Systemic Surgery

SYSTEMIC SURGERY
2.1 GIT & ABDOMEN 15
2.2 ORTHO 20
2.3 UROGENITAL 22
2.4 SALIVARY GLANDS 25
2.5 THYROID 27
2.6 BREAST 28

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2.1 GIT & ABDOMEN

1. Esophageal perforation most often caused b/c of INSTRUMENTATION (removal of foreign body)
surgical emphysema of neck n upper chest is pathognomonic Dx: do X-RAY, gastrograffin contrast study if
-ve do dilute barium study/CT scan
2. For perforation of CERVICAL ESOPHAGUS = manage conservatively if abscess=drain by Penrose
drain but For ABDOMINAL ESOPHAGUS = ALWAYS DO SURGERY other indications of surgery: large septic
load, Boer heave, breach in pleura for thoracic esophagus = conservative but if above 4 = surgery
3. Regarding surgical options for esophageal perforation:
i) 4-6 hours = Do primary repair (always stitch the MUCOSA)
ii) >12 hours = edema develops = so; Fill up PROXIMAL END and close DISTAL for feeding = Feeding
jejonustomy after few days apply colon/jejunum graft, by placing T-Tube + local drain placement drain
the proximal end
4. Early endoscopy is mandatory for corrosive esophageal injury and regular follow up ENDOSCOPIES
are advised to assess the development of stricture Do not do N/G aspiration in acute corrosive injury
Feeding jejunostomy can be done
5. Esophageal diverticula may be Traction or Pulsion (false) Zenker diverticula is a pulsion diverticula
which is found Above the upper esophageal sphincter in Killian dehiscence (b/w thyropharyngeas and
cricophrangyus ) patient presents with Slowly progressive dysphagia with regurgitation of undigested food
b/w meals along with foul smelling breath (Halitosis). Leads to lung abscess and tracheal compression
Diagnosed by Barium swallow (endoscopy is contraindicated) Rx: Myotomy with Excision of sac. (Failure
of cricopharyngeus to relax during swallow so pressure increases and divertula forms)
6. A young patient with dysphagia for both solid and liquid, regurgitation ACHALASIA Dx:
i) C-xray: wide mediastinum
ii) Barium: Bird beak appearance
iii) Manometry (gold std) = Increased LES tone with decreased peristalsis Rx: Pneumatic dilatation
If fails = Heller’s Dor Myotomy. Complications of Achalasia = Nocturna cough, lung abscess.
7. Barret esophagus is intestinal metaplasia of lower esophagus increased risk for adenocarcinoma
give PPI and follow up using endoscopy
i) If just metaplasia = endoscopy every 2-3 years
ii) If low grade dysplasia = endoscopy 6-12 months
iii) If high grade dysplasia = ablation with endoscopy; photodynamic; argon laser; plasma
coagulation; esophagectomy
8. Complications of peptic ulcer surgery includes: RECURRENCE; DUMPING SYNDROME; ALKALI
REFLUX/BILE REFLUX; POST-VAGOTOMY DIARRHEA; GASTRIC CA; GALLSTONES; NUTRITIONAL DEFICIENCY
9. Dumping syndrome: Early dumping is due to hypovolemia whereas late dumping is due to
hypoglycemia Dumping will improve with time
10. If reflux gastritis happens... treat by cholestyramine and metoclopramide if persists do ROUX-EN-
Y RECONSTRUCTION
11. A patient on chronic NSAID/peptic ulcer; smoker with sudden onset of pain in abdomen with
distention = PERFORATED PEPTIC ULCER = X-ray = Gas under diaphragm Rx:
i) Resuscitation
ii) Laparotomy with upper midline incision
iii) Wash the peritoneal cavity with Normal saline
iv) Localize the perforation
a) If duodenal = Graham omentopexy

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b) If gastric = simple wedge resection and biopsy/ multiple biopsies and Graham patch.
12. Hepatic adenoma is associated with OCP; found in young women; there are no Kupffercells in it;
it can cause intra-peritoneal bleeding; it can predispose malignancy so do biopsy and do surgical resection
13. Focal nodular hyperplasia is associated with trauma; gives central stellate scars on liver with
radiating septa producing mass effect; it HAS KUPFFER CELLS so detected by SULPHUR COLLOID NUCLEAR
SCAN; not premalignant so no treatment required.
14. Dilated intrahepatic ducts b/c of congenital hepatic fibrosis = CAROLI DISEASE = may lead to bile
stasis and stone formation in the liver if infected: treat by antibiotics drain bile segment of liver can be
removed or Liver transplantation is last resort.
15. Splenunculi are accessory spleens in 10-30% people mostly found at splenic hilum but may be
found In the ligaments of spleen So in patients undergoing splenectomy especially for hematologic disease
always look for Splenunculi and resection them also because they can be site for recurrence
16. Splenic artery aneurysm more common in females; in pregnancy; if it is symptomatic or >2cm
treat by Embolization/ Splenectomy.
17. Splenic infarction caused by myeloproliferative disease, sickle cell, portal vein thrombosis does
not always needs surgery but if it gets infected/abscess formation, do splenectomy.
18. In ITP= splenectomy is done if
i) Failure to steroid therapy
ii) 2 relapses after steroid
iii) Persistent ITP before surgery => if platelet count is low= transfuse platelets, stop giving
platelets once splenic artery is ligated b/c rebound thrombocytosis is happening now.
19. 2 weeks before splectomy = give Pneumovax for strep pneumoniae,; meningococcal vaccine; and
also Hib if patient not got in childhood, if splenectomy has been performed in emergency i.e for trauma =
give these vaccines as soon after surgery before discharge.
20. In HEREDRITY SPHEROCYTOSIS= splenectomy is done after 6 years of age before splenectomy =
do ultrasound to rule out gallstones.
21. Choledocal cyst is dilation of extra/intrahepatic biliary system,
i): fusiform
ii) CBD diverticulum
iii) pancreatic cyst
iv) Intra+extra v) only intra (Caroli disease dx: do USG best is MRCP treat with excision of cyst and
Roux-en-Y hepaticojejunostomy Choledocal cyst: predispose to CHOLANGIOCARCINOMA.
22. Perforation and abscess in diverticulits are strong indications of surgery if Abscess = 1st drain the
abscess percutaneously then after some time = do Resection of segment with end-end anastomosis if
perforation = Do hartman procedure / or / Resection and exteriorization.
23. Investigation of choice for acute diverticulitis = CT scan never do barium/colonoscopy in case of
acute diverticulitis b/c of risk of perforation.
24. Colonic diverticula are acquired disease and the most common site is SIGMOID they never involve
Rectum because its muscle layer is complete and it does not split into tinea they may lead to Fistula
formation (e.g.: VESICO-COLIC most common). In diverticulosis barium and colonoscopy can be done
barium shows SAW TOOTH APPEARANCE.
25. In case of Amebic liver abscess = give trial of Metronidazole 1st; but in case of Pyogenic liver
abscess = USG guided p/c aspiration is effective in 80-90%.; so do it in addition to antibiotics but remember
to treat the underlying cause as well.
26. Femoral hernia is the 3rd most common hernia; more common in females; has high incidence of
strangulation; BELOW AND LATERAL TO PUBIC TUBERCLE; more common on right side; although they have

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more chances of strangulation but they are mostly asymptomatic and unnoticed as compared to inguinal
hernia; differentiate it from Inguinal hernia, sephna varix, femoral lymph node; lipoma, femoral aneurysm
and psoas abscess Treat by
i) Lockwood (infra-inguinal)
ii) Lothessian (transinguinal)
iii) McEverdy (high inguinal) Remember: femoral hernia has got more chance of strangulation
= so always repair it Note: Both indirect and femoral hernia are mostly found on right side.
27. Inguinal hernia is mostly found in males; Indirect in young and direct in elderly; Treatment
principle include
i) Dissection of sac
ii) Ligation of sac
iii) Reduction of sac
iv) Mesh placement if patient refuses surgery = Truss can be used.
28. Umbilical hernia=conical in shape; in children ; rarely strangulate; mostly resolve spontaneously;
wait for 4 years---> if not resolve--->do herniorapphy.
29. Gastrinomas (ZES) are mostly malignant found in gastrinoma triangle associated with MEN1 labs
reveal increased fasting gastrin >1000pg/ml confirmed by SECRETIN STIMULATION in which after secretin
>200pg/ml rise in gastrin takes place.
30. After doing left hemicolectomy colostomy should be done if gut is not prepared (e.g: if emergency
intestinal obstruction b/c of left colon ca= do resection and colostomy b/c gut was not prepared in
emergency) but after doing right hemicolectomy anastomosis can be effectively done (no need of
colostomy/ileostomy).
31. Sudden onset of abdominal pain with tyre like feeling; x-ray showing OMEGA SIGN= SIGMOID
VOLVOLUS = Do rigid sigmoidoscopy and try to reduce it if fails do laparotomy if area is dead = resect and
do double barral colostomy if viable do sigmoid colectomy and Hartman procedure.
32. Most common clinical presentation of Merkel diverticulum is PAINLESS BLEEDING P/R others:
Diverticulitis, intestinal obstruction, intussusception, peptic ulcer, volvulus, Hernia of litter Investigation
of choice=Tc-99 scan (detects gastric mucosa/bleeding diverticula), Angiography (detects vitellointestinal
artery) Rx: Segmental resection; Merkel diverculectomy Merkel diverticulum is the most common
congenital abnormality of GIT a silent merkel diverticulum if found incidentally on any operation should
be ONLY RESECTED IF IT IS THICK WALLED or NARROW MOUTH. Merkel diverticula has its own blood
supply.
33. Cholangiocarcinoma = Adenoca of intra/extrahepatic biliary apparatus most common risk factors
are PSC & CHOLEDOCAL CYSTDx: ERCP, Endoscopic USG, PTC (especially useful for tumor at confluence)
Do resection, bypass, bilioenteric anastomosis, stenting.
34. Most common mesenteric cyst is Chylolymphatic; it is thin wall; has independent blood supply; so
treat by ENUCLEATION.
35. Other mesenteric cyst is ENTEROGENOUS; it is thick wall; has common blood supply with
intestine; so ALWYAS RESECT INTESTINE WITH IT.
36. In Achalasia; the constricted portion has normal ganglion cells while the dilated portion has
absent/few ganglion cells.
37. In Hurschprung disease: M>F; the constricted portion is ABSENT in ganglion cells while dilated
portion is NORMAL NERVE TRUNKS UNDERGO HYPERTROPHY most common site: RECTUM….. Risk factor:
Down/familial Neonate: Delayed passage of meconium; Abdominal distention; bilious vomiting Child:
Chronic constipation; abdominal distention; failure to thrive Dx: full thickness rectal biopsy (best), Barium
enema shows coning; Anorectal manometry Tx:

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i) Do colostomy (imp 1st step correct nutritional status when child is over 10kg
ii) Swenson (pull through)
iii) Soave (resection and anastomosis with sleeve mucosectomy of anal canal and rectum) in
old
iv) Duhamel
v) Transanal
vi) Myomectomy
38. Angiodysplasia: AV malformation of Ascending colon; >50 years most common site: cecum
associated with aortic stenosis and v-wb disease Dx: Angiography,Colonoscopy, Tc-99 RBC scan Rx:
excision/ colectomy.
39. Most common site of small bowel diverticula = JEJNUM Duodenal diverticula are on 2nd and 3rd
part and on MESENTERIC BORDER…. While merkel diverticulum is on ANTIMESENTERIC BORDER.
40. Colonic diverticula are acquired disease and the most common site is SIGMOID, They never
involve Rectum b/c its muscle layer is complete and it does not split into tinea they may lead to Fistula
formation (e.g.: VESICO-COLIC most common) in diverticulosis barium and colonoscopy can be done
barium shows SAW TOOTH APPEARANCE.
41. Investigation of choice for acute diverticulitis = CT scan never do barium/colonoscopy in case of
acute diverticulitis b/c of risk of perforation For uncomplicated diverticulitis: bed rest, antibiotics,
analgesics and barium enema after acute phase subsides Perforation and abscess in diverticulitis are
strong indications of surgery if Abscess = 1st drain the abscess percutaneously then after some time = do
Resection of segment with end-end anastomosis if perforation = Do hartman procedure / or / Resection
and exteriorization
42. Ulcerative colitis : Less common in SMOKERs; presents with bloody diarrhea with mucus; Loss of
haustrations on barium enema, pseudo polyps Most common site involved= RECTUM (40%) may lead to
TOXIC MEGACOLON indicated by colon diameter on X-RAY >6cm Do surgery if:
i) Dysplasia
ii) Toxic megacolon
iii) Steroid dependant
iv) Extra intestinal
v) Sever hemorrhage/stenosis
vi) Fulminant not medical responsive
vii) Fever, tachycardia, hypoalbunimia, >6 stools/day viii) Chronic disease with anemia, tenesmus,
and urgency Surgical options:
i) Total proctocolectomy + end-ileostomy (for toxic/ in old)
ii) Restorative proctocolectomy + ileo-anal pouch (park) preferred elective surgery
iii) Rectal and anal dissection
iv) Colectomy with ileo-anal anastomosis
Ileostomy with a continent intra-abdominal pouch (Kock’s)Risk of MALIGNANT TRANSFORMATION
increases in U.C if:
i) Pancolitis
ii) Disease starting in childhood
iii) Long duration of disease overall risk is 3.5% 2% at 10 years; 8% at 20 years ; 18% at 30
years as after 10 years 2% chance is there = so do colonoscopy every 10 years and if signs
of dysplasia found = do surgery Role of Colonoscopy in U.C:
i) To see proximal extent of disease
ii) To diff it from crohn

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iii) To see response to therapy
iv) To see for malignant change NEVER DO COLONOSCOPY IN TOXIC
MEGACOLON
43. Palpable mass in Right iliac fossa:
i) Crohn disease
ii) Ileocecal TB
iii) Ameboma
iv) Carcinoma of cecum
v) Appendicular mass (Peri-appendicular Phlegmon)
vi) Actinomycosis of cecum.
44. Grid-iron incision is given for appendectomy if the diagnosis of appendicitis is certain;
ILEOHYPOGASTRIC NERVE is vulnerable to damage and so RIGHT INDIRECT INGUINAL HERNIA is a
complication of this (skin/sub/fasica/ext oblique = cut in line of incision) (internal ob/trans = splitted).
45. Rutherford-Morrison incision is given for para/retrocecal and fixed appendix (all layers are cut in
line of incision).
46. Lanz incision: transverse skin crease 2cm below umbilicus.
47. Lower midline incision is used when diagnosis is in DOUBT.
48. Ileoinguinal nerve is damaged in hernia repair = leads to anesthesia on root of penis.
49. Acute appendicitis: Pointing sing; Rovsing sign; Psoas sign; Obturator sign.
50. Rovsing: palpation of left iliac fossa = pain in right iliac fossa b/c of displacement of gas.
51. Psoas: Hip flexion relieves pain = +ve in Retrocecal appendix.
52. Obturator: Hip flexion +internal rotation = pain in hypogastrium +ve in Pelvic appendix.
53. Most common location of appendix = RETROCECAL Then Pelvic.
54. In post-ileal position of appendix= no typical symptoms of acute appendicitis = so missed
appendix…diarrhea is there.
55. Most common tumor of appendix = Carcinoid…most common location= distal part of appendix
Rx: If <2cm = Appendectomy If >2cm = Right hemicolectomy Carcinoid tumors of appendix rarely
metastasize.
56. Adenocarcinoma of appendix = Rx by Right hemicolectomy.
57. For Peri-appendicular phlegmon OSCHNER SHERREN REGIMEN is used.

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2.2 ORTHO

1. Newborn with uneven gluteal folds; limitation in abduction; limp; positive barlow and ortolani est
= DDH= more common in females; Do ultrasound and xray = Treat with Flexion+Abduction splinting with
Palvlick harness, after 1 year = open reduction with bony realignment by spica cast. Risk factors: family,
breech, spina bifida.
2. Under 2 years child with Limp and pain in groin/knee/thigh; abnormal gait; = Legg-Perthes disease
= Do AP & lateral x-ray for diagnosis=shows small and dense femur head; (LPD is avascular necrosis of
epiphysis of femur).
3. Adolescent with Limp and pain in groin/knee/thigh; legs showing external rotation=Slipped capital
femoral epiphysis (dislocation b/w epiphysis and metaphysis) = do x-ray and do immediate emergency
repair.
4. Young child after respiratory tract infection; decreased leg movements; painful leg and flexed,
abducted and externally rotated = Septic arthritis.
5. Fracture where one side of bone is bent and other side fractured = Greenstick fracture Cortex is
partially broken.
6. Abducted arm; prominent acromion; externally rotated (just like shaking hand position); after
injury to shoulder; = ANTERIOR DISLOCATION OF SHOULDER= do lateral and AP XRAY= Treat after ATLS
and proper analgesia : do CLOSED REDUCTION by
i) Kocher method of TEAR
ii) Hanging arm/gravitational method
iii) Hippocrite method Complications:
i) Nerve damage: Axillary, brachial plexus
ii) iMuscle injury: Supra-spinatus
iii) Recurrent dislocation
iv) Bone damage: Compression fracture of humerus
v) Cartilage injury: Injury to glenoid labrum (bankart lesion).
7. Adducted arm; internally rotated after attack of EPILEPSY = POSTERIOR DISLOCATION OF
SHOULDER Humeral shaft = radial nerve damage = 2-3 week conservative with splint= Immediate surgery
= if brachial artery injured For radial nerve: 1st manage conservatively; but if fracture heals but nerve not
= Use nerve graft.
8. Young child fall on outstretched hand = SUPRACONDYLAR FRACTURE= 97% EXTENSION; 3%
FLEXION type 3= complete dissplacement = Do closed reduction but if fails/ vascular injury = ORIF (open
reduction and int.fixation) by K-wires Complications: A) EARLY : Nerve(anterior interroseous, median,
radial, ulnar); Arterial (Brachial artery; Volkman ischemic contracture), compartment syndrome, soft
tissue injury, wound infection, heamarthrosisB) DELAYED: Non-union, mal-union, delayed union, joint
atrophy, Sudehk atrophy, myositisossificans.
9. Malunion in case of SUPRACONDYLAR FRACTURE leads to CUBITUS VARUS (gun-stock deformity).
10. Anterior interroseous nerve is most common nerve injured in supracondylar fracture.
11. Volkman ischemic contracture is PERMANENT FLEXION CONTRACTURE of hand and wrist leading
to claw hand b/c of compromise of BRACHIAL ARTERY leading to muscle fibrosis.
12. Old aged; osteoporotic women fall on outstretched hand = Dinner fork deformity = COLLE'S
FRACTURE= extra-articular fracture of lower part of radius within 2.5cm Do X-ray ap and lateral after ATLS
and analgesia

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i) NON-OPERATIVE: volar forearm splint temporarily, close reduction--->apply cast ---> place
arm in palmar flexion and ulnar deviation
ii) OPERATIVE: if above fails (internal fixation)
iii) PER-CUTANEOUS wires may also be placed
13. Old age and fall on flexed hand = smith fracture.
14. Young age ; fall on outstretched hand wrist pain and tenderness over ANATOMICAL SNUFFBOX =
SCAPHOID FRACTURE do X-RAY : XRAY will be absolutely normal b/c the fracture is obvious after 2-3
weeks. Rx
i) Thumb spica cast
ii) Repeat x-ray after 3 weeks if un-displaced = apply plaster; if displaced = ORIF
Complications:
i) High rate of NON-UNION
ii) ii) AVASCULAR NECROSIS of proximal pole.
15. X-RAY does not show any finding in SCAPHOID FRACTURE so repeat should be done after 3 weeks.
16. PROXIMAL ULNA FRACTURE with DISLOCATION OF RADIUS = Montegia fracture.
17. FRACTURE OF RADIUS with DISLOCATION OF ULNA = Gellazi fracture.
18. Both mottegia and gellazi fracture need ORIF.
19. Intracapsular fracture of Femoral neck leads to ischemia and avascular necrosis of femoral head
If it is Undisplaced: INTERNAL FIXATION+DYNAMIC HIP SCREW if Displaced: ARTIFICIAL HEAD/THR by
prosthesis but do DHR in young pts old patients if immobilized are increased risk of DVT SO GIVE POST-
OP anticoagulation as well.
20. Smith Peterson nail is used for fixation of fracture of neck of femur.
21. Fracture of femoral shaft:
i) Infant = Use Galow traction
ii) Child = balanced traction
iii) Adult= Intramedullary nail fixation
22. Femoral shaft fracture leads to extensive blood loose: so RESUCITATION is the key element in
management.
23. Flexion and rapid rotation e.g. during kicking football; normal x-ray; Click sound in knee when
knee is extended = Medial meniscus tear DO MRI ARTHROSCOPIC REPAIR/ Menisectomy.
24. Football injury; severe knee pain; pain on MEDIAL aspect; ABDUCTION more than normal (valgus
stress test) = INJURY TO MEDIAL COLLATERAL LIGAMENT.
25. Football injury; severe knee pain; pain on LATERAL aspect; ADDUCTION more than normal (varus
stress test) = INJURY TO LATERAL COLLATERAL LIGAMEN use HINGED CAST for both these ligament
injuries.
26. Football injury; knee pain and swelling; on knee flexion leg at 90 o is pulled anteriorly (Anterior
drawer sign) and also on fixation of knee at 20 o pulls anteriorly (Lachman test) = ANTERIOR CRUCIATE
LIGAMENT TEAR do MRI Immobilize the patient/ arthroscopic reconstruction.
27. For bone tumors from epiphysis; metaphysis; diaphysis (GOE)
i) Epiphysis = Giant cell tumor: soap bubble appearance on x-ray... do surgery
ii) Metaphysis = Osteosarcoma: sun-burst/ codman triangle on xray... surgery; chemo; radio
iii) Diaphysis = Ewing sarcoma: Onion peel appearance on xray... chemo; radio; surgery
28. Pelvis fracture: severe bleeding is main problem (1500-2000)…… Ischial tuberosity is not fractured
Most are not displaced. Separation of pubic symphysis = open book fracture.

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2.3 UROGENITAL

1. Kidney fusion at lower poles in front of L4 = Horseshoe kidney increased risk of infection and
stone formation.
2. Intermittent and moderate hematuria is a feature of APKD: 75% have hypertension, USG inv of
choice; IVU shows stretched calyces; Rx by Rovsing operation, low protein diet, Renal transplant.
3. Cystic dilation of intra-mural portion of ureter is called URETEROCELE and it gives "ADDER HEAD"
DEFORMITY on urography patients are increased risk for stone formation. Treat by endoscopic diathermy.
4. The most common cause of ureteric injury is IATROGENIC (hysterectomy & gut surgery), and the
best way to prevent this is to place PRE-OPERATIVE STENT in the ureter to enable better palpation of
ureter during surgery if it gets injured:
i) either do end to end anastomosis if injury is large so that tension will happen on ureter if
anastomosed then u can do
ii) Mobilize the kidney
iii)Take flap from bladder (Boari flap)
iv) Flap from appendix
v) Insert ureter into opposite ureter
vi) Ureterosigmoidostomy
5. Pelviureteric junction obstruction (PUJ) leads to unilateral hydronehprosis treatment is
PYELOPLASTYS.
6. Kidney stones: (CPU) 90% kidney stones are RADIO-opaque
i) Calcium oxalate: most common; irregular with sharp projections and give rise to hematuria.
ii) Phosphate (staghorn/struvite) due to proteus or staph (in alkaline urine).
iii)Uric acid stones are RADIOLUCENT confirmed by CT.
iv) Cystine stones are resistant to ECSWL b/c they are hard.
7. Stone <5mm passes spontaneously... so manage it conservatively.
8. If there are bilateral stones the better functioning kidney should be treated first.
9. ECSWL is indicated for kideny stones <2cm and for ureteric stones <1cm C.I: Pregnancy,
uncontrolled coagulopathy, uncontrolled hypertension, UTI, Urinary tract obstruction.
10. Ureteric stones produces pain but if it completely obstructs the ureter PAIN STOPS the best
treatment of ureteric stones >1cm is URETEROSCOPIC STONE EXTRACTION and it is superior to DORMIA
BASKET.
11. Stones which are formed in kidney; if they pass and go to bladder they are called PRIMARY
BLADDER STONES whereas SECONDARY BLADDER STONES are those which form in bladder b/c of BOO,
infection or foreign body bladder stones are treated by LITHOLAPAXY.
12. Urethral stricture, contracted bladder and large stones are contra-indications of LITHOLAPAXY so
here u can do
i) PERCUTANEOUS SUPRAPUBIC LITHOLAPAXY
ii) ECSWL
13. PYONEPHROSIS occurs b/c of
i) Acute pyelonephritis
ii) Renal stone
iii) Pre-existing hydronephrosis it should be treated aggrasively b/c sepsis can take place
i) Do NEPHRECTOMY if other kidney is normal
ii) PERCUTANEOUS NEPHROSTOMY if patient is too sick for surgery

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iii) If pus is thick=OPEN NEPHROSTOMy
14. Flank pain; Fever; Pus cells in urine = Acute pyelonephritis.
15. Flank pain; fever; flank mass; pus cells in urine; = Pyonephrosis.
16. Flank pain; fever; flank mass; 1st no pus cells but later pus cells in urine = Renal carbuncle (abscess
it is caused by hematogenous spread and CT is investigation of choice for it Percutanous drainage.
17. Flank pain; fever; flank mass; NO pus cells in urine = PERINEPHRIC ABSCESS Ultrasound
differentiates it from RENAL ABSESS but investigation of choice is CT Treat: Percutaneous Aspiration with
wide bore needle.
18. TB of KIDNEY AND BLADDER = pain relieved by micturation; sometimes painlesshematuria sterile
pyuria (no organisms but pus cells are in urine On cystoscopy u will find: i) Linear ulcers ii) Hunner ulcer
iii) Golf hole appearence of ureteric orifice iv) Timble bladder for kidney TB... give ATT and after that do
nephrectomy (if kidney function lost) if bladder is contracted (timble) = do Augmentation cystoplasty.,
instill dimethylsulphoxide.
19. TB of epidydymitis and and testis is very resistant to ATT so do surgery.
20. For RCC = in early stage do RADICAL NEPHRECTOMY use TRANS-PERITONEAL APPROACH: Do not
mobilize the kidney until RENAL ARTERY AND VEIN PEDICLE IS TIED also PALPATE RENAL VEIN for any
deposit.
21. Most effective treatment for SUPERFICIAL BLADDER CA = INTRAVESICAL CHEMOTERAPY (BCG).
22. Blow on distended bladder = Intraperitoneal rupture of bladder.
23. Pelvic fracture = extraperitoneal rupture.
24. Abdominopelvic injury; urinary retention; scrotal hematoma; blood at tip of penis = Urethral
injury Do ascending urethrogram + suprapubic cystostomy.
25. Abdomniopelvic injury; no urinary retention; hematuria on folley may be KIDNEY or BLADDER
INJURY ascending cystogram will diagnose for BLADDEER RUPTURE while IVP, CT, USG for kidney injury.
26. Priapism is caused by SICKLE CELL DISEASE, INJ OF PAPAVERCINE.
27. Most common part of urethra which is ruptured in PELVIC FRACTURE = MEMBRANOUS URETHRA
–o.
28. Cryptorchidism mostly unilateral (on right side)do surgery after 1 year and before the child goes
to school complications:
i) Cancer
ii) Torsion
iii) Trauma
iv) Atrophy
v) Hernia Orchidopexy is done but it does not reduce the chance of malignancy in testis.
29. Sudden onset of testicular pain TESTICULAR TORSION differentiate from EPIDYDIMOORCHITIS by
PREHN SIGN Doppler USG is confirmatory but do immediate surgery ORCHIDOPEXY (by scrotal incision)
other normal testis should also undergo ORCHIDOPEXY.
30. For testicular tumors ALWAYS DO HIGH-INGUINAL ORCHIDECTOMY (not scrotal) after histological
diagnosis for SEMINOMA = RADIOTHERAPY for TERATOMA = CMBV Cisplatin, methotrexate, bleomycin,
vincristine retroperitoneal lymph node dissection can also be done.
31. Congenital hydrocele is the only hydrocele which is treated by HERNIOTOMY; and it
communicates with peritoneum it presents with intermittent hydrocele when patient lies down =
hydrocele disappears if congenital hydrocele is bilateral = think about ASCITIES.
32. Hydrocele and Epidydimal cyst = both are trasilluminant + but hydrocele is not separated from
testis wehreas Epidydimal cyst is separated from testis; is bilateral mostly and feels like bunch of grapes.
33. For other hydroceles = do either Jobuley repair (eversion of sac Lords plication).

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34. Spermatocele is UNILOCULAR retention cysts arising from epididymis fluid resembles BARLEY
WATER and contains spermatozoan mostly located on upper pole.
35. REMEMBER= NEVER EVER USE SCROTAL APPROACH FOR ORCHIDECTOMY FOR TESTICULAR
CANCER JUST USE HIGH-INGUINAL APPROACH.

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2.4 SALIVARY GLANDS

1. There are 450 minor salivary glands and contribute 10% saliva. They are histologically similar to
major salivary glands and may be found on lip mucosa. Their tumors are more likely to be malignant (90%)
as compared to major salivary glands.
2. If any salivary gland tumor is <1cm and benign = do EXCISIONAL BIOPSY.
3. Sublingual gland lies on mylohyoid muscle. It is paired and each of the part has more than one
duct. 85% of Sublingual gland tumors are Malignant and treated by Wide excision with neck dissection.
4. Mucus retention cyst of sublingual gland = Ranula translucent swelling on floor of mouth (just like
frog belly); brilliantly transillument Rx: excision of cyst and sublingual gland.
5. TUMORS:
i) 90% minor salivary glands = Malignant
ii) 85% sublingual gland = Malignant
iii)50% submandibular gland = Malignant
iv) Very low PAROTID tumors are malignant and mostly are benign Means: smaller the gland =
more likely the chance of malignancy.
6. Inflammation of submandibular gland = Sial-adenitis= leads to radio-opaque stone formation.
7. Stone in salivary gland = Sialo-lithiasis: = Swelling precipitated by eating and relieved 1-2 hrs after
meal
i) Submandibular stone= RADIO-OPAQUE; Dx by XRAY; remove by longitudinal incision most
common stone in salivary gland: SUBMANDIBULAR
ii) Parotid stone = RADIOLUCENT; dX by Sialography (USG) remove along with parotid gland Do
not do Sialography in acute suppurative parotitis.
8. Parotid gland lies on MASSETER it contains:
i) Facial nerve
ii) External carotid artery
iii) Retromendibular vein.
9. Most common benign tumor of parotid = PLEOMORPHIC ADENOMA = mostly involves the
superficial lobe of gland= if long standing- y Dx: FNAc Rx: Superficial
parotidectomy (Never do just enucleation b/c of risk of recurrence If deep lobe involved so that tonsils
are pushed medially = total parotidectomy.
10. Signs of malignancy: i) Recent size increase ii) Involvement of skin iii) Facial nerve palsy iv) Cervical
lymphadenopathy.
11. Most common malignant tumor of parotid = MUCOEPIDERMOID CARCINOMA Dx: FNAC Rx: If low
grade = Superficial parotidectomy (patey’s operation If high grade = Radical parotidectomy Acini cell
carcinoma is low grade and exclusively found in parotid.
12. Complications of parotid surgery: Hematoma, seroma, frey, infection, facial nerve palsy, great
auricular nerve damage.
13. Frey syndrome = gustatory sweating b/c of regeneration of parasymphatic fibers Dx: Iodine starch
test Rx: Tympanic neurectomy, botulinm toxin PREVENTION: Place muscle flap from SCM between skin
and parotid/ facial flap/ insert artificial membrane.
14. All salivary glands tumors are most commonly found in parotid gland except i) Adenoid cystic
carcinoma = Minor salivary gland ii) Squamous cell carcinoma = Submandibular gland.
15. Most common benign tumor of salivary glnad = pleomorphic.
16. Most common malignant tumor of salivary gland = mucoepidermoid.
17. Most common malignant tumor of minor salivary gland = adenoid cystic carcinoma.

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18. Most common bening tumor of paotid in children = hemangioma.
19. Most common radiation induced neoplasm of salivary gland = mucoepidermoid carcinoma.
20. All parotid tumors are more common in females except WARTHIN TUMOR which is most common
in males; WARTHIN TUMOR arise exlusively from parotid gland; mostly found in tail of parotid; 10%
bilateral; Rx by SUPERFICIAL PAROTIDECTOMY.
21. Adenoid cystic carcinoma is most common malignant tumor of minor salivary glands; it is low
grade; and shows PERI-NEURAL INVASION.

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2.5 THYROID

1. For thyrotoxicosis: if <45 years = do surgery >45 years = Radioiodine ablation.

2. If Goiter and thyrotoxicosis appear simultaneously = primary thyrotoxicosis.
3. If goiter appears early and thyrotoxicosis late = secondary thyrotoxicosis.
4. Cardiac signs are more pronounced in Secondary whereas eye signs are more pronounced in
primary thyrotoxicosis.
5. Investigation of choice for TOXICITY with NODULARITY = Thyroid scan.
6. Treatment of choice for solitary thyroid nodule = Lobectomy/Hemithyroidectomy.
7. Papillary carcinoma: radiation exposure is a risk factor; It is bilateral and Multifocal in origin;
spreads through lymphatics; has best prognosis; diagnosed easily by FNAC; treated by TOTAL
THYROIDECTOMY with neck dissection. & post op radio-iodine.
8. Follicular carcinoma: endemic goiter is a risk factor; unifocal; more aggressive than papillary;
haematogenous spread; poor prognosis and greater recurrence rate; can ‘not be diagnosed with FNAC;
treat by TOTAL THYROIDECTOMY with neck dissection & post-op radio-iodine.
9. Medullary carcinoma: RET proto-oncogene mutation; associated with MEN-2; mulcentric c-cell
hyperplasia; spreads to lymph nodes; high levels of CEA and CALCITONIN Treat with TOTAL
THYROIDECTOMY with neck dissection but there is NO ROLE OF POST-OP RADIO-IODINE... If at any time
in patient life RET oncogene is found in screening do prophylactic thyroidectomy even if there is no
evidence of medullary carcinoma.
10. Anaplastic carcinoma: Worst tumor; diagnosed by TRU-CUT biopsy treat with radiotherapy ... but
if TRACHEAL OBSTRUCTION= do ISTHMUSECTOMY remember: never to tracheostomy if emergency
tracheal obstruction has happened b/c of anaplastic ca always do isthmusectomy b/c tracheostomy may
cause it to spread.
11. Lymphoma: associated with autoimmune thyroiditis; diagnosed by FNAC but needs further
confirmation by TRUCUT for early stage = radiotherapy, for late = chemo.
12. The most common cause of respiratory distress after thyroidectomy is TENSION HEMATOMA/
Reactionary hemorrhage leading to Laryngeal edema........ Rx: Do wound exploration and secure airway
Early comp of thyroidectomy: Hemorrhage, Infection, thyroid strom, Nerve (RLN, ELN), Respiratory
obsturection Late: Insuff, recurrence, Exophtlamos, Keloid, stitch granuloma, Parathyroid insuff.
13. After papillary and follicular carcinoma of thyroid to prevent recurrence of thyroid; SUPRESSIVE
DOSE OF THYROID is given (200ug) but after medullary carcinoma.... REPLACEMENT DOSE IS GIVEN
(150ug).
14. Technicium-99 sistimibi (MIBI) isotope scan localizes the Parathyroid gland before surgery if after
recurrence: localize by CT, PET, MRI, arteriography Adenoma: remove if hyperplasia: remove all 4 glands
& implant 50mg parathyroid tissue in brachioradialis.
15. Insulinoma : whipple triad C-peptide.
ZES = gastrinoma = malignant =found in gastrinoma triangle = Fasting gastrin: >1000ng/dl SECRETIN
STRIMULATION TEST : >200pg/ml increase secretin.

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2.6 BREAST

1. Fibroadenoma (1-2cm): most common breast tumor <35 years... firm rubbery mass (Breast
mouse) do triple assessment Excision / enucleation.
2. If fibroadenoma>5cm = Giant fibroadenoma.
3. Phyllodes tumor: females >40 years mass >5cm Arise from proliferation of stroma have somewhat
malignant potential do triple assessment Rx by Wide local excision with rim of normal tissue.
4. Bloody discharge from nipple without any palpable mass = Intra-ductul PAPILLOMA do triple
assesment..... Rx by Microdiscetomy.
5. Bloody discharge from nipple with palpable mass = Breast cancer.
6. Galactorrhea: milky discharge from nipple Most common physiological cause: nipple stimulation/
sexual intercourse Most common pathological cause: Prolactinoma Most common non-pituitary
pathological cause: Hypothyroidism.
7. Galactocele is associated with use of OCP = do aspiration.
8. Smoker female with greenish brown / greenish black discharge, slit like nipple retraction and
painful sub-areolar mass, sometimes fistula formation = DUCTECTASIA/PERIDUCTUL
MASTITIS/PLASMA CELL MASTITIS = Do triple assessment = Rx: antibiotics and Hadfield operation
(Cone excision) / Microdochectomy (tennis racquet incision) Hadfield operation: done if the site of
discharge is uncertain Cone of tissue removed and defect filled by purse suture/suction drain.
9. Breast cancer <3cm = Do Breast conservation therapy >3cm = Modified radical mastectomy.
10. Breast conservation therapy includes:
i) Wide local excision with 1cm healthy margin
ii) Axillary lymph node dissection
iii) Post-op Radiotherapy.
11. Modified radical mastectomy: Whole breast along with nipple areola removed; axillary lymph
nodes upto level 2; PECTORALIS MINOR IS ALSO REMOVED but PECTORALIS MAJOR NOT.
12. Post op hormonal therapy: premenoupasal = Tamoxifen postmenopausal = Anastrazole.
13. Tamoxifen decreases the recurrence and incidence of bone mets ... also decreases the death rate
and should be given for 5 YEARS.
14. The most common indication for post-op RADIOTHERAPY is BREAST CONSERVATION THERAPY....
it decreases the recurrence but not METS.
15. After radiotherapy and axillary dissection = Chance of LYMPHEDEMA IN ARM INCREASES.....and
this LYMPHEDEMATOUS arm may transform into MALIGNANT= ANGIOSARCOMA/
LYMPHANGIOSARCOMA.
16. In pregnancy with breast cancer; No radiotherapy in pregnancy No chemotherapy in 1st trimester.
17. Slit like retraction = periductul mastitis.
18. Circumferential retraction = Carcinoma.
19. Benign horizontal retraction (simple nipple inversion of unknown etiology).

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