Vaginal Examination
3. Systemic Examination
Describe all system.
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C. SUmmARY OF THE CASE
D. PROVISIOnAl DIAGnOSIS
E. InVESTIGATIOnS SUGGESTED
F. DIFFEREnTIAl DIAGnOSIS
How far you should expose for an abdominal examination?
Patient lying supine in bed with exposure from the mid-thigh to just above the xiphisternal junction.
How do you divide the abdomen into different quadrants?
For clinical examination abdomen may be divided
into four quadrants by drawing a vertical line in the
midline and a horizontal line at right angle to the
vertical line crossing at the umbilicus (Fig. 3.3).
„ Right upper quadrant
„ Right lower quadrant
„ Left upper quadrant
„ Left lower quadrant
How do you divide abdomen into different
regions?
For clinical examination abdomen may be divided
into nine regions. Two horizontal planes and two
vertical planes divide the abdomen into nine regions.
The upper horizontal plane is the transpyloric
plane (TPP), which is drawn midway between the
Figure 3.3: Quadrants of abdomen
suprasternal notch and the symphysis pubis. This
also corresponds to a plane drawn one hands
breadth (of patient) below the xiphisternal junction
and passes through the tip of ninth costal cartilages
on either side.
The lower horizontal plane is the trans tubercular
plane (TTP), which is drawn by joining the tubercle
of the iliac crest on either side. The tubercle of the
iliac crest is found out by palpating backward from
the anterior superior iliac spine where the tubercle
is palpated in the iliac crest and usually lies 5 cm
behind the anterior superior iliac spine.
The vertical planes are drawn on either side
by joining the midclavicular point and the
midinguinal point (Fig. 3.4).
The nine regions are:
1. Right hypochondrium
Figure 3.4: Region of abdomen. e.g. TPP:
2. Epigastrium
Transpyloric plane; TTP: Transtubercular plane;
3. Left hypochondrium
MCP: Midclavicular plane
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4.
5.
6.
7.
8.
9.
Right lumbar
Umbilical
Left lumbar
Right iliac fossa
Hypogastrium
Left iliac fossa
How will you ascertain position of the umbilicus?
The normal umbilicus is situated in the midline midway between the xiphisternal junction and
the symphysis pubis.
How will you look for peristaltic movements in the abdomen?
Gross peristaltic waves may be seen on simple
inspection.
Sit by the side of the patient and look
tangentially. Ask the patient to take a deep breath
and hold the breath at the end of expiration so
long he can. Observe for any visible peristaltic
wave. If peristaltic waves are seen describe the
character of the peristaltic wave (Fig. 3.5).
Gastric peristaltic waves are large peristaltic
waves seen in the epigastrium, umbilical or as
low as hypogastrium moving from left to right
(Figs 3.6A and b).
Small intestinal peristaltic waves are seen in
central abdomen showing in step ladder pattern.
Peristaltic waves in transverse colon may be
seen in the right hypochondrium, epigastrium,
umbilical and left hypochondriac region moving
from right to left.
A
Figure 3.5: Sit by the side of the patient and look
tangentially. Ask the patient to take a deep breath
and hold the breath at the end of expiration so
long he can. This should be observed for about
30 secs to 1 minute
B
Figures 3.6A and B: Visible gastric peristalsis: Large peristaltic waves seen moving from left to
right
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How will you look for pulsation in abdomen?
Patient lies supine. The examiner looks tangentially from the side to look for any pulsation in the
abdomen (Fig. 3.5). The patient is asked to hold the breath at the end of expiration to obscure
the respiratory movement so that pulsation, if present, is seen well.
How will you ascertain whether the pulsation is transmitted or expansile?
This is done by palpation. The index and the middle fingers of both hands are placed close to
each other on the epigastrium on either side of the midline.
In case of transmitted pulsation all the fingers are simply lifted up.
In case of expansile pulsation the fingers of two hands are lifted up and are also separated
(see Figs 1.31A to C, Page No. 32).
How will you palpate the abdomen?
The palpation is done with the patient supine,
with the arms by the side of the patient and
asking the patient to take deep breathing with the
mouth open. The abdominal muscle gets relaxed
during expiration and in the pause between
inspiration and expiration. The forearm of the
clinician should be kept horizontally at the same
level of the abdomen. Palpate with a warm hand
particularly during winter. If hands are cooler
rub two hands together to make the hand warm
before palpating the abdomen (Fig. 3.7).
The palpation is best done with the flexor
surfaces of the fingers and not with the tip of
the fingers.
Figure 3.7: Palpation of abdomen
How will you ascertain temperature in abdomen?
This is done by palpating with the back of the fingers in all the quadrants of the abdomen. The
temperature of the abdomen is compared with the temperature of the chest or the other covered
parts of the body (Figs 3.8A to C).
A
B
Figures 3.8A and B: Ascertaining the temperature of the abdomen with dorsal aspect of the
fingers
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Figure 3.8C: Ascertaining the
temperature of the abdomen
When you find engorged veins in the abdominal wall, how will you ascertain the
flow?
In normal persons the flow in the veins in abdominal wall is away from the umbilicus both
above and below the umbilicus.
A
B
C
D
Figures 3.9A to D: Ascertaining the direction of flow in engorged veins in abdominal wall
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Engorged veins in the abdominal wall may be due to:
Portal hypertension
„ Inferior vena cava obstruction
„ Superior vena cava obstruction.
The direction of flow may be ascertained by palpation. Empty a segment of vein above the
umbilicus by milking with index finger of both hands (Figs 3.9b and C).
Remove the lower finger: If the vein remains collapsed, the flow is from above downward.
The veins fill quickly, if the flow is from below upward (Fig. 3.9D).
Empty the vein segment in the same way. Remove the upper finger: The vein remains collapsed
if the flow is from below upward. The vein fills quickly, if the flow is from above downward.
The same procedure is repeated by emptying a segment of vein below the umbilicus.
• In portal hypertension the flow will be away from the umbilicus in both segments of the
vein below and above the umbilicus.
• In inferior vena cava obstruction, the flow will be from below to up in both segments of the vein.
• In superior vena cava obstruction, the flow will be from above to down in both segments
of the vein.
„
How will you assess feel of the abdomen?
The feel of the abdomen is assessed during superficial palpation. The normal feel of the abdomen
is soft and elastic. As the abdomen is pressed it yields and on release the abdomen recoils back
to original position.
In perforative peritonitis there may be muscle guard or rigidity. In presence of muscle guard,
there is resistance when trying to yield the abdomen. In case of rigidity the abdomen cannot
be yielded at all.
This can be better appreciated by palpating with two hands one placed over the other. The
lower hand is pressed by the upper hand gently and the feel of the abdomen is assessed (Figs
3.10A and b).
A
B
Figures 3.10A and B: Superficial palpation with two hands
How will you palpate liver?
Patient supine with legs flexed at the hips and knees.
Place the hand flat on the abdomen parallel to the right costal margin with the fingers pointing
upward and placed lateral to the rectus muscle and the fingertips are placed to lie parallel to
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the edge of the liver. Start palpating from the right iliac fossa and move upward. Ask the patient
to take deep breaths with open mouth. With each expiration the hand is moved nearer to the
right costal margin. If the liver is enlarged the margin of the liver will ride over the tip of the
fingers. Palpate the margin of the liver—sharp, rounded, firm, smooth or irregular. Using the
palmar aspect of the fingertips the margin and the surface of the liver is palpated by changing
the position of the fingertips along the surface and margin of the liver (Figs 3.11A and b).
Alternatively the enlarged liver border may be palpated with the radial border of the index
finger. Start palpating from right iliac fossa toward the right costal margin keeping the radial
border of index finger parallel to the right costal margin. Describe the enlargement as . . . cm.
below the right costal margin (Figs 3.11C and D).
Figure 3.11A: Start palpation at right iliac fossa
using the tip of the fingers
Figure 3.11B: Palpate upwards towards the
costal margin using the tip of fingers
Figure 3.11C: Start palpation at right iliac fossa
using the radial border of index finger
Figure 3.11D: Palpate upwards towards the
right costal margin using the radial border of
the index finger
How will you delineate the upper border of liver?
Start percussing in the right midclavicular line at 2nd intercostal space, and if, clear resonant
note is obtained percuss downward until a dull note is obtained. This marks the upper border
of liver dullness (Fig. 3.12).
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B—22 Fr. Three way Foley’s balloon catheter with a balloon capacity of 30–50 mL
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1–Thickness of the sutures; 2–Code number; 3–Type of suture;
4–Length of the suture; 5–Name of manufacturer; 6–Lot number/
batch number; 7–Description of the needle; 8–Manufacturing
licence number, manufacturing date and expiry date; 9–Price of
the foil pack.
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Section 9 operative Surgery
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22
Operative Surgery
StepS of LichtenStein herniopLaSty
Describe the steps of Lichtenstein hernioplasty.
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Anesthesia: Spinal anesthesia.
Position of the patient: Supine.
Antiseptic cleaning and draping.
Incision: inguinal incision. Starting medially at the pubic tubercle and laterally extending
beyond the deep inguinal ring 2 cm above and parallel to the inguinal ligament.
The two layers of subcutaneous tissue (Superficial fatty layer—fascia of camper and the
deeper membranous layer—fascia of Scarpa) are incised in the same line as skin by using
diathermy. While incising the subcutaneous tissue the superficial epigastric vessels are
coagulated and cut. Medially, superficial external pudendal vessels and laterally superficial
circumflex iliac vessels may come in the field and needs coagulation and division.
Exposure of the inguinal canal: The external oblique aponeurosis is exposed deep to the
subcutaneous tissue. A nick is made in the external oblique aponeurosis. The cut margins
are picked up in between two pairs of hemostatic forceps and external oblique aponeurosis
is incised medially dividing the superficial inguinal ring and laterally the external oblique
aponeurosis is incised beyond the deep inguinal ring.
The upper flap of external oblique aponeurosis is dissected upwards and the conjoint
tendon is exposed. The lower flap of external oblique aponeurosis is dissected downwards
to expose the shining inguinal ligament from pubic tubercle medially to laterally beyond the
deep inguinal ring.
Dissection of hernial sac: The spermatic cord along with the hernial sac is dissected in between
fingers using a gauze piece and lifted up from the fascia transversalis.
in case of indirect inguinal hernia the hernial sac lies anterolateral to the cord covered by
the cremasteric muscle and the internal spermatic fascia. in case of direct inguinal hernia, the
hernial sac lies posteromedial to the cord structures covered by the internal spermatic fascia.
The cremasteric muscle and fascia is incised and deep to this internal spermatic fascia is
incised. The cord structures are splayed inbetween fingers and the hernial sac is identified
by shiny white margin. The margin of the hernial sac is picked up by a pair of hemostatic
forceps and the hernial sac is dissected by sharp dissection from the cord structures taking
care not to damage the vas deferens and the testicular vessels.
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The hernial sac is dissected from the fundus to the neck of the sac. The neck of the sac is
identified by:
• Most constricted part of the sac
• There is a collar of fat pad around the neck
• inferior epigastric vessels are seen medial to the neck of the sac
„ opening of hernial sac and reduction of contents: The hernial sac is opened at the fundus
and the interior of the sac is inspected to exclude a sliding component.
(in case of complete inguinal hernia when the fundus of the hernial sac lies at the bottom of the
scrotum, the whole sac need not be dissected. The sac is dissected from the cord structures in
the inguinal canal and transected at the middle and the distal part of the sac is left as such. The
proximal part of the sac is then dissected up to the neck of the sac). The contents of the hernia
are reduced into the peritoneal cavity.
Herniotomy: The hernial sac is twisted and the neck of the sac is transfixed and the distal
sac is excised.
„ Reinforcement of the posterior wall by placement of a polypropylene mesh: A standard 15 cm
× 7.5 cm sized mesh is required for inguinal hernia. The lateral end of the mesh is split at the
lower 1/3rd and upper 2/3rd junction to accommodate the spermatic cord. The lower margin
of the mesh is fixed to the inguinal ligament starting medially at the fascia over the pubic
tubercle extending laterally along the inguinal ligament beyond the deep inguinal ring using
2-0 polypropylene suture.The mesh is medially sutured to the lateral border of the rectus
sheath. The mesh is fixed above to the conjoint tendon using 2-0 polypropylene sutures.The
split lateral end of the mesh is resutured beyond the spermatic cord.
„ Closure of external oblique aponeurosis: The external oblique aponeurosis is sutured using
runing 1-0 polyproylene suture creating a new superficial inguinal ring.
Closure of sucutaneous tissue and skin: The skin and subcutaneous tissue is apposed using
interrupted sutures with monofilament polyamide. Alternatively the skin and subcutaneous
tissue my be apposed using subcuticular sutures with 3-0 polyglactin.
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StepS of herniotomy for congenitaL hernia
Describe the steps of herniotomy for congenital hernia?
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Simple herniotomy is required
Anesthesia: operation is usually done under general anesthesia.
Skin Incision: A transverse skin incision is made over the groin overlying the deep inguinal
ring parallel to the inguinal ligament.The skin and superficial fascia are incised (Fig. 22.1A).
Incising the external oblique aponeurosis: The external oblique aponeurosis is incised in the
same line (Figs 22.1B and c).
Dissection of hernial sac: The cord with its covering and the hernial sac is isolated and
dissected free from the fascia transversalis. The coverings of the cord—external spermatic
fascia, the cremaster a and internal spermatic fascia are gently teased open just distal
to superficial inguinal ring to dissect the hernial sac. The sac is dissected from cord
structures (Figs 22.1D and e)
Opening of sac and reduction of the contents of sac: The sac is opened and contents of the sac
is milked into the peritoneal cavity.
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D
F
figures 22.1a to f: Steps of herniotomy
Transection of the sac: The sac is transected distal to the superficial inguinal ring and the
distal part of the sac is left open as such ensuring that there is no bleeding from the distal
stump of the sac.
„ Ligation of the neck of the sac: The proximal stump of the sac is held up by a hemostatic forcep
and dissected proximally up to the internal inguinal ring. By rotating the clamp, the sac is
twisted and ligated by transfixation at the neck and the redundant sac excised (Fig. 22.1F).
„ Closure: The cord structures are covered by closing the covering of the sac.
the external oblique aponeurosis closed with absorbable suture and skin apposed by
subcuticular suture (Fig. 22.1F).
„
What is the difference in technique in older children?
in child more than 2 years of age, the external and internal ring become widely separated so
that direct dissection is no longer possible.
in these cases, skin incision is made slightly laterally over the internal inguinal ring. The skin
and superficial fascia is incised. The external oblique aponeurosis is incised and inguinal canal
exposed—the external ring is not opened.
The cremesteric fascia and internal spermatic fascia is incised and sac dissected free from
the cord structures. The sac is clamped across and the distal part of the sac transected and kept
open. The proximal part of the sac is dissected up to the deep ring and tackled as described above.
StepS of tapp operation
Describe the steps of TAPP operation (Fig. 22.2).
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Anesthesia: General anesthesia with endotracheal intubation.
Position of the patient: Initially supine. After creation of pneumoperitoneum patient turned
to Trendelenburg position with slight elevation of the side to be operated. Monitor kept at the
leg end towards the side of hernia. Surgeon stands on the contralateral side. Assistant stands
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Section 9 Operative Surgery
figure 22.2: Transabdominal preperitoneal laparoscopic hernia repair (TAPP)
„
opposite to the surgeon. Bilateral hernia can be operated from either side.Patient’s hand kept
by the side of trunk and patient well strapped to the table.
Pateint should be catheterized.
Creation of pneumoperitoneum: A 10 mm subumbilical incision is made. And a Veress needle
inserted into the peritoneal cavity. After confirming the position of the Veress needle in the
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Operative Surgery
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peritoneal cavity the Veress needle is connected to the automatic electronic insufflator set to
12 mm Hg intra-abdominal pressure and intial flow rate to 1 liter/min. Pneumoperitoneum
achieved with insufflation of carbon dioxide.
Placement of subumbilical ports: A 10 mm subumbilical port is inserted with gentle rocking
movement taking care not to injure the intrabdominal organ or vessels.
Placement of subsequent ports: Two more 5 mm port is inserted in right and left lower quadrant
of the abdomen slightly below the umbilicus lateral to the rectus abdominis taking care not to
injure the inferior epigastric vessels.
• Inspection of pelvic anatomy: Inspect the bladder, median umbilical fold (containing the
obliterated urachus), medial umbilical fold (containing the obliterated umbilical artery),
lateral umbilical fold (containing the inferior epigastric artery).
The indirect hernial sac descends through the deep inguinal ring which is lateral to the
lateral umbilcal fold.The direct hernial sac descends through the Hesselbach’s triangle, which
lies medial to the lateral umbilical fold. The triangle of Doom is the area bounded.
− Laterally by the testicular vessels
− Medially by the vas deferens
− Above by the line joining the vas deferens and the testicular vessels.
The external iliac vessels lie in this triangle.
Division of peritoneum: The hernial contents are reduced. The peritoneum is picked up by a
grasper about 2 cm medial to the anterior superior iliac spine about 3–4 cm above the inguinal
ligament. The peritoneum is incised at this level by an endoscissor. This incision is then carried
medially above the hernial defect up to the medial umbilical fold.
Downward reflection of peritoneum and dissection of preperitoneal space: The incised
peritoneum is reflected downwards by sharp and blunt dissection and the preperitoneal space
is delineated. Medially the dissection is done up to the symphysis pubis. Below the dissection is
done up to the obturator foramen. Laterally the dissection is done up to the iliopsoas muscle.
Following the Cooper’s ligament the deep,inguinal ring is identified.
Dissection of hernial sac: In case of direct hernia, the hernial sac is dissected while lifting the
peritoneal flap. In case of indirect inguinal hernia the hernial sac lies anterior to the cord
structure. Using two grasping forceps the hernial sac is dissected off from the cord structures
taking care not to injure the cord structures. The hernial sac is dissected up to the fundus distally
and the proximal limit of dissection is up to the point where the vas deferens and the testicular
vessels diverges. If the hernial sac is complete, the hernial sac is transected at the middle and
the distal sac kept laid open.
Placement and fixation of mesh in preperitoneal space: A polypropylene mesh size of 12
cm × 15 cm is ideal for inguinal hernia. The mesh is rolled and a suture is placed in the
middle of the rolled mesh which helps in better placement and unrolling. The rolled mesh
is inserted into the peritoneal cavity through the 10 mm trocar. The mesh is placed in the
preperitoneal space. Medially the mesh is placed up to the symphysis pubis and laterally 2
cm medial to the anterior superior iliac spine. Below the mesh is placed along the Cooper’s
ligament and lateral to the deep ring along the inguinal ligament. The mesh is unrolled
and spread to cover the deep inguinal ring and the Hesselbach’s triangle. The mesh is fixed
by tacker to the Cooper’s ligament medially, above to the anterior abdominal wall. Care
is taken not to place any tacker over the triangle Doom and the triangle of pain (lateral to
the testicular vessels).
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Section 9 Operative Surgery
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Repositioning of peritoneal flap and closure of peritoneal defect: The peritoneal edge is grasped
and returned to its normal postion. The peritoneal defect is apposed by intracorporeal suturing
or by using tackers to avoid contact of mesh with the intra-abdominal viscera.
Closure of port sites: 10 mm port site—linea alba apposed by 1-0 polyglactin sutures.
Skin apposed with monofilament polyamide sutures.
StepS of tep operation for inguinaL hernia
Describe the steps of TEP operation for inguinal hernia.
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Anesthesia—General anesthesia with endotracheal intubation.
Position of patient: Same as TAPP operation.
Placement of Subumbilical port: An infraumbilical 1.5 cm incision is made. The subcutaneous
tissue is dissected and the anterior rectus sheath is exposed. The anterior rectus sheath is incised
horizontally. The rectus muscle is dissected from the linea alba and retracted laterally.
Creation of preperitoneal space: A balloon trocar is inserted into the space between the rectus
abdominis muscle anteriorly and the posterior rectus sheath posteriorly. The ballon is inflated
by air and the preperitoneal space is created.
Insertion of 11 mm trocar: The balloon trocar is removed and a 11 mm trocar is introduced
into the preperitoneal space thus created and CO2 gas is insufflated through the cannula and
the preperitoneal space is created further.
Insertion of telescope: A 10 mm telescope attached to the light source and camera is introduced
through the subumbilical trocar. Further creation of the preperitoneal space may be achieved
by blunt dissection using the telescope.
Placement of subsequent ports: Placement of 2 more 5 mm ports is required. One 5 mm port
is inserted in the midline under direct vision about 1 cm above the symphysis pubis. Another
5 mm port is inserted in the midline midway between the suprapubic and subumbilical trocar.
Patient is placed in the Trendelenburgh position with the side of the hernia being tilted up.
Dissection of the hernial sac: The Cooper’s ligament is identified lateral to the symphysis pubis
and cleared of any preperitoneal fat.
If direct hernia is present, the sac will be readily identified during this dissection and reduced.
Dissection of indirect hernial sac: The lateral dissection is done by using a Maryland grasper.
The indirect hernial sac lies lateral to the inferior epigastric vessels and anterolateral to the cord
structures. The hernial sac is dissected off from the cord structures taking care not to injure the
testicular vessels and the vas deferens.
Parietalisation of the cord structures: For ease of placement of the mesh, the cord structures
are dissected from the preperitoneal loose areolar tissue till the point of divergence of the vas
deferens and the testicular vessels.
During dissection of the preperitoneal space, if the peritoneum is opened inadvertently there
will be loss of preperitoneal space due to creation of pneumoperitoneum.
In this situation the option will be to:
• Close the peritoneal rent
• Insert a Veress needle into the peritoneal cavity for deflation or
• Convert this to a TAPP procedure.
Placement and fixation of the mesh—same as TAPP procedure.
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Desufflation of the peritoneal space by a slow and controlled manner and the trocars are
removed.
Closure at 11 mm port site anterior rectus sheath apposed by 2-0 vicryl suture and skin with
monofilament polyamide suture.
anatomy of aBDominaL inciSionS
What is the technique of an upper midline abdominal incision?
Midline incision allows rapid access with minimal blood loss and is an ideal incision for
emergency exploratory laparotomy.
Skin and subcutaneous tissue: The skin and subcutaneous tissue is incised in the same line
extending from below the xiphoid to just above the umbilicus. if required the incision may be
extended below around the umbilicus.
Incising linea alba: once the skin and subcutaneous tissues are incised the linea alba is exposed.
The linea alba is identified by the interdigitating fibers. The linea alba is incised with a knife in
the same line for the full length of the skin incision.
Incising surgical peritoneum: Pick up the peritoneum between two pairs of hemostatic forceps and
confirm by palpation that no bowel is adherent. nick the peritoneum in between the hemostatic
forceps. Hold the cut margins of the peritoneum with hemostatic forceps. insert two fingers
beneath the cut margin of the peritoneum and divide the peritoneum with scissors up to the full
length of the skin incision. While incising above cut on one side of the falciform ligament. care
must be taken to look for any adherent viscera to avoid injury while incising the peritoneum.
in lower midline incision, the linea alba is more wide. care must be taken while incising the
peritoneum toward the lower end to avoid injury to the urinary bladder.
Closure of midline incision: The peritoneum and the linea alba is apposed in single layer with
running 0 or 1 polypropylene suture. The bites should be taken at 1 cm interval and 1 cm from
the edge of the cut margin.
Skin is closed with interrupted monofilament polyamide suture or silk sutures.
Why linea alba and peritoneum are closed in one layer?
Mass closure of peritoneum and linea alba is as effective as a layered closure and it is quicker.
What is the length of suture material required for closing an incision?
The stitches should be applied at 1 cm interval and 1 cm from the edge of the cut margin.
Using this technique, the suture required is 4 times the length of the incision. This is called
Jenkins’ rule.
What is the anatomy of a paramedian incision?
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Skin and subcutaneous tissue: Skin incision about 2.5 cm from the midline. Subcutaneous
tissue incised in the same line.
Anterior rectus sheath: once the skin and subcutaneous tissues are incised the anterior rectus
sheath is exposed. incise the anterior rectus sheath in the same line as skin incision.
Separating the rectus abdominis muscle: A number of hemostatic forceps are applied on the
medial cut margins of the anterior rectus sheath and lifted up. The rectus abdominis muscle
is adherent to the anterior rectus sheath at the tendinous intersections. With sharp dissection
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Section 9 Operative Surgery
with knife, these tendinous intersections are separated from the medial cut margin of the
anterior rectus sheath.
„ Retraction of the rectus abdominis muscle: once the tendinous intersections are separated
from the medial cut margins of the rectus sheath the rectus abdominis muscle is retracted
laterally and the posterior rectus sheath is exposed.
„ Incising the posterior rectus sheath: The posterior rectus sheath is a composite layer comprising
of posterior lamella of the internal oblique aponeurosis, transversus abdominis (muscular
fibers at the upper third and the aponeurotic fibers at the middle third), fascia transversalis,
extraperitoneal fatty tissue and the parietal peritoneum. in the lower third, the posterior
rectus sheath is deficient.
The posterior rectus sheath is lifted up by two pairs of hemostatic forceps and the lifted up
posterior rectus sheath is palpated in between fingers to confirm that no gut is lifted up. A nick
is made in the peritoneum. The cut margins of the peritoneum is held by hemostatic forceps
and the peritoneum incision extended up and down up to the full length of the skin incision.
Closure of paramedian incision: closure is done in three layers.
„ The peritoneum with posterior rectus sheath is closed with running sutures of 0 or polyglactin
or polydioxanone.
„ The anterior rectus sheath with running sutures of 0 or 1 polyglactin or polydioxanone.
„ Skin closed with interrupted monofilament polyamide suture.
What is the anatomy of McBurney’s gridiron incision?
Skin incision: An oblique skin incision of about 5–7 cm length at right angle to the right
spinoumbilical line passing through the McBurneys’ point as the center point.
(McBurneys’ point lies at the junction of medial two thirds and lateral one third of the right
spinoumbilical line). The subcutaneous tissue (fascia of camper and fascia of Scarpa) are
incised in the same line.
„ External oblique aponeurosis: A nick is made in the external oblique aponeurosis and the
external oblique aponeurosis is incised in the same line along the direction of its fibers.
„ Internal oblique and transversus abdominis muscle: Both internal oblique and transversus
abdominis muscle is split along the direction of their fibers. The closed end of a Mayo’s
scissors is thrushed through both internal oblique and transversus abdominis muscle
and the blades are opened. The split is then widened by stretching it between two fore
fingers. two Langenbach’s retractors are then inserted to retract the muscles medially and
laterally.
„ Peritoneum: The surgical peritoneum comprising of fascia transversalis, extraperitoneal
fatty tissue and the parietal peritoneum is then picked up by two pairs of hemostatic
forceps. Palpate the peritoneum to exclude that nothing else is picked up. A nick is made
in the peritoneum and the two incised ends are picked up with hemostatic forceps and the
peritoneum incision extended up and down up to the full length of the skin incision.
Closure: closure is done in four layers.
„ Surgical peritoneum closed with 0 or 2-0 polyglactin suture.
„ internal oblique and transversus abdominis muscles are approximated with interrupted 2-0
polyglactin sutures.
„ external oblique aponeurosis apposed with running 2-0 polyglactin sutures.
„ Skin approximated with interrupted monofilament polyamide sutures.
„
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What is Lanz incision?
The Lanz incision is identical to McBurney’s incision but here the skin incision is transverse
running along the McBurney’s point.
Apart from the skin incision, the rest of the approach is like McBurney’s incision.
What is the anatomy of Kocher’s subcostal incision?
Skin incision: About 15 cm long incision begins in the midline below the xiphoid process
and runs downward and laterally 2.5 cm below and parallel to the right costal margin. The
subcutaneous tissue is incised in the same line.
„ Anterior rectus sheath and the external oblique aponeurosis and muscle: once the subcutaneous tissues are incised the anterior rectus is exposed on the medial half of the incision
and on the lateral half of the incision, the external oblique aponeurosis and the muscle is
exposed. The anterior rectus sheath and the external oblique aponeurosis and the muscle
is incised in the same line.
„ Rectus abdominis muscle and the internal oblique muscle: After incising the anterior rectus
sheath and the external oblique, the rectus abdominis muscle is exposed on the medial
half of the incision and the internal oblique aponeurosis and the muscle is exposed
on the lateral half of the incision. the rectus abdominis muscle is divided across the
direction of its fibers. The internal oblique aponeurosis and the muscle is divided along
the direction of its fibers.
„ Posterior rectus sheath: The posterior rectus sheath, comprising of posterior lamella of internal
oblique, transversus abdominis muscular fibers, fascia transversalis, extraperitoneal fatty
tissue and the parietal peritoneum is exposed next. The posterior rectus sheath is picked up
by two pairs of hemostatic forceps and a nick is made in the sheath. The cut margins are then
held up by hemostatic forceps and the incision on the posterior rectus sheath is extended
medially up to the midline and laterally up to the lateral extent of the skin incision.
The 8th, 9th and 10th intercostal nerves are seen running between the internal oblique and
the transversus abdominis muscle.
„
Closure: closure is done in three layers.
• The peritoneum with the posterior rectus sheath is apposed with running 1-0 polyglactin
sutures. Laterally this layer also takes the internal oblique and the transversus abdominis
muscle.
• next the anterior rectus sheath and the external oblique aponeurosis and the muscle is
approximated with running 1-0 polyglactin sutures.
• Skin approximated with interrupted monofilament polyamide sutures.
What is the anatomy of transverse abdominal incision?
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Skin: The skin and the subcutaneous tissue is incised transversely at the desired level.
Anterior rectus sheath: The anterior rectus sheath is incised in the same line as the skin.
Rectus abdominis muscle: There are two ways of approach through the rectus abdominis
muscle.
Transverse division of transversus abdominis muscle: Both the rectus abdominis muscles
are divided transversely and the posterior rectus sheath is exposed. This is suitable in upper
abdominal incision, where there are tendinous intersections where the recti are adherent to
the anterior rectus sheath. The recti muscles do not retract.
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Section 9 Operative Surgery
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Vertical separation of the recti: This is suitable in lower abdominal incision where the recti
does not have tendinous intersections. The anterior rectus sheath is dissected upward and
downward from the rectus abdominis muscle by sharp dissection. The two recti muscles are
then widely separated by blunt dissection and stretching in between the fingers.
Posterior rectus sheath or the peritoneum: in upper abdominal incision, the posterior rectus
sheath is exposed and incised transversely.
in lower abdominal incision after vertical separation of the recti the surgical peritoneum
(comprising of parietal peritoneum, extraperitoneal fatty tissue with the fascia transversalis)
are exposed and are incised vertically.
Closure of transverse incision: closure is done in layers.
• Posterior rectus sheath or peritoneum, extraperitoneal fatty tissue with fascia
transversalis—Approximated with running 1-0 polyglactin sutures. The divided recti
muscles do not require any suture.
• Anterior rectus sheath: Approximated with running 1-0 polyglactin sutures.
• Skin approximated with interrupted stitches with monofilament polyamide sutures.
StepS of D2 gaStrectomy for gaStric cancer
Describe the steps of D2 gastrectomy for gastric cancer.
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Anesthesia: General anesthesia with endotracheal intubation.
Position of the patient: Supine.
Antiseptic dressing and draping.
Incision: Midline incision starting below the xiphisternal junction to halfway between the
umbilicus and the symphysis pubis. The skin and subcutaneous tissue are incised in the
same line.
Division of linea alba: The linea alba is incised in the same line.
Division of surgical peritoneum: The fascia transversalis, extraperitoneal fatty tissue and the
parietal peritoneum are lifted up in between two pairs of hemostatic forceps and a nick is
made in the peritoneum and the opening in the peritoneum is then extended in the same
line.
Assess for distant spread liver metastasis, peritoneal deposits, omental deposits, pelvic
deposits and presence of ascites. in presence of distant metastasis, curative resection is not
attempted. if resectable, resection of the primary growth offers best palliation.
Assessment of lymph node status: Assess the site of involvement and number of lymph nodes
involved whether mobile or fixed. Gross lymph node involvement also precludes a curative
resection.
Exploratory laparotomy: Assess the local growth, the location, size and depth of invasion,
involvement of adjacent structures. Gross invasion to adjacent structures precludes a curative
resection. involvement of transverse mesocolon and tail of pancreas may be managed with
resection of a segment of colon and tail of pancreas.
Division of greater omentum and anterior layer of transverse mesocolon: The procedure begins
with division of greater omentum from the transverse colon by sharp dissection through a
bloodless plane. Some small blood vessels may be controlled with diathermy.
The greater omentum is cleared from the whole of transverse colon. The anterior layer of
transverse mesocolon is incised and stripped up up to the anterior surface of the pancreas.
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Division of right gastroepiploic vessels: As the greater curvature is lifted up along with the
greater omentum the right gastroepiploic vessels are seen entering the pyloric end of greater
curvature. The right gastroepiploic vessels are divided in between ligatures.
Division of lesser omentum (gastrohepatic ligament): The gastrohepatic omentum is dissected
and divided close to the porta hepatis and the right gastric artery is ligated and divided close
to its origin from the hepatic artery. The omentum to the right of ascending part (lst part) of
the duodenum is divided and the duodenum is kocherised.
Division of duodenum: once the right gastric artery and right gastroepiploic arteries are
tied the first part of the duodenum is dissected all around. two pairs of soft clamps are then
applied and the stomach divided just beyond the pylorus.
The subpyloric and the suprapyloric lymph nodes are also included with the specimen.
Closure of duodenal stump: The duodenal stump is closed in 2 layers—1st layer with through
and through continuous 3-0 polyglactin sutures and a second layer of inverting suture with
3-0 mersilk.
Alternatively the duodenum may be divided with a linear cutter which cuts the duodenum
and staples both the cut ends.
The duodenal stump may also be closed with a linear stapler.
Dissection of lymph nodes: The divided stomach is lifted up and the lymph nodes in the gastric
bed are dissected. The lymph nodes along the hepatic artery are dissected up to their origin.
The lymph nodes along the splenic artery are dissected up to the hilum of spleen. The left
gastric artery is divided at its origin from the celiac trunk and the lymph nodes around the
left gastric artery are resected en bloc.
Resection of the stomach: two pairs of gastric occlusion clamps are applied obliquely.
on the lesser curvature side the line of resection is just below the cardia. on the greater
curvature side the line of resection is just below the last short gastric vessels. it should be
at least 5 cm proximal to the proximal margin of the tumor. The stomach is then transected
between the two pairs of occlusion clamps.
Alternatively, the stomach may be divided by using GiA linear cutter.
Gastrojejunal anastomosis: The proximal loop of the jejunum is brought up through a rent in
the transverse mesocolon and placed alongside the transected stomach. Afferent loop may
be brought to the lesser curvature and efferent loop to the greater curvature side. two pairs of
Babcock’s tissue forceps are applied to the jejunal loop and a light intestinal occlusion clamp
is applied to the jejunum and holding the two clamps together, the stomach and jejunum
are kept side by side.
Alternatively a Roux-en-Y gastrojejunal anastomosis may be done.
A continuous seromuscular suture is applied between the stomach and the jejunum with
3-0 mersilk.
to create a valvular anastomosis the upper part of the cut end of the stomach is closed with
through and through sutures using 3-0 polyglactin sutures leaving 5 cm area open. The jejunum
is incised for 5 cm and is anastomosed with the remaining cut end of the stomach. The posterior
through and through and anterior through sutures are applied with continuous 3-0 polyglactin
suture. The anterior seromuscular layer is applied with continuous 3-0 mersilk suture.
Fixation of stomach to the mesocolon rent: The anastomosis is brought down through the
rent in the mesocolon. The margins of the rent is sutured to the stomach wall by interrupted
stitches.
Drainage: A 26 Fr. tube abdominal drain is kept in hepatorenal pouch of Morrison close to
the duodenal stump.
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Closure: Pertioneum and linea alba closed in single layer with continuous no. l polypropylene
suture.
Skin closed with interrupted monofilament polyamide suture.
StepS of truncaL vagotomy anD gaStrojejunoStomy
Describe the steps of truncal vagotomy and gastrojejunostomy.
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Anesthesia: General anesthesia with endotracheal intubation.
Position of the patient—supine.
Antiseptic cleaning and draping.
Incision: A upper midline incision extending from xiphoid to the umbilicus. the skin
subcutaneous tissue, linea alba and the surgical peritoneum incised in the same line.
Exploration of abdomen: A thorough exploration of abdomen to identify any associated
disease. The site of the ulcer is palpated.
Exposure of the abdominal part of the esophagus: A self-retaining retractor is placed to retract
the abdominal wall on either side. The left triangular ligament of liver is incised and the left
lobe of liver is retracted towards the right to expose the abdominal part of the esophagus.The
peritoneum reflecting from the esophagus is incised transversely for about 3–4 cm on either side
Division of the anterior vagus nerve: The stomach is held by the assistant pulling it downards
and outwards. the anterior vagus now stands out infront of the abdominal part of the
esophagus and gastroesophageal junction is well seen. The anterior vagus nerve is dissected
with a right angled forceps. The nerve trunk is held by two pairs of hemostatic forceps both
above and below and the intervening 1 cm of the nerve trunk is excised. The proximal and
distal cut ends are ligated with silk sutures.
Division of posterior vagus nerve trunk: The gastrohepatic omentum is divided close to the
cardioesophageal junction and lesser sac is entered. The stomach is held by the assistant
upwards and outwards and the posterior vagal nerve trunk is identified by finger dissection
in the groove between posterior wall of esophagus and the aorta. The thick nerve trunk is
dissected using a right angled forceps, held by two pairs of haemostatic forceps at upper
and lower dissected end and the intervening 1 cm of segment is excised. The cut ends are
ligated with black silk.
Drainage procedure: truncal vagotomy should be combined with a drainage procedure. This
may be achieved either with pyloroplasty or gastrojejunostomy.
Roux-en-Y gastrojejunal anastomosis: earlier a loop gastrojejunostomy was usual practice.
But a now a days a Roux-en-Y gastrojejunal anastomosis is preferred.
Fashioning of a Roux loop of jejunum: the Roux loop is fashioned about 15 cm from
duodenojejunal flexure. The jejunal loop is held up by the assistant and the mesentery is
illuminated. The vessels in the mesentery are well seen. At the point of proposed jejunal
transection, the mesentery is divided after the mesenteric vessels are dissected, ligated and
divided taking care to maintain adequate blood supply to both the proximal and distal limb
of the loop after division. The jejunum is transected at the point of division of the mesentery.
The distal loop may be lengthened by dividing the intermediate branches joining the arcade,
taking care to maintain the blood supply via the adjacent arcade.
Closure of the end of distal jejunal limb: The end of the distal jejunal limb is closed in 2 layers
using inner through and through (all coat) layers using 3-0 polyglactin sutures and outer
seromuscular layer using same suture.
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Gastrojejunal anastomosis: A posterior gastrojejunostomy is preferred. An incision is made in
the transverse mesocolon to the right of middle colic vessels (space of Riolan). The posterior
wall of the stomach is held up by two pairs of Babcock’s tissue forceps and delivered through
the rent in the transverse mesocolon. A pair of gastric occlusion clamp is applied keeping
an adequate length of the stomach beyond the clamp. the distal limb of the Roux en Y
loop is brought close to the stomach keeping the closed end towards the left. An intestinal
occlusion clamp is applied to the jejunum and the stomach and jejunum kept side by side.
The anastomosis is done in following layers:
A continuous posterior seromuscular suture appposing the stomach to the jejunum with
3-0 polydioxanone suture (PDS suture).
About 5 cm gastrotomy and jejunotomy is made using diathermy knife parallel to the
seromuscular suture applied.
The next layer is posterior through and through taking all layers of stomach and jejunum
using 3-0 polyglactin suture.
once posterior through and through layer is completed the same suture is continued as
continuous anterior through and through layer taking all coats of the stomach and jejunum.
The occlusion clamps are removed and check for any bleeding.
The anastomosis is completed by applying continuous anterior seromuscular layer using
3-0 polydioxanone suture.
Closure of the mesocolon rent: The stomach wall is anchored to the mesocolon rent by
applying few interrupted 3-0 mersilk suture to prevent internal herniation through the
mesocolon rent.
Jejunojejunal anastomosis: the jejunal continuity is maintained by jejunojejunal
anastomosis about 35 cm distal to the gastrojejunal anastomosis. The proximal jejunum
is kept by the side of distal jejunum at the site of proposed anastomosis. A jejunotomy
is made at the antimesenteric border of the distal jejunum matching the lumen of the
proximal jejunal limb.The anastomosis is done by single layer interrupted all coat stitches
using 3-0 PDS suture.
Approximation of the cut margin of jejunal mesentery: The cut margin of the proximal jejunal
mesentery is apposed to the distal jejunal mesentery by interrupted 3-0 mersilk suture to
prevent internal herniation. care should be taken so that jejunal vessels are not punctured
while taking these stitches.
Closure: The surgical peritoneum and the linea alba is closed in single layer by a contiunuous
suture using no. 1 loop PDS suture. Skin is apposed by interrupted 2-0 monofilament
polyamide suture.
StepS of repair of peptic perforation
Describe the steps of repair of peptic perforation.
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General anesthesia with endotracheal intubation and assisted ventilation.
Position of patient—supine.
Antiseptic dressing and draping.
Abdomen opened by an upper midline incision. Skin and subcutaneous tissues are incised.
The linea alba is incised in the same line. The surgical peritoneum is lifted up in-between
two pairs of hemostatic forceps and incised in-between the pairs of hemostatic forceps. The
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peritoneum incision is then extended up and down. As soon as the peritoneum is incised,
gas and bile stained peritoneal fluid escape.
The peritoneal fluid is aspirated and the site of perforation is localized. The liver is retracted
by a Deaver’s retractor and the stomach is drawn downward by the assistant using a moist
sponge (Fig. 22.3A). The distal stomach and the duodenum is inspected.
Simple closure of the perforation is the preferred surgical treatment.
Three or four interrupted polyglactin (vicryl) or polyglycollic acid (Dexon) sutures are inserted
along the axis of the gut. The central stitch traverses through the center of the perforation
(Fig. 22.3B).
The corner sutures are tied first and the central stitch is tied last. The suture line may be
reinforced by placing a tag of omentum over the site of perforation and the sutures are tied
over the omentum (Fig. 22.3c).
A
B
figures 22.3a to c: Repair of peptic perforation
C
After closure of the perforation the meticulous peritoneal toilet is done. The subphrenic paces,
paracolic gutters and the pelvis are cleared of all turbid fluid and these areas are irrigated
with normal saline and the lavage fluid aspirated back.
„ A drain is placed in the hepatorenal pouch of Morrison and abdomen is closed. However,
the use of drain is not always essential.
„ The peritoneum and the linea alba is closed with a continuous no. 1 polypropylene sutures.
The skin is closed by interrupted sutures using monofilament polyamide sutures.
Postoperative management:
„ nasogastric aspiration is to be continued.
„ intravenous fluid to maintain fluid and electrolyte balance.
„ Antibiotics:
• inj. cefotaxime 1 gm iV twice daily.
• inj. Amikacin 500 mg iV twice daily.
• inj. Metronidazole 500 mg iV thrice daily.
„ intravenous Ranitidine or omeprazole.
„ Monitoring of pulse, blood pressure, respiration, temperature and urine output.
„ once bowel sounds return and the patient passes flatus, oral fluid is started and by 3–5 days
patient is given semisolid diet.
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StepS of LaparoScopic choLecyStectomy
Describe the steps of laparoscopic cholecystectomy.
Sac and the spermatic cord
Repositioning of testis into the scrotum: The testis with the everted hydrocele sac is reinserted
into the scrotal sac taking care so that there is no rotation of the testis. This is ascertained by
keeping the head of the epididymis superiorly and sinus of the epididymis laterally.
Check for hemostasis: if there is oozing, a corrugated rubber sheet drain may be placed into
the scrotum.
Closure: The internal spermatic fascia, cremesteric fascia , external spermatic fascia and the
Dartos muscle are apposed by a continuous 2-0 chromic catgut sutures. Skin is apposed by
interrupted monofilament polyamide suture. A coconut bandage is applied.
„ Anesthesia: The operation is done under general anesthesia with endotracheal intubation.
„ Antiseptic cleaning and draping: From midchest to midthigh.
„ Position of the Patient: initially patient is supine. The position is changed after induction of
pneumoperitoneum. Patient is placed in reverse trendelenburg position with right side up
position.
1. Establishment of pneumoperitoneum: intra-abdominal pressure is preset to 12 mm Hg
to 14 mm Hg in automatic insufflator. An 1 cm size smiling incision is made below the
umbilicus. A Veress needle is inserted into the abdomen at right angle taking care not to
injure the underlying abdominal organs or big vessel. The position of the needle inside
the peritoneal cavity is confirmed by injecting about 5 mL of saline and reaspirating it. if
the needle is in correct place the saline could be pushed easily and on aspiration nothing
will come. This can also be confirmed by drop test. A drop of saline is placed at the back of
needle and abdominal wall is lifted up. The needle is in correct place, the saline drop will
be sucked in. once the needle is confirmed to be in the peritoneal cavity, it is connected
to an automatic carbon dioxide insufflator by the insufflation tube. The carbon dioxide
flow is started at slow rate (1–2 liter/min). Afterwards the flow rate is increased. once the
abdomen is inflated to a sufficient level the Veress needle is withdrawn.
2. First Trocar Entry: The first trocar is placed blindly and there is risk of injury to the underly
in viscera or vessels. A 10 mm trocar and cannula is inserted into the abdomen below
the umbilicus and trocar is removed keeping the cannula in place.
3. Introduction of the telescope attached to a video camera: The video camera light case
attached to 30 degree, 10 mm telescope is inserted into the peritoneal cavity through
the infraumbilical trocar.
4. Inspection of the peritoneal cavity: The picture of the abdominal cavity is now displayed
in the video screen.
The pelvis is inspected first and then attention is drawn towards the gallbladder.
5. Introduction of 2nd,3rd and 4th port (Fig. 22.4A): The next three ports are made under
direct vision.
The second 10 mm port is made at the epigastrium below the xiphoid just to the right
of midline so that the trocar goes into the abdomen to the right of falciform ligament.
one 5 mm port is made in the right midclavicular line just below the right costal margin
and a second 5 mm port is made in the right anterior axillary line at the level of the
umbilicus.
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A
C
B
D
E
figures 22.4a to e: Laparoscopic cholecystomy
one toothed grasper is introduced through the anterior axillary port and this grasps the
fundus of the gall bladder and pushes it up towards the diaphragm thereby exposing the
site of calot’s triangle. one more grasper is introduced through the midclavicular port
to hold the Hartmann’ s pouch of the gallbladder. Through the epigastric port is inserted
a Maryland dissector attached to a diathermy.
6. Dissection of cystic pedicle and the Calot’s triangle (Fig. 22.4B): The patient is positioned
reversed trendelenburg’s position with the right side up to allow the intestine to fall
away from the right hypochondriac region. With the Maryland dissector the anterior leaf
and the posterior leaf of the cystic pedicle is teased off and the cystic duct and artery is
dissected clearly. Posterior dissection of the calot’s triangle is the most important initial
step. Anterior dissection of the calot’s triangle is complementary and should be done
after the posterior dissection is done. A large window is created between the cystic duct
and the artery so that the clips may be applied easily.
7. Application of clips and division of cystic duct and artery (Fig. 22.4c): once the cystic
duct and artery is cleared off they are clipped with titanium clips applied by a 10 mm.
clip applier inserted through the epigastric port. Three clips are applied in the cystic
duct and three in the cystic artery and the duct and artery is divided by an endoscissors
keeping two clips in the cystic duct and artery towards the bile duct side.
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8. Dissection of the gallbladder from gallbladder bed of liver (Figs 22.4D and e): once the
cystic duct and the artery is divided the gallbladder is now dissected by using a unipolar
diathermy hook from the liver bed.
9. Irrigation and suction: once the gallbladder is free, the gallbladder bed is irrigated
with normal saline and check for any bleeding which may be controlled by diathermy
coagulation.
10. Extraction of gallbladder: The separated gallbladder is then held up by a crocodile forceps
and removed through the epigastric port.
11. Placement of drain: Placement of a drain is optional. if there is slight oozing or if the
surgery is difficult then a tube drain may be placed in the hepatorenal pouch of Morrison
for 24–48 hours.
12. Closure of the incision: The cannulas are withdrawn and the incisions are closed. The
sheath in the 10 mm port areas are closed with vicryl sutures.
Why do you prefer laparoscopic cholecystectomy?
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Laparoscopic cholecystectomy has been established as a gold standard for the treatment of
gall stone diseases
Surgery is safe in the hands of a trained surgeon
Less pain, less hospital stay
cosmetic
early return to work is possible
More acceptance by the patient.
While you take consent for laparoscopic cholecystectomy what should you tell the
patient
Laparoscopic cholecystectomy sometimes need conversion to open procedure if there is gross
adhesion and the anatomy in the area of calot’s triangle is not clear and there is excessive
bleeding. So an informed consent is to be taken from the patient that if laparoscopic procedure
is not safe, it may need conversion to open cholecystectomy.
open choLecyStectomy
What are the indications of cholecystectomy?
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Gallstone disease
chronic cholecystitis
Acute cholecystitis
Mucocele of gallbladder
empyema of gallbladder
cholesterosis of gallbladder
Porcelain gallbladder
carcinoma of gallbladder
Gallbladder polyp
Acalculous cholecystitis
traumatic rupture of gallbladder
Along with Whipples' operation.
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Steps of open cholecystectomy:
Anesthesia: General anesthesia with endotracheal intubation.
„ Position of the patient: Supine. if intraoperative cholangiogram is required then patient should
be placed on a special operation table with transparent top. There should be provision for
insertion of a Buckey grid for placement of an X-ray plate for exposure.
„ Antiseptic cleaning and draping: Antiseptic cleaning by application of povidone iodine
solution from midchest to midthigh.
„ Incision: Right subcostal incision (Kocher’s incision).
„ The structures incised in Kocher's subcostal incision:
„ Preliminary exploration: The stomach, duodenum, colon, pancreas and liver are examined
first. The gallbladder is examined, look for color, any adhesions, palpated for any calculi.
The supraduodenal part of the common bile duct is palpated at the free margin of the lesser
omentum with index finger in the epiploic foramen and thumb in front to exclude presence of
any calculi. The retroduodenal part of the common bile duct is palpated by keeping the finger
tips along the lateral border of the second part of the duodenum and by placing the thumb
anteriorly in the groove between the duodenum and the pancreas.
„ Placement of mops: The next step is good exposure. Three mops are placed. The first mop
is placed in the hepatorenal pouch to retract the right colic fiexure downward. The second
mop is placed in the lower part of the wound to retract the duodenum, transverse colon and
the small intestine. The third mop is placed more medially to retract the stomach.
„ Retraction and exposure: Deep retractors are placed and held by the assistants for good
exposure. one Deaver’s retractor retracts the right lobe of the liver upward and another
Deaver’s retractor retracts the lower part of the wound.
„ Dissection of the cystic pedicle: the fundus of the gallbladder is held by a Moynihan’s
cholecystectomy forceps. Another Moynihan’s cholecystectomy forceps is applied at the
Hartmann’s pouch and the gallbladder is retracted downward and to the right. The anterior
layer of the peritoneum covering the cystic duct and artery is snipped off with a scissors and
the cystic duct and artery dissected by blunt dissection using a peanut swab. The cystic artery
often runs anterior to the cystic duct.
„ Ligation of cystic artery and duct: The cystic artery is dissected by using a right angle forceps
and two ligatures of no. 1-0 silk suture is passed around the cystic artery. These are then tied
and the cystic artery is divided inbetween the ligatures. Similarly the cystic duct is dissected
by using the right angle forceps and two ligatures are passed around the cystic duct. These
ligatures are tied and the cystic duct divided inbetween the ligatures. For safety one additional
ligature may be applied in the cystic artery and the duct.
„ Dissection of gallbladder from liver: The gallbladder is retracted by using the Moynihan’s
cholecystectomy forceps and a finger is insinuated between the gallbladder and the liver and
the gallbladder is gently dissected from its bed. As the gallbladder is lifted from its bed, fine
fringes stand out. These are divided with diathermy or ligated and divided, as fine vessels are
present in these strands. As the gallbladder is dissected, the peritoneal reflection from the
gallbladder to the liver is divided with scissors or diathermy knife. A fringe of peritoneum is
kept on either side of the gallbladder bed. While lifting the gallbladder from gallbladder bed
in liver, look for any cholecystohepatic duct.
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Hemostasis: The gallbladder bed is checked for bleeding. Bleeding points are either ligated
or coagulated with diathermy. A hot moist pack may also control minor bleeding in the
gallbladder bed. The margins of the raw area of the gallbladder bed may be apposed with
interrupted or continuous sutures of chromic catgut.
Drainage: A drainage tube is kept in the subhepatic space.
Closure: closure is done in layers (see abdominal incisions).
What is retrograde cholecystectomy?
The usual technique of cholecystectomy described above—ligation of cystic duct and artery and
dissection of gallbladder from its bed starting from the neck to the fundus is called retrograde
cholecystectomy.
What is fundus first cholecystectomy?
if there is dense adhesion at the calot’s triangle area and the anatomy is not discernible, then
attempt at dissection of cystic duct and artery may result in excessive bleeding or inadvertent
injury to the bile duct. in such situation it is safer to start dissection of the gallbladder fundus from
the gallbladder bed in the liver and dissection carried toward the neck of the gallbladder and
the cystic duct and artery ligated and divided. This is called fundus first cholecystectomy.
excessive traction of the mobilized gallbladder may cause kinking of the bile duct and may
result in bile duct injury.
if dense adhesion prevents isolation of cystic artery and cystic duct clearly, it is better to keep
a part of the gallbladder neck. The gallbladder is transected at the neck and the cut margins are
suture ligated.
StepS of choLeDochoLithotomy
Describe the steps of choledocholithotomy (Fig. 22.5).
if operated for gallstones and common bile duct stones—Kocher’s subcostal or right paramedian
or midline incisions.
A laparotomy is done and presenceof gallbladder and common bile duct stone confirmed by
palpation. The gallbladder is held by Moyhnihan’s cholecystectomy forceps and the peritoneum
of the cystic pedicle is dissected and the cystic duct and artery is dissected. cystic artery ligated
and divided. A suture is passed around the cystic duct for ease of lateral retraction.
Identifying the bile duct: The bile duct is dissected by lifting and incising the peritoneum from
its anterior aspect. Bile duct identified by aspirating bile.
Application of stay sutures: two stay sutures are applied on either side of the supraduodenal
part of the bile duct using 3-0 atraumatic chromic catgut suture.
Making a choledochotomy: choledochotomy is done in supraduodenal part of common bile
duct in between the stay sutures and the incision extended for about 2 cm.
Removal of CBD stones: A Desjardin’s choledocholithotomy forceps is introduced into the bile
duct and the stones removed. This may be aided by introduction of a choledochoscope through
the choledochotomy and stone may be extracted by a Dormia basket catheter introduced through
the choledochoscope.
The bile duct is then irrigated with normal saline to flush off the small fragments of stone
or debris.
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figure 22.5: Choledocholithotomy
An intraoperative cholangiogram is done to ascertain complete clearance of the bile duct
stones.
Introduction of tube: A t tube is fashioned for placement in the bile duct. The horizontal limb
is deroofed and proximal end kept for about 2–5 cm and distal end kept for about 4 cm. The
choloedochotomy is closed keeping a t tube in the bile duct.
Alternatively a choledocho duodenostomy may be done.
StepS of choLeDochoDuoDenoStomy
Describe the steps of choledochoduodenostomy.
This is usually done following choledocholithotomy.
Anesthesia: General anesthesia with endotracheal intubation.
„ Position of patient supine
„ Antiseptic cleaning and draping.
„ Incision: Approach is as in open cholecystectomy, through Kocher’s subcostal incision.
„ Cholecystectomy: Mops are placed to expose the area of Calot’s triangle.
„ Gallbladder is held by Moynihan’s cholcystectomy forceps at the fundus and the Hartman’s
pouch and the cystic pedicle is dissected, ligated and divided.
„ Choledocholithotomy: The cystic duct stump is retracted to reach the bile duct.
„ The peritoneum in front of the bile duct is incised and the bile duct is exposed. Bile duct is
confirmed by aspiration of bile.
„ Two stay sutures are applied on either side of the midline in the anterior wall of bile duct using
3-0 chromic catgut suture.
„ A choledochotomy is done.. and the stones are removed from the bile duct using Desjardin’s
choledocholithotomy forceps. The bile duct is irrigated with saline to clear off the any residual
stone or debris.
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Choledochoduodenostomy:
Mobilisation of the 1st part of duodenum: The first part of the duodenum is mobilized by
dividing the hepatoduodenal ligament. The right gastric artery is ligated and divided. This
allows 1st part of the duodenum to be brought up for choledochoduodenostomy without
tension.
Incision on duodenum: Choledochotomy is already made for removal of bile duct stones.A
similar incision is made in the anterior wall of duodenum along its axis.
Anastomosis: Anastomosis is done with interrupted suture using 4-0 polyglactin or
polydioxanone.
Take bite from the angle of the duodenotomy to the middle of the choledochotomy on either
side. Interrupted suture at 3 mm interval is taken between the duodenum and the bile duct
forming the posterior wall. All the sutures in the posterior wall are then tied.
The anterior layer of sutures are then taken between the duodenum and the bile duct and tied
at the end.
Closure: Check for hemostasis. A drain is kept in the hepatorenal pouch of Morrison.
Incision is closed in layers.
StepS of WhippLe’S pancreaticoDuoDenectomy
Describe the steps of Whipple’s pancreaticoduodenectomy.
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Anesthesia: General anesthesia with endotracheal intubation.
Position of the patient: Supine.
Antiseptic cleaning and draping
Incision: A long midline incision extending from xiphoid to well below the umbilicus. The
subcutaneous tissue is incised in the same line. The linea alba and the surgical peritoneum is
incised in the same line and the peritoneal cavity entered. (In obsese patient with wide costal,
margin a roof top incision provides better exposure).
Exploration of abdomen: Assess for distant metastasis—presence of ascites, liver,omentum and
pelvis is examined for presence of any nodules. Presence of distant metastasis is a contraindication
for resection. Mobile lymph nodes within the area of resection is not a contraindication for resection.
However, presence of fixed nodes is a contraindication for resection.
Assessment for resectability: This involves a number of steps to decide about the resectability.
Exposure of the duodenum and the head of the pancreas: The peritoneum lateral to the right
colic flexure is incised and the colic flexure is dissected down to expose the duodenum and the
head of the pancreas. While doing so the right gastroepiploic vein draining into the superior
mesenteric vein needs ligature and division.
Kocherisation of duodenum: The peritoneal attachment at the lateral border of 2nd part of
duodenum is incised and the duodenum kocherized lifting it up from the inferior vena cava,
aorta and the retroperitoneum. Any infiltration of the tumor into the inferior vena cava or aorta
is a contraindication for resection. The first part of the duodenum is also mobilized by incising
the peritoneum from the superior border of the duodenum up to the foramen of Winslow.
Exposure of the pancreas: The greater omentum is divided in between ligature and the head,
neck and body of the pancreas is exposed well.Small vessels infront of the head pancreas needs
ligature and division for proper exposure of the head of the pancreas.
Exposure and dissection of superior mesenteric vessels: The Kocher’s maneuver is extended to
the third part of the duodenum. The third part of the duodenum is mobilized and the superior
mesenteric vessels are identified crossing the 3rd part of the duodenum, SMA to the left and SMV
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to the right. Small vessels joining the middle colic vein, SMV from the pancreaticoduodenal
vein needs ligature and division. An attempt is made to create a tunnel between the superior
mesenteric vein and the neck of the pancreas. A judgement is made at this stage regarding
tumor invasion into the SMV or portal vein. Any invasion indicates inoperability.
However, now a days if expertise is availbale, it is possible to resect a segment of portal vein
with the tumor followed by reconstruction with a prosthetic graft.
Dissection of hepatoduodenal ligament and portal structures: The heaptoduodenal ligament
is divided close to the liver and the peritonuem and the loose areolar tissue over the bile duct,
hepatic artery and the portal vein are dissected alongwith the pericholedochal lymph nodes.
The bile duct is dissected all around. The gastroduodenal artery arising from the hepatic artery
is dissected, ligated and divided. This gives a good exposure of the portal vein. An attempt is
now made to complete the tunnel between the neck of the pancreas and the portal vein. If there
is no invasion into the portal vein the resection can proceed.
Cholecystectomy and division of bile duct: The cystic artery is dissected and ligated. The
gallbladder is dissected off from the liver bed starting with the fundus and dissected up to the
bile duct. The already dissected bile duct is divided above the cystic duct insertion.
Division of gastrohepatic omentum and lymph nodes: The lesser omentum is incised close
to,the liver and the peritoneum over the common hepatic artery is incised. The lymph nodes
around the CHA is dissected and swept down towards the specimen. The lymph nodes around
the common bile duct and the portal vein are also swept down towards the specimen.
Distal gastrectomy: While dissecting the hepatic artery, the right gastric artery is dissected,
ligated and divided close to the pylorus. The distal third of the stomach needs resection in
Whipple’s operation. The right gastroepiploic artery is dissected, ligated and divided near
the lower border of the pylorus. The left gastric arcade along the lesser curvature is dissected,
ligated and divided at the site of proposed gastric resection. The left gastroepiploic arcade is also
dissected, ligated and divided at the greater curvature at the site of proposed gastric resection.
Two pairs of intestinal occlusion clamps are applied and the stomach divided inbetween.
Division of the neck of the pancreas: Two pairs of stay sutures are applied along the upper and
lower border of the junction of body and neck of the pancreas to minimize bleeding. A soft clamp
may be applied to the specimen side and the neck of the pancreas is transected using cutting
diathermy. While doing so the portal vein lying behind the neck of the pancreas is safeguarded
by placing a dissector inbetween the neck of the pancreas and the portal vein.
Division of the jejunum: The duodenojejunal flexure is identified at the infracolic compartment.
The ligament of Treitz is identified and incised taking care not to injure the inferior mesenteric
vein. Two pairs of intestinal occlusion clamps are applied about 10 cm from the D-J flexure
and the jejunum is transected. The mesentery of the proximal jejunum is incised close to the
jejeunal wall taking care not to injure the superior mesenteric artery or vein.A double row of
short vessels runs from the fourth part of duodenum to the uncinate processes. These vessels
are dissected, ligated and divided.
Once these vessels are divided, the divided jejunum may now be brought to the right behind
the superior mesenteric vessels.
Division of uncinate process: At this stage the only attachment of the specimen is between
the uncinate process and the superior mesenteric vessels. There are multiple short vessels
runing between the uncinate process and the superior mesenteric vessels. These vessels
are dissected in small bits, ligated and divided, taking care not to injure the superior
mesenteric vessels.
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Removal of specimen: Once the uncinate
process is cleared off from the superior
mesenteric vessels ,the specimen consisting of
gallbladder, common bile duct, distal third of
the stomach, head , neck and uncinate process
of the pancreas, whole of duodenum, proximal
10 cm of jejunum along with regional lymph
nodes are now free to be removed.
Reconstruction: Once resection is complete
reconstruction is to be done to maintain
pancreatic, biliary and gastric continuity.
Pancreaticojejunal anastomosis: The jejeunal
loop is lengthened by dividing the vascular
arcade in the mesentery taking care to
maintain the vascularity at the cut end of the
figure 22.6: Structures that are to be removed
in Whipple’s operation are shown to the right
jejunum. The cut end of the jejunum is closed by
of superior mesenteric artery
2 layers of sutures, inner through and through
layers taking all coats of jejunum with 3-0
polyglactin sutures. Outer seromuscular
layer with 3-0 interrupted mersilk sutures.
The jejunal limb is brought up through a rent
in the transverse mesocolon in an avascular
area to the right of middle colic vessels.
An end to side pancreaticojejunal
anastomosis is done in 2 layers. Interrupted
4–0 PDS sutures are applied between the
posterior pancreatic capsule with the
posterior seromuscular coat of jejunum.
A jejunotomy is made at the level of
pancreatic duct. Using 4–0 PDS suture the
pancreatic duct mucosa is sutured to the all
coat of the jejeunum first applied posteriorly
and then anteriroly.
The anastomosis is completed b y
interrupted sutures using 4-0 PDS apposing
the anterior pancreatic capsule with anterior
seromuscular coat of jejunum.
Hepaticodochojejunostomy: About 15 cm
distal to the pancreaticojejunal anastomosis
an end to side hepaticodochojejunostomy is
figure 22.7: Structures as seen before anastomosis
done. A jejunotomy is made in the jejunum
matching the hepatic duct diameter. A single
layer anastomosis is done by taking all coat
of jejunum and the hepatic duct with interrupted 4-0 PDS sutures.
Gastrojejunal anastomosis: About 15 cm distal to the hepaticodochojejunostomy an end to
side gastrojejunal anastomosis is done in 2 layers. The posterior seromuscular suture is applied
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first by a runing 4-0 PDS suture. The gastrotomy
is partially closed by all coat runing suture with
4-0 PDS, leaving about 5 cm for anastomosis.
The posterior through and the anterior through
suture is applied by runing 4-0 PDS sutures
taking all coat bite of the stomach and jejunum.
The anastomosis is completed by applying runing
anterior seromuscular layer with 4-0 PDS.
Closure of transverse mesocolon rent : The
rent in the transverse mesocolon is sutured
to the seromuscular coat of the jejunum with
interrupted 3-0 mersilk to prevent internal
herniation through the mesocolon rent.
Feeding jejunostomy: A feeding jejunostomy
is done 15 cm distal to the gastrojejunal
anastomosis. A no. 20 Fr. Foleys catheter is
used for creating a feeding jejunostomy and the
figure 22.8: Reconstruction after pancreati­
catheter brought out through a stab wound.
coduodenectomy. (1) Choledochojejunostomy.
This is useful for maintaining nutrition in
(2) Pancreatojejunostomy. (3) Gastrojejuno­
postoperative period in situation of delayed
stomy
gastric emptying or development of pancreatic
fistula.
Placement of drain: A wide bore drain is placed in the heaptorenal pouch of Morrison close to
the pancreaticojejunal anastomosis.
Closure of abdomen: Surgical peritoneum with linea alba in single layer with runing suture
using 1 polypropylene or 1 PDS suture. Skin apposed with interrupted 2-0 monofilament
polyamide sutures.
The jejunostomy tube and the drainage tube is fixed to the skin.
StepS of LateraL pancreaticojejunoStomy
Describe the steps of lateral pancreaticojejunostomy.
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Anesthesia: GA with endotracheal intubation.
Position of the patient: Supine.
Antiseptic cleaning with povidone iodine and draping by placement sterile sheets.
Incision: A roof top or chevron incision gives very good exposure. In patient with narrow costal
margin a long upper midline incision extending from below the xiphoid to about 4 cm below
the umbilicus also gives adequate exposure.
Preliminary exploration of abdomen: On opening the peritoneum the abdomen is explored
for diagnosis of any unforseen pathology. Pancreas is palpated for confirmation of diagnosis.
Exposure of pancreas: The gastrocolic omentum is divided in between ligature and the body
and tail of pancreas is exposed. The head of pancreas is exposed by dividing the duodenocolic
ligament and reflecting the right colic flexure downwards. While doing so the right gastroepiploic
vein needs dissection and division after ligature.The small branches of gastroduodenal artery
also needs division for exposure of the entire head of the pancreas.
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Kocherization of duodenum: An incision is made in the posterior parietal peritoneum at
the lateral border of 2nd part of duodenum and the duodenum kocherized lifting it up from
the inferior vena cava and posterior abdominal wall. The head of the pancreas can now be
palpated properly.
Exposure of body and tail of pancreas: The gastrocolic ligament is divided in between ligature
and the body and tail of pancreas is exposed.
Identification and opening of pancreatic duct: A grossly dilated duct with calculi in lumen
can be easily palpated. If the duct is not palpable a hypodermic needle is inserted into the
pancreatic parenchyma lateral to the neck of the pancreas at the upper 1/3rd and lower 2/3rd
junction. As the needle reaches the pancreatic duct pancreatic juice will start flowing out. The
needle is kept in that position.Following the shaft of the needle the pancreatic parenchyma is
incised with a diathermy knife and the pancreatic duct is opened up. A metal dilator is inserted
through the opened duct towards the body and tail of the pancreas and the duct is opened by
incising the pancreatic parenchyma using a diathermy knife to minimize bleeding. The dilator
is then inserted towards the head of the pancreas and the duct is opened similarly keeping 1
cm margin from the medial border of the duodenum to prevent injury to the vessels lying in
the pancreaticoduodenal groove.
Removal of ductal calculi: Using Desjardins choledocholithotomy forceps all the stones and
debris are cleared from the pancreatic duct. Some stones and debris may be cleared by irrigating
the duct lumen with saline.
Pancreatic head coring: For adequate pain relief a proper head coring is also required. The
thickened pancreatic parenchymal tissue of the head of pancreas is excised in piecemeal using
electrocautery keeping a 1cm rim of tissue around the medial border of the duodenum.
Creation of a Roux-en-Y loop of jejunum: A Roux-en-Y limb of jejunum is created about 15 cm.
distal to the duodenojejunal flexure. The vessels in the mesentery are divided in such a fashion
so that blood supply to both the proximal and distal limb is well maintained.The jejunum is
divided and the cut end of the distal jejunal limb is closed by 3-0 polydioxanone (PDS) sutures
in 2 layers (inner through and through layers and outer interrupted seromuscular layers.).
Pancreaticojejunal anastomosis: The distal limb of the Roux-en-Y loop is brought up behind
the transverse colon through an avascular area in the mesocolon to the right of middle colic
vessels (space of Riolan).
The jejunum is placed by the side of the opened pancreatic duct. A longitudinal jejunotomy is
made along the antimesnteric border matching the opening in the pancreatic duct. A single layer
pancreaticojejunal anastomosis is done by interrupted through and through stitches taking
bites in all layers of jejunum and the pancreatic parenchyma and the duct mucosa using 4-0
PDS suture.
(Alternatively a 2 layer anastomosis may be done. A outer layer of continuous suture taking
seromuscular coat of jejunum and the pancreatic parenchyma using 4-0 mersilk. An inner
layer of interrupted suture taking jejunal mucosa and the pancreatic duct mucosa using 4-0
PDS suture.)
Closure of mesocolon rent: The mesocolon rent is closed by taking interrupted suture between
the margin of the mesocolon rent and the jejunal serosa.
Jejunojeunal anastomosis: The intestinal continuity is maintained by doing a jejunojejunal
anastomosis about 35 cm distal to the pancreaticojejunal anastomosis. Single layer
jejunojejunal anastomosis is done with interrupted all coat stitch using 4-0 PDS sutures.
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Closure of jejunal mesenteric gap: The mesenteric gap between the proximal and the distal
jejunum loop is apposed by interrupted sutures using 3–0 mersilk
Placement of drain: Check for hemostasis and a wide bore abdominal drain (No. 32 Fr.) is
placed in the hepatorenal pouch of Morrison.
Closure: Closure in layers. The internal oblique, transversus abdominis and the surgical
peritoneum laterally and the posterior rectus sheath medially is apposed by continuous suture
using No.1 PDS suture.
The external oblique muscle and aponeurosis laterally and the anterior rectus sheath medially
is apposed by a continuous suture using 1 PDS suture.
The skin is approximated by interrupted 2-0 monofilament polyamide sutures.
StepS of right hemicoLectomy
Describe the steps of right hemicolectomy.
(For growth in cacum and ascending colon a standard right hemicolectomy involves resection
of terminal 10 cm of ileum, cecum, ascending colon and right 2/3rd of transverse colon along
with whole of greater omentum and the regional lymph nodes epicolic, paracolic , intermediate
and the central lymph nodes.)
„ Anesthesia: General anesthesia eith endotracheal intubation.
„ Position of patient: Supine.
„ Antispetic cleaning with povidone iodine and draping.
„ Incision: A long midline incision from midepigastrium to about 5 cm below the umbilicus.
Skin subcutaneous tissue, linea alba and surgical peritoneum incised in the same line.
„ Exploration of abdomen: Assessment for metastasis, presence of ascites, any distant spread to
liver, omentum, peritoneum and pelvis. Palpate for involvement of regional lymph nodes—
epicolic, paracolic, intermediate and central lymph nodes (lymph nodes around the origin
of superior mesenteric vessels).
Assessment of the local growth to decide about the resectability. Assess whether the
growth has invaded the posterior abdominal wall, ureter, gonadal vessels and duodenum
and pancreas. Any adherence of small gut to the growth.
„ Exteriorization of small gut: For ease of dissection the whole of small gut is exteriorized and
wrapped in a moist towel taking care not to twist the mesentery.
„ Division of greater omentum: The greater omentum is ligated and divided close to the greater
curvature of stomach preserving the gastroepiploic arcade.
„ Mobilization of right colon: The cecum and the ascending colon is retracted medially and
the peritoneum is incised using diathermy along the white line of toldt at the right paracolic
gutter.The right colon along with the terminal ileum is reflected towards the left to expose the
vessels supplying the right colon—ileocolic, right colic and the middle colic vessels. While
doing so, care is taken to prevent injury to the structures lying deep to the right colon—
gonadal vessels, right ureter and the duodenum. Small bleeding in the retroperitoneum may
be controlled by placement of a moist mop.
„ Divisions of vessels of right colon: The vessels supplying the terminal 10 cm of ileum are
dissected, ligated and divided. The ileocolic vessels and the right colic vessels are ligated as
high as possible. The right branch of the middle colic vessels are ligated close to its origin
from the trunk of middle colic artery. The mesentery inbetween these vessels are divided
and taken with the specimen.
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Dissection of lymph nodes: While dissecting and ligating the vessels all the lymph nodes along
these vessels are dissected and taken along with the specimen. The lymph nodes around the
trunk and origin of the superior mesenteric trunk is also dissected and removed along with
the specimen.
„ Division of terminal ileum and the transverse colon: two pairs of intestinal occlusion clamps are
applied at the site of proposed ileal resection and the ileum is resected using cutting diathermy.
„ Division of transverse colon: two pairs of intestinal occlusion clamps are applied at the site of
proposed transverse colon resection and the colon is divided using cutting diathermy. care
is taken to preserve the blood supply to the end of ileum and the transverse colon.
„ Ileocolic anastomosis: A two layer anastomosis is done. The anastomosis may be done either
as end to end , or the cut ends may be closed and a side to side anastomsosis (functional end
to end anastomosis) may be done.
The posterior seromuscular suture is applied by interrupted suture using 3-0 mersilk sutures.
The posterior through and through and anterior through layer is applied by runing suture
using 3-0 polydioxanone (PDS).
The anterior seromuscular suture is completed by interrupted 3-0 mersilk sutures.
(Alternatively a single layer anastomosis may be done by interrupted suture using 3-0 PDS
suture).
„ Closure of mesenteric gap: The gap between the mesentery of ileum and transverse mesocolon
is closed by interrupted suture using 3-0 mersilk.
„ Placement of drain: Hemostasis is checked and a tube drain is placed at hepatorenal pouch
of Morrison by making a stab incision at the right lumbar region.
„ Closure of abdomen: The surgical peritoneum and the linea alba is closed by runing suture
using no. 1 loop PDS suture.
Skin is apposed by interrupted 2-0 monofilament polyamide sutures. The drain tube is fixed
to the skin.
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StepS of LoW anterior reSection
Describe the steps of anterior resection (or low anterior resection).
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Anesthesia: General anesthesia with endotracheal intubation.
Position of patient: Growth in upper rectum if hand sewn anastomosis is contemplated patient
should be in supine.
For growth in midrectum or lower rectum, if the decision might change to APR during
operation or anastomosis is contemplated with a circular stapler patient should be in modified
lithotomy position.
Incision: A lower midline incision from just above the symphysis pubis to about 5cm above
the umbilicus.The skin subcutaneous tissue, linea alba and surgical peritoneum is incised in
the same line.
Exploration of abdomen:
• Assessment for presence of ascites, any distant spread to liver,omentum, peritoneum and
pelvis. Palpate for involvement of regional lymph nodes—pararectal lymph nodes and
central lymph nodes (lymph nodes around the origin of inferior mesenteric artery).
• Assessment of the local growth to decide about the resectability. Assess whether the growth
has invaded the posterior or lateral pelvic wall and ureter.
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Exteriorization of small gut: The whole small gut is delivered ouside and kept wrapped in moist
towel taking care not to twist the mesentery.
Mobilization of sigmoid and descending colon: The mobilization starts on the left side of the
pelvic brim. The left leaf of mesosigmoid is incised close to the pelvic brim in an avascular
area. This incision is taken upwards towards the splenic flexure. The avascular plane between
the mesosigmoid and the posterior pelvic wall is being entered by sharp dissection and the
rectosigmoid junction along with superior rectal vessels are lifted up. The left ureter crossing the
apex of the mesosigmoid is safeguarded during this dissection. The right leaf of the mesosigmoid
is then incised going upwards up to the bifurcation of aorta and going down up to the point in
lateral pelvic wall where the mesosigmoid reaches the lateral pelvic wall peritoneum. During
this dissection the right ureter is safeguarded.
Mobilization of splenic flexure and descending colon: The lateral peritoneum along the line of
Toldt is incised taking this incision upwards up to the splenic flexure. The leinocolic and the
renocolic ligaments are then divided and the splenic flexure brought down to ensure a tension
free colorectal anastomosis.
Ligation of inferior mesenteric vessels and lymphatic dissection. The inferior mesenteric artery
is dissected close to its origin at the aorta and the lymph nodes around are dissected towards
the colon. The inferior mesenteric artery is dissected beyond the origin of the left colic artery,
ligated and divided. The inferior mesenteric vein is dissected near the duodenojejunal flexure,
ligated and divided close to the lower border of the pancreas and the lymphatic tissue around
this is taken down with the colon.
The lymphatic tissue around the bifurcation of the aorta and the common iliac vessels are taken
down towards the specimen. The intervening mesentery is divided.
Mobilization of the mesorectum and the rectum: This is the most important step in anterior
resection
• Posterior or presacral dissection: The mobilized sigmoid colon is drawn upwards and
forwards which opens up the presacral space.The avascular areolar tissue which surrounds
the mesorectum is identified and divided by sharp dissection. This dissection is initially
carried downwards in the midline along the curve of the sacrum up to the coccyx. Beyond
this the dissection carried forwards in front of the anococcygeal raphe dividing the Waldeyer’s
fascia. This dissection has to be done in proper plane preserving the presacral vessels and
nerves.
• Lateral dissection: The dissection from the posterior midline is carried around the lateral wall
of the mesorectum and sharp dissection is done along the lateral pelvic wall.The dissection is
first done on the left side and the lateral ligament is put on stretch by retracting the rectum
towards the right. A right angled forceps is used to dissect the lateral ligament and the right
angled forceps is passed around the lateral liagment which is divided by using diathermy.
Sometimes the middle rectal vessles runing along the lateral ligament needs ligature and
division. With similar maneuver the right lateral ligament is divided. While dividing the
lateral ligament the ureter and the hypogastric nerves are taken care of to prevent injury
to these structures.
• Anterior dissection: The anterior dissection is different in male and female patients.
In male patient: The bladder is retracted anteriorly by a Llyod Davis retractor or a Deavers
retractor and the peritoneum lining the rectovesical pouch is incised. This peritoneal incision is
extended laterally to the lateral pelvic wall. The posterior leaf of the incised peritoneum along
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with the Denonvillier’s fascia is picked up with a long hemostatic forceps and retracted in an
upwards and posterior direction. By sharp dissection (using diathermy or a Metzenbaum
scissor), the rectum along with the mesorectum is separated from the seminal vesicle and the
prostate. Few bleeding vessels during this dissection may be controlled by diathermy.
In female: Then uterus is retracted anteriorly and the peritoneum of the rectouterine pouch
(pouch of Douglas) is incised and the incision is carried on either side to the lateral pelvic wall.
The posterior leaf of the incised peritoneum along with Denonvillier’s fascia is picked up by a
long hemostatic forceps and retracted in a posterior and cephalad direction and the rectum
along with mesorectum is separated from the cervix and the posterior vaginal wall, small
bleeding during this dissection may be controlled by using diathermy.
Division of proximal colon: (The extent of colonic resection for anterior resection is 7 cm
proximal to the proximal margin of the growth. The distal margin for anterior resection is 5
cm from the distal margin of the grwoth. For low anterior resection this margin may be as low
as 2 cm. In ultralow anterior resection even a 1 cm distal margin is acceptable.)
At the point of proposed resction of proximal colon, the marginal artery is dissected, ligated and
divided. Two pairs of intestinal occlusion clamps are applied at the site of proposed resection of
colon and the proximal colon is divided by cutting diathermy inbetween the intestinal occlusion
clamps.
Division of rectum: At the point of proposed rectal resection, the superior rectal artery is dissected
and ligated close to the rectal wall. A C shaped occlusion clamp is applied around the rectum
distally and an intestinal occlusion clamp is applied proximally and the rectum is divided
inbetween using cutting diathermy. The specimen is removed.
Colorectal anastomosis
Hand sewn anastomosis: A single layer colorectal anastomosis is done with interrupted suture
using 4-0 polydioxanone or mersilk suture either by full thickness suture or extramucosal suture.
Stapler anastomosis: In low or ultralow anterior resection a stapler anastomosia is preferable.
This is done by using a circular stapler. The rectal stump is closed by applying a purse string
suture using 1-0 polypropylene suture. The anvil of the circular stapler is passed into the
proximal cut end of the colon and the end of colon closed around the anvil by a purse string
suture. The handle of the circular stapler is passed through the anal canal and delivered
through the rectal stump by a sharp puncture. The anvil is fitted into the handle of the circular
stapler. The stapler knob is gradually closed whereby the colonic end is brought closer to the
rectal stump. Once the indicator in the stapler shows that is in the firing range. The stapler is
unlocked and fired. This will create colorectal anastomosis. Once the anastomosis is done the
stapler is opened up by turning the knob one and half turn and the stapler is delivered out
through the anal canal.
Checking the donuts: The anvil is opened up and the donut is examined. Two complete donut
indicates that a proper anastomosis has been done.
Testing the anastomsis: An intestinal occlusion clamp is applied to the colon proximal to the
anastomosis. Pour normal saline into the pelvis so that the site of anastomosis remains under
the saline. Using a 50 mL syringe air is pushed into the rectum through the anal canal. Look
for any air bubble escaping through the anastomsis. In perfect anastomosis there should be no
leakage of air through the anastomsis.
Proximal diversion colostomy or ileostomy: When there is any doubt regarding the colorectal
anastomosis, a proximal diversion transverse colostomy or ileostomy is preferable to safeguard
the anastomosis.
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Placement of drain: Hemostasis is checked and a tube drain is placed inside the pelvis.
Closure of abdomen: The surgical peritoneum and linea alba in single layer using no.1 loop
polydioxanone suture. Skin closed with interrupted suture using monofilament polyamide
sutures.
StepS of aBDominoperineaL reSection
Describe the steps of abdominoperineal resection.
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Anesthesia: General anesthesia with endotracheal intubation.
Position of patient: Patient is placed in a modified lithotomy Trendelenburg position. The
operating surgeon stands on the left side of the patient. Operation is simultaneously done by
two teams of surgeons.
Antiseptic cleaning and draping of both abdomen and perineal area with povidone-iodine
and draping done to expose the abdomen and perianal area.
Incision: A midline incision is made starting just above the symphysis taking the incision up to
the right of umbilicus to about 5 cm above the umbilicus. The subcutaneous tissue, linea alba
and the surgical peritoneum is incised in the same line.
Exploration of abdomen: A self-retaining retractor is applied for better exposure. General
exploration of abdomen to assess for any ascites, omentum,peritoneal surface, pelvis and liver
for any metastasis. Assess the regional lymph nodes for any enlargements. Palpate the rest of
the large gut for any evidence of synchronous growth.
Assess the rectal growth for deciding about resectability. If the tumor is fixed to the prostate,
seminal vesicle or the growth is fixed to the sacrum posteriorly, it is not wise to procced with
resection.
Mobilization of sigmoid colon: The sigmoid colon is lifted up and towards the right. The left leaf
of the mesosigmoid is incised at its apex and the incision is carried upwards up to the sigmoid
colon and descending colon junction and carried distally up to the base of the bladder in male
(in female up to the lateral margin of posterior vaginal wall). During this dissection, the left
ureter crossing the sigmoid mesocolon is taken care of. The sigmoid colon is lifted up from the
posterior pelvic wall by sharp disection. The sigmoid colon is then retracted up and towards
the left and the right leaf of the mesosigmoid is incised. This incision is carried up up to the
bifurcation of the aorta and carried below around the lateral pelvic wall up to the base of the
bladder in male (in female up to the lateral margin of posterior vaginal wall).While doing so
the right ureter is taken care of. The peritoneal incision is joined anteriorly across the base of
the bladder in male and in female around the posterior vaginal wall.
Ligation of inferior mesenteric vessels and lymphatic dissection: The inferior mesenteric artery
is dissected close to its origin at the aorta and the lymph nodes around are dissected towards
the colon. The inferior mesenteric artery is dissected beyond the origin of the left colic artery,
ligated and divided. The inferior mesenteric vein is dissected near the duodenojejunal flexure,
ligated and divided close to the lower border of the pancreas.
The lymphatic tissue around the origin of inferior mesenteric artery and lymph nodes around
the bifurcation of the aorta and the common iliac vessels are taken down towards the specimen.
The intervening mesentery is divided.
• Mobilization of the mesorectum and the rectum: This is the most important step in
abdominoperineal resection
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• Posterior or presacral dissection: The mobilized sigmoid colon is drawn upwards and
forwards which opens up the presacral space.The avascular areolar tissue which surrounds
the mesorectum is identified and divided by sharp dissection. This dissection is initially
carried downwards in the midline along the curve of the sacrum up to the coccyx. Beyond
this, the dissection carried forwards in front of the anococcygeal raphe dividing the
waldeyer’s fascia. This dissection has to be done in proper plane preserving the presacral
vessels and nerves.
• Lateral dissection: The dissection from the posterior midline is carried around the lateral wall
of the mesorectum and sharp dissection is done along the lateral pelvic wall.The dissection is
first done on the left side and the lateral ligament is put on stretch by retracting the rectum
towards the right. A right angled forceps is used to dissect the lateral ligament and the right
angled forceps is passed around the lateral liagment which is divided by using diathermy.
Sometimes the middle rectal vessles runing along the lateral ligament needs ligature and
division. With similar maneuver the right lateral ligament is divided. While dividing the
lateral ligament the ureter and the hypogastric nerves are taken care of to prevent injury
to these structures.
• Anterior dissection: The anterior dissection is different in male and female patients.
In male patient: The bladder is retracted anteriorly by a Llyod Davis retractor or a Deavers
retractor and the peritoneumm lining the rectovesical pouch is incised. This peritoneal incision
is extended laterally to the lateral pelvic wall. The posterior leaf of the incised peritoneum along
with the Denonvillier’s fascia is picked up a long hemostatic forceps and retracted in an upwards
and posterior direction. By sharp dissection (using diathermy or a Metzenbaum scissor), the
rectum along with the mesorectum is separated from the seminal vesicle and the prostate. Few
bleeding vessels during this dissection may be controlled by diathermy.
In female: Then uterus is retracted anteriorly and the peritoneum of the rectouterine pouch
(Pouch of Douglas) is incised and the incision is carried on either side to the lateral pelvic wall.
The posterior leaf of the incised peritoneum along with Denonvillier’s fascia is picked up by a
long hemostatic forceps and retracted in a posterior and cephalad direction and the rectum
along with mesorectum is separated from the cervix and the posterior vaginal wall, Small
bleeding during this dissection may be controlled by using diathermy.
Division of sigmoid colon: The point of division of sigmoid colon is 7 cm proximal to the
proximal margin of the growth. Adequate length of sigmoid (about 5 cm) is required to create
an end sigmoid colostomy. At the proposed site of sigmoid transection, the marginal artery is
dissected, ligated and divided. Two pairs of intestinal occlusion clamps are applied and the
sigmoid colon divided inbetween using cutting diathermy.
Perineal dissection: The perineal dissection ideally starts when the abdominal surgeon has
decided about the resectability of the tumor and the abdominal and perineal dissection should
proceed simultaneously.
A purse string suture is applied around the anal orifice.
Perineal incision: An elliptical incision is made around the anal orifice and the incision is
extended anteriorly 3–4 cm from the anal verge and posteriorly the incision is extended up to
the tip of the coccyx.
Lateral dissection: The medial leaf of the incised skin margin is lifted up and medially by using
a pair of Allis tissue forceps and the lateral skin leaf is retracted laterally by using a skin hook.
The incision is deepened into the perirectal fat up to the pelvic diaphragm (Levator ani). The
anterior and posterior branches of inferior hemorrhoidal vessels which runs in the ischiorectal
fossa below the levator ani are coagulated and divided.This dissection is done on either side.
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Posterior dissection: The posterior leaf of the skin margin is lifted up posteriorly and the incision
is deepened down. The anococcygeal ligament is divided using diathermy.A dense layer of
fascia (Waldeyer’s fascia attaches the posterior rectum and mesorectum to the presacral
and precoccygeal area. The anal canal is lifted and the Waldeyer’s fascia is divided using
electrocautery and this dissection is continued upwards in the presacral space till the perineal
surgeon reaches the area reached by the abdominal surgeon.
Division of levator ani: The index finger is inserted through the presacral area and the finger
is swept across the superior aspect of the levator ani muscle on each side of the pelvis and
levator ani muscle is divided on either side of the lateral pelvic wall. The puborectalis muscle
is also divided.
Anterior dissection: The anterior incision is deepened along a plane at the posterior border of
deep transverse perinei muscle. The rectourethralis muscle is divided.
In male: The attachment of anterior mesorectum to the prostate and seminal vesicle has already
been divided by the abdominal surgeon. The remaining attachement of the anterior mesorectum
to the neck of the prostate is dissected from the perineal side. Once the mesorectum is dissected
all around the specimen is now free to be removed from the perineal side.
In female: The attachment of the anterior mesorectum to the posterior vaginal wall is divided
till the area reached by the abdominal surgeon is met. Once the mesorectum is dissecteds all
around the specimen is removed from the perineal side.
Closure of the perineal incision: The perineal wound is irrigated. A suction drainage tube is placed
in the perineal wound which is brought out through the posterior aspect of the perineal wound.
The muscles of the pelvic floor does not require to be sutured in the midline.The ischiorectal fat
pad and subcutanoeus tissue of the pelvis is apposed with 2-0 polyglactin sututres.
Skin is apposed with interrupted 2-0 monofilament polyamide suture. The skin may also be
apposed by subcuticular suture. (If there is gross contamination, the perineal wound may be
kept open by placement of a gauze pack.)
Constructiuon of end sigmoid colostomy: The ideal site of colostomy should be marked before
the operation starts. The colostomy should be located in left lower quadrant of the abdomen.
The colostomy should be placed at the junction of medial 1/3rd and lateral 2/3rd junction
of left spinoumbilical line. At the site of proposed colostomy, the skin is picked up by a pair
of Allis tissue forceps and a circle of skin is excised appropriate to the diameter of colon. The
subcutaneous tissue is incised.
A cruciate incision is made over the anterior rectus sheath. The rectum abdominis muscle is
split by using a straight hemostatic forceps.
The posterior rectus sheath is picked up by 2 pairs of hemostatic forceps and the posterior rectus
sheath along with peritoneum is incised.
The cut end of the sigmoid colon is brought out through this wound by using a Babcock’s tissue
forceps, taking care so that there is no rotation of the end of the sigmoid colon. The colon is
fixed to the anterior rectus sheath using interrpted 2-0 polyglactin sutures. The colostomy is
constructed by taking interrupted suture with 3-0 polyglacitn suture, taking all coats of the
sigmoid colon and the subcutaneous tissue.
Closure of lateral space: The lateral space between the exteriorized sigmoid colon is obliterated
by taking few interrupted suture between the seromuscular coat of the sigmoid colon and
the posterior parietal peritoneum. This prevents development of internal herniation in
postoperative period.
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Abdominal closure: The pelvic cavity is irrigated with normal saline. The pelvic peritoneum is
apposed by suturing with 2-0 polyglactin sutures.
The surgical peritoneum and linea is apposed by suturing with No. 1 polypropylene or No. 1
PDS suture. The skin is apposed with interrupted monofilament polyamide sutures.
StepS of tranSverSe coLoStomy
Describe the steps of transverse colostomy.
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indications of transverse colostomy:
• to relieve left colonic obstruction.
• For fecal diversion to safeguard against leakage following low anterior resection or left
colonic anastomosis.
• Fecal diversion in patient with rectovaginal fistula or Hirschsprung’s disease.
Anaesthesia: General anesthesia. May also be done under regional or local anesthesia.
Position of patient—supine.
Antiseptic cleaning and draping.
Skin incision: The site of the colostomy should be planned well before the operation. The ideal
site of right transverse colostomy is at the right upper quadrant of the abdomen at a point
midway between the right subcostal margin and the umbilicus over the rectus abdominis
muscle.
A transverse incision is made at a point midway between the right costal margin and the
umbilicus. The incision extends medially 2 cm to the right of midline and laterally extending
just beyond the lateral border of the rectus sheath. The subcutaneous tissue is incised in the
same line.
Incising the anterior and posterior rectus sheath and the peritoneum: A cruciate incision is
made over the anterior rectus sheath. The rectus abdominis muscle is exposed. The rectus
abdominis muscle is split by inserting a Kelly hemostatic forceps and the posterior rectus
sheath is exposed. The posterior rectus is lifted up by two pairs of hemostatic forceps and
incised inbetween. The peritoneal opening is stretched by inserting two fingers.
Delivery of the transverse colon: The transverse colon is identified by looking at taenia coli,
haustration and attachment of the greater omentum and transverse mesocolon.The greater
omentum attached to the transverse colon is divided close to the colon for about 6–7 cm and
the transverse mesocolon is identified. The antimesenteric border of the transverse colon
is held up by a pair of Babcock forceps and delivered out in the wound. The loop of colon
should remain out of the wound without any tension.
Insertion of a colostomy device through the transverse mesocolon: The transverse colon is
pulled up and a rent is made in the transverse mesocolon in an avascular area close to the
mesenteric border of the colon and a plastic colostomy device is passed through the rent to
keep the colon in place so that it does not retract.
Fixation of the colon: The projecting colon is fixed to the anterior rectus sheath by few
interrupted suture using 2-0 polyglactin sutures.
Construction of colostomy: A 5 cm long incision is made in the colon along the taenia coli.
The edges of the colon are turned back and the cut margin of the colon is sutured to the
subcutaneous tissue by interrupted 3-0 polyglactin sutures.
A colostomy bag may be applied to the skin around the colostomy so that the opening in the
bag snugly fits around the opened up colon.
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Skin closure: The remaining skin incision site is apposed by interrupted monofilament
polyamide suture.
StepS of cLoSure of coLoStomy
Describe the steps of closure of colostomy.
Before closure of colostomy the primary cause has to be treated.
The distal colon should be assessed by either colonoscopy or radiographic examination with
barium (distal cologram) to assess patency of the distal colon up to the rectum.
„ Anaesthesia: Regional anesthesia.
„ Antiseptic cleaning and draping.
„ Mobilization of the colostomy: 6-8 interrupted 3-0 mersilk sutures are inserted around the
mucocutaneous junction of colostomy. These sutures are kept long and held up by a number
of haemostatic forceps for traction. An incision is made around the edge of the colostomy
taking about 2 mm fringe of skin around the colostomy. if required, the incision may be
extended on either side in a transverse plane.
traction is applied in the sutures already placed around the colostomy, and the colon
is dissected all around up to the rectus sheath. The dissection is done further up to the
peritoneum and the peritoneum is opened all round and the colon is mobilized well.
„ Freshening the margin of colostomy: The fringe of skin around the colostomy is excised up to
the margin of mucosa and the mucosa of the colon is freed all around.
„ Closure of colon: The incision in the colon is closed with interrupted sutures taking all coats
with 3-0 polydioxanone suture. The apposition may also be done with interrupted sutures
taking the seromuscular coats (extramucosal stitch).
„ Closure of abdominal wound: Single layer closure of posterior and anterior rectus sheath
with runing 1 PDS suture.
Skin apposed with interrupted monofilament polyamide sutures.
Step of appenDicectomy
Describe the steps of appendicectomy.
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General anesthesia with endotracheal intubation (Appendicectomy may also be done under
regional anesthesia—spinal or epidural).
Position of the patient—supine.
Antiseptic cleaning and draping.
Incision: McBurneys’ gridiron incision. An oblique skin incision of about 3 inches (one
inch above and two inches below the spinoumbilical line) is made at right angle to the
right spinoumbilical line passing through the McBurneys’ point (Fig. 22.9A). The skin and
subcutaneous tissues are incised in the same line.
Division of external oblique aponeurosis: A nick is made in the external oblique aponeurosis
and the external oblique aponeurosis is incised along the direction of its fibers (Fig. 22.9B).
Splitting internal oblique and tranisversus abdominis muscle: The internal oblique muscle is
exposed and deep to it lies the transversus abdominis muscle. A Mayo’s scissor is thrushed
with the blades closed through the internal oblique and the transversus abdominis muscle
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figures 22.9a to h: Steps of appendicectomy
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and the blades are opened up to split both these muscles along the direction of their fibers
(Fig. 22.9c).
Incising the peritoneum: two Langenbachs’ retractors are inserted deep to these muscles
and the peritoneum is exposed. The peritoneum is lifted by two pairs of hemostatic forceps
and a nick is made in the peritoneum and the peritoneal incision is then extended along the
line of skin incision (Fig. 22.9D).
Identifying the cecum: As soon as peritoneum is opened turbid or clear fluid may escape from
the peritoneal cavity (This fluid may be due to peritoneal reaction to local inflammation).
The cecum is identified by its pale color, presence of taenia coli and absence of mesentery.
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Delivering the cecum and the appendix: The caecum is delivered into the wound by holding it
with a plain dissecting forceps. The caecum is grasped with a moist sponge and is delivered
into the wound further when the appendix will come into view. if appendix is not visible,
follow the anterior taenia coli in the caecum which will guide into the base of the appendix.
Division of the mesoappendix: The appendix is held by Babcock’s tissue forceps—one applied
near the tip, one applied at the body of the appendix and another Babcock’s tissue forceps
applied at the base of the appendix. The mesoappendix is clamped with one or more pair of
hemostatic forceps and divided and ligated. Alternatively a mosquito hemostatic forceps is
thrushed through an avascular area in the mesoappendix near its base and a ligature passed
around the mesoappendix and ligated. The mesoappendix attached toward the appendix is
then divided (Fig. 22.9e).
Division of the base of appendix: The base of the appendix is crushed by applying a hemostatic
forceps. A ligature of 1-0 chromic catgut is then passed around the base of the appendix at
the crushed area and the base of the appendix is ligated. A hemostatic forceps is applied at
the appendix about 5 mm distal to the site of ligature at the base of appendix. The appendix
is divided with a knife close to the forceps and the stump of the appendix is swabbed with
povidone iodine lotion (Fig. 22.9F).
The appendix, swab, knife with the hemostatic forceps which are contaminated are kept in
a bowl and removed from the operation field.
Burying the base of appendix: Most surgeons do not invert the base of appendix routinely. if
the stump of the appendix is to be inverted, a purse string suture is applied on the cecal wall
around the base of the appendix. The stump of the appendix is held by a dissecting forceps
and the purse string suture is tightened and the stump of the appendix is inverted as the
purse string suture is tied (Figs 22.9G and H).
Check for hemostasis: The mesoappendix stump is checked for bleeding.
Look for Meckel’s diverticulum: Bring out the terminal ileum and look up to two feet from the
ileocaecal junction to exclude any associated Meckel’s diverticulum.
Closure: The wound is closed in layer.
What is retrograde appendicectomy?
When the appendix is retrocecal, the tip may not be accesssible easily. if the base is easily
accessible a retrograde appendicectomy is preferred in such situation.
the base of the appendix is dissected by passing a hemostatic forceps through the
mesoappendix . The base of the appendix is crushed by a hemostatic forceps applied around the
base of the appendix. The crushed base of the appendix is then ligated with 1-0 chromic catgut
sutures. A hemostatic forceps is applied 5 mm distal to the ligature at the base of the appendix
and the appendix is divided inbetween. The mesoappendix is then held between the hemostatic
forceps and divided and ligated from the base up to the tip. once whole of the mesoappendix
is ligated the appendix becomes free and is removed.
When you should not crush the base of appendix during appendicectomy?
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if the appendix is gangrenous.
if there is perforation at the base of the appendix.
if the base of appendix and the caecum is edematous.
How many ports are required for laparoscopic appendicectomy?
Three ports are required:
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infraumbilical 10 mm port—for telescope and the camera.
one 5 mm port in the right iliac fossa.
one 10/5 mm port in left iliac fossa or suprapubic area.
SpLenectomy
What are the indications of splenectomy?
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Splenic trauma: Severe degree of splenic injury requires splenectomy. Mild splenic trauma
may be managed with splenic conserving surgery.
chronic hemolytic diseases like hereditary spherocytosis, thalassemia, sickle cell anemia.
idiopathic thrombocytopenic purpura.
Hypersplenism causing pancytopenia due to portal hypertension, lymphomatous infiltration
or in leukemias.
Splenic cysts, splenic abscess or tumors.
incidental splenectomy in association with radical gastrectomy or shunt surgery for portal
hypertension.
Steps of splenectomy
Anesthesia: General anesthesia with endotracheal intubation.
„ Position of the patient: Supine with a sand bag placed under the left side of the chest.
„ Incision: Approach is either by a long midline or left subcostal incision (see abdominal
incision).
„ Exploration: The spleen is examined. The liver, gallbladder and the bile duct are examined.
in hemolytic anemias there may be stones in the gallbladder or in the common bile duct.
Thorough exploration of the abdomen is to be done for presence of any splenunculi or
lymphadenopathy.
„ Mobilization of the spleen: The left hand is passed between the spleen and the diaphragm
and the spleen is drawn toward the abdominal incision. This maneuver brings the lieno-renal
ligament in view. The posterior leaf of the lienorenal ligament is incised with the scissors and
the spleen is mobilized and delivered into the abdominal wound.
„ Division of splenic vessels: As the spleen is mobilized into the wound, the posterior surface of
the hilum of the spleen is dissected. The splenic vein and artery come into view. The splenic
artery is seen running along the upper border of the pancreas. The splenic artery is dissected
using a right angle forceps and three ligatures of no. 1 silk are passed around the artery and are
ligated. The splenic artery is divided inbetween the ligatures keeping two ligaturestoward the
proximal side. The splenic vein is dissected carefully taking care not to injure the pancreatic
tail. Three ligatures are passed around the splenic vein and the ligatures are tied. The splenic
vein is divided keeping two ligatures toward the portal vein side.
„ Division of short gastric vessels: The short gastric vessels run in the gastrosplenic ligament.
The gastrosplenic ligament is divided inbetween series of hemostatic forceps and ligated
with no. 1-0 silk.
„ Division of anterior leaf of lienorenal ligament: once the gastrosplenic ligament, splenic
vessels are divided and the pancreatic tail is dissected from the splenic hilum, the anterior
leaf of the lienorenal ligament is exposed. This is usually avascular and may be divided with
the scissors.
The spleen is now free to be removed.
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Placement of drain and closure: A suction drain is kept in the splenic bed and the abdomen
is closed in layers.
Postoperative management
„ intravenous fluid to maintain hydration. iV fluid is continued till bowel sounds return.
This usually takes about 48–72 hours.
„ nasogastric aspiration.
„ Prophylactic antibiotics.
„ Vaccination against Pneumococcal and H. influenza infection.
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nephrectomy
What are the indications of nephrectomy?
carcinoma of kidney
Severe renal injury with avulsion of renal pedicle
„ Hydronephrosis with nonfunctional kidney
„ Renal calculus with gross destruction of kidney
„ chronic pyelonephritis
„ Pyonephrosis of kidney
„ Donor nephrectomy for transplantation.
Nephrectomy through a loin incision:
„ Anesthesia: General anesthesia with endotracheal intubation.
„ Position of the patient: For approach to the right kidney, patient lies in left lateral position.
The upper arm is supported on an arm rest and is used for venous cannulation and blood
pressure measurements. The left lower limb is kept flexed at the hip and knee to 90 degrees
and the right lower limb is kept extended supported on a pillow kept between the two legs.
The area between the right costal margin and the iliac crest is opened by lifting the kidney
bridge and breaking off the table towards the leg end. The position is maintained by a leather
strap or a broad band of adhesive strap fixing the iliac crest and the greater trochanter to the
operation table. The right shoulder is also anchored to the operation table by adhesive strap.
„ Antiseptic dressing and draping?
„ Skin incision: The skin incision starts from the angle between the 12th rib and the lateral
border of the erector spinae muscles and passes downward and forward about 1 cm below
the 12th rib to a point about 2 cm above and anterior to the anterior superior iliac spine up to
the lateral border of the rectus sheath.
The subcutaneous tissue is incised in the same line.
„ Division of superficial muscles: in the posterior part of the wound, the latissimus dorsi muscle
is incised. in the anterior part of the wound, the external oblique muscle and the aponeurosis
is incised.
in the posterior part of the wound once the latissimus dorsi is incised the serratus posterior
inferior muscle is exposed. The serratus posterior inferior muscle is also incised. At the
anterior part of the incision, the internal oblique muscle and aponeurosis is incised in the
same line.
„ Division of thoracolumbar fascia: An incision is made in the thoracolumbar fascia taking care
not to injure the subcostal nerve. The incision is carried backward up to the lateral border of
the erector spinae muscle. Using a Gallies swab, with blunt dissection the parietal peritoneum
is stripped off from the transversus abdominis muscle.
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the transversus abdominis muscle is divided by carrying forward the incision in the
thoracolumbar fascia. Hemostasis is secured.
Exposure of perinephric space: The cut margins of the thoracolumbar fascia is retracted and
the parietal peritoneum is further stripped off medially and the perinephric space is exposed.
Incision of perirenal fascia: The perirenal fascia (fascia of Gerota) is lifted at the lateral aspect
with two pairs of hemostatic forceps and incised with a knife inbetween the hemostatic
forceps. The incision in the perirenal fascia is then extended with a scissors.
Exposure of the kidney: once the perirenal fascia is incised the pale yellow perinephric fat is
exposed and deep to this fat lies the kidney.
Mobilization of kidney: By blunt finger dissection, the kidney is mobilized. The lower pole,
posterior surface and the anterior surface of the kidney are mobilized. There may be an
accessory artery and vein at the lower pole while mobilizing. These vessels should be clamped
and divided.
Division of the ureter: The upper ureter is identified, dissected and divided inbetween clamps
and the cut ends are ligated. The proximal ureter is followed up to the hilum.
Division of the renal vessels: The renal artery lies posterior to the renal vein and approach
from the posterior aspect will allow better tackling of the artery. The artery should be ligated
before the vein to avoid congestion of blood in the kidney. A right angle forceps is used to
dissect and pass ligatures around the artery. Three ligatures are passed and the vessel is triply
ligated. The renal artery is divided keeping two ligatures toward the proximal side.
The renal vein is similarly dissected, triply ligated and divided keeping two ligatures toward
the inferior vena cava side.
Mobilization of the upper pole of the kidney: After the renal vessels are ligated and divided,
the upper pole is mobilized separating the adrenal from the upper pole of the kidney by blunt
dissection taking care to avoid injury to the adrenal gland.
Check for hemostasis: After the kidney is removed, the renal fossa is exposed well and
inspected carefully to look for any bleeding which may be controlled with diathermy or
ligature. A tube drain is kept in the renal fossa.
closure of the incision:
• closure is done in layers:
− transversus abdominis muscle with running 0 chromic catgut or vicryl sutures
− internal oblique and serratus posterior inferior with running 0 chromic catgut or vicryl
sutures
− external oblique and latissimus dorsi with running 0 chromic catgut or vicryl sutures
− Skin closed with interrupted monofilament polyamide sutures.
StepS of moDifieD raDicaL maStectomy
Describe the steps of modified radical mastectomy (Patey).
General anesthesia with endotracheal intubation
Patient is placed supine with the arm on the operated side supported on an arm table.
Antiseptic cleansing and draping.
The position of the lump is delineated.
Skill incision (Fig. 22.10A): A transverse elliptical skin incision is made encircling the nipple and
areola and encompassing 5 cm of skin margin around the mass.
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figures 22.10a to f: Modified radical mastectomy
Raising of skin flaps (Figs 22.10B and C): The skin flaps are raised by sharp dissection with scalpel
or scissor in the plane between the subcutaneous fat and the mammary fat. The upper skin flap
is raised up to the clavicle and the lower skin flap is raised up to the upper quadrant of the rectus
sheath. The bleeding points are coagulated with diathermy taking care to avoid burn of the skin.
Raising the breast (Fig. 22.10D): The uppermost part of the breast is dissected off from the
fascia covering the pectoralis major. A cleavage is created between the breast tissue and the
fascia covering the pectoralis major and the whole breast is lifted off from the pectoralis major
fascia. The perforating vessels on the medial side is controlled with diathermy or are ligated. The
breast is lifted above from the level of the clavicle, below up to the upper quadrant of the rectus
sheath, medially up to the midline and laterally up to latissimus dorsi. The breast is allowed to
hang laterally keeping the axillary tail of the breast in continuity with the axillary lymph nodes.
Axillary dissection (Fig. 22.10E): The lateral border of the pectoralis major is cleared of the loose
areolar tissue and all the loose areolar tissue and level i lymph nodes in the axilla are cleared
taking care not to injure the axillary vessels and the nerves. The pectoralis minor muscle is
dissected and it is divided from its insertion into the coracoid process. The level ii and iii lymph
nodes are then dissected off from the axilla. The lateral dissection is carried up to the anterior
border of the latissimus dorsi. The clearence of the lymphatics and the loose areolar tissue is
kept confined to the anterior and inferior aspect of the axillary vein and no attempt is made
to clear the structures above the vein. The structures so separated are dissected away from the
chest wall by dissection using a peanut swab. The nerve to serratus anterior is identified along
the lateral chest wall and preserved. nerves to latissimus dorsi is identified running along the
subscapular vessels and preserved. The intercostobrachial nerve is dissected and preserved.
Hemostasis is secured.
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Closure (Fig. 22.10F): A suction drain is inserted—one tube kept in the axilla and another tube
kept underneath the breast flap. The skin incision may be closed with a subcuticular sutures or
interrupted silk or nylon sutures. After skin closure the vacuum drain is activated and fluid is
squeezed out from beneath the skin flaps and the skin flaps adheres to the chest wall.
What structures are to be preserved during modified radical mastectomy?
1. Long thoracic nerve (supplies serratus anterior).
2. Thoracodorsal nerve (supplies latissimus dorsi).
3. cephalic vein.
4. Axillary vein.
StepS of LumBar Sympathectomy
Describe the steps of lumbar sympathectomy.
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Anesthesia: General anesthesia with endotracheal intubation.
Position of patient: Supine with slight tilting by placing a pillow behind the loin on the side
of operation.
Antiseptic dressing and draping.
Incision: An oblique lumbar incision starting from the lateral border of the erector spinae
and then extended medially up to the lateral border of the rectus abdominis. The skin and
the subcutaneous tissues are incised in the same line.
Division of abdominal flat muscles and aponeurosis: the external oblique muscle and
aponeurosis are incised in the same line as skin incision.
The internal oblique and the transversus abdominis muscles are cut in the same line.
Stripping of the peritoneum: once the flat muscles are divided, the extraperitoneal fatty tissue
and the peritoneum is exposed. This layer is stripped off medially by dissecting with a swab
taking care not to open the peritoneum. if the peritoneum is opened inadvertently, it should
be sutured with 1-0 chromic catgut sutures.
Identification of the sympathetic chain: The sympathetic chain is situated in the lateral side
of the body of the lumbar vertebrae medial to the medial margin of the psoas muscle. on the
right side, this is overlapped by the inferior vena cava and on the left side this is overlapped
by aorta.
The sympathetic chain is identified by the presence of ganglia and the rami communicantes
passing from the ganglia. The first lumbar ganglion is situated high up under cover of the crus
of the diaphragm and contains both gray and white rami communicantes. The white rami
communicans carries the preganglinic fibers and the gray rami communicantes carries the
postganglinic fibers.
For complete sympathetic denervation of the lower limb the l st, 2nd, 3rd and 4th lumbar
ganglia are to be removed. if bilateral sympathectomy is contemplated, the 1st lumbar
ganglion on one side is to be preserved. Bilateral division of 1st lumbar ganglion will result
in sterility due to paralysis of the ejaculatory mechanism.
Dissection of the sympathetic chain: The first lumbar ganglion is identified and dissected by
using a right angled forceps and divided inbetween ligatures. The sympathetic trunk is then
dissected downwards up to the 4th lumbar ganglia lying behind the common iliac vessels
and divided in between ligatures at this point. While dissecting the sympathetic chain some
lumbar vessels might need ligature and division.
Closure of incision in layers.
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StepS of totaL thyroiDectomy
Describe the steps of total thyroidectomy
Anesthesia: General anesthesia with endotracheal intubation.
Position of patient: Patient is supine, neck extended by placing a pillow in—between the shoulder
blades and head resting on a ring.
Dressing and draping: Povidone iodine painting done from the level of the chin to the upper
chest. Three towel draping done for the head and operative area isolated by further placement
of draping.
Incision: The approach is through a cervical collar incision made 2 cm above the suprasternal
notch extending from posterior border of one sternocleidomastoid to the posterior border of
opposite sternocleidomastoid. The skin incision is marked by pressing with a thread on the skin
(Garrotte mark). The collar incision is made, the skin, superficial fascia and platysma are cut.
The platysma is incised at a little higher level than the skin (Fig. 22.11A).
Raising the skin flaps: The upper skin flap, superficial fascia and the platysma is dissected and
the upper flap is raised up to the upper border of the thyroid cartilage. The lower flap of skin,
superficial fascia and the platysma is raised up to the suprasternal notch (Fig. 22.11B).
Incision of deep cervical fascia: The investing layer of the deep cervical fascia is incised in the
midline. if the anterior jugular veins come on the way, these may be ligated and divided (Fig.
22.11c).
Raising the fascial and strap muscles flap: The investing layer of the deep cervical fascia along
with the strap muscles are lifted up from the thyroid gland to expose the lateral lobes of the gland
covered by the pretracheal fascia (Fig. 22.11D). The pretracheal fascia is incised and the finger
passed around the plane between the pretracheal fascia and the thyroid gland. if the enlarged
lobes are large, the strap muscles may be divided at a upper level as the nerves enters the strap
muscles from below.
Division of the middle thyroid vein: The thyroid lobe is mobilized medially and the middle thyroid
vein is identified passing from the middle of the lateral lobe to the internal jugular vein. The
middle thyroid vein is dissected and divided in between ligatures (Fig. 22.11e).
Division of superior thyroid vessels: The muscles are retracted upwards and laterally and the
superior pole of lateral lobe of thyroid is exposed. The superior thyroid vessels are dissected close
to the upper pole of the lobe. The superior thyroid artery and vein should be ligated separately.
Three ligatures are passed around the superior thyroid artery, ligated and divided keeping two
ligatures towards the proximal side. The superior thyroid vein is ligated and divided similarly.
care should be taken to avoid damage to external laryngeal nerve (Fig. 22.11F).
Division of inferior thyroid artery: The gland is retracted medially and the branches of the inferior
thyroid artery are identified entering the lower pole of the thyroid lobe. At this stage the recurrent
laryngeal nerve is identified running vertically up along the tracheoesophageal groove. The
parathyroid glands are identified and preserved. The individual branches of the inferior thyroid
artery are identified and divided in between ligatures (Fig. 22.11G).
Division of inferior thyroid veins: The inferior thyroid veins emerge from the lower pole of the
lateral lobe. These veins are dissected and divided in between ligatures.
The dissection on the other side now divides the middle thyroid vein, superior thyroid vessels,
inferior thyroid artery branches and the inferior thyroid veins in the same way as done above.
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H
figures 22.11a to h: Steps of subtotal thyroidectomy
Dissection of the thyroid isthmus: The thyroid isthmus is dissected free from the trachea by using
a thyroid dissector. Arteria thyroidea ima if present should be dissected,ligated and divided.
once these vessels are ligated and divided, thyroid lobes and isthmus are attached to the
larynx and trachea by pretracheal fascia and Berry’s ligament. The small vessels from tracheal
and esophageal branches are cauterized and divided. The pretracheal fascia and Berry’s ligament
is then divided taking care not to injure the recurrent laryngeal nerve.
Control of bleeding and placement of drain: All bleeding points are checked and bleeding
controlled with ligatures or diathermy coagulation. two suction drainage tubes are kept one
each at the sites of resected lobe.
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Closure: The investing layer of the deep fascia is apposed with interrupted 3-0 polyglactin sutures.
The platysma is apposed with 3-0 polyglactin sutures. The skin is apposed with interrupted
monofilament sutures or by subcuticular sutures.
StepS of Left hemithyroiDectomy
Describe the steps of left hemithyroidectomy.
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Anesthesia: General anesthesia with endotracheal intubation.
Position of the patient: Patient supine with neck extended by placing a sand bag inbetween
the shoulder blades, head resting on head ring. The head end is elevated by about 15 degrees
to reduce the venous congestion.
Antiseptic dressing and draping: Antiseptic cleaning with povidone iodine from chin to
midchest. Three towel draping for head area. A Mayo’s table is placed over the chest area
and draping done by placement of jaconate and sterile sheets.
Incision: cervical collar incision along the skin crease 2 cm above the suprasternal notch
and extending from posterior border of one sternocleidomastoid to the posterior border of
opposite sternocleidomastoid. The skin incision is marked by pressing the line of incision
with a black silk thread (Garrotte mark).
The skin and subcutaneous tissue is incised and the platysma muscle is incised at little higher
level along the same line of skin incision.
Raising of skin flaps: Both the upper and lower skin flaps is to be raised.
The upper skin flap is lifted up by applying a pair of sharp skin hook and dissection is carried
out in subplatysmal plane and the upper skin flap is lifted up up to the upper border of thyroid
cartilage.
The lower skin flap is lifted up similarly and the dissection done in subplatysmal level up to
the suprasternal notch. Small bleeding vessels may be controlled with electrocautery.
Incising the investing layer of deep cervical fascia: once the skin flaps are raised these are held
up by applying a pair of Joll’s thyroid retractor and the skin flaps are retracted by opening
the Joll’s thyroid retractor. A nick is made in the investing layer of deep cervical facia in the
midline. The cut margins are picked up by two pairs of hemostatic forceps and the incision
extended above up to the upper border of thyroid cartilage and below up to the suprasternal
notch. if the anterior jugular vein comes in the way, this may be ligated and divided.
Exposure of the thyroid lobe: The investing layer of deep cervical fascia is picked up by a
number of haemostatic forceps and the strap muscles (superficial—sternohyoid, omohyoid
and the deeper sternothyroid) are lifted up from the thyroid lobe by blunt dissection. once
this is done, the thyroid lobe covered by pretracheal fascia is exposed.
if the thyroid lobe is hugely enlarged, for proper exposure the strap muscles may be divided
transversely at a higher level (as the nerve supply comes from below)
Incising the pretracheal fascia: The pretracheal fascia covering the thyroid lobe is picked up
by hemostatic forceps and incised. A plane is created between the pretracheal fascia and the
thyroid lobe on the side to be operated.
Division of middle thyroid vein: This is the first vessel to be tackled in thyroidectomy as it is a
slender vessel and is a direct tributary of internal jugular vein. The thyroid lobe is retracted
medially and the middle thyroid vein is identified emerging from the middle of the thyroid
lobe runing transversely into the internal jugular vein. The vein is dissected by a right angled
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Operative Surgery
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forceps and two ligatures are passed around the vein, ligated and the vein is divided in
between two ligatures.
Division of superior thyroid vessels: The strap muscles are retracted laterally and the thyroid
lobe is retracted downwards and medially to expose the superior pole of the lateral lobe
of the gland.The superior thyroid vessels are dissected close to the upper pole of the gland
taking care not to injure the external laryngeal nerve. The superior thyroid artery and vein
should be ligated separately. Three ligatures are passed around the superior thyroid artery,
ligated and divided keeping two ligatures towards the proximal side. The superior thyroid
vein is ligated and divided similarly.
Division of inferior thyroid artery: The earlier concept was to tie the inferior thyroid artery away
from the gland to avoid injury to the recurrent laryngeal nerve. However, this is associated
with higher incidence of parathyroid infarction.
• The recent concept is to ligate the individual branches of the inferior thyroid artery close
to the gland. The thyroid lobe is retracted further medially and the parathyroid gland and
the recurrent laryngeal nerve is identified runing in the tracheoeosphageal groove. The
individual branches of the inferior thyroid artery is dissected using a right angled forceps,
ligated and divided inbetween ligature, taking care not to injure the recurrent laryngeal
nerve.
Division of inferior thyroid vein: The inferior thyroid vein emerges from the lower pole of the
lateral lobe of the gland. The inferior thyroid veins are dissected with right angled forceps,
ligated and divided in between ligature.
Dissection of thyroid isthmus: The thyroid lobe is dissected from the trachea and esophagus
by dividing the pretracheal fascia and the Berry’s ligament (thickening of pretracheal fascia
attached to the cricoid cartilage)
• The thyroid lobe is lifted up and medially. Lower pole of the isthmus is dissected from
the trachea and if an arteria thyroidea ima is present, this is to be dissected, ligated and
divided. The isthmus is dissected from the anterior surface of trachea. A pair of hemostatic
forceps is applied at the junction of the isthmus with opposite lobe and the isthmus is
divided with a knife, taking care not to injure the underlying trachea. The cut margin of
the isthmus is overrun with 3-0 polyglactin sutures.
closure: check for hemostasis. Any bleeding needs to be controlled with diathermy or ligature.
Placement of drain: A suction drain is placed in the neck at the site of resected lobe.
closure: The investing layer of deep cervical fascia is approximated with interrupted 3-0
polyglactin sutures. The platysma is apposed by a runing 3-0 polyglactin suture. The skin is
apposed by subcuticular suture using 3–0 polyglactin.
StepS of SuperficiaL parotiDectomy
Describe the steps of superficial parotidectomy
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General anesthesia with endotracheal intubation.
Position of patient: Supine with neck extended by placing a sand bag below the shoulder blade.
Head resting on a head ring and turned to the opposite side of operation. Head end elevated
by 15 degree to reduce venous congestion. Eyes covered with a eye pad.
Antiseptic cleaning and draping.
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Incision: An S shaped cervico-mastoid-facial incision is made. The incision starts below the
zygomatic arch taken infront of the tragus turns around the ear lobule bending backwards to
the mastoid process and then curves downwards transversely in the skin crease of the neck.
Raising of skin flaps: The cervical, part of the incision is deepened first then the mastoid and
finally the facial part of the incision. The incision is deepened down to the subcutaneous tissue
and the platysma. The anterior skin flap is picked up by a sharp skin hook and the anterior skin
flap is raised by sharp dissection below the platysma up to the anterior border of the parotid
gland. Superiorly the skin flap is raised up to the zygomatic arch. The posterior skin flap along
with the ear lobule is lifted up to some extent to expose the sternocleidomastoid muscle (SCM)
and the mastoid processs, and cartilaginous part of the external auditory canal.
Exposure and dissection of the posterior margin of the parotid gland: The external jugular
vein is dissected ligated and divided at the lower pole of the gland. The great auricular nerve
exposed may be divided if required for ease of subsequent dissection. The dissection is done
between the anterior border of SCM and the posterior border of the parotid gland upwards
to reach up to the mastoid process. Small bleeding vessels along the anterior border of SCM
needs control with electrocautery. The SCM is retracted laterally to expose the posterior belly
of digastric and the stylohyoid muscle.
Identification of facial nerve: There is a dense layer of temporoparotid fascia which extends
from tympanomastoid fissure to the posterior border of parotid gland. This fascia is incised and
deep dissection is done along the anterior border of mastoid process. The assistant retract the
parotid gland medially. As the dissection is deepened there appears multiple small branches of
posterior auricular artery which needs electrocautery and division. The deep dissection is done
further to reach the junction of cartilaginous and bony part of the external auditory canal. The
facial nerve is identified emerging from the stylomastoid foramen lying infront of the styloid
process and at the junction of cartilaginous and bony part of the external auditory canal. The
nerve runs transversely or obliquely for about 1–2 cm and divides into temporofacial (upper)
and cervicofacial (lower) division and enters into the faciovenous plane of the parotid gland
dividing the gland into superficial and deep lobe.
Small bleeding vessels may be controlled with pressure packing or by use of bipolar diathermy.
Dissection of facial nerve branches: All the facial nerve branches are traced from the point of
entry of the nerve into the gland up to its exit from the anterior border of the gland. A curved
mosquito forceps with concavity upwards is pushed between the nerve branch and the parotid
tissue of the superficial lobe infront in small bits and the overlying parotid tissue divided using
scissors or bipolar cautery. This is continued up to the anterior border of the gland. All the
nerve branches are dissected in the same way. The zygomatic branch is traced up towards the
zygomatic arch at the upper pole of the gland and the cervical branch is traced at the lower
pole towards the neck. The other branches are traced to the anterior border of the gland.
Removal of superficial part of the gland: As all the nerve branches are dissected and the overlying
parotid tissue divided the whole of superficial part of the gland now lies free with attachement
of the parotid duct at the anterior border of the gland. The parotid duct is ligated at the anterior
border of masseter muscle and the superficial part of the gland is removed.
A suction drain is placed at the parotid fossa, brought out through a stab wound in the
anterior skin flap in the neck.
• Closure: Closure is done in single layer with interrupted 3-0 monofilament polyamide suture.
Alternatively the platysma may be apposed by 3-0 polyglactin suture and the skin apposed
by subcuticular suture using 3-0 polyglactin.
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StepS of SuBmanDiBuLar SiaLoaDenectomy
Describe the steps of submandibular sialoadenectomy
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Anesthesia: General anesthesia with endotracheal intubation.
Position of patient: Patient supine, neck extended by placing a sand bag inbetween shoulder
blades, head resting on head ring and chin turned to the opposite side. Head end elevated by
15 degrees to reduce venous congestion.
Antiseptic cleaning with povidone iodine and draping. Head area draped with three towel
technique.
Incision: A transverse neck crease skin incision is made 3–4 cm below the lower border of the
mandible medially extending up to 2 cm lateral to midline and laterally extending up to the
point below the angle of lower jaw.
Raising of skin flaps: The skin incision is deepened to incise the subcutaneous tissue, platysma
and the investing layer of deep cervical fascia. The upper skin flap is reflected up towards
the lower border of the mandible, taking the deep cervical fascia along with the skin flap
to prevent injury to the marginal mandibular branch of facial nerve. The lower skin flap is
similarly raised to expose the superficial lobe of the submandibular gland. While raising
the skin flaps the superficial vein including the anterior facial vein needs to be ligated and
divided.
Mobilization of superficial lobe of submandibular gland: The superficial lobe of the
submandibular gland is retracted superiorly and then lower pole of the gland is dissected
towards the posterior end. Towards the posterior end of the lower pole, the trunk of facial,
artery and vein are identified, dissected, ligated and divided. The superficial lobe of the gland
is mobilized by combination of sharp and blunt dissection. At the upper pole of the superficial
lobe of the gland, the facial artery and vein are again encountered, dissected ligated and
divided close to the gland.
Mobilization of the deep part of the gland: As the superficial lobe of the gland is mobilized the
posterior border of the mylohyoid muscle is identified and the mylohyoid muscle is retracted
to expose the deep part of the gland which lies between the mylohyoid and the hyoglossus
muscle. Multiple small vessels lying between mylohyoid and hyoglossus muscle needs division
with electrocautery.
Identification of lingual nerve: The deep part of the submandibular gland is retracted
downwards to identify the lingual nerve as a broad band of white tissue runing above the
submandibular duct.
The lingual nerve runs forward over the hyoglossus intially above the submandibular duct
and then crosses the superficial aspect of the duct and winds round the lower border of the duct
to cross its medial aspect from below upwards.
Dissection and division of submandibular duct: The submandibular duct emerges from the
anterior end of the deep part of the gland and runs on the hyoglossus muscle in close relation
to the lingual nerve. The submandibular duct is dissected up to, the floor of the mouth taking
care not to injure the lingual nerve and the hypoglossal nerve. The submandibular duct is
ligated with 2-0 polyglactin suture and divided close to the floor of the mouth. The lingual
nerve runs first above the submandibular duct then winds round it from lateral to medial side.
Removal of deep part of the gland: The deep part of the gland is mobilized and dissected off
from the hyoglossus muscle taking care not to injure the hypoglossal nerve which lies deep to
the deep part of the gland on the hyoglossus.
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Closure: Hemostasis secured. A suction drain is placed at the submandibular fossa. The
subcutaneous tissue with the platysma is apposed with runing 3-0 polyglactin suture. Skin
apposed with 3-0 polyglactin subcuticular suture or with interrupted suture using 3-0
monofilament polyamide suture.
StepS of type i moDifieD raDicaL neck DiSSection
Describe the steps of type I modified radical neck dissection.
(There are three types of modified radical neck dissection:
Type I: Radical Neck dissection with preservation of spinal accessory nerve.
„ Type II: Radical neck dissection with preservation of spinal accessory nerve and the internal
jugular vein.
„ Type III: Radical neck dissection with preservation of all three structures—spinal accessory
nerve (SAN), internal jugular vein (IJV) and the sternocleidomastoid muscle (SCM).
„ Anaesthesia: General anaesthesia with endotracheal intubation.
„ Position of the patient: Patient supine, arms on the sides of the body. Head turned to the
opposite side resting on a head ring and the head end elevated by about 15 degrees to reduce
the venous congestion.
Antiseptic dressing and draping: The antiseptic cleaning with povidone iodine from chin to the
midchest. Three towel draping for the head and draping of the remaining area by placement
of sterile sheets to expose the site of the operation.
„ Incision: For unilateral dissection a Y shaped incision is made. The horizontal limb of the Y
starts from the point below the chin and taken downwards towards the hyoid bone and then
curves upwards towards the mastoid process. The vertical limb of the incision starts from the
middle of the horizontal limb and and then continue downwards in an S shaped manner
and ends just above the clavicle. The skin incision is deepened to incise subcutaneous fat and
the platysma.
„ Raising of skin flaps: The posterior skin flap is raised first. The skin flap with subcutaneous
tissue and platysna is lifted up by two skin hooks and the the skin flap is lifted up by sharp
dissection from the underlying soft tissue till the anterior border of trapezius. While lifting
the posterior skin flap the spinal accessory nerve entering the anterior border of trapezius
should be preserved.
While raising the upper skin flap two branches of facial nerve cervical branch and the
marginal mandibular branch has to be preserved. To do so, the deep fascia is incised at the
level of hyoid bone and extending up to the fascia covering the submandibular salivary gland.
The upper skin flap along with the deep fascia attached to the upper flap is lifted up by sharp
dissection up to the lower border of mandible taking care not to injure the branches of facial
nerve.
The medial or anterior skin flap is lifted up by skin hooks and lifted in a subplatysmal plane
by sharp dissection just beyond the midline medially and below up to the clavicle exposing the
supraclavicular fossa.
„ Early division of SCM and IJV: The lower end of the SCM at its origin from the sternum and
clavicle is dissected and divided by diathermy knife. The SCM is lifted up to expose the carotid
sheath.
The fascia covering the carotid sheath is incised and the lower end of the internal jugular vein is
dissected by using a right angled forceps and 3 silk ligatures are passed around the IJV and IJV is
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ligated and divided keeping two ligatures distally. The lower cut end of the IJV may be transfixed
with 3-0 mersilk. While dissecting the IJV the vagus nerve should be taken care of.
Supraclavicular dissection: The posterior triangle of the neck is divided by the inferior belly
of omohyoid into the upper occipital and lower supraclavicular triangle. The fascia over the
fat pad lateral to internal jugular vein is incised and the fat pad with the lymph nodes are
dissected up. While doing so the phrenic nerve running over the scalenus anterior muscle is
preserved. All the fat pad along with supraclavicular lymph nodes are dissected off from the
supraclavicular triangle taking care not to breach the prevertebral fascial layer covering the
brachial plexus. While dissecting the supraclavicular triangle the external jugular vein needs
to be dissected ligated and divided. The transverse cervical vessels also needs ligature and
division. The inferior belly of omohyoid is dissected close to its origin from the upper border of
scapula and divided by diathermy.
Dissection of Chaissaignac’s triangle: This is the area between the medial border of scalenus
anterior muscle, IJV and the common carotid artery. The loose areolar tissue and the lymph
nodes are cleared from this area by sharp and blunt dissection. Important structures like
thyrocervical trunk, vertebral vein and thoracic duct on the left side and jugular lymphatic
trunk on the right side lies in this area. These strucutres are to be preserved carefully.
Dissection of occipital triangle: Before starting dissection of occipital triangle the spinal
accessory nerve (SAN) needs to be dissected and safeguarded. The SAN is identified at the
posterior border of SCM at the junction of upper 1/3rd and lower 2/3rd. This is about 1cm above
the Erb’s point where the great auricular nerve turns around the posterior border of SCM. Once
the nerve is identified the SAN nerve is dissected along the posterior triangle up to the anterior
border of trapezius at its lower third. The nerve may also be identified using a nerve stimulator.
Once the SAN is safeguarded, the dissection proceeds along the anterior border of trapezius up
to the mastoid process and all loose areolar tissue and the lymph nodes in the occipital triangle
are cleared of the ascending branch of transverse cervical artery runing along the anterior
border of trapezius needs ligature and division.
Division of upper end of SCM: Taking care of the SAN, the SCM is lifted up up to its insertion
into the mastoid process. The upper end of SCM is dissected free and divided close to its insertion.
The internal jugular vein is exposed.
Division of upper end of IJV and carotid dissection: As the SCM and IJV are lifted up, the level
III and level IV lymph nodes are cleared off along with the IJV. The upper end of IJV is dissected
and 3 silk ligatures are passed around and ligated. The upper end of the IJV is now divided
keeping 2 ligatures towards the proximal side. Near the termination of internal jugular vein
the posterior belly of digastric muscle may be lifted up to clear the level II lymph nodes. While
dissecting the level II, III and IV nodes, the vagus nerve and common carotid artery is to be
taken care of.
Dissection of level I lymph nodes: The fat in the submental area is incised and cleared. The
anterior belly of the digastric muscle is exposed. The superficial lobe of the submandibular
gland is exposed. The upper border of the of the submandibular gland is freed by dissecting
and dividing the facial vein and artery in between ligature at the lower border of the mandible.
The lower border of the superficial lobe is similarly freed by dissecting ,ligating and dividing
the facial artery and the vein at lower pole of the gland. The myelohyoid muscle is retracted in
a forward direction to identify the deep part of the submandibular gland. The lingual nerve
is identified as a broad band along the upper pole and the branches from the lingual nerve
to the submandibular ganglion is ligated and divided. The lingual nerve crosses around the
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submandibular duct. The submandibular duct is dissected up to the floor of the mouth, ligated
and divided. The hypoglossal nerve runing in between the deep part of the submandibular
gland and the hyoglossus muscle is also preserved. All the loose areolar tissue and the lymph
nodes from submental triangle and submandibular triangle are cleared off by sharp and blunt
dissection. The small vessels that come on the way is controlled by electrocoagulation. The lower
pole of parotid gland is excised and overrun with 3-0 vicryl sutures.
Check for hemostasis: Hemostasis is checked and any bleeding is controlled by electrocautery.
The wound is irrigated with normal saline.
Placement of drain: Two 12 Fr tube drain is placed through the posterior flap and connected
to a vacuum drainage bag.
Closure: The subcutaneous tissue and the platysma is apposed by 3-0 polyglactin sutures. Skin
is approximated by interrupted 3-0 monofilament polyamide suture. Alternatively skin may
be apposed by subcuticular suture or skin staplers.
venouS cut DoWn (veneSection)
This involves exposure of a vein, venotomy and introduction of a wide bore cannula inside the
vein under direct vision.
A long cannula may be passed down the vein up to the superior vena cava and central venous
pressure (cVP) may be measured.
indications of venesection
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For intravenous access in shocked patient requiring rapid infusion of fluid
For prolonged period of intravenous fluid therapy
For parenteral nutrition
For measurement of central venous pressure.
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Great saphenous vein at the ankle or at the groin
Basilic vein at the arm
cephalic vein at the deltopectoral groove.
Describe the steps of venous cut down?
procedure
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Wash hands and wear sterile gloves
The area is cleaned with an antiseptic solution (povidone iodine) and draped with towel
inject 1 % lignocaine at the site transversely across the vein to be cannulated (Fig. 22.12A).
A small transverse incision is made across the selected vein. The incision is deepened up to
the subcutaneous tissue
The subcutaneous tissue is incised (Fig. 22.12B)
The vein is isolated by blunt dissection (Fig. 22.12c)
two ligatures are passed around the vein. The distal one is tied and held by a hemostatic
forceps (Fig. 22.12D)
A curved needle is passed through the middle of the basilic vein wall and the vein wall in
front of the needle is incised (Fig. 22.12e)
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figures 22.12a to h: Steps of venesection
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A no. 6 or 9 sterile infant feeding tube is introduced through the venotomy and the cannula
is advanced proximally so that its tip lies in the superior vena cava. The proximal ligature is
tied to fix the cannula within the vein (Figs 22.12F and G)
The end of the cannula is connected to an intravenous fluid channel
The skin incision is closed with interrupted skin sutures (Fig. 22.12H)
The cannula is fixed to the skin by a suture passed around the cannula
Sterile dressing is applied.
tracheoStomy
What are the indications of tracheostomy?
See instrument section.
Describe the steps of tracheostomy.
„
Position of patient: Patient supine with neck extended by placing a sand bag in—between
the shoulder blades and head supported with a ring.
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Anesthesia: Usually done under local anesthesia by injecting 1% lignocaine hydrochloride.
Incision: For elective tracheostomy a transverse neck crease incision is made midway between
cricoid cartilage and the suprasternal notch. in emergency a vertical incision from the lower
border of the thyroid cartilage to the suprasternal notch may be used.
Procedure:
• The skin, subcutaneous tissue and the platysma is incised in the same line. The investing
layer of the deep cervical fascia is incised in the midline and the strap muscles are retracted
on either side.
• The thyroid isthmus is exposed. This isthmus is divided in the midline in between forceps
and the trachea is exposed. The trachea is held fixed by a single hook retractor. A 1–2 cm
vertical incision is made on the trachea centering 3rd or 4th tracheal ring using a no. 11
knife. A tracheal dilator is inserted into the trachea with the blades in closed position. The
blades are opened and a cuffed tracheostomy tube is inserted into the trachea through
the tracheotomy. The tracheostomy tube is fixed by a strap tied around the neck. The
bleeding from the cut ends of the thyroid isthmus is controlled. The skin is closed with
interrupted silk stitches.
What are the complications of tracheostomy?
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Bleeding from the thyroid isthmus or brachiocephalic vein and inferior thyroid veins
Blockage of tracheostomy tube—may result even in death.
tracheal stenosis.
gaStroStomy
indications
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For feeding in patients with esophageal obstruction: corrosive stricture or carcinoma of
esophagus.
For gastric decompression in a postoperative patient when passage of a nasogastric tube is
not feasible
in cases of duodenal fistula: two tubes may be inserted through the gastrostomy. one kept in
the duodenum proximal to the site of leakage for aspiration and another tube passed beyond
the duodenum 25–30 cm beyond the fistula for feeding.
Describe the steps of gastrostomy.
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Anesthesia: General anesthesia or local anesthesia. For local anesthesia inject 20 mL
0.5% of injection lignocaine in the skin and subcutaneous tissue. After incising the skin
and subcutaneous tissue, another 20 mL is injected along the linea alba and the parietal
peritoneum.
Incision: About 5 cm midline vertical incision starting from just below the xiphoid.
Procedure:
• Skin and subcutaneous tissues are incised along the line of incision (Fig. 22.13A)
• The linea alba is incised in the midline
• The peritoneum is lifted in between the hemostatic forceps and a nick is made in the
parietal peritoneum and the incision in the peritoneum is extended
• The wound margin is retracted and the stomach is identified (Figs 22.13B and c)
• The skin below the left costal margin is infiltrated with injection lignocaine and an incision
is made lateral to the outer border of rectus abdominis (Fig. 22.13D).
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figures 22.13a to h: Gastrostomy
• The gastrostomy tube (22 Fr. Foley’s or Malaecot’s catheter) is brought into the abdomen
through this stab wound (Fig. 22.13e).
• The stomach is held by two pairs of Babcock’s tissue forceps. A stab wound is made in the
anterior wall of the stomach high up in the body between the greater and lesser curvature
of the stomach (Fig. 22.13F). The gastrostomy tube is introduced through the stab wound
with the tip directed toward the pylorus
• A purse string suture is applied around the stab wound and is tightened around the tube.
insert two more purse string suture around each 0.5 cm apart inverting the previous layers
(Fig. 22.13G)
• The stomach wall is fixed to the parietal peritoneum by 2 or 3 interrupted chromic catgut
sutures (Fig. 22.13H)
• The incision is closed in layers. The gastrostomy tube is fixed to the skin.
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What is Witzel gastrostomy?
in Witzel gastrostomy instead of series of purse string suture, the gastrostomy tube is buried in
the stomach wall by creating a tunnel in the stomach wall. The wall of the stomach on either
side of the gastrostomy tube is sutured to create the tunnel.
What is Deepage Janeway gastrostomy?
This is a technique of permanent gastrostomy. A flap is raised from the anterior wall of the
stomach and is formed into a tube. The stomach tube is brought out and sutured to the skin to
create a permanent gastrostomy.
What are the other techniques of gastrostomy?
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Laparoscopic gastrostomy
Percutaneous endoscopic gastrostomy.
Why it is not desirable to do a gastrostomy in a patient with inoperable carcinoma of
esophagus?
in inoperable carcinoma of esophagus patient has problems of swallowing of food and saliva.
Gastrostomy allows feeding but does not provide any relief for the distressing problems of
swallowing of the saliva. So it is not desirable to do gastrostomy. Some form of esophageal
stenting is preferable.
StepS of everSion of Sac
What are the steps of eversion of sac (Fig. 22.14)?
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Antiseptic dressing and draping.
Anesthesia: operation is done under local
anesthesia. The spermatic cord is infiltrated
with 2% lignocaine hydrochloride. The scrotal
skin along the line of incision is also infiltrated
with lignocaine hydrochloride.
Skin incision: A vertical incision is made
parallel to the median raphe of the scrotum.
Incising the layers of scrotum: The incision
is deepened to cut the dartos muscle the
scrotal fascia and the hydrocele sac lined by
the parietal layer of the tunica vaginalis is
exposed.
Incising the parietal layer of tunica vaginalis:
figure 22.14: Eversion of sac
The tunica vaginalis sac is separated from the
dartos muscle layer by finger dissection and
a space created between the tunica vaginalis
and the dartos.
An incision is made over the tunica vaginalis in an avascular area anteriorly away from the
testis, epididymis and cord structures and fluid drained.
The tunica vaginalis incision is then extended and testis delivered out of the tunica vaginalis
sac.
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Eversion of sac: The cut margin of the tunica vaginalis sac is everted around the testis.
Suturing the cut margins of tunica vaginalis: The cut margin is stitched behined the testis
with 1-0 chromic catgut sutures.
„ Hemostasis is secured and the testis with the everted sac placed back into the scrotal sac.
„ Closure: The dartos muscle is stitched with 1-0 continuous chromic catgut sutures.
The skin is sutured with interrupted monofilament polyamide suture. A coconut bandage
is then applied.
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circumciSion
indications
1. Religious: Muslims and Jews
2. Phimosis
3. Paraphimosis.
Describe the steps of circumcision (Figs 12.15A to F).
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in adults this is usually done under local anesthesia and in children usually done under
general anesthesia
The penis is cleaned with an antiseptic solution (povidone iodine) and draped with a sterile
sheet
A
B
D
C
E
F
figures 22.15a to f: Steps of circumcision
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infiltration anesthesia using 1% lignocaine injection (without adrenaline). The local anesthetic
is injected all around the base of the penis. Wait for 5 minutes.
The tip of the prepuce is grasped with two pairs of mosquito forceps and the adhesion between
the prepuce and the glans penis is separated (Fig. 22.15A).
A dorsal cut is made in the prepuce with scissors extending proximally up to 5 mm of the
corona glandis (Fig. 22.15B). The cut is then taken around the penis to the ventral aspect
toward the frenulum and the preputial skin is excised (Figs 22.15B and c).
once the prepuce is excised there are bleeding from a number of points. The skin is retracted
over the penis and the bleeding points are held up by mosquito forceps and ligated with 3-0
catgut sutures.
The skin edges are then sutured with 3-0 chromic catgut sutures. The dorsal and ventral
midline sutures are applied first and the remaining cut edges of the prepuce is sutured with
interrupted 3-0 chromic catgut sutures (Fig. 22.15e). A figure of 8 stitch in ventral mid line
controls the frenular artery (Fig. 22.15F).
A light dressing is applied.
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Surgical Anatomy
1. INGUINAL CANAL
What are the boundaries of inguinal canal (Fig. 23.1)?
inguinal canal is an oblique canal with a length of about 3.8 cm, situated at the lower part of
anterior abdominal wall and extends from the deep inguinal ring to the superficial inguinal ring.
This canal is bounded:
„ Anteriorly: By the external aponeurosis along its whole length and reinforced laterally by the
muscular fibers of the internal oblique.
„ Posteriorly: By the fascia transversalis throughout and reinforced medially by the conjoint
tendon.
„ Medially: By the lateral border of the rectus sheath.
„ Roof: Formed by the conjoined tendon and arched fibers of internal oblique and transverses
abdominis.
„ Floor: Formed by the lacunar ligament medially and the inguinal ligament laterally.
Figure 23.1: Surgical anatomy of inguinal canal
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What is Hesselbach’s triangle?
The medial part of the inguinal canal is Hesselbach’s triangle being bounded:
Laterally by the inferior epigastric vessels.
„ Medially by the lateral border of the rectus sheath.
„ Base is formed by the upper concave surface of the medial part of the inguinal ligament and
the lacunar ligament.
„
What are the contents of inguinal canal?
The inguinal canal contains:
Spermatic cord in male and round ligament of uterus in female.
„ in addition, the ilioinguinal nerve traverses through the inguinal canal.
„ The nerve does not come through the deep ring enters the inguinal canal by piercing the
internal oblique muscle and emerges out through the superficial inguinal ring.
„
What are the constituents of spermatic cord?
The spermatic cord comprises of:
Vas deferens
„ testicular artery
„ Artery to the vas
„ Artery to the cremester
„ Pampiniform plexus of veins
„ testicular lymphatic vessels
„ testicular sympathetic plexus
„ Genital branch of genitofemoral nerve.
„
What are the coverings of spermatic cord?
The coverings of spermatic cord are outside inwards:
External spermatic fascia: Derived from the external oblique aponeurosis and covers the cord
beyond the superficial inguinal ring.
„ Cremesteric muscle and fascia: Derived from the
internal oblique aponeurosis.
„ Internal spermatic fascia: Derived from the fascia
transversalis.
„
What is Fruchaud’s myopectineal orifice
(Fig. 23.2)?
This is osseo-musculoaponeurotic hiatus in the lower
abdomen through which all groin hernia occurs.
This is bounded:
„ Laterally by the iliopsoas muscle.
„ Medially by the lateral border of the rectus sheath.
„ Below by the pecten pubis
„ Above by the arched fibers of internal oblique and
transversus abdominis.
What is the anatomy of deep inguinal ring?
The deep inguinal ring lies 1.25 cm above the inguinal
ligament at the midinguinal point (A point midway
between the symphysis pubis and anterior superior
Figure 23.2: Fruchaud’s myopectineal
orifice is bound—by lateral border of rec­
tus sheath (1), iliopsoas muscle (2), pecten
pubis (3), and conjoint tendon (4)
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iliac spine). This is actually not an opening but the mouth of a prolongation of fascia transversalis
dragged down by the gubernaculum. The inferior epigastric vessels lies medial to the deep
inguinal ring.
The spermatic cord in male and round ligament in female emerges through the deep inguinal
ring.
What is the anatomy of superficial inguinal ring (Fig. 23.3)?
The superficial inguinal ring is formed by splitting of external oblique aponeurosis at its insertion
medially. Base is 1.25 cm and the height is 2.5 cm.
The boundary of superficial inguinal ring are:
„ Base: Formed by the pubic crest.
„ Medially: Superomedial crus of external oblique aponeurosis.
„ Laterally: inferolateral crus of external oblique aponeurosis
• The two crura are joined by intercrural fibers.
Figure 23.3: Schematic diagram of superficial inguinal ring
What structures emerges through the superficial inguinal ring?
in addition to spermatic cord in male and round ligament of uterus in female, the ilioinguinal
nerve emerges through the superficial inguinal ring.
What are the different ligament in relation to external oblique aponeurosis?
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Inguinal ligament (Poupart ligament):
This is a condensation of the lower part of the aponeurosis of the external oblique aponeurosis.
This is usually 10 cm in length and is attached laterally to the anterior superior iliac spine
and medially to the pubic tubercle.
The lateral part of the inguinal ligament is thick, rounded and cord like. The medial part of
the inguinal ligament is flat and bent upon itself, so that it has an upper concave surface. This
concave upper surface of the ligament forms the floor of the inguinal canal.
Lacunar ligament:
This is one of the extension of inguinal ligament.This is triangular in shape.The apex is attached
to the pubic tubercle. The base is free, concave and forms the medial boundary of the femoral
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ring.The lower surface is convex and the upper surface is concave and forms the floor of the
inguinal canal medially.
Cooper’s ligament or pectineal ligament:
This is the continuation of the lacunar ligament along the pecten pubis of the pubic ramus
and may extend upto the iliopubic eminence.
The femoral vessels runs in between the inguinal ligament and the cooper’s ligament and is
enclosed by the femoral sheath.
Reflected part of the inguinal ligament:
This starts from the lateral crus of the superficial inguinal ring and passes behind the superficial
inguinal ring, and in front of the conjoint tendon to get blended with the linea alba.
Which structures passes deep to the inguinal ligament (Fig. 23.4)?
The following structures passes deep to the inguinal ligament from lateral to medial side:
iliacus muscle.
„ The lateral femoral cutaneous nerve passing in front of the iliacus muscle.
„ Femoral nerve lies in the groove between the iliacus and the psoas major muscle. nerve to
pectineus arises from the femoral nerve passes behind the inguinal ligament and supplies
the lateral part of the pectineus muscle.
„ Psoas major muscle.
„ Pectineus muscle.
„ in between the inguinal ligament and the pectineus and psoas major lies the femoral sheath
with its contents (femoral artery, femoral vein and lymphatics).
„
Figure 23.4: Schematic diagram of inguinal ligament
What is conjoint tendon?
The conjoint tendon or falx inguinalis is formed by the fusion of lower fibers of internal oblique
and transversus abdominis. The conjoint tendon arches behind the superficial inguinal ring and
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medial part of the inguinal canal (forming the posterior wall of the medial part of the inguinal
canal) and is inserted into the pubic crest and the pectineal line of the pecten pubis.
What is femoral sheath?
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This is a fascial sheath present in the groin enclosing the femoral vessels.
Femoral sheath is funnel-shaped with wide mouth upwards.
Formed by the prolongation of the fascia of the abdomen.
• The anterior layer of femoral sheath is formed by the prolongation of fascia transversalis
behind the inguinal ligament descending to about 4 cm below the inguinal ligament
• The posterior layer of the femoral sheath is formed by the prolongation of the fasica iliaca.
• The medial and lateral wall is formed by the blending of the two layers.
What are the different compartments of femoral sheath (Fig. 23.5)?
The femoral sheath is divided into three compartments by two septae:
Lateral or arterial compartment: contains the proximal part of the femoral artery with its
branches.The femoral branch of genitofemoral nerve lies at first anterior and then lateral to
the artery.
„ Intermediate or the venous compartment: This contains the femoral vein. The great saphenous
terminates into the femoral vein at saphenous opening.
„ Medial or lymphatic compartment: This is also called femoral canal. This contains loose
areolar tissue, one deep inguinal lymph node (Lymph node of cloquet) and lymphatic vessels.
„ The opening of the femoral canal proximally is known as femoral ring which is covered by
femoral septum which is formed by condensation of extraperitoneal fatty tissue.
„
Figure 23.5: Schematic diagram of femoral sheath
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What is the boundary of femoral ring (Fig. 23.5)?
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Anteriorly: inguinal ligament.
Posteriorly: Fascia covering pectineus and cooper’s ligament.
Medially: concave margin of lacunar ligament.
Laterally: Septum separating the femoral vein.
Which factors normally prevents development of hernia in the groin?
The following factors are important in preventing development of hernia at the groin:
Obliquity of the inguinal canal: Provides a flap valve like action preventing descent of
abdominal contents through the inguinal canal.
„ Shutter mechanism: When there is increase of intra-abdominal pressure the anterior wall of
the canal contract and press against the deep inguinal ring thereby shutting the deep inguinal
ring thereby preventing escape of abdominal contents through the deep inguinal ring.
in the medial part of the inguinal canal, the conjoint tendon forming the posterior wall comes
froward and shuts the medial part of the inguinal canal thereby preventing any escape of
abdominal contents through the inguinal canal.
The arched fibers of the internal oblique and the transversus abdominis forming the roof of
the canal also contracts and descends down thereby decreasing the height of the inguinal
canal from above.
„ Ball valve mechanism: contraction of cremester muscle draws up the spermatic cord towards
the superficial ring thereby occluding the superficial inguinal ring.
„ Slit valve mechanism: contraction of external oblique aponeurosis results in approximation
of two crura of the superficial inguinal ring, preventing herniation through the superficial
inguinal ring.
„
What is processus vaginalis and what are its fate?
This is a pouch of peritoneum dragged down during the descent of gubernaculum of testis or
ovary. This extends from the deep inguinal ring and emerges through the superficial inguinal
ring to the bottom of scrotum in male and labia majora in females.
Fate of processus vaginalis: normally the part of the processus vaginalis from the deep
inguinal ring to the upper pole of testis disappears and the distal part in the scrotum persists
as tunica vaginalis of testis.
What are the abnormalities of processus vaginalis?
There may be some abnormalities in relation to persistence of processus vaginalis:
Whole of processus vaginalis may persist leading to congenital hydrocele or hernia.
„ The processus vaginalis may persist from just beyond the deep inguinal ring to the upper
pole of testis, leading to a funicular type of hydrocele.
„ The intermediate part of the processus vaginalis may persist and may lead to formation of
encysted hydrocele of the cord.
„ The processus vaginalis may persist from beyond the deep ring to the bottom of the scrotum
leading to infantile hydrocele.
„
What is the boundary of femoral triangle?
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Above (Base): inguinal ligament.
Laterally: Medial border of Sartorius.
Medially: Medial border of adductor longus.
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Apex: By meeting of medial border of adductor longus and medial border of sartorius.
Roof: Skin, superficial fascia and deep fascia of thigh.
Floor: Medial to lateral—adductor longus, pectineus, iliacus and psoas muscles.
What are contents of femoral triangle?
The contents of femoral triangle are:
Femoral artery and its branches:
• Three superficial branches—superficial external pudendal, superficial epigastric and
superficial circumflex ilica.
• Three deep branches—deep external pudendal, profunda femoris and muscular branches.
„ Femoral vein—Lies medial to the artery and the tributaries corresponds to the arterial
branches.
„ nerves—Femoral nerve lies lateral to the femoral artery, nerve to pectineus, femoral branch
of genitofemoral nerve, lateral cutaneous nerve of thigh.
„ inguinal lymph nodes—Superficial and deep inguinal lymph nodes.
„
ANATOMICAL CONCEPT IN VIEW OF LAPAROSCOPIC REPAIR OF HERNIA
What is preperitoneal space?
This is a potential space lying in between the fascia transversalis and the parietal peritoneum.
in laparoscopic hernia repair the mesh is placed in this space.
What is space of Retzius?
The potential area deep to the fascia transversalis and lying behind the symphysis pubis and
the anterior wall of the bladder is the space of Retzius. This space traced laterally is described
as the space of Bogros. This space lies between the fascia transversalis and the peritoneum.
What are the different umbilical ligaments and folds?
When the groin area is viewed from within the peritoneal cavity following structures are seen
(Fig. 23.6):
Figure 23.6: Inguinal anatomy from behind
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Median umbilical ligament and median umbilical fold: The midline peritoneal fold lifted by
the obliterated urachus is known as median umbilical fold. The obliterated urachus is the
median umbilical ligament.
The peritoneal fold raised by the obliterated umbilical artery is the medial umbilical fold and
the obliterated umbilical artery is the medial umbilical ligament.
The peritoneal fold raised by the inferior epigastric vessels is the lateral umbilical fold.
What is supravesical fossa and the inguinal fossa?
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Supravesical fossa: The space between the median umbilical fold and the medial umbilical
fold.
Medial inguinal fossa: The space between the medial umbilicial fold and the lateral umbilical
fold site of direct inguinal hernia.
Lateral inguinal fossa: The space lying lateral to the lateral umbilical fold (Fig. 23.6). Site of
indirect inguinal hernia.
2. ANTERIOR ABDOMINAL WALL
RECTUS SHEATH
How is rectus sheath formed (Figs 23.7A to D)?
Rectus sheath is a musculoaponeurotic sheath enclosing the rectus abdominis and the
pyramidalis muscle. The rectus sheath is formed by the aponeurosis of external oblique, internal
oblique and the muscular fibers and aponeurosis of transversus abdominis.The anterior and
posterior wall of the rectus sheath varies at different levels and is formed as follows:
1. Rectus sheath above the lower costal margin:
The anterior wall of the sheath is formed only by the external oblique aponeurosis.
The posterior wall of the sheath is deficient here and the rectus abdominis muscle is attached
to the lower costal cartilages and the xiphoid process (Fig. 23.7A).
2. Rectus sheath from the costal margin upto midway between the umbilicus and xiphoid process.
The anterior wall of the rectus sheath at this level is formed by the external oblique aponeurosis
and the anterior lamella of the internal oblique aponeurosis.
the posterior wall of the sheath is formed by the posterior lamella of the internal
oblique aponeurosis, muscular fibers of the transversus abdominis, fascia transversalis,
extraperitoneal fatty tissue and the parietal peritoneum. All these layers are blended to form
the posterior rectus sheath (Fig. 23.7B).
3. Rectus sheath from the above level to midway between the umbilicus and the symphysis pubis.
The anterior wall of the sheath is formed by the external oblique aponeurosis and anterior
lamella of the internal oblique aponeurosis.
The posterior wall is formed by the same layers as in level ii except that the transversus
abdominis is aponeurotic at this level (Fig. 23.7c).
4. Rectus sheath from the above level upto the symphysis pubis.
The anterior wall of the sheath at this level is formed by the aponeurosis of all three muscles—
external oblique, internal oblique and the transversus abdominis.
The posterior wall of the rectus sheath is deficient at this level and the rectus abdominis
muscle lies on the fascia transversalis (Fig. 23.7D).
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A
B
C
D
Figures 23.7A to D: Formation of rectus sheath at three levels: (A) Above the level of costal
margin; (B) Between costal margin and a point midway between umbilicus and symphysis
pubis; (C) Below the point midway between umbilicus and symphysis pubis; (D) Above the
symphysis pubis
What are the contents of rectus sheath?
The contents of the rectus sheath include:
Rectus abdominis muscle.
„ Pyramidalis muscle.
„ inferior epigastric artery and vein.
„ Superior epigastric artery and vein
„ terminal parts of 7th to 12th (Subcostal) nerves along with their collateral branches.
These nerves runs in between the transversus abdominis and internal oblique muscle and
enters the rectus sheath by piercing the posterior lamella of the internal oblique, supplies the
rectus abdominis muscle by entering into the muscle from its lateral side. The nerve comes out
as anterior cutaneous nerve by piercing the anterior rectus sheath.
„
What is linea alba?
This is the median raphe formed by the interlacing fibers of the anterior rectus sheath.
Above the umbilicus the linea alba is wide (about 1.25 cm) and below the umbilicus it
becomes linear.
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Above it is attached to the xiphoid process. Below it splits into two layers—superficial and
deep. The superficial fibers are attached to the anterior surface of the symphysis pubis. The deep
fibers are attached to the posterior surface of the pubic crest.
What is the fascial disposition in anterior abdominal wall?
Deep to the skin there are two layers of superficial fascia in the abdomen. There is no deep
fascia in the abdomen.
Disposition of superficial fascia of abdomen:
The superficial fascia of abdomen consists of:
„ An outer fatty layer (Fascia of camper) and
„ An inner membranous layer (Fascia of Scarpa).
The two layers of the superficial fascia is distinctly discernible below the level of umbilicus.
What are the prolongations of fascia of Scarpa?
The fascia extends to the thigh below the inguinal ligament to about 1.25 cm and blends with
the deep fascia (fascia lata) of the thigh.
„ Medial to the pubic tubercle the fascia extends over the penis as fascia of the penis and over
the scrotum as dartos muscle. This fascia extends into the perineum as fascia colles. The fascia
colles covers transversus perinei superficialis muscle and is attached to the perineal membrane.
„ in the midline the fascia of Scarpa is attached to the linea alba and is prolonged downward
to form the two ligaments of the penis.
The fundiform ligament is attached to the linea alba above and splits to enclose the penis
and is attached to the median raphe of the scrotum.
The suspensory ligament of the penis is attached to the front of the symphysis pubis and the
fascia of the shaft of the penis.
„
What are the disposition of fascia transversalis in abdomen?
Fascia transversalis is a tough fibrous membarne covering the deep surface of transversus
abdominis muscle.
extent:
„ Anteriorly the fascia is blended at the linea alba and becomes continuous with the opposite side.
„ Posteriorly it is continuous with the anterior layer of thoracolumbar fascia and at the lateral
border of the kidney becomes continuous with the fascia of Zerota (renal fascia).
„ Below it is attached to the inner lip of the ventral segment of the iliac crest, inguinal ligament,
pubic crest and the pecten pubis and becomes continuous with the fascia iliaca.
„ Above it is continuous with the diaphragmatic fascia.
What are the prolongations of fascia transversalis?
The fascia transversalis has prolongations outside the abdominal wall as:
Prolongation through the deep inguinal ring around the spermatic cord as internal spermatic
fascia.
„ Prolongation over the femoral vessels deep to the inguinal ligament as anterior layer of
femoral sheath.
„
What are the coverings of kidney (Fig. 23.8)?
The coverings of kidney are :
The fibrous capsule: Thin membrane closely investing the kidney.
„ Perinephric fat: This is a layer of adipose tissue lying between the fibrous capsule and the
renal fascia.
„
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Figure 23.8: Coverings of kidney. Note that fascial capsule is
open inferiorly as shown by the arrow
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Renal fascia or fascia of Gerota-This is a fibroareolar sheath investing the kidney.
Paranephric fat: This is a layer of adipose tissue lying outside the renal fascia. This also fills
the paravertebral gutter posterior to the kidney.
What is the disposition of renal fascia?
The renal fascia consists of:
Anterior layer or fascia of toldt.
„ Posterior layer or fascia of Zuckerkandl.
A number of trabeculae connect the renal fascia to the fibrous capsule across the perinephric
fat.
„ traced above the two layers meet at the upper pole of the kidney and then split to enclose
the suprarenal gland and meet again at the upper pole of the suprarenal gland and becomes
continuous with the fascia covering the diaphragm.
„ traced below the two layers remain separate, encloses the ureter. The anterior layer fuses
with the extraperitoneal fatty tissue at right iliac fossa and the posterior layer gets blended
with the fascia iliaca.
„ Laterally the two layers fuse together and become continuous with the fascia transversalis.
„ Medially, the anterior layer passes infront of the renal vessels and becomes continuous with
the fascial covering of the abdominal aorta and inferior vena cava. The posterior layer becomes
continuous with the fascia covering the quadratus lumborum and the psoas major muscle.
At the medial border of the kidney there is a septum between the two layers of the fascia. The
renal vessels pierces this septum and enters into the hilum of the kidney.
„
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ESOPHAGUS
What is the extent of esophagus?
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in an adult of average height, the length of the esophagus is about 25 cm.
Begins at the lower border of the cricoid cartilage at the level of 6th cervical vertebra.
terminates at the gastroesophageal junction at the level of t 11 vertebra.
Distance from incisor teeth to beginning of esophagus—15 cm.
Distance from incisor teeth to gastroesophageal junction—40 cm.
What are the esophageal sphincters?
There are sphincters at the the commencement and termination of the esophagus.
Upper esophageal sphincter: this is an anatomical sphincter formed by the inferior
constrictor muscle of the pharynx.This muscle consists of two parts.
i. An upper oblique fibers (thyropharyngeus) arising from the cricoid and the thyroid cartilage
and encircle the hypopharynx and are inserted into the median raphe.
ii. The lower horizontal fibers (cricopharyngeus) arising from the cricoid cartilage and pass
horizontally backward round the pharynx and are inserted into the median raphe at the back.
During swallowing the upper oblique fibers contracts and propels the food downwards and
the lower horizontal fibers relaxes to allow the food to pass into the esophagus.
„ Lower esophageal sphincter: There is no anatomical lower esophageal sphincter. The
esophagogastric junction acts as a physiological sphincter.
The esophageal hiatus is surrounded by the left limb of the right crus. The median arcuate
ligament is a tough, 1–3 mm wide fibrous condensation of the medial fibrous borders of the
two crura of the diaphragm. This does not contribute to the competence of esophagogastric
junction. This is used to anchor the fundus of the stomach during fundoplication operation.
„
How pharyngeal diverticulum is formed?
incoordination of action of thyropharyngeus and the cricopharyngeus, with failure of
cricopharyngeus to relax, results in increased intrapharyngeal pressure and leads to formation
of a pharyngeal diverticulum.
What are the sites of normal constriction of esophagus?
There are 4 sites of normal constriction in the esophagus:
At the commencements at the pharyngoesophageal junctions at the lower border of the
cricoid cartilage, lying at a distance of 15 cm from the incisor teeth.
„ At the point of crossing by the aorta, about 22.5 cm from the incisor teeth.
„ At the point where it is crossed by the left root of the lung, about 27.5 cm from the incisor teeth.
„ At the esophageal opening in the diaphragm, about 37.5 cm from the incisor teeth.
„
What is the arterial supply of the esophagus?
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Above: By branches of inferior thyroid artery and esophageal branches of the aorta.
Below: By the branches from left gastric and inferior phrenic arteries.
What is the venous drainage of esophagus?
„
the cervical esophagus drains into the inferior thyroid veins and thence into the
brachiocephalic veins.
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The left half of the throacic esophagus drains into the hemiazygos vein and thence into the
brachiocephalic vein.
The right half of the thoracic esophagus drains into the azygos system of veins and thence
intro the superior vena cava.
The cardioesophageal junction and the abdominal esophagus drains into the coronary,
spelnic and retroperitoneal and inferior phrenic veins.There is free communication between
the portal and systemic veins. in portal hypertension these veins may become engorged and
form esophageal varices.
How the lymphatics from esophagus are drained (Fig. 23.9)?
Lymph nodes draining the esophagus are divided into:
Paraesophageal lymph nodes: These lymph nodes lie on the wall of the esophagus. These include
cervical, upper, middle and lower thoracic paraesophageal nodes and paracardiac nodes.
„ Periesophageal lymph nodes: they are located on the structures lying adjacent to the
esophagus. These include cervical, scalne, paratracheal, subcarinal, posterior mediastinal,
diaphragmatic, left gastric, lesser curvature and celiac nodes.
„ Lateral esophageal nodes: These are located lateral to the esophagus and receives efferent
lymphatics from the para and periesophageal nodes. These include posterior triangle nodes,
hilar, suprapyloric, common hepatic and greater curvature lymph nodes.
„
Figure 23.9: Sites of normal constriction of esophagus (1, 2, 3, 4) and
groups of lymph nodes draining the esophagus
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The lymphatic vessels arising from the mucous membrane forms a submucous plexus. The
lymphatic vessels in the submucosa runs up and down and penetrates the muscular layer and
forms a plexus in the adventitial coat. These adventitial lymphatics drains into the adjacent
lymph nodes.
What is the nerve supply of esophagus?
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Cervical esophagus: Recurrent laryngeal nerve and branches from the middle and inferior
cervical ganglia.
Thoracic esophagus: By branches from the esophageal plexus, from the thoracic splanchnic
nerves, branches from the sympathetic nerve trunk.
Abdominal esophagus: By branches from the anterior and posterior gastric nerves which
arises from the esophageal plexus.
STOMACH
What are the parts of stomach (Fig. 23.10)?
Anatomically the stomach is divided into :
Fundus: This is the part of the stomach lying
above a horizontal plane from the cardiac
notch to the greater curvature.
„ Body of the stomach: this is the part of
the stomach lying between the fundus
and the pyloric part of the stomach,being
demarcated from the pyloric part of the
stomach by a plane drawn from the incisura
angularis to the greater curvature.
„ The pyloric portion of the stomach: this
Figure 23.10: Parts of stomach
extends from the distal part of the body
to the pyloric constriction.This is further
subdivided into:
• Pyloric antrum: extends from the incisura angularis to another plane drawn from the right
end of the bulging of the greater curvature.
• Pyloric canal: The narrowed part of the distal stomach extending from the end of the
pyloric antrum to the pyloric orifice.
„ Lesser curvature of the stomach: This is the concave border of the stomach and is continuous
with the right free border of the esophagus.
„ Greater curvature of the stomach: This is the convex border of the stomach and starts at the
left border of the esophagus where it joins the stomach.
„
What are the different gastric glands?
Histologically there are three different types of gastric glands in different parts of the stomach.
Cardiac glands: These are mucus secreting glands, situated in a small area of the stomach
around the esophagogastric junction.
„ Body or fundic glands: These glands are situated in the fundus and body of the stomach. The
mucosa contains two varieties of cells—The zymogenic cells secrete pepsin and the oxyntic
cells secrete hydrochloric acid.
„
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Pyloric glands: The pyloric glands are mucus secreting glands. These glands also secrete
gastrin.
How lymphatic drainage of stomach occurs?
Intrinsic lymphatics of stomach:
Lymphatics of stomach starts in the subepithelial layer and forms a plexus around the gastric
glands (Periglandular plexus). Lymphatic vessels from the perigalandular plexus pierces the
muscularis mucosae and and forms a submucus plexus. Lymphatic vessels from the submucous
plexus pierces the circular and the oblique muscle coat and forms an intramural plexus.
Lymphatics from the intramural plexus pierces the longitudinal muscle coat and the serous
coat to drain into the adjacent lymph nodes.
For lymph node stations for drainage of gastric lymphatics (see Long case, Page no. 100-101,
chapter 3).
What are the arterial supply of stomach (Fig. 23.11)?
There are major and minor arteries supplying the stomach. These includes:
Vessels along the lesser curvature:
• Left gastric artery—branch of celiac trunk.
• Right gastric artery—branch of hepatic artery.
These two arteries anastomose along the lesser curvature and divides into anterior and
posterior branches and supplies the body and pyloric part of the stomach.
„ Vessels along the greater curvature:
• Right gastroepiploic artery—a branch of gastroduodenal artery.
• Left gastroepiploic artery—a branch of splenic artery.
„
Figure 23.11: Arterial supply to the stomach: L. Inf Ph = left inferior
phrenic artery; SG = short gastric artery; L.GE = left gastroepiploic
artery; R.GE = right gastroepiploic artery; S = splenic artery;
GP = great pancreatic artery; Inf P = inferior pancreatic artery;
PD = pancreaticoduodenal artery; DP = dorsal pancreatic artery;
GD = gastroduodenal artery; R.G = right gastric artery; H = hepatic
artery; CT = celiac trunk; L.G = left gastric artery
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These two arteries anastomose along the greater curvature and gives off branches which
supplies the body and pyloric part of the stomach.
Short gastric arteries, which are branches of splenic artery runs along the gastrosplenic
ligament and supplies the fundus of the stomach.
Some branches from gastroduodenal artery supplies the pyloric part of the stomach.
What is the venous drainage of stomach?
The veins follows the arteries along the lesser and greater curvature
Veins along the lesser curvature:
• Right gastric vein drains into the portal vein.
• Left gastric vein drains into the portal vein.
„ Veins along the greater curvature:
• Right gastroepilploic vein drains into the superior mesenteric vein.
• Left gastroepiploic vein drains into the splenic vein.
• Short gastric vein drains into the splenic vein.
Prepyloric vein of Mayo runs anterior to the pylorus of the stomach and connects the right
gastric vein with the right gastroepiploic vein.
„
What are the distribution of vagal trunk in stomach (Fig. 23.12)?
The right and left vagus nerve enters
into the abdomen through the
abdomen through the esophageal
opening in the diaphragm and
continue as anterior and posterior
vagus nerve respectively.
The anterior vagus nerve gives off
the hepatic branch and continue
along the lesser curvature and
gives off branches to to the anterior
wall of the fundus and body of the
stomach. The anterior vagal trunk
then continues as anterior nerve of
Laterjet and ends like a crows feet
supplying the pyloric region of the
stomach.
The posterior vagus nerves gives off
celiac branch and then continue along
the lesser curvature of the stomach
giving off branches supplying the
posterior wall of the fundus and the
Figure 23.12: Distribution of vagus nerve in stomach
body of stomach and then continue
as posterior nerve of Latarjet and
supplies the pyloric region of the stomach.
What is the arterial supply of colon (Fig. 23.13)?
The colon is supplied with branches from superior and inferior mesenteric arteries.
Cecum: Supplied by anterior and posterior cecal artery which are branches of inferior division
of ileocolic artery.
„
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Figure 23.13: Arterial supply of colon
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Ascending colon: Supplied by right colic artery which is a branch of superior mesenteric
artery. The right colic artery divides into ascending and descending branches. The ascending
branch joins with the right branch of middle colic artery and the descending branch joins
with the superior branch of ileocolic aretry.
Right colic flexure: This is supplied by the ascending branch of right colic artery and the right
branch of middle colic artery.
Transverse colon: Right 2/3rd of transverse colon develops from the midgut, hence is supplied
by the middle colic branch of superior mesenteric artery and the left 1/3rd develops from
the hind gut and is supplied by the inferior mesenteric artery.The middle colic artery divides
into right and left branch.The right branch joins with the ascending branch of right colic
artery and the left branch joins with ascending branch of left colic artery. The end arteries
vasa recti arises from the marginal artery running along the mesenteric border of the colon.
Descending colon: Supplied by the left colic branch of the inferior mesenteric artery.
Sigmoid colon: Supplied by the sigmoid branches of the inferior mesenteric artery.
What is the lymphatic drainage of colon (Fig. 23.14)?
Lymphatic of the colon starts at the submucosa and emerges through the serous coat and drains
into the following groups of lymph nodes:
„ Epicolic lymph nodes: These lymph nodes lie on the wall of the colon.
„ Pericolic lymph nodes: These lymph nodes lie along the terminal vessels (vasa recti) entering
the wall of the colon.
„ Intermediate lymph nodes: These lymph nodes lie along the main branches of the vessels
supplying the colon (ileocolic, right colic, middle colic, left colic and sigmoid branches).
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Figure 23.14: Lymphatic drainage of colon
Principal lymph nodes: These are preaortic lymph nodes which lie along the origin of the
superior and inferior mesenteric arteries for the aorta.
The terminal lymphatics from the caecum, ascending colon and the right half of the transverse
colon drain into the superior mesenteric lymph nodes. The terminal lymphatics for the left
half of the transverse colon, descending colon and the sigmoid colon drain into the inferior
mesenteric lymph nodes.
„
What are the blood supply of rectum and anal canal (Fig. 23.15)?
The rectum and anal canal are supplied by the following arteries:
Superior rectal artery: This is the continuation of inferior mesenteric artery. This divides into
right and left branches and near the middle of the rectum it divides into further branches
and pierces the muscle of the rectum and descends in the submucus coat up to the level
of sphincter ani internus and anastomose with the branches of middle and inferior rectal
arteries.
„ Middle rectal artery: This is branch of anterior division of the internal iliac artery. it runs along
the lateral ligaments of the rectum and pierces the muscle coat of the rectum and anastomoses
with the branches of the superior and inferior rectal arteries.
„ Inferior rectal artery: This is a branch of internal pudendal artery. This traverses the ischiorectal
fossa and divides into a number of branches which pierces the anal canal and anastomoses
with the superior and middle rectal arteries.
„ Median sacral artery: Arises from the posterior surface of the bifurcation of aorta and supplies
branches to the lower rectum and anal canal.
„
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Figure 23.15: Arterial supply to the rectum and anus
What are the venous drainage of rectum and anal canal (Fig. 23.16)?
The veins starts in the anal valves as columns of veins at the following sites:
At 11 o’clock position (Anterior and right)
„ At 3 o’clock position (Anterior and left)
„ At 7 o’clock position (Posterior and right)
in addition there are columns of veins:
„ At 1 o’clock position (Anterior and left).
„ At 5 o’clock position (Posterior and left).
(Dilatation of veins at 11, 3 and 7 o’clock position forms primary piles. The dilatation of veins
at 1 and 5 o’clock position forms secondary piles).
These columns of veins ascend in the submucus coat of the rectum and forms a plexus in lower
part of the rectum—internal rectal venous plexus. From this venous plexus, the drainage occurs as:
„ Veins from the upper part of the plexus pierces the circular and longitudinal muscle coat of
rectum and forms a venous plexus in the pararectal tissue—external rectal venous plexus.
The veins from this plexus drains as:
• From the upper part of the external venous plexus 6–7 veins emerges on either side which
ascends up joins to form a single vein known as superior rectal vein which ascends behind
the rectum and continue as the inferior mesenteric vein in the pelvic mesocolon. The
inferior mesenteric vein ends at the splenic vein and receives sigmoid vein and left colic
vein as tributaries.
• From the lower part of the external rectal venous plexus 6–8 veins emerges on either side
which joins to form middle rectal vein,one on either side which drains into the internal
iliac vein.
„
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Figure 23.16: Venous drainage of the rectum and anal canal
„
There is a plexus of veins in the skin lined part of the anal canal which communicates above
with the internal rectal venous plexus. These veins drains via the inferior rectal veins into
the internal pudendal vein.
How the lymphatics from rectum and anal canal are drained (Figs 23.17 and 23.18)?
Intrinsic lymphatics of the rectum: Lymphatics of the rectum starts in the mucous membrane and
forms a plexus in the submucus coat. Lympahtics from the submucus plexus pierces the circular
muscle and forms a intramural plexus inbetween the circular and the longitudinal muscle coat
of the rectum. Lymphatics from the intramural plexus pierces the longitudinal muscle coat of
the rectum and froms an extramural plexus.
Lymphatic drainage:
„ From the upper part of the extramural plexus the lymphatic vessels drains into the pararectal
lymph nodes lying in the pararectal tissue. The efferent lymphatics from the pararectal lymph
nodes drains as:
• efferents from the upper pararectal lymph nodes ascends along the superior rectal vessels
and then along the inferior mesenteric vessels and drains into the preaortic lymph nodes
lying along the origin of the inferior mesenteric artery.
• efferents from the other pararectal lymph nodes drains into the common iliac and internal
iliac lymph nodes.
„ From the lower part of the extramural lymphatic plexus the lymphatics runs laterally and
forms another plexus on the levator ani and drains ultimately into the internal iliac lymph
nodes.
Lymphatics of the anal canal:
„ Lymphatics of anal canal above the pectinate line:
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Figure 23.17: Lymphatic drainage of the
rectum and anal canal
Figure 23.18: Lymphatic drainage of the rectum and anal canal
Lymphatics runs with the rectal lymphatics and joins the plexus on the levator ani. From this
the lymphatics drains into the internal iliac lymph nodes.
„ Lymphatics of anal canal below the pectinate line:
The lymphatics from the skin lined part of the anal canal drains into the medial group of
superficial inguinal lymph nodes.
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ANATOMY OF LIVER AND EXTRAHEPATIC BILIARY SYSTEM
What is the average weight of liver
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The liver is the largest organ of the body.
in adult male—1.4 kg. to 1.8 kg.
in adult female—1.2 kg to 1.4 kg.
What are anatomical lobes of liver (Fig. 23.19)?
the liver is demarcated into right and left lobes anatomically by the attachment of falciform
ligament in front and above and below and behind by the fissure for ligamentum teres
and ligamentum venosum. the right lobe constitutes 5/6th and the left constitues 1/6th
of the liver.
Figure 23.19: Lobes of liver
What are physiological or surgical right and left lobes of liver (Fig. 23.20)?
the physiological right and left lobe of liver is demarcated by an imaginery plane called
cholecystocaval plane which passes through the floor of gallbladder fossa and inferior vena
cava. These lobes are supplied by the right and left branches of the hepatic artery and portal
vein and the bile drains into the corresponding right and left hepatic ducts. The caudate lobe
belongs to the physiological left lobe of the liver. However, it receives supply from both the right
and left branches of hepatic artery and portal vein.
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Figure 23.20: Physiological or surgical right and left lobes of liver. A = anterior;
C = caudate; I = inferior; L = lateral; M = medial; P = posterior; S = superior;
CHD = common hepatic duct; CP = caudate process
What are the segments of liver (Fig. 23.21)?
French anatomist, couinaud, described eight segments in the liver depending on the distribution
of branch of hepatic artery, portal vein and bile duct. The segments are functional units of the
liver being supplied by a branch of hepatic artery, portal vein, hepatic duct and drained by a
tributary of hepatic vein.
There are eight segments in the liver. Segments i-iV in left lobe of liver. Segments V-Viii in
right lobe of the liver.
Figure 23.21: Segments of liver. Arrows indicate positions
of hepatic segments according to clockwise order I to VIII
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Segment i is the anatomical caudate lobe of the liver.
Segment ii is located in the lateral end of the left lobe.
Segment iii is the medial end of the anatomical left lobe.
Segment iV is between the ligament of teres and the segment iii.
Segments V and Vi in anterior aspect of right lobe.
Segments Vii and Viii in posterior aspect of right lobe.
What are ligaments in relation to the liver (Fig. 23.22)?
The following ligaments are attached to the liver:
Falciform ligament: A sickle shaped
peritoneal fold connects the liver
to the undersurface of diaphragm
and anterior abdominal wall up
to the umbilicus. it consists of two
layers of peritoneum and at the
free margin contains ligamentum
teres.
„ Coronary ligament: it consists
of upper layer reflected from the
liver to the diaphragm and lower
layer reflected from the liver to the
kidney (Hepatorenal ligament).
„ Right triangular ligament connects
Figure 23.22: Ligaments in relation to the liver
right lateral surface of the liver to
the diaphragm.
„ L e f t t r i a ngu l a r l ig a m e nt : it
connects the upper surface of the left lobe to the diaphragm.
„ Lesser omentum: it consists of two layers of peritoneum and connects the lesser curvature of
the stomach and proximal 2.5 cm of duodenum to the liver.
„
What is portal fissure (Fig. 23.23)?
This is a nonperitoneal H-shaped fissure located in posterior and inferior surface of the liver.
The right limb of the fissure consists of groove for inferior vena cava and fossa for gallbladder.
The left limb of the fissure consists of fissure for ligamentum teres and ligamentum venosum.
The horizontal limb of the fissure is formed by the porta hepatis.
What is porta hepatis (Fig. 23.23)?
This is a nonperitoneal transverse fissure on the under surface of the liver through which the
heaptic artery (right and left branches) and the portal vein (right and left branches) enters into
the liver and the hepatic ducts (right and left branches) and lymphatics exit from the liver.
The relation of structures at the porta hepatis from before backwards are:
„ Hepatic ducts in the front
„ Branches of hepatic artery
„ Branches of portal vein.
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Figure 23.23: Schematic diagram of porta hepatis
What is ligamentum teres?
Ligamentum teres is the remnant of left umbilical vein and runs from the umbilicus to the fissure
for ligamentum teres and ends in left branch of portal vein in the inferior surface of liver. This
runs in the free margin of the falciform ligament.
What is ligamentum venosum?
This is remnant of ductus venosus, which in fetal life connects the left branch of portal vein with
the left hepatic vein or the inferior vena cava. This lies in the fissure for ligamentum venosum
in the inferior surface of liver.
What constitutes extrahepatic biliary system (Fig. 23.24)?
The extrahpatic biliary tree consists of :
Right and left hepatic ducts.
„ common hepatic duct.
„ Gallbladder and cystic ducts.
„ common bile duct
„ Ampulla of Vater.
„
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Figure 23.24: Anatomy of extrahepatic biliary system
What are the parts of gallbladder?
The gallbladder lies in the gallbladder fossa on the undersurface of the liver. This is a pear shaped
structure with an average length of 7–12 cm and capacity of 30–50 mL. The gallbladder consists of:
„ Fundus: Part of the gallbladder projecting beyond the inferior border of the liver.
„ Body: Part of the gallbladder extending from the end of the fundus to the neck of gallbladder.
„ Neck: The neck of the gallbladder forms an S-shaped curve and connects the body of the
gallbladder to a narrow infundibulum which is continued as cystic duct. From the neck a
small diverticulum may project towards the duodenum. This is known as Hartman’s pouch.
The portion of the neck giving attachment to the Hartman ‘s pouch is known as isthmus of
gallbladder.
What is the peculiarity in structure of gallbladder?
The gallbladder consists of three coats—mucus, fibromuscular and serous coat. There is no
submucous coat in gallbladder.
The mucous membrane is thrown into innumerable folds which sinks into the muscle coat.
These are called crypts of Luschka.
The muscle fibers are arranged in a criss-cross fashion and is well developed near the neck
of the gallbladder.
The serous coat covers the gallbladder on all sides except part of the gallbladder in contact
with the gallbladder bed in liver.
What is the disposition of hepatic ducts, cystic duct and common bile duct (Fig. 23.24)?
The right and left hepatic duct emerges at the porta hepatis. The left hepatic duct purses a longer
course than the right hepatic duct. These two duct joins at the confluence to form the common
hepatic duct.
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The common hepatic duct is 3 cm in length and runs in the free margin of the lesser omentum.
The cystic duct emerges from the neck of the gallbladder is 3 cm long and joins the right
margin of the cHD to form the common bile duct.
The common bile duct is 7.5 cm long and is divided into four parts:
„ Supraduodenal part: 2.5 cm long runs in the free margin of lesser omentum lying to the right
of hepatic artery and infront of portal vein.
„ Retroduodenal part: Lying behind the first part of the duodenum.
„ Infraduodenal part lies in the groove or in a tunnel in the posterior surface of the head of
pancreas.
„ Intraduodenal part: Runs obliquely through the wall of the second part of the duodenum,
dilates to form the ampulla of vater and joined by the pancreatic duct opens at the
posteromedial wall of the duodenum at the major duodenal papilla.
What are the sphincters around the bile duct (Fig. 23.25)?
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Sphincter choledochus (Sphincter of Boyden): Sphincter around the terminal part of the bile
duct.
Sphincter pancreaticus: This is the sphincter muscle around the terminal part of the pancreatic
duct.
Sphincter of Oddi: Sphincter around the ampulla of Vater.
Figure 23.25: Sphincters around the bile duct
What is the blood supply of gallbladder and biliary tree (Figs 23.26A and B)?
The gallbladder is supplied by the cystic artery which is usually a branch of right hepatic
artery. The cystic artery arises behind the common hepatic duct, crosses behind and enters
the gallbladder (Fig. 23.26A).
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A
B
Figures 23.26A and B: Arterial supply of gallbladder
An accessory cystic artery arising from the gastroduodenal artery may also supply the
gallbladder (Fig. 23.26B).
The bile duct is supplied by two vertical arteries arising from the hepatic artery running
along the bile duct at 3 and 9 o’clock position and giving off circumferential arteries anteriorly
and posteriorly.
What is Moynihan’s hump (Fig. 23.27)?
This is one of the anomalies in relation to the course
of hepatic artery. The hepatic artery makes a tortuous
course infront of the bile duct near the entry of cystic
duct. The cystic artery arising from this hump or the
hump of right hepatic artery is usually short. this
is a dangerous anomaly as hepatic artery may be
confused with cystic artery and may be clipped during
cholecystectomy.
How venous drainage of gallbladder occurs?
the cystic veins draining the gallbladder does not
accompany the cystic artery. These veins pierces the
fossa for the gallbladder and drains into the intrahepatic
part of portal vein. Rarely cystic vein drains into the right
branch of portal vein.
Figure 23.27: Moynihan’s hump
What is the lymphatic drainage of biliary tree (Fig. 23.28)?
The lymphatics of gallbladder drain into the cystic lymph node of Lund. The cystic lymph node
lies at the junction of cystic duct and common hepatic duct.The efferent from the cystic lymph
nodes drains into the pericholedochal lymph nodes and lymph nodes at the porta hepatis and
supeorior and posterior pancreatico dudenal lymph nodos. These lymphatic then passes into
the celiac lymph nodes.
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Figure 23.28: Lymphatic drainage of biliary tree
What is the boundary of Calot’s triangle (Fig. 23.29) ?
The calot’s triangle is bounded:
Above by the inferior surface of liver
„ Below by the cystic duct and
„ Medially by the common hepatic duct.
„
Figure 23.29: Calot‘s triangle. CA = cystic artery; CD = cystic
duct; CBD = common bile duct; RHA = right hepatic artery;
LHA = left hepatic artery; CHD = common hepatic duct
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What are the functions of gallbladder?
Gallbladder performs a number of functions:
Storage of bile: Gallbladder stores the bile during fasting. in fasting state the bile secreted by
the liver is diverted into the gallbladder via the cystic duct as the sphincter of oddi remains
in spasm.
„ Concentration of bile: Gallbladder concentrates the bile by active absorption of water, sodium
bicarbonate and sodium chloride.The gallbladder is 5-10 times concentrated than the liver
bile.
„ Emptying of bile: in response to feeding, the gallbladder contract and the sphincter of oddi
relaxes, resulting in emptying of bile into the duodenum. This is mediated by the hormone
cholecystokinin.
„ Secretion mucus-Gallbladder has the capacity of secretion of mucus. About 20 mL of mucus
is secreted by the gallbladder mucosa per day. if the cystic duct is obstructed due to any
reason the bile cannot enter into the gallbladder and the mucus secreted by the gallbladder
remains pentup in the gallbladder resulting in mucocele of gallbladder.
„
What is the location and parts of pancreas (Fig. 23.30)?
Pancreas (Greek Word- “Pan” means all and “kreas” mean flesh) weigh approximately 80–90
gm and is located in the retroperitoneum behind the stomach and from the concavity of the
duodenum to the hilum of the spleen.
The pancreas consists of following parts:
„ Head: Lies within the concavity of the duodenum. constitute about 30% of the mass of
pancreas.
„ Neck: The junctional area between the head and body of the pancreas. The neck of the
pancreas overlies the superior mesenteric vein and the formation of portal vein.
Figure 23.30: Five parts of pancreas. The line between the body and
the tail is arbitrary
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Body: extends from the left margin of the portal groove to the tail of the pancreas.
Tail: The extreme left portion of pancreas lying between two layers of lienorenal ligament
extending upto the hilum of the spleen.
Uncinnate process- This is a triangular projection from the lower and left portion of the head
of pancreas which passes upwards and medially behind the superior mesenteric vessels.
What is the disposition of pancreatic duct (Fig. 23.31)?
The main pancreatic duct (duct of Wirsung) drains
the tail, body and ventral part of the head of the
pancreas and joins the common bile duct to form
the ampulla of Vater and opens in the posteromedial
wall of the 2nd part of the duodenum over the major
duodenal papilla.
The minor pancreatic duct (of Santorini) draining
the part of the head of the pancreas into the
posteromedial wall of the 2nd part of the duodenum
above the opening of ampulla of Vater over the
minor duodenal papilla.
How does the pancreas develops?
Figure 23.31: Disposition of pancreative duct
The pancreas develops from the dorsal and ventral pancreatic bud.
The dorsal, pancreatic bud arises from the dorsal side of the duodenum and forms the body
and tail of pancreas. The duct arising from the dorsal bud and draining the body and tail opens
in the minor papilla.
The ventral pancreatic bud arises from the base of the hepatic diverticulum and forms the head,
neck and uncinate process of the pancreas. The duct draining the head and neck area, opens into
the major duodenal papilla distal to the opening of dorsal duct. Fusion occurs between the two
buds and the ducts also fuses.
The ventral duct and the distal portion of the dorsal duct fuses and forms the main pancreatic
duct (Duct of Wirsung).
The proximal portion of the dorsal duct forms the minor pancreatic duct (Duct of
Santorini).
What is pancreas divisum (Fig. 23.32)?
Pancreas divisum is a congenital anomaly where there is failure
of fusion of dorsal and the ventral pancreatic duct.
In this condition the dorsal pancreatic duct draining the body
and tail of the pancreas opens into the minor duodenal papilla.
The ventral pancreatic duct draining the head and neck of the
pancreas opens into the major duodenal papilla.
This may result in functional obstruction of the minor duodenal
papilla draining the major part of the pancreas resulting in
recurrent pancreatitis.
Figure 23.32: Schematic dia­
gram of pancreas divisum
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What are the islet of Langerhans?
These are endocrine cells in the pancreas and constitutes about 10–20% of pancreatic mass. This
consists of:
„ Beta cells (70%): Secretes insulin.
„ Alpha cells (20%): Secretes glucagon.
„ Delta cells: Secretes somatostatin.
„ Pancreatic polypeptide cells: Scretes pancreatic polypeptide.
„ VIP cells: Secretes vasoactive intestinal polypeptide.
What is the arterial supply of pancreas (Fig. 23.33)?
Head and neck : Supplied by superior and inferior pancreaticoduodenal arteries.
Superior pancreaticoduodenal artery is the branch of gastroduodenal artery, and inferior
pancreaticoduodenal artery is the branch of superior mesenteric artery. Each of these arteries
gives off dorsal and ventral branches and an anastomotic network is formed on the ventral
and dorsal aspect of the head of pancreas.
„ Body and tail: Supplied by the pancreatic branches of splenic artery. One of these branches is
large and accompanies the main pancreatic duct and is known as arteria pancreatica magna.
Occasionally a dorsal pancreatic branch arising from splenic artery or coeliac trunk may supply
the dorsal surface of the pancreas.
A capillary plexus supplies the islet cells and the acini.
Venous drainage: The veins follows the arteries and drains into the superior mesenteric vein,
splenic vein and the portal vein.
„
Figure 23.33: Arterial supply of pancreas
What is the effect of secretin and pancreozymin on pancreatic secretion?
In response to a meal pancreas secretes juice containing enzymes and bicarbonates.
The hormone secretin released by the duodenal mucosa stimulates pancreas to secrete
pancreatic juice rich in bicarbonate.
The hormone pancreozymin (cholecystokinin) released by the duodenal mucosa in response
to food stimulates pancreas to secrete a juice rich in enzymes.
Vagal stimulation increases volume of pancreatic secretion.
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APPENDIX
What is the length of appendix?
The length of appendix is highly variable and ranges between 2–20 cm.
What are the parts of appendix?
The appendix has a base, body and tip. The mesentery attached to the appendix is known as
mesoappendix.
Where the base of appendix is located (Fig. 23.34)?
The base of the appendix is attached to the posteromedial wall of the cecum 2 cm below the
ileocecal junction.
if the taenia coli in the cecum are traced downwards all the three taenia coli converges to the
base of the appendix and continue as the longitudinal muscle coat of the appendix.
on the surface the base of the apendix lies at MacBurney’s point which is located at the right
spinoumbilical line (Line joining between the anterior superior iliac spine and the umbilicus)
at the junction of medial two-thirds and lateral one-third.
Figure 23.34: Different anatomical positions of
the appendix
What is mesoappendix?
This is the mesentery of the appendix attached to the mesenteric border of the appendix. The
mesoappendix contains the appendicular vessels. The mesoappendix does not extends up to
the tip of the appendix and the appendicular vessels stops just before the tip of the appendix.
The tip of the appendix is the least vascular area, and in obstructive type of appendicitis the
commonest site of gangrene is the tip of the appendix.
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Which vessels supply the appendix?
The appendix is supplied by appendicular artery which is a branch of inferior division of ileocolic
artery. The appendicular artery is an end artery.
Sometimes an accessory appendicular artery may arise from the posterior cecal artery and
may supply the appendix in addition to appendicular artery.
Why appendix is known as abdominal tonsil?
The submucous coat of appendix contains lots of lymphoid follicles. The presence of lymphoid
follicles is one important etiological factor for development of appendicits.
What are the different locations of appendix (see Fig. 23.34)?
The base of the appendix is usually located at the MacBurney’s point. The body and the tip of
the appendix may lie at different locations and hence named according to the location as:
„ Retrocecal (60–70%): commonest location, lies behind the cecum.
„ Pelvic (20–30%): Second commonest location lies towards the pelvis.
„ Paracecal (1–2%): Lies along the side of the caecum.
„ Subcecal (1%): Lies below the cecum.
„ Splenic (1–2%): Lies towards the terminal ileum. May be:
• Preileal: Runs infront of the terminal ileum
• Postileal: Runs behind the terminal ileum.
ectopic appendix: Due to malrotation of the gut, the appendix along with cecum may be located
in left iliac fossa or in the right subhepatic region.
What is the extent and branches of abdominal aorta (Fig. 23.35)?
„
Extent of abdominal aorta: The descending thoracic aorta is contined as abdominal aorta
at the lower border of the t 12 vertebra passing through the aortic hiatus of the diaphragm
behind the median arcuate ligament. it runs in front of the vertebral body of L1 to L4 lying
little to the left side of the midline. At the level of the body of L4 vertebra it terminates by
dividing into two common iliac arteries.
Branches: The branches of abdominal aorta includes:
Ventral branches: Three unpaired ventral branches supplies the gastrointestinal tract.
• Celiac trunk: Divides into left gastric, hepatic and splenic arteries.
• Superior mesenteric artery: Gives off inferior pancreaticoduodenal, jejunal and ileal
branches, middle colic, right colic and terminates as ileocolic artery
• Inferior mesenteric artery: Gives off left colic, sigmoid branches and terminates as superior
rectal artery.
„ Lateral branches: These are paired branches.
• Inferior phrenic arteries: First branch of abdominal aorta arise at the level of t12 vertebra.
• Middle suprarenal arteries.
• Renal arteries.
• Testicular or ovarian arteries
„ Dorsal branches: These are:
• Lumbar arteries: 4 pairs.
• Unpaired median sacral arteries.
„
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Figure 23.35: Branches of abdominal aorta
What are the branches of celiac trunk (Fig. 23.36)?
This is the 1st ventral branch of abdominal aorta. This subdivides into:
Left gastric: Runs along the lesser curvature and anastomose with the right gastric artery.
Gives off branches to esophagus, fundus of stomach, body and cardiac end of stomach.
„ Hepatic artery: The hepatic artery runs in the gastrohepatic omentum. Part of the hepatic
artery from its origin to the origin of gastroduodenal artery is called the common hepatic
artery. Part of the hepatic artery from the origin of gastroduodenal artery to its bifurcation is
called the hepatic artery proper. The branches of hepatic artery includes:
• Gastroduodenal which divides into superior pancreaticoduodenal and right gastroepiploic
artery.
• Right gastric.
• Branches to bile duct: Arteries to the bile duct runs at 3 o’clock and 9 o’clock position.
• cystic artery arises from the right branch of the hepatic artery.
• two terminal branches: Right and left hepatic branches supplying the corresponding
lobes of the liver.
• An accessory hepatic artery may arise from the superior mesenteric artery or left gastric artery.
„ Splenic artery: Runs along the upper border of pancreas and reaches the splenic hilum. The
branches of splenic artery are:
• Short gastric branches
• Left gastroepiploic artery.
„
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Figure 23.36: Branches of celiac trunk
What are the branches of superior mesenteric artery (Fig. 23.37)?
The superior mesenteric artery is a ventral branch of abdominal aorta and arises at the level of
L1 vertebra. The branches includes:
„ inferior pancreaticoduodenal: Runs in the pancreaticoduodenal groove and anastomose
with the superior pancreaticoduodenal artery.
Figure 23.37: Branches of superior mesenteric artery
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Middle colic
Right colic
ileocolic
Jejunal and ileal branches.
What are the branches of inferior mesenteric artery (Fig. 23.38)?
inferior mesenteric artery is a ventral branch of the aorta at the level of L3 vertebra.The branches
includes:
„ Left colic artery.
„ Sigmoid artery: May be more than one in number.
„ Superior rectal artery: inferior mesenteric artery continues as the superior rectal artery.
Figure 23.38: Branches of inferior mesenteric artery
What are the extent and tributaries of inferior vena cava (Fig. 23.39)?
„
„
„
Origin: The inferior vena cava is formed by the union of right and left common iliac vein at
the level of the 5th lumbar vertebra about 2.5 cm to the right of midline.
Termination: The inferior vena cava opens at the lower and posterior part of right atrium.
This opening is guarded by the valve of the inferior vena cava.
Tributaries of inferior vena cava:
• Right and left common iliac veins which joins to form the inferior vena cava.
• Median sacral vein.
• Lumbar veins.
• Lumbar azygos vein.
• Right testicular or ovarian vein (The left gonadal vein drains into left renal vein).
• Right and left renal veins.
• Right suprarenal vein (left suprarenal vein drains into left renal vein).
• Right inferior phrenic vein (left inferior phrenic vein drains into left suprarenal vein).
• Hepatic veins (right, middle and left hepatic veins).
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Figure 23.39: Tributaries of inferior vena cava
Describe anatomy of portal vein (Fig. 23.40).
The portal system of veins carries blood from the abdominal part of the gastrointestinal system,
spleen, pancreas and gallbladder to the liver.
The blood in the portal system traverses through two sets of capillaries:
„ 1st set of capillary in the wall of the gut
„ 2nd set of capillary at the liver where the blood drains into the sinusoids and from there the
blood is returned via the hepatic veins and the inferior vena cava.
„ Origin of portal vein: This is formed by the union of superior mesenteric vein and the splenic
vein behind the neck of the pancreas.
„ Course of portal vein:
The portal vein ascends behind the neck of the pancreas and the pyloric part of the stomach
and runs in the free margin of the lesser omentum running inbetween and behind the bile
duct and the hepatic artery. The bile duct lies in the right free margin and the hepatic artery
lies to the left of the duct. As the vein reaches to the porta hepatis it divides into the right and
left branches and enters into the liver.
Tributaries of portal vein:
„ Superior mesenteric vein.
„ Splenic vein (inferior mesenteric vein drains into the splenic vein).
„ Right gastric vein.
„ Left gastric vein (coronary vein).
„ cystic vein.
„ Sometimes prepyloric vein.
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Figure 23.40: Anatomy of portal vein
„
„
Superior pancreaticoduodenal vein.
Paraumbilical vein drains into left branch of portal vein.
What are the sites of portacaval anastomosis (Fig. 23.41)?
At the abdominal part of the esophagus:
• Portal: esophgeal tributaries of left gastric vein.
• Systemic: esophageal tributaries of azygos and accessory hemiazygos vein.
„ At the dentate line of anal canal:
• Portal: Superior rectal vein.
• Systemic: Middle and inferior rectal veins.
„ Around the umbilicus:
• Portal: Paraumbilical vein.
• Systemic: Thoracoepigastric and superficial epigastric.
in portal hypertension these veins forms a bunch of dilated veins around the umbilicus
(caput medusae).
„ In the bare area of liver:
• Portal: Veins from the liver.
• Systemic: Diaphragmatic veins.
„ In the retroperitoneum:
• Portal: Veins of colon and duodenum.
• Systemic: Retroperitoneal veins and veins from kidney.
„ If due to developmental error the ductus venosus remains patent, then there is direct
communication between the left branch of portal vein and the inferior vena cava providing
a portacaval anastomosis.
„
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Figure 23.41: Sites of portacaval anastomosis
Describe anatomy of renal vein (Fig. 23.42).
Formation of renal vein: The interlobular vein carries blood from the cortex and medulla and
drains into the venous arcades lying along the base of the medullary pyramids. These arcades
drains into the interlobar veins which joins to form lobar veins. These lobar veins joins to from
5–6 tributaries which ultimately forms the renal vein.
Figure 23.42: Anatomy of renal vein
Termination of renal vein:
The right renal vein is short and drains into the inferior vena cava. There is no tributaries of
right renal vein.
The left renal vein is long (about 7.5 cm), passes anterior to the abdominal aorta and drains
into the inferior vena cava at a little higher level than the right renal vein. The left renal vein
receives following tributaries:
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Left adrenal vein
Left gonadal vein (testicular or ovarian)
Sometimes left inferior phrenic vein.
AUTONOMIC NERVOUS SYSTEM
What constitutes the autonomic nervous system?
The autonomic nervous system consists of:
Sympathetic nervous system
„ Parasympathetic nervous system.
„
What constitutes the sympathetic nervous system?
The sympathetic nervous system consists of:
Preganglionic sympathetic fibers: These are axons of the nerve cells located at the lateral
horn cells of the spinal cord at all the thoracic and upper two lumbar segments (T1 –L2.
Thoracolumbar outflow).
„ Sympathetic trunk with the sympathetic ganglia and other paravertebral ganglia.
„ Postganglionic sympathetic fibers.
„
What constitutes the parasympathetic nervous system?
The parsympathetic nervous system consists of :
Preganglionic fibers arising from the brain and the sacral segments of the spinal cord
(Craniosacral outflow).
The preganglionic cranial fibers arises from:
„ Edinger-Westphal nucleus (Runs along IIIrd nerve).
„ Superior and inferior salivary nucleus (Runs along VIIth and IXth nerve).
„ Dorsal motor nucleus (Runs along Xth. nerve).
The sacral fibers arise in the gray matter of the spinal cord from second to fourth sacral
segments.
• Peripheral parasympathetic ganglia
• Postganglionic parasympathetic fibers.
The peripheral autonomic nervous system is under the control of central autonomic centers in
the brainstem, hypothalamus and the cerebral cortex.
The preganglionic sympathetic fibers are short synapses with many postganglionic neurons
and this results in an enhanced effect following a sympathetic discharge.
The preganglionic parasympathetic fibers are long and synapses with only few postganglionic
neurons, so the parasympathetic discharge results in a more limited effect.
„
What are the important neurotransmitters in autonomic nervous system?
„
„
„
„
Preganglionic sympathetic fibers: Acetylcholine.
Postganglionic sympathetic fibers: Noradrenaline, except postganglionic fibers to the sweat
glands where the neurotransmitter is acetylcholine.
Preganglionic parasympathetic fibers: Acetylcholine.
Postganglionic parasympathetic fibers: Acetylcholine.
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What are white rami communicantes?
The white rami communicantes carries the preganglionic synmpathetic fibers from the spinal
nerves into the sympathetic trunk.
The preganglionic fibers of the sympathetic system arises from the lateral horn cells of the spinal
cord from T1 to L2 segments. These fibers exits from the spinal cord along the anterior nerve roots
of the spinal nerve and then runs a short course along the mixed spinal nerve and exits from
the mixed spinal nerve via a white rami communicantes to enter into the sympathetic trunk.
So the white rami communicantes are present from T1 to L2 spinal nerves to the corresponding
sympathetic ganglia. The postganglionic fibers passess through the gray rami communicantes to
the spinal nerve and runs along the vessels.
What constitutes the sympathetic nervous system?
The gray rami communicantes carries postganglionic sympathetic fibers from the sympathetic
ganglia to the corresponding spinal nerves.The gray rami communicantes are present from the
cervical to the sacral segments of the sympathetic trunk to the corresponding spinal nerves.
What are the characteristics of sympathetic trunks?
Sympathetic trunks situated one on either side of the vertebral body consists of ganglia joined by
nerve fibers.The sympathetic trunks extends above to the base of the skull and ends below in front
of the coccyx as ganglion impar.
There are following sympathatic ganglia along the sympathetic trunks:
Three cervical ganglia: Superior, middle and inferior cervical ganglia.
„ Eleven thoracic ganglia.
„ Four lumbar ganglia.
„ Four sacral ganglia.
Developmentally each spinal nerve segment had one ganglia. Due to subsequent fusion the
numbers of ganglia are reduced.
The ganglia from T1 to L2 communicantes with the corresponding spinal nerves via the white
rami communicantes. The gray rami communicantes are, however, present in all the sympathetic
ganglia connecting the ganglia to the corresponding spinal nerves.
„
What are the distribution of postganglionic sympathetic fibers?
The postganglionic sympathetic fibers are distributed as :
Somatic fibers:
The preganglionic sympathetic fibers enters into the sympathetic trunk via the white rami
communicantes to synapse with the ganglia corresponding spinal segment or in a ganglia
higher or lower in the sympathetic trunk. The postganglionic fibers exit through the gray rami
communicantes to the corresponding spinal nerves. These postganglionic fibers are distributed
via the spinal nerves as :
• Vasomotor fibers to the cutaneous blood vessels.
• Sudomotor fibers to the sweat glands.
• Pilomotor fibers to the arectores pilorum.
„
„
Visceral fibers:
• Thoracic viscer are supplied by the postganglionic fibers arising from the cervical and upper
thoracic ganglia via the cardiac, esophageal and pulmonary plexuses.
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• Abdominal visceras are supplied by the fibers which exit from the sympathetic trunk without
synapsing and run along the greater, lesser and the lowest splanchnic nerves and synapse
in the ganglia of one of the prevertebral plexuses.
• Fibers to the adrenal medulla run through the sympathetic trunk without synapsing and
run through the greater splanchnic nerve and celiac plexus into the adrenal medulla where
they synpase with the ganglion cells which has same embryologic origin as the sympathetic
ganglia.
Postganglionic fibers to the cranial structures like salivary glands, dilator pupillae are carried
via the gray rami communicantes which accompany the carotid vessels.
What are the characterisitcs of lumbar sympathetic trunk?
The lumbar sympathetic trunk lies retroperitoneally on the anterolateral surface of the bodies of
lumbar vertebrae. The sympathetic trunk lies medial to the psoaas muscle. On the right side it is
partially overlapped by the inferior vena cava and the left side it is partially overlapped by the
abdominal aorta.
There are four lumbar sympathetic ganglia. The L2 and L3 lumbar sympathetic ganglia usually
fuses to form a single ganglia.The branches of lumbar sympathetic trunk include:
„ The ventral rami of L1 and L2 spinal nerve gives off white rami communicantes to the
corresponding lumbar ganglia. These white rami communicantes carries preganglionic fibers
to the symapathetic trunk.
„ Gray rami communicantes to all lumbar spinal nerves.
„ Splanchnic nerves arising from the lumbar ganglia join the celiac, intermesenteric and superior
hypogastric plexus.
BREAST
What are the quadrants of breast (Fig. 23.43)?
one vertical and one horizontal line is drawn through the nipple. the area of the breast
corresponding to the nipple areolar complex is the central quadrant. The outer quadrant are:
„ Upper outer quadrant
„ Upper inner quadrant
„ Lower outer quadrant
„ Lower inner quadrant
Figure 23.43: Quadrants of breast and tail of Spence
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What is the extent of normal breast (Fig. 23.43)?
The extent of the normal breast varies in nulliparous and multiparous women.
in nulliparous women the breast extends:
„ Above up to the 2nd rib.
„ Below up to the 6th rib.
„ Medially up to the lateral border of sternum.
„ Laterally up to the anterior axillary line.
in multiparous women the breast extends:
„ Above up to the clavicle.
„ Below up to the 8th rib.
„ Medially up to the midline.
„ Laterally up to the posterior axillary line.
The axillary tail of breast is a prolongation of a part of the breast towards the axilla.
What are breast lobules?
The lobules are the structural units of breast. This consists of acini lined by cuboidal or columnar
cells. each lobules is drained by a ductules and 10–100 ductules joins to form a lactiferous duct.
There are 15–20 lactiferous ducts in each breast. These ducts runs circumferentially and
opens into the nipple. These lactiferous ducts are lined by specialized myoepithelial cells. At
the terminal part of the lactiferous ducts there is an ampulla which stores milk before discharge.
What are ligament of Cooper?
These are fibrous strands extending from the breast parenchyma to the skin of the breast. When
cancers cells spreads along these fibrous strands there appears dimpling of the skin due to
attachments of the ligaments to the skin.
What are the boundaries of axilla (Fig. 23.44)?
Axilla is a pyramidal shaped space between the upper part of the arm and lateral side of the
upper chest wall. The axilla has four walls, an apex and a base.
Figure 23.44: Cross­section of axilla to show its wall
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Apex is bounded :
• Anteriorly by the clavicle.
• Posteriorly by the upper border of the scapula.
• Medially by the upper border of the 1st rib.
• Laterally by the coracoid process.
„ Base of the axilla is formed by the axillary fascia stretching between the pectoralis major and
latissimus dorsi.
„ Anterior wall of the axilla is fleshy and is formed by the pectoralis major muscle throughout
and behind this by the pectoralis minor and subclavius muscle enclosed within the
clavipectoral fascia. Anterior axillary fold is formed by the lateral border of the pectoralis
major muscle.
„ Posterior wall of the axilla is formed by the subscapularis, latissimus dorsi and teres major muscle.
The posterior axillary fold is formed by the subscapularis latissimus dorsi and the teres major muscle.
„ The medial wall of the axilla is formed by the upper 4 or 5 digitations of the serratus anterior
muscles and 2nd to 6th ribs with the intercostal muscles being covered by the serratus
anterior muscle.
„ Lateral wall of the axilla is formed by upper part of the shaft of the humerus and the conjoint
origin of the coracobrachialis and the short head of biceps brachii.
„
What are the origins and insertion of pectoralis major muscle?
„
„
„
„
Origin: The pectoralis major muscle arises by two heads:
Clavicular head: Arises from anterior aspect of the clavicle
Sternal head: Arises from the anterior surface of the body of the sternum meeting in the
midline with opposite muscle and above extends up to the sternoclavicluar joint blending
with the clavicular head.
Insertion: The pectoralis major muscle is inserted by a trilaminar aponeurosis into the lateral
lip of the bicipital groove of the humerus. The fibers of the clavicular head is inserted by
anterior lamina anmd blends with the middle lamina lying behind it. The sternal fibers get
folded upon itself and is inserted by middle and posterior lamina. The upper sternal fibers
pass on to the middle lamina and the lower sternal fibers pass onto the posterior lamina. The
lowest fibers of origin become the highest fibers of insertion.
What are the actions of pectoralis major muscle?
The pectoralis major muscle helps in adduction and medial rotation of the shoulder.
The clavicluar head of the muscle helps in flexion of the shoulder by raising the humerus
during pushing.
The sternal head of the muscle helps in extension of the shoulder joint by bringing the flexed
humerus downward and backward to the side.
What are the nerve supply of the muscle?
Supplied by both the medial and lateral pectoral nerves arising from the medial and lateral
cord of the brachial plexus. The medial pectoral nerve pierces the pectorlais minor muscle and
supplies both the muscles.
What are the origins of the pectoralis minor muscle?
Origin: This arises from the anterior surfaces of the 2nd to 6th rib and the adjacent costal cartilages.
Insertion: This is inserted by an aponeurosis into the coracoid process near its tip.
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What are nerve supply of the pectoralis major and minor muscle?
Supplied by medial and lateral pectoral nerves.
What are the disposition of clavipectoral fascia?
This is a fascial condensation lying between the pectoralis minor and the clavicle.
Attachment of clavipectoral fascia:
„ Above, it splits to enclose the subclavius. The superficial layer is attached to anterior margin
of the subclavian groove on the inferior aspect of clavicle.The deep layer is attached to the
posterior margin of the subclavian groove and is continued into the neck with deep cervical
fascia covering the inferior belly of omohyoid.
„ Below, it splits to enclose the pectoralis minor muscle and at the lower border of pectoralis
minor it is continued as the suspensory ligament of axilla.
„ Laterally, it is attached to the coracoid process and the coracoclavicular ligament.
„ Medially, it is attached to the first rib and blends with the fascia covering the 1st and 2nd
intercostal space.
Which structures pierces the clavipectoral fascia?
The following structures pierces the clavipectoral fascia:
cephalic vessels.
„ Lateral pectoral nerve—a branch of lateral cord supplies the pectoralis major muscle.
„ Acromiothoracic vessels.
„ Lymphatic vessels.
„
What are the parts of axillary artery?
Axillary is the continuation of the subclavian artery and extends from the outer border of the first
rib and the outer border of the teres major muscle wherein it is continued as the brachial artery.
Axillary artery is divided into three parts in relation to the pectoralis minor muscle.
„ 1st Part:
• Part of the artery lyng between the outer border of the 1st rib and the upper border of
pectoralis minor.
„ 2nd Part:
• Part of the artery lying behind the pectoralis minor muscle.
„ 3rd Part:
• Part of the artery lying between the lower border of the pectoralis minor and the lower
border of teres major muscle.
What are the branches of axillary artery (Fig. 23.45)?
one branch from 1st part, 2 branches from 2nd part and 3 branches from 3rd part of axillary
artery as follows:
„ 1st part: (1 branch) Superior thoracic artery.
„ 2nd part: (2 branches)
• Thoracoacromial: Arises at upper border of pectoralis minor, pierces pectoralis minor
divides into 4 branches—clavicular, pectoral, acromial and deltoid branches.
• Lateral thoracic: Runs along the lower border of the pectoralis minor to the chest wall.
„ 3rd part: (3 branches)
• Subscapular: Largest branch runs along the posterior wall of the axilla. Gives off circumflex
scapular artery which forms a plexus on the dorsum of scapula
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Figure 23.45: Branches of axillary artery
• Posterior circumflex humeral and
• Anterior circumflex humeral. The circumflex arteries encircles the surgical neck of the
humerus. The posterior circumflex humeral accompanies the axillary nerve.
What are the different groups of axillary lymph nodes?
See Breast in Long case Section.
What are the contents of the axilla?
„
„
„
„
„
Vessels of the upper limbs.
nerves of the upper limbs.
two heads of the biceps brachii.
origin of the coracobrachialis.
Loose areolar tissue and the lymph nodes.
What are the origins and insertion of serratus anterior muscle?
Origin: The serratus anterior muscle arises by fleshy digitations from the outer surfaces of the
upper eight ribs. The fibers arising from the upper four ribs lies deep to the pectoralis minor
muscle and the fibers arising from the next four ribs interdigitate with the fibers of external
oblique muscle of the abdomen.
Insertion: This is inserted on the costal aspect of the medial border of the scapula a nd by a
larger triangular insertion at the costal surface of the inferior angle of the scapula and a smaller
triangular area at thecostal surface of the upper angle of the scapula.
Action: The serratus anterior helps in pulling the scapula forward while the arm is raised either in front
of the body or away to the side. if paralyzed the medial border and the inferior angle of the scapula
will project from the back during the above movement, this is known as winging of the scapula.
nerve supply: By long thoracic nerve.
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What are the layers of scalp (Fig. 23.46)?
The scalp is the soft tissue covering of the skull and consists of:
S: Skin
c: Subcutaneous tissue
A: Galea aponeurotica and occipitofrontalis
L: Loose connective tissue
P: Pericranium.
Figure 23.46: Schematic diagram of layer of scalp
What is the peculiarity of subcutaneous tissue of scalp?
The subcutaneous tissue of scalp consists of a close network of fibrofatty tissues and is attached
firmly to the overlying skin and the underlying galea aponeurotica. numerous vessels are found
in this layer. The walls of the blood vessels are densely adherent to the fibrous tissue.
in case of scalp injury, these vessels remain open in the network of fibrous tissue resulting in
profuse bleeding. The bleeding can be controlled by pressure over the injured scalp against the bone.
What is the disposition of galea aponeurotica?
The galeal or the epicranial aponeurosis is a thin tendinous sheet which unites the occipital and
frontal bellies of occipitofrontalis muscle.
Behind it extends between the two bellies of occipitofrontalis muscle and is attached to the
external occipital protuberance and highest nuchal line. in front it sends a narrow slip between
the two bellies of frontalis muscle and blends with the subcutaneous tissues at the root of nose.
Laterally it blends with the temporal fascia.
What are the peculiarities of loose areolar layer of the scalp?
The loose areolar tissue lies deep to the aponeurotic layer. The loose areolar tissue contains few
small arteries and some important emissary veins.The emissary veins are valveless and connects the
superficial veins of the scalp with the diploic veins of the skull bones and intracranial venous sinuses.
An infection in this layer may rapidly spread to intracranial venous sinuses, so this layer of
the scalp is also known as danger area of the scalp.
collection of blood or pus in this layer produces generalized swelling of the scalp posteriorly
extending up to the highest nuchal line and anteriorly extends up to the upper eyelid as there
are no bony attachment of the frontalis muscle.
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What is the blood supply of the scalp (Fig. 23.47)?
The scalp has a rich blood supply and a small cut may cause profuse bleeding. The following
arteries supply the scalp:
i. Supratrochlear and supraorbital arteries, branches of ophthalmic artery run along the
corresponding nerves
ii. Superficial temporal artery, the smaller terminal branch of the external carotid artery runs
up infront of the tragus along with auriculotemporal nerve.
iii. Posterior auricular artery, a branch of external carotid artery ascends pehind the pinna.
iv. occipital artery, a branch of external carotid artery runs up in occipteal region along with
greater occipital nerve.
The venous drainage occurs through:
i. Supratrochlear and supraorbital veins, which joins at the medial angle of the orbit to form
the facial vein
ii. Superficial temporal vein, which joins with the maxillary veins in the substance of the
parotid gland to form the retromandibular vein.
ii. Posterior auricular vein, which joins with the posterior division of the retromandibular vein
to form the external jugular vein.
iv. occipital vein, which drains into the occipitial venous plexus. The occipitial venous drains
into both the vertebral vein or internal jugular vein.
The veins of the scalp freely anastomose with each other and are connected to the diploic
veins of the skull bone. These veins also communicates with the intracranial venous sinuses
through the valveless emissary veins.
Figure 23.47: Scalp—Arterial supply shown on right and nerve
distribution shown on left. Veins are not shown, but follows the
arteries
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What are the nerve supply of the scalp (Fig. 23.48)?
The following nerves supply the scalp:
i. Supratrochlear and supraorbital nerves which are branches of ophthalmic nerve.
ii. Zygomaticotemporal nerve, a branch of maxillary division of trigeminal nerve.
iii. temporal branch of facial nerve supplies the frontal belly of occipitofrontalis.
iv. Auriculotemporal nerve, a branch of mandibular division of trigeminal nerve.
v. Posterior branch of greater auricular nerve.
vi. Posterior auricular branch of facial nerve, supplies occipital belly of occipitofrontalis muscle.
vii. Lesser occipital nerve from c1 nerve of cervical plexus.
viii. Greater occipital nerve from c2 of cervical plexus.
ix. The third occipital nerve from dorsal ramus of c3 nerve.
Figure 23.48: Nerve supply of the scalp
What are the veins of the face (Fig. 23.49)?
The following veins drains the facial region:
i. Facial vein: The facial vein begins as the angular vein at the inner angle of the orbit by joining
of supratrochlear and supraorbital veins. in the neck the facial vein is joined by anterior
division of retromandibular vein and forms the common facial vein which drains into the
internal jugular vein.
ii. Retromandibular vein: The retromandibular vein is formed within the substance of the
parotid gland by joining of superficial temporal and maxillary vein. At the lower pole of the
parotid gland the retromandibular vein divides into anterior and posterior division.
The anterior division joins the facial vein to form the common facial vein. The posterior
division joins with posterior auricular vein to form the external jugular vein.
iii. External jugular vein: The external jugualr vein is formed by joining of posterior division
of retromandibular vein and the posterior auricular vein. The external jugular vein drains
into the subclavian vein.
iv. The occipital vein joins the suboccipital venous plexus which drains either into the internal
jugular vein or into the vertebral vein.
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Figure 23.49: Veins of the face
v. Anterior jugular vein: The anterior jugular vein is formed below the chin by union of small
veins from the submandibular region and descends downwards in the neck on either side
of the midline.
What are the sensory nerve supply of the face (Fig. 23.50)?
The face is supplied by sensory branches of three divisions of the trigeminal nerve—ophthalmic,
maxillary and mandibular divisions.Three distinct areas in the face are supplied by these nerves:
„ Ophthalmic zone: tip and sides of the nose, forehead and the upper eyelid.
„ Maxillary zone: Upper lip, part of the sides of the nose lower eyelid, malar prominence and
a small portion of temporal region.
„ Mandibular zone: Lower lip, chin, skin overlying the mandible excluding the angle, cheek,
part of pinna, external acoustic meatus and most of the temporal region.
An area near the angle of the mouth is supplied by the greater auricular nerve.
The following nerves supplies the dfferent areas of the face:
i. Branches from the ophthalmic division:
• Lacrimal nerve—supplies the lateral part of the upper eyelid.
• Supraorbital nerve—supplies the forehaed and the scalp upto the vertex.
• Supratrochlear nerve—supplies the middle of the forehead and scalp.
• infratrochlear nerve—supplies the medial part of the upper eyelid and side of the nose.
• external nasal nerve—supplies the tip and ala of the nose
ii. Branches from the maxillary division of trigeminal nerve:
• infraorbital nerve: continuation of maxillary nerve and emerges through the infraorbital
foramen and divides into three branches:
− Palpebral branch supplies the lower eyelid.
− Labial branch supples the uper lip and cheek.
− nasal branch supplies the sides and ala of the nose.
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Figure 23.50: Sensory nerves of face
• Zygomaticofacial nerve—emerges through the zygomatic foramen and supplies the
overlying skin.
• Zygomaticotemporal nerve supplies the temporal region.
iii. Branches from the mandibular division of trigeminal nerve:
• Auriculotemporal nerve: Runs vertically upwards across the posterior root of zygoma and
divides into:
− Auricular branch—supplies the pinna and the external acoustic meatus.
− temporal branch—supplies the skin over the temporal region.
• Buccal branch—supplies skin over the cheek and also the mucous membrane of the cheek
after piercing the buccinator muscle.
• Mental nerve—emerges through the mental foramen supplies the skin and mucous
membrane of the lower lip.
How does the face and lips develop?
During the 2nd week of intrauterine life the face of the embryo is represented by an area bounded
cranially by the neural plate caudally by the pericardium and laterally by the mandibular process
of the 1st pharyngeal arch on each side. A depression appears in the center of this area known
as stomodaeum. The inner lining of the stomodaeum is the buccopharyngeal membrane and at
4th week of intrauterine life the buccopharyngeal membrane disappears and the stomodeum
communicates with the foregut.
A number of processes develop around the stomodeum and help in development of face.
What is the disposition of deep cervical fascia of neck?
The deep cervical fascia consists of 3 distinct layers of fasciae:
investing layer,
„ Pretracheal layer, and
„ Prevertebral layer.
„
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What is the disposition of investing layer of deep cervical fascia (Fig. 23.51)?
The investing layer of deep cervical fascia extends as follows:
Posteriorly attached to the ligamentum nuchae and the spines of cervical vertebrae.
„ This fascial layer splits to enclose the trapezius muscle and runs medially to form the roof
of the posterior triangle.
„ At the lateral border of the sternocleidomastoid it splits to enclose the sternocleidomastoid
muscle and runs medially to form the roof of the anterior triangle of the neck and becomes
continuous with investing layer of the deep cervical fascia of the opposite side.
„ Superiorly this fascial layer is attached to the:
• external occipital protuberance
• Superior nuchal line
• Mastoid process
• Base of the mandible.
This layer splits to enclose the parotid and submandibular salivary glands.
inferiorly this fascial layer is attached to the:
„ Spine of scapula
„ Acromian process
„ clavicle and the upper border of the manubrium sterni.
this fascial layer splits inferiorly to form the suprasternal space of Burns and the
supraclavicular space.
Anteriorly this fascial layer is attached to the symphysis menti and hyoid bone above and
becomes continuous with the investing layer of the fascia of the opposite side.
„
Figure 23.51: Disposition of layers of cervical fascia
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What is the disposition of pretracheal layer of the deep cervical fascia?
Deep to the sternocleidomastoid muscle a fascial prolongation reaches the thyroid gland where
it splits to enclose the thyroid gland and medially this gets blended with the fascial covering of
the trachea.
A part of this pretracheal fascia extending between the thyroid gland and the cricoid cartilage
is thickened to form the Berry’s ligament.
Superiorly this, layer is attached to the hyoid bone, oblique line of thyroid cartilage and the
cricoids cartilage.
inferiorly, this layer invests the thyroid veins runs behind the brachiocephalic vein and gets
blended with the fascial covering of the arch of the aorta.
What is the disposition of prevertebral layer of the deep cervical fascia?
This layer invests the prevertebral muscles and forms the floor of the posterior triangle of the neck.
Superiorly attached to the base of the skull.
inferiorly this fascial layer is attached to the anterior longitudinal ligament and the body of
the fourth thoracic vertebra.
Anterior to the prevertebral fascia is the retropharyngeal space containing loose areolar tissue.
THYROID GLAND
What are the parts of thyroid gland?
Thyroid gland weighing about 25 gm, is a butterfly-shaped structure located in the front and
sides of the lower part of the neck. The gland consists of:
„ Right and left lateral lobes
„ isthmus
„ Sometimes a pyramidal lobe may project upwards from the isthmus.
Where is the thyroid gland located?
The thyroid gland is located in the thyroid region.
each of the lateral lobes extends above up to the oblique line of the thyroid cartilage and
below upto the 4th or 5th tracheal ring.
The isthmus of the thyroid gland lies over the 2nd, 3rd and 4th tracheal rings.
What are the parts of each lobe of the thyroid gland?
The thyroid lobe consists of two borders and three surfaces:
Borders:
• The anterior border is thin and is related to the anterior branch of superior thyroid artery.
• The posterior border is broad and rounded and is related to the branch of the inferior
thyroid arteries and the parathyroid glands.
„ Surfaces: There are three surfaces:
• The anterolateral surfce is convex and is covered by sternothyroid, sternohyoid, superior
belly of omohyoid, and medial border of sternocleidomastoid.
• The medial surface is related to 2 tubes—trachea and esophagus, 2 nerves—external
laryngeal and recurrent laryngeal and 2 muscles—inferior constrictor of pharynx and
cricothyroid.
• Posterior surface is related to carotid sheath.
„
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What is the disposition of the isthmus of the thyroid gland?
The isthmus of the thyroid gland joins the two lobes and lies over the 2nd, 3rd and 4th tracheal
rings.
The isthmus has superior and inferior borders and anterior and posterior surfaces. The
posterior surface lies over the 2nd, 3rd and 4th tracheal rings.
What is pyramidal lobe?
This is described as a third lobe and may be present in some cases extending from the upper
border of isthmus and may extend up to the hyoid bone.
What is levator glandulae thyroidae?
in some cases a fibrous band may be present extending from the body of the hyoid bone to the
isthmus or to the pyramidal lobe.
What are the capsules of the thyroid gland?
The capsules of the thyroid gland are:
true capsule- Formed by condensation of the connective tissue of the gland.
„ False capsule- The pretracheal layer of the deep cervical fascia splits to enclose the thyroid
gland and forms the false capsule.
A rich venous plexus lies deep to the true capsule of the thyroid gland. So, during
thyroidectomy dissection is done between the false and true capsules of the thyroid gland.
Dissection deep to the true capsule will result in excessive bleeding.
„
What are the blood supply of thyroid gland (Fig. 23.52)?
Arterial supply: The arterial supply is by:
Superior thyroid artery: First branch
of external carotid artery. Runs
in close relation to the external
laryngeal nerve at its initial course
and at the upper pole divides into
an anterior and posterior branch.
• The anterior branch runs along
the anterior border of the lateral
lobe and continues along the
upper border of the isthmus to
anastomose with the same artery
of the opposite side.
• The posterior branch runs along
the posterior border of the lateral
lobe and anastomoses with an
ascending branch of inferior
thyroid artery.
„ Inferior thyroid artery: A branch
of thyrocervical trunk (Branch of
subclavian artery) runs deep to the
carotid sheath and reaches the lower
pole of the thyroid gland gives off Figure 23.52: Arterial supply of thyroid gland
„
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4–5 branches which supplies the thyroid gland. An ascending branch anastomoses with the
posterior branch of superior thyroid artery and supplies the parathyroid glands. The recurrent
laryngeal nerve is in close relation to the inferior thyroid artery close to the gland.
Arteria thyroidea ima: in about 3% of patients there may be an additional supply by arteria
thyroidea ima which arises from the brachiocephalic trunk or arch of the aorta and enters
into the lower part of the isthmus.
Tracheal and esophageal branches: in addition to the above named arteries the thryoid gland
is also supplied by minor branches arising from the tracheal and esophageal branches.
Venous drainage (Fig. 23.53):
The venous drainage is via:
„ Superior thyroid vein: Runs along the superior thyroid artery and drains into the internal
jugular vein.
„ Middle thyroid vein: A short and slender vein emerges from the middle of the thyroid lobe
and drains into the internal jugular vein.
„ Inferior thyroid veins: emerges at the lower of the lateral lobes and joins at the lower border
of the isthmus and drains into the left brachiocephalic vein.
„ A fourth thyroid vein (Vein of Kocher): May present emerging between the middle and inferior
thyroid vein and drains into the internal jugular vein.
Figure 23.53: Venous drainge of thyroid gland
What are the lymphatic drainage of thyroid gland (Fig. 23.54)?
There is a rich lymphatic plexus within the thyroid gland. The lymphatics emerges from the
gland and drains as:
„ From upper part of the gland—to level ii, level iii, level V lymph nodes and prelaryngeal
lymph nodes (Level Vi)
„ From lower part of the gland, the lymphatic reaches the level iV, level V and pretracheal
lymph nodes (level Vi).
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Figure 23.54: Lymphatic draingage of thyroid glaind
How does the thyroid gland develops?
What are fates of thyroglossal duct?
See Short case Section, Page no. 424, chapter 11.
What is the location of parathyroid glands?
There are two pairs of parathyroid glands each weighing about 50 mg. They lie as:
Superior parathyroid gland: Develops from 4th branchial pouch. More constant in position.
Lies at the middle of the lateral lobe along the posterior border of the thyroid gland. Lies close
to the arterial anastomosis of superior and inferior thyroid artery.
„ Inferior parathyroid gland: Develops from the 3rd branchial pouch. Their location is variable
and may lie:
• Within the thyroid capsule near the lower pole.
• outside the thyroid capsule immediately above the inferior thyroid artery.
• in superior mediastinum in an ectopic location.
„
What are the branches of arch of the aorta?
The branches of the arch of the aorta are:
Brachiocephalic trunk—divides into right subclavian and the right common carotid artery.
„ Left common carotid artery.
„ Left subclavian artery.
„ Arteria thyroidea ima in some cases.
„
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SUBCLAVIAN ARTERY
What are the parts of subclavian artery (Fig. 23.55)?
The subclavian artery is a branch of brachiocephalic trunk on the right side and branch of arch
of the aorta on the left side.
The subclavian artery extends from the sternoclavicular joint to the outer border of the first
rib where it is continued as axillary artery.
The subclavian artery is crossed by scalenus anterior muscle and is divided into three parts
in relation to this muscle.
„ First part: Lies medial to the scalenus anterior muscle.
„ Second part: Lies behind the scalenus anterior muscle
„ Third part: Lies lateral to the scalenus anterior muscle.
Figure 23.55: Branches of right subclavian artery
What are the branches of subclavian artery?
The branches of subclavian artery are:
Vertebral artery: Arises from the 1st part of subclavian artery (first and largest branch).
Ascends in the foramen transversarium of cervical vertebrae and the skull through
foramen magnum and joins with the vertebral artery of the opposite side to form the
basilar artery.
„ Internal thoracic artery: Arises from the inferior aspect of the 1st part of the subclavian artery.
Descend in the thorax lying posterior to the costal cartilages and ends at the level of 6th rib
by dividing into superior epigastric and musculophrenic arteries.
„ Thyrocervical trunk: Arises from the front of the 1st part of the suclavian artery. This divides
into:
• inferior thyroid artery,
• Suprascapular, and
• transverse cervical artery.
„
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Costocervical trunk: Arises from the dorsal aspect of the 2nd part of subclavian artery. The
costocervical trunk divides into:
• Deep cervical artery, and
• Superior intercostal artery, which divides into 1st and 2nd posterior intercostal artery.
• Dorsal scapular artery: occasionally arises from the 3rd part of the subclavian artery.
Anatomy of common carotid artery in the neck (Fig. 23.56).
common carotid artery on the right is a branch of brachiocepahalic trunk and on the left side
this is a branch of arch of the aorta.
in the neck this artery lies in the carotid sheath lying medial to the internal jugular vein and
anteriorly covered by the sternocleidomastoid muscle.
The artery lies in front of the transverse processes of lower 4 cervical vertebrae and ends at the
level of upper border of thyroid cartilage by dividing into external and internal carotid arteries.
Branches: Apart from two terminal branches there are no other branches in the neck.
„
What is carotid sinus?
carotid sinus is a slight dilatation at the termination of the common carotid artery or at the
beginning of internal carotid artery. At the region of the carotid sinus the tunica media is thin but
the tunica adventitia is thick and contains a rich nerve plexus derived from the glossopharyngeal
nerve and sympathetic nerve. The carotid sinus acts as a baroreceptor and helps in regulation
of blood pressure.
What is carotid body?
This is a small oval, reddish-brown structure situated behind the bifurcation of common carotid
artery. Supplied by a rich nerve plexus derived from glossopharyngeal, vagus and sympathetic
nerves. This acts as a chemoreceptor and responds to changes in oxygen, carbon dioxide and
pH of blood.
What are the branches of external carotid artery (Fig. 23.56)?
The external carotid artery begins at the level of the upper border of the thyroid cartilage medial
to the sternocleidomastoid muscle and anterior to the transverse process of c4 vertebra.
The external carotid artery terminates behind the neck of mandible by dividing into maxillary
and superficial temporal artery.
The branches of external carotid artery may be grouped as:
„ Anterior branches:
• Superior thyroid artery
• Lingual artery
• Facial artery.
„ Posterior branches:
• occipital
• Posterior auricular
„ Medial branch:
• Ascending pharyngeal
„ Terminal branch:
• Maxillary
• Superficial temporal.
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Figure 23.56: Branches of external carotid artery
What are the different triangles in the neck (Fig. 23.57)?
There are different triangles in the neck. Broadly these are :
Anterior triangle: Boundary
• Anteriorly: Midline of the neck from chin to the suprasternal notch.
• Posteriorly: Lateral border of the sternocleidomastoid.
„
Figure 23.57: Triangles of neck
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• Base: Lower border of the mandible and a line joining between the angle of mandible
and mastoid process.
• Apex: Lies at the suprasternal notch.
Posterior triangle: Boundary:
• Anteriroly lateral border of sternocleidomastoid.
• Posteriorly medial border of trapezius.
• Base is formed by the clavicle.
• Apex at the mastoid process where trapezius and the sternocleidomastoid meet.
What are the subdivisions of anterior triangle of the neck?
The anterior triangle is subdivided into number of triangles:
Submental triangle.
„ Digastric or submandibular triangle.
„ Carotid triangle.
„ Muscular triangle.
„
What is the boundary of submental triangle?
Submental triangle is bounded by:
on either side—anterior belly of digastrics
„ Base is formed by the body of the hyoid bone.
„ Floor formed by the right and left mylohyoid muscles.
„
What is the boundary of digastric or submandibular triangle?
Digastric triangle is bounded by:
Anteroinferiorly by the anterior belly of digastric muscle.
„ Posteroinferiorly by posterior belly of digastric muscle.
„ Base is formed by the lower border of the mandible and a line joining from the angle of the
mandible to the tip of mastoid process.
„ Floor is formed by the mylohyoid muscle anteriorly and hyoglossus posteriorly and a small
part of middle constrictor of the pharynx.
„
What are the boundary of carotid triangle?
carotid triangle is bounded by:
Anterosuperiorly: Posterior belly of digastric muscle and stylohyoid.
„ Anteroinferiorly: Superior belly of omohyoid.
„ Posteriorly: Anterior border of sternocleidomastoid muscle.
„ Floor is formed by middle constrictor of pharynx, inferior constrictor of pharynx and
thyrohyoid membrane.
„
What are the boundary of muscular triangle?
„
„
„
Anteriorly: Midline of the neck from body of the hyoid bone to the suprasternal notch.
Posterosuperiorly: Superior belly of omohyoid.
Posteroinferiorly: Anterior border of sternocleidomastoid muscle.
What are infrahyoid muscles?
There are two layers of infrahyoid muscles:
Superficial layer: Sternohyoid medially and superior belly of omohyoid.
„ Deeper layer: Sternothyroid and thyrohyoid muscles.
These muscles are supplied by ventral rami of 1st 2nd and 3rd spinal nerves via ansa cervicalis.
„
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When these muscles need to be divided during thyroidectomy, where will you divide?
if these muscles need division during thyroidectomy, they are to be divided at a higher level as
the nerve supply reaches these muscles from below.
What is ansa cervicalis (Fig. 23.58)?
This is a loop of nerve lying in front of the carotid sheath and the larynx and supplies the
infrahyoid muscles.
„ Formation:
• Superior root: From the descending branch of hypoglossal nerve. its fibers are derived
from the ventral rami of 1st cervical nerve.
• inferior root is formed by the branches from ventral rami of 2nd and 3rd cervical nerve.
− Supply: Branch from the superior root supplies the superior belly of omohyoid.
− Branch from the ansa supplies the sternohyoid, sternothyroid and inferior belly of omohyoid.
Figure 23.58: Ansa cervicalis
SALIVARY GLANDS
What is the boundary of parotid region?
What is the disposition of parotid fascia?
See Page no. 464, chapter 12.
What are the parts of parotid gland?
The parotid gland is divided into superficial and deep parts by faciovenous plane of Patey.
The retromandibular vein is formed within the gland by joining of superficial temporal and
maxillary vein which divides into anterior and posterior division as it emerges from the gland.
The facial nerve emerges from the stylomastoid foramen and enters into the parotid gland
lying superficial to the veins.
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ANATOMY OF TESTIS, BLOOD SUPPLY AND LYMPHATIC DRAINAGE
What are the coverings of testis?
The coverings of the testis are the layers of the scrotum and the intrinsic coverings of the testis.
These are from outside inwards:
„ Skin
„ Dartos muscle
„ external spermatic fascia
„ cremesteric fascia
„ internal spermatic fascia
„ Parietal layer of tunica vaginalis
„ intrinsic coverings of the testis. The intrinsic coverings of the testis includes the visceral layer
of tunica vaginalis, tunica albuginea and tunica vasculosa.
What structure lie along the posterior border of the testis?
The posterior border of the testis is broad and the epididymis lies along the posterior of testis.
The head of the epididymis lies at the upper pole and the tail of the epididymis lies at the lower
pole of the testis.
How do you identify the lateral surface of the testis?
on the lateral surface the epididymis overhangs the testis and is separated by a semilunar
recess of tunica vaginalis sac called sinus of the epididymis. So the lateral surface of the testis
is identified by the presence of sinus of epididymis.
What is the internal structure of testis (Fig. 23.59)?
Figure 23.59: Internal structure of testis
The testis is covered by a tough fibrous layer known as tunica albuginea. near the posterior border
a fibrous vertical partition projects into the interior of testis known as mediastinum of testis.
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From the convex anterior surface of the mediastinum testis numerous fibrous septa project
to the anterior border of the testis dividing the testis into 200–300 lobules. Within these lobules
there are 2–3 seminiferous tubules which are convoluted.
The straight part of the seminiferous tubules ascend in the mediastinum of testis and joins
with adjacent tubules and form a plexiform network known as rete testis.
About 15–20 efferent ductules arises from the upper part of the rete testis and enters the
head of the epididymis. These efferent ductules joins to form a single duct known as canal of
the epididymis and by convolutions forms the body and tail of the epididymis. At the tail of the
epididymis this is continued as the vas deferens.
What are the interstitial cells of testis?
The interstitial cells includes:
Sertoli cells: These are polyhedral cells lie along the basement membrane of seminiferous
tubules. These cells provide nutrition to the growing spermatogonia and also secrete some
estrogen.
„ Leydig cells: Thes are polyhedral cells located in the lobules outside the basement membrane
of seminiferous tubules. These cells secrete testosterone. These cells are abundant in featl
life, disappear at birth and reappear at puberty and persist throughtout the reproductive
period of life.
„
What is the blood supply of testis (Fig. 23.60)?
Arterial supply:
The testis is principally supplied by the testicular artery which is a lateral branch of abdominal
aorta at the level of L1 vertebra.
The testis may also be supplied by the artery to the vas which is a branch of superior vesical artery.
A minor supply may come from cremasteric artery which is a branch of inferior epigastric artery.
Figure 23.60: Arterial supply of testis
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Venous drainage:
The testis is drained by pampiniform plexus formed by 15–20 veins emerging from the upper
pole of the testis. At the level of the superficial inguinal ring these veins join to form 4–5
veins and at the level of deep inguinal ring these veins join further to form 2 veins and at the
retroperitoneum these two veins join to form a single testicular vein. The right testicular veins
drain at the inferior vena cava and the left testicular vein drains into the left renal vein.
How does the lymphatic of testis drains (Fig. 23.61)?
The lymphatics of testis follows the vessels and drains into the para aortic lymph nodes at the
level of L1 vertebra.
How does the testis develops (Fig. 23.61)?
„
„
„
„
„
„
„
„
„
The testis develops in the retroperitoneum from the
genital ridge which lies medial to the mesonephros
at the level of 1st lumbar vertebra around 4th to 6th
week of intrauterine life.
The cells of the genital ridge proliferate and migrate
into the mesoderm of the mesonephros as solid
cords known as testis cords.
the central cells of these cords degenerate and
canalization occurs leading to formation of
seminiferous tubules and the rete testis.
these rete testis join the blind ends of the
mesonephric tubules attached to the Wolffian duct
and recanalization occurs.
the mesonephros disappears by 10th week of
intrauterine life. The mesonephric duct (Wolffian
duct) persists and forms the epididymis and vas
deferens.
The developing testis is attached to the posterior
abdominal wall by mesorchium which transmits
Figure 23.61: Development of testis
the neurovascular bundle of the testis.
the germ cells are derived from the wall of the
primitive yolk sac and migrates into the mesoderm of the mesonephros and gets incorporated
within the testis cords. These germ cells form spermatogonia which are the precursors of
spermatozoa.
The interstitial cells of testis are derived from the mesoderm between the testis cords. These
cells secrete testosterone which is required during testicular development and descent.
The mesoderm of the mesonephros cuts off the connection of the testis cords from the genital
ridge and forms the tunica albuginea. This mesoderm also forms the mediastinum testis and
septa testis.
What is the chronology of testicular descent? (see also Page No. 558, Chapter 15)
testes develops in the lumbar region. The descent starts after 2nd month and traverses the
following route to reach the scrotum.
„ Lumbar region: Remains up to the 2nd month.
„ Iliac fossa: traverse the retroperitoneum from 2nd to 3rd month and lies at right iliac fossa
at the end of 3rd month.
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„
„
„
„
Deep inguinal ring: Descends from right iliac fossa to the region of deep inguinal ring during 3rd
to 4th month. The testes remains at the region of the deep inguinal ring from 4th to 7th month.
Superficial inguinal ring: The testis traverses the inguinal canal during 7th to 8th month and
lies at the superficial ring at the end of 8th month.
Root of the scrotum: Runs from superficial inguinal ring to the root of the scrotum during 8th
to 9th months and remains at the root of the scrotum at the end of 9th month.
Bottom of the scrotum: testes descends to the bottom of the scrotum shortly before birth or
after the birth.
What are the systems of veins in lower limbs (Fig. 23.62?
The venous drainage of lower limb occurs through
following system of veins:
Deep veins: The deep veins in the legs start in the
plantar aspect of the foot and the dorsum of the
foot and accompany as venae comitantes of the
arteries in the legs, venae comitantes of posterior
tibial vein and the anterior tibial vein. The venae
comitantes of posterior tibial vein and the venae
comitantes of the anterior vein join to form the
popliteal vein which lie alongside the popliteal
artery and continued higher up as the femoral
vein which is continued as the external iliac vein.
Superficial system of veins: Great saphenous
vein starts from medial side of dorsal venous
arch joined by medial marginal vein of foot runs
in front of the medial malleolus ascends along
subcutaneous surface of tibia and then passes
one hands breadth behind the medial border of
the patella and the ascend in the thigh to end at
femoral vein at the saphenous opening which lies
3.5 cm below and lateral to pubic tubercle.
the short saphenous vein starts from the
Figure 23.62: Superficial veins in the lower limb
lateral side of the dorsal venous arch joined by
the lateral marginal vein of the foot and ascends
in the leg behind the lateral malleolus and runs in
the posterior aspect of the leg running between the two gastrocnemii. This ends at the popliteal
vein at a variable distance of 2–15 cm from the knee joint line.
Communicating vein: these are superficial veins lying superficial to the deep fascia
communicating between the great and short saphenous veins.
Perforating veins: These are veins which connects the superficial system of veins to the deep
veins. The perforating veins may be:
„ Direct perforators which joins directly between the superficial and deep veins
„ indirect perforators of the perforating veins from superficial vein join the venous plexus in
the muscle and from the venous plexus in the muscle another perforating vein drains into
the deep vein thereby indirectly connecting the superficial and deep veins.
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What are the common sites of perforating veins?
in great saphenous system:
Saphenofemoral junction at saphenous opening—largest perforator
„ Adductor canal perforator (Hunterian perforator) at mid thigh
„ Perforator above the knee
„ Perforator below the knee (Boyd’s perforators)
„ Medial ankle perforator at 5 cm, 10 cm and 15 cm above the medial side of the leg (cockett
and Dodd perforators)
„ Perforators at the level of ankle (May or Kuster perforator)
„ Apart from these constant perforators there are some other inconstant perforators at different
level joining the superficial and deep system of veins.
in short saphenous system:
„ Saphenopopliteal junction situated at 2 cm below to 15 cm above the knee joint line.
„
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Index
Page numbers followed by f refer to figure.
Adenoacanthoma 750
Adenoid cystic carcinoma 469
Adenolymphoma 466
Adenoma carcinoma sequence
770
Adenomatous polyps 763
Adenomyomatosis of
gallbladder 788
Adjuvant therapy in malignant
melanoma 351
after breast conserving
surgery 218
in GIST, role of 109
in periampullary carcinoma,
role of 142
Adson’s
hemostatic forceps 878
test 448, 448f
Advanced trauma and life
support 591
Adynamic obstruction
causes of 642
Airway tubes 934
AJCC staging
for malignant melanoma 349
of oral carcinomas 497
Allis’ tissue forceps 884
ALND see Axillary lymph node
dissection
Alpha adrenergic blocking drugs
649
Alteration of bowel habit 771
Amebic point 79
Amelanotic melanoma 345
Ameloblastoma 511, 512
Ameloblastoma or
adamantinoma 511
Ampulla of vater 636, 638, 1047
Abdomen 54, 76, 81, 184
into different quadrants 81
Abdominal
aorta, branches of 1056,
1057f
aortic aneurysm 940, 941,
942
compartment syndrome 71
incisions 876
injury 606
in right iliac fossa 722
tonsil 1056
tuberculosis 757
wound dehiscence 644
Abdominoperineal resection
996
steps of 996
Abductor pollicis
brevis, test for 412f
longus, test for 399, 399f
Abnormal nipple discharge 658
Abnormalities of vitellointestinal
duct 761
ABPI see Ankle brachial blood
pressure index
Abrahamson nylon darn repair
60
Abscesses 840
Acalculous cholecystitis 131,
786, 983
sentinel lymph node biopsy
216
Achalasia 708
branchial sinus 431
cardia 707-709
Achlorhydria 743
Acinic cell tumor 469
Acral lentiginous melanoma 347
Acrocyanosis 383
Acute
alcoholic pancreatitis 634
appendicitis 629, 724-726,
752-754
biliary peritonitis 911
cholangitis 625
cholecystitis 130, 625, 629,
634, 784-786, 790, 983
Crohn’s ileitis 629
cystitis 651
exacerbation of chronic
peptic ulcer 634
gangrenous cholecystitis
782f
gastritis 634
intestinal obstruction 626,
629, 630, 640, 676, 677,
679, 680, 756
pancreatitis 625, 629, 635638, 700, 784
paronychia 846
peptic ulcer 625
perforated peptic ulcer 634
pseudocyst 638
retention of urine 564, 647,
807
small intestinal obstruction
678
subdural hematoma 600
Adamantinoma see also
Ameloblastoma
Adductor
canal perforator 285f
pollicis, test for 409f
A
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Bedside Clinics in Surgery
surgery
in 233
in a case of carcinoma of
breast 233
in locally advanced breast
cancer 224
role of 224
vein 1007
Axonotmesis 405
B
sa
x
Babcock’s 885, 885f
tissue forceps 885
Backhaus’ towel clip 874
Bacteroides fragilis 663
Balanitis xerotica obliterans 811
Balfour’s type 900
Bard Parker’s handles 874, 874f
Barium
carcinoma colon 727
enema 669, 727, 728
follow through
ileocecal tuberculosis/
jejunal stricture 720
recurrent appendicitis
724
meal 669
X-ray 713-715, 717
-ray of chronic duodenal
ulcer 713
swallow 669, 710
carcinoma of esophagus
710
X-ray 707, 709
X-ray of esophagus 707
Barrett ‘s esophagus 712
Basal acid output 743
Basal cell
carcinoma 361, 361f, 363,
364, 812
nevus syndrome 366
spreads 363
superficial type 363
treatment 361
types of 362, 363
Baseline arterial blood gas
analysis 832
Bassini’s
operation 55
repair 54, 55, 55f
d
tls
Arteries lie in relation to parotid
gland 465
Arteriovenous fistula 299, 384,
385
A
822
Ascaris lumbricoides, life cycle
of 701
Ascending venography 300
Ascites 152, 729
Assess condition of arterial wall
21
Asopa’s 581
technique of urethroplasty
581
Aspiration of
cyst, indications for 419
pleural fluid 852
Associated anemia, treatment
of 792
Astler Coller’s modification for
ukes staging 730
Asymptomatic gallstones 688
Atherosclerotic peripheral
vascular disease 302
A
591
Atraumatic or eyeless needle
891
Atraumatic suture 946
biliary colic 130
Atypical presentation of
carcinoma of kidney 196
patient with carcinoma
kidney 797
Auscultopercussion 96
Autoclaving 870
Autonomic nervous system
1063
Axilla 341, 1066
contents of 1069
Axillary
abscess 843
artery
branches of 1068, 1069f
parts of 1068
dissection 1006
lymph node
dissection 236
pulse 313
palpation for 314f
sampling 218
c
a
Amputation in
Buerger’s disease 322
extremity sarcoma 369
Anal
fistula, types of 905, 905f
Anaplastic
carcinoma 273, 571
of thyroid, diagnosis of
272
thyroid carcinoma 272
Anatomical
parts of penis 575
repair 72, 528
Anatomy of abdominal incisions
973
Anchoring testis in scrotum,
techniques of 556
Anderson-Hynes pyeloplasty
191f
Anemia 13
assess 13
Aneurysm 940
Aneurysm needle 939
Ankle brachial blood pressure
index 317
Ann rbor staging of gastric
lymphoma 107
Anorectal abscesses 843
Ansa cervicalis 1084, 1084f
Anterior
abdominal wall 1030, 1032
cranial fossa fracture 736
resection 993
Antithyroid drugs 263, 264
Aortoiliac disease 303
Appendicectomy 1001
Appendicular abscess 631-633,
754
Appendix 1055
Arnold- hiari malformation 393
Arteria
dorsalis pedis
palpation for 312f
thyroidea IMA 1078
Arterial
supply of
colon 1038, 1039f
esophagus 1034
pancreas 1054, 1054f
penis 575
stomach 1037
testis 1086f
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Index
C cell hyperplasia 274
Calculus
in submandibular duct 471
Calot’s triangle 127, 982, 1051,
1051f
Camellotte sign 167
Cancer colon in ulcerative colitis
775
C
and fistula, development
of 428f
case of 427
cyst develop 428
sinus 430, 431
Branchiogenic carcinoma 433
Branham’s sign 384, 385
Breast 198, 203, 1065
abscess 841, 845, 846f
cancer 226
carcinoma 228, 234
conservation in locally
advanced breast cancer
224
conserving surgery 217, 221
examination of 210f, 658
lobules 1066
reconstruction 234
Breathing
assessment of 592
maintenance of 592
Bubonocele 42
Buerger’s angle 305
of circulatory insufficiency
311
Buerger’s
disease 302, 306, 317, 320,
321, 655, 657
exercise 321
test 305, 656
Built or physique 10
Burhene technique 706
Burn 340
injury 620
shock, causes of 340, 622,
623
wound 624
Burst abdomen 643, 644
Buschke Löwenstein tumor 812
of penis 576
ads
i
carcinoma 802
stone 647
Blood
pressure 22, 653
measurement of 22f
supply of
gallbladder and biliary
tree 1049
nerves 374
rectum and anal canal
1040
scalp 1071
testis 1086
thyroid gland 1077
Blue nevus 355
Body mass index 12
Boey’s score 640
Bony
indentation 28
jaw swelling 511
Bormann’s classification for
advanced gastric cancer 749
Botulinum toxin, role of 709
Boundary of
axilla 1066
Calot’s triangle 127, 128f
carotid triangle 1083
digastric 1083
Bow sign 548
Bowel
wash 823
Bowen’s disease 358, 359
Boyd’s perforators 1089
Brachial plexus 402
Brachiocephalic trunk 1079
Brachioradialis muscle, test for
399, 399f
Brachytherapy in soft tissue
sarcoma, role of 370
Branches of
axillary artery 1068
celiac trunk 1057
external carotid artery 1081
subclavian artery 1080
Branchial
arches 429
cartilage 433
cleft 429
and pharyngeal pouches
429
cyst 427, 427f, 428, 429
Battle’s sign 737
Beck’s triad 604
Benign
enlargement of prostate 649,
804
gastric ulcer 714, 741
hyperplasia of prostate 647,
651, 805
nevus 353
papilloma of urinary bladder
800
peptic ulcer 742
pigmented nevus 353
Berry’s sign 240, 249
Bidigital palpation of right
parotid duct 459f
Bilabial muscles 480
Bilateral
cleft lip 479, 479f, 485
hydronephrosis 192, 793
gynecomastia 518, 519f
case of 519
hydronephrosis 192, 806
case of 192, 793
impalpable testis 559
incomplete cleft lip 485, 486
neck node metastasis 440
recurrent laryngeal nerve
palsy 654
vaginal hydrocele 540f
Bile duct 701
stones 149
Biliary
colic 130, 785
tract disease 125
Bilocular hydrocele 544
Bilroth II gastrectomy 116
Biological therapy in gastric
cancer, role of 104
Biopsy in
breast lesion 213
leukoplakic patch 493
parotid carcinoma 468
thyroid lesions 257
Br
category 211
Bird’s beak deformity 685
Black
braided silk 951f
pigment stones 781
Bladder
cancer 803
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1094
ap
a
Casonis test 167
Cat’s paw or volkman’s retractor
899, 899f
Catgut sutures 944, 944f
Catheter introducer 927, 927f
Catheterization
for retention of urine 839
complications of 840, 924
Causalgia 406
Causes
for development of incisional
hernias 70
of pseudocyst formation 173
of recurrence of hernia 66
Cavernous hemangioma 375,
376
Cavity of hydatid cyst 164
Ce 177
Ce classification 289
Cecal volvulus 685, 686
Cecum 179f, 683
Celiac trunk 1056
branches of 1057, 1058f
Cellulitis 660
Central venous line 837
Cephalic vein 1007
Cerebral
concussion 597
laceration 598
Cervical
lymph nodes 19, 435
examination of 240
rib 445, 446, 448
Cervicodorsal sympathectomy
382, 383
Chaissaignac’s triangle 1015
Characteristics of seminoma
testis 808
Charcot’s triad 148
Chemical
sterilization 870
sympathectomy 320
Chemoreceptor apparatus 452
carcinoma of
breast 226
gallbladder, role of 154
carcinoma penis, role of 573
cholangiocarcinoma, role of
158
of kidney 192, 195, 196, 650,
795, 1004
of left submandibular gland
473f
of lip 502, 502f
of pancreas 144, 145
of penis 569
of periampullary region 139
of prostate 647, 650, 651
of rectum 769, 770, 772, 908
of right breast
of stomach 98, 123, 746, 750
of submandibular salivary
gland 473
of thyroid gland 266
of tongue 494, 495f
of urinary bladder 802
parotid gland 467
penis 569, 574, 811
right parotid gland 467f
stomach 95, 104, 715, 716
thyroid 266f, 268, 270
tongue 499
Carcinomatous epulis 515
Card test 408
Cardiac
disease 656, 830
tamponade 593, 601, 603,
604, 738
Cardiovascular
manifestations in
thyrotoxicosis 265
symptoms 3
Carnett’s test 93
Carney’s triad 108
Caroli’s disease, treatment for
161
Carotid
body tumor 449-451
case of 450
pulse 315
sinus 1081
triangle 1083
Cart wheel appearance 163
Carwardine’s twin intestinal
occlusion clamps 918
case of 526
Case of
abdominal lump 162
thyroglossal fistula 426
Cancer en cuirasse 816
Cannon ball metastasis 692
Capillary
filling 592
time 311, 312, 656
hemangioma 375, 376
types of 376
refilling 310
Capsules
of prostate 805
of the thyroid gland 1077
Carcinoembryonic antigen 177
Carcinoid tumor 721, 728, 750,
755
Carcinoma
breast 218, 660, 816
cecum 631, 730
cheek, types of 505
colon 683, 727
esophagus 710, 711
esophagus spreads 711
gallbladder 152, 153, 788
head of pancreas 133
in hard palate, types of 508
in male breast 516, 517
kidney 796, 797
kidney spreads 796
lip 504
stomach 715
tongue spread 497
of bladder 647
treatment of 650
of body and tail of pancreas
144
of breast
during pregnancy 235
with distant metastasis
225
of cecum and ascending
colon 178
of cheek 505, 505f
of colon 175, 178, 765-767
of esophagus 710
of floor of mouth 507
of gallbladder 133, 151, 154,
155, 156, 783, 784, 788,
790
of hard
palate and upper alveolus
508
pancreas 137, 143, 144
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Index
s
Colonic
carcinoma 180, 731, 768
gas shadows 676
obstruction 704
polyps, types of 181, 763
pseudo-obstruction 686
Colorectal
cancer 177
carcinoma, distribution of
181, 767
Colostomy, mobilization of 1000
Columbia clinical classification of
breast cancer 818
Combined median and ulnar
nerve injury 410
Combined median, causes of
414
Common
bile duct 125, 1047, 1051f
carotid artery 451
exposure of 861
hepatic duct 1045f, 1047,
1051f
in the neck 1081
obstruction 704
peroneal nerve injury 416
Compartments of femoral sheath
1027
Complications of
acute pancreatitis 638
choledochal cyst 161
chronic duodenal ulcer 110
cystic hygroma 419
dermoid cyst 328
herniorrhaphy/hernioplasty
57
hydatid cyst 779
hydronephrosis 192, 794
of peptic ulcer surgery 119
of pseudocyst 174
of renal injury 618
of renal stones 691
of sclerotherapy 295
of splenectomy 611
of thyroidectomy 265
Compound
cleft lip 480
nevi 354
nevus 354
volvulus 683
Compressible 32
Choriocarcinoma see Malignant
teratoma trophoblastic
Chromaffinomas 390
case of 124
development of 742
Chronic
cholecystitis 124, 785
duodenal ulcer 110, 112
gastric ulcer 112, 113
sialoadenitis 471
Chronology of testicular descent
558, 558f, 1087
Chylocele 543
Cimino’s fistula 386
Circumcision
steps of 1021, 1021f
Circumferential burns 625
Cirrhosis of liver 177
Cirsoid aneurysm 377, 378
of scalp and forehead 377f
Classical
claw hand deformity 414
radical neck node dissection
440
triad of presentation of
carcinoma kidney 797
Classification of thyroid tumors
269
Clavipectoral fascia 1068
Claw hand 410
Cleft
lip 478
of soft palate 489
palate 487
Clinical examination 494, 516
Clinical presentations of splenic
injury 609
Cloquet’s
hernia 531
lymph node 530
Closed loop obstruction 680
Closure of colostomy, steps of
1000
Clubbing 15
Clutton’s metallic bougie 928
Cock’s peculiar tumor 332
Colloid
goiter 254
nodule 258
R
gastric lymphoma 107
metastatic breast cancer, role
of 226
node negative 220
parotid carcinoma, role of
469
CC, role of 196
regime for
Hodgkin’s lymphoma 444
testicular tumors 589
side effects of 219, 444
soft tissue sarcoma 370
regime for hodgkin’s
lymphoma 444
Chest 341
injury 600, 737
tube insertion, complications
of 854
X-ray 737, 832
Cheyne- tokes breathing 23
Chief complaint 1
Cholangiocarcinoma 156, 157,
158, 774
development of 156
spreads 157
types of 156, 157
Cholangiopancreatography 147
Cholangitis 700
Cholecystectomy 132, 150, 153
forceps 911
Choledochal cyst 158, 160, 161,
788
complications of 161
treatment of 161
types of 160, 160f, 161
Choledochoduodenostomy 986
steps of 986
Choledochojejunostomy 990f
Choledocholithiasis 146
gallbladder 134f
Choledocholithotomy 150, 985,
986f
steps of 985
Cholelithiasis 780
Cholesterol gallstones 781
Cholesterosis
appearance of 787
of gallbladder 787, 983
diagnosis of 787
Chordee correction 580, 580f
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Bedside Clinics in Surgery
g
D2 gastrectomy 976
for gastric cancer, steps of
976
Dahl froment’s sign 683
Dalrymple’s sign 241, 259
De Pezzer’s catheter 927, 927f
Deaver’s retractor 900, 900f, 980
Deep
cervical fascia 1076
of neck 1074
extensor muscles of forearm
402f
inguinal ring 49f, 1024
lobe of parotid gland 470
palpation for 460f
ring occlusion test 40, 47
sensation 7
tender spots 79, 79f
vein thrombosis 660, 663
venous thrombosis 660
X-ray therapy, role of 337
Deepage Janeway gastrostomy
1020
Defects in incision line 70
Deformity in bilateral complete
cleft lip 486
Degrees of clubbing 16
Dehydration 11, 672
correction of 825
Delaire’s technique 485
t
D
Cystic
hygroma 417
neoplasms of the pancreas
175
pedicle 128
Cystine stones 690
Cystoenterostomy 159, 170, 171f
for large pseudocyst,
problems of 171
Cystography 652
Cystojejunostomy 171
Cystosarcoma phylloides 521,
521f
Cystourethroscopy 803
Czerney’s retractor 897, 897f
Courvoisier’s law 134, 134f, 147
Coverings of kidney 1032
Cremesteric
muscle and fascia 1024
Cricopharyngeal myotomy 454
Cricothyrotomy 855
Crile’s method 244
for palpation of thyroid gland
244, 244f
Criminal nerve of rassi 115,
115f
Crohn’s
ileitis 631
colitis 671
disease 671, 683, 721-723,
728, 755, 767, 906
Cronkhite Canada syndrome
763, 765
Crossed leg test 312
Crushing
clamps functions 921
role of 362
Cryosurgery in basal cell
carcinoma 362
C scan staging of carcinoma of
stomach 98
Cuffed tracheostomy tube 936
Cullen’s sign 627
Cupid’s bow 485
Curettage in basal cell
carcinoma, role of 362
Curling’s
ulcer 625
syndrome 24
Cut margin of jejunal mesentery
979
Cutaneous
glomus body 379
horn 811
hyperesthesia 725
malignancies 365, 366
Cutting needle 891
Cyanosis 15
Cyst of epididymis 546
and spermatocele 547
hygroma 419, 428
lesion in
liver 162
pancreas 174
neoplasms of pancreas 175
pedicle 128
Condyloma acuminata see also
Genital wart
Congenital
arteriovenous fistula,
treatment of 385, 386
hernia 522, 968
hydrocele 544
phimosis 564
ureteric stenosis 793
ureteropelvic junction
obstruction 793
Conjoint tendon 60, 1026
Consequences of gastric outlet
obstruction 96, 718
Conservative
total parotidectomy 468
treatment for
acute appendicitis, role of
725
appendicular lump 633
renal injuries, indications
of 617
Consistency of swelling, assess
28
Constriction
colostomy 999
of esophagus 1034
Constrictor muscles of pharynx
455f
Contact dissolution 706
Contents of a hernia 58
Continuous fever 24
Conventional cutting needle
890f
Cooper’s ligament 57, 59, 60,
204, 971, 972, 1026, 1028
repair 57, 65
Cope’s technique for reduction
759
Cord
holding forceps 903, 903f
of brachial plexus 403
Core
biopsy, role of 257
needle biopsy 212
Corrugated rubber sheet drain
938, 938f
Corrugator supercilii 461
test for 461f
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1097
p
Double
contrast barium enema 176,
727f, 768
duct sign 135, 137
Down’s syndrome 482
Doyen’s
cross action type towel clip
873
intestinal occlusion clamps
918, 918f
mouth gag 934, 934f
Drainage
appendicular abscess, steps
of 633
breast abscess 845
empyema 853
in situ 234
ischiorectal abscess 845f
of infection in space of
arona 851
of pulp space infection of
finger 847
peritonsillar abscess 841
procedure 978
pulp space infection of finger
847, 847f
subphrenic abscess 697
Drug therapy is effective in
hydatid cyst 167
Duct of wirsung 1053
Ductography 227, 658
Duke’s staging 730, 771
for carcinoma
colon 182, 730
of rectum 771
Dumbbell
neurofibroma 389
parotid tumor 470
Duodenal
ileus 719
injury 700
obstruction 704, 717, 719
point 112
stump blow out 120
stump, closure of 977
ulcer, complication of 111,
921
Duodenum 118, 155
division of 977
Duplex scanning 317
Diagnostic
investigations 108
laparoscopy
role of 152
in carcinoma stomach 99
peritoneal lavage 608
Diaphragm 670
Dietl’s crisis 192, 794
Different
lymph nodes in the neck 499
triangles in the neck 1082
Diffuse axonal injury 598
Digastric or submandibular
triangle 1083
Digital nerve block 866, 867f
Dipping method 95f
palpation by 87f
Direct
inguinal hernia 65
Discussion on
cholangiocarcinoma 156
Disinfection 869
of instruments, techniques of
869
Displacement of nipple 203
Disposition
galea aponeurotica 1070
isthmus of thyroid gland
1077
layers of cervical fascia 1075f
of clavipectoral fascia 1068
of investing layer of deep
cervical fascia 1075
pancreatic duct 1053
parotid
duct 464
fascia 464
renal fascia 1033
Dissecting aneurysm of aorta
634
Distribution of the radial nerve
401
Doppler shift 318
Dorsal
branches 1056
interossei, test for 407, 408f
slit of prepuce 859
DOTS treatment regimen for
tuberculosis 436
Demonstrate
bony guttering 326
fluctuation 30
minimal free fluid in
abdomen 93
Peau d’orange 207
shifting dullness 91
skin fixity 205
slip sign 334
succussion splash 95
transillumination 32, 5431
tremor 249
Denonvillier’s fascia 995
Dental cyst 509, 510
Dentigerous cyst 510
case of 510
Depressed fracture 736
Depth of burn 622
Dercum’s disease 336
Derivatives of
branchial arch
first 429
fourth 430
sixth 430
third 430
Dermal
flares or thread veins 301
nevus 354
Dermoid cyst 324-327
Descending
colon 179f, 730, 1039
venography 300
Descent of testis 557
Desjardin’s
choledocholithotomy forceps
912, 912f, 985
forceps 912
Desmoid
tumor 538, 631
development of 538
Devine and Horton’s operation
569
Diabetes
and pancreatic cancer,
relationship between 145
mellitus 69, 143, 446, 626,
754
Diabetic foot 655
Diagnose gastric lymphoma 106
Diagnosis of carcinoma of
stomach 97
Index
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1098
ls
E
E
E
E
E
E
E
E
E
E
E
E
sg
E
E
E
valuation of hydronephrosis
190
version of sac, steps of 542,
1020
v 294
xamination of
abdomen 6, 78
cardiovascular system 7
nervous system 7
respiratory system 6
xcision of
a branchial sinus 432
lipoma 858
sebaceous cyst 858
xomphalos 524, 761
major 525, 525f, 526
minor 525
xophthalmos 247f, 259, 260
demonstration of 246
in thyrotoxicosis 260
xpansile pulsation 32
xploration
for renal trauma, indications
of 618
of abdomen 978, 992, 993,
996
xploratory laparotomy 611, 976
xplore the common bile duct
128
xposure
and ligature of the internal
iliac artery 862
in adductor canal 864
of subclavian artery in the
neck 861
of the external iliac artery
863
of the femoral artery in the
thigh 864
of the popliteal artery 866
xstrophy of bladder 583
xtensor
digitorum longus muscle
399f
pollicis brevis, test for 399,
400f
xtent
and branches of abdominal
aorta 1056
of gastric resection 102
E
E
E
E
E
V
E
E
E
E
E
E
E
E
E
E
ER
R
E
E
E
E
E
E
E
ast
E
E
E
E
E
E
E
E
E
­
E
E
agle’s criteria for cardiac risk
stratification 830
arly
carcinoma of breast 210, 214,
660
gastric cancer 104, 749
postcibal syndrome 122
astern cooperative oncology
group 9
chinococcosis 168
Echinococcus
granulosus 776
life cycle of 777f
multilocularis 776, 778
ctocyst 778
ctopia vesicae 582, 582f, 583
case of 582
ctopic testis 559
dema 16
ef
607
ffects of benign prostatic
hyperplasia 805
lective
lymph node dissection 343
neck dissection 499
lephantiasis neurofibromatosa
389
with am’s horn penis
561f
licit
Murphy’s sign 88
rebound tenderness 91
mbryonal carcinoma see
Malignant teratoma
anaplastic
mergency
appendicectomy 630
exploratory laparotomy 629
mergent testis 560
mpyema of gallbladder 131,
784, 786, 983
ncysted
hydrocele 544
of the cord 545
E
E
ndo needle holder 964, 964f
ndocyst 778
ndograsping forceps 960f, 962
ndoscissors 961, 961f
ndoscopic
clip applicator 962, 962f
crocodile forceps 962, 962f
diathermy
hook 963, 963f
spatula 964, 964f
drainage of pseudocyst 172
pyelolysis 191
retrograde cholangiopan
creatiography 159, 669,
698, 702f
spoon forceps 963, 963f
ultrasonography, role of 137
ndovenous laser surgery 294
ngorged veins in abdominal
wall 84, 84f
nlarged irchow’s lymph node
19f
nterocele 43
pidermoid
carcinoma 691
cyst 331, 547
pididymal cyst
case of 546
pididymo-orchitis 539
pigastric hernia 528, 528f, 529
pulis 514
case of 514
rb-Duchenne paralysis 415
CP 136, 700
chronic pancreatitis 702
rythroplasia of Queyrat of penis
576
sophageal carcinoma 713
sophagus 1034
stablishing central venous line
837
tiological factors for
development of
acute appendicitis 753
carcinoma head of pancreas
143
carcinoma kidney 195
carcinoma of stomach 748
u
137
valuate common bile duct 147
E
E
E
E
Dynamic
intestinal obstruction 679
venography 300
E
Bedside Clinics in Surgery
Universal Free E-Book Store
Index
External
branches of carotid artery 860, 1081, 1082f
carotid artery 860
iliac artery, exposure of 863, 864f
jugular vein 1072
piles 908
Extracorporeal shock wave
lithotripsy 150, 691
Extradural hematoma 598, 599
Extrahepatic biliary system 1047
anatomy of 1044, 1048f
Extraintestinal manifestation of
ulcerative colitis 774
Eye signs 246
Eyed and eyeless needles 891f
F
Facial
artery 860
nerve
branches of 463, 463f
injury 469
vein 1072
Facies of
acromegaly 11f
Cushing syndrome 10f
thyrotoxicosis 10f
Factors for development of
chronic peptic ulcer 117
False
cyst 327
epulis 514
Familial
adenomatous polyposis 763
coli 728, 764
breast cancer 229
Family history 4
Fascia of
camper 967, 1032
covering pectineus 1028
Gerota 1005
Scarpa 1032
transversalis in abdomen, disposition of 1032
Zuckerkandl 1033
Fashioning of Roux loop of
jejunum 978
Fast 607
Fate of
cystic hygroma 418
thyroglossal duct 424
Fdg pet scan 137
Fegan’s test 287, 287f
Female metallic catheter 930,
930f
Femoral
artery
branches of 865
in thigh, exposure of 864, 865f
canal
contents of 530
hernia 49, 51, 51f, 530-532
case of 530
pulse 313
ring, boundary of 531, 1028
sheath 1027, 1027f
boundary of 530f
triangle 559f
boundary of 1028
vein 283
Fever 774
quartan 24
quotidian 24
tertian 24
types of 23f, 24
Fibroadenoma 520, 660
breast 520, 658
Fibroadenosis 658, 660
Fibrous
epulis 514
Field fire 362
Filarial scrotum and Ram’s horn
penis 561
First line antitubercular drugs
437
Fisch nerve hook 899, 899f
Fistula 35, 905
Fixed renal pain 188
Fixity of the lump to serratus
anterior 206
Flail
chest 594, 604, 738
Flatus tube 933, 933f
Flexor
carpi ulnaris, test for 409
1099
digitorum
profundus, test for 412, 412f
superficialis, test for 413, 413f
pollicis longus, test for 411f
Fluctuation 30, 540
Fluid thrill 91
FNAC in
breast lesion, role of 213
gist, role of 108
Foam sclerotherapy 295, 296
Focussed abdominal sonogram
for trauma 607
Foley’s balloon catheter 925,
925f
Follicular
adenoma 654
and carcinoma 268
Follow up protocol for
patient with carcinoma colon 181
colonic cancer 731
sts 371
hodgkin’s lymphoma 444
Formation of
gallstones 782
rectus sheath 1031f
renal vein 1062
Fowler’s stephen’s procedure
556
Free gas under diaphragm 607
Frey’s syndrome 465, 466
Froment’s sign 409, 409f
Frontal belly of occipitofrontalis
460
Fruchaud’s myopectineal orifice
62f, 1024
boundary of 62
Fuchsig’s test 305, 312f
Fuller’s bivalve metallic
tracheostomy tube 935, 935f
Functional
effect of right hemicolectomy 180
neck dissection 499
Functions of gallbladder 1052
Fundus first cholecystectomy
985
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1100
Bedside Clinics in Surgery
Funicular
direct inguinal hernia 65
hydrocele 544
Fuschig’s test 656
G
Galactocele 659, 1047
Gallbladder 160f, 1048
cancer, advanced 154
parts of 1048
point 79
polyp 983
Gallstone 687, 782
causes pancreatitis 636
cholecystitis 636
development of 784
disease 780
ileus 640, 678, 784
palpation for 310f
toe 319
types of 129, 781
Gangrene of right great toe 655
Gardner’s syndrome 763, 764
Gas sterilization 870
Gastrectomy 901
Gastric
biopsy 118
glands 1036
lavage 99, 825
lymphoma 106
types of 106
occlusion clamps 914, 914f
outlet obstruction 94, 97, 156, 717, 718, 824
point 112
Gastrohepatic
ligament 977
omentum 696
Gastrointestinal
symptoms 2
in thyrotoxicosis 265
stromal tumors 107, 921
Gastrojejunal anastomosis 977,
979
Gastrojejunostomy 111, 116,
120, 140f, 141, 156, 901, 917,
978, 990f
Gastrostomy 1018, 1019f
Gelbard’s operation 569
Gene therapy in Buerger’s
disease, role of 322
General survey 5, 9
Generalized neurofibromatosis
390
Genetic 143
basis of medullary thyroid
cancer 274
testing in breast cancer, role of 229
Genital wart 811
Genitalia and urethra 539
Genitourinary tract 665
Gerota’s fascia 194, 797
Giant
fibroadenoma 521
prosthetic reinforcement of
visceral sac 61
Gilbert’s classification for groin
hernia 62
Gingivoperiosteoplasty 487
Gist 107
Glandular hypospadias, treat
581
Glanuloplasty 581
Glasgow coma scale 597
Glomus
body 379
tumor 378
Glutaraldehyde solution 869,
870
Goldman’s cardiac risk index 829
Goodsall’s rule 906
GPRVS 61
Grade muscle power 316, 397
Grades of
liver injury 612
renal injury 617
ulcerative colitis 774
varicocele 550
Gradings for
depth of burns 622
soft tissue sarcomas 372
Graham’s patch 639, 673
Graves’ disease 259, 261, 262
Gray Turner’s sign 627
Great saphenous vein, course of
308, 309
Greater curvature of stomach by
auscultopercussion 96f
Groin hernia 62
Grolin’s syndrome 366
Gross
Peau d’orange 207f
types of carcinoma tongue 497
Ground glass appearance 607
in abdomen 670f
in X-ray 671
Groups of lymph nodes in neck 250
gstric ulcer, types of 119
Guillotine method 567
Gut preparation 177, 182
Gynecomastia 518, 519
H
H. pylori 113, 117
infection 113
Hematogenous spread 796
Hemorrhage, grades of 879
Hamartomas 378
Hand 341
infections 846
Hartman’s potch 961
Harvey’s sign 304, 310
Head injury 597, 598
Heath’s suture cutting scissors
896, 896f
Height of jugular venous
pressure 17f
Heineke-Mikulicz pyloroplasty
116, 116f
Helicobacter pylori 118f, 742, 748
Heller’s operation 709
Hemangioma 32, 374, 375
Hematocele 543
Hematuria 650, 791, 792, 794,
799, 806
Hemicolectomy, 901
Hemimandibulectomy 512
Hemithyroidectomy 254, 271, 654
closed 910
Hemostatic forceps 877, 877f
uses of 878
Hemothorax 853
management of 739
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Index
Henry Gray’s forceps 911
Heparinized saline 150
Hepatic
artery 100f, 1057
branches of 1046
ducts in front 1046
flexure 179f
injuries 612
metastasis from colonic carcinoma, treat 180
resection 901
in hepatic trauma, role of 614
trauma 613, 614
Hepatorenal pouch of morison
639, 696
Hereditary 635, 711
breast cancer 229
nonpolyposis
colorectal cancer 748
colon cancer 766
Hernia 37, 42, 683
complications of 63
contents of 58, 63
repair 56, 65
GPRVS 61
surgery in adult 53
Hernial sac 58, 73f
parts of 58, 58f
Herniography 64
Hernioplasty 60
complications of 57
techniques of 60
Herniotomy 55, 968
steps of 969f
Hesselbach’s traingle 52, 65, 530,
1024
High
dose chemotherapy in
carcinoma of breast 226
inguinal orchidectomy 586f
level disinfection 869
pressure autoclaving 870
tracheostomy 936
Highly selective vagotomy 114,
115, 115f, 116
Hilton’s method 883
for drainage of abscess 841
Histologic types of carcinoma of
stomach 749
History of present illness 2
Hodgkin’s
lymphoma 435, 444
Homan’s sign 646, 660
Hook retractors 898, 898f
Hormone 353
replacement therapy and
breast therapy 695
in early breast cancer, role of 219, 518
role of 197
therapy 219
Horner’s syndrome 415
Hot spot in bone scanning 232
Hunterian perforator 1089
Hurthle cell tumors 273
Hutchinson’s melanotic freckle
347, 354, 355
Hydatid cyst 163, 775, 779
bentonite flocculation test 167
casonis test 167
complement fixation test 167
detection of circulating
antigen 167
diagnosis of 167
indirect hemoagglutination test 167
of liver 162
Hydatid sand 167
Hydration status, assess 11
Hydrocele 543
Hydrocephalus 392, 395
Hydronephrosis 188, 191, 631,
733, 792-794
Hyperplastic tuberculosis 721,
756
Hypertension 22
Hypospadias 576, 577
case of 576
Hypotension 22
Hypothenar muscles 407, 414
Hypovolemic shock 622
I
Ideal
gastrojejunostomy 116
mesh 73
Identification of sympathetic
chain 1007
1101
Identify facial nerve trunk 462
Idiopathic
gynecomastia 519
intussusception in infants 758
Ileal loops 676
Ileocecal tuberculosis 629, 631, 720, 721
types of 721
Iliopsoas abscess 631
Imatinib
in gist 109
resistant disease 109
Immunization history 4
Immunohistochemical
characteristics of gist 109
Immunotherapy
in malignant melanoma, role of 352
in RCC, role of 197
Impalpable testis implies 559
Implantation dermoid 328, 329
on palmar aspect of left hand 329f
Implication of serum markers for
staging 587
Incarcerated hernia 63
Incidental cholecystectomy 132
Incision
for open
appendectomy 726
cholecystectomy 127, 127f
for superficial parotidectomy 462f
for trendelenburg’s operation 291f
hernia 67, 69, 69f
in layers, closure of 1007
of deep cervical fascia 1008
of perirenal fascia 1005
Incisional hernia 67, 69
Indications of tracheostomy 936
Indirect reducible inguinal
hernia in adult 41
Indwelling urinary catheter 645
Infantile
hydrocele 544
Infants congenital hernia 523
Infected sebaceous cyst 332
Infection 791, 792, 854, 942
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1102
Bedside Clinics in Surgery
in palmar space 841
diagnosis of 850
of hand 850
of flexor tendon sheaths 851
of middle palmar space 849
of the radial bursa 851
of ulnar bursa of the hand 850
Inferior
constrictor muscle, parts of 455
epigastric artery and vein 1031
mesenteric artery 1056, 1059
branches of 1059, 1059f
rectal artery 1040
thyroid artery 1077, 1080
thyroid vein 1078
vena cava thrombosis 299
Inflamed hernia 63
Inflammatory carcinoma of
breast 224, 815
Infrahyoid muscles 1083
Ingrowing toe nail, management
of 859
Inguinal canal 1023
anatomy of 62
boundary of 1023
contents of 1024
exposure of 967
in children 523
Inguinal
fossa 1029, 1030
hernia 41, 42, 972
bubonocele, types of 43f
complete, types of 43f
funicular, types of 43f
incomplete, types of 43f
right sided 41f
surgery 53
types of 43, 43f
with prostatism 64
herniorrhaphy 543
Inguinopelvic block dissection
345
Insertion of
chest drain 853
nasogastric tube 835
Instruments 869
for laparoscopic surgery 955
parts of 871f
Intermittent claudication 315
grades of 316
Intermittent fever 24, 722
Internal
iliac artery
exposure of 863f
ligature of 863f
jugular vein 1014
cannulation 839
structure of testis 1085
Interossei muscles 407
test 407
Interpret deep ring-occlusion
test 49
Interstitial cells of testis 1086
Intestinal
anastomosis techniques of 919
metaplasia 751
needles 892
occlusion clamps 918
Intraoperative
cholangiography 149, 150, 150f
criteria 128
Intraperitoneal rupture of cyst
166
signs of
Intraperitoneal subphrenic
spaces 696
Intravenous
line 836
urography 190
hydronephrosis 732
carcinoma kidney 734
Intrinsic lymphatics of stomach
1037
Intussusception 757, 758
Invagination test 39, 45
Invasion of malignant melanoma
348f
Invasive
bladder cancers 803
breast cancer 221
Ionizing radiation in breast
cancer 231
Irreducible hernias 63
Ischiorectal abscess 841, 844,
845
Islet of langerhans 1054
Isolated nodule 256
Isotope
renography 190
scanning 253
Isthmus of thyroid gland,
palpation for 243f
Ivor lewis 712
J
Jackson’s staging for carcinoma
penis 812
Japanese classification 100f
for early gastric cancer 749
Japanese classification for early
gastric cancer 749
Jaundice 14, 77, 645, 653, 729
assess 14
Jenkins’ rule 973
Joffroy sign 241, 247, 259
demonstration of 248f
Joffroy sign 247
Joll’s thyroid retractor 902, 902f
Jugular
venous pressure 17, 604
assess 17
venous pulsation 17
Junctional
nevi 354
nevus 354
Juvenile polyps 763
K
Kangri cancer 358
Keetley Torek technique 556
Kehr’s
sign 610
t-tube 913
Kelly’s
hemostatic forceps 878
rectal speculum 932, 932f
Keloid 336
case of 336
Kerley’s line 693
in chest X-ray 693
Kidney
coverings of 1032, 1033f
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Index
Killian’s dehiscence 454, 455
Klatskin’s tumor, treat 158
Klippel-trenaunay syndrome
386
Klumpke’s paralysis 415
Koch’s postulate 664
Kocher’s
gastric occlusion clamp 914
hemostatic forceps 881, 881f
subcostal incision, anatomy of 975
test 240, 653
thyroid dissector 903, 903f
Kuster perforator see also May
perforator
L
Labiomental muscles 480
Lacunar ligament 1025
Ladd and gross technique 556
Lahey’s
forceps 910f
method 241
Lahshal system of cleft lip 489
Lane’s paired gastrojejunostomy
clamps 916, 916f
tissue forceps 885, 885f
Langenbach’s retractor 897, 897f
Lanz’s incision 726, 876, 975
Laparoscopic
appendectomy 726
cholecystectomy 126, 981, 983
choledocholithotomy 150, 707
instruments 955
Palomo’s operation 552
surgery in colonic carcinoma 180
repair of
hernia 1029
inguinal hernia 67
surgery 957
in colonic carcinoma, role of 180
in peptic perforation 640
Laparoscopy in
carcinoma stomach 99
choledocholithiasis, role of 148
hydronephrosis surgery 191
Large bowel obstruction 684
Late
dumping 123
postcibal syndrome 122
Lateral
aberrant thyroid 268
cord 403
pancreaticojejunostomy 990
Latissimus dorsi see
Thoracodorsal nerve
Laugier’s femoral hernia 531
Lauren’s classification for gastric
cancer 748
Layer of
deep cervical fascia 1075
hydatid cyst 779
scalp 1070
Left
colonic carcinoma 768
hemithyroidectomy 1010
kidney, palpation for 90f
Leg
rising test 93, 93f
test or Fuchsig’s test 312
ulcers, causes of 296
Lentigo 354
melanoma 347
types of 493
maligna or hutchinson’s melanotic freckle 355
Leukoplakic patch 359, 493
excision of 493
Levator
alaeque nasi 480
anguli oris 461
glandulae thyroidae 1077
labii superioris 480
of thyroid hormone 252
test for 461f
Levels of
invasion of malignant
melanoma 347
lymph nodes in the axilla 210
Lewis or lewis tanner approach
for esophagectomy 712
Lichtenstein
tension free repair 54
hernioplasty, steps of 967
1103
Liga clip–LT
300 965
400 965
Ligament
in relation to
external oblique aponeurosis 1025
liver 1046
of cooper 1066
Ligaments 1046
Ligamentum
teres 1047
venosum 1047
Ligation of
cystic artery and duct 984
neck of sac 969
Ligation see also Hepatic artery
embolization
Ligature of external carotid
artery 860
Lily’s modification 160
Linea alba 1031
Linen sutures 952
Linings of exomphalos sac 525
Lip muscles in
bilateral cleft lip,
abnormalities of 481
unilateral cleft lip,
abnormalities of 481
Lipoma 333, 334, 631
Lips develop 481
Lister’s
metallic bougie 929
sinus forceps 883, 883f
Lithogenic bile 131, 786
Littre’s hernia 59
Liver 125, 160f, 232, 1044
function test 135, 176, 627, 632, 820
injury 611, 612
grades of 612
system, anatomy of 1044
trauma 612
Lobes of liver 1044
Local examination 5
Locally advanced carcinoma of
breast 221, 223, 224
Location of
ectopic testis 559f
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appendix 1056
thyroglossal cyst 424f
London sign 606
Long thoracic nerve 1007
Loop obstruction, closed 680
Lord’s operation for hydrocele
542, 542f
Lovibond angle 16, 16f
Low
anal fistula 905, 906
anterior resection, steps of 993
treatment for 906
Lower radical gastrectomy 100
Ludwig’s angina 841
Lumbar
sympathectomy 1007
sympathetic trunk 1065
arteries 1056
hernia 533
Lumbosacral
meningocele 392
meningomyelocele 394f
Lumbricals, test for 408, 409f
Lump 658
in breast 658
in right iliac fossa 631
Lymph node
biopsy 857
dissection in carcinoma
stomach 101
in the neck 18
stations in lymphatic
drainage of stomach 100
Lymph
nodal metastasis 501
stomach 101
Lymphangiomas 32
Lymphatic drainage of
biliary tree 1050, 1051f
colon 1039, 1040f
of testis drains 1087
of tongue drains 499
penis 575f
rectum and anal canal 1043f
stomach 100
stomach occurs 1037
thyroid gland 1078, 1079f
Lymphatics
from esophagus 1035
from rectum and anal canal
are drained 1042
from the penis are drained 574
of the penis drains 812
of tongue drains 499
Lymphoma 442, 721, 728, 755
radiotherapy for 443f
Lytle’s repair 61
M
tc sestamibi scan 267
Macburney’s point 1055
Macroscopic types of carcinoma
of stomach 749
Macvay 532
repair for inguinal hernia 57
Magic trial for chemotherapy in
gastric carcinoma 103
Magnetic resonance
cholangiopancreaticography
703
Maintain
airway 591
circulation 592
Major flail chest 593
Malaecot’s
catheter 926
metallic catheter 930, 930f
Male metallic catheter 930
Malignant
change in a benign mole 355
lymphoma 441
melanoma 341
melanoma spread 350
potential in gist 109
Malleable olive pointed probe
904
Mammography 211
Manage
breathing 592
small residual varicosities 292
venous ulcer 297
Manchester staging of breast
cancer 818
Marjolin’s ulcer 364, 364f
diagnosis 365, 368
99M
Mark
out dull and resonant area 92f
pubic tubercle 284
Maryland dissector 959, 959f
Mass in body and tail 146
Massive hemothorax 593
Mastectomy in early carcinoma
of breast 217
Maternal diabetes mellitus 482
Maxillary artery 465, 860
Mayo-Robson’s incision 127, 876
Mayo’s
pedicle clamp 883, 883f
repair 74
scissors 894, 894f, 895
McBurney’s
gridiron incision 726, 876, 974
anatomy of 974
incision 633
point 79, 629, 974
Mcindoe scissors 895, 895f, 896
McKeown approach for
esophagectomy 712
Measure
blood pressure 22
size of swelling 27
Mechanical
obstruction 642
preparation of bowel 823
Meckel’s diverticula 760, 761
Medial cord 403
Median nerve
block 867, 867f
injury 410
Medical
adrenalectomy 229
treatment for bph 806
treatment of chronic duodenal ulcer 113
Medullary carcinoma of thyroid
274
Melanuria 351
Meningocele 391
Meningomyelocele 391, 394,
395
Meningomyelocele see also
Meningocele
Menstrual history 4
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Menstruation and breast cancer,
relationship of 230
Mental state 9
Mercedez Benz incision 877
Mesoappendix 1055
Metachronous carcinoma 770
Metallic
airway tube 935
bougie 928
Metastasis from carcinoma of
breast 232
Metastatic cervical lymph node
swelling with unknown
primary 438
Metzenbaum scissors 896, 896f
Michel clip applier 894
Microsclerotherapy 295
Midarm circumference,
assessment of 12f
Middle
cranial fossa fracture 736
incision 726, 876
Mid-palmar space, anatomy of
849
Millard’s operation 483
Milligan-Morgan technique of
hemorrhoidectomy 910
Millin’s self-retaining bladder
retractor 901, 901f
Mini-cholecystectomy 128
Minor
surgical procedures 835
flail chest 605, 738, 739
Mirault-Blair technique 485
Mixed parotid tumor 458, 459,
463
Möbius sign 241, 247, 259
Modes of spread of carcinoma
breast 817
Modified
bassini’s repair 54
perthes’ test 287
radical neck dissection 1014
steps of 1005
Mohs micrographic surgery 360
Monocryl sutures 949, 949f
Monofilament polyamide
sutures 954, 954f
Mopp regime 444
Morris’ retractor 898, 898f
Moses’ sign 646
Mosquito hemostatic forceps
882, 882f
Motor supplies of median nerve
410
Mouth and oral cavity 477
Moynihan’s
cholecystectomy forceps 984, 985
gastric occlusion clamp 914
hump 1050
MR colonography 684
MRCP for evaluation of bile duct
126
Mucocele of
appendix 726, 754
gallbladder 124, 131, 780f, 784, 786, 983
Mucoepidermoid tumor 469
Multinodular goiter case of 251
Murphy’s
kidney punch 187
sign 79, 88, 125, 627
positive 125
Muscles in
lips 480
soft palate 490
Muscular defect in
bilateral 481f
triangle 1083
unilateral cleft lip 481f
N
Naffziger method 246
for demonstration of exophthalmos 246f
Narath’s femoral hernia 531
Nasolabial muscles 480
Natural
absorbable suture catgut 944
course of a malignant melanoma 347
nonabsorbable sutures, silk 951
Near total thyroidectomy 255,
271
Neck 339, 341
1105
dissection, types of 440
swellings 417
Necrotizing soft tissue infection
666
Needle 889
holders 888, 888f
Neoadjuvant chemoptherapy 370
in advanced gastric cancer, role of 103
Nephrectomy 1004
Nephron sparing surgery 196
Nerve
arise from
medial cord 403
posterior cord 403
roots of brachial plexus 403
injuries 395
latarjet 114
supply of the scalp 1072
Nervous system 820
examination of 7, 341
higher functions 7
motor system 7
sensory system 7
Neurofibroma 386, 387
case of 387
Neurofibromatosis 373
Neurogenic and vascular
claudication 316
Neurolipoma 335
Neurological
manifestations of thyrotoxicosis 265
symptoms 3
Neuropraxia 404
Neurotmesis 405
Nevin’s staging for carcinoma of
gallbladder 154, 789
NHL, types of 445
Nicoladoni’s sign 384, 385
Nodular melanoma 347
Non-hodgkin’s lymphoma 444
Nonabsorbable sutures 942
Non-cuffed tracheostomy tube
936
Nonrecurrent 268
laryngeal nerve 268
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Nontoxic multinodular goiter or
colloid goiter 250
Normal urethra develop 578
Nucleation 783
Nutritional problems following
gastrectomy 123
Nyhus classification for groin
hernia 61
Nylon sutures 954
O
Obesity 64
and breast cancer, relation of 230
Obstetrical history 4
Obstructed hernia 63
Obstructive jaundice 132, 134, 135, 784
case of 132, 133, 146, 158
due to periampullary carcinoma 132
to choledochal cyst 158
to choledocholithiasis 146
Occipital triangle 1015
Occlusive arterial disease 382
diagnosis of 317
Ochsner’s
clasping test 413, 413f
sherren regime 632
Ocular manifestations of
thyrotoxicosis 266
Oesch phlebectomy hook 292
Ogilvie syndrome 686
Ogilvie syndrome see Pseudoobstruction
Olive pointed fistula director
with frenum slit 907
Ombredann’s technique 556
Omentectomy 103
Open
appendectomy 726
cholecystectomy 127, 983
steps of 984
choledocholithotomy 150, 151, 707
depressed fracture 736
pneumothorax 601
prostatectomy 75
surgery 807
urethroplasty 650
Opponens pollicis, test for 411,
412f
Opposite stratum 559f
OPSI, treatment of 611
Optimal extent of axillary
dissection 216
Oral leukoplakia 492
Orbicularis oris 461, 480
test for 461f
Orchidectomy in undescended
testis 557
Orchidopexy 554, 555, 555f
principles of 554
steps of 555
Orchiectomy, indication of 67
Original Bassini’s operation 55
Origins of pectoralis minor
muscle 1067
Orthodontic management 490
Osler-Rendu-Weber syndrome
377
Osteomyelitis of jaw 513
case of 513
P
Pachydermatocele 388
Pachydermatocele see Plexiform
neurofibromatosis
Paget’s disease of
nipple 815
penis 812
Paget’s test 31
Pain
abdomen 672, 774
in right lower quadrant of
abdomen 629
in right upper quadrant of abdomen 625
Pair 168
Palmar interossei, test for 408,
408f
Palomo’s operation 551
Palpate
abdomen 83
axillary lymph node 207
breast 203, 658
cervical lymph nodes 19
femoral pulse midinguinal point 314f
for thrill over thyroid gland 249
gallbladder 87, 134, 147
gangrenous area 310
isthmus of thyroid gland 242
kidneys 90, 187
liver 85, 134
in presence of ascites 87
normal peripheral pulses 312
parotid
duct 459
gland 459
posterior surface of thyroid
lobes 242
spleen 88, 134
supraclavicular fossa 209f
for supraclavicular lymph
nodes 20f
swelling scrotum 540f
Palpation
of thyroid gland, methods for 243
right iliac fossa 89f
Palpitation 653
Pampiniform plexus 549
Pancreas 125, 155
divisum 635, 703, 1053
parts of 1052
Pancreatic injury 614
Pancreaticoduodenectomy 140,
146, 990f
Pancreaticojejunostomy 140f,
704, 901
Pancreatitis 177
Pancreatojejunostomy 990f
Pantaloon hernia 59
Papillary carcinoma 269, 270, 800
of urinary bladder 800
spread 272
with lymph node metastasis 270
Papillary
microcarcinoma 269
renal cell carcinoma 796
Paradoxical
aciduria 97
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in metabolic alkalosis 97
movement of flail segment 604
respiration 594
Paraesophageal lymph nodes
1035
Paralytic ileus 642, 679
Paramedian incision 876, 973
anatomy of 973
closure of 974
treat 566
Paraphimosis 566
Parasite
Parasympathetic nervous system
1063
Paraumbilical hernia 526f, 527
Park’s classification for perianal
fistula 906
Parotid
abscess 841, 842, 842f
duct 459, 464
duct orifice 459
inspection of 459f
fascia 464
fistula 475
case of 475
gland 465
parts of 464
lymphoma, treat 473
region, boundary of 464, 464f
swelling 458
tumor 466
Part of
appendix 1055
hernia 57
pancreas 144
parotid gland 460
Partial amputation of penis 571
Parts of
an instrument 871
axillary artery 1068
Past history 3
subclavian artery 1080
Patey’s modified radical
mastectomy 220
Pathological changes in
acute appendicitis 753
tubercular lymphadenitis 435
types of carcinoma breast 815
Payrs’
appendix crushing clamps 922, 922f
crushing clamps 920
gastric crushing clamps 920, 921
intestinal crushing clamps 922, 922f
PCNL, complications of 692
Peak acid output 743
Peau d’orange 207, 816, 817
Pectineal ligament 1026
Pectoral fixity of the lump 205
Pectoralis
major muscle, actions of 1067
minor muscle 1067
Pel-ebstein fever 24
Pelvirectal
abscess 845
fistula 906
Pelviureteric junction
obstruction 191
Pemberton sign 246
demonstration of 246f
Peptic
complications of 119, 745
disease 112
of hernia swelling 52
over hernia swelling in standing position 52f
perforation 639, 672, 979
case of 671
management of 745
ulcer 741
Percutaneous
catheter drainage of
pseudocyst 172
nephrolithotomy 691
transhepatic
biliary drainage 157
cholangiography 137, 669
route 151
Perforated
benign gastric ulcer 745
gastric 697
Perforating veins 1089
Perforation 754
Performance status 9
Periampullary carcinoma 132,
133, 135
1107
case of 139
diagnosis of 136
Pericardiocentesis 854
Perinephric abscess 843, 844f
Perineum 559f
Periodicity of pain 76
Peripheral
cyanosis 15
nerve blocks 866
vascular disease 302
Peristaltic movements in
abdomen 82
Peritoneal fluid tap 855
Peritoneum 974
Peritoneum see also Posterior
rectus sheath
division of 971
Peritonsillar abscess 841
Persistent vitellointestinal duct
534
Personal history 3
Perthes test 287, 288
Pes anserinus 463
Peutz Jegher’s syndrome 24, 24f,
763, 764
Peyronie’s disease 567
case of 567
Peyronie’s diseases 567
Pharyngeal
pouch 429, 452, 454, 455, 455f, 456
development of 456
Pheochromocytomas 390, 796
Phimosis 564, 564f, 565, 574, 648
case of 564
Phylloides tumor 521
in breast 521
holding forceps 907, 907f
Physical examination 5
Pigment gallstones 781
Pigmentation 24
Piles 908
holding forceps 907
Pizzillo’s method 243
for palpation 244f
placement of 971
thyroid gland 243
Plain dissecting forceps 886
Plasna sterilization 870
Plastibell technique for
circumcision 567
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Pleomorphic salivary adenoma
463
Plexiform
hemangioma 377
neurofibromatosis 388, 388f
case of 388
Plunging ranula 421, 421f, 422,
428
in floor of mouth 421f
Pneumoperitoneum 957, 958
closed technique of 958
creation of 970
induction of 957, 958
Pneumothorax 853
Pneumothorax see
Hyperresonance
Point block 54
Polycystic
kidney 790, 791
liver disease 166
renal disease 792
Polydioxanone suture 950, 950f
Polyfilament suture 943
Polyglactin
rapide suture 949
sutures 948
vicryl 947
Polyglecaprone 949
Polyglycolic acid
suture 947f
dexon 947
uses of 948
Polyposis of colon 762
Polypropylene suture 953, 953f
Pond depressed fracture of skull
736
Poor abdominal muscle tone 50f
Popliteal
artery, exposure of 866
femur, palpation for 313f
in intercondylar area of
tibia, palpation for 313f
Port wine stain, treat 376, 377
Porta hepatis 1046, 1047f
Portacaval anastomosis 1061
Portal
fissure 1046
vein 1060
anatomy of 1060, 1061f
Positive
Berry’s sign 249
Postauricular dermoid cyst 325f
Postburn contracture 338
Postcholecystectomy syndrome
129
Postcibal syndromes 122
Posterior
cord 403
tibial nerve block 868
Postfixed brachial plexus 402
Postoperative burst abdomen
644
Post-trauma arteriovenous
fistula 619
Postvagotomy diarrhea
causes of 123
treat 124
Pouch of douglas 995, 997
Poupart ligament see Inguinal
ligament
Preauricular dermoid cyst 326f
Precancerous lesion of lip 504
Prefixed brachial plexus 402
skin 358
Premalignant lesions
in the skin 358
of penis 811
Preoperative
biliary stenting, role of 136
preparation
for elective major surgery 819
in gastric outlet obstruction 824
in obstructive jaundice 825
in toxic goiter 822
of patient with chronic renal disease 832
with diabetes mellitus 826
Preparation of patient with
associated heart disease for surgery 829
chronic respiratory disease
for elective major surgery 831
Preperitoneal space 74, 1029
Preputioplasty 565
Presentation of
gist 108
patient with
pancreatic cancer 143
gallstones 784
Primary
bile duct stones 149
carcinoma 721, 755
survey 591
thyrotoxicosis 259
varicose vein 298
gastric lymphoma 106
treat 107
hemorrhage 879
hydrocele 543
lesion in
carcinoma penis 573
malignant melanoma 351
Processus vaginalis 558, 1028
abnormalities of 1028
Proctocolectomy with ileoanal
anastomosis 764
Proctoscope see Kelly’s rectal
speculum
Prognostic
factor
in breast cancer 231
in carcinoma of breast 228
in mtc 276
of colonic carcinoma 731
of rcc 797
marker for carcinoma thyroid 270
Pronator teres, test for 413, 413f
Prophylactic cholecystectomy
132
Prophylaxis against
OPSI 611
tetanus infection 821
Prostate, parts of 804
Prothrombin time 820
in obstructive jaundice 135
Pseudoachalasia 708
Pseudocyst
of pancreas 169
types of 173
Pseudo-obstruction 683
Psoas
abscess 629
sign 627, 725
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Ptc 137
Pubic tubercle 284
Pulse 20
PVC airway tube 935
Pyelolithotomy forceps 923,
923f
Pyelolymphatizc backflow 794
Pyeloplasty, types of 191
Pyelovenous backflow 794
Pyloroplasty see also
Gastrojejunostomy
Pylorus conserving
pancreaticoduodenectomy 140
Pyrexia of unknown origin 24
Q
Quadrantectomy 218
Quadrants of
abdomen 81f
breast 816, 203f
Quadruple ligation 385f
Quart 218
Queyrat disease 574
R
R0, r1 and r2 resection 102
Radial
distribution of 401
injury 396
nerve
palpation for 314f
pulse 313
Radical
cholecystectomy 153
lymph node dissection 468
neck dissection 498
nephrectomy 195
mastectomy 220
in early carcinoma of breast 234
neck dissection 440, 498, 1014
nephrectomy 194, 195
radiotherapy 650
Radioiodine therapy in
thyrotoxicosis 264
Radionuclide
scanning, role of 425
thyroid scanning 261
Radiopaque
gallstone and kidney stone 687
kidney stones and bladderstone 689
Radiotherapy in
carcinoma kidney 196
carcinoma of gallbladder 154
mangement of soft tissue sarcoma 369
Raising fascial and strap muscles
flap 1008
Rami communicantes 320, 1064
Rampley’s swab holding forceps
872
Randall’s plaque 691
Ranson’s criteria 637
Ranula 420, 421
Raspberry tumor 536
Raspberry tumor see also
Umbilical adenoma
Rationalities of elective lymph
node dissection 343
Raynaud’s
disease 379, 380, 380f, 381
phenomenon 321, 381
causes of 381
syndrome 379
causes 383
Reactive hyperemia test 315
Rebound tenderness 91
Rectus sheath 1030
above lower costal margin 1030
breast 233
Recurrent
appendicitis 724, 726
bile duct stones 149
cholangitis 784
inguinal hernia 66
right sided 66f
intestinal obstruction 723
peptic ulcer 121
Reducibility 46
Reed-sternberg giant cells 442
1109
Reflected part of inguinal
ligament 1026
Refractory metabolic alkalosis
97
Regional limb perfusion 352
Regions 81
Relief of
gastric outlet obstruction 142
jaundice 142, 153
pain 142, 153
in carcinoma of pancreas 143
Relieve cardiac tamponade 738
Remittent fever 24
Removal of cbd stones 985
Remove in total amputation of
penis 571
Renal
angiography 194
angle 185
arteriography 652
calculus with gross
destruction of kidney 1004
colic 188
fascia 1033
stones 690
trauma 617
vein 1062
injury
grades of 617
Renogram of patient with
hydronephrosis 190f
Repair
complete cleft lip 486
in incisional hernia 73
of peptic perforation 979
Residual bile duct stones 149
management of 707
Respiratory
distress 654
symptoms 2
Rest pain 316
Retention cyst 174, 658
Retractile testis 560
Retrograde
appendicectomy 726, 1002
cholecystectomy 985
pyelography 190, 733
Retromandibular vein 1072
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Retropubic prostatectomy 807
Retrosternal prolongation 241
of goiter 245, 245f
Reynold’s pentad 149
RFA in varicose vein, principle
of 292
RFA treatment of varicose vein
293, 294
RFA vs EVLS, treatment result
with 295
Rib fracture 602
Richter’s hernia 58, 58f, 678
Right
angled forceps 910
colonic carcinoma 729, 768
hemicolectomy 178, 992
Rigid metal pin stripper 291
Risk factors for developing
breast cancer 231
Rives
prosthetic repair of inguinal hernia 60
stoppa’s technique of mesh
repair of incisional hernia 74
Road traffic accident 591, 614
Robson’s staging for RCC 797
Rodent ulcer 362
Roof top or chevron incision
876
Round bodied needle 890f, 891
Route of infection 117
Roux loop of jejunum 978
Roux-en-Y
anastomosis of jejunum to esophagus 102f
cystojejunostomy 165
gastrojejunal anastomosis 978
limb of jejunum 156
Ruchauds myopectineal orifice
62
Rutherford Morrison’s incision
633
Ryle’s tube 608, 744, 835, 836
S
Salivary gland 457, 1084
calculi, composition of 472
tumors, classification of 464
Salmon patch 376
Santorini 1053
Saphena varix 301
Saphenofemoral junction 283,
290, 290f
Saphenous nerve 291
Saturday night palsy 403
Scalene triangle 447, 448f
Scalp 1070
Schamroth sign 15, 16f
Schwannomas 390
Schwartz test 286
Sclerotherapy 295, 375
complications of 295
contraindications of 859
cure varicose veins 295
for ganglion 857
for piles 856
for varicose veins 859
indications of 859
in hydrocele, role of 542
indications of 856
Sclerotherapy
for ganglion 857
for piles 856
for varicose veins 859
in hydrocele 542
Scolicidal agents 168
Screening in breast cancer 235
Scrotal sebaceous cyst 333
treat 333
Sebaceous cyst 326, 330-333
case of 330
Sebaceous horn 332
Second
degree burn 624
degree piles 909
line of antitubercular drugs 437
Secondary
bile duct stones 149
carcinoma of penis 575
gastric lymphoma 106
treatment for 107
survey 593
Secretin and pancreozymin
1054
Segments of liver 1045, 1045f
Selective neck dissection 441
Self-retaining abdominal
retractor 900, 900f
Seminomas, types of 808
Sensory nerve
dysfunction 397
supply of the face 1073
Sentinel lymph node 214, 214f,
215, 344, 572
biopsy 214-216
advantages of 214, 344
contraindications of 216
in carcinoma penis, role of 572
in early breast cancer, role of 214
importance of 344
number of 216
Seps 296
for treatment of varicose veins 296
Sequelae of acute cholecystitis
130
Sequestration dermoid 327
Serratus anterior muscle 1069
Serum
ulcerative colitis 774
Shifting dullness 91
Shoelace darn technique 72
Short
gastric
artery 1037f
saphenous
system of vein 291
Shouldice
repair 56
technique for local anesthetic block 53
Sigmoid
colectomy 180
volvulus 682-685
Signs of peripheral ischemia 308
Silbar procedure 556
Silent
gallstones 131
or asymptomatic gallstones 688
Simple rubber catheter no. 10
924
Single bladed
blunt hook 937, 937f
sharp hook 938, 938f
Sinus 35
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Sistrunk operation 425
Site distribution of carcinoma
tongue 497f
Sites of
peptic ulcers 118
portacaval anastomosis 1061
Skin 1085
and subcutaneous tissue 323, 324, 973
closure clips and accessories 893
fixity 205
staplers 894
tethering 204
Skull bone fracture 735
Sliding hernia 58
Slip sign 334
Small
bowel obstruction 677
cut stricture 755
gut resection
anastomosis 920
intestinal obstructions 677
Soft tissue sarcoma 366, 367f
Solitary
thyroid nodule 251, 255, 256, 257, 270, 652
evaluation of 256
right lobe 255f
treatment for 257
toxic nodule 654
Space of retzius 1029
Spencer Well’s hemostatic
forceps 877
Spermatic cord, coverings of
1024
Spermatocele 547
Sphincter
around bile duct 1049f
choledochus 1049
of boyden 1049
of oddi 1049
pancreaticus 1049
Spinal
accessory nerve 1014
Spleen
hooking method, palpation for 89f
palpation 89f, 134
Splenectomy 1003
indications of 1003
Splenic
artery 1037f, 1057
injury 607, 609
Split skin graft 343
Sporadic and familial gist 107
Squamous cell carcinoma 355,
357-359, 360, 712, 750, 801,
812
Sssi 665
Stab injury abdomen 674
Stage
IV carcinoma stomach, treatment for 103
lymphoma 443
squamous cell carcinoma 358
Staging
investigations for carcinoma of breast 231
laparotomy in hodgkin’s lymphoma 442
Stainless steel wire 955, 955f
Standard autoclaving 870
Staright X-ray abdomen 627
Stauffer’s syndrome 797
Stauffer’s syndrome see also
Hepatic dysfunction
Stellate ganglion 383
Stellwag sign 248
Steps of
appendicectomy 1000
closure of colostomy 1000
tapp operation 969
Sterilization 869, 872, 874, 875, 878, 881-883, 886, 893, 904, 919, 921-923, 926, 927, 933, 940, 955
of instruments 870
Sternocleidomastoid muscle
1014
Stomach 1036
Stove in chest 594, 605
Straight X-ray
KUB 652
of abdomen 607
of chest 670
Strangulated hernia 63
Strangulation obstruction 679,
680
Strategy for thyroid cyst,
management 259
1111
Strawberry
angioma 376
gallbladder 131
Structures
passes deep to the inguinal ligament 1026
pierces the clavipectoral fascia 1068
will you remove 139
Sturge-weber syndrome 377
Subcapsular hematoma 609, 610
of spleen 610
Subclavian artery 1080
anatomy of 861
branches of 1080
Subclavian pulse 315
palpation for 315f
Subclavian vein
cannulation, complications of 839
puncture 837, 838f
Subcostal incision 876
Subdural hematoma 599
Submandibular
sialoadenectomy 1013
duct 472
gland 475
salivary gland 472
sialoadenectomy, steps of 1013
triangle 1083
Submental
dermoid 329
triangle 1083
Subphrenic
abscess 695, 697
spaces 695
Subtotal colectomy in carcinoma
of left colon 178
Succussion splash,
demonstration of 95, 95f
Sucking wound in the chest 605
Suction irrigation cannula 961,
961f
ring, anatomy of 1025, 1025f
lobe of parotid gland 459f
muscles, division of 1004
palpation with two hands 85f
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1112
Bedside Clinics in Surgery
parotidectomy, steps of 462, 1011
parotidectomy 462
phlebitis 656
sensation 7
spreading melanoma 346
system of veins 1088
temporal 465
artery 860
artery pulse, palpation for 315f
pulse 315
Sunderland’s classification for
nerve injury 405
Superficial
inguinal ring 1025
parotidectomy 462, 1011
spreading melanoma 346
Superior mesenteric artery 1058
Supraclavicular
fossa midclavicular point 315f
lymph nodes, palpation for 208
Supraomohyoid neck dissection 441
Suprapubic cystolithotomy
forceps 923, 923f
Supravesical fossa 1029, 1030
Surgery for
chronic duodenal ulcer 116
piles, indications of 909
renal
cell carcinoma 196
trauma, extent of 618
thyroid nodule 258
Surgery in
cleft lip 483
metastatic breast cancer 227
pharyngeal pouch,
indications of 454
recurrent hernia 66
secondary gastric lymphoma 107
thyrotoxicosis 263
ulcerative colitis, indications of 775
Surgical
bilioenteric bypass 157
blades 875, 875f
pathology 741
problems 591
treatment of a solitary thyroid
nodule 257
Suture
material, type of 645
materials 942
Swab holding forceps 872f, 908
Swelling 25
Sympathetic
ganglia 320
nervous system 1063
Synchronous carcinoma 770
Synthetic
absorbable sutures 946, 948f
nonabsorbable sutures 953
T
Tabes mesenterica 756
Tails of lockwood 560, 560f
Tamoxifen 568
Taper cut needles 891
TAPP operation, steps of 969
Tapper cut needle 890f
Tapping for relief of hydrocele,
role of 542
Technique of
cystectomy 164
small gut resection anastomosis 920
Telescope 955
Temperature 23
Tennison’s repair 485
Tension
of pulse wave, assess 21
pneumothorax 592, 603, 738
TEP operation for inguinal
hernia, steps of 972
Teratocarcinoma see Malignant
teratoma intermediate
Teratoma, types of 809
Teratomatous dermoid 328
Test
adductor pollicis 409
for facial nerve palsy 460
for other perforator incompetence 284
for the lumbricals 408
Testes and spermatic cord,
palpation for 186f
Testicular tumors 585, 807
Testing for
fixity of lump to serratus
anterior muscle 206f
frontal belly of occipitofrontalis 460f
medial ankle perforator 285, 285f, 286f
orbicularis oculi 460f
Testis
anatomy of 1085
coverings of 1085
development of 557, 1087f
Tetanus prophylaxis 625
The liver 1046
Thenar
muscles 414
space infection 849
Therapeutic embolization 195
Thermography 227
Thigh abscess 841
Thinner space, anatomy of 849
Third degree
burns or full thickness burns 622
piles 909
Thoracocentesis 852
indications of 852
Thoracolumbar fascia, division
of 1004
Threatened abortion 482
Thrill and bruit over thyroid
gland 653
Thrombophilia 662
Thyrocervical trunk 1080
Thyroglobulin 272
assay, role of 272
Thyroglossal
cyst
case of 423
duct, course of 424f
case of 426
fistula 425
Thyroid 237
cancer 272
carcinomas 267, 271
develops 424
cyst 258
gland 1076
gland develops 424
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Index
Thyroidectomy 654
complications of 265
in multinodular goiter 255
Thyrotoxic myopathy 266
Thyrotoxicosis 263, 265
treatment for 262, 264
Tinel’s sign 406
Tnm definition for carcinoma
colon 731
of gallbladder 789
of stomach 751
of urinary bladder 802
penis 813
TNM
definition for carcinoma of
gallbladder 789
stomach 751
staging for carcinoma
colon 731
gallbladder 155
penis 813
staging for
cancer breast 817
malignant melanoma 348
RCC 797
rectal cancer 771
soft tissue sarcomas 371
testicular tumors 587, 810
Todani see Types of choledochal
cyst
Toothed dissecting forceps 887,
887f
Total
colectomy 180
for thyroid cancer 273
gastrectomy, indications of 921
steps of 1008
thyroidectomy 1008
Towel clips 873, 873f
Toxic goiter 264
Tracheal
and apex beat shifting to
opposite side 592
and esophageal branches 1078
dilator 938, 938f
obstruction 254
Tracheostomy 1017
steps of 1017
tube 936, 937
Traction test 546f
Transcystic exploration of bile
duct 148
Transfection 234
Transhiatal esophagectomy 712
Transillumination 32, 541
test 541f
Transitional cell
carcinoma 801
tumors of bladder 801
Transmitted pulsation 32
demonstration of 32f
Transplantation 750
Transpyloric plane 81, 81f
Transrectal ultrasonography
649, 652, 906
Transtubercular plane 81f
Transverse
abdominal incision, anatomy of 975
cervical artery 1080
colostomy 999
steps of 999
Trastuzumab 219
Traumatic
arteriovenous fistula 384, 384f
fat necrosis 659
gangrene 655
hemothorax 602, 739, 853
pneumothorax 602, 603, 739, 853
rupture of gallbladder 983
urethral stricture 620
Treat
megaloblastic anemia
following gastrectomy 123
stage iv colonic cancer 181
Treatment
for resectable gist 109
history 4
in advanced carcinoma of breast, aims of 225
of early gastric cancer 104
Tremor in
out-stretched hands 249f
tongue and hands 653
Trendelenburg’s
operation 291
test 280, 282, 283f
1113
Triangle of
doom 552, 552f
neck 1082f
Tributaries of
inferior vena cava 1059, 1060f
portal vein 1060
Triceps muscle, test for 397, 397f
Trocar and cannula 958
Troisier’s sign 145
Tropical eosinophilia 694
Trousseau sign see Migratory
thrombophlebitis
Trousseau’s sign 145
Trucut needle biopsy 257
True
cyst 327
epigastric hernia 529
contents of 529
Truncal vagotomy 116
steps of 111, 917, 978
vagotomy and gastrojejunostomy 917, 978
Trunks of brachial plexus 402
T-tube cholangiogram 669, 705,
706
Tube thoracostomy 593
case of 434
Tubercular
lymphadenitis 433, 434, 436
stricture 755
Tuberculosis 650, 651, 721, 728,
755
of breast 659
of kidney 798, 799
Tubulodermoid 328
Tumescence anesthesia 293
Tumor markers in gastric cancers
751
Tumor thickness in malignant
melanoma 348
Tumors 648
importance of 348
type of 561
Turban tumor 364, 389
Turcot’s syndrome 763, 764
Turnbull’s no touch technique
178
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1114
Bedside Clinics in Surgery
Types of
cholangiocarcinoma 156
choledochal cyst 160
dermoid cyst 328
gstric ulcer 119
pancreatic trauma 615
U
Ulcer 34
Ulcerative colitis 11, 177, 671,
767, 772-775
Ulcerative lesion in tongue 495
Ulnar
claw hand 410
nerve
block 867, 867f
injury 406, 406f
palsy, case of 406, 414
Ultrasonography 125, 733
of abdomen 612, 627, 652, 684, 941
of kidney 64
ureter 649
Ultrasonography helps in
evaluation of patients with
obstructive jaundice 135
Umbilical adenoma 536
case of 536
Umbilical adenoma or raspberry
tumor 536
Umbilical hernia 524, 527
case of 524
diagnosis 524
ligaments 1029
management 524
Underlying bony indentation,
assess 28
Underlying cause, treatment of
648
Undescended testis 553, 558, 559
case of 553
Unilateral cleft lip 479, 479f
treat 483
Unilateral
hydronephrosis, causes of 191, 793
incomplete cleft lip 479f
varicocele 550
Upper
abdominal transverse incision 127
level of jugular venous
pulsation, assessment of 17f
midline abdominal incision 973
Urachal
cyst 537
fistula 536, 537
Urethra 539
Urethral
dilatation 650, 929
complications of 929
rupture 620
Urethroplasty 580
Urinary
bladder 651
development of 583f
cases 183
symptoms 2
tract injury 616
Urodynamics study 649
V
Vagal trunk in stomach,
distribution of 1038
Vaginal hydrocele 539, 544
case of 540
Vagotomy 116, 901
on gastrointestinal tract 123
Vagus nerve 978
Varicocele 547, 551
case of 548
Varicose
ulcer 292, 296, 297
vein 278, 280, 289, 298-300
Varieties of cervical rib 447
Various parts of ulcer 34f
Vasodilator drugs in Raynaud’s
disease, role of 382
Veins
in lower limbs 1088
of the face 1072
Venesection 1016
steps of 1017f
Venous drainage 1078
occurs through 1071
of esophagus 1034
of rectum and anal canal 1041
of stomach 1038
Venous
cut down 1016
filling time 310
guttering 308
ulcer 297
Veress needle 956, 956f
Vessels of
right colon, division of 992
Vicryl rapide suture 949, 949f
Virchow’s gland 18, 434
Vitellointestinal duct 534, 535f,
760, 761
Volar space infection 848
Volkman’s spoon or scoop 931,
931f
Volvulus 683
von Graefe’s sign 241, 247, 259
von Recklinghausen’s
disease 390
case of 390f
disease of bones 391
W
Waltman-Walters syndrome 911
Wardill-Kilner-Veau four flap
technique 492f
Water
lily sign 163
Web space
anatomy of 848
infection 848
What is
a fistula 905
the location and parts of pancreas 1052
the optimal treatment 719
Whipple’s
pancreaticoduodenectomy 987
operation 139, 140, 141, 146, 660, 876, 948, 983, 989f
White
blood cell count 665
rami communicantes 1064
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Index
Whole body bone scanning 231
Witzel gastrostomy 1020
Worm in
bile duct 701
common bile duct 700
Wound infection 663
Wrist 341
drop with right sided radial nerve injury 396f
Writing a surgical long case 1
X
Xanthine stones 690
Xeroderma pigmentosum 346,
358, 366
X-ray 669
appearance 671
of abdomen 606
levels 675
skull 735
skull, bone fracture 735
1115
Z
Zachary cope 725
Zadek’s operation 859
Zieman’s test 49, 50f
Zollinger-Ellison syndrome 743,
921
Zygomaticofacial 463
nerve 1074
Zygomaticotemporal nerve
1072, 1074
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Opinions About the Book
“Bedside Clinics in Surgery, a book which is needed by the undergraduate and postgraduate students alike.
It forms the logical next step to ‘Clinical Surgery’ by Dr Das, and may even replace it as the student’s companion
for clinical cases.
One of the prime difficulties in reading textbooks is the long paragraphs and prose, uninterrupted by
photographs, diagrams or color diagrams. The author has successfully overcome this by formatting the text as
questions and answers. The inclusion of photographs, especially color pathology slides, is welcome.
Each section starts with an outline for describing a case. This would be extremely useful for the students, as
they know which points are to be stressed during presentation. I would further commend the author in pointing
out errors usually made by the students, e.g. saying ‘nothing significant’ in family history.”
I have not come across another book, which covers the case, from a clinical point of view so well, e.g. even
the doses and side effects of antituberculous drugs are given. Hence, the student does not have to cross-refer
to a number of books.
One of the problems, postgraduate students face, is the variety of ways in which a problem can be tackled.
This book gives the most widely accepted technique of doing so.
The inclusion of pathology specimens is the first of its kind as far as I know. Description of X-rays and
instruments makes it a complete book for the exam-going students.
—AK Attri, JIMA, November 2005 Issue
“The book has an interesting question and answer format, which is exam oriented. I found it to be informative
and accurate. The diagrams are clear and simple. The instruments and pathology specimens are clear.”
—Dr Benjamin Perakath, Professor and Head
Department of Surgery Unit V, Christian Medical College, Vellore, India
“I like it very much. I have recommended it to my students. The clinical examination, eliciting signs, writing a
case sheet, common questions that will be asked and answers to the questions, surgical pathology, instruments,
operative procedures and totally the presentation of book shows the experience and expertise of the author.
I am sure a student who has no knowledge can excel with this book in hand and do well in the examination.”
—Dr B Kanchana, Professor and Head, Department of Surgery
Aarupadai Veddu Medical College and Hospital
Kirumampakkam, Puducherry, India
“Students from our institute are also looking for an additional book on surgery clinics to do better than others
in practical examination.”
—Dr Suneel Kumar Gadikota, Associate Professor of General Surgery
Kamineni Institute of Medical Sciences, Narketpally, Nalgonda, Andhra Pradesh, India
“The book has great scope for undergraduates, postgraduates and staff as well. It includes all contemporary
material. The book is a boon for undergraduates as the text is made very easy to understand and in friendly
language with most frequently asked questions in examinations.”
—Dr Gurpal Singh Chhabda, Associate Professor of General Surgery
Kamineni Institute of Medical Sciences, Narketpally, Nalgonda, Andhra Pradesh, India
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“I have gone through the book titled as Bedside Clinics in Surgery by Dr Makhan Lal Saha, which is highly
educative and complete in all aspects of the surgery for the students of undergraduate and postgraduate
courses. Everything is discussed in a comprehensive manner on long and short cases including traumatic and
emergency services. It is also a rare phenomenon to discuss in detail about the X-ray procedures and surgical
pathology pertaining to the patients. It has also a practical discussion procedures. No other book discusses in
such a great length about the instruments which are quite crucial for exam-appearing students. Though it is not
a substitute for textbook of surgery, it gives readymade guidelines for the students appearing for undergraduate
and postgraduate examinations.”
—Superintendent, Osmania General Hospital, Hyderabad, Andhra Pradesh, India
“The book is good and it will be useful to the undergraduates and postgraduates in surgery.”
—Dr BS Gedam, Professor
Department of Surgery, Government Medical College, Nagpur, India
“It has plenty of information for a quick revision before examinations or even before presentations. Highly
recommended.”
—Dr RCM Kaza, Professor
Department of Surgery, Maulana Azad Medical College, New Delhi, India
“The question and answers given in each chapter are the frequently asked questions in any standard examination
by the examiner.
The author should be congratulated for using the clinical photographs from his own collection and colleagues.
The book covers not only clinical surgery but also X-rays, surgical pathology, preoperative preparations, minor
surgical procedures and instruments.”
—Dr N Dorairajan, Professor, Department of Surgery
Madras Medical College, Chennai, Tamil Nadu, India
“Keeping in view the practical and viva-voce of MBBS examinations, the book has been designed in a different
style. The content of the book is precise and methodical. Series of common long and short cases with related
questions will prove helpful to the students. The author has very well compiled the common operative procedures;
details of routine instruments and various common radiographs.”
—Prof M Amanullah Khan, Chairman, JN Medical College
Aligarh Muslim University, Aligarh, Uttar Pradesh, India
“Dr Saha has done a very good job and the book is a very useful not only for undergraduates but also for
postgraduate students as well. The section on short cases in surgery is particularly helpful for the students and
gives them relevant information as a question-answer session.”
—Dr Navneet Kaur, UCMS and Guru Tegh Bahadur Hospital, Delhi, India
“I have gone through the book and found to be useful for the undergraduate students of MBBS, and I strongly
recommend this book for reference to MBBS students.”
—Dr AT Kamble, Professor and Head, Department of Surgery
Indira Gandhi Government Medical College, Nagpur, Maharashta, India
“The book discusses all the probable questions that may be asked in the clinical examination. The author must
be a good examiner and also observed the questions asked by other examiners in the clinical examination. The
investigations described are relevant to the clinical cases. The surgical pathology, X-rays, surgical procedures
and instruments described are adequate and essential for surgical students.
I recommend this book for all MBBS students. Junior teaching faculty members will be benefited by reading
this book and will help them in taking bedside clinics.”
—Dr D Premkumar, Professor and Head, Department of Surgery
IRT—Perundurai Medical College and Hospital, Tamil Nadu, India
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