Problem solving : a quiz in general surgery.pptx

surgical cases, anatomy, and operations. (question and answer)

1. Problem solving T eam E

2. Question 1

3. 4 week old male infant presented with dehydration and non-bilious, projectile vomiting after each feeding. Abdominal U/S was done. 1- What are the U/S findings? 2- What is the diagnosis? 3- Mention the risk factors for this condition. 4- How to treat this condition?

4. Answer : 1- The longitudinal plane shows elongated pylorus with thickened pyloric muscle. The length was 16 mm (upper limit of normal 14 mm), and the muscle thickness was 4 mm (upper limit of normal 3 mm). This image also shows the “ antral nipple sign ” - redundant pyloric mucosa protruding into the gastric antrum , and the “ cervix sign ” - indentation of the pylorus into the fluid-filled antrum . On the short axis, the hypertrophied pyloric canal gives the appearance of 'target sign '. 2- Infantile H ypertrophic P yloric S tenosis.

5. 3- Risk factors : Male sex. White race. F irst-born infants (30% to 40% of cases). P reterm birth. M acrolide antibiotics. B ottle feeding. Smoker mother.

6. 4- Treatment : Fluid resuscitation and correction of electrolyte abnormalities and metabolic alkalosis. Surgical treatment : Ramstedt (open) pyloromyotomy . Laparoscopic pyloromyotomy . Gastric peroral endoscopic myotomy (G-POEM ).

7. Question 2

8. 7 5 year old patient presented with asymptomatic, slowly growing skin lesion in the temporal region of 9 months duration. 1- Describe the lesion. 2- What is the diagnosis? 3- What are the most commonly involved body sites? 4- What are the risk factors of this condition? 5- Mention the treatment modalities.

9. Answer : 1- a well demarcated solitary erythematous scaly plaque. 2- Bowen's disease : is an in-situ squamous cell carcinoma of epidermis . 3- Common in photo-exposed areas of skin : Head and neck ( 45%) (most common site). L ower extremity (30%). U pper extremity (20%). T runk ( 6%).

10. 4- The risk factors include : Immunosuppression. Human Papilloma Virus (HPV) infections. Ultraviolet light exposure . Arsenic exposure I onizing radiation. Thermal skin injury. Age more than 60. Caucasian race. F air skin. Photo-sensitive individuals. Increase in total occupational and recreational sun exposure.

11. 5 - Therapeutic options are: Topical chemotherapy : (Fluorouracil). Surgical modality (Excision): minimum of 4 mm margin in well-defined lesion of <2 cm in diameter and at least 6 mm margin for larger lesion. Destructive modality: (Cautery, Cryotherapy ). Light-based procedures: (Photodynamic therapy, Lasers).

12. Question 3

13. A 29-year-old woman , with no particular past medical history, presented with subcutaneous induration in the right breast. 1- Describe the images. 2- What is the diagnosis? 3- What are the involved structures? 4- How to manage this condition?

14. Answer : 1- Cord-like subcutaneous induration in the periareolar region of the right breast. Mammography demonstrates superficially located tubular beaded hyperdensity (yellow arrows ). Colored D oppler Ultrasound shows tubular anechoic structure with beaded appearance with no internal blood flow due to clotting. 2- Mondor’s disease of the breast : is a syndrome of sclerosing superficial thrombophlebitis of the veins of the breast and anterior thoracic wall.

15. 3- Mondor disease may involve one or more of three venous channels: the thoracoepigastric vein. the lateral thoracic vein. the superior epigastric vein. The upper inner portion of the breast is never involved. Illustration of the venous channels involved in Mondor disease. A is superior epigastric vein. B is thoracoepigastric vein. C is lateral thoracic vein

16. 4- M anagement : In general, MD is a self-limited , resolves in four to eight weeks without any specific treatment. Supportive care and expectant management are sufficient in most cases. Warm compresses. Nonsteroidal anti-inflammatory medications. A bstinence from tight clothing and strenuous activities. low molecular weight heparin or aspirin (only when there is underlying hypercoagulable state).

17. Question 4

18. T his is an intraoperative image of neck dissection. 1- Name the structures with colored markers. 2- What are the cervical lymph nodes groups? 3- What are the types of neck dissection?

19. Answer : 1- MH : mylohyoid muscle. DG : digastric muscle. SAN : spinal accessory nerve. SCM : sternocleidomastoid muscle. (*) : occipital artery

20. 2 - C lassification of cervical LN groups: Level I : IA: submental LN. IB: submandibular LN. Level II : (upper jugular LN). Level III : ( middle jugular LN). Level IV : (lower jugular LN). Level V : ( posterior triangle of the neck) Level VI : ( Anterior or Central compartment of the neck ) Level VII :( superior mediastinal LN).

21. For oral cavity cancers, the lymph nodes at greatest risk are located in Levels I, II, and III. The lymph nodes at greatest risk for oropharyngeal and laryngeal cancers are located in Levels II,III , and IV. And for thyroid cancer, are in Level VI.

22. 3- Radical neck dissection: involves the removal of lymph nodes in levels I-V in addition to the sternocleidomastoid muscle, spinal accessory nerve, and internal jugular vein . Modified Radical Neck Dissection: remove levels I-V (similar to a radical neck dissection). It is modified in the structures it preserves . Type I: Spinal accessory nerve is preserved. Type II: Spinal accessory & internal jugular vein or sternocleidomastoid. Type III: Spinal accessory & internal jugular vein & sternocleidomastoid.

23. Selective Neck Dissection : preserve one or more lymph node levels . other non lymphatic structures are preserved. different types of selective neck dissections based on nodal levels removed : Supraomohyoid : SND I-III Lateral : SND II-IV Posterolateral : SND II-V

24. Question 5

25. 6 year old male presented with intermittent left hip pain and limping for 1 month. Pelvic radiograph was performed. 1- Describe the radiograph. 2- What is the diagnosis? 3- What are the clinical manifestations? 4- Mention the treatment options.

26. Answer : 1- Pelvic x-ray showing both hip joints and proximal femora. The left femoral epiphysis is markedly flattened, and sclerotic with early fragmentation and loss of height. Enlargement and deformation of the femoral head and neck. There are also sclerotic changes in the left acetabulum. The right hip appears normal . 2- P erthes disease (Legg- Calvé - Perthes disease).

27. 3- Symptoms : insidious onset. may cause painless limp. intermittent hip, knee, groin or thigh pain. Physical exam : hip stiffness: loss of internal rotation and abduction. gait disturbance: antalgic limp. limb length discrepancy is a late finding.

28. 4- treatment : Non-operative : observation alone. activity restriction ( non- weightbearing ). physical therapy ( ROM exercises). Operative : femoral and/or pelvic osteotomy. valgus and/or shelf osteotomies hip arthroscopy.

29. Question 6

30. A 26-year-old male presented to the ER with 1day history of lower abdominal pain. Examination revealed signs of peritonism . Under the suspicion of acute abdomen of probable appendicular etiology, an urgent diagnostic laparoscopy was performed. The procedure was converted to a laparotomy by a midline incision.

31. 1- What is the diagnosis? 2- How to diagnose? 3 - Mention other presentations of this pathology? 4- Discuss the surgical management options.

32. Answer : 1- Meckel’s diverticulum perforated by a foreign body (toothpick). 2- Diagnosis of Meckel’s diverticulum : Technetium-99m (99mTc) scan , also called Meckel scan or nuclear scintigraphy scan, is the investigation of choice to diagnose Meckel's diverticula in children . This scan is more accurate in children because gastric mucosa is found in 90% of bleeding diverticula; which is the most common symptom in children, not adults . Plain radiography, barium studies, angiography, CT scan, and ultrasonography all play complementary roles in the diagnosis of the complications of Meckel diverticulum. Most Meckel diverticula are diagnosed during surgery (laparotomy or laparoscopy), with imaging playing a secondary role.

33. 3- Other presentations in Meckel's diverticulum: H aemorrhage (most common): seen in pediatric age (Maroon- coloured blood). Intestinal obstruction due to bands/adhesions. lntussusception , volvulus of small bowel. Peptic ulceration. Diverticulitis. Littre's hernia: it is presence of Meckel's diverticulum in hernial sac as content. It is observed in inguinal/femoral hernia . Silent Meckel's diverticulum found during laparotomy or laparoscopy. Carcinoid or GIST can occur in Meckel's diverticulum.

34. 4- Indication Long Diverticulum Short Diverticulum Simple diverticulitis Diverticulectomy Segmental resection Bleeding Diverticulectomy Segmental resection Complicated diverticulitis with inflamed or perforated base Segmental resection Segmental resection Intestinal obstruction Segmental resection Segmental resection

35. Thank you …