Bedside Clinics in Surgery
Transcription
Bedside Clinics in Surgery
SURGERY Bedside Clinics in Surgery Universal Free E-Book Store Donate Us, In order to keep our Service Alive, We have to pay for placing files (Abstracts, Books, Literature & Software) on File Hosting Servers, Your donations will make our process of payment a bit easier, Please use any one of the Payment Gateway for Donation. Never matter what amount you donate (10’s or 100’s or 1000’s). or http://url-s.gq/paypal or http://url-s.gq/payumoney Universal Free E-Book Store Universal Free E-Book Store ditio n d E n c o 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 Universal Free E-Book Store Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: [email protected] Overseas Offices Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bld. 237, Clayton Panama City, Panama Phone: + 507-301-0496 Fax: + 507-301-0499 Email: [email protected] J.P. Medical Ltd 83, Victoria Street, London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: [email protected] Jaypee Medical Inc The Bourse 111 South Independence Mall East Suite 835, Philadelphia, PA 19106, USA Phone: + 267-519-9789 Email: [email protected] Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: +08801912003485 Email: [email protected] Jaypee Brothers Medical Publishers (P) Ltd Shorakhute, Kathmandu Nepal Phone: +00977-9841528578 Email: [email protected] Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 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] 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 Universal Free E-Book Store 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. Universal Free E-Book Store Universal Free E-Book Store 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 Universal Free E-Book Store Universal Free E-Book Store 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 Universal Free E-Book Store Universal Free E-Book Store 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, Universal Free E-Book Store 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] Universal Free E-Book Store 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. Universal Free E-Book Store xiv 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] Universal Free E-Book Store 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. Universal Free E-Book Store xvi Bedside Clinics in Surgery 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. Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store Universal Free E-Book Store 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. Universal Free E-Book Store 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 Universal Free E-Book Store 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. Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store Chapter 1 Introduction 5 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 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). Universal Free E-Book Store 6 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 1 Introduction 7 • 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 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 Universal Free E-Book Store 8 Section 1 Surgical Long Cases • 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. Universal Free E-Book Store Chapter 1 Introduction 9 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............. Universal Free E-Book Store 10 Section 1 Surgical Long Cases 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) Universal Free E-Book Store Chapter 1 Introduction 11 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 Universal Free E-Book Store 12 Section 1 Surgical Long Cases 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. Universal Free E-Book Store Chapter 1 Introduction 13 • 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 Universal Free E-Book Store 14 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 1 Introduction 15 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 Universal Free E-Book Store 16 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 1 Introduction 17 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). Universal Free E-Book Store 18 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 1 Introduction 19 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 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) Universal Free E-Book Store 20 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 Universal Free E-Book Store Chapter 1 Introduction 21 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 Universal Free E-Book Store 22 Section 1 Surgical Long Cases 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. Universal Free E-Book Store Chapter 1 Introduction 23 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 Universal Free E-Book Store 24 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 1 Introduction 25 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 Universal Free E-Book Store 26 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 1 Introduction 27 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 Universal Free E-Book Store 28 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 1 Introduction 29 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. Universal Free E-Book Store 30 Section 1 Surgical Long Cases 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. Universal Free E-Book Store Chapter 1 Introduction 31 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. Universal Free E-Book Store 32 Section 1 Surgical Long Cases 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) Universal Free E-Book Store Chapter 1 Introduction 33 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 Universal Free E-Book Store 34 Section 1 Surgical Long Cases OUTLINE FOR WRITING A CASE OF ULCER HISTORY 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 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 Universal Free E-Book Store Chapter 1 Introduction 35 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). Universal Free E-Book Store 36 Section 1 Surgical Long Cases 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 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 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 Universal Free E-Book Store Chapter 2 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 Universal Free E-Book Store 38 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 2 Hernias 39 • 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 Universal Free E-Book Store 40 Section 1 Surgical Long Cases • 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. Universal Free E-Book Store Chapter 2 Hernias 41 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. Universal Free E-Book Store 42 Section 1 Surgical Long Cases 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). Universal Free E-Book Store Chapter 2 A B Hernias 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. Universal Free E-Book Store 44 Section 1 Surgical Long Cases 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. Universal Free E-Book Store Chapter 2 Hernias 45 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. Universal Free E-Book Store 46 Section 1 Surgical Long Cases 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). Universal Free E-Book Store Chapter 2 Figure 2.8A: Method for reduction of hernia: Patient lies down and Flex the hip and knee Hernias 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). Universal Free E-Book Store 48 Section 1 Surgical Long Cases 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). Universal Free E-Book Store Chapter 2 Hernias 49 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). Universal Free E-Book Store 50 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 Universal Free E-Book Store Chapter 2 Figure 2.16B: Abdominal muscle tone and appearance of bulging in the flanks may also be observed by leg rising test Hernias 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 Universal Free E-Book Store 52 Section 1 Surgical Long Cases 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. Universal Free E-Book Store Chapter 2 Hernias 53 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 Universal Free E-Book Store 54 Section 1 Surgical Long Cases 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. Universal Free E-Book Store Chapter 2 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. Hernias 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. Universal Free E-Book Store 56 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 2 Hernias 57 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? 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. Universal Free E-Book Store 58 Section 1 Surgical Long Cases 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) Universal Free E-Book Store Chapter 2 A Hernias 59 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). Universal Free E-Book Store 60 Section 1 Surgical Long Cases 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? 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 Universal Free E-Book Store Chapter 2 Hernias 61 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 Universal Free E-Book Store 62 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 2 Hernias 63 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. Universal Free E-Book Store 64 Section 1 Surgical Long Cases What are the aetiological factors for development of hernia? 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. Universal Free E-Book Store Chapter 2 Hernias 65 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? 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? 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? Shouldice repair Cooper’s ligament repair Rives preperitoneal mesh repair Stoppa's GPRVS Laparoscopic mesh repair (TAPP and TEP). Universal Free E-Book Store 66 Section 1 Surgical Long Cases 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? 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? 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. Universal Free E-Book Store Chapter 2 Hernias 67 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? 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 ....................................... Universal Free E-Book Store 68 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 2 Hernias 69 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? 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 Universal Free E-Book Store 70 Section 1 Surgical Long Cases • 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. Universal Free E-Book Store Chapter 2 Hernias 71 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? 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? 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? 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. Universal Free E-Book Store 72 Section 1 Surgical Long Cases In case of midline incisional hernia what do you mean by anatomical repair? 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? 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. Universal Free E-Book Store Chapter 2 A B C Hernias 73 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? 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 Universal Free E-Book Store 74 Section 1 Surgical Long Cases What are the different types of mesh used for hernial repair? 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? 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. Universal Free E-Book Store Chapter 2 Hernias 75 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? 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. Universal Free E-Book Store Chapter 3 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 Universal Free E-Book Store Chapter 3 • • • • Abdomen 77 − 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 Universal Free E-Book Store 78 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 3 Abdomen 79 » 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. Universal Free E-Book Store 80 Section 1 Surgical Long Cases • 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. Universal Free E-Book Store Chapter 3 Abdomen 81 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 Universal Free E-Book Store 82 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 3 Abdomen 83 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 Universal Free E-Book Store 84 Section 1 Surgical Long Cases 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 Universal Free E-Book Store Chapter 3 Abdomen 85 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 Universal Free E-Book Store 86 Section 1 Surgical Long Cases 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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Three way Foley’s balloon catheter with a balloon capacity of 30–50 mL Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store 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. Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Universal Free E-Book Store Section 9 operative Surgery chapter 22 Operative Surgery StepS of LichtenStein herniopLaSty Describe the steps of Lichtenstein hernioplasty. 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. Universal Free E-Book Store 968 Section 9 Operative Surgery 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. StepS of herniotomy for congenitaL hernia Describe the steps of herniotomy for congenital hernia? 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. Universal Free E-Book Store chapter 22 A B C E Operative Surgery 969 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). 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 Universal Free E-Book Store 970 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 Universal Free E-Book Store chapter 22 Operative Surgery 971 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). Universal Free E-Book Store 972 Section 9 Operative Surgery 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. 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. Universal Free E-Book Store chapter 22 Operative Surgery 973 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? 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 Universal Free E-Book Store 974 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. Universal Free E-Book Store chapter 22 Operative Surgery 975 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? 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. Universal Free E-Book Store 976 Section 9 Operative Surgery 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. 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. Universal Free E-Book Store chapter 22 Operative Surgery 977 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. Universal Free E-Book Store 978 Section 9 Operative Surgery 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. 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. Universal Free E-Book Store chapter 22 Operative Surgery 979 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. 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 Universal Free E-Book Store 980 Section 9 Operative Surgery 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. Universal Free E-Book Store chapter 22 Operative Surgery 981 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. Universal Free E-Book Store 982 Section 9 Operative Surgery 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. Universal Free E-Book Store chapter 22 Operative Surgery 983 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? 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? 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. Universal Free E-Book Store 984 Section 9 Operative Surgery 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. Universal Free E-Book Store chapter 22 Operative Surgery 985 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. Universal Free E-Book Store 986 Section 9 Operative Surgery 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. Universal Free E-Book Store chapter 22 Operative Surgery 987 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. 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 Universal Free E-Book Store 988 Section 9 Operative Surgery 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. Universal Free E-Book Store chapter 22 Operative Surgery 989 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 Universal Free E-Book Store 990 Section 9 Operative Surgery 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. 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. Universal Free E-Book Store chapter 22 Operative Surgery 991 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. Universal Free E-Book Store 992 Section 9 Operative Surgery 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. Universal Free E-Book Store chapter 22 Operative Surgery 993 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. StepS of LoW anterior reSection Describe the steps of anterior resection (or low anterior resection). 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. Universal Free E-Book Store 994 Section 9 Operative Surgery 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 Universal Free E-Book Store chapter 22 Operative Surgery 995 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. Universal Free E-Book Store 996 Section 9 Operative Surgery 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. 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 Universal Free E-Book Store chapter 22 Operative Surgery 997 • 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. Universal Free E-Book Store 998 Section 9 Operative Surgery 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. Universal Free E-Book Store chapter 22 Operative Surgery 999 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. 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. Universal Free E-Book Store 1000 Section 9 Operative Surgery 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. 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 Universal Free E-Book Store chapter 22 A C Operative Surgery 1001 B D E F G H figures 22.9a to h: Steps of appendicectomy 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. Universal Free E-Book Store 1002 Section 9 Operative Surgery 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? 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: Universal Free E-Book Store chapter 22 Operative Surgery 1003 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? 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. Universal Free E-Book Store 1004 Section 9 Operative Surgery 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. 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. Universal Free E-Book Store chapter 22 Operative Surgery 1005 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. Universal Free E-Book Store 1006 Section 9 Operative Surgery A B C D E F 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. Universal Free E-Book Store chapter 22 Operative Surgery 1007 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. 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. Universal Free E-Book Store 1008 Section 9 Operative Surgery 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. Universal Free E-Book Store chapter 22 A B C D E F G Operative Surgery 1009 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. Universal Free E-Book Store 1010 Section 9 Operative Surgery 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. 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 Universal Free E-Book Store chapter 22 Operative Surgery 1011 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 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. Universal Free E-Book Store 1012 Section 9 Operative Surgery 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. Universal Free E-Book Store chapter 22 Operative Surgery 1013 StepS of SuBmanDiBuLar SiaLoaDenectomy Describe the steps of submandibular sialoadenectomy 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. Universal Free E-Book Store 1014 Section 9 Operative Surgery 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 Universal Free E-Book Store chapter 22 Operative Surgery 1015 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 Universal Free E-Book Store 1016 Section 9 Operative Surgery 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 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. Sites 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 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) Universal Free E-Book Store chapter 22 A B D G Operative Surgery 1017 C E F H figures 22.12a to h: Steps of venesection 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. Universal Free E-Book Store 1018 Section 9 Operative Surgery 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? 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 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. 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). Universal Free E-Book Store chapter 22 A Operative Surgery B D C E G 1019 F H 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. Universal Free E-Book Store 1020 Section 9 Operative Surgery 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? 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)? 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. Universal Free E-Book Store chapter 22 Operative Surgery 1021 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. circumciSion indications 1. Religious: Muslims and Jews 2. Phimosis 3. Paraphimosis. Describe the steps of circumcision (Figs 12.15A to F). 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 Universal Free E-Book Store 1022 Section 9 Operative Surgery 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. Universal Free E-Book Store Section 10 Surgical Anatomy chapter 23 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 Universal Free E-Book Store 1024 Section 10 Surgical Anatomy 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) Universal Free E-Book Store Chapter 23 Surgical Anatomy 1025 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? 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 Universal Free E-Book Store 1026 Section 10 Surgical Anatomy 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 Universal Free E-Book Store Chapter 23 Surgical Anatomy 1027 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? 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 Universal Free E-Book Store 1028 Section 10 Surgical Anatomy What is the boundary of femoral ring (Fig. 23.5)? 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? Above (Base): inguinal ligament. Laterally: Medial border of Sartorius. Medially: Medial border of adductor longus. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1029 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 Universal Free E-Book Store 1030 Section 10 Surgical Anatomy 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? 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). Universal Free E-Book Store Chapter 23 Surgical Anatomy 1031 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. Universal Free E-Book Store 1032 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1033 Figure 23.8: Coverings of kidney. Note that fascial capsule is open inferiorly as shown by the arrow 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. Universal Free E-Book Store 1034 Section 10 Surgical Anatomy ESOPHAGUS What is the extent of esophagus? 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? 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1035 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 Universal Free E-Book Store 1036 Section 10 Surgical Anatomy 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? 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1037 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 Universal Free E-Book Store 1038 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1039 Figure 23.13: Arterial supply of colon 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). Universal Free E-Book Store 1040 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1041 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. Universal Free E-Book Store 1042 Section 10 Surgical Anatomy 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: Universal Free E-Book Store Chapter 23 Surgical Anatomy 1043 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. Universal Free E-Book Store 1044 Section 10 Surgical Anatomy ANATOMY OF LIVER AND EXTRAHEPATIC BILIARY SYSTEM What is the average weight of liver 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1045 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 Universal Free E-Book Store 1046 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1047 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. Universal Free E-Book Store 1048 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1049 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)? 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). Universal Free E-Book Store 1050 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1051 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 Universal Free E-Book Store 1052 Section 10 Surgical Anatomy 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 Universal Free E-Book Store Chapter 23 Surgical Anatomy 1053 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 Universal Free E-Book Store 1054 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1055 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. Universal Free E-Book Store 1056 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1057 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. Universal Free E-Book Store 1058 Section 10 Surgical Anatomy 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 Universal Free E-Book Store Chapter 23 Surgical Anatomy 1059 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). Universal Free E-Book Store 1060 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1061 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. Universal Free E-Book Store 1062 Section 10 Surgical Anatomy 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: Universal Free E-Book Store Chapter 23 Surgical Anatomy 1063 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. Universal Free E-Book Store 1064 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1065 • 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 Universal Free E-Book Store 1066 Section 10 Surgical Anatomy 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 Universal Free E-Book Store Chapter 23 Surgical Anatomy 1067 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. Universal Free E-Book Store 1068 Section 10 Surgical Anatomy 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 Universal Free E-Book Store Chapter 23 Surgical Anatomy 1069 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. Universal Free E-Book Store 1070 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1071 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 Universal Free E-Book Store 1072 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1073 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. Universal Free E-Book Store 1074 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1075 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 Universal Free E-Book Store 1076 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1077 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 Universal Free E-Book Store 1078 Section 10 Surgical Anatomy 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). Universal Free E-Book Store Chapter 23 Surgical Anatomy 1079 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. Universal Free E-Book Store 1080 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1081 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. Universal Free E-Book Store 1082 Section 10 Surgical Anatomy 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 Universal Free E-Book Store Chapter 23 Surgical Anatomy 1083 • 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. Universal Free E-Book Store 1084 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1085 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. Universal Free E-Book Store 1086 Section 10 Surgical Anatomy 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 Universal Free E-Book Store Chapter 23 Surgical Anatomy 1087 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. Universal Free E-Book Store 1088 Section 10 Surgical Anatomy 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. Universal Free E-Book Store Chapter 23 Surgical Anatomy 1089 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. Universal Free E-Book Store 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 Universal Free E-Book Store 1092 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 Universal Free E-Book Store 1093 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 Universal Free E-Book Store 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 Bedside Clinics in Surgery Universal Free E-Book Store 1095 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 Universal Free E-Book Store 1096 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 1104 Bedside Clinics in Surgery 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 Universal Free E-Book Store Index 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 Universal Free E-Book Store 1106 Bedside Clinics in Surgery 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 Universal Free E-Book Store Index 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 Universal Free E-Book Store 1108 Bedside Clinics in Surgery 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 Universal Free E-Book Store Index 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 Universal Free E-Book Store 1110 Bedside Clinics in Surgery 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 Universal Free E-Book Store Index 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store 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 Universal Free E-Book Store “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 Universal Free E-Book Store