Surgery

- Dr. Risheek Gupta

Kindly report any errors @Gup2000109

or in BTR group chat
Nerve Injuries ILN injured in Pyriformis fossa

-Breast surgery axilla clearance- Inter-costo-brachial trunk # T2 Apex of axilla 2 axilla

T4 Nipples T2 x 2 nipples= T4
-Thyroid surgery- ELN>SLN>RLN [ILN doesn’t injure in thyroid Sx]
T6 Xiphoid process T-siX
-Parotid surgery- a) Deviation of angle- Marginal mandibular nerve T10 Umbilicus Umbilicus is round
like 0
b) Anaesthesia at angle- Great auricular nerve(C2-C3) Submandibular injury d/t T12 Inguinal ligament
Sialolithiasis surgery/
c) Frey- Auriculotemporal nerve(gustatory sweating) Wharton duct involvement
- Lingual nerve
-Submandibular surgery- Marginal mandibular nerve
-Hernia surgery-
a) Loss of sensation over lateral thigh Lat. cut. n. of thigh(MC n. # in Lap.
Hernia Sx)
b) Loss of sensation over suprapubic region Iliohypogastric n.
(Mesh entrapment assd. #)
c) Loss of sensation over root of penis Ilio-inguinal n.(MC # in Open hernia
(Vowels stick together) repair)
d) Loss of Cremasteric reflex Genito-femoral n.(both afferent & efferent of reflex)
-Thymectomy Phrenic nerve Retrograde ejaculation
Lateral Cut. N. of Thigh #
-Rectal Ca Surgeries (IMA ligation)Superior hypogastric plexus # (Sympathetic • Meralgia paraesthetica
• Hernia surgery(MC in Lap. Hernia Sx)
-Pelvic dissection Nervi-erigentes #(leads to Impotence) fibre) • Extreme lithotomy/McRobert’s position
during management of Shoulder dystocia
SUTURES Monofilament : weaker but lesser r/o infection
Polyfilament : stronger but higher r/o infection

Absorbable Non - Absorbable

Mechanism:
Hydrolysis

Synthetic Natural Synthetic Natural

SILK
Monocryl: CATGUT
Nylon-Polyamide/ Ethilon
Polygycaparone

PDS: Polydiaxonone Microsurgical suture

Prolene – Polypropylene

Vicryl: Polygalactin
Novafil - Polybutester

Dexon: Polyglycolic acid Polyester- Ethibond

 Everted edges desired in skin sutures
SUTURES Inverted edges desired in bowel sutures
Purse string sutures
Simple continuous suture RECTAL PROLAPSE
Perineal-TAD bit too easy
Thiersche cerclage
Altemier’s procedure
Simple interrupted sutures Delorme procedure
Abdominal-
• Cervical incompetence Ripstein rectopexy
• Herniotomy for Congenital
hydrocele Wells
• Rectal prolapse

JENKIN’S RULE:
Subcuticular sutures Length Of Suture Should Be 4 Times The Length Of Wound
Angle Of Entry Of Suture Needle, IM injection: 90
Verees Needle Angle, SC Injection: 45
Horizontal mattress suture
ID injection:10-15
Verees needle(Bevelled margins to reduce trauma) : Pneumoperitoneum creation
CO2 MC used for insuffalation because : for Lap. Sx
Vertical mattress sutures CO2 :
• soluble in blood(no risk of air embolism)
15-20mmHg • Non-combustible(cautery can be used safely)
pressure, Only theoretical risk of hypercarbia therefore avoided in
<2L volume
COPD patients(use Room air/Helium/N2O)
*Peritoneal stretching d/t CO2 may lead to bradycardia via J-reflex
INSTRUMENTS
Blade number :
10. 11. 12. 15.

Bard-
Parker
handle Granny’s
Square/Reef
Surgeon’s knot knot(slips,
Skin/muscle I&D Suture Precise incision/ knot(secure
cutting removal minor OT proc
(Secure knot) not secure)
knot)
SUTURE KIT

Hold needle @ junction of post.(Swayed end) Scissors

Needle holder 1/3rd & ant.(pointed end)2/3rd of needle
Short & thick

Mayo
Long & slim

Adson’s tissue Metzenbaum

holdingForceps
FORCEPS
Transverse Transverse striations
striations ~ Single tooth
traumatic + transverse Multiple
striations teeth

Hemostasis
& ARM LSCS
Kocher’s
Kelly’s hemostatic Mixter’s right Allis’ forceps Green armytage
forceps
Artery forceps angled forceps forceps

Longitudinal No lock
Rampley’s striations ~
sponge Atraumatic
Ovum Desjardin’s Mayo’s
Babcock’s holding
Intestinal forceps choledocho- towel
forceps forceps
clamp (for lithotomy clip
RPOC) forceps
RETRACTORS
CZerney’s retractor
Doyen’s
retractor(for
bladder in
LSCS)

Daever’s retractor
Lagenback’s
retractor(narrow Morrison’s retractor Balfour’s self-
blade) (wide blade) retaining retractor
Joll’s thyroid
retractor
8 teeth 6 teeth

Makes a P

Jensen’s retractor Perkin’s retractor

Mollison’s retractor (6 letters)
(8 letters)
Mastoid retractors
 Time of drain removal : A) Thyroidectomy - w/in 24 hrs In sepsis/infections,

BAGS AND DRAINS B) GI anastomosis - 3-5 days

C) T tube - 2-3 weeks
remove drains after
infection subsides

ICD bag/Chest drain bag JP drain

Romovac(thoracic DJ stent
(underwater seal line) (abdominal drain)/
Abdominal Adequacy of tube placement : drain/
Hemovac(larger
drain bag oscillating water column Minivac(smaller
capacity variant) capacity variant)
Excessive bubbling : suspect
Types of drains :
Broncho-pleural fistula
A. Open(gravity & passive drainage)
Pigtail catheter eg. corrugated tube drain
Malecot’s catheter B. Closed :
i) Suctioned : Active drain(negative
pressr. via suction) eg. Romovac/JP
drain
ii) Non-suctioned : passive
drain(capillary action & gravity) eg.
Abscess drainage Kehr’s T tube urinary catheter, NGT
 HEMOSTATIC DEVICES

Linear
stapler(Zenker’s
CUSA(Cavitatory diverticulum)
Ultrasound Surgical
Aspirator)
Monopolar cautery Bipolar cautery • Ligature : pressure
• NS/RL not used • NS/RL can be used induced heat
• Distilled water
coagulation
used(r/o
• Harmonic scalpel :
hyponatremia) Circular stapler
oscillation induced
OR Glycine 1.5% (Hemorrhoids)
heat coagulation
• Blue :
• Thunderbeat :
Coagulates(Blue is
pressure +
glue)
oscillation induced
• Yellow : Cuts
heat coagulation
Surgical safety checklist
Before induction of Before skin incision Before patient leaves
anesthesia operating room OT ZONES
Sign In Time Out Sign Out
Zone 1:
q PATIENT HAS CONFIRMED q CONFIRM ALL TEAM MEMBERS Nurse verbally confirms with the
• IDENTITY HAVE INTRODUCED team: -Protective reception,
• SITE THEMSELVES BY NAME AND waiting, trolley bay, change
• PROCEDURE ROLE q The name of the procedure
• CONSENT recorded rooms
q SITE MARKED/NOT q Surgeon, anesthesia
q That instrument, sponge and Zone 2:
needle counts are correct (or
APPLICABLE professional and nurse verbally
not applicable) -clean area –preoperative,
confirm
• Patient
q How the specimen is labelled recovery, plaster room,
(including patient name)
• Site staff lounges, stores
• Procedure
Zone 3:
q ANAESTHESIA SAFETY Anticipated Critical Events
CHECK COMPLETED -Disposal area –dirty utility,
disposal corridor
q PULSE OXIMETER ON PATIENT Has antibiotic prophylaxis been q Surgeon, anesthesia
AND FUNCTIONING given within the last 60 minutes? professional and nurse review
the key concerns for recovery
DOES PATIENT HAVE A:
and management of this patient
KNOWN ALLERGY?
DIFFICULT AIRWAY? Cefazolin i.v. 30-60
RISK OF >500ML BLOOD LOSS? minutes before incision
Post - Op Fever
Timing Etiology Prevention Mnemonic
Anytime Drug reactions, - Wonder Incentive spirometer
malignant drugs
hyperthermia
POD 1-3 MCC ON D1- Incentive spirometry, Wind
Atelectasis early mobilization
antibiotics
POD 3-4 MCC OVERALL- Shot-term foley use Water
UTI
POD 4-5 Deep venous Early mobilization, Walking
thrombosis LMWH, sequential
compression socks

POD 7+ Surgical site infection Dressing changes, Wound

preoperative antibiotics
 SSI
SSI definition- within 30 days of Surgery/1 yr of implant Southampton wound grading score

BURST ABDOMEN
Day- D6 Salmon colored
Pathognomic sign: serosanguinous
Mx- Bagota bag/Urobag fluid
Laparotomy

Intra-abdominal abscess
MC site: Supine- Hepato Overall/ Ambulatory- Pelvis/
IOC CECT renal POD
TOC Pigtail pouch
drainage
Criterion ASEPSIS score
A Additional Treatment
S Serous discharge
E Erythema
P Purulent exudates
S Separation of deep tissues
I Isolation of bacteria Induration is not a
S Stay in hospital prolonged over 14 days part of the score
Types of surgery
-Gross purulence or existing infection? Class IV-Dirty /Infected
-Perforated viscera˃ 4 hours old? Yes e.g. surgical management of
-Traumatic wound open ˃4 hours? abscess, repair of perforated
-Penetrating injury ˃4 hours old? bowel
NO

-Acute, non-purulent inflammation? Class III- Contaminated

-Unplanned entrance into GI/GU/ respiratory Yes e.g. non –sterile debris in field,
tracts? cholecystectomy with bile spillage
-Major break in sterile technique? or acute inflammation, Open
cardiac massage
NO
Elective

Yes
Controlled/international entry into the GI,GU, Class II- Clean-Contaminated
or respiratory tracts? e.g. hysterectomy, lobectomy,
laryngectomy, small bowel
resection, TURP, LSCS

NO Class I- Clean
e.g. mastectomy, hernia repair,
thyroidectomy, TKR, THR, CABG
 qSOFA score ~ Revised Trauma score(RTS)
White THR(SBP not a component)
SIRS –2 or more +:
Core Temperature ˂36oC or ˃ 38oC
HR >90bpm
RR ˃20/min or Pco2 ˂32 mmHg GCS RR BP
White blood cell count ˃12,000 /μL,
<4000/μL, 10% bands

CO SVR CVP

Cardiogenic

Hypovolemic

Obstructive
Hyperdynamic
Neurogenic shock(spinal) : all parameters decrease
Distributive
SHOCK + WARM EXTREMITIES + MV02 >70%: state
Shock index- HR/SBP Septic shock
Neurogenic
Modified shock index- HR/MAP

-Best clinical indicator of adequacy of resuscitation: Urine output

ADULT: >0.5mL/kg/hr CHILDREN: >1mL/kg/hr INFANTS:>2mL/kg/hr
-Best indicator to estimate fluid required for resuscitation: CVP(Rt. Atrial Pressr.)
-Best lab parameter to monitor tissue perfusion: Lactate/Base deficit
Trauma-Basics
TRIAGE: PRIMARY SURVEY:
Immediate: immediately life-threatening injuries A Airway w/ C-spine stabilisation
Delayed: injuries requiring treatment within 6 hours B Breathing w/ Ventilation
Minimal: walking wounded
Dead C Circulation
D Disability - neurological assessment
Primary survey Identify what
(W/in is killing the patient
6hrs)
ADJUNCTS: E Exposure w/ environmental control
CXR/Pelvic X-ray/eFAST
Field: cABCDE where c = control of
Resuscitation Treat what is killing the patient
haemorrhage/exsanguinating bleed
Secondary survey Identify other possible injuries
CT scan Definitive : oral ET
Definitive care Make a management plan intubation
failure OR C/I to
intubate
eg. maxillofacial #)

Immediate :
Jaw thrust Head tilt- Cricothyroidotomy

f
Definitive :
C-spine # Chin lift Tracheostomy
CHEST TRAUMA
Flail chest not included
Triage level : RED

TENSION MASSIVE CONSOLIDATION / CARDIAC

PNEUMOTHORAX HEMOTHORAX CONTUSION TAMPONADE

TYPE OF SHOCK
Obstructive Hypovolemic - Obstructive
JVD Increase Decrease Normal Increase
TRACHEAL SHIFT
C/L C/L No shift No shift
BREATH SOUNDS /
VOCAL FREMITUS
Decrease Decrease Increase Normal
PERCUSSION
Hyper-resonant Dull Dull Dull(Ewart sign)
HEART SOUNDS Normal Normal Normal Muffled
Beck’s triad of CT : Muffled
heart sounds + Raised JVP +
Obstructive shock
Management of Cardiac tamponade: Emergency Pericardiocentesis f/b Thoracotomy
 Triangle of safety : P.major(ant.), Insert tube along Upper border of Lower rib as

CHEST TRAUMA Latissimus dorsi (post.) & 5th ICS(floor) with

axillary apex as apex
neurovascular bundle is present around lower
border of upper rib
Inferior rib notching seen in Coarctation of aorta(Rosler’s sign)

Air fluid levels

in a spherical
cavity : Lung
abscess

Seashore sign ~ Normal

M-mode USG

Air fluid levels in Xray : Diaphragm injury :

Haemothorax Pneumothorax Hydropneumothorax fundal air bubble in
A. Stable/unstable A. Stable managed by ICD Managed by ICD(no role thorax
managed by ICD in triangle of safety of needle ICD is C/I
B. No role of Needle B. Unstable(Tension) decompression )
placement managed by Needle f/b ICD Barcode/Stratosphere
sign ~ Ptx
Indications of Thoracotomy MC in Penetrating trauma
-IOC:Diagnostic laparoscopy > CECT
-Mx: Surgical repair
-Triad:Bergiust triad : Diaphragm #
+ rib # + spine/pelvis #
Shock
Parameter Class I Class II Class III Class IV
(Mild) (Moderate) (Severe)
Blood loss ˂15% 15-30% 31-40% ˃40%
<500mL 500-1000mL 1500-2000mL >2000mL
Heart rate ↔ ↑ ↑ ↑↑
Blood pressure ↔ ↔ ↓ ↓
Pulse pressure ↔ ↓ ↓ ↓
Respiratory rate ↔ ↔ ↑ ↑
Urine output ↔ ↔ ↓ ↓↓ Tranexamic acid
Glasgow coma ↔ ↔ ↓ ↓
scale score
Base deficit* 0 to -2mEq/L -2 to -6mEq/L -6 to -10 m Eq/L -10mEq/L or
less
Need for blood Monitor Possible Yes Massive Any pt. with
products Transfusion SBP < 110
OR
HR > 110

Mx of hypovolemic patients in shock (ATLS):

Min Cannula- 18G Fluid type- Isotonic Fluid volume- 1Ltr. prewarmed bolus(if
(green) crystalloid <40kgs then 20mL/kg)
 DAMAGE CONTROL SURGERY

• Primary Emergency Surgery

Metabolic Acidosis • Hemostasis Drainage of septic contamination
Stage
(pH<7.2) • Temporary abdominal closure
I
• (Bogota Bag, skin closure, Negative Pressure
Abdominal Closure Covers)

Trauma Stage • Resuscitation and ICU care: 24-48 hours

triad of II
death
Coagulopathy Hypothermia • Definitive Surgery
(<35 C) Stage • Full gastrointestinal repair
III • (Resection, Anastomosis, abdominal closure –
temporary or permanent )

• Abdominal Closure
Stage
• Patients on whom abdominal closure was not
IV
performed during definitive surgery
 ABDOMINAL TRAUMA

Subxiphoid SR pouch

eFAST +ve Seatbelt injury :

Free fluid in peritoneal space a. Mesenteric injury
Thorax b. Chance #
HR/ Morrison pouch Pelvis

-MC organ injured in BTA: Spleen

-MC organ injured in PTA: Liver > Stomach
-MC organ injured in GSW: Small intestine
-Kehr sign Left shoulder tip pain - splenic #
-Balance sign Dull note in LUQ - splenic #
eFAST: Extended Focused Assessment Sonography in Trauma
Sensitivity: ~100mL
LIMITATIONS: Retroperitoneal hematoma, Meseteric-bowel injury
ABDOMINAL TRAUMA
BLUNT TRAUMA

Unstable Stable
eFAST eFAST

Explorative Laparotomy CECT Observe

IOC : to localise injury
Grade : AAST

PENETRATING TRAUMA

-Unstable Local exploration Stable

-Gunshot (if stab wound)
-Peritoneal breach eFAST
-Impaled object
-Bleeding via orifice
-Evisceration Take to OT
CECT
 RP TRAUMA
Zones Contents Management
Zone I Central vascular structures Exploration
such as aorta and IVC Left medial visceral rotation:
Mattox Visualise Aorta
Right medial visceral:Visualise
Kocher’s/ Cattle Brasch IVC
Zone II Kidneys and adrenal glands Observation

Zone III Retroperitoneum associated External pelvic compression

with pelvic vasculature and fixation
Binder/Bedsheets
Zone IV Retro hepatic IVC and Observation
hematoma behind portal
vein
Sustained ACP >20mmHg w/ new onset MODS is ACS
Abdominal compartment pressure > 30mmHg =
indication of fasciotomy
Abdominal compartment IOC: Intravesical pressure
Anuria: Decompression
GU Trauma
AAST
-IOC for renal trauma in stable: CT Urography • Grade I: Subcapsular hematoma or contusion
-IOC for renal trauma in unstable: Single shot IVP • Grade II
-IOC for bladder injury: CT Cystography o Superficial laceration ≤1 cm depth not involving the collecting
-IOC for urethral injury:Retrograde Urethrogram(RGU) system
o Perirenal hematoma confined within the fascia

Mgt. : • Grade III

o Laceration >1 cm not involving the collecting system
Surgery o Vascular injury or active bleeding confined within the perirenal
fascia

• Grade IV
o Laceration involving the collecting system with urinary
Mgt. : extravasation Leaking
Foley’s contrast Urinoma +ve
catheter

o Vascular injury to segmental renal artery or vein

o Segmental infractions without associated active bleeding
o Active bleeding extending beyond the perirenal fascia

Dome rupture o Grade V

o Shattered kidney
Intraperitoneal Extraperitoneal
o Avulsion of renal hilum or laceration of the main renal artery or
bladder rupture bladder rupture(MC) vein: Devascularised kidney with active bleeding
 Distal urethral rupture : Straddle # - Penile/Bulbar Urethra #
URETHRAL TRAUMA Proximal urethral rupture : Pelvic # - Membranous/Prostatic urethra #

C/F: Inability to void + High riding prostate

on DRE(not done
+ nowadays d/t r/o
Bloods at meatus aggravating trauma)

Wait & watch if bladder

IOC: RGU not palpable for SPC

Normal RGU
Thigh(only up to Holden’s line if at all)

Supra-pubic Cystostomy(SPC) Q. A 14 year old boy presents to

the ED after a straddle injury
and rupture of bulbar urethra.
Delayed Extravasated urine can be seen
Urethroplasty in:
(after 4-6 wks) a) Scrotum
Buccal mucosal graft b) Thigh
c) Ischiorectal fossa
d) Deep perineal space
Bulbar Urethral rupture
 HEAD TRAUMA NCCT is IOC for head trauma except DAI(IOC : MRI)
Alcoholic-fall H/o RTA H/o RTA H/o RTA, GCS-9
Intraparenchymal
Star of death
Microbleeds : Blooming pattern
bleed/Contusion d/t
coup-countercoup #

Acute SDH Acute EDH Acute SAH Gold std. - DSA Diffusely Axonal
Thunderclap headache Injury
(Worst headache of life)
• Bridging veins • Artery Ant. div. of • Trauma> Aneurysm • NCCT Normal/
IOC : CTA
• Trivial trauma • RTA MMA • MC site: petechial
Circle of Willis TOC : Endovasvular
• Sutures: Can cross • Sutures: X hemorrhage
• Midline X • Midline Can cross ACA - ACOM jn. Coiling • IOC: MRI/SWI
Adam’s classification:
1 - GM-WM 2 - Corpus callosum
3 - Brainstem
HEAD TRAUMA
Transtentorial herniation

Base of
mandible

MC injured
Most accessible

Cricoid

Suprasternal
notch
3rd CN # Mount Fuji sign Max. mortality
Chronic SDH EDH
Tension
Swirl sign pneumocephalus
Active bleed is an
indication of I/L dilated pupil Penetrating neck trauma = Breach of platysma
Decompression using (Hutchinson pupil) • Expanding or pulsatile hematoma
Craniectomy/Burr • Active bleeding
I/L hemiplegia(d/t
• Shock
hole compression of C/L • Airway compromise
crus cerebri(false • Massive subcutaneous emphysema
localising sign) • Neurologic deficit
• ZONE 2
 TRAUMA SCORES
E4V5M6 Mangled Extremity Severity Score (MESS) ELISA
Type Characteristic Injury Point
Energy of injury s
1 Low energy Stab wound, simple closed fx, small-caliber 1
GSW
2 Medium
3 energy Open/multilevel fx, dislocation, moderate 2
4 High energy crush shotgun, high-velocity GSW 3
Massive crush 4
Logging, railroad, oil rig accidents
Shock Group Shock
Decerebrate 1 Normotensive BP stable 0
Transiently
Decorticate 2 Hypotensive BP unstable in field but responsive to fluid 1
Prolonged SBP ˂90mmHg in field and responsive to IV
3 hypotension fluids
2
In OR
Ischemia Group Limb Ischaemia
1 None Pulsatile, no signs of ischemia 1
Always score the better response 2 Mild Diminished pulses without signs of ischemia 2
No Doppler able pulse, sluggish cap refill,
3 Moderate Paresthesia, diminished motor activity 3

Max score : 15 GCS - P : Max score - 15 4 Advanced Pulseless, cool, paralyzed, numb without cap 4
refill
Min score : 3 Min score - 1 Age Group Age
Intubated patient : VNT(non-testable) 1 ˂30y/0 0
2 ˃30 ˂ 50 1
 BURNS
Depth Histology Appearance Sensation Healing
Fist-degree Epidermis only Erythema; blanches with Intact; 3-6 days without scarring
pressure mild to KEEP OPEN
moderate pain
Second degree
Superficial Epidermis and superficial Erythema, Blisters, moist, Intact; 1-3 weeks without scarring
dermis; skin appendages intact blanches with pressure severe pain DRESSING: Paraffin dressing
Deep Epidermis and most dermis; White, dry, waxy, reduced Decreased; ＞3 weeks, Scarring and
most skin appendages blanching to pressure less painful contractures
destroyed Hydrocolloid/ Collagen
dressing retains moisture
EXCISION AND GRAFTING
Third – Epidermis and all of dermis; White, charred, dry and Anesthetic; Does not heal;
degree destruction of all skin leathery; does not blanch not painful severe scarring and
appendages contractures
ESCHAROTOMY
EXCISION AND GRAFTING

MCC of death in burns: IV Fluids Latest ATLS:

-Immediate: Asphyxia > Neurgenic Fluid of choice in adults- R/L Adults: 2mL x wt. x %TBSA
-Early: Hypovolemic shock shock Fluid of choice in children- R/L + 5% <14yr: 3mL x wt. x % TBSA
-Late/ Overall: Sepsis Time: dextrose Electrical injury:4mL x wt. x %TBSA
-Organism: Pseudomonas 1/2 - 8hrs 1/2 - 16hrs Increased r/o Rhabdomyolysis
From time of burn
 Lund & Browder’s chart - Most accurate
Rule of 9-MANAGEMENT Berkley’s chart

Silver sulfadiazine: active against Pseudomonas but decreased

18% penetration
9% Silver nitrate: active against Pseudomonas, black
discolouration
18% 18% Mafenide acetate Causes metab. acidosis
9% 9% 9% 9% Cerium nitrate Best option(increases CMI)
18%
18%
1%
Cooling burn- NOT ICE
14% 14%
Effective upto: 1 hr
18% 18%
Ideal temp: 15 C

Adults Child FROSTBITE COOLING: Gradual rewarming(40-42 C)

Jackson’s staging

Laryngeal edema
Soot
Singed hair

Reduced perfusion
Immediate intubation

Increased perfusion
THYROID
-MC associated with RT, TGC: Papillary Ca
-Most common, Best prognosis, Lymphatic mets:
-Hematogenous mets:
Follicular Ca
-MC in iodine deficient areas, MNG:
-MC in MEN2 (RET point mutation): Medullary Thy. Ca Lahey’s Gille’s method
Pizillo’s
-RET/PTC (t 10;17): Papillary Ca method method
-RAS GOF, PAX8-PPARG(t2;3): Follicular Ca
-Worst prognosis: Anaplastic Ca
-GNAS mutation: Toxic nodular goitre
-Wolf chaikoff: Iodine induced Hypothyroidism
-Jod Basedow: Iodine induced Hyperthyroidism Pemberton method Berry’s test
(SVC syndrome OR Mediastinal CCA
invasion of thyroid)
Thyroglossal cyst
MC location: Infrahyoid
Management: Sistrunk procedure
 Thyroid Eye signs
Stellwag sign (STAREwag sign)

No creases on
Joffroy sign Joffrey’s head)

Orphan Annie eye Eosinophilic extracellular

nuclei amyloid Superior eye folds जल
Coffee bean nuclei A-Calcitonin Jellnick sign (जल-nick) के hyperpigmented
Psammoma bodies Medullary Thy. Ca
Papillary Ca Thyroid cancer w/ assd.
Diarrhoea(d/t 5HT), CEA+ve Hurt-hoge then lat. eyebrows are lost
Hertoge sign

का DaKo(डाकू)
Dalrymple sign UP
Retracted(Retarded)

Von Graffe sign

Granuloma Möbius sign
DeQuervian’s Thyroiditis Black thyroid d/t Kocher’s sign :upper lid retraction on fix gaze
Painful gland + h/o URTI Minocycline Enroth/Vigoroux sign : Eyelid swelling
(VS Lymphocytic Eyes swell Gifford sign : difficulty everting upper lid
Thyroiditis - painless) Vigorously when
Abadie sign : LPS spasm with lid retraction A-BADdIE’s LiPS spasm
EnRAGEd
Graves Disease LATS/TSI +ve

Thyroid Eye ds
Coca-cola sign
IMSLOw
IR MR SR LR s/iO
Sequence of involvement

No coca-cola sign in
orbital pseudotumour
Beefy Red/Pink Scalloping of Pachydermo- Pretibial
OR colloid periostitis a.k.a myxedema Class 0: No signs or symptoms
Angry Thyroid Acropachy (GAGs Class 1: Only signs (lid retraction, stare ±lid lag)
NOSPECS
deposited) Class 2: Soft tissue involvement Classification of
Management of Graves Class 3: Proptosis Thyroid
Ophthalmopathy
Class 4: Extraocular muscle involvement
RADIO-IODINE DRUGS SURGERY
Class 5: Corneal involvement
ABLATION I-131 Pregnancy : Severe TED
Class 6: Sight loss (optic nerve involvement)
Mainstay(B+r) PTU in T1 (Decompression Sx)
C/I : pregnancy, Methimazole in Thyroid hormone: Osteopenia
severe TED T2/3 High Osteoclast- High resorption
S/Es :
PTU : Agranulocytosis
Methimazole : Agranulocytosis, Choanal atresia, Cutis aplasia
APPROACH TO STN

TSH LOW TSH HIGH

RADIOLOGICAL IOC:

IOC:
FNAC can’t distinguish Follicular
Bethesda grading adenoma from carcinoma(IOC :
Thyroiditis OR Factitious Cant distinguish: Surgical biopsy)
hyperthyroidism/
Exogenous thyroid OR
Struma Ovarii
(Diffusely low uptake)
THYROID SURGERY
(1 lobe +
Baehr’s triangle:Max. r/o Upward extension prevented by: -Hemithyroidectomy: isthmus
CCA-ITA-RLN RLN # Sternothyroid & Sternohyoid muscles resected)
(4 gms tissue
Downward extension into -Subtotal: left in each lobe)
Triangle of concern: ITA # mediastinum is prevented by:
Berry ligament-RLN-Trachea Ligament of Berry -Near total: (4 gms tissue
Thyroid moves during deglutition: left in 1 lobe)
Pretracheal fascia

Chvostek sign Trosseau’s sign(obstetrician’s hand)

COMPLICATIONS HypoCalcemia d/t
PTH adenoma : MCC of MCC- ITA # ass. Necrosis HypoPTH
MACIS : Completeness of surgery C/F time- 48-72 hrs
Post-op score hypercalcemia
IOC : SPECT > Tc99
Inability to extubate- B/L RLN #
Sestamibi
MCC of intra-op thyroid storm:
MIAMI CRITERIA: >50% decline in 10minutes Inadequate patient preparation
MCC of hypercalcemia in hospitalized patient: Malignancy
MEN
Inheritance Gene Manifestations
Prophylactic
thyroidectomy:
MEN 1 = 1. Pituitary adenoma(MC Prolactinoma)
AD Menin MEN2A : 5 years
Wermer 2. Parathyroid hyperplasia > adenoma
Chr 11 MEN2B/3 : 1 year
3. Pancreatic neoplasm(Gastrinoma MC)
MEN2a= 1. Parathyroid adenoma
Sipple RET
AD 2. Medullary thyroid cancer
Chr 10
3. Pheochromocytoma
MEN2b=3 1. MTC 4. Mucosal neuroma
RET 2. Pheo 5. Megacolon
AD Chr 10 3. Marfanoid 6. Medullated
habitus corneal n. fibre
Non - > Insulinoma Passaro’s triangle :
MC Pancreatic NET:
functional jn. of D2-D3, Jn. of CHD & Cystic
MC NET in MEN1: Gastrinoma
Refractory ulcers, Diarrhea, ZES duct & Jn. Of Head & neck of pancreas
IOC :DOTANOC PET scan(Somatostatin Rc)
Most Panc.NETs lie in this triangle. NETs
of MEN syndrome however mostly present
outside this triangle & have poorer prognosis
 Surgery
— Dr. Risheek Gupta

Kindly DM any corrections on

telegram @Gup2000109
BREAST 00:00:20

Screening- Annual mammography(starting @ >=40 yrs) Intralobular stroma -MED12 mutation

High-risk/ BRCA +/ RT : >25 yrs - MRI
Diagnosis of lump in young / lactating female: USG
Solid Vs Cystic
Ca breast quadrant: MC in UOQ
MC gene mutation in sporadic/TNBC: p53 Genes on Chr 17
i)p53
ii)BRCA1
MC gene in familial breast ca: BRCA1 iii)NF1

Ca breast in men: BRCA2 Linguini sign of Popcorn calcification Phyllodes tumour

inntracapsular
implant rupture Fibroadenoma a.k.a X LN involvement, High r/o
IOC for breast implants- MRI Genes on Chr 13
i) RB
breast mouse recurrence
Most sensitive for DCIS- MRI ii) BRCA2
iii) ATP7B Rx: Simple mastectomy
Most sensitive for microcalcifications- Mammography
Cranio-caudal view Media-Lateral “Breast in breast”
Oblique view Hamartoma
More breast
Fibroadenolipoma
tissue
visualised
Axilla can be
seen
BIRADS
BIRADS Category % risk of Further
cancer management Triple assessment: Clinical + Radiological + HPE
Additional BIRADS:Breast Imaging Reporting And Data System
0 Incomplete N/A investigations to Modalities: USG/MRI/Mammography
assessment complete assessment
1 Normal 0 Screening
2 Benign 0 Screening
3 Probably benign 0-2% F/U @ 6months
4 Suspicious for
malignancy 2-10%
4a
Low suspicion
4b 10-50%
Biopsy Cluster Spiculated margins
Moderate Microcalcifications
4c suspicion 50-95%
Signs of Ca Breast
High suspicion
5 Highly suggestive >95% Biopsy
of malignancy
Core biopsy needle
6 Known biopsy N/A Continue as
proven
(14G ideal)
malignancy going
Staging CA breast
T2 : 2-5cms

T4d :
Inflammatory
Breast Ca.,
T4a: Chest wall T4c : both >1/3 LVSI &
#(Intercostal, T4b : skin #(Peau d’orange, skin & chest skin #
Serratus Ulceration, Satellite lesions wall #
T3 : >5cms Worst prognosis
anterior,Ribs. a.k.a PUS)
T1 : <2cms
Doesn’t include
pectoralis
involvement

Peau d’orange : involvement of Retraction - Lactiferous duct #

subdermal lymphatics giving Dimpling - Ligament of Cooper #
orange peel appearance
Dimpling & Nipple retraction
are not included in skin
involvement
Molecular classification IHC : DAB(Diamino-benzidine)

Luminal HER2 TNBC

(ER+, PR+) (HER2+) (ER-, HER2-)
Allred score CK5/6/EGFR +:Basal type
EMT+: Claudin - low
High Ki67 ~ >14%
Ki67:Low Ki67: High Ki67: High Ki67: High
HER2 - HER 2 -/ +
Luminal A Luminal B Metaplastic variant
MC; Best Medullary variant
Young females. Poor prognosis
prognosis
but best pathological response

Luminal A : Upon IHC : 0/1+ = -ve

Papillary variant 2+ = Unequivocal —> perform FISH
Tubular variant 3+ = +ve
Mucinous variant
BREAST CA MANAGEMENT
Methylene blue
Early: Anything else than LABC MRM/BCS BCS CI:
LABC: T3N1 or T4 or N2/N3 NACT f/b MRM f/b RT 1. Pregnancy
2. Prior RT to CW
Chemotherapy: LABC or LN or TNBC 3. Collagen vascular
X Lapatinib diseases
Her2neu +:Trastuzumab(S/E : Cardiotoxic)
Radiotherapy: LABC or LN + Sentinel LN Biopsy 4. Multicentric >
BCS Always f/u with RT Clinical node -ve + BCS Multifocal
Hormonal treatment: ER/PR +ve 5. Lobular ca
Premenopausal:Tamoxifen[S/E : Cystic endometrial hyperplasia] 6. LABC
Postmenopausal: Letrozole[(Aromatase inhibitor) S/E : Osteoporosis]

MRM Preserve: Axillary vein,

MC complication: Seroma Bell’s nerve, Cephalic vein,
Dorsal thoracodorsal N

Auchinclaus Scanlon Patey Same quadrant, Multiple lesions =

Retract Incise Remove Multifocal
Different quadrant, single lesions =
Multicentric
 BREAST HIGH-YIELD Van Nuys Grading(GAMS)
PREFIXES:
c- Clinical
p- Pathological
r- Recurrent
y- Neoadjuvant
m- Multifocal
a- Autopsy
Lympedema untreated
Lymphangiosarcoma Doesn’t include ER/PR status
(w/in weeks) k.a. Stuart Treves Most important prognostic factor: LN
syndrome To determine use of ChemoTh. FLAPS: DIEP: Ideal (Deep inferior epigastric vessel)
MOLECULAR TESTS: TRAP: MC used but high abd. wall
NIPPLE DISCHARGE: T1/T2 N0 LUMINAL A morbidity (Superior epigastric artery)
Oncotype Dx: 21
Mammaprint: 70
Endopredict: 12
PAM 50: 50
Ca Breast CAN assist:Indian

Smoking: Mondor’s disease, Duct ectasia, Ca breast

Nulliparity, Early menarche, Late menopause

Duct Papilloma Duct ectasia
OCP? Hyperestrogenic conditions are R/F
(Rx : Microdochectomy) Rx: Hadfield’s proc.
 VASCULAR INJURY 00:31:10

Mediastinal
widening(>8cm)

Yin-Yang sign
on USG Doppler
Aortic dissection
R/F : HTN(MC), CTD
Lt. Hemothorax Aneurysm of Arch of Aorta IOC in stable : CTA
IOC in unstable : TEE

MC vessel- Circle of Willis

MC extracranial/ MC Mycotic- Abdominal aorta
MC peripheral- Popliteal
AORTIC INJURY IOC: CTA
-MC site: Isthmus Management: AAA Atherosclerosis MC
-IOC: CTA Indication: Marfan’s >4.5 cm
-Initial Mx: Beta blockers • symptomatic/signs of rupture Medical mgt w/
HR <80, MAP:70mm Hg • Asymptomatic w/ size >5.5cm or rapidly surgical mgt
i.v. Esmolol

-Definitive Mx: EVAR + graft growing(6mm in 6m OR >1cm in 1yr) Stanford

DeBakey
Aortic occlusion
ACUTE: MC d/t embolus esp. d/t R/Fs like CHRONIC
A.Fib
Source- 6Ps Intermittent claudication
1.Pain Boyd classification
2.Pulselessness ABI INTERPRETATION
3.Pallor >1.4 Heavily Calcified
4.Paralysis
0.9-1.3 Normal
5.Paresthesia
6.Poikilothermia
0.5-0.9 Intermittent
0.3-0.5 Rest pain
Fogarty’s cathter <0.3 Critical Limb Ischaemia
Pain on 1ststep: Osteoarthritis (gangrene)
Lumbar canal stenosis Neurogenic
claudication
C/F:
Buttock pain +
Aorto-iliac- impotence
SYNDROME: Leriche Normal triphasic Doppler
flow in an artery
Iliac- Thigh *Triphasic EEG waveform :
Balloon angioplasty Femoral- Calf(MC) Hepatic encephalopathy

Popliteal- Foot

Initial Ix- Doppler USG

Cirsoid aneurysm IOC- CTA
(AVF of Supf. Temporal art.) Gold standard- DSA
 VARICOSE VEINS/ DVT IOC: Doppler
Brodie tredelenburg
A A
Morrissey SFJ incompetence
Schwartz V Monophasic
Fegan Perforator incompetence
Pratt/ Perthes DVT
Mickey Mouse
sign E : etiological; A : anatomical; P : pathophysiological NORMAL DVT
VEIN
CEAP classification of Varicose veins
C1 Telangiectasias or reticular veins COMPRESSIBILITY Present Absent
C2 Varicose veins
C2r FLOW Monophasic Absent
Recurrent varicose veins
C3 Edema 3 is E
C4 Changes in skin and subcutaneous SFJ incompetence: EVLA > RFA
tissue Peforator:Tessari sclerotherapy technique
C4a Pigmentation or eczema Nerve injury: GSV- Saphenous nerve(medial)
SSV- Sural nerve
C4b Lipodermatosclerosis or atrophie
Corona phlebectasia
blanche b : बड़ा नाम/big name) Sertrol(1) + Air(3)
C4c Corona phlebectatica Sclerotherapy
C5 Healed
C6 Active venous ulcer Lipodermatosclerosis
C6r Recurrent active venous ulcer
Active venous ulcer
APPROACH TO ULCERS:
Tip of toes, lateral malleolus, thin and shiny skin
Arterial ulcer
Stemmer’s sign
Gaiters area-medial malleolus, sloping edge
Bisgaard regimen Venous ulcer

Ischium/GT, Pressure >30mm Bed sore, 2hrly change Charles proc.

Plantar aspect of foot, loss of sensationNeuropathic ulcer Lymphedema

Brunner’s Classification

Arterial ulcer Neuropathic Vacuum assisted

ulcer dressing(VAC)
-125mmHg Grade 1: Non-blanchable erythema of intact skin
Grade 2: Partial thickness skin loss
Grade 3: Full thickness skin loss
Grade 4: Damage to muscle, bone
Bed Sores
 MEDIASTINAL MASSES 00:00:20

FAT -ve HU
Calcium +ve HU Dumbbell sign

Thymoma(MC) Teratoma Neurogenic tumour

Anterior mediastinal masses : 4Ts MC : Posterior mediastinum
1. Teratoma
2. Thyroid mass
3. Thymoma
Myasthenia gravis
PRCA 4. Terrible Lymphoma

Good’s syndrome
(Hypogammaglobulinemia)
UROLOGY-URINE CRYSTALS 00:00:20

Rhomboid crystals Calcium Calcium oxalate Coffin lid shape Cystine(not Leucine stone
Uric acid oxalate monohydrate Triple phosphate cysteine) Lamellated
Acidic pH dihydrate Dumbbell shaped stones crystals crystal
Rx : urine Envelope (MONa is (Mg + NH4 + Hexagonal,
alkalinisation shaped DUMB) PO4) very hard
Very hard stones Forms struvite Cystinuria
MC variety
Acidic pH stones or (COLA Tin)
Acidic pH
staghorn calculi
Alkaline
pH(proteus
infected urine) Cystinuria - COLA
found in urine
• Cystine
• Ornithine
• Lysine
• Arginine
 Obstructive symptoms

Normal >15mL/s

Urodynamic study for

neurogenic bladder
Uroflowmetry

Whitaker test: Renal/Bladder pressure Complications of Duplicated Collecting Weight Meyer Law in a
Hydronephrosis system duplicated collecting
Upper moiety : system(Drooping Lily/
• obstruction Water Lily sign)
*Not to be confused
• Inferomedial placement to trigone with Water Lily sign
• Ectopic ureter of Hydatid

• Ureterocoele

Lower moiety :
• VUR
UROLITHIASIS
>2cm PCNL
Infection
Obstruction
Cystine / COM/ brushite

Staghorn calculus

for Lower pole stones

Hyperdense lesion on CT Steinstrasse RIRS Retrograde Intra -
ESWL Renal SX
(Stone street)
Initial Investigation:USG/Xray
IOC: NCCT/CT urography <2cm soft stones
Partial vs complete CI: Pregnancy, infection,
obstruction: Di-ureteric DTPA scan obstruction, bleeding diathesis,
pacemaker, obese, children
Radiolucent calculi: C/I to ESWL
Struvite / Uric acid / Xanthine /
Orotic acid/ Indinavir
 Based on 2 most common
PROSTATE PSA 3- 10: BPH, Cancer, Prostatitis
PSA > 10: Highly suggestive of Cancer pathological patterns on HPE

TZ: BPH CA PROSTATE

PZ: AdenoCa prostate "PAP" Initial: PSA > 10 + TRUS
IOC : MRI (PIRADS)
Perineural PMSA PET for. Metastasis
invasion
1. Prostate Ca GOLD STANDARD- TRUS guided biopsy
2. Adenoid No. of cores- 12 (sextant based)
cystic
max. tumour
TURP
glands 3. Pancreas DISTAL LIMIT- Verumontanum
Ca MC complication- Retrograde ejaculation
TURP syndrome- Hyponatremia causing
altered sensorium d/t distilled
water for monopolar cautery

T1/ T2: Confined to prostate

<10yr survival, PSA<10,Gleason <6: Active surveillance
>10yr survival: Radical prostatectomy

T3/T4: Capsular invasion / Adjacent organ invasion

Androgen ablation +/- RT : Palladium / Gold/ Cs Gleason grade group 3 is more severe than group 2
GnRH agonist continuous: Goserelin/Leuprolide
Flutamide
Orchidectomy
TESTES IOC for Torsion & Epididymo-
orchitis : Doppler HAL
Painless testicular mass
HAL Bag of worms
appearance of testis :
Varicocoele
MC- Seminoma (Pampiniform plexus
Initial- scrotal USG + tumour markers dilation)
Contraindicated due to risk of seeding and
Biopsy/FNAC? formation of anti-sperm Abs (Immune privilege)
IOC for T staging- High inguinal radical orchidectomy(HIRO)
Chevassu’s maneuver- Frozen section Epididymo-orchitis
Torsion
IOC for RP LN- CECT (Absent blood flow) Normal testis
(increased blood flow due
to inflammation)
Prehn sign :
Seminoma → RT/CT × 1 cycle Pain decreases on lifting :
inflammation
NS-GCT → CT x 1 cycle
Undescended testes
MC site: Superficial inguinal ring
Secondary sexual characters? Normal
Adjuvant IOC: Diagnostic laparoscopy>MRI (Leydig
Time to operate: 6-12m cells
Chemotherapy
B/L non-palpable testes: normal,
f/b RPLND HCG Increase - explore
resistant to
loading test Decrease - anorchia changes in
U/L non-palpable tempr.)
Exploration
 UB AND PENIS
Hypospadias
VS Benzene
CA UB BenziDine(blaDDer) CA PENIS
(Leukemia)
Smoking, Textile dyes:TCC(MC) Bowen's disease (shaft) Premalignant
Stones, Schistosomiasis: Sq. CC Erythroplasia of Queyrat (glans)
Ectopia vesicae, Urachus: AdenoCa Jackson staging
IOC: Cystoscopic biopsy > MRI Moh’s micrographic surgery Anal Ca
Radiological IOC: MRI Excision with 2cm margin Vulval Ca
VIRADS FNAC/ SLNB for inguinal LN Penile Ca
Malakoplakia Papillary Ca Chordee correction
Ta/T1-Till submucosa BCG
Orthoplasty-Urethroplasty->
Cystoscopic excision + contact CT Meatoplasty -> Glanuloplasty-
T2-Superficial muscle Mitomycin-c
> Skin cover
NMP22 Radical cystectomy
OUMG > OUGM
T3/T4-Deep muscle/adjacent
NACT f/b cystectomy
Cutaneous Urinary diversion: Ileal conduit
malakoplakia

Michaelis guttman bodies

 Hernia medial to Inf. Epigastric artery : Direct hernia
HERNIA Hernia lateral to Inf. Epigastric artery : Indirect hernia
Triangle
of DOOM

Inf. epigastric
vessels Lat.
border of
Rectus
Lacunar
ligament
Triangle
of PAIN
Conjoint tendon = roof Hasselbach’s triangle
Int oblique + Transversus abdo: Roof Due to weakness of Corona Mortis(Circle of death) d/t aberrant
conjoint tendon obturator artery(from Inf. Epigastric art.)
External oblique: LIP Direct hernia
Lacunar/Inguinal/Pectineal ligaments Common site for all - direct,
Overall MC hernia in both males & indirect & femoral hernia
Frouschard’s orifice
females : Indirect hernia
But Femoral hernia is MC in females MYOPECTINEAL
ORIFICE:
Girls like BLT sandwich
Conjoint tendon
Femoral: Below and lateral to PT Iliopsoas muscle
Inguinal: Above and medial to PT
Lacunar ligament
 EPONYM

Litter Meckel’s diverticulum

Amyand Appendix
Gibson Hydrocele + hernia
Pantaloon Direct + Indirect
Sliding Sigmoid colon
Richter Part of circumference of bowel + diarrhoea
Oglive Congenital direct hernia
Maydle W shaped contents(necrosis/strangulation of apex)

Hernia mimicking Peptic ulcer: Epigastric(linea alba) hernia

Infraumbilical, above arcuate line: Spigelian hernia

Appropriate mesh for hernia: Low weight, Large pore mesh

Trans-abdominal
pre-peritoneal
approach(TAPP)

Ipom

Total Extra-peritoneal
GI: ESOPHAGUS
15cm Crico-pharynx(narrowest)
Arch of aorta/Left main
25cm bronchus
40cm GE junction

Ca Esophagus Sign:Bird beak sign on Ba swallow

Sign: Diagnosis: Rat tail on Ba swallow Diagnosis: Achalasia cardia(loss of NO & VIP)
IOC: UGIE + Biopsy Eckardt scale Hurst phenomenon
Sudden release of barium
IOC for-T/N staging: EUS IOC:HR manometry into stomach d/t pressure
M staging: PET CT Classification:Chicago in esophagus
Elderly with regurgitation IRP >15mm + No peristalsis
and halitosis Killian’s Esophagectomy Conduit: Stomach(Rt. • 100% failed peristalsis Type 1
Pulsion
dehiscence Gastroepiploic • Pan-esophageal pressurization Type 2
False -McKeown • Spasm Type 3
art.)
TOC: Dohlman’s proc. -Ivor Lewis • DCI> 8000 Nutcracker/Hypercontractile/Jackhammer esophagus
Zenker’s diverticulum -Orringer • Distal latency <4s DES(Corkscrew esophagus)
• Management: Heller’s myotomy OR POEM
 ESOPHAGUS
Normal Seattle protocol: 4 IOC for GERD: 24hr pH monitoring
quadrant at 2cm DeMeester’s score
intervals Management: Fundoplication
Vienna classification 360° Nissen: S/E - Bloating
Barrett’s esophagus 270° anterior Thal / Besley (transthoracic)
Premalignant 270° posterior Toupet
Low grade : surveillance 180–200° anterior Dor
Intermediate : RFA + F/U LINX reflux Mx
High grade : manage Ca
MC @ cricopharynx
Ginkgo leaf sign
MCC of esophageal rupture: Iatrogenic(UGIE)
Boerhave syndrome: Spontaneous; alcoholics;
Triad: lower esophagus
Mackler’ triad
Intestinal columnar metaplasia with Subcut. Emphysema+Chest pain +Vomiting
goblet cells(stains with alcian blue) IOC:
CECt with oral contrast(iohexol>gastrograffin)
Z-line(squamous- Mallory Weiss Tear: Mucosal tear
columnar jn.) Hematemesis
Pulled up in Pneumomediastinum Resolves spontaneously, if not then do UGIE
Barrett’s + subcut. Emphysema
STOMACH TUMORS
Irish: Lt. Axillary LN Indian file pattern
JAPANESE: Early BORMANN:
Virchow / Troiser sign: Lt. Supraclavicular LN Muscle invasion
Sister Mary Joseph: Periumbilical Invasive lobular Ca
Blummer: POD
Krukenberg: Ovarian mets(signet ring cells)
LAUREN: Intestinal/Diffuse - CDH11 - E-Cadherin
DAWSON criteria:GI Lymphoma
Diffuse gastric Ca :Linitis plastica

MC Johnsonn’s
ulcers
Siewart’s classification

Esophageal Ca
Elevated
acid levels Stomach Ca
Optimal
clearance

NSAIDs induced
 Dumping syndrome

Necrotic Early Late

mass
~45 min

Watermelon stomach Dielfouy’s lesion Rx : frequent small

GAVE LGA meals, complex carbs
vascular ectasia

Spindle cells

Interstitial cells of Cajal

Mgt : Surgery. If fails then cKITi
Diagnosis:GIST Menetrier’s disease
Markers: MC - cKIT/CD117 Cerebriform app.
CD34; SDH deficiency; TGF-alpha
PDGFRA; most sp. : DOG1 Fovealar cell hyperplasia
Carney triad: GIST + Protein losing
Chondroma + Paraganglioma enteropathy
Fletcher grading ;CHOI criteria
ACUTE APPENDICITIS

Least common

Umbilicus
2/3 AP diameter> 6mm Caecal bar sign
MC McBurney’s pt. Appendicitis Arrow head app.
ASIS 1/3
McBurney’s point tenderness
Psoas / Cope sign Flexion of hip elicits pain
Rovsing sign LIF palpation —> RIF pain
Initial Ix- USG
IOC- CECT
IOC in pregnancy- MRI
Rutherford-Morrison
Appendiceal lump- Oschner-sherren regimen
INCISIONS AND NAMED SURGERIES
= Chevron incision

Muscle splitting

Skin crease incision Rutherford incision : Muscle cutting Gibson incision :

uro-gynaecological
 GI bleed Angiodysplasia + Aortic stenosis : Heyde syndrome

MCC of UGIB- PUD > Varices

MCC of LGIB- Diverticulosis >
Hemetemesis- UGIB Angiodysplasia
Malena- Black stools d/t UGIB
Hematochezia- LGIB
Occult- FOBT +ve
Obscure- Source? UGIE/colonoscopy Double balloon
mostly Small intestine normal colonoscopy
Meckel’s
Rockall score(CASE) Capsule endoscopy diverticulum
Small intestine
Bleed score Tc99 pertechnate

FORREST Classification
Approach to GI bleed Variceal
Resuscitation

DOC- Terlipressin
UGIE + Band ligation>Sclerotherapy MC- Octreotide
Submucosal Not used- Beta blockers(only prophylaxis)
dilatations on UGIE
Warren shunt
No bleed Re-bleed

UGIE
Prophylaxis : Beta blockers
Rebleeds S/E : Hepatic
encephalopathy
Balloon Tamponades Transplant Bridge
TIPSS
Linton SB tube Minnesota (Transjugular
EHPVO intrahepatic
portovenous
shunt Sx)

REX shunt(b/w SMV & PV)

MC early complication- Capsular rupture
MC late complication- Stent thrombosis
 GI HIGH-YIELD

LRV
Duodenum

Tillaux sign(cyst moves Duke’s criteria - Ca Colon

perpendicular to axis of mesentary)
Diverticulosis
CRC - MC : Rectum Saw tooth app.
LRV : Nutcracker syndrome(Hematuria) Diverticulitis : LLQ pain
Duodenum : SMA/Wilkie/Cast syndrome IOC : CECT
Sudden wt. loss, Strong proc. Hinchey Classification
Total Mesorectal 1a Pericolonic Phlegmon and inflammation
Excision(TME) 1b Pericolonic abscess ＜4cm
2 Pelvic or inter-loop abscess or abscess ＞
IOC for ca rectum: MRI
4cm
Proximal 5cm Distal 2cm
3 Purulent peritonitis
TOC: Anterior resection
Within 2cm of anorectal ring APR with Colostomy 4 Feculent peritonitis
 UGIE Short bowel syndrome:
60cm MCC CHILD- NEC/Jejunal atresia
MCC ADULT- Crohn’s ds./Mesenteric Ischaemia
Mx:
Teduglutide GLP2+ Lengthening proc.
Bianchi, Step, Kimura procedure

Enterocutaneous
fistula

160cm Duodenal fistula

Max risk of malnourishment:
Protoscope(15cm)
25cm Bishop-Koop : Meconium ileus
10cm • Cystic fibrosis
• x air fluid levels
• Stippled calcification
Puestow / Begar / Frey
Bishop Koop
ANAL CANAL
Hairy, above natal cleft,
prolonged sitting/drivers
PARK classification
Pilonidal sinus
Barren’s Extra
Painless banding

Pectinate line
Painful Supra

Inter
Trans

Milligan morgan
hemorrhoidectomy
Symptomatic
haemorrhoids Bascom / Karydakis /
Goosdsall’s rule Limberg RHOMBOID
IOC: MRI TRANSPOSITION
TOC- Fistulectomy
HIGH FISTULA-Seton’s proc. FLAPS
HEPATOBILIARY SURGERY

Bowel
Air in biliary obstruction
tree

Gallstone
in bowel
A) Hepatocystic
Mirizzi syndrome triangle : inferior
margin of liver +
Csendes classification Double duct sign CBD stone CHD + cystic duct
Gallstone assd. Jaundice Periampullary cancer B) Calot’s triangle :
Waxing-waning Cystic duct + CHD +
Rigler’s triad : Gallstone ileus Jaundice Cystic artery
• pnuemobilia
• Stone in small bowel
• Small bowel obstruction
d/t Fistula b/w bowel & GB Porcelain GB
(premalignant)
GB Cancer during Cholecystectomy
Non muscle infiltrating: Simple cystectomy 4b/5
Muscle infiltrating ca GB: Extended cholecystectomy LNs
R4U line & Be safe approach
LIVER-HYDATID CYST
GHARBI 1 3 2 4 5 Dead end/
Accidental host
WHO CE1 CE2 CE3 CE4 CE5
CE1/2 : Active Honey- Water Lily Hydatid Calcified
disease combing sign sand cyst
CE3 : Transitional
stage
CE4/5 : Dead cyst

Albendazole x 2-3 wks f/b PAIR

Indications of PAIR :
• any active lesion(CE1-3)

2. Aspiration Bilirubin Echinococcus granulosus(Dog tapeworm)

Pericyst(host
Scolex derived)
Fistula(C/I to PAIR)
Brood capsule
C/I to PAIR : Ectocyst
• multiloculated cyst Hydatid fluid

95% ethanol • Inactive cyst

• Fistula Endocyst
Hypertonic saline Hydatid sand
X formalin
CHOLEDOCHAL CYST Premalignant condition

Todani/Mod. Alonso-Lej classification

Caroli’s disease : Central dot sign

(Central venous radicle)

Choledochal cyst occurs d/t Anomalous

pancreatico-biliary junction
BILE DUCT INJURIES
Bismuth-
Strasberg
classification

Cystic
duct leak

Aberrant post. sectoral duct #

Post-op leak/jaundice

Circumferential Bile duct # - benign bile duct strictures USG : Bilioma

Pigtail catheter drainage

• Stewart-Way: Laparoscopic CBD injury IOC : ERCP
Most sn : HIDA
• CBD + Vascular: Hannover Classification
 LIVER-Tumors BCLC management of HCC
Enhancement Washout Capsule

Arterial phase Venous phase Delayed Phase

uptake

IOC of HCC : triple phase CT/MRI

Hepatocellular Carcinoma
Neurotensin B
is the tumour
Trans-arterial
marker for Milan criteria For liver transplant chemo-embolisation
Fibrolamellar
• Single tumor < 5 cm, or
variant of Summary of BCLC mgt.(guidelines at a glance) -
HCC • 2-3 tumors none exceeding 3 cm, and • 0 stage : Resection OR LT
• No vascular invasion and/or extrahepatic spread • Early stage(A) : LT OR RFA
UCSF Criteria
• Multinodular/Intermediate HCC(B) : TACE
• Single tumor < 6.5 cm, or • Advanced(C) : Sorafenib
• 2-3 lesions, none exceeding 4.5 cm, with total • Terminal(D) : Palliation
tumor diameter < 8 cm
HBP SCORES
Model For End Stage Liver Disease (MELD) CBI Pediatric End-Stage Liver Disease (PELD) BAAGI
Creatinine (mg/dL) -Total bilirubin Doesn’t include Creatinine
Bilirubin (mg/dL) -Albumin
INR -Age (˂ 1 Y)
Revised: Na -Growth failure
Child Pugh Score(ABCDE) #CC -INR d/t metabolic causes
1 2 3 King’s College Criteria for Liver Transplant in ALF
Encephalopathy Acetaminophen-induced ALF Non-acetaminophen-induced
Encephalopat None Mild to Severe
ALF
hy moderate (grade 3 or 4)
(grade 1 or 2) Arterial pH ˂7.30 Prothrombin time ˃100 sec (INR
Ascites None Mild to Severe ˃6.5)

Distension moderate (diuretic

Or all of the following Or any 3 of the following:
(diuretic refractory)
d/t Ascites • Prothrombin time ˃100 sec • Non-A, non-B viral hepatitis,
responsive)
(INR ˃6.5) drug-induced or
Bilirubin ˂2 2-3 ˃3 • Serum creatinine ˃ 3.4 indeterminate etiology of
(mg/dL) mg/dL ALF
Albumin (g/dL) ˃3.5 2.8 – 3.5 ˂2.8 • Grade 3 or 4 hepatic • Time from jaundice:
encephalopathy encephalopathy ˃7 days
PT Coagulation ˂4 4-6 ˃6 • Age ˂10 years or ˃3.5)
INR studies ˂1.7 1.7-2.3 ˃2.3 • Serum bilirubin ˃17.4 mg/dL
Class A= 5 to 6 points (least severe liver disease)
Class B = 7 to 9 points (moderately severe liver diseases) NAZER index:Wilson’s diesease
Class C = 10 to 15 points (most severe liver disease) Bilirubin
PT/INR
AST
 PANCREAS
Whipple’s is the
PHD level proc. of
all Surgeries

Pancreatico-
jejunostomy has Sausage pancreas : Poor prognosis
highest r/o leaks
Autoimmune
Modified Whipple’s proc.
Pancreas Hepatic Duodenum
Pancreatitis
IgG4 related ds. Revised Atlanta criteria
Pancreatico- Hepatico- Duodeno-
jejunostomy jejunostomy jejunostomy
BISAP Score
BUN • BUN ˃ 25 mg/dL (8.9 mmol/L)
Impaired mental • Glasgow coma score ˂ 15
status
SIRS • Evidence of SIRS
Age • Age ˃ 60 years old
Pleural effusion • Pleural effusion P is not Pseudocyst
Pancreatic Cystic Neoplasms
Intraductal papillary mucinous
Features Serous CA MCN IPMN
neoplasm
Age Grand mother Mother Grand father
Pathology Benign 30% malignant 65% malignant
Appearance Microcysts Larger cysts, septations Dilated MPD + nodules
Central stellate scar
Calcification Central Peripheral Rare
Epithelium Glycogen-rich Columnar mucin-producing Columnar
cuboidal with ovarian stroma mucin-producing
Aspirate Low CEA High CEA High CEA
Low amylase Low amylase High amylase

Fish mouth defect

SKIN GRAFTS AND FLAPS
WOUND HEALING
10%- 1 week
80%- 3 months
100%- Never
Humby’s knife Collagen- Early stages : Type 3
Later stages : Type 1
SPLIT/ THIERSCH FULL / WOLFE
Part: Epidermis + Partial dermis Epidermis + Dermis
Supraclavicular,
Site: Thigh
Retroauricular Hypertrophic scar(Regularly Keloid
Primary arranged, parallel connective Haphazardly arranged
Contracture: Secondary
(Full = First = 1) tissue) collagen
Cosmesis: Better cosmesis Rx : Intralesional
Triamcinalone

Bilobed
Tip of nose

CLEFT LIP ALONE: 5MONTHS (MC: MILLARD)

CLEFT PALATE ALONE: SOFT AT 6MON, HARD AT 15-18MON
(MC: Wardill-Kilner repair)
BOTH: CL + SOFT AT 5MON, HP AT 15-18MON
BARIATRIC SURGERY
Indication of Bariatric surgery:
BMI >40,
BMI >35 with comorbidities

Reversible MC done Most acceptable Most effective results

STOP-BANG Obstr. Sleep Apnoea

TRANSPLANT SURGERY
UW solution : Renal transplant Liver transplant HCV>alcohol
Adenosine Energy src. MC indication adult DM MC indication adult: Cirrhosis
Allopurinol Antioxidants MC indication child Glomerulonephritis MC indication child: EHBA
Glutathione Side: Lt. Kidney along w/ Lt. Renal vein TYPES OF LT:
Lactobionate Reduces edema Planed in RIF extraperitoneal Split LT:1 liver to both a child & an adult
Hydroxyethyl starch (HES) MC infection(3-6mon) : CMV HALT:Heterotrophic auxiliary LT (Metabolic)
MC malignancy: Sq. Cell Ca of Skin APOLT:Auxillary Partial Orthotopic LT
Warm Ischemia time: ~ 30 min PTLD:EBV Domino LT: MSUD/Amyloid/Wilson’s
Orthotopic LT Sequence:
Cold ischemia time: IVC f/b PV f/b Hepatic Art.
Min- Heart > Lung APOLT used for Mushroom poisoning
Max- Kidney & PCM toxicity

Not CRC
MISCELLANEOUS SCORES
The MUST tool Malnourishment assessment
Thoracoscore
Age (years) (i) BMI (kg/M2) (ii) Weight loss in 3- (iii) Acute disease
0 = ＞20.0 6 months effect:
Gender (male) 1 = 18.5-2.0 0 = ＜5% little nutrition
ASA 2 =＜18.5 1 = 5-10% intake for ＞5 days
2 = ＞10%
Performance status
Dyspnoea score Transplant Surgery : Masstricht Classification
Priority of surgery Maastricht Presentation of DCD Situation
Death
Procedure class
I Dead on arrival Uncontrolled
Diagnosis group
II Unsuccessful Uncontrolled
*Not complication of surgery resuscitation
III Anticipated cardiac Controlled
arrest
GB - 6 IV Cardiac arrest in Controlled
Intra-op LN removed
Breast brain dead donor
GB C R- eST
10
Colon & Rectum - 12
V Unexpected cardiac Uncontrolled
Esophagus - 15 arrest in a hospital
Stomach - 16 inpatient