SRBs

for oral examination

By Dr. Ibrahim Odeh
 Classification of Surgical Wounds
• a. Clean wound : does not enter into normally colonised viscus.
– Herniorrhaphy.
– Infective rate is less than 2%.
• b. Clean contaminated : enters into a colonised viscus
– Appendicectomy, Gallbladder, biliary surgeries.
– Infective rate is 8-10%.
• c. Contaminated wound :gross contamination is present
– Acute abdominal conditions.
– Infective rate is 15-30%.
• d. Dirty infected wound : when active infection is present.
– Empyema gallbladder, Faecal peritonitis.
– Infective rate is > 40%.
 Wound healing
• is complex method to achieve anatomical and
functional integrity of disrupted tissue in an organised
staged pathways:—

→ Hae ostasis platelets – 24 hours

→ I fla atio PMNs, a ophages – 6 days
→ P olife atio g a ulatio & TNF-) - 6 months.
→ epithelialisation (epithilium).
→ Mat i synthesis (collagen)
→ maturation & remodelling (collagen cross-linking)
→ wound contraction (by myofibroblasts).
 Factors that affect Wound Healing

Local
Infection FB Poor blood supply Irradiation

General
Malnutrition
(Zn, Vit-C, Vit- anemia Jaundice Dm Steroids Chemotherapy
A)
 Keloid
• Defective wound healing which causes scar
extends beyond the wound edges
• Due to :
– Defect in synthesis , maturation and stabilization
of collagen fibrils.
– Scar continues to grow without time limitation.
 Hypertrophic scar
• Defective wound healing which causes ugly
scar formation, that does not extends beyond
the wound edges
• Due to :
– Defect in synthesis , maturation and stabilization
of collagen fibrils.
• Growth limits for 6 months only.
 Clinical examination for Ulcer
• History
– onset
– Duration
– Pain
– Discharge
– Associated disease
 Local examination of an ulcer
• Full exposure : both limbs , hidden ulcers
• Site — over the digits; over the malleoli; over heel , pressure
points
• Size : wet gouse
• Shape : oval , round ,
• Margin whether regular/irregular/well-defined/ill-defined.
• Edge : slopping, punched-out, undermining, everted.
• Floor (by inspection while base by palpation) : Red color in
healing ulcer; slough , proliferative and nodular in SCC;
pigmented—melanoma.
• Discharge (serrous, bloody, greenish – psudomonas)
• Surroundings :for erythema , oedema, varicose , cord like
structure , scarring, pigmentation , skin , hair distribution, nails
shinny skinn.
• Do ’t fo get hidde ul e s.
 Type of wound edges
• Slopping : In healing Ulcer , inner part red and
represents granulation tissue , outer : white ,
intermediate : blue.
• Punched-out : in Trophic ulcer (DM, pressure sores).
• Raised : in basal cell carcinoma.
• Everted (malignant ulcers)
• Undermined : here epidermis proliferate inwards,
seen In TB
 Local examination of an ulcer
• Palpation
– Tenderness over edge, base and surrounding area.
– Warmness
– Induration/fixity
– Bleeding or discharge on palpation and touching.
• Examination of regional lymph nodes is essential.
• Examination of arterial pulse, peripherally in relation to ulcer
• Examination for varicose veins in standing position
 Fistula
• SINUS
• It is a blind track lined by granulation tissue
leading from an epithelial surface into the
surrounding tissues.
• FISTULA
• It is an abnormal communication between
two epithelial lining .
 Causes
• Congenital:
– Branchial fistula.
– Tracheo-oesophageal fistula.
• Acquired:
– Traumatic : surgery, trauma
– Inflammatory : IBD, TB, appendicular fistula
– Malignancy : Rectovesical (as in Rectal Ca.)
– Irradiation
 Causes of persistent sinus or fistula
• Foreign body or necrotic tissue inside
• Distal obstruction
• Persistent infection
• Epithilization of fistulo-tract.
• Lake of drainage
• If the cause is malignant
Complication of fistula:-
• Electrolyte imbalance
• Malnutrition
• Sepsis (Rectovesical fistula)
• Skin excoration.
 ABSCESS
• localized collection of pus in a cavity lined by granulation
tissue, o tai s dead WBC’s, ultipl i g a te ia, toxins
and necrotic material.
• Types:
– Pyogenic abscess
– Pyaemic abscess
– Metastatic abscess (endocarditis >> splenic abcess)
– Cold abscess due to chronic infection
 Treatment of abcess
• Abscess should be formed before draining.
Exceptions for this rule are:
– Parotid abscess
– Breast abscess
– Axillary abscess
– Thigh abscess
– Ischiorectal abscess
 Surgical site infection
• Any infection in any space occupied by the surgeon
which occurs within 30 days of operation or 1 year if an
implant is present.
• Classification of (SSI): (According to the Depth)
• Superficial incisional: involves only skin and subcutaneous tissue
• Deep incisional: involves deep soft tissues of the incision (sheet)
• Organ space infection: involves anatomic structures not opened or
manipulated during surgery

• mainly occur at day 5 post op

 Skin leasions
• SEBACEOUS CYST : due to blockage of the
duct of sebaceous gland, causing a cystic
swelling.
• LIPOMA : It is a benign tumour arising from
yellow fat.
• Dermoid cyst is a teratoma of a cystic nature that
contains an array of developmentally mature, solid tissues. It
frequently consists of skin, hair follicles, and sweat glands
Fluids and eclectrolytes
 Classification of sutures
• Monofilament – polyfilament
• Synthetic – natural
• Absorbable – nonabsorbable.

• Size :
– 0,1,2,3 increasing in diameter
– O-1, O-2 , O-3, …… O-12 decreasing in diameter.
 Suture material

Non-
• Synthetic
• Monocryl : violent.
absorbable
• vicryl (polyglycan-910) : violent • Synthetic
• Dexon (polyglycolic acid): green • Prolene
• PDS (Polydioxanon) : gray • Ethelon (nylon) : blue – High memory
• Natural • Natural
• Collagen (catgut) – chromic = brown • Silk : black
• stainless steel : silver

absorbable
 polyglycan – 910 (Vicryl®)
• Poly-galactic acid – violent in color
• Braided synthetic absorbable sutures
• Maintain tensile strength for 7-14 days
• After 2 weeks remain 75% of tensile strength
• 50 % of tensile strength will lost after 30 days.
• Totally absorbed after 60 -70 days by hydrolytic
degradation.
• Lactic acid has hydrophobic character which delay
loss of tensile strength.
• Need 4 knots to be secured while nylon needs 7
knots to be secured.
 Tensile strength
• Is the strength , which is required to hold the
tissue in a proper apposition.
 Plades

The usual blades used in surgery are #10 or #20 for skin incision.
. Blade #11 : abscess drainage
. Blade #15 : for vascular & plastic surgery
 IVF
• Crystalloids :
– Hypotonic (<250mmol/L) : 0.45% saline, D5W
– Isotonic (250-375) : 0.9 % saline , LRs
– Hypertonic (>375) : D5(1/2)saline
• Colloids :
– Albumin 25%
– Dextrane
– HES 10%
– Manitol
 Fluids
• Crystalloids
– Isotonic
– Hypertonic
– Hypotonic
• Colloids
– HES
– Albumin
 Requirments
• Caloric requirement:
• Neonatal 100 kcal/kg/day.
• Adult 40 kcal/kg/day.
• Adult with catabolism 60 kcal/kg/day.
• It is given as:
• Carbohydrates 50%.
• Fat 30-40%.
• Protein 10-15%.
Indications for Nutritional Support
• Preoperative nutritional depletion.
• Intestinal fistula
• Pancreatitis, malabsorption, ulcerative colitis, pyloric stenosis.
• Trauma—multiple fractures, fasciomaxillary injuries.
• Burns.
• Renal and liver failure.
• Short bowel syndrome.
Contraindications of Enteral Nutrition
• Intestinal obstruction
• GI bleeding
• Paralytic ileus.
• Severe diarrhoea,
• high output fistula.
• Low cardiac output.
• If safe access to enteral feeding is not present.
 Indications for TPN
• F™ailure or contraindication for any enteral nutrition for 7-10 days
• High output abdominal fistulas
™
• Duodenal, biliary, pancreatic fistulas
• Short bowel syndrome
™
• Severe pancreatitis, bowel ischaemia, peritonitis, ileus
™
• Massive GI bleeding.
™
• High-risk of aspiration
™
• Hyperemesis gravidarum
™
• Head injury, severe burns - ulcers
™
 Assessment of nutrition

• ™ ody weight
B
• Mid-arm circumference
™
• Serum albumin
™
• Lymphocyte count
™
 Shock
• Shock is a state of hypo-perfusion with impaired
cellular metabolism.
• At cellular level :
– hypoxia causes anerobic metabolisim
– lactic acidosis
– deficient cellular energy.
– Lysosomes get released causing cell lysis.
– Hypoxia and acidosis release free oxygen radicals and
cytokines which damage capillary endothelium.
– Subsequent muti-organ dysfunction and even faliure
 Causes of shock
1. Hypovolemic : hemorrhage , Burn, peritonitis.
2. Cardiac : MI, tamponade, trauma
3. Septic : Endotoxin release
4. Neurogenic: spinal cord injury, anaesthesia
5. Anaphylactic: type I hypersensitivity
6. Obstructive : PE, tension pnumothorax.
7. Endocrine : Adrenal insufficency.
8. Distributive : toxins
Complications of Blood Transfusions
1. Immune system complication :-
1. Febrile reactions
2. Allergic reaction
3. Acute hemolytic reactions
4. Transfusion related acute lung injury
5. Transfusion related graft versus host disease
2. Infection Transmition (HBV,HCV, CMV,HIV)
3. Over Load valium overload, Iron over load)
4. Coagulopathy (Delusional , consumption by DIC, low platelets)
5. Electrolyte (Hypocalcemia, Hyperkalemia)
6. Acid base imbalance (Metabolic Acidosis) .
 MASSIVE BLOOD TRANSFUSION
• transfusion of blood equivalent to patient’s
blood volume in < 24 hours
• Or single transfusion of blood more than
2,500 ml continuously
• Intrensic pathway : exposed collagen to XIIa
• Extrensic pathway : damaged tissue > Tissue thromboplastin
Trachiostomy tube
 Diathermy (heating through)
• Also called electrocautery
• This type of diathermy use high frequency A.C
electrical current.
• Can be used to :
– Coagulation : by sealing of blood vessels.
– Fulguration : destructive coagulation of tissue.
– Cutting : to divide tissue.
• Diathermy types : Monopolar , bipolar.
 Diathermy types
• Monopolar : current pass from the active
electrode near targeted tissue to another fixed
electrode elsewhere in the body (buttocks or
around the legs) through the body.

• Bipolar : both electrodes are mounted on the

same forceps like device , current pass only
through targeted tissue between the tips of the
special forceps. Useful in micro surgery and in
patient with pacemaker.
 TYPES
• Based on type of current used:
– Unipolar cautery.
– Bipolar cautery. It is safer because its effect is seen only in
between electrode points. Adjacent tissues will never get
damaged.
• Based on type of action:
– Coagulation cautery which causes haemostasis by tissue
coagulation. Here temperature is 100 degree (blue switch).
– Cutting cautery: Here temperature is 1,000 degree which
disintegrate the tissues. It is not haemostatic (yellow
switch).
 Pulse oxymeter
• Using light source and light detector and
calculate the ratio between oxyhemoglobin
(red ) and de-oxyhemoglobin (infrared)

• Factors affecting the accuracy :

– Hypothermia , hypotension , Hypovolemia.
– CO intoxication.
– Ambient room light .
– Shocked patient.
 ABDOMINAL INCISIONS
Principles
• Incision should be long enough for a good exposure.
• Splitting the muscle is better than cutting, except
rectus muscle.
• Avoid cutting nerves and vessels in the abdominal
wall.
• Retract muscle, abdominal organs towards the
neurovascular supply.
• Insert a drainage tube through a separate incision.
• Transverse incisions are better than vertical incisions
 Abdominal incisions
Requirements

• Accessibility
• Extensibility
• Security
Different abdominal incisions are:
• Upper midline.
• Upper right paramedian.
• Upper left paramedian.
• Ko he ’s i isio ight subcostal).
• Left subcostal.
• Bucket handle.
• Upper horizontal.
• Thoracoabdominal.
• Subumbilical.
• Incision for lumbar sympathectomy.
• Lower midline.
• Lower right or left paramedian.
• Incisions for appendicectomy—M Bu e ’s, Rutherfold
• Mo iso ’s, Lanz, laparoscopic.
 BURNS
Types of burns
1. Thermal injury
1. Scald: spillage of hot liquids
2. Flame burns : hot air
3. Flash burns : intense and short exposure to heat
2. Contact burns—contact with hot metals/objects
3. Electrical injury
4. Chemical burns—acid/alkali
5. Cold injury—frost bite
6. Ionising radiation
7. Sun burns.
 Mortality : 45-55%

Just in
oropharynx

The main mechanism of injury

 Zones of burn
• Zone I : zone of erythema (vasodilatation)
• Zone II : zone of stasis (Vaso-distruction)
• Zone III : zone of coagulation(necrosis)
 ELECTRICAL BURNS
• Low tension injury: Less than 1000 volts, only
cause local burn .
• High tension injury: More than 1000 volts
tempreture here up to 2000C, it can also
cause ventricular fibrillation or cardiac arrest
 Trauma Managment
• Primary survey
• Completion of primary survey (Investigations)
• Secondary Survey
• Definitive Care
 Primary survey - Goals
• Identify life-threatening conditions.
• Decide appropriate treatment to the area of trauma.
• Rapid assessment.
• Rapid resuscitation.
• Rapid stabilisation.
 Primary survey - AIRWAY
• Is patient responsive?
• If (yes) rapid AMPLE history taking then primary survey (BCDE)
• If (not) : triage to CPR
• Assess spontaneous breathing ?
• If (yes) : neck collar + oro-pharengeal airway protection
• If (no) :
– Ne k olla … C-spine
– Oropharynx suctioning (vomitus or blood)
– Chin lift > jaw thrust > oral airway > Endotrachial Intubation
– Even Crico-thyroidotomy if indicated.
 Primary survey - Breathing
• O2 mask , monitor pulse oxymeter
• Assessment :
– Inspection :
• bilateral chest rise
• Chest wall deformity , wounds
• dyspnia, RR.
• jugular vein distention, tracheal deviation

– Auscultation : Assess breathing sound bilaterally

 Primary survey - CIRCULATION

• monitoring (BP).
• Monitoring (ECG)
• Open two large bore (14Fr) canula.
• Control of external bleeding if present.
• Check peripheral pulse. 60-70-80
 Primary survey - Disability
• Check Glasgow coma scale.
• Neurological Examination (motor, Sensory)
• Pupil reaction to light.
 Primary survey - Exposure
• Expose the patient from head to toe.
• Examination for :
– Axilla
– Back
– Perineum
– Scrotum
– Orifices.
• Environment : Rewarming .
Primary survey – Finger and tubes
• PR - finger
• Follys
• NG-tube if needed
 Completion of primary survey -
Investigation

• Blood group & cross matching

• X-ray : (C-spine, Chest , pelvis)
• FAST
• Brain CT scan
• Electrolyte, urine analysis
 Secondary Survey
• Re-evaluate the patient completely again.
• According to the site of direct injury.
• Full abdominal examination.
 Definitive Care
• Last one
Diagnostic peritoneal lavage (DPL)
• done in case of blunt injury abdomen
• Through a subumbilical lavage catheter.
• one litre of o al sali e/Ri ge ’s la tate is infused
into the peritoneal cavity.
• Patient is changed to different positions and side-to-
side.
One of the criteria's signifies positive lavage

• 10 ml or more of gross blood

• RBC count more than 1,00,000/cm3
• WBC count more than 500/cm3
• Amylase level in the fl uid more than 175 IU/dl
• Presence of bile, bacteria, food particles.
 Diagnostic peritoneal lavage
• Follys catheter and NG-tube
• local anaesthesia into subumbilical region, 2-3 cm vertical sub-umbilical
midline incision is made.
• Skin, linea alba is incised.
• Catheter (standard peritoneal dialysis catheter) is introduced into the
peritoneal cavity.
• If blood enters the catheter immediately, it means early laparotomy is
needed
• one litre of normal saline is infused into the peritoneal cavity rapidly
• in few minutes through the catheter using a drip set with elevation of
the fluid bottle/bag.
• Patient is moved well to mix the fluid in all four quadrants.
• Now bag is lowered below so that fluid from the peritoneal cavity
reenters/siphoned into the bag.
DPL may not be useful in :
1- bowel injury
2- retroperitoneal injury
3- diaphragmatic injury
4- organ haematoma
• If patient is decided for observation catheter
can be left in situ for repeat DPL after 6 hours.
One has to remember
 Indications
• It is the procedure of choice in physiologically
unstable patient with blunt abdominal injury
(like with spinal injury, unconscious patient).
Or PaCO2<32mmHg
CLASSIFICATION OF SKIN TUMOURS:

• Benign
– Seborrhoeic keratosis.
– Sebaceous adenoma.
– Sebaceous epithelioma.
– Dermatofibroma.
– Nevi.
• Malignant
– Squamous cell carcinoma.
– Basal cell carcinoma.
– Melanoma.
– Secondaries in the skin. Sister Joseph nodules around
umbilicus.
 NAEVI
• It is a hamartomata of melanocytes due to
excessive stimulation.
• It may present during birth or appear later in life.
• Types:-
– Hairy mole
– Nonhairy mole
– Blue naevus
– Junctional naevus
– Juvenile navys
– Hutchinson’s freckle
Five most important features of melanoma :

• Asymmetry
• Border irregularity
• Colour variation
• Diameter > 6 mm
• Elevation
ANATOMY OF LYMPHATICS OF
HEAD AND NECK
1. Inner Waldeyer’s Ring:
1. Adenoids above
2. lingual tonsils below
3. Two palatine tonsils laterally one on each side
2. Outer Waldeyer’s Ring:
– Occipital
– Postauricular
– Preauricular
– Parotid
– Facial
– submandibular,
– Submental
– superficial cervical
– anterior cervical
Levels of lymph nodes in the neck:
• Level I: submental, submandibular
• Level II : superior jugular
• Level III: middle jugular
• Level IV: inferior jugular
• Level V : posterior triangle
• Level VI : Anterior compartment
• Level VII: superior mediastinal
DDx midline neck mass
1. Sub-mental lymphadenopathy
2. Lipoma/sebasious cyst
3. Dermoid cyst
4. Thyroglossal duct cyst
5. Thyroid mass or goiter
6. Thymic swilling
7. Lud ig’s a gi a.
DDx lateral neck masses:-
• Lymphmadenopathy
– Reactionary
– Metastatic
– lymphoma
• Brachial cleft cyst.
• Cystic hygroma.
• Carotid body tumor.
• Torticollas
 Carotid body tumor
• Type of Para-ganglioma
• from neural crest.
• From adventitia of carotid bifurcation
• pulsatile mass
• Mobile horozontally
Why is thyroid mass move with swallowing ?

• Becouse of ligament of Berry

• Which pass through thyroid and pre-trachial fascia into cricoid
cartilage .
 Causes of thyrotoxicosis
• Diffuse toxic goiter (Graves disease)
• Toxic nodule : (follicular adenoma or carcinoma)
• Toxic multi-nodular goiter (Plummer's disease)
• A ute phase of th oiditis DeQu a ’s
• TSH stimulation (Hydatiform mole, choriocharcinoma)
• Drug induced (Amiodarone, contrast)
 Causes of hypothyroidism
1. Autoimmune Hashi oto’s, post-partum)
2. Iatrogenic (thyroidectomy , radioactive ablation)
3. Infiltrative : (secondaries, chronic thyroiditis).
4. Defect in T4 synthesis : (iodine deficiency, Anti-thyroid drugs)
5. Secondary : (hypo- pitutarism).
6. Congenetal : Agenesis (deGo gi’s syndrome)
 Causes of goiter / Thyroid mass
1. Diffuse :
1. Physiological (pregnancy)
2. Autoimmune (Graves, Hashimoto)
3. Iodine deficiency (endemic goiter)

2. Nodular :
1. Solitary, multi-nodular , fibrous (Redel’s)

3. Neoplastic mass :
1. Primary (papillary, follicular, medullary , anaplastic)
2. Secondary (lymphoma, mets)
 Hyperparathyroidism
• Primary
– Adenoma (75-90%)
– Hyperplasia (20-24%)
– Carcinoma, rare (1%)
• Secondary i e al failu e i espo se to ↓Ca
• Teritary
after renal transplantation in hyperplastic parathyroids
 Lymphatic Drainage of the Breast
• axillary lymph nodes—75%.
– Level I : Below and lateral to the pectoralis minor muscle
– Level II : Behind the pectoralis minor muscle
– Level III : Above and medial to pectoralis minor .

• Internal mammary nodes. 25%

Axillary lymph node drainage:-
• 75% of breast.
• Superficial chest wall.
• Abdominal wall (above the level of umbalicus).
• Upper limb.
• Upper back
Breast imaging reporting and data system (BIRADS) :

• Grade Feature
• 0 Need further imaging
• 1 Negative
• 2 Benign—repeat mammography 1 year
• 3 Probably benign—mammography after 6 months
• 4 Suspicious of carcinoma—biopsy
• 5 Highly suggestive of carcinoma—biopsy
• 6 Known carcinoma
Indication of breast MRI
• Quiry mamography
• Screening for high risk women for breast Ca.
• Pre-op evaluation for breast Ca.
• Investigation of choice for silicon implants
Malignant finding in mammography:
• Microcalcifications
• Spiculations
• duct distortion.
• Satellite appearance.
DDx of breast mass (lump) :
• Begnin:
– (ANDI) classification
• Fibroadenoma
• Sclerosing adenosis
• Fibrocystic Disease
• Duct ectasia
– Galactocele
– Lipoma
– Fat necrosis

• Non invasive neoplastic

– DCIS
– LCIS
– Phylloid tumor

• Invasive neoplastic
– Invasive ductal carcinoma
– Invasive lobular carcinoma
 ANDI classification of benign breast disorders

Lobular development Fibroadenoma , fibrocystic disease

Stromal development Gynecomastia
Ductal Duct ectasis, Periductal mastitis
 Fibroadenoma
• It is a type of (ANDI) classification of begnin
breast lesions in lobules
• aberration in normal development (AND)
involution of a lobule.
 Fibrocystic disease
• It is due to Aberration of Normal Development
and Involution (ANDI) of begnin breast lesions
causing:
– Stromal fibrosis
– Microcyst formation
– Glandular proliferation (Adenosis)
– Hyperplasia (Epitheliosis)
– Papillomatosis
Classification of primary breast cancer
• Noninvasive epithelial
– LCIS
– DCIS : papillary, solid, cribriform, comedo (MCT)
• Invasive epithelial
– Invasive lobular
– Invasive ductal
– Papillary
– Medullary
– Tubular
– Colloid
• Stromal
– Phyllodes
– Angiosarcoma
• Metastatic disease
– Form lung carcinoma
 Nottingham Prognostic Index
• (NPI)= ( 0.2 × size in cm) + Lymph node stage + Tumor grade
– NPI score—< 3.4 Good prognosis with 80% survival (15 years)
– NPI score—3.4 –5.4 Moderate prognosis with 40% survival
– NPI score—> 5.4 Poor prognosis with 15% survival
 Paget’s disease of the ipple
• is a superficial manifestation of an underlying breast
carcinoma. It presents as an eczema-like condition of
the nipple and areola, which persists despite local
treatment.
 Inflammatory breast cancer
• Inflammatory carcinoma is a fortunately rare,
highly aggressive cancer that presents as a
painful, swollen breast, which is warm with
cutaneous oedema.
• This is the result of blockage of the subdermal
lymphatics with carcinoma cells.
 Breast cancer classification
• Tis Intraepithelial
• T1 less than 2 cm
• T2 2-5 cm
• T3 more than 5 cm
• T4 chest wall, skin involvement, inflamatory breast cancer

• N1 ipsilateral axillary (1-3)

• N2 > 4 LNE , fixed LNE
• N3 infraclavicular/supraclavicular/intramamary

• M1 Distant mets
 Hernia - definition
• Hernia is defined as an abnormal protrusion of a
viscous or a part of a viscous through an opening,
artificial or natural with a sac, covering it.
 Hernia - types
• Internal
– Hiatal
– Diaphramatic hernia
– Paradudenal
– Retroanastomitic

• External
– Inguinal : direct, indirect
– Umbilical / paraumbilical
– Epigastric
– Femoral
 Hernia - Types
• Congenital :
– Umbilical
– Diaphragmatic
– Indirect inguinal hernia

• Acquired:
– Direct inguinal hernia
– Para-umbilical
– Incisional hernia
– Epigastric
– Femoral
 Classification : Based on Sites
• Inguinal hernia
• Femoral hernia
• Obturator hernia.
• Diaphragmatic hernia.
• Lumbar hernia.
• Spigelian hernia.
• Umbilical hernia.
• Epigastric hernia.
 Hernia – Sequels
• Reducible
• Irreducible
• Incarcerated
• Obstructed : causing Intestinal obstruction
• Strangulated : compromised blood supply
 Groin hernia – surgical classification
Nyhus classification
• Stage I : Indirect inguinal hernia with normal internal ring
• Stage II : Indirect inguinal hernia with widened (IR)
• Stage III : weak posterior wall with
– A. direct inguinal hernia
– B. Pantaloon hernia
– C. Femoral hernia.
• Stage IV : all recurrent hernia
Iguinal hernia repairs are of the
following three general types:
• Herniotomy (removal of the hernial sac only)
• Herniorrhaphy (herniotomy plus repair of the posterior wall of the
inguinal canal)
• Hernioplasty (herniotomy plus reinforcement of the posterior wall of the
inguinal canal with a synthetic mesh)
 How to perform an Open Inguinal Hernia Mesh
Repair: (Hernioplasty or Herniorrhaphy) in a Male.
1. Prior to surgery ensure you have taken an adequate history and examination.
1. Confirm a hernia is present and you have identified the correct side.
2. Is it reducible?
3. Does it extend into the scrotum.
4. Is there an associated hydrocoele etc.
2. Under general anesthesia in supine position after painting and toweling.
3. The landmarks of the anterior superior iliac spine (ASIS) to the pubic tubercle should
be palpated. This marks the line of the inguinal ligament.
4. An oblique incision parallel to this line should be made above - 3 cm (2 fingers).

5. The skin, underlying superfical fatt la e Ca pe ’s fas ia .

6. The superficial inferior epigastric vein should be ligated.
7. the the deepe fi ous la e S a pa’s fas ia down onto the external oblique
tendon.
8. Once the edge of the inguinal ligament has been visualized it confirms the correct
anatomical landmarks. The next step is to incise external oblique – with and above
the superficial inguinal ring and parallel to aponurotic fibers.

9. The hernia sack or cord structures may adhere to the inferior aspect of the divided
tendon and should be carefully dissected away. The same thing with ilio-inguinal
nerve To be continued >>
10 – The cord and hernia should be dissected to expose the inguinal
ligament edge inferiorly and the pubic tubercle medially.
11- Non-traumatic forceps (eg Lanes) may be used to safely retract
and separate the cord structures
12- Once the hernial sac is identified, it can be dissected till reaching
the periperitonial fat.
13- The sac contents can be carefully opened, remembering that the
hernia may contain bowel! The hernia may comprise of
retroperitoneal fat, bowel, bladder, omentum or any combination.
Ensure the contents is fully reducible inside the abdominal cavity,
through the deep inguinal ring (indirect hernia).
14- transe-fix suture ligation to the sac
15- check posterior wall weakness +/- plication
16- the mesh is ready to be inserted. under the external oblique
tendon, inferior edge of the mesh should be split , mesh should
gives adequate medial coverage at the tubercle. at the deep
inguinal ring, Enough space should be left for the spermatic cord
to pass through, but not loose enough that an indirect hernia
might recur.
17- reducing testis to the scrotum
18- closure layer by layer.
 Abdominal mass inspection
• After inspection of abdomen
• Site
• Size
• Shape
• Margin (regular/Irrigular)
• Surface
• Pulsatile?
 Intestinal Obstruction causes

Functional Mechanical

Paralytic ileus Intraluminal Intramural Extramural

Mesenteric
Fecal impaction Intussusception Adhesion , band
ischemia

Pseudo-
Gall stone Neoplasm Volvolus
obstruction

Stricture
Bezoars Hernia
oh ’s

Foreign body
Pathogenesis of intestinal obstruction
• Functional : loss of propulsive peristaltic movement
• Mechanical : loss of GI continuity . Both causes :
1. Ingested and flora-produced Gas accumulation
2. Indoluminal digestive secretion accumulation.
3. Intestinal stimulated to secrete more fluids
4. Inhibition resorption of fluid and electrolytes
5. Sever bowel dilatation
6. Impaired venous out flow
7. Impaired arterial inflow
8. Ischemia > perforation > bacterial translocation
9. Peritonitis > sepsis
 Chest tube
• Pt is lying on bed comfortable, not dyspnic , nor in
pain. Under IV set for fluid.
• As I can see also: The e is tho a osto tu e
arising from Rt/Lt chest connecting with
underwater seal drain system .
• Content: serrous, Serosagonous, Creamy, water
• Amount
• Functioning/not
• Bubbling/not
• Open / closed
 Chest tube Drain-content
• Bloody : hemothorax
• Serosanguineous : malignant effusion
• Serious : post lobectomy
• Pinkish creamy : thoracic duct injury
• Pus : Empyema
 Chest tube - Aim
• To regain normal physiological negative
pleu al p essu e du i g i spi atio -5 to -7
through draining any accumulated fluid or air
in the pleura .
• Underwater seal : to keep fluids\air from
siphoning back to pleural cavity.
 Foll ’s athete
• Pt is lying on bed comfortable, not dyspnic ,
nor in pain. Under IV set for fluid.
• As I a see also the e is a u e /sili o
urethral catheter connected with a bag to
drain under-gravity.
• Content
• Amount
 Foll ’s athete
• 8 blue Indications:
1- monitoring urine output
• 10 black 2- skip obstruction in BPH
• 12 white 3- securing bleeding in extensive refractory
posterior Epistaxis.
• 14 green
• 16 orange
• 18 red Contraindications:
1- suspected urethral injury
• 20 yellow 2- urethral stricture .
 DDx epigastric mass
• Gastric mass
• Pancreatic pseudocyst
• Liver mass (benign/malignant)
• Omental cyst
• Transverse colon mass
• Giant lymph node (metastatic).
• Retro- peritoneal tumor.
 DDx – Groin henia
• Lymphmadenopathy
• Lipoma / sebaceous cyst
• Direct / indirect inguinal hernia
• Ectopic testis
• Hydrocele of the cord.
• Psoas abcess
• Cecal mass.
• Tubo-ovarian mass
• Bony swilling
• Ectopic kidney .
• Femoral artery aneurysm
 Indication of splenectomy:
• Trauma
• Hematological : ITP, TTP, spherocytosis, thalassemia , HbSS, staging NHL
• Tumors : (hemangiosarcoma, lymphoma).
• Swillings : splenomegally, hypeersplenism.
• Vascular : Portal HTN , splenic vein thrombosis, distal splenic artery anurysm.
• Inflamatory : Splenic abcess.
Splenic ligaments
 Splenic ligaments
• Vascular
– Lino-renal (spleno-renal): splenic vessels +tail of pancreas
– Gastrosplenic : short gastric vessels
• Avascular
– Spleno-colic
– Spleno-phrenic
 Splenectomy - Emergency
1. Under GA, supine position, Painting- Toweling.
2. Midline incision, opining layer by layer.
3. Packing, clots removing
4. Dissection of phreno-splenic ligament (to mobilize the spleen)
5. Release of posterior leaf of lino-renal ligament with Clamping and cutting for
spleen mobilization. And expouser of lesser sac
6. If active blood loss is present > clamp the helium.
7. Careful dissection posterior wall of spleen (tail of pancreas)
8. Ligation and division of gastrosplenic ligament (short gastric vessels)
9. Expose lesser sac, dissect vessels from tail of pancreas gentely
10. Ligation over the clamp and dissection of splenic artery & splenic vein each one
alone to prevent fistula formation . Three ligatures
11. Ligation & cutting gastrosplenic ligament with short gastric vessels for further
mobilization.
12. Dissection anterior leaf of lino-renal ligament.
13. Removing the spleen
14. Irrigation , drain placement.
15. Closure layer by layer
Defferance between emergency and
ellective splenectomy :

Splenectomy Emergency Elective

Incision midline Subcostal/ laparoscopic
ligation Artery and vein togather Artery then vein

before clouser exclude ass injuries remove other splenules

--------------------------------------------------------------------------------------------------------------
sqweez no need need sqweez for
autotransfusion
 Complication of splenectomy
• Operative -----------------------------------------------------
– Primary Hemorrhage
– Injury to stomach , tail of pancreas , diaphragm
• Post op (Early)-------------------------------------------------
– Reactionary hemorrhage
– Pulmonary : Lt. sided Atelectasis , lt. plural effusion
– Acute gastric dilatation / perforation / fistula
– Pancreatitis / Pancreatic fistula
– Portal vein thrombosis
– Sub- phrenic abscess.
– Wound infection
• Post op (Late) -------------------------------------------------
– Overwhelming post splenectomy sepsis.
– Thrombocytosis & thrombotic complication, leukocytosis
Causes of urethral injury:
• Pelvic #
• Suddle injury
• Penile #
• Iat oge i foll ’s
Signs of urethral injury 3-5%
• Gross Haematuria
• Bleeding per meatus
• Penile hematoma
• Perennial hematoma
• High riding prostate by PR
• Retrograde urethroscopy > extravasation
Signs of death:-
1. Loss of vital function
2. Perminant cessation of cerculation/respiration
3. Flat ECG
4. Lack of internal/External environmental responsiveness
5. Fixed dilated pupils
6. Abcese of gag and cough reflex
7. Loss of corneal reflex
8. Hypothermia
 Pain
• Radiating : Extension of pain from original site to another site with
persistence in-between due to dermatome involvement.
– Duodenal ulcer , pancreatitis to back (L2)
– Cholecystitis to back > T7?? Dermatome

• Referred pain : Pain is felt in original site but felt in another distant site
due to innervation by the same nerve .
– Cholecystitis and tip of scapula (phrenic nerve)
– Hip and Knee joint (obturator nerve)

• Shifting pain : original site of pain disappear to shift to another site due to
(parietal to visceral) mechanism
– Acute appendicitis
 Hydatid cyst
• Is a paracytic infection of Echinococcus
granulosus causing cystic disease in
intermediate host (Humans).
 Echinococcus granulosus – life cycle
• In the infected definitive host (dogs) the parasite transformed
from immature to adult form in the intestine.
• Adult form pass through feco-oral rote into intermediate host
(Humans, sheep)
• It can penetrate intestinal lining into circulation which curry it
throughout the body.
• After localizing in specific organ , it developed to larval form
• Here where numerous tiny parasite heads (called
protoscolices) are produced via sexual reproduction in
daughter cysts.
• These heads are capable to infect the defenitive host feco-
orally again.
 Hydatid Cyst - Layers
• pericyst : Outer (adventitial layer) , Host collagen capsule with blood supply
• Ectocyst (laminated Layer) : acellular , Hyaline membrane
• Endocyst : Inner (germinal layer), Contain daughter cyst

• Fluid which is allergic and toxic .

• Growing 2-3 cm annually

• 75% liver (segment VII) , 15% lung

Ultrasound based classification of liver Hydatid cysts :

• Type 1 – Pure fluid collection

• Type 2 – Fluid collection with split (detached) wall
• Type 3 – Fluid collection with multi- septated
• Type 4 – Heterogeneous appearance
• Type 5 – Reflecting thick walls - calcification
 Course of the Disease – Hydatid cyst
• cyst eventually may get calcified.
• cyst enlarges and is palpable per abdomen.
• jaundice due to pressure over biliary tree.
• Rupture into the peritoneal cavity causes anaphylactic reaction
• Rupture into biliary channels > sclerosing cholangitis
• Secondary infection causing suppuration and septicaemia
• Disseminated abdominal hydatidosis
 Liver Hydatid cyst - Treatment
• Surgical pericystectomy
• Albendazole : (15mg/kg/day)
– 4 days preoperatively
– 1 month post-operatively
 Hemorrhage
• Primary (during insult)
– Occurs at the time of trauma or surgery

• Reactionary (within 48 hours post op or trauma)

– Usually 4-6 hours post op
– rise of arterial or venous pressure
– Poor surgical hemostasis (slipped ligature) .
– Cessation of reflex vasospasm.
– Platelets dysfunction or thrombocytopenia (hematological disease)
– Coagulopathy (liver disease)

• Secondary (within 48-72 hrs from initial injury)

– Caused by sloughed vessel due to adjacent infection
– Common after hemorrhoid surgery , amputation
 Gastric Ulcers - Types
• Type I : Lesser curviture
• Type II : Body + dudenal
• Type III : Prepyloric
• Type IV: proximal (cardiac)
• Type V : pangstritis

• Type I : hemigastrectomy (billiroth I or Billiroth II)

• Type (II + III) ass with hyperacidity > needs
anterectomy and vagotomy
 Dumping syndrome
• Early (30 min) : rapid movement of hypertonic food
to small intestine. > GI symptoms
• Late (2-3 Hr) Large carbon hydrate load in the small
intestine . Release of too much insulin and causing
hypoglycemia. > neurological symptoms
 Bowel surgery anastomosis
• Types :
– Hand sewn or stapled anastomosis
– Side to side
– End to End
– End to side
• Principals :
– Mainly Double layered
– Starting from the posterior walls
– First layer – inner (by 0-4 vicryl) through submucosa and muscular
layer – continuous locked technique.
– Second layer –outer by (0-4 vicryl) : simple interrupted technique @
seromuscular level.
– Never suture mucosa
 Colon Polyps
1. Inflammatory Ul e ati e olitis, C oh ’s
2. Hamartomatous : ( PJS, juvenile polyps)
3. Neoplastic : Adenoma(Tubular, villous, tubulovillous)
4. Metaplastic : hyperplastic
5. Stromal : lyiomyoma, Lipoma , Hemangioma
 DDx Lower GI bleeding
1. Upper GI bleeding :
1. Peptic ulcer disease
2. Para-esophageal hernia
3. hematobilia

2. Small bowel :
1. mesenteric ischemia
2. Angiodysplasia
3. Me kel's di e ti ulu ….

3. Colo-rectal causes
1. Anatomic : anorectal disease, diverticulitis
2. Vascular : Angiodysplasia, ischemic colitis, Ischemia Irradiation
3. Neoplastic : polyposis, colorectal cancer
4. Inflammatory : : Ul e ati e olitis, oh ’s
5. Infectious : Salmonella , shegella
 ANUS
• 4 cm canal from anorectal junction descends
backwards and downwards to pelvic diaphragm.

• Divided into upper and lower half by dentate line.

• From endoderm to ectoderm.

• Columnar epitheium to squamous epithelium.

 Anal glands
1. Submucosal (80%)
2. Internal sphincter
3. Intersphinteric
4. Penetrate External sphincter
5. With longitudinal muscle

Its ducts open into anus at dentate line between

Morgagni column, if the duct obstruct infection and
abcess will occur.
Perianal Abcess – Classification

1. Perianal. (60%)
2. Ischiorectal.
3. Submucous.
4. Pelvi-rectal.
5. Fissure abscess
 Fistula-in-ano

• Intersphincteric – commonest 70%

• Transphincteric 25%
• Supralevator
• Suprasphincteric 4%
• Extrasphincteric 1%
 Colon Cancer
• Tis : intraepithelial
• T1 : invade submucosa
• T2 : invade muscularis propria
• T3 : invades serosa
• T4 : perforate visceral peritoneum, invade
adjacent structure

• N1 : 1-3 LNE
• N2 : > 3 LNE
Indication for Rt. hemicolectomy
• Neoplasm of the :
– Cecum
– Appendix
– Ascending colon
• Diverticular disease
• Angiodysplasia
• Iatrogenic injury to the cecum
 Anastomosis between SMA and IMA
• Marginal artery of Drummond :
– a continuous arterial circle or
arcade along the inner border of
the colon formed by the
anastomosis of the terminal
branches of the superior
mesenteric
artery (SMA) and inferior
mesenteric artery (IMA).
• Arch of Riolan
– an central arterio-arterial
anastomosis between the superior
and inferior mesenteric arteries.
 Rt . hemicolectomy
1. Under GA in supine position after painting and toweling.
2. Midline incision and open layer by layer.
3. After determination of the extent of the disease we should now
decide the extent of resection (tumor resectability)
4. Mobilization of Rt. Colon through separating the terminal ileum and
cecum from retro- peritoneal attachments with careful to injury of :
1- ureter 2- gonadal vessels 3- duodenum
5. I isio of Toldet’s li e pe ito eu late all u til hepati fle u e .
6. Devascularization by ligation of iliocolic artery and Rt. Colic artery +/-
middle colic artery.
7. Prepare and clear proximal and distal ends to perform anastomosis
(ilium – transverse colon ) end- to – end anastomosis
8. Anchoring of the terminal ileum @ Rt. Lateral abdominal wall.
9. Securing hemostasis, drain placement, closure layer by layer.
10. Dressing

11. Structure removed (cecum, ascending colon , hepatic flexure ,

proximal transverse colon) – at least 30 cm from ileum.
Types of large bowel operations
 Jundice

Jaundice
Prehepatic Hepatic Posthepatic

Crygler- Hepatitis
Obstructive
Hemolytic najjar (viral, Liver mets
jaundice
syndrome Drugs)
Conjagulated (direct bilirubin) water soluble
 Cholecystitis
1. Mostly due to cystic duct or neck of GB stone impaction.
2. Increased intraluminal pressure >> distention
3. GB dysfunction (dysmotility, malabsorbtion)
4. Over production of mucus >> mucocele
5. blood flow compromise to the wall >> hydrops of gall bladder.
6. Bacterial translocation >> Empyema of the GB
U/S finding in acute cholecystitis
1. Impacted stone (neck ,duct )
2. Distended GB (>4cm)
3. Wall thickness (>3mm)
4. Hyperemic GB wall by doppler.
5. Pericholecystic fluid collection
6. Sonographic Murphy's sign
Complication of GBS
1. Acute cholecystitis
2. Acute cholangitis
3. Acute pancreatitis
4. Obstructive jaundice
1. Choledocholithiasis
2. Mi izzi’s s d o e
5. Entero-cystic fistula
6. Gall stone ilius
7. Gall bladder cancer
Pathophysiology of acute pancreatitis
 Acute pancreatitis – Types
1. Interstitial edematous
1. Acute Peripancreatic collection
2. pseudocyst
2. Necrotizing
1. Acute necrotic collection
2. Wall-off necrosis
 Alcohol pathology
• Sphincter of Oddi spasm
• Toxic metabolite of Ethanol @ aciner cells
• Small duct obstruction by protein plugs
• Ethanol cause satellite cell activation > fibrosis
> chronic pancreatitis
Mortality and prognosis
 APACHE – II score
• Acute physiology and chronic health evaluation

• Helpful in determination of mortality in pt with acute

pancreatitis.

• Disease is sever if APACHE – II score > 8

• APACHE – II score = acute physiology score + age points + chronic health points
Significant hemoptysis
hematemesis
 Peritoneal circulation
• 50 ml , circulation through diaphragmatic movement and
peristaltic movement
• Predominantly towards the hepatic flexure .
• cleared in subphrenic space and submesothelial lymphatics
• Linorenal & phrenocolic ligament block fluids @ lt side
Blade type(name) Purpose Shape discibtion
No.10 blade It is generally used for with its large, curved cutting edge, is one of the more
making large incisions traditional blade shapes used in veterinary surgery
in the skin and
subcutaneous tissue,
as well as cutting
other soft tissues.
No.11 blade It has a strong, is an elongated, triangular blade sharpened along the
pointed tip, making it hypotenuse edge
ideal for stab
incisions and precise,
short cuts in shallow,
recessed areas. It is
used in various
procedures, such as
the creation of
incisions for chest
tubes and drains,
opening major blood
vessels for catheter
insertion (cut-downs),
removing the mop
ends of torn cruciate
ligaments, and for
meniscectomy
type Perpose Shape discribtion
No.12 blade It is sometimes utilized as a is a small, pointed, crescent
suture cutter, is used for cat shaped blade sharpened along
declaws and disarticulating the inside edge of the curve
small joints, such as those
between the metacarpals,
metatarsals, and phalanges
during digit amputation.
No.15 blade It is one of the most popular has a small, curved cutting
blades in small-animal surgery edge
because its shape is ideal for
making short and precise
incisions. It is utilized in a
variety of surgical procedures,
including the excision of small
skin lesions, organ biopsy, and
fine neurological applications
No.22 blade It is often used for creating s a larger version of the No.10
large incisions through thick blade with a curved cutting
skin, and for soft tissue edge and a flat, unsharpened
dissection in large-animal back edge
surgery.
 Spread of malignant tumors
• Local spread

• Lymphatic spread:
– By permiation (‫ – )تغلغل‬breast to axilla
– By embolization into distant level of lymph – breast to subclavicular LN group.
– By retrograde lymphatic spread :
- in breast cancer at the opposite breast
- in melanoma through dermal lymphatics (in transite nodules)

• Blood (hematogenous) spread

– By permiation (renal cell carcinoma into renal artery)
– By emboliztion

• Seedling
– Kiss cancer : (Lip, vocal cord, bladder).
– Recurrence at scare of previous oncological surgery.
– Seedling in peritoneal cavity causing intractable ascitis.

• Transcoelomic :
– ku ku e g’s tumor during ovulation.
 Types of biopsies
biopsy is sent in 10% formaldehyde solution for fixation
• Incisional biopsy : taken from the edge of the lesion. (SCC, Large
mass, ,,)

• Excisional biopsy: it takes the whole lesion. (Small lesion, Melanoma)

• Punch biopsy : full thickness skin biopsy taken by pencil-like device

with circular blade.

• Tru-cut biopsy : using specialized device wherein gun with Tru-cut

(folded and punched) tip, so it will cause a minimal trauma.

• FNAC (Fine needle aspiration cytology) : using 23 or 24 gauge needle

fixed to specialized syringe device made for cytological diagnosis –
not histopathological diagnosis.

• Frozen section biopsy : unfixed fresh biopsy but frozen by CO2 gas,
To insure clear margins and floor during the operation.
 Management of Lymphedema
• Conservative : exercise, weight loss, elevation
• Stock wearing, compression garments
• Intermittent pneumatic compression
• Antibiotic
• Topical antifungal
• Wound and skin care
• Manual lymphatic drainage
• Surgery :-
– Excisional
– Physiological (omentoplasty)
– Bypass
– Limb reduction (sistrunk, Ho a ’s, thombson)
 Cross match
• To detect clinically significant (IgG) antibodies
at temperature 37 degree.
• By mixing patient serum with donor RBCs

• After centrifuging FOR one hour :

– No agglutination : compatible.
– Agglutination : incompatible.
 Inguinal Lymph Node Drainage
• Superficial : Below the inguinal ligament (12-20):
– Anterior abdominal wall below umbalicus
– Lower part on anal canal
– External genitalia

• Deep : medial to femoral vein (3-4) and one in

the femoral canal – Clo uet’s ode
– Superficial inguinal LN
– Lower limb.
 Hand Lymphatic drinage
• Thumb + index >> cephalic vein >> infraclavicular lymph node.
• Little and ring finger >> basilic vein >> epitrochlear lymph node
• Middle finger >> deltopectoral lymph node
 T- tube
Especially required when there is need for long term
drainage of bile.
• CBD injury or after CBD exploration. If there were :-
– Stricture (malignant or iatrogenic)
– recurrent CBD stones
• After laparoscopic or open Cholecystectomy if there
were :-
– Explore and drain CBD
– Intra operative cholangiography In case of suspect slipped
stone , biliary tree abnormality.
• Persistent duodenal fistula
• In hepatojujenestomies.
 T-tube
• When to remove??
– 14 days after insertion
• Contraindication to remove?
– Pain or leak after clamping
– Abnormal T-tube cholangiography.
– Cha ot’s t iad RUQ-pain, Fever, jaundice)
 Possible complication
• Fluid and electrolyte imbalance
• Early dislodgment
• Tube dislocation
• Cholangitis
 How to remove T-tube
• Progressive clamping of t-tube at POD 8#
with Observation for (Fever, Jaundice, Pain).

• Post operative day 11 # >> t-tube

cholangiography (to find any leak)

• At day 14 # removal of t-tube by continuous slow

sustain traction , if the patient has:
– good condition (no Charcot's triad)
– normal urine , stool color.
– normal AST, ALT.
– normal cholangiographic study
Macroscopic fi di g i croh ’s Disease
• Terminal ileitis:
– Fairy red terminal ileum
– Skip lesions by palpation
– Thickened incompressible wall .
– Fatty creeping towards the anti-mesenteric side.

• Mesentery:
– Thickening
– fat wrapping
– enlarged LN
Co plicatio of croh ’s disease
 ERCP preparation
(Endoscopic Retrograde Cholangio-pancreatography)

• Stop tacking anticoagulants , antiplatelets.

• PT, PTT, INR should be normal
• I.V.F hydration (correct jaundice)
• no solid food after midnight the night before procedure.
• clear liquids until 6 hours before procedure. Then NPO
• Oral or I.V antibiotic prophylaxis.
•
 ERCP complications
• Pancreatitis : Occur in 5% of all patients , high
amylase (chemical pancreatitis) 20%
• Cholangitis
• Duodenal perforation (retroperitoneal )
• Bleeding (Oddi sphincter injury)
• Sterilization : removing all bacteria , fungi ,
viruses and spores.
• Disinfection: removing bacteria, fungi , viruses
but not spores
• Antisepsis : inhibition of bacterial growth.
 Gastric polyps
• Begnin
– Hyperplastic
– Fundic gland
• Hamartmoatous
– Juvenile polyps
– Peutz-jeghe ’s polyp
• Neoplastic
– Villous
– Tubular
– Tubulo-villous
 Gastric lesions
• Mesenchymal tumors 54% (GIST)
• Ectopic pancreas 16%
• Lipoma
• Carcinoid tumor
• Lymphoma (MALToma, diffuse large B-cell)
• Hemangioma
 Perforated DU
• Dudenal >> graham patch >> how>?
• Gastric >> ??
Macroscopic finding in anal fissure
• Acute fissure
– Superficial
– No induration
– Defined margins

• Chronic fissure :
– Sentinel skin tag
– Anal ulcer with induration
– Hypertrophic anal papilla
 Abdominal mass examination
• Inspection : site , size, shape, overlaying skin (discoloration, tethering)

• Transilumination : hygroma, seroma , hydrocele

• Palpation : movable to underlying structure or to skin, smooth outline

or not, distinct or not, cough impulse. Consistency :
– Hard like elbow
– Soft like nose
– Gurgling : bowel content
– Doughy : omentum

• Auscultation : bruit (vascular origin)

 Abdominal gas
• Normally foun in : stomach, terminal ilium, rectum

• In pediatrics gas in small bowel consider normal

• Come from:
– Airophagia 75%
– Bacterial fermintation 20%
– CO2 Diffusion from blood 5%
– O2 from metabolic oxidation 1%
 Complication of burn
• Early
– Shock : neurogenic, Hypovolemic, septic
– Asphyxia (glottis)
– Inhalational injury
– Fluid and electrolyte disturbances
– Acute gastric dilatation , paralytic ileus
– Cu li g’s duode al ul e
– Acute renal failure (prerenal, renal- myoglobinurea)
– Compartment syndrome

• Late
– Keloid , hypertrophied scar, wound contraction
– Ma joli ’s ul e
 Itching in obstructive jaundice
• Accumulation of bile salts in skin which is irritant to nerve
endings
• Treatment by chlestramine , antihistamine, rifampicin
(cytocrom p-450), UVB

• Jaundice is clinically detectable when bilirubin double normal

range ( above 2.5mmol/l or 35 mg/dl ).
 Damage control surgery
• Used in severely injured patient
• Directed towards saving patients life rather than definitive
surgical repair

• Phase 0 : haemostatic resuscitation

• Phase 1 : abbreviated surgery
• Phase 2 : ICU
– Hypothermia management
– Coagulopathy correction
– Acidosis correction
• Phase 3 : definitive management by second look surgical
repair
 DVT Prophylaxis
• Pre-op
– Determine if the patient at risk by history and physical examination
taking
– weight reduction
– Smoke sensation

• During operation
– Minimize operation time
– Minimize soft tissue dissection
– Intermittent Pneumatic compressor devices if procedure > 60 min

• Post op
– Early ambulation
– If no bleeding tendency and high risk for DVT
• pharmacological prevention : LMWH,UFH, warfarin.
– If there were bleeding tendency and high risk for DVT
• Only mechanical prophylaxis.
 Trauma
• Responsive patient
– AMPLE Hx
– ABCDE

• Unresponsive patient
– Maintain C-spine
– ABCDE
 Neck examination
• General look
– Calm or restless patient
– Eye abnormalities
– Hair loss (eyebrow)
– Sweatiness

• Inspection
– Symmetrical or not
– Site of mass
– Size
– Shape
– Skin overlaying (tethering , discoloration)
– Supra clavicular fossa
– suprasternal notch obliteration . (retrosternal goiter extension)
• Special tests :
– swallowing and tongue protrusion test
– Transilumination test
 Thyroid palpation
While pt sitting down , Physician from behind

• Surface : Mass outline (smooth, nodular, ,, )

• Moving over skin or over underlying tissue
• Moving with swallowing and tongue protrusion.
• Consistency ha d, soft …
• Edge : will , ill defined
• Thrill : at upper pole (superior thyroid artery is superficial)
 Auscultation
• Brui : hyperthyroidism, toxic goiter
– Usually at upper lobe.
 Eye manifestations
• Exophthalmoses : protruded eye ball due to
accumulation of antigen , inflammatory cells ,
polysaccharides at retro-bulbar space.

• Also called Proptosis (sign) by Examination Eye ball

beyond the orbital cavity.

• Upper eye Lid retraction : visible sclera above the

Limbus (overactive muscle of Muller) .

• Lid lag :
• Rare or ncomplete blinking
• Eyelid fullness
• Restriction ocular movement (muscle involvement)
• Ophthalmoplegia , fixed gauze
• Visual filed impairment , even visual loss.
Male breast cancer
Biliary cancers
Panceratic
Gastric cancers
 Drains
• Content amount lock at >> bag
• Content Color look at >>> tube
– Bloody : bright red
– Serosanguineous : pale pink
– Purulent : hazy yellowish-green, brown
– Serous : clear straw color
– Lymph : creamy pink
– Bile : clear greenish yellow, golden (foamy after jarring)
• Neoplasia : uncontrolled cell proliferation , could be:-
– begnin (no spread ability) -Fibroadenoma
– malignant (spread ability) – papillary thyroid carcinoma

• Dysplasia : Change in cell architicture and differentiation

– Ulcerative colitis
– Cervical cancer

• Metaplasia : transformation of a cell type into another with same

differentiation ( same cells architecture ) usually reversible
– Barrett's Esophagitis.

• Hyperplasia : increase in number of cells only

– BPH

• Hypertrophy : increase cell size

– Uterine in pregnancy
 Stoma complication
• Early
– Retraction
– Necrosis
– Detachment
– Excoriation dermatitis
– Poor location

• Late :
– Prolapse
– Stenosis
– bowel obstruction
– Parastromal hernia
 Chest tube
• Upwards and posteriorly > in pnumothorax
• Downwards and posteriorly > in hemothorax and effusion.

• When to remove :
– When there is no further expected benifit
– Trauma
• pnumothorax : If acillating and not bubbling after coughing and
normal CXR can be removed at day 3# post trauma
• Hemothorax : if there is no hematoma on CXR can be removed when
discharge less than 100 cc per day

– Non-traumatic :
• Malignancy : discharge less than 400 cc/day
• Medical : discharge less than 150 cc/ day
In any trauma to chest Open pnumothorax
do ’t forget ECG ,
troponin , Fast to R/O
cardiac injury.

ECG in management of flail chest

 Flail chest
• Three or more consecutive rib fracture in tow or more
places

• Management
– Good analgesia
– Stabilize chest wall : bandage
– If respiratory compromise
• Chest tube + Endotrachial intubation
– No respiratory compromise : full oxygenation and
analgesia or spinal anesthesia .
– ECG monitoring , troponin
– Physiotherapy
 Closed loop syndrome
• Afferent loop syndrome
• Mechanism :
– Complete large bowel obstruction with competent
iliocecal valve .
– Small bowel volvolus
– Internal hernia
– Biliroth II (gastrojujenostomy)
• Bacterial overgrowth >> over consumption of Iron
and B12,B9
• Liqidification of stool by fluid shift >> diarrhea
after constipation.