Surgery Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 21)

This is a part of free booklet series designed by Dr. Aryan for rapid review of basic concepts of medical science. I grant you right to share the booklet for fair use (teaching, scholarship, education and research) anywhere in the world exclusively for non-monetary purposes.

1. Surgery Review A Free Booklet Series by Dr. Aryan

2. Preface: This is the study material designed by Dr. Aryan with creation and compilation of the best of the best and the most finest slides on the subject. I would like to offer a billion heartily thanks for everyone who contributed directly or indirectly to the creation of the material through creation and dissemination of the scientific information. Covering everything in one study material is next to impossible. Hence, refer to gold standard textbooks for building solid concepts or in case of any doubt. Textbooks are acknowledged at the end of the presentation. If any source has been missed to acknowledge, it doesn’t lessen their impact and contribution in any way. Don’t keep searching for pattern between the consecutive slides. You won’t find many. Rather to boost your recall and review, I have constructed many slides and are deliberately placed with no much relation between the preceding and the succeeding ones. The main rule of a review material is that it must make you recall or learn maximum amount of information in minimum amount of time and space. Motivational quotes and articles are included within the slides. Always remember that every good idea, nice piece of information and everything else is literally and absolutely worthless unless you execute. If you know everything in the slides in much detail, you probably wouldn’t need this material. Best of luck WORK & SUCCESS! Dr. Aryan (Anish Dhakal)

3. Dr. Aryan (Anish Dhakal)

4. Causes of ascites

5. Intestinal Obstruction Dr. Aryan (Anish Dhakal)

6. Supportive Treatment for Intestinal Obstruction Nasogastric decompression NPO Fluid and electrolyte replacement Analgesics Antibiotics Urine output monitoring Vital Monitoring Dr. Aryan (Anish Dhakal)

7. Types of Paralytic Ileus Postoperative Self-limiting (24-72 hrs) Infection Intra-abdominal sepsis Reflex ileus After fracture of spine or ribs Metabolic Uremia and hypokalemia Dr. Aryan (Anish Dhakal)

8. Summary of Management of Esophageal V arices Dr. Aryan (Anish Dhakal)

9. Charcot neurologic triad (MS): nystagmus, intention tremor and dysarthria Murphy triad in appendicitis: RIF pain, Fever and Vomiting Dr. Aryan (Anish Dhakal)

10. Dr. Aryan (Anish Dhakal)

11. Transmitted Vs. Expansile Pulsations Dr. Aryan (Anish Dhakal)

12. TB in Ileocaecal region Dr. Aryan (Anish Dhakal)

13. Position of Appendix Dr. Aryan (Anish Dhakal)

14. Dr. Aryan (Anish Dhakal)

15. Confusion Corner: Clinical Reasoning in Appendicitis Shifting pain: Firstly visceral vague pain starts around the umbilicus (due to same dermatomal innervation). Later the pain changes to specifically localized somatic pain (due to irritation of the parietal peritoneum). Rovsing’s sign : Palpation of LIF induces pain in right iliac fossa due to shifting of bowel loops which irritates parietal peritoneum. Hyperextension causes pain in retrocecal appendix due to irritation to psoas muscle (patient in flexion attitude for comfort). Internal rotation in pelvic appendix irritates obturator internus . Silent appendix in case of retrocecal appendix which means that cecum distended with gas prevents the pressure from palpation to reach the inflamed appendix. Early diarrhea and increased frequency of micturition in case of pelvic appendix due to its contact with rectum and bladder. When the appendix is completely pelvic, classical signs like abdominal rigidity and tenderness over the McBurney’s point is absent as well. Dr. Aryan (Anish Dhakal)

16. Incisions in Appendectomy Dr. Aryan (Anish Dhakal)

17. COI for Ochsner-Sherren regimen include doubtful diagnosis, appendicitis in elderly and children, gangrenous appendicitis and diffuse peritonitis. Appendicular mass ( periappendicular phlegmon ) consists of inflamed appendix, greater omentum , edematous cecum, terminal ileum, loop of intestine, ascending colon and adjacent peritoneum. Dr. Aryan (Anish Dhakal)

18. Ochsner-Sherren regimen in a Nutshell NG tube decompression NPO for 48 to 72 hours Drugs Antibiotics for Gram positive, negative and anaerobic bacteria (Ceftriaxone 1 gm IV BD & Metronidazole 500 mg IV TDS) Analgesics (Tramadol 50 mg IV TDS. Stronger analgesics like pethidine may mask complications) PPI IV fluids Monitoring Vital signs (temperature, pulse, RR, BP) 4 hourly Size of the mass marked twice daily Per abdominal examination for features of peritonitis TC and DC (if increased may mean appendicular abscess formed) Interval appendectomy after 6-8 weeks Dr. Aryan (Anish Dhakal)

19. Sequelae of appendicitis Complete resolution Appendicular lump Appendicular abscess Gangrenous appendicitis Mucocele Perforation Dr. Aryan (Anish Dhakal)

20. Complications of Appendectomy Paralytic ileus Reactionary hemorrhage Pyelophlebitis (suppurative and inflamed thrombosis of portal vein) Would sepsis Fecal fistula Right inguinal hernia (injury to ilioinguinal nerve) Adhesions & Intestinal obstruction Respiratory problems & DVT Dr. Aryan (Anish Dhakal)

21. Complication of Cholecystectomy Bile duct injury Bile leak Biliary stricture Biliary fistula Injury to colon, duodenum or mesentery Hemorrhage Waltman-Walter syndrome (accumulation of bile in right subhepatic and subphrenic space compressing the IVC) Dr. Aryan (Anish Dhakal)

22. IBS Treatment Dr. Aryan (Anish Dhakal)

23. SIRS Criteria Dr. Aryan (Anish Dhakal)

24. Dr. Aryan (Anish Dhakal)

25. Confusion Corner: Movement of Pain Types of Movement Description Radiation of pain Extension of pain to other side while original site of pain persists. Pain in pancreatitis radiating to back is an example. Referred pain Pain is experienced but at a site distant from the original site of pathology due to same innervation. E.g. irritation to diaphragm supplied by phrenic nerve (C3, C4, C5) is referred to shoulder (C3, C4). Shifting/Migrating pain Pain is experienced at one site, then it shifts to another site and pain at original site disappears. Classic example is acute appendicitis when pain is first felt in umbilical region (T9, T10: same as appendix) which later irritates the parietal peritoneum overlying appendix and pain is felt in RIF. Dr. Aryan (Anish Dhakal)

26. Swelling with impulse on coughing other than hernia? Swelling with positive cough impulse are typically continuous with one of the body cavities: Abdominal cavity (Hernia, Iliopsoas abscess, Lumbar abscess) Pleural cavity (Empyema necessitans) Spinal canal (Meningocele) Dr. Aryan (Anish Dhakal)

27. Slip sign in Lipoma When edge of the solid swelling is palpated the margin of the solid swelling does not yield to the palpating finger but slips away from it. Dr. Aryan (Anish Dhakal)

28. Claudication Arterial Claudication develops after walking a fixed distance (Claudication distance). Boyd classification distinguishes the same: I- pain relieved on walking, II- walks in pain, III- compelled to take rest, IV- pain at rest (relieved by hanging leg by side of bed due to pooling of blood secondary to gravity ).

29. What are signs of ischemia due to arterial insufficiency? Thinning of the skin Diminished growth of hair Loss of subcutaneous fat Shininess Trophic changes in the nails which become brittle with transverse ridges Minor ulceration in pressure areas viz. heel, malleoli, ball of the foot, tip of the toes Dr. Aryan (Anish Dhakal)

30. Ischemic tests for Upper Limbs Description Disappearing Pulse Syndrome Examine the pulse. Exercise the limb. Pulse would disappear after claudication develops secondary to vasodilation and increased vascular space. Elevated Arm Test (Modified Roo’s Test) Ask the patient to abduct arm to 90° and then externally rotate the arm. Open an close the hands for 5 minutes. If any pain, fatigue, paresthesia, tingling or numbness develops, the test is positive for thoracic outlet syndrome. Allen’s Test Ask patient to clench the fist and press on the radial and ulnar artery of the wrist. Ask patient to open and close the fist for 1 minute. Release artery one by one. Costo-clavicular compression ( Falconi’s Test) Feel the radial pulse. Then throw the shoulder backward and downward as exaggerated military position. Absent or feeble pulse occurs secondary to subclavian artery compression between clavicle and 1 st rib. Hyperabduction manoeuvre (Halsted Test/ Pectoralis Minor Syndrome) Feel the radial pulse. Passively hyperabduct the arm. Radial pulse would be feeble or absent due to compression of artery by pectoralis minor tendon. Adson’s Test (Cervical Rib/ Scaleous Anticus Syndrome) Ask the patient to sit on a stool and take a deep breath. Turn the face to affected side. Radial pulse would be absent due to compression of subclavian artery. Branham’s Sign/ Nicoladonis Sign It is very simple test for AV fistula. At least remember the name of the test. All you have to do is press proximal to the fistula and you are done. It would cause reduction in size of the swelling, disappearance of bruit, fall in pulse rate and pulse pressure returns to normal. Dr. Aryan (Anish Dhakal)

31. Harvey’s Sign for Limb Ischemia The sign checks adequate venous refilling Press two index fingers side by side touching each other on a vein Move finger nearer to heart proximally to empty the vein between the two fingers The vein is empty now Release the distal finger Observe for venous refilling Delayed venous refilling in ischemic limb Dr. Aryan (Anish Dhakal)

32. Buerger’s Postural Test for PAD Perform Buerger’s test in broad daylight. Keep at 20° for 2 minutes. If no pallor or discomfort then elevate to 30°, 45°, 60° to 90°. If pallor is absent in suspected case, support the leg and ask patient to flex and extend ankle and toes to the point of fatigue which causes pallor & veins on dorsum becomes empty and guttered. Within few minutes cyanotic hue appears. Additionally you can also check for: Capillary filling time: elevated normal leg remains pink throughout. Ischemic limb will show pallor on elevation, pink in horizontal position and later dusky red (purple) due to deoxygenated oxygen. Venous refilling time: Normal limb will show guttering at 90° and normal refilling as soon as 5 minutes. Ischemic limb will be guttered on 10° or even while horizontal. Dr. Aryan (Anish Dhakal)

33. What is Crossed Leg Test & Reactive Hyperemia test for ischemia detection? Crossed leg test: Ask the patient to sit with leg crossed over the other leg so that popliteal fossa of one leg will lie over the knee of another. Divert the attention. If oscillatory movement is seen that would be synchronous with the pulse of popliteal artery. Reactive hyperemia test: This is a very simple test. Blood pressure cuff is inflated for 250 mm Hg and kept for 5 minutes. In normal limb, red flush will appear within seconds. The more severe is the ischemia, additional time would be required to get the flushing. Dr. Aryan (Anish Dhakal)

34. Brodie- Trendelenburg test The objective of the test is to determine incompetency of sapheno-femoral valve and perforating veins Place the patient in recumbent position to empty the veins and ask to quickly stand up with pressure on. Two ways to perform the test: Release the pressure: If blood rapidly fills from above, there is incompetence of sapheno-femoral valve. Keep the pressure on for 1 minute: If blood gradually from below, there is incompetence of perforator veins or communicating veins. Basic Anatomy: Lower limb veins have superficial and deep systems connected by communicating or perforator veins. Flow is always from superficial to deep veins unless pathology exists. Many mechanisms like venae comitantes and calf pump exists for venous drainage. Valves are present throughout the venous system. Incompetence of perforators or valves result in varicose veins . Dr. Aryan (Anish Dhakal)

35. Tests for Venous System (Lower Limb) Description Tourniquet test ( Oschner Mahorner’s test: Multiple tourniquet test) Tie tourniquet at different level after emptying the veins. Ask the patient to stand up. If veins above tourniquet fills up: perforator incompetence above. If it fills below and above remains collapsed: perforator incompetence below. Perthe’s test In Perthe’s test, elastic bandage is wrapped from toes to groin and patient is asked to move around. Severe crampy pain suggests DVT. In modified Perthe’s test instead of elastic bandage, a tourniquet is tied below saphenofemoral junction without emptying the veins. Ask the patient to walk quickly. If deep and communicating veins are normal, varicose veins will shrink. If blocked veins would be more distended and bursting pain felt. Schwartz test The Schwartz test simply checks continuous column of blood due to valvular incompetence. Keep one finger at saphenofemoral junction or upper end of visibly dilated veins and tap dilated vein at lower end of leg: impulse felt. Pratt’s test Apply Esmarch bandage from toes to groin. Apply tourniquet at groin and take off the bandage. Apply the bandage from groin downwards. Look for blow outs or visible varices in place of perforators. Morrisey’s Cough Impulse test Empty the vein by elevating it. Ask the patient to cough and feel the expansile impulse at saphenofemoral junction. Fegan’s test Mark the excessive bulges within the varicosities. Ask the patient to lie down. Palpate along the marked areas to feel for crescenteric gaps/pits in deep fascia.

36. Moses’ Sign: While gently squeezing lower part of calf from side to side, pain develops in DVT Neuhof’s Sign: Thickening and deep tenderness elicited while palpating deep in calf muscles Dr. Aryan (Anish Dhakal)

37. Causes of breast retraction? Developmental retraction Carcinoma of breast Developmental retraction Carcinoma of breast Circular Slit like (see the picture ) Can be everted Cannot be everted No underlying swelling palpable Underlying swelling palpable Dr. Aryan (Anish Dhakal)

38. Breast Examination Positions Purpose of the Position Sitting position with arms by the side of body Information on level of nipples, lump and palpation of axillary lymph nodes Sitting position with arms raised over the head Lump or nipple retraction becomes more prominent Sitting and bending forward Fixity of the breast to chest wall and pectoralis major muscle Sitting and hands on the waist Abnormal movement of nipples or exaggeration of skin dimples Recumbent with 45° head end elevation and both hands by side of head To palpate the breast lump against the chest wall in recumbent position Dr. Aryan (Anish Dhakal)

39. Blockage of subcuticular lymphatics with oedema of skin Deepens the mouth of sweat glands and hair follicles Typical orange peel appearance Peau d’ orange appearance in Breast Carcinoma Dr. Aryan (Anish Dhakal)

40. What is Bapat test? Also known as bed shaking test, bapat test is used to diagnose early peritonitis Foot end of the bed is moved slightly Pain is evoked at the site of inflamed organ Dr. Aryan (Anish Dhakal)

41. Poor Stream of Urine: Does the stream improve on straining? Yes: Urethral Stricture No: BPH BPH Carcinoma Prostate Consistency: Rubber like Consistency: Stony hard Surface: Smooth Surface: Irregular Median groove and lateral sulci: Deepened Median groove and lateral sulci: Obliterated Mobility of rectal mucosa: Present Mobility of rectal mucosa: Absent Arises from transitional zone (Submucosal gland) Arises from peripheral zone (Prostatic gland proper) Dr. Aryan (Anish Dhakal)

42. What are the criteria for removal of Chest T ube? Lung fully expanded in Chest X-Ray with no air leak on removal of suction or forceful coughing. If this is confirmed, chest tube placed on water seal for 4-24 hours depending on initial severity and another CXR is taken. If no renewed pneumothorax and no air leak on forceful cough, remove chest tube. T ube clamping can also be performed for 4-6 hours before removal with chest radiograph repeated at intervals viz. 2 hours, 6 hours and 12 hours. If no accumulation, remove chest tube. Ideally for pneumothorax, the chest tube should remain in place for at least 24 hours after the lung reexpands and air leak ceases. Drainage of <50 cc fluid/day. If patient is on mechanical ventilation, the chest tube may be needed as long as the patient needs mechanical ventilation. Dr. Aryan (Anish Dhakal)

43. Surgical Site Infection (SSI) Infection within 30 days after surgery if no implant is placed and within 1 year if implant is in place and infection appears to be related to the operation Dr. Aryan (Anish Dhakal)

44. Superficial Incisional Surgical Site Infection Involves only skin and subcutaneous tissue of incision with at least one of the following: Purulent drainage with or without laboratory confirmation from superficial incision Organisms isolated from aseptically obtained culture of fluid or tissue from superficial incision A least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, heat and incision is deliberately opened by surgeon unless incision is culture negative Diagnosis made by surgeon or attending physician Dr. Aryan (Anish Dhakal)

45. Deep Incisional Surgical Site Infection Involves deep tissue (muscles, fascia) with at least one of the following: Purulent discharge from deep incision but not from organ/space An abscess or evidence of infection involving the deep incision is found on direct examination, during reoperation, by histopathlogic or radiological examination A least one of the following signs or symptoms of infection: fever (>38°C), localized pain or tenderness , and incision is deliberately opened by surgeon unless incision is culture negative Diagnosis made by surgeon or attending physician Dr. Aryan (Anish Dhakal)

46. Organ/Space Surgical Site Infection Involves any part of anatomy (organ and spaces) other than incision which has opened or manipulated during surgery with at least one of the following: Purulent drainage from a drain placed through a wound into the organ/space Organisms isolated from aseptically obtained culture of fluid or tissue in organ space An abscess or other evidence of infection involving the organ space that is found during direct examination, reoperation, by histologic or radiologic examination Diagnosis made by surgeon or attending physician Dr. Aryan (Anish Dhakal)

47. Rates of SSI according to W ound Types Wound types Infection rate Clean 1-2% Clean contaminated <10% Contaminated 15-20% Dirty <40% Infection rates are variable based on various researches. These percentages are just general guidelines on what to expect. Dr. Aryan (Anish Dhakal)

48. What is Ogilvie Syndrome? Acute dilatation of colon in absence of any mechanical obstruction in severely ill patients (usually in elderly sedentary patients immobilized for other surgeries) Also referred to as “acute megacolon” or “paralytic ileus of the colon” Correct fluid and electrolytes followed by colonoscopy to suck out all air and place a long rectal tube Cholinergic drug Neostigmine can stimulate and increase colonic motility but has a potential dangerous consequence if given in case of actual obstruction . Dr. Aryan (Anish Dhakal)

49. Setons in a Nutshell A seton is a nonabsorbable nylon or silk suture that is guided through the fistula tract and tied exteriorly to be kept for weeks to months in order to compress and maintain suture placement in the tract. Ischemic compression created by the seton and the local inflammatory reaction of adjacent tissues initiate fibrosis. Fibrosis maintains the integrity of the sphincter musculature during subsequent fistulotomy. Also allow epithelialization of the fistulous tract , thereby preventing secondary closure and facilitating the drainage of abscesses. Loose setons are used before advanced techniques (fistulectomy, advancement flap, cutting section), as a part of staged fistulotomy (for high level fistulas e.g. transsphincteric and suprasphincteric fistulas, simple fistulotomy is contraindicated) & for long term palliation to avoid septic and painful exacerbations by effective drainage. Cutting or tight setons are used for many reasons like when the fistula is high enough and passes through enough portion of sphincter muscle and to minimize sphincter dysfunction. Cutting seton gradually transect the anal sphincter musculature underlying the fistula by externally tightening the suture to induce pressure necrosis . Dr. Aryan (Anish Dhakal)

50. Signs of Peritoneal Irritation Tenderness Rebound tenderness Guarding Rigidity Absent bowel sounds (silent abdomen) Dr. Aryan (Anish Dhakal)

51. Techniques of Lowering Intracranial Pressure Pathophysiology Head elevation (up to 30 degrees) Increased venous outflow from brain Sedation & Hypothermia Decreased metabolic demand and control of hypertension Mannitol Osmotic diuretic, extraction of free water out of brain tissues (risk of rebound phenomenon). Use diuretics (e.g. furosemide) but not to the point of lowering systemic arterial pressure (Brain perfusion = Arterial pressure – ICP) Hyperventilation Carbon-dioxide washout, leading to cerebral vasoconstriction (unmonitored hyperventilation can lead to iatrogenic brain ischemia) Steroids Decrease CSF production and edema Surgery Ventriculostomy, external drains, shunt operations, craniotomy, craniectomy or lobectomy Intracranial pressure is a overall function of pressure of brain parenchyma (fairly constant except in mass lesions), CSF (fairly constant unless ventricular flow obstruction is present) and Cerebral Blood Flow (CBF). CBF increases due to hypercapnia, increased metabolic demand and hypoxia. Elevated blood pressure further adds to the pressure milieu that sets in .

52. Dr. Aryan (Anish Dhakal)

53. What are the reasons behind post-operative atelectasis? Postoperative pain promotes shallow and rapid breathing (particularly in abdominal and thoracoabdominal surgeries) Narcotic analgesics depress the respiratory drive and cough reflexes Anesthetic agents as well as drugs can decrease mucociliary clearance and may promote bronchoconstriction Pickwickian syndrome (Obesity hypoventilation syndrome) Supine position increases the intraabdominal pressure acting on the undersurface of the diaphragm limiting alveolar expansion at end expiration thereby reducing Functional Residual Capacity (FRC) Treatment includes incentive spirometry, adequate pain control, chest physiotherapy, frequent repositioning or early ambulation, deep breathing exercises, continuous positive airway pressure and intermittent positive pressure breathing. Dr. Aryan (Anish Dhakal)

54. Dumping Syndrome in a Nutshell Post gastrectomy complication in which rapid emptying (dumping) of hypertonic gastric content into duodenum and small intestine Release of intestinal vasoactive polypeptides and stimulation of autonomic nervous system Postprandial abdominal cramps, weakness, light-headedness and diaphoresis is common Symptoms may start around half and hour after eating Dietary changes are helpful. Octreotide has shown some benefits as well. Resistant cases might require reconstructive surgeries. Dr. Aryan (Anish Dhakal)

55. Anterior Urethra Injury Posterior Urethra Injury Penile and bulbar urethra distal to urogenital diaphragm Prostatic and Membranous urethra Blunt trauma to the perineum (straddle injuries) or instrumentation of urethra Pelvis fractures are notorious for causing posterior urethral injuries Examination: Normal prostate Examination: High riding prostate with blood at urethral meatus Stricture may be present Stenosis is seen in posterior urethra Inability to urinate may not be seen at the outset but delayed presentation might be complicated by sepsis secondary to extravasation of urine to perineum, scrotum or abdominal wall Inability to void following major trauma Injury to the urethra or bladder neck/anterior bladder (injury to the dome of bladder can cause urinary leakage to the peritoneum) does not cause peritonitis by itself. The reason of the coexistence is the association of these injuries with pelvic fractures or major trauma. Dr. Aryan (Anish Dhakal)

56. Urethral Trauma Dr. Aryan (Anish Dhakal)

57. Is it really undescended testicle? Undescended testicle that has not reached the scrotum by the age of one needs to be surgically corrected and brought down to place for fixing (Orchiopexy) If you find the testicle in the canal at birth which can easily be pulled down where it belongs, then it is not a case of cryptorchidism Rather it is highly suggestive of a benign entity, known as hyperactive cremasteric muscle (retractile testis). Dr. Aryan (Anish Dhakal)

58. Dynamic Fluid Response Administer 250-500 mL fluid over 5-10 minutes Based on the response of HR, BP and CVP: Responders Transient responders Non-responders Dr. Aryan (Anish Dhakal)

59. Layers of the Scrotum Dr. Aryan (Anish Dhakal) S kin D artos muscle and fascia E xternal spermatic fascia C remasteric fascia I nternal spermatic fascia T unica vaginalis T unica albuginea (@Some Daring Englishmen Called It True Testis)

60. Dr. Aryan (Anish Dhakal)

61. Usually non-tender thus could mimic neoplasm Incision and Drainage needs to be done. In some sites like breast, axilla, parotid, thigh, ischiorectal abscess, we do not even wait for fluctuation i.e. for abscess to fully form before drainage. Dr. Aryan (Anish Dhakal)

62. After confirmation of abscess by aspiration, skin is excised parallel to the neurovascular structures in most dependent position . Pyogenic membrane is broken by sinus forceps. All loculi are broken with sinus forceps or little finger. A drain is placed. Wound is not sutured or closed. Dr. Aryan (Anish Dhakal)

63. Dr. Aryan (Anish Dhakal)

64. Cellulitis Necrotizing soft tissue infection An acute, diffuse spreading infection of the skin, subcutaneous tissues and superficial lymphatics (sparing the deep fascia) Rapidly spreading infection involving subcutaneous tissues and deep fascia Patient less toxic, blisters are absent Patient more toxic, blisters present Skin and fascial layers cannot be separated by finger (Finger test is negative) Finger test is positive Mild to moderate leukocytosis Marked leukocytosis Remember to distinguish NSTI and gas gangrene. Gas gangrene is clostridial, involves muscle and crepitus is heard. Dr. Aryan (Anish Dhakal)

65. Wound is defined as breach or discontinuity in skin, tissues or mucous membranes which may be associated with its disruption of structure and function. Dr. Aryan (Anish Dhakal)

66. Southampton Wound Grading System Major wound typically contains significant pus and patients are more ill systemically with discomfort and delayed return to home. Dr. Aryan (Anish Dhakal)

67. ASEPSIS SCORING

68. Breast Carcinoma TNM Dr. Aryan (Anish Dhakal)

69. Confusion Corner: Right Vs. Left? Anterior Vs. Posterior? Right sided colon cancer presents with bleeding and left sided with features of obstruction Posterior gastric ulcers are more prone to bleeding and anterior ones to perforation Dr. Aryan (Anish Dhakal)

70. Truncal vagotomy causes gastric stasis, hence drainage is required. In HSV, nerve of laterjet is preserved while criminal nerve of Grassi must be severed. Alternatively, truncal vagotomy with antrectomy could be done for chronic duodenal ulcers which again requires reconstruction of the GI tract (Billroth I and II viz. gastroduodenostomy & gastrojejunostomy). Dr. Aryan (Anish Dhakal)

71. Types of Gastrectomy Billroth I Standard for gastric ulcers Distal stomach with pylorus is excised, new lesser curve to match the size of duodenum created End to end gastroduodenal anastomosis is made Pylorus preserving gastrectomy (Maki) Pylorus along with the pyloric branches of vagus is preserved Prevent rapid gastric emptying Billroth II Resection of around two thirds of stomach, closing the duodenum and end to end gastrojejunal anastomosis Physiology is much altered Vagotomy and antrectomy Along with truncal vagotomy, antrectomy and reconstruction of the GI tract is done Subtotal gastrectomy Stomach closed from lesser curvature and Roux loop is created with gastrojejunostomy Radical or total gastrectomy Entire stomach, lymph nodes, greater and lesser omentum is removed Oesophagojejunostomy with a Roux en Y loop is created Dr. Aryan (Anish Dhakal)

72. Dr. Aryan (Anish Dhakal)

73. Dr. Aryan (Anish Dhakal) Steps of Hand washing

74. Kocher’s Hemostatic Forceps Vs. Allis Tissue Forceps Dr. Aryan (Anish Dhakal)

75. Define Hernia Abnormal protrusion of a viscous or a part of viscous through an opening, artificial or natural in the walls of its containing cavity with a sac covering it. Parts of hernia are covering, sac (with mouth, neck, body and fundus) and its contents ( omentum , intestine, bladder, meckel’s diverticulum- Littre’s hernia, bowel wall- Richter’s hernia)

76. Inguinal Hernia Anatomy Superficial inguinal ring: 1.25 cm above and medial to the pubic tubercle Deep inguinal ring: 1.25 cm above the mid inguinal point Inguinal canal: 4 cm in length, directed anteriorly, medially and downwards Dr. Aryan (Anish Dhakal)

77. Contents of the inguinal canal Spermatic cord in males Vas deferens Artery to the vas deferens Testicular and cremasteric artery Genital branch of genitofemoral nerve Pampiniform plexus of veins Remains of processus vaginalis Symphathetic plexus around artery to vas Round ligament in females Ilio -inguinal nerve Dr. Aryan (Anish Dhakal)

78. Hernia Hydrocele Swelling in the inguinal region extending into the scrotum Hydrocele is a scrotal swelling Shape is variable. Femoral is retort shaped, indirect hernia is pyriform shaped and direct hernia is globular Mostly globular Cough impulse may be present No cough impulse Fluctuation test and fluid thrill are negative Fluctuation test and fluid thrill is positive To get over the swelling not possible Possible to get over the swelling Transillumination test is negative Transillumination test is positive Dr. Aryan (Anish Dhakal)

79. Late complications of blood transfusion include delayed hemolytic transfusion reaction, post transfusion purpura , transfusion related graft versus host disease and iron overload in multi transfused patients. Dr. Aryan (Anish Dhakal)

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82. Hypothermia Finding of “J” waves (Osborn waves) is characteristic finding of hypothermia.

83. Easiest entry is through left subclavian or right internal jugular veins. Dr. Aryan (Anish Dhakal)

84. PAIR Procedure for Hydatid Cyst Indications Contraindications Inoperable or patient refusing surgery Inaccessible cysts Pregnant woman and children < 3 years Calcified cysts Multiple cysts Cysts with multiple thick internal septal divisions (Honeycombing pattern) Infected cysts Cysts with detached laminar membrane Dr. Aryan (Anish Dhakal)

85. Hydatid cyst PAIR procedure Dr. Aryan (Anish Dhakal)

86. Hydatid cyst in Echinococcus Dr. Aryan (Anish Dhakal)

87. Dr. Aryan (Anish Dhakal)

88. Acute Cholecystitis: Dr. Aryan (Anish Dhakal)

89. The boundaries of Calot’s ( Hepatobilliary triangle) is: Superiorly: Inferior margin of liver/cystic artery Laterally: Cystic duct Medially: Common hepatic duct Dr. Aryan (Anish Dhakal)

90. Dr. Aryan (Anish Dhakal)

91. Courvoisier’s Law Dr. Aryan (Anish Dhakal) A palpable gallbladder is unusual in patients with obstructive jaundice because the obstruction causes inflammation, thickening, fibrosis, contraction and nondistensible gall bladder. Courvoisier’s Law: “In a jaundiced patient if gallbladder is palpable and non tender, it is rarely due to stones.” Exceptions to Courvoisier’s Law: Double impacted stone- one in CBD & one in cystic duct with mucocele of gall bladder Large stone in Hartman’s Pouch Empyema Gall B ladder

92. Why direct hernia is very rare in females? Because of the stress of the childbearing, the transversalis fascia in females is stronger in the floor of the inguinal canal than in males, so since Hesselbach triangle consists of only transversalis fascia covered by external oblique aponeurosis they provide additional strength to females. Weakening of the conjoint tendon can precipitate a direct hernia. Deficient insertion of this conjoint tendon predisposes men to direct hernia. In females, the attachment is quite wider hence the protective effect. Dr. Aryan (Anish Dhakal)

93. Hemorrhoids refer to sliding down of vascular and connective anal cushions i.e. aggregation of blood vessels, smooth muscles and connective tissues abnormally due to straining and other causes. Dr. Aryan (Anish Dhakal)

94. Primary positions for hemorrhoids are 3,7 and 11 o’clock positions. Above is the classification of internal hemorrhoids. External hemorrhoids present as painful, olive shaped blue cutaneous swellings. Dr. Aryan (Anish Dhakal)

95. Post-operative Fever Dr. Aryan (Anish Dhakal)

96. Anal Fissure in a Nutshell Conservative treatment of anal fissures is similar to that of hemorrhoids. Adequate fluid, alteration of bowel habits to make defecation less traumatic, fiber diet, stool softeners, sitz baths, topical anesthetics before defecation, pharmacological agents to relax internal sphincter and increase blood flow. Operative treatment include Lord’s dilation, dorsal fissurectomy with sphicterectomy & lateral anal sphicterectomy . Dr. Aryan (Anish Dhakal) Anal fissure is a small tear or cut in the lining of the anus.

97. The accumulated products like lactic acid, potassium, complement, neutrophil and microvascular thrombi are flushed into the mainstream circulation causing widespread damage. Dr. Aryan (Anish Dhakal)

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99. Causes of Acute Pancreatitis Drugs include corticosteroids, isoniazid, valproate, thiazides, azathioprine, oestrogen Dr. Aryan (Anish Dhakal)

100. Whipple Procedure ( P ancreaticoduodenectomy ) Parts resected: Gall bladder CBD Head of pancreas Duodenum Proximal 10 cm of jejunum Part of stomach i.e. pylorus (in non-pylorus preserving type) Lymph nodes ( peripancreatic , perihepatic , pericholedochal , periduodenal ) Anastomosis: Pancreaticojejunostomy Choledochojejunostomy Gastrojejunostomy Dr. Aryan (Anish Dhakal)

101. Important Acronyms APACHE: Acute Physiology And Chronic Health Evaluation POSSUM: Physiologic and Operative Severity Score for the enUmeration of Morbidity and Mortality Dr. Aryan (Anish Dhakal)

102. Acute Pancreatitis Conservative Management (@PANCREAS) Pain relief Protease inhibitors Plasma Rehydration – IV fluids, blood plasma Ranitidine iv 50 mg 8 hourly Respiratory support Resuscitation when required Analgesics Anticholinergics Endotracheal intubation Electrolyte management NG aspiration, NPO Nutritional support (TPN) Nasal oxygen Antacids Calcium gluconate 10 mL 10% 8 hourly Calcitonin CVP line Somatostatin , Swan- Ganz catheter for CVP and TPN Surgery if required ( Necrostomy , wide debridement, drainage, open if infected pancreatic necrosis) Dr. Aryan (Anish Dhakal)

103. Ranson Criteria for Acute Pancreatitis: On admission After 48 hours Age > 55 years Blood Urea Nitrogen > 5 mg percent WBC count > 16000/mm 3 PaO 2 < 60 mmHg Blood glucose > 10 mmol/L Serum calcium < 2 mmol/L LDH > 700 units/L Base deficit > 4 mmol/L AST > 250 units/L Fluid sequestration > 6 L Dr. Aryan (Anish Dhakal)

104. Glasgow Scale for Acute Pancreatitis: On admission After 48 hours Age > 55 years Serum calcium < 2 mmol/L WBC count > 15000/mm 3 Serum albumin < 3.2 g/L Blood glucose > 10 mmol/L LDH > 600 units/L Serum urea > 16 mmol/L AST/ALT > 600 units/L PaO2 < 60 mmHg Dr. Aryan (Anish Dhakal)

105. Pancreatic Pseudocyst Dr. Aryan (Anish Dhakal)

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109. Though Goldman's index of cardiac risk doesn't exactly assess the risk, it's still useful to list out the high risk factors. Ejection fraction below 35%, JVP distention, transmural or subendocardial MI is associated with very high mortality. Dr. Aryan (Anish Dhakal)

110. Subclavian steal syndrome A blockade at the origin of subclavian artery allows blood supply to the arms for normal activity but not enough to meet the higher needs. When demand increases, the arm may be supplied by blood flowing in a retrograde direction down the vertebral artery at the expense of the vertebrobasilar circulation . Presents with both vascular (coldness, tingling, muscle pain) and neurologic (visual disturbances, equilibrium problems) symptoms. Dr. Aryan (Anish Dhakal)

111. Dr. Aryan (Anish Dhakal) Melanoma Risk Factors

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113. Sheehan’s Syndrome Dr. Aryan (Anish Dhakal)

114. What can be considered 5 th vital sign in Surgery apart from temperature, pulse, blood pressure and respiratory rate? Pain scale CRT is considered as fifth vital sign in pediatrics. Dr. Aryan (Anish Dhakal)

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116. Splenic Injury Dr. Aryan (Anish Dhakal)

117. Timing of Hematuria Dr. Aryan (Anish Dhakal)

118. Magnesium ammonium stone ( Struvite ) stones can be very large. Most sensitive to ESWL is uric acid and least sensitive is cysteine. Risk factors include Vitamin A deficiency, dehydration, urinary stasis and decreased urinary citrate. Dr. Aryan (Anish Dhakal)

119. Dr. Aryan (Anish Dhakal) Normal narrowing of the Ureter:

120. Free gas under Diaphragm Perforation of hollow viscus (peptic ulcer or colonic perforation) Penetrating abdominal injury Post operative: Laprotomy , laproscopy , peritoneal dialysis Hysterosalphingogram Infection by gas forming organisms Not to be confused with fundic gas which is irregular & lighter if free gas under diaphragm is in left side. True pneumoperitoneum is usually crescentric and darker. Also, careful to exclude Chiladiti syndrome (interposition of colon between liver and diaphragm also known as pseudopneumoperitoneum ). Dr. Aryan (Anish Dhakal)

121. Sinus Vs. Fistula Sinus is a blind ending tract that connects a cavity lined with granulation tissue with an epithelial surface. Fistula is an abnormal communication between two epithelial surface. Just like the cavity in sinus, the tract is lined by granulation tissue but may become epithelialized in chronic cases. Dr. Aryan (Anish Dhakal)

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125. Surgery for Cleft Lip & Cleft Palate Dr. Aryan (Anish Dhakal)

126. Dr. Aryan (Anish Dhakal)  A  flap  is transferred with its blood supply intact, and a  graft  is a transfer of tissue without its own blood supply or a extra tissue material. Therefore, survival of the  graft  depends entirely on the blood supply from the recipient site.

127. Small Bowel Obstruction Erect X-Ray Multiple air fluid levels in erect X-Ray of abdomen Normal air fluid levels: Fundus Duodenal cap Terminal ileum Dr. Aryan (Anish Dhakal)

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129. Sterilization of Instruments I. Physical Heat (Dry & Moist Heat) Radiation Filtration II. Chemical Liquids (Alcohol, Phenolics, Aldehyde, Halogen, Dye, Surface active agents) Gaseous (Ethylene oxide, Formaldehyde) Dr. Aryan (Anish Dhakal) Autoclaving (121°C at 15 lbs) can sterilize most metallic instruments and rubber goods except sharp instruments. Metallic instruments require 30 minutes and rubber good require 15 minutes. Sharp instruments are kept dipped in concentrated Lysol for 1 hour or 2% glutardehyde (cidex) for 4 hours to sterilize.

130. Autoclave Principle Dr. Aryan (Anish Dhakal)

131. Common Modes of Antisepsis Chlorhexidine Povidine iodine Cetrimide ( Savlon ) Alcohol Hypochlorites Chloroxylenol (Dettol) Dr. Aryan (Anish Dhakal)

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135. Plain Catgut (Yellow) Chromic Catgut (Brown) Polypropylene (Blue) Silk (Black) Loses 50% tensile strength in 3 days, 100% in 15 days. Completely absorbed in 60 days. Made from submucosa of jejunum of sheep. Loses 50% tensile strength in 7 days, 100% in 28 days. Completely absorbed in 90 days. It is catgut with chromic acid salt. Non absorbable Non absorbable To tie small subcutaneous vessels To approximate subcutaneous tissue during closure of incision In circumcision to suture cut margins of prepuce To tie mesoappendix and base of appendix in appendectomy In two-layer anastomosis of small gut or anastomosis during gastrojejunostomy To stop bleeding from gall bladder bed in cholecystectomy In repair of posterior inguinal wall during hernia surgery To secure a prolene mesh Closure of skin incisions Repair tendon injuries To ligate cystic duct and cystic artery in cholecystectomy To ligate pedicels in nephrectomy and splenectomy To secure drain tubes To ligate vagus nerve trunk in truncal vagotomy Dr. Aryan (Anish Dhakal)

136. Surgical drain systems Special features Open (static) drain Drained fluid collects in gauge pad or stoma bag Infection rate is higher Utilize the principle of gravity and capillary action Examples include corrugated drain & penrose drain Closed siphon drain Drain connected to sterile bag with or without one way valve Closed suction drain Negative pressure of -100 to 500 mm Hg is utilized Sump suction drain Negative suction with a parallel air vent is used to prevent adjacent soft tissues being sucked into the lumen of the drain Under water seal drain For drainage of pleural space Drain is a channel that allows fluid or air to be expelled out after the closure of main wound. Dr. Aryan (Anish Dhakal)

137. Corrugated Rubber Drain Used for draining blood, pus or bile following surgeries. Also used in hydrocele operation following eversion of sac. It prevents residual infection, does not get blocked and is cheap but can cause retrograde infection, lack of quantitative or qualitative assessment of drained fluid and discomfort due to soakage. Dr. Aryan (Anish Dhakal)

138. Dr. Aryan (Anish Dhakal) @ Maggot SCAM

139. Lethal triad of Trauma Tissue trauma and hypovolemic shock in combination would cause Acute Traumatic Coagulopathy (ATC). Resuscitation should be done with caution as it could be counter-intuitive. Resuscitation with cold fluids could aggravate two wheels of the triad causing dilutional coagulopathy and hypothermia.

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144. Viability check of gut after relief of obstruction Dr. Aryan (Anish Dhakal)

145. Dermoid Vs. Sebaceous Cyst Dr. Aryan (Anish Dhakal)

146. Cold Abscess: Never forget that since cold abscess are very different from usual pyogenic abscess we commonly encounter, treatment approach also varies. After surgery, to avoid persistent drainage, there should be nondependent incision, suturing of the would after drainage and no drain is kept. Dr. Aryan (Anish Dhakal)

147. Keloid Hypertrophic Scar Non-cancerous fibrous proliferation in dermis after injury Thickened , wide, often raised scars developed after injury Genetic predisposition, more in females and black No genetic, gender or racial predisposition Extends beyond original wound/incision Limited to original wound Do not promote scar contracture Promote scar contracture Vascular, tender and itching Non-vascular, non-tender and no itching Etiology is not known Related to tension lines Progressive, very high recurrence Regressive, recurrence is uncommon Usually in chest wall, upper arm, lower neck or ears Anywhere Dr. Aryan (Anish Dhakal)

148. Pseudocyst Cysts which either have no epithelial lining or the fluid thus collected is derived from degeneration and exudation, not as a result of secretion from the lining. Exudation cyst ( pseudocyst of pancreas) Degenerative cyst (cystic degeneration of a tumor) Traumatic cyst Q: What is a corn? A: localized, palpable, painful nodule with central core of dead cornified skin over bony projections like head of metatarsals. Dr. Aryan (Anish Dhakal)

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152. In children, measure length from alae nasi to tragus and then to xiphisternum. Dr. Aryan (Anish Dhakal)

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154. What do you understand by surgical emphysema? Collection of gas or air in the subcutaneous tissues or fascial plane. Causes include lung, tracheal or chest wall injuries and after laparoscopic procedure. Dr. Aryan (Anish Dhakal)

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156. What do you mean by post-cholecystectomy syndrome? Symptoms may be due to bile flow in upper GI tract causing reflux esophagitis and gastritis while bile flow in lower GI tract causes lower abdominal pain and diarrhea. Other symptoms could be attributed to structures in biliary tree and extra biliary structures like esophagus, stomach and duodenum. Dr. Aryan (Anish Dhakal)

157. Notice that here the stone is not in the CBD rather its impacted in the Hartmann pouch of gallbladder and compresses CBD. Dr. Aryan (Anish Dhakal)

158. Ankle-Brachial Pressure Index Dr. Aryan (Anish Dhakal)

159. Classification of Ulcers Pathological Classification Wagner’s Grading Clinical Classification Specific (tuberculous, syphilitic, fungal) Grade 0 to Grade 5 Spreading Non specific (traumatic, trophic, apthous) Healing Malignant Callous Dr. Aryan (Anish Dhakal)

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161. Ulcer Edge varieties Dr. Aryan (Anish Dhakal)

162. Boundaries of Safety triangle Dr. Aryan (Anish Dhakal)

163. Hydrocele is the abnormal accumulation of serous fluid in a part of processus vaginalis , usually the tunica vaginalis . Etiology : Excessive production e.g. in secondary hydrocele Defective absorption as in most primary hydrocele Interference with lymphatic drainage of scrotal structures Connection with peritoneal cavity via patent processus vaginalis (congenital) Complications: Rupture, Bleeding ( Hematocele formation), Degeneration (calcification), Infection Herniation of sac through dartos muscle Testicular atrophy, dermatitis, micturition and sexual issues Treatment: Herniotomy for congenital & treatment of cause on secondary hydrocele Jaboulay’s procedure (eversion of sac) Lord’s plication (subtotal excision and plication of remnant of sac) Aspiration of hydrocele fluid (but would reoccurs in a week, elderly or unfit patients for surgery) Injection of sclerosant viz. tetracycline Dr. Aryan (Anish Dhakal)

164. Jaboulay’s Procedure (Eversion of sac) Dr. Aryan (Anish Dhakal)

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166. Six Steps of Breaking Bad News Dr. Aryan (Anish Dhakal)

167. What to ask for history of a swelling? Duration Usually the patient’s answer is the duration since he noticed the swelling Mode of onset Progression Inflammatory swelling would first increase and then later decrease in size once the inflammation subsides Exact site Usually for a huge swelling. Patient might be better able to tell it as he/she had seen its progression Pain Secondary changes Softening Ulceration Fungation Inflammatory changes Associated features Fever Impairment of function Loss of body weight Chest pain, hemoptysis, cough, bone pain,etc . Others Past history of swelling, personal, family, treatment, allergy history as usual

168. What are 6 “S” of inspection? Site Size Shape Surface Skin Surrounding area Dr. Aryan (Anish Dhakal)

169. Inspection of a swelling Palpation of a swelling Site Temperature Size Tenderness Shape Confirmation for inspectory findings Surface Consistency Skin Fluctuation Surrounding structures Transillumination Edge Reducibility Number Compressibility Pulsation/Peristalsis Pulsatility Impulse on coughing Fixity of overlying skin Movement on respiration, deglutition, protrusion of tongue Relation to underlying structures Any pressure effect Indentation Percussion is performed for some swellings including bowel containing hernias (enterocele), hydatid thrill. All pulsatile swelling should be auscultated for bruits and murmurs. Dr. Aryan (Anish Dhakal)

170. Dr. Aryan (Anish Dhakal) In infants : Head : 18% Each legs: 14% & 14% (more specifically its 13.5 % allocating 1% to perineum) For child greater than 1 year, for each year decrease head by 1% and add those 0.5% to each legs .

171. Burn Dr. Aryan (Anish Dhakal) If a patient presents late to the health facility, calculate the fluid to be administered from the time on the burn, not from the time of presentation if no fluid was administered before presenting to the health facility.

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173. Confusion Corner: Do we always use Parkland formula for fluid calculation in burns? Parkland aka Baxter formula in honor of Dr. Charles R. Baxter and other formulas are not the exclusive ways to dictate fluid administration If burn surface area is >20%, administer 1000 mL/ hr of RL without sugar (20 mL/kg/ hr in babies), then adjusted and fine-tuned the amount to maintain urinary output 1 or 2 mL/kg/ hr Why is sugar avoided in Ringer Lactate? Sugar causes osmotic diuresis from glycosuria. Since we are using urinary output as our guiding factor for fluid administration, it is avoided to prevent falsely increased urinary output. Dr. Aryan (Anish Dhakal)

174. Boerhaave syndrome occurs when a person vomits against a closed glottis causing leak into the mediastinum, pleural cavity and peritoneum. Mallory Weiss syndrome causes longitudinal tear in the mucosa just below cardia , leading to severe hematemesis. Dr. Aryan (Anish Dhakal)

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176. Gastric Outlet Obstruction: Dr. Aryan (Anish Dhakal)

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178. Inflammatory Bowel Disease Dr. Aryan (Anish Dhakal)

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181. Which gas and instrument is used to create pneumoperitoneum in laparoscopic surgery? Carbon dioxide gas Veress needle Dr. Aryan (Anish Dhakal)

182. Level of axillary lymph nodes Level I: below and lateral to pectoralis minor ( anterior, posterior and lateral ) Level II: behind pectoralis minor (central) Level III: above & medial to pectoralis minor (apical) Dr. Aryan (Anish Dhakal)

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184. Causes of Urinary Retention Male Female Both Bladder Outlet Obstruction Retroverted gravid uterus Blood clot Urethral stricture Bladder neck obstruction Urethral calculus Urethritis & Prostatitis Rupture of the urethra Phimosis Neurogenic (injury or disease of spinal cord) Fecal impaction Anal pain (like in hemorrhoidectomy ) Post-operative Drugs Spinal anesthesia Dr. Aryan (Anish Dhakal)

185. Primary Vs. Secondary Bladder Stones Primary stone is the one that develops in sterile urine. Often originates in kidney and passes down the ureter to the bladder where it enlarges. Secondary stone is the one that occurs in the presence of infection, bladder outflow obstruction, impaired bladder emptying or foreign body like nonabsorbable sutures, metal staples or catheter fragments. Dr. Aryan (Anish Dhakal)

186. PSA value in locally confined cancer is usually < 10-15 ng /ml while its >30 ng /ml in metastatic carcinoma. In prostate, the peripheral zone is the carcinomatous while transitional and central zones are adenomatous, hence site for BPH. Dr. Aryan (Anish Dhakal)

187. What is Bladder Outlet Obstruction? It is a urodynamic concept based on pressure flow studies characterized by low urinary flow rate ( <10 mL/s) and high voiding pressure (>80 cm of H 2 O) Normal urinary flow rate is >15 mL /s. 10-15 mL /s is equivocal. Normal voiding pressure is <60 cm of H20. 60-80 cm of H 2 O is equivocal. Dr. Aryan (Anish Dhakal)

188. Lower Urinary Tract Symptoms (LUTS) Voiding Storage P oor flow F requency I ntermittent stream U rgency S ensation of incomplete voiding N octuria S training (not improved by straining in BPH unlike strictures) Urge & Nocturnal incontinence (Enuresis) Hesitancy & terminal d ribbling LUTS previously was called Prostatism but LUTS can be caused by any causes of BOO (e.g. prostate cancer, bladder neck stenosis or hypertrophy, urethral strictures, functional obstruction due to neuropathic causes), idiopathic detrusor overactivity, degeneration of bladder smooth muscles and so on. Hence the interchangeable use is avoided. Dr. Aryan (Anish Dhakal)

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193. Undescended Testis in a Nutshell Surgical treatment is orchidopexy by Stephen and Flower technique. Orchidectomy can also be done if the testis is atrophied. Dr. Aryan (Anish Dhakal)

194. Testicular Torsion in a Nutshell Testicular torsion compromises testicular blood supply. It is a surgical emergency. Risk factors include inversion of testis, high investment of tunica vaginalis & separation of epididymis from the body of testis. Signs in testicular torsion: Phren’s sign: p ain not relieved on lifting the scrotum (difference from epididymo-orchitis ) Angel sign: a nother testis is clappered Demin sign: twisted testis is higher than normal testis Dr. Aryan (Anish Dhakal)

195. Pathology: Adenocarcinoma Colon Macroscopically, 4 forms of tumor can be seen 1. Annular type (obstructive symptoms) 2. Tubular type 3. Ulcer 4. Cauliflower type Bleeding Dr. Aryan (Anish Dhakal)

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197. Paradoxical breathing is usually certain for clinical diagnosis. Dr. Aryan (Anish Dhakal)

198. Boundaries of femoral canal which allows expansion of femoral vein Anteriorly: Inguinal ligament P osteriorly: P ectineal ligament Laterally: Femoral vein Medially: Lacunar ligament   Dr. Aryan (Anish Dhakal)

199. Boundaries of Hesselbach's triangle (Inguinal triangle) Inferiorly: Inguinal ligament Superiolaterally : Inferior epigastric vessels Medially: Lateral margin of rectus sheath known as linea semilunaris Dr. Aryan (Anish Dhakal)

200. Femoral triangle ( Scarpa's triangle) boundaries Superiorly: Inguinal ligament Laterally : Medial border of sartorius Medially: Medial border of adductor longus Contents: lateral to medial (NAVEL) Dr. Aryan (Anish Dhakal)

201. Boundaries of Inguinal C anal Anterior wall: 2 aponeurosis (external and internal oblique ) Posterior wall: 2 T (Transversalis fascia and Conjoint tendon) Roof: 2 Muscles: Internal oblique & Transversus abdominis Floor: 2 ligaments (inguinal and lacunar ligaments) Dr. Aryan (Anish Dhakal)

202. Three fingers in Zieman’s test for Hernia Index: deep inguinal ring (indirect hernia ) Middle : superficial inguinal ring (direct hernia) Ring: saphaneous opening (femoral hernia) Dr. Aryan (Anish Dhakal)

203. Intussusception Currant jelly stool Sausage shaped mass Claw sign on barium enema (ileocolic) Target sign/ Doughnut/ Bull’s eye (USG) Dr. Aryan (Anish Dhakal)

204. Reflux : is backward flow of gastric content. Regurgitation : is defined as the perception of flow of refluxed gastric content into the mouth or hypopharynx . Dr. Aryan (Anish Dhakal)

205. Sleeping on several pillows could create further compression on your abdomen by bending you at the waist (similar to “sit ups”) and might promote reflux episodes while you are sleeping. Dr. Aryan (Anish Dhakal)

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208. Treatment of Achalasia Cardia Dr. Aryan (Anish Dhakal)

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210. Suspensory ligament of Berry connects to the cricoid cartilage while pretracheal fascia attaches to the body of the hyoid bone. Dr. Aryan (Anish Dhakal)

211. Lid signs in Thyrotoxicosis Dalrymple’s sign: retraction of upper lids producing the characteristic staring and frightened appearance (90% cases) Lid lag (von Graefe’s sign ): when globe is moved downward, upper lid lags behind (50% cases) Enroth’s sign: fullness of eyelids due to puffy oedematous swelling Gifford’s sign: difficulty in eversion of upper lid Stellwag’s sign: infrequent blinking Dr. Aryan (Anish Dhakal)

212. Management of Myxoedema Coma Medical emergency (carries a high mortality rate) Altered mental state Hypothermia and a Precipitating medical condition, for example cardiac failure or infection Thyroid replacement, either bolus of 500 mcg of T4 or 10 μg of T3 (IV or orally) every 4–6 hours If the body temperature <30 degree Celsius the patient must be warmed slowly Other measures includes Intravenous broad-spectrum antibiotics and hydrocortisone (in divided doses) Cautious use of IV fluid High flow oxygen Dr. Aryan (Anish Dhakal)

213. Acknowledgements: Best of the best slides, pictures and information on the web. Special thanks to all those brilliant minds for their act of creation and compilation of scientific material without which this work would not be possible Bailey and Love short practice of surgery SRB’s Manual of Surgery, 5 th Edition A Manual on Clinical Surgery, S.Das Sabiston Textbook of Surgery Dr. Aryan (Anish Dhakal)

214. Do we really need to have specific goals at all times in our life? Do you feel directionless and lost without goals? https://medium.com/@anishdhakal718/do-we-really-need-specific-goals-at-all-times-ca27912fd7c7 Dr. Aryan (Anish Dhakal)

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