Class Notes on

Common Short Case and Long Case

in Surgery

Dr. Murtoza Shahriar, MBBS (SSMC)

 Dedicated to
Prof. Dr Rafiques Salehin Sir
 Contributed by
Md. Sakib Sadid khan sisir
Nishat Ferdous
Md Tanvir Hossain
 Index
Common Short Cases in Surgery
Hernia 6
Inguinal Hernia 11
Ulcer 18
Lump 33
Lipoma 40
Sebaceous Cyst 42
Hydrocele 43

Common Long Cases in Surgery

Ca Stomach 51
Surgical Jaundice 56
Ca Breast 62
Colorectal Carcinoma 68
Cholecystitis 73
Benign Enlargement of Prostate 77
Common Short Cases in Surgery
Hernia 6
Inguinal Hernia 11
Ulcer 18
Lump 33
Lipoma 40
Sebaceous Cyst 42
Hydrocele 43
 6
Hernia
A hernia is an abnormal protrusion of the whole (e.g. Ovary) or a part of viscous
(e.g. Loop of Intestine)(fig 1.1)though an opening in the wall of the cavity in which it
is contained.

Fig 1.1 An Inguinal Hernia

••••
Types

1. Internal Hernia (Concealed Hernia):Protrusion through internal defect or into

peritoneal recess & can not be seen from outside.
Hiatus Hernia (fig 2.2)
Diaphragmatic Hernia (fig 2.1)

2. External Hernia: Protrusion through a weak part of abdominal cavity & can
be seen from outside.
Common:
1. Inguinal Hernia (fig 1.1)
2. Incisional Hernia (fig 2.4)
3. Umbilical Hernia(fig 2.5)
4. Femoral Hernia (fig 2.8)
Less Common:
1. Epigastric Hernia (fig 2.7)
2. Para-umbilical Hernia (fig 2.10)
3. Lumbar Hernia
Rare:
1. Gluteal Hernia
2. Obturator Hernia (fig 2.8)
 7
tooooo

Fig 2.1 Congenital Diaphragmatic Hernia Fig 2.2 Hiatal Hernia Fig 2.3 Inguinal Hernia

Fig 2.4 Incisional Hernia Fig 2.5 Umbilical Hernia Fig 2.6 Inguinal and Femoral Hernia

Fig 2.7 Epigastric Hernia Fig 2.8 Obturator Hernia Fig 2.9 Femoral Hernia

Fig 2.10 Umbilical and Paraumbilical Hernia Fig 2.11 Different site of Hernia
 8
Precipitating Factors

A. Weakness of The Abdominal Wall

a. Congenital
b. Aquired:
i. Obese (rectus abominis is a thin muscle. Fat may deposit in muscle fiber
causing decrease strength of the wall.
ii. Repeated Pregnency
iii. Wasting Disease
iv. Poor Wound Healing ( following suturing of an incision during surgery, if
wound has not healed properly, incisional hernia may occur.)

B. Continued or Repeated increases in Abdominal Pressure

a. Chronic cough, e.g., COPD
b. Continuous Constipation.
c. Benign Enlargement of prostate ( Enlarged prostate causing increased intra
abdominal pressure during micturation) (fig 3.1)
d. Severe Heavy Work
e. Vomiting

Fig 3.1 Compression of urethra due to prostatic enlargement

 9
Parts of a Hernia

1. A peritoneal Sac: The sac consists of four parts.

I. The mouth i.e., the opening of the sac through which the contents enter the sac.
II. The neck of the sac which is the most constricted part and passes through the
abdominal musculature.
III. The Body i.e. the main part of the sac holding the contents
IV. The fundus which is the most redundant and dependent part of the sac.

2. The coverings of the sac

3. The contents of the sac.The contents may comprise one of the following:
I. A loop of intestine (Enterocele)
II. Omentum (omentocele/epiplocele)
III. Meckel’s Diverticulum
IV. Bladder Wall
V. Ovary (with or without Fellopian Tube)

Fig 4.1 Parts of a Hernia A. Crosssection B. External

Basic Features a Hernia

1. They occur through a weak spot of the abdominal wall.

2. They must have an expansile cough impulse (Hernia expand followed by goes
back to normal position during cough due to increased intra abdominal pressure)
3. They are reducible - either on lying down or with manual pressure.

N.B. Hernia Become irreducible and cough impulse may absent in

- Obstructed Hernia
- Strangulated Hernia (followed by obstructed hernia. Increased obstruction
causes arrest of blood supply to the contained intestine
 10
Complications of a hernia

1. Irreducibility: It may be irreducible by

• adhesion formed between the contents and the sac (e.g. Omentum) or between
the contents themselves;
• growth of the omentum within the sac;
• narrowing of the neck of the sac because of fibrosis
• retention of faces in the large intestine occupying the sac.

2. Obstruction: Gut content cannot pass through the neck due to narrowing of
neck leading to obstruction.Patient of intestinal obstruction may comes with Colicky
pain, vomiting, constipation, abdominal distension.
Features of Obstructed Hernia
• Irreducible but painless ( may be painful)
• The sac is lax not tender
• Features of intestinal obstruction

3. Strangulation: Irreducibility + features of intestinal obstruction + arrest of blood

supply to the contained intestine leading to hypoxia followed by infraction and
then Necrosis ultimately gangrene.
The features are:
• irreducible & painful.
• The sac is tense and tender.
• Cough impulse absent.
• Features of intestinal obstruction present - pain in abdomen, vomiting,
abdominal distension, rebound tenderness.

* Rebound tenderness usually a feature of Peritonitis.

Fig 5.1 Obstructed and Strangulated Hernia ago

 Inguinal Hernia 11

The most common type of abdominal hernia. There are two types:
1. Direct Inguinal Hernia
2. Indirect or Oblique Inguinal Hernia
Patient comes with swelling in the inguinal region or inguinoscrotal region ( when
inguinal hernia or swelling reach to scrotum. It may be complete ( swelling has
reached upto the base of scrotum) or incomplete ( swelling has not reached upto
base of the scrotum))

fHµqa8B Bq@ •gq dkB

Fig 6.1 Normal Inguinal Canal, Direct Inguinal Hernia, Indirect Inguinal Hernia

Anatomy of Inguinal Canal

It is a fibromusucular canal of 4 cm length in the lower part of the anterior

abdominal wall. (Fig 6.2, 6.3)

Boundaries

Anterior Wall
1. Skin
2. Superficial Fascia
3. External Oblique Aponeurosis
4. Internal Oblique Muscle

Posterior Wall
1. Fascia Transversalis
2. Conjoint tendon

Roof
Arched fibrs of internal oblique and transversus abdominis muscle

Floor
1. Upper Grooved surface of the inguinal ligament
2. Upper surface of lacunar ligament
 12

Fig 6.2 Inguinal Canal Fig 6.3 Inguinal Canal

Fig 6.4 Hesselbach’s Triangle

Fig 6.5 pathophysiology of Inguinal Hernia

Fig 6.6 Hesselbach’s Triangle Fig 6.7 Hesselbach’s Triangle

 13
Contents of Inguinal Canal

In Male: Spermatic Cord

In Female: Round Ligament of Uterus
In Both Sex: Ilioinguinal nerve

Indirect Inguinal Hernia

• The hernia enters the inguinal canal through the deep inguinal ring. (Fig 6.1, 6.5)
• Generally it follows the course of spermatic cord and can reach to base of the
scrotum. So, complete hernia or hernia reached to scrotum. always indicate
indirect hernia.
• Indirect Hernia is pyriform or conical in shape. As it has narrow neck it may
turned to obstructed or strangulated hernia.

Direct Inguinal Hernia

• The hernia protrudes directly through the posterior wall of the inguinal canal
in the Hesselbach’s triangle. (Fig 6.1, 6.5)
• Caused by weakness of muscle
• Direct hernia never get obstructed as it has wider neck.
• Direct hernia always occurs at old age, at child age all the hernia is indirect
type.

Hesselbach’s triangle

This triangle is situated in the posterior wall of the inguinal canal. The
triangle is bounded (Fig 6.4, 6.6, 6.7)
I. medially by the outer border of rectus abdominis muscle;
2. laterally by the inferior epigastric vessels;
3. below by the inner half of the inguinal ligament;
4. floor is formed by the fascia transversalis.
 14

Short Case Examination of Inguinal Hernia

Examiner may ask:
1. Examine the inguinal region: We have to examine only inguinal region.
2. Examine the inguinoscrotal region: We have to examine both inguinal
region and scrotum.

Procedure

A. Approach to a patient

1. Greet the patient.

2. Introduce yourself.
3. Ask for screening and attendant ( in case of opposite sex).
4. Position (At first examine in standing posture then examine in lying position).
5. Expose ( expose the site of the hernia and associated region entirely).

B. Ask for

1. Chronic Cough
2. Constipation
3. Difficulty in micturation (Must ask in older male as BEP is very common)
4. H/O previous surgery
5. Occupation ( May associated with increased intra abdominal pressure e.g.
heavy work, weight lifting)

C. Inspect

1. Site: Rt/ Lt/ Bilateral

2. Size: measure in length(cm) X Width (cm)
3. Shape: Pyriform (Indirect)/ Globular(Direct)
4. Margin: Regular/ Irregular
5. Visible Cough Impulse: Present/Absent
C. Palpate 15

1. Temperature (in normal-abnormal-normal pattern, normal may evaluate from

thigh)

2. Tenderness

3. Consistency : Elastic (Intestine), Doughy (Omentum), Tense (Obstructed

Hernia)

4. Get above the swelling

• Only for inguinoscrotal swelling
• To differentiate between hydrocele and hernia. Get above the swelling
positive in hydrocele as it is limited in scrotum whereas hernia is continuous to
content of abdomen. So, get above the swelling is not possible.

5. Palpable cough impulse:

Instruct the patient to cough and palpate the swelling simultaneously. Check for
any impulse. Palpate the testis after that for any malignant condition.

6.Deep Ring Occlusion Test

After that instruct the patient to lying down. Perform deep ring occlusion test by
following procedures.
I. Ask the patient to reduce the swelling on his own. (Reducibility)
II. If reduced, identify the deep ring
• find out the insertion of rectus abdominis by elevating the head or leg on lying
condition (pubic tubarcle)
• Identify the anterior superior iliac spine ( upper anterior extremity of iliac crest)
• Deep ring is situated at 1.25 cm above from the midinguinal point( midpoint of line
connecting anterior superior iliac spine and pubic tubercle)
III. Compress the deep ring with thumb and ask the patient to cough.
IV. If swelling does not protrude to inguinal region it indicates indirect hernia. And if
swelling protrude to inguinal canal it indicates direct hernia.

Fig 7.1 Deep Ring Occlusion Test

 16
Management

Treatment of the cause

Treat for chronic cough, constipation, BEP.

Operative treatment
• Hernioplasty : Reinforcement of the weak posterior wall of the inguinal canal
using prolene mesh (proline mesh is suitable as it does not react with the body
and connective tissue deposit in the mesh to strengthen the mesh.

• Laperoscopic repair of inguinal hernia:

1. Totally extra-peritoneal approach (TEP)
2. Trans-abdominal preperitoneal approach (TAPP)
Indications
1. Bilateral hernia
2. Both direct and indirect hernia
3. Recurrent hernia

•Herniotomy: Excision of the sac only

Indications
1. In infants and children

• Herniorraphy
Herniotomy + Reconstruction of the posterior wall of inguinal canal by
Basini’s repair

Fig 8.1 Hernioplasty

 17

Complications of Hernia Operation

During Surgery
1.Injury to the external iliac or femoral vessels.
2. Injury to the vas deferens especially in children.
3. Injury to the urinary bladder and colon especially
with sliding hernia.
4. Injury to the inferior epigastric vessels.
5. Injury to the contents of the sac.
6. Injury to the testicular artery.

Early postoperative complications

1. Retention of urine.
2. Hematoma of the cord and scrotum.
3. Wound infection.

Late postoperative complications

1. Recurrence.
2. Sinuses.
3. Neuralgic pain due to involvement of ilioinguinal nerve in the suture
4. Painful scar.
5. Atrophy of the testis due to injury to testicular
 18

ULCER
An ulcer is a break in the continuity of the the covering
epithelium- Skin or mucous membrane. It may follow either
molecular death of the surface epithelium or its traumatic
removal.

Fig: Different types of ulcer

History
The following points are particularly noted in the history of a
case of an ulcer:
1.Mode of onset
*How has the ulcer developed?

Following a trauma: Traumatic ulcers generally heal by

themselves if the traumatic agent is removed.
it
%
But the ulcer may take turns towards chronicity if the
trauma continues that means traumatic agent persists.
e.g: Dental ulcers of the tounge.
 19

Over a joint: Healing of an ulcer is delayed if it lies over a

joint for want of rest.

Over a swelling: Ulcers which originate spontaneously may

follow swelling, which may be-
*Matted tuberculosis lymph node or
*Gumma(in case of syphilis) or
*Rapidly growing malignat tumor(epithelioma/
malignant melnoma)

Matted TB lymph node Syphilitic gumma Malignant melanoma

Over the leg: Ulcers may be present in the leg with-

*Vericose veins or
*Vascular insufficiency.
 20

Over a scar: Malignant ulcers sometimes may develop

on the scar of a burn.
e.g: Marjolin's ulcer.

1- 2. Duration
*How long is the ulcer present there?
Acute: Will be present for a shorter duration.
Chronic: Will remain for a long period.

3. Pain
*Is the ulcer painful?
it
I
Only those ulcers associated with inflammation will be painful.

Syphilitic ulcers and trophic ulcers resulting from

nerve disease are painless.

Tuberculous ulcers are slightly painful.

 21

Ulcers from malignant diseases such as epithelioma or

Basal cell carcinoma are absolutely painless to start with
and never become painful unless the infiltrate structures
supplied by pain nerve endings.

Epithelioma Basal cell carcinoma Ulcerated malignant

melanoma

4. Discharge
*Does the ulcer discharge or not?
If it discharges enquiry must be made about its nature,
such as -
*Serum: ulcer is heading towards healing.
*Pus : it indicates infection.
*Blood : due to erosion of blood vessels/till now non
healing.

Pus Blood Serous

5. Associated disease
*Is there an association with any disease?

If present-Nervous disease,such as-

*Tabes dorsalis
*Syringomyelia
*Transverse myelitis
*Peripheral neuritis
may result an ulcer(trophic or perforating ulcer).
 22

Generalized tuberculosis, nephritis or diabetes may lead

to ulcer formation.Syphilis at the primary stage gives
rise to chancre and in the tertiary stage gives rise to
gummatous ulcer.

Chancre Gumma

Local examination
ÉA. Inspection
*The following points are particularly noted:
1.Size & Shape:
*The size of an ulcer is important to know the time which will
be required for healing. A bigger ulcer will definitely take a
longer time to heal. To record exactly the size and shape of an
ulcer, a sterile gauge may be pressed on to the ulcer to get its
measurements.
Tuberculous ulcers are generally oval in shape but their
coalescence may give an irregular cresentic border.
Syphilitic ulcers are similarly circular or semilunar to
start with but may unite to form a serpiginous ulcer.
Vericose ulcers are generally vertically oval in Shape.
Carcinomatous ulcers are irregular in size and Shape.

Oval Circular Vertically oval Irregular

 23

2. Number
Tuberculous,gummatous, vericose ulcers and soft chancres
may be more than one in number.
3. Position
*This is very important and often by itself gives a clue to the
diagnosis.

An ulcer on the medial malleolus of a lower limb which

shows varicose veins, is obviously a vericose ulcer.

Rodent ulcers are usually confined to the upper part of the

face above a line joining the angle of the mouth to the
lobule of the ear, occuring frequently near the inner
canthus of the eye.

Tuberculous ulcers are commonly seen where tuberculous

adenopathy is commoner that means in the neck,axilla or
groin.

Vericose ulcer on Rodent ulcer Tuberculous ulcer

medial mallolus

Gummatous ulcers are only seen more commonly over

the subcutaneous bones such as tibia

Perforating or trophic ulcers are commoner on the heel of

the foot or on the ball of the foot, which carries maximum
weight of the body.

Malignant ulcers may occur anywhere in the body but

more commonly seen on the lips, tongue, breast, penis
and anus
 24

Gummatous ulcer perforating ulcer Malignant ulcer

4. Edge
*It's not only gives a clue to the diagnosis of the ulcer but also
to the condition of the ulcer.

a. Undermined edge: It destroyes the sub cutaneous tissse

faster than the skin.The overhanging skin is thin, friable,
reddish blue and unhealthy.
*eg: Tuberculosis.

b. Punched out edge: The edge drops down at right angle to

the skin surface as if it has been cut out with a punch. The
diseases which cause the ulcers are limited to the ulcer
itself and do not tend to spread to the sorrounding tissue.
*eg: Gummatous/Deep trophic ulcer.

c. Sloping edge: Every healing ulcer has a sloping edge,

which is reddish purple colour an of new healthy epithelium.
*eg: Healing traumatic venous ulcer.
 25

d. Raised and pearly white beaded edge: This type of edge

developes in invasive cellular disease and becomes necrotic
at the centre.
*eg: Rodent ulcer.

e. Roled out(everted) edge: This ulcer is caused by fast

growing cellular disease, the growing portion at the edge of
the ulcer heaps up and spills over the normal skin to produce
an everted edge
*eg: Squamous-cell adenocarcinoma.

[ 5. Floor
*This is the exposed surface of the ulcer.

When floor is coverd with red granulation tissue, the ulcer

seems to be healthy and healing. Pale and smooth
granulation tissue indicated a slowly healing ulcer.

Wash-leather slough(like wet chamois leather) on the floor

of an ulcer is pathognomonic of gummatous ulcer. One
must be very careful to note what is there at the floor of an
ulcer.
 26

A trophic ulcer that penetrates down even to the bone,

which forms the floor in this case.

A black mass at the floor suggests malignat melanoma.

Granulation tissue Gummatous ulcer

Trophic ulcer penetrates Malignant melanoma

down to the bone

[ 6. Discharge
A healing ulcer will show scanty serous discharge.

A spreading and inflamed ulcer will show purulent discharge.

Sero- sanguineous discharge is often seen in a tuberculous

ulcer or a malignant ulcer.

Serous discharge Purulent discharge Sero-sanguinous discharge

 27

7. Sorrounding area
If the surrounding area off an ulcer is glossy, red and
edematous, the ulcer is acutely inflamed.

The whole limb should be examined in case of an ulcer.

Presence of varicose vein and deep vein thrombosis
Will indicate the ulcer to be a varicose ulcer. Neurological
insufficiency will indicate the ulcer to be a trophic one.

B. Palpation
1. Tenderness
An acutely inflamed ulcer is always exquisitely tender.

Chronic ulcers such as tuberculous and syphilitic ulcers

are slightly tender.

Vericose ulcers may or may not be tender.

Neoplastic ulcers are never tender.

2. Edge & Margin
*These two terms should not be confused and both these
terms demand separately entity.

Margin is the junction between normal epithelium and the

ulcer, so it is the boundary of the ulcer.

Edge is the area between the margin and the floor of the
ulcer.
 28
it
Activity is maximum at the margin and edge of the ulcer,

:
though the degree of activity will vary according to the
type of ulcer.

% In palpation the different types of the edge of ulcers are

corroborated with the findings of inspection. Besides this
a careful palpation of the edge and the surroundings
tissue will give a clue to the diagnosis.

Marked induration (hardness) of the edge is characteristic

feature of a carcinoma, or a squamous cell carcinoma or
adenocarcinoma.

A certain degree of induration or thickness is expected in

any chronic ulcer, wheather it is a gummatous ulcer or a
syphilitic chancre or a trophic ulcer.

3. Base
*on which the ulcer rests.
it
;
Students must understand the difference between the floor
and the base.

The floor: Exposed surface within the ulcer.

The base: On which the ulcer rests and it is better felt than
seen.
it
%
Slight induration of the base is expected in any chronic ulcer
but marked induration(hardness) of the base is an important
feature of Squamous cell carcinoma and Hunterian chancre.

Squamous-Cell carcinoma Hunterian chancre

 29

4. Depth
The students must make an assessment regarding depth
of the ulcer. It can be recorded in the examination sheet
in millimeters. Trophic ulcers may be as deep as to reach
even the bone.

5. Bleeding
*Whether the ulcer bleeds to touch or not?

It is a common feature of a malignant ulcer, because here

epithelial tissue becomes very friable.
eg: Carcinoma of cervix.

Carcinoma of cervix
it
I
Healing ulcer is also bleeds on touch but the amount of
blood is minimum, but in case of malignant ulcer there is
massive bleeding.
 30

6. Relations with the deeper structures.

*The ulcer is made to move over the deeper structures to know
whether it is fixed to any of those structures.
A gummatous ulcer over a subcutaneous bone(tibia or
sternum) is often fixed to it. Malignant ulcer will obviously
be fixed to the deeper structure by infiltration.

Malignant ulcer

7. Surrounding skin
*Skin around the ulcer must be palpated and examined.
Increased temperature and tenderness of the sorrounding
skin indicates the the ulcer to be of acute inflammatory
origin.

C. Examination of lymph node

•
*Examination of lymph node is very important in short case
ulcer examination. Student must examine the lymph node in
ulcer examination.

In acutely inflammed ulcers, the regional lymph node

become enlarged, tender and show the sign of acute
lymphadenitis. Later on, the nodes become soften to form
an abcess.

In tuberculous ulcer the lymph nodes become enlarged,

matted and slightly tender.

In rodent ulcer also the lymph nodes are not affected

possibly because of the early obliteration of the lymphatics
by the neoplastic cells.
 31

In malignant ulcer the nodes are stony hard and may be

fixed to the neighbouring structures in late stage.

Simple enlargement of the lymph nodes in malignant

disease does not suggest lymphatic metastasis. The lymph
nodes may be enlarged because of secondary infection
rather than anything else. So palpation of the lymph nodes
in case of malignant ulcer is very important. Stony hard
consistancy will suggest secondary involvement.

ÉD. Examination for vascular insufficiency.

When the ulcer is situated on the lower part of the leg, one
should always search for vericose veins in the upper part
of the leg or thigh.

If there is no vericose vein and the cause of ulcer is not

determined, the clinician must examine the condition of the
arteries proximal to the ulcer. Atherosclerosis, Buerger's
disease, Raynaud's disease etc. may be the cause of the
ulcer from poor circulation.

Atherosclerosis Buerger's disease Raynaud's disease

oE. Examination for nerve lesion.

Examine the nerve lesion for any neurological deficit.
e.g: Diabetes, Tabes dorsalis, Peripheral neuritis etc.
 32

Treatment
1. Removal of traumatic agent.

2. Skin grafting(split thickness skin grafting) by auto-graft.

*common site: buttock, thigh.

3. Treatment of specific disease, e.g: Diabetes, Syphilis etc.

 Lump 33

A lump or swelling may arise from the skin, subcutaneous tissue, muscle,
tendon, bone, nerve, lymphatics and lymph nodes, blood vessels, gland or
lie within one of the body cavities.

Fig 1.1 A lump (Sebaceous Horn)

Causes of a lump or swelling

A. Congenital
• Present since birth, e.g., meningocele (fig 2.1), dermoid cyst (fig 2.2) , teratoma(fig
2.6).
• Not evident at birth but appears years later, e.g., thyroglossal cyst (fig 2.5) ,
cystic hygroma (fig 2.7) , branchial cyst (fig 2.3).

B. Acquired
• Traumatic: Swelling develops immediately after a trauma, e.g., haematoma (fig
2.4), muscular lump caused by rupture, bony projections following fracture or
dislocation (fig 2.8) .
• Inflammatory: Acute or chronic.
• Neoplastic: Benign or malignant.
• Otherwise, e.g., autoimmune disease.
 BEADED 34

Fig 2.1 Meningocele Fig 2.2. Dermoid Cyst Fig 2.3 Branchial Cyst

Fig 2.4 Hematoma Fig 2.5 Thyroglossal Cyst Fig 2.6 Sacrococcegeal Teratoma

Fig 2.7 Cystic Hygroma Fig 2.8 Fructure swelling Fig 2.9 Keloid

Fig 2.10 Neurofibroma Fig 2.11 Carcinomatous lesion Fig 2.12 Cellulitis
 35
Diagnosis of a Lump or swelling

Examiner may ask:

1. Examine the Swelling on his back

History

A. Approach to a patient

1. Greet the patient.

2. Introduce yourself.
3. Ask for screening and attendant ( in case of opposite sex).
4. Position your patient.
5. Expose ( expose the site of the lump and associated region entirely).

B. Ask for

1. What is your problem?

2. How long the swelling is present? (Duration)

-Congenital lump present since birth or not evident at birth but appears years
later.

3. How has it produced? (Mode of onset)

-May be associated with trauma or previous scar (e.g Kiloid) . (Fig 2.9)

4. Is it painful or Painless?
-Traumatic or inflammatory lump is painful. Benign tumor is not usually painful.
(e.g. cellulitis) (Fig2.12)

5. Is It enlarging or regressing (if yes, how rapid?) ?

-Rapid enlargement indicates malignant tumor, slow enlarging tumor usually
benign.Traumatic lump usually regressed by time.

6. Is there any more swelling?

- Multiple Swelling may present in lipoma or neurofibroma. (Fig 2.10)

7. Is there any other problem?

 36
Examination

C. Inspection

1.Site: Lump In front of neck may associated with thyroid enlarging.Midline

swelling in back indicates meningocele or myocele. Swelling at lateral side of the
eyebrow or behind the ear may indicates dermoid cyst.

2. Size

3.Shape: oval/ rounded (fig 3.2)

4. Number: Single/ multiple. Multiple lump may indicate neurofibromatasis or

lipoma. (Fig 2.10)

5. Overlying skin condition: Ulcer may present in case of malignancy

(carcinomatous lesion).(fig 2.11) Puncta present in case of sebaceous cyst. (Fig 6.1)

6.Any discharge

7. Surface: (fig 4.1)

-Smooth: It may be cystic
-Lobulated: may indicate lipoma
-Nodular: Indicates lymph node or thyroid gland
-Rough/ Irregular: may indicate malignancy
Fig 3.1 Ranula

8. Edge of the swelling: ( fig 3.4)

-Rounded: Found in cystic swelling
-Regular: Found in Lipoma
-Irregular: Usually indicates malignancy
-Well defined: May represent cellulitis
-Ill-defined: It usually indicates malignancy

9. Colour: (fig 2.4, fig 3.1, fig 3.2) Fig 3.2 Melanoma

-Reddish: Usually indicates inflammatory swelling or haemangioma

-Bluish: Ranula/ Mucous cyst
-Blackish: Melanoma

10. Visible pulsation: Swelling itself is pulsatile. E.g. Aneurysm

Pulsation is transmitted from underlying structure.
 37

11. Visible cough impulse: Present in herniated swelling.

12. Movement with deglutition: inspect in case of neck swelling. May associated
with thyroid swelling. (e.g. thyroglossal cyst) (fig 2.5)

13. Pressure effect for swelling: There may be presence of edema, symptoms of
nerve compression (e.g. lateral leg swelling may compress common peroneal
nerve which lead to foot drop)

D. Palpation

1. Temparature: increased in case of acute inflammation (e.g.cellulitis) or abcess.

2. Tenderness: May present in inflammation or bone fructure.

3. Confirm the site, size and shape, surface and edge.

4. Consistency:
-soft (lipoma, haemangioma)
-cystic (cyst, aneurysm and abscess)
-firm (fibroma, papilloma) Assumption of Consistency
• Hard: Prominent bone (e.g. Forehead)
-hard but yielding (chondroma) • Firm: Tip of the nose
-stony hard (metastatic lymph nodes) • Soft: lip
-bony hard (osteoma, osteochondroma).

5. Fixity/ Mobility:
a. Fixed with skin: Try to pinch out only skin. If Possible then it is not fixed with
skin. (Fig 4.6)
b. Fixed with underlying structure: Try to move the swelling and palpate if it is
stucked with underlying structure. (Fig 4.7)

6. Slipping sign (in case of lipoma): Swelling slept in compression in case of

lipoma (Fig 4.2)

7. Indentation: Present in sebaceous cyst or dermoid cyst. (Fig 4.5)

8. Compressibility: Some soft or cystic lumps arecompressible. When they are

squeezed they diminish in size considerably or disappear, but reappear slowly
on release of pressure. (Fig 4.3, 4.10)
 38

Fig 3.3 Different shapes of lump

Fig 3.4 Margin of lump

Fig 4.1 Surface of lump Fig 4.2 Slipping Test

Fig 4.4 Relations of lump with underlying Structure

Fig 4.3 compensability Fig 4.5 Indentation

Fig 4.6 Fixity with overlying skin Fig 4.7 Fixity with underlying structure

Fig 4.8 Aneurysm Fig 4.9 fluctuation

 39

7. Fluctuation test: This determines the presence of fluid or gas in swelling (fig 4.9)

8. Transillumination test: Once the swelling is found to be cystic, test for

translucency in order to determine the nature of the fluid in the cyst-clear or
otherwise. Cystic swelling containing clear fluid (e.g. hydrocele, meningocele,
cystic hygroma, ranula, bursa, etc.) will transilluminate with pointed light
provided the coveringskin is thin.Hydrocele due to filaria, haematocele, though
cystic, will not transilluminate.

9. Pulsatility: Palpate to find out if it is expansile pulsation (e.g. Aneurysm) (fig 4.8)
or transmitted pulsation. Compression of proximal and distal end of the swelling
diminished pulsation in case of expansile pulsation. (Fig 4.11)

10. Reducibility: In case of hernia, reducibility is checked. (Fig 4.10)

11. Impulse on coughing: Present in hernia.

12. Thrill: Present in arteriovenous fistula.

E. Percussion

Percussion node become woody dull if swelling contain fluid and it become stony
dull in case of solid mass containing swelling.

F. Osculatation

Osculatate for bruit or murmur.It may found in thyrotoxic goitre.

rgm
Bog •

Rodeo
@

Fig 4.10 Compensibility & Reducibility Fig 4.11 Expansile Pulsation Vs Transmitted Pulsation
 Lipoma 40

It is a benign, connective tissue tumour arising from the fat cells. (Fig 5.1) It is a
cluster of fat cells which become overactive and produce palpable swelling.

Examination Fig 5.1 Lipoma

A. Inspection
• Site: Usually found in back
• Size: Usually globular (fig 4.1)
• Shape: Measuring in cm X cm
• Number: May be multiple
• Discharge: Usually not present
• Overlying skin condition: Normal

B. Palpation

• Temperature: Normal
• Tenderness: Usually Non tender
• Surface: usually lobulated (fig 4.2)
• Margin: Regular (fig 3.4)
• Consistency: Firm
• Fixity: Usually is not fixed (fig 4.6, fig 4.7)
• Slipping sign: Positive (fig 4.2)
• Regional lymph node: Not enlarged
• Fluctuation: Negative
N.B. Positive slipping sign is the most important findings in lipoma

Differential Diagnosis

• Neurofibroma
• Fibroma: Usually firm in consistency, slipping sign negative
• Sebaceous cyst: Punctum absent, tethered to overlying skin
• Hemangioma
 41
Investigation

Usually lipoma is a case of clinical diagnosis. Investigation is done for anasthesia

fitness. FNAC can be done in case of suspiscion.

Treatment

Excision of capsulated swelling under local or general anasthesia.Usually

incision is done through the skin cringe ( in small lipoma) or elliptical incision
over the swelling (in large lipoma) (fig 5.2)

Fig 5.2 Excision of lipoma

Where surgery is necessary?

1. If pain present.
2. Calcification occurs in swelling. (observed in X-ray)
3. Lipoma causing mechanical obstruction.
4. If patient felt cosmetic discomfort
5. Causig joint or nerve lesion
6. If it may transform into malignancy

Complications

1. Cosmetic deformity in case of large lipoma

2. Saponification
3. Calcification
4. Malignant change
5. infection
6. Ulcer
7. Haemorrhage
 Sebaceous cyst 42

It caused by closure of duct of a sebaceous gland causing retention of sebum in

gland and opening of the duct is converted in punctum. (Fig 6.1)

* Punctum is an unique feature of sebaceous cyst

* It never occurs in skin absent of hair follicle (e.g. palm, sole)
* Common site: Scalp, face, scrotum, etc.

Fig 6.1 Structure of Sebaceous Cyst

Complications

1. Infection (fig 6.2)

2. Ulceration
3. Rupture and formation of sinus
4. Calcification
5. Sebaceous horn

Fig 6.2 Infected sebaceous cyst

Treatment

Excision of cyst and antibiotic in case of infection

43
44
45
46
47
48
49
Common Long Cases in Surgery
Ca Stomach 51
Surgical Jaundice 56
Ca Breast 62
Colorectal Carcinoma 68
Cholecystitis 73
Benign Enlargement of Prostate 77
 Ca stomach
51

Particulars of Patient

1. Sex: Male Predominant

2. Age: Usually 40 years+
3. Address: Usually people lives near to river who have eat more smoked food or shutki
fish have more tendency to develop cancer stomach.(e.g. Japanese, people lives near the
river like padma etc.)

Presenting Complaints

1. Vomiting of undigested food for 2 months

2. Weakness for 1 month. ( weakness is always less than vomiting)
3. Weight loss for same duration
4. Pain in the upper abdomen
5. Lump in the upper abdomen

N.B. Different types carcinoma shows different symptoms, in case of ulcerative lesion, if
there malignant cell grows ,There will be bleeding leads to melena followed by anaemia.
Malignant cell also consume large number of nutrition leads to mild malnutrition and
weakness. Malignant cell also secreate interlukin leads to anorexia. But in this case vomiting
is less common. And as there is no obstruction food bolus can pass and rate of weight loss
is slow.

But in case of cauliflower shape mass in the stomach all the above symptoms is present
along with moderate vomiting. Rate of weight loss is also moderate. Usually in this case sign
of anaemia is less severe

And if there is complete obstruction due to carcinoma there is massive vomiting associated
with marked weight loss. Haematemesis may be present.
H/O Presenet Illness 52

According to the statement of the patient he was reasonably well 2 months back. Then he
developed vomiting which was projectile ( forcefully eject) in nature, consist of undigested
food particle which is not bile stained. (semi digested food particle and bile containing vomit
indicates small intestinal obstruction). The patient also complains of generalized weakness for
1 month. He also said that he has lost significant weight ( write down if mentioned how
much) in last 2 month. ( significant weight loss to refers to losing 10% of body weight without
any intention. If patient can not mention ask for fitting about clothing). Ask for stool color
( sometimes altered blood contain stool known as melena can not be recognised as blood to
patient).
Mention if there any lump with size, shape, site, surface, margin, rate of growing, fixity,
tenderness and temparature.
Also mention signs of metastasis. In case of lung metastasis there will be cough, chest pain,
hemoptysis. Liver metastasis causing jaundice and hepatomegaly. Rectal metastasis causing
per rectal bleeding.
Exclude pyloric stenosis by acuteness and PUD by burning episodic pain.In PUD patient will
to take to food but fear to take for pain. This is not anorexia.
Mention patient DM, HTN, Asthma and COPD status.

H/O of past Illness

Usually nothing contributory

Drug and Treatment History

Mention drug taken by the subject for present co-morbidity . Must mention about
consumption of anti platelet drug (e.g Aspirin, clopidogrel) as it causes bexcess bleeding
tendency and decrease viscosity of blood which can hamper in surgery.

Personal History

History of Smoking. It causes intestinal metaplasia which is precancerous lesion. In case of

female patient must take obstetric history including LMP.
 53
Family History

Usually nothing contributory

Allergy History

Must mention about drug allergy

Clinical Examination

General Examination
1. Anaemia: Present
2. Jaundice: Present in case of liver metastasis
3. Lymph node: left supraclavicular lymph node may enlarged
4. Nutritional Status: Malnourished

Local Examination (Abdomen Examination)

Inspection: A lump may be seen
Palpation:Mention the size, shape, site, surface, consistency, fixity, margin, temperature
and tenderness of the lump in superficial palpation
On deep palpation mention if hepatomegaly present.
DRE: In rectal metastasis there may be present of mass in rectum. (Blummer shelf)

Other System

Other systems reveals no abnormalities

Salient Feature
Mention particulars along with H/O present illness with positive and negative findings.
 54
Provisional Diagnosis

It may be a case of gastric outlet obstruction due to carcinoma stomach

Differential Diagnosis

Gastric outlet obstruction due to pyloric stenosis.

carcinoma stomach seen in barium meal picture

and also through endoscopy.
Ulceroproliferative growth in the
antrum—an endoscopic view.
Investigations

Diagnostic
1. Upper GI endoscopy followed 6-10 biopsy and histopathology.
For Staging
1. Contrast CT scan Abdomen
2. CT scan chest
3. X Ray chest in P/A view
4. LFT if necessary

For GA fitness
1.CBC : To correct anaemia
2. S. Electrolyte profile: To correct electrolyte imbalance
3. S. Creatinine
4. S. Albumin
5. ECG
6. Echo in case of older patient for ejection fraction

For screening
1. HBsAG
2. Anti HCV
3. HIV
4. RT-PCR for Covid19
 55
Diagnosis

Gastric outlet obstruction due to carcinoma stomach

Treatment

Roux En Y reconstruction surgery

Roux-en-Y reconstruction

How will you prepare

Gastric lavage to remove the obstructed food. In this case 200 mL normal saline is infused
in the stomach through nasogastric tube. After tossing of the patient content is sucked out
untill fresh water starts to come out.
By doing this edema may subside and obstruction may reduced which help to perform
anastomoses.
To correct anaemia: blood transfusion
To correct electrolyte: Normal saline+ KCl
To correct albumin: Albumin infusion
 56

Surgical Jaundice
It is also known as obstructive jaundice. Because in case of obstructive jaundice
1. A stone may be impact Bile duct or biliary pathway or
2. Head of the pancreas may compress the CBD or
3. stricture may develop in CBD
All of which can’t be fixed without surgical intervention. So, it is known as surgical jaundice.

What Happend in Surgical Jaundice

After RBC completing its life span, it breakdown into Heme and globin. Heme then
converted into biliverdin and sequentially into bilirubin which then enters into the
circulation and binds with plasma protein and reach to liver. Then it is converted into
Bilirubin di glucorinide which is known as conjugated bilirubin. Then it is conveyed into
second part of the duodenum through bilirubin pathway as bile.

In obstructed jaundice, this conjugated bilirubin can not enters into duodenum and back
flow into circulation. So, There is Elevated level of conjugated bilirubin.

As bile can not transported into duodenum, digestive action of bile is hampered in the
subject. As bile is emulsifier (Breakdown in smaller part) of fat, it can be digested
properly causing increased fat content in stool (Bulky Stool) which float into water and
difficult to flash out.
 57

If this condition persists for months the patient may loose some weight ( features of
malnourishment) and he also develops deficiency of Fat soluble vitamin. ( Vitamin A,
Vitamin D, Vitamin E, Vitamin K) as fat is not absorbed properly. Vitamin K is essential for
post translational modification of clotting factor II, factor VII, factor IX, factor X. So, in
case of obstructed jaundice patient may develop clotting factor deficiency leads to
coagulopathy. Clinically we found increased Prothrombin time, INR ( defective extrinsic
pathway).

One of the factor of color of normal stool is bilirubin. As it is not present in stool in case of
obstructive jaundice stool become pale or silvery gray in color.

Urine also becomes dark. Because in surgical jaundice blood with conjugated bilirubin
enters into kidney through circulation which in turns found in urine causing dark color.

Normally, Bilirubin converted into stercobilinogen in duodenum and passes with stool.
Some of the stercobilinogen firther converted into urobilinogen and enters into kidney
through circulation. but in case of obstruction as it os not passed into duodenum, no
urobilinogen found in urine.

As there is increased bilirubin in blood it may deposit in different tissues. Bile salts binds
with collage of connective tissue and causing stimulation of basophils which release excess
histamine which causing severe itching.

If obstruction caused by stone patient may comes with cholangitis (inflammation of CBD).
Patient may comes with fever, Jaundice with chills and rigor.

If obstruction caused by pancreatic carcinoma there may be features of carcinoma. These

includes Weakness, Weight loss, Anaemia.
 58
Long case Examination

Presenting Complaints

Patient may comes with varieties of complaint such as:

1. Yellow coloration of skin
2. Dark urine and pale stool
3. Generalised weakness (in pancreatic carcinoma)
4. Severe itching
5. Lump in epigastrium ( if carcinoma head of pancreas become huge)

H/O Present Illness

According to patient statement he was reasonably well 1 months back. Suddenly he

develops jaundice ( then we have to elaborate it) which is associated with pale stool, dark
color urine, and severe itching. (If there is features of carcinoma other diseases then we
have to mention it.)
If you have to present as carcinoma then you must have to clarify if the cancer has
metastasised. Carcinoma of head of the pancreas may spread to portal vein, lungs, liver,
bones. We have to explain signs of positive and negative metastasis.
Bowel and bladder habit should be mentioned.
H/O DM , HTN should be taken.

H/O Past Illness

Mention if associated illness is present

Drug History

Mention the drugs patient is taking which is associated with surgery e.g. Aspirin, Clopidogrel

All other history should be mentioned which is usually not significant

 59
General Examination

We have to check for

Anaemia
Jaundice (must be in broad daylight)
Lymph node enlargement

Systemic Examination

Local ( Abdominal)

A. Inspection
Shape: Scaphoid
Movement with respiration: Abdomino thoracic (Male)/ Thoraco abdominal (Female)
Umbilicus: Centrally placed, inverted and vertically slitted
Scratch mark: Present all over the abdomen.
No scar mark, engorged vein, visible peristalsis, fullness in right hypochondrium (due to
distended gallbladder: Can be seen in very thin patients)

B. Palpation:
Temperature: Not raised
Tenderness: Non-tender
No palpable mass, muscle guard or hyperesthesia
Murphy's sign: Negative
Liver, spleen, kidney, UB: Not palpable

C. Percussion:
Tympanic
Fluid thrill and shifting dullness absent

D. Auscultation:
Bowel sound present

Other Systems

Nervous system examination: Revealed no abnormality

Respiratory system examination: Revealed no abnormality
CVS examination: Revealed no abnormality

Salient Feature

Mention particulars along with H/O present illness with positive and negative findings.
 60
Provisional Diagnosis

Obstructive jaundice due to carcinoma head of the pancreas

Or Obstructive jaundice due to choleducolithiasis (stone from gall bladder enters into
biliary channel. Usually colicky pain is associated)

Usually in case of carcinoma head of the pancreas jaundice is progressive. But in case of
choleducolithiasis usually it is intermittent.

Investigation

Diagnostic
1.USG of W/A with special attention to HBS and Pancreas
2. MRCP
3. ERCP
4. LFT
S. Bilirubin: increased
S. ALP: increased
PT: Increased
S. Albumin: Markedly Decreased

If diagnosis is carcinoma Then for staging we advice

1.CT scan abdomen
2. CT scan Chest

For G/A fitness

1. CBC
2. S. Creatinine
3. S. Electrolyte
4. CXR P/A view
5. ECG
6. Echocardiogram for above 40 years patient
7. Urine R/E

For screening
1.HBs Ag
2. Anti HCV
3. Anti HIV
4. RT PCR for Covid
 61
Treatment

If Carcinoma head of the pancreas : Whipples Procedure (tripple bypass surgery:

gastrojejunostomy, pancreaticojejunostomy, jejunojejenostomy)

If Choleducolithiasis : Choleducolithotomy by open or laparoscopic method.

N.B. We have to correct anaemia and decreased S. albumin and decreased vitamin K
prior to surgery.
Injection vitamin k1 is given intramuscular to prevent coagulopathy in 5 days. If surgery is
urgent then Fresh frozen plasma is given.
5% DA or 5% DNS is given pre operatively.
 62
Ca Breast
Carcinoma breast is a very common.
If we sort the patients according to occurance rate in our country -
1.Chronic calculus cholecystitis 2.Ca breast

Ca breast is the second most common cancer among cancers of female

Most common carcinoma is Ca cervix.We find these cases in gyniae.Where as we find the
patients of Ca breast in surgery ward.

Particulars of the patient

Age:Ca breast is found in people of more than 20 year old.. More commonly found in
above 30 year old patients.
Sex: (Male can also suffer from carcinoma breast) 0.5% or less Its more notorious or
agressive if it occurs in males because in males theres are less adipose tissue. So
lymphatics are closer together. So cancer can spread easily.
Estrogens role-Development of breast,increase in size
Progesterone- Growth of Ductal system
Increased exposure to estrogen can increase the chances of Ca breast
Nulliparous older women of 26/30 is getting continuous stimulation of estrogen for long
time or Women taking OCP containg estrogen for years can develope Ca breast.
Some women who have a long productive age. i.e.. Early menarche, late menopause.
Lets assume from 13yr -50yr get long time ecposure to estrogen. They can develope Ca
breast.
Genetic influence- Chromosome 17 has a gene called BRCA-1 & Chromosome 13 has a
gene called BRCA 13..If there is mutation in these genese someone may develope Ca
breast..
People having Positive faimily history - 1st degree relatives like mother,sister,
Aunt(mothers sister) may develope Ca breast
Adress: Developed countries have higher incidence rate. Beacuse they focus more on
their carriers and they conceive late. Take one child. Also using of OCP is more common
 63
Presenting complaints/Chief complaints:

Usually common-
1.This patient came with a lump(Notice I said lump.not swelling) in right /left brease for
6mon/1yr. ( People rarely come to hospital in early stage)
2.Occasional nipple discharge(blood stain/greenish etc) (found in mostly advanced stage.)
for... days ( Usually Ca breast is painless)
1.bones (ask patient if there is bone pain)
2.Lungs(mention if there is history of hemoptysis,chest pain,caughing) 3.kidney
4.liver
Ask about Bladder & bowel habit.
Ask about HTN of DM.
(The patient is diabetic or non diabetic)
(Dont say the patient is not hypertensive.Say the patient is normotensive.)

History of past illness

Ask if the patient was hospitalized before? If so for what. If the patient had TB or other
carcinomas or any other problems.

Drug &Treatment history

Look for any drug the patient takes that can produce such sign symptom.
(Rifampicin can produce urine like jaundice)
(Before the surgery 2 drugs should be stopped. Aspirin & Clopidogrel.
Aspirin before 7 days
Clopidogrel before 3 days
Because they are anti platelet agent.They decrease the viscosity and coagulative tendency
of blood..So Bleeding would be harder to stop.

Personal history

Does the patient use OCP?

Does the patient drink of smoke?
Smoking & Alcohol has direct affect.
 64
Family history

Ask if there is such symptoms in her family

Obsteric history

Age of last child, age of menarche,age of Menopause

Examination

General examination

Special focus on
anemia (Most females are suffeeing from anemia)
Nutritional status-poor
Lymph adenopathy -Enlarged
Bony tenderness-may be positive in metastasis

Local examination
Loco regional; Breast examination
1.Site (in which quadrent)
2.Size
3.Shape
4.Surface(Smooth/bosselated) 5.Margin(Regular/irregular) 6.Consistencey(hard)
7.Fixity(with underlying structure in Carcinoma)
First examine normal breast..Forbetter comparision in mind.
Examine the axilary lymph nodes. Mention the group,size, tenderness)

Other systems examination

Respiratory,CVS,Neurological: Mention any metastatic features

Salient features

In short Particulars of the patient.

Important positive & negative findings.
We should write the salient features so that it can exclude the D/D
 65
Provisional diagnosis

Carcinoma of Right /Left breast

Differential Diagnosis

A D/D can be Antibioma (Hard mass formed due to Prescribing Antibiotic without draining
a absess). Sometimes they mimic carcinoma.
TB in breast
Fibroadenoma (no fixity)
Chronic breast absess(usually painless)
You will have to explain the D/D you wrote. Why they are not diagnosed. So you should
not write more D/D than you can explain.

Investigation

Diagnostic
TRU cut biopsy & Histopathology is done. Its core biopsy.
(FNAC are note done in tertiary medical facilities. So you should not tell it to the
professor..Its not done because it has less diagnostic value. Although it may be done at
upazila level.)
Mammography: Done to older women, age 35+ whose breast density is less.
USG: Done to younger women.whos brest density is high. USG of both breast & Axila.

Staging
Determine the spread by Isotope bone scan
CT scan of abdomen,chest,sometimes even skull
Receptor status: Estrogen receptor Progesterone receptor HER-2 receptor
If these are positive its good. Because then hormone treatment will shrink the tumor.
If one is positive its good. If two are positive then much better. If all three are positive its
even more better.

GA fitness
CBC,serum creatinin,ECG, Echo(if>40yr), Urine R/M/E,RBS,HbA1C

Screening
For surgeons safety- HbsAg,Anti HCV, Anti HIV 1,2 RT PCR for Covid 19
 66
Staging of Ca breast

Two types of classification

Manchester staging

Stage-1 Stage 3(Locally advanced)

Growth is confines in breaset. (Organ III A: fixed
confined) Mobile Size >5 cm
Size= <2 cm Palpable LN(axilary)(fixed)
No palpable axilary lymph node T=3(5-10 cm)
T=1 (if the tumor is <2 cm) N=2 ( Lymph node is involved & fixed)
N=0(as there is no lymph node M=0
involvement)
M=0 (as there is no metastasis) IIIB :fixed lump
T1N0M0 Any size
As any size- may spread to skin/chest
Stage -2 (Loco regional) wall Palpable fixed axilary LN
Growth is confined to the brest. T=4(>10 cm)
Size=2-5cm N=3( if supraclavicular lymph node is
Mobile palpable)
Mobile palpable axilary lymph node M=0
T=2 (2-5 cm)
N=1 (in one set) Stage-4
M=0(No metastasis) What ever T& N is there is Metastasis.
T2N1M0
Early caricinoma is upto stage 2

T1= <2cm fixation

T2=2-5 cm skin tetharing
T3=5-10 cm(may have ulceration/peau d'orange)
N=0(No palpable lymph node)
N=1 (mobile plpable)
N=2(fixed palpable)
N=3( Supraclavicular LN palpable)
M=0 ( If no metastasis)
M=1 (if metastsis)
 67
Treatment

Stage1
wide local excision of the tumor or Lumpectomy followed by Sentiniel lymph node
biopsy(1st draining LN from the site)
& follow up
Or, Quadrantectomy

Stage 2
Wide local excision followed by Axillary clearence Or,modified radical mastectomy

Stage 3
We want the tumor to shrink.So before surgery neo -adjuvant chemotherapy is a 2-3 cycle
is adminstered. Then again asess the size. Then simple mastectomy with axillary clearance
Then again chemotherapy

If atleast 2 receptors are positive hormone therapy is given. We use TAMOXIFEN

If the patients situation is very bad & clearence is not possible.then Radiotherapy is given.

Stage-4
No surgery
Only chemotherapy
Total mastectomy (for palliation)

(for patients mental relief in case of huge lump on TAMOXIFEN.(Tamoxifen is not

estrogen.it blocks the estrogen receptor)

Follow up

1st year- 3 monthly 4 visits 2nd year-6 monthly 2 visits Then 1 yearly visits Because of
rucurrance
 Colorectal Carcinoma 68

Colorectal carcinoma is one of the common carcinoma as our dietary pattern has changed
a lot in last few decades. And also consumption of lots carcinogen in our diet make it more
common.

Particulars of the Patient

1. Age: Above 50 Years

2. Sex: Carcinoma colon is more in male ( Male: Female = 3: 2) and rectal carcinoma is
common in female.
3. Religion: Not more significant but subject who taken more red meat and less vegetables
has more chance to develop carcinoma.
4. Address: Urban people consume less vegetable and more cholesterol rich food. More
cholesterol need more bile to digest. Bile salts in bile is more carcinogenic. So, prevalence
of colorectal carcinoma in urban people is more.
5. Occupation: Occupation related to radiation exposure (e.g. cancer patient, medical
technologist, surgeon who use portable x ray) has more chance to develop carcinoma.
 69
Presenting Symptoms

1. Constipation in case of cauliflower shape mass in gut passage.

2. Haematochezia in case of ulcerative lesion.
3. Anaemia in case of long term haematochezia.
4. As most of the carcinoma is of adenocarcinoma ( carcinoma of glandular cell) , so there
is more secreation. As a result there may be symptoms of diarrhoea. So, patient has
altered bowel habit.
5. Features of intestinal obstruction in case of annular apperance
6. There may be a lump or a mass in the region of colon. Commonly found in right iliac
fossa as ceacal carcinoma is the commonest form.
7. Anorexia, Weight loss, generalised weakness and anaemia is common presentation for
any carcinoma.
N.B Usually pathology in the right side present with constipation and bleeding whereas left
side pathology present with signs of obstruction.

Features of Intestinal Obstruction Diferential diagnosis of Right iliac region

1. Constipation swelling
2. Pain 1. Appendicular Lump
3. Abdominal Distension 2. Ileiocecal TB
4. Foul smelling and sometimes fecal 3. Carcinoma Ceacum
matter containing vomiting. 4. Crohns disease
 70
History of present illness

According to the statement of the patient he was reasonably well 6 months back. Then he
noticed a lump in the right iliac fossa which is painless and progressively increasing in size.
The patient also complains of hematochezia. ( After that we have to ask if blood is on the
surface of the stool or stool is mixed with blood. Usually Blood mixed with the stool
indicates the source of the blood is in the colon where it got mixed with the stool. Blood on
the surface of the stool indicates blood from rectum.) Stool is mixed with blood. This patient
also have altered bowel habit.
( Mention if there is symptoms of obstruction like that: Patient comes with absolute
constipation (not fecal matter or not flatus can pass) associated with pain in the periphery of
abdomen which is colicky in nature and foul smell projectile vomiting. Patien also complains
of lower abdominal distension.

If colorectal carcinoma metastasized there may be other symptoms which should be

mentioned. Common symptoms include
Liver: Signs of jaundice and hepatomegaly
Lungs: Cough, Hemoptysis and chest pain

In rectal carcinoma, there may be

1. Spurious diarrhoea due to accumulation of excess mucus overnight from the
adenocarcinoma.
2. Blood on the surface of the stool
3. Tenesmus (Incomplete sensation of evacuation)
4. Anorexia
5. Anaemia
6. Features of local invasion

H/O past illness

There may be presence of familial adenomatous polyp, ulcerative colitis, chron’s disease
previously

Drug and treatment history

Mention history of taking anti platelet drug (e.g. Aspirin, clopidogrel) and other drugs

Personal History

Mention the history of smoking and alcoholism

Clinical Examination 71

General Examination

1. Anaemia: Present
2. Jaundice : Present in case of liver metastasized
3. Lymph node : Left supraclavicular lymph node may enlarged

Local Examination

Inspection: Normal
Palpation: On superficial palpation mass or lump may be found . If found size, shape,
margin, surface , skin over the swlling, temparature, tenderness should be described.
On organ palpation there may be symptoms of hepatomegaly in case of metastasis.
DRE: A mass may be found in the rectal wall in case of rectal carcinoma. Blood may soaked
in the gloves in case of carcinoma.

Other system reveals no abnormality

Salient Feature

Describe the particulars with history and important positive and negative findings

Provisional diagnosis
This may be a case of colorectal carcinoma

Differential Diagnosis

1. Appendicular lump: Excluded by previous history of appedicytis

2. Ilioceacal TB: Excluded by fever of TB
3. Chrons Disease: Excluded by presence of generalized sign of carcinoma
 72
Investigation

Diagnostic
1. Barium Enema Xray: Apple core deformity
2. Colonoscopy Followed by biopsy and histopathology
3. CT colobogram

For Staging
1. CT Abdomen
2. CT Chest

For prognosis
1. Carcinoembryonic antigen (CEA)

For G/A fitness

Regular investigation

In case of rectal carcinoma sigmoidoscopy or proctoscopy followed by biopsy and

histopathologt may be done.
In case of rectal carcinoma MRI of pelvic region is done as rectum of surrounded by soft
tissue, so CT scan is not appropriate.

Treatment

1.Hemicolectomy: Excision of pathological side along with 1/3 rd of transverse colon

2. Adjuvent chemotherapy: Chemothrapy following surgery
3. Neoadjuvent chemotherapy: Chemotherapy prior to surgery in case of huge carcinoma to
reduce the size of the mass for better operative purpose.
4. APR (Abdominoperneal ressection) followed by colostomy
 Cholecystitis
73

Also known as Chronic calculous cholecystitis

Particulars of the patient

1. Sex: Female predominant (Fair lady)

Presenting complaints

1. Recurrent upper abdominal pain for 6 months

2. Occassional upper abdominal discomfort after having meal for same duration
3. Nausea for same duration

History of Present Illness

According to the statement of the patient, she was reasonably well 6 months back. Then she
developed recurrent abdominal pain located in right hypochondriac region, colicky in
nature. The pain is referred to the tip of the right shoulder. The pain aggrevates after taking
a heavy fatty meal, subsidies by taking anti spasmodic drugs (tiemonium methylsulphate).
There is no periodicity. She has been suffering from occasional nausea for the same
duration. There is no fever nor chills with rigor ( if present, mention it, and it will indicate
cholangitis. In that case, there will be fever at the time of acute attack, which will be
included in the history). Her bladder and bowel habit is normal. She is normotensive, non
diabetic.

(Note: Here our differential diagnosis:

PUD→ excluded by no periodicity
Acute pancreatitis→ excluded by region of the pain and nature. The pain would be severe
and it would radiate to the back)
 74
History of past illness

Nothing significant

Drug and treatment history

If she takes any medication on regular basis, mention it. Our special attention is towards anti
platelet agents like aspirin or clopidogrel.

Personal History
Take smoking and alcoholism history.
In female take LMP, obstetric history and mention she is lactating or not

Immunization History

History of EPI and Covid 19

Allergic history

Alllergy to any drug

 75
Clinical Examination

General Examination

1. Jaundice: May present

2. Anaemia: May present

Local Examination (Abdominal Examination)

Abdominal examination: Inspection :

Shape: Scaphoid
Movement with respiration: Abdomino thoracic (Male)/ Thoraco abdominal (Female)
Umbilicus: Centrally placed, inverted and vertically slitted
Scratch mark: Absent
No scar mark, engorged vein, visible peristalsis, fullness in right hypochondrium (due to
distended gallbladder: Can be seen in very thin patients)
Palpation:
Temperature: Not raised
Tenderness: Non-tender
No palpable mass, muscle guard or hyperesthesia
Murphy‟s sign: Negative (positive in acute cholecystitis)
Liver, spleen, kidney, UB: Not palpable
Percussion:
Tympanic
Fluid thrill and shifting dullness absent Auscultation: Bowel sound present
DRE: Revealed no abnormality

Other systemic examination reveals no abnormalities

Salient features

Present with particulars along with H/O present illness along with important positive and
negative findings.

Provisional diagnosis
It may be a case of chronic cholecystitis
 76
Differential Diagnosis

1.PUD
2. Chronic pancreatitis

Investigation

Diagnostic
1. USG of whole abdomen with special attention to hepatobiliary system and pancreas.
Why whole abdomen
1. To exclude other pathology of whole abdomen
2. To exclude Any congenital anomalies
3. To exclude pancreatitis
Findings in cholecystitis
1. Increased gall bladder thickness
2. Posterior acuostic shadow.

For GA fitness
1.CBC : To correct anaemia
2. S. Electrolyte profile: To correct electrolyte imbalance
3. S. Creatinine
4. ECG
5. Echo in case of older patient for ejection fraction
6. Urine R/E

For surgeon safety (screening)

1. HBsAG
2. Anti HCV
3. HIV
4. RT-PCR for Covid19

In acute cholecystitis treatment plan is different. We usually keep our patien NPO and antibiotic if there is
translocation of bacteria. Anti spasmtic is given.
 77
Benign Enlargement of the Prostate
Aka Benign prostatic hyperplasia

Particular of Patients

1. Age: usually occurs after 50 years. (Due to impaired testosterone oestrogen ratio and
production of more potent Dehydrotestosterone (DHT))
2. Sex: Male (Female does not have prostate)

Presenting Complaints

1. Acute or chronic or acute on chronic retention of urine.: Unable to pass urine.

2. Direct inguinal hernia
3. Hesitancy: Difficulty in intiation of micturation
4. Dribbling
5. Urgency
6. UTI
7. Incomplete evacuation
8. Distension and lower abdominal pain

H/O of Presenting Illness

According to the statement of the patient, he was reasonably well _ days back. Then he
develops difficulty in micturition with hesitancy, dribbling, weak stream and increased
frequency. He also complaints about nocturia. He has pain in the hypogastric area. He
has no history of weight loss, anorexia or general weakness. History of haematuria is
absent.
 78
H/O Past Illness

He may has history of UTI or cystitis

Drug and Treatment History

May has taken tamsulosin and fenesteride
History of taking aspirin and clopidogrel should be taken.

General Examination

Dehydration may be positive

Local Examination

Abdomen may be distended with tenderness at suprapeubic region

Per Rectal Examination: Firm mass is palpable with median sulcus. There is not presence of
blood

Provisional Diagnosis

It may be a case of BEP

Investigations 79

Diagnostic
USG of KUB region with special attention to prostate with PVR & MCC
Uroflowmetry: >15 mL/ sec
Cystoscopy
Transrectal ultrasound
Serum PSA: Prognostic factor
IVU
S. Electrolyte

For GA fitness
1.CBC : To correct anaemia
2. S. Electrolyte profile: To correct electrolyte imbalance
3. S. Creatinine
4. ECG
5. Echo in case of older patient for ejection fraction
6. Urine R/E

For surgeon safety (screening)

1. HBsAG
2. Anti HCV
3. HIV
4. RT-PCR for Covid19

Management

In acute retention: Urinary Catheterisation. If catheter cannot be passed then suprapeubic

cystostomy is done.

Surgical Management :
Transurethral resection of Prostate (TURP) (Gold standard)
Freyers Suprapeubic transvesicle prostectomy