Surgery

- Dr. Risheek Gupta

Kindly report any errors @Gup2000109

or in BTR group chat
Nerve Injuries ILN injured in Pyriformis fossa

-Breast surgery axilla clearance- Inter-costo-brachial trunk # T2 Apex of axilla 2 axilla

T4 Nipples T2 x 2 nipples= T4
-Thyroid surgery- ELN>SLN>RLN [ILN doesn’t injure in thyroid Sx]
T6 Xiphoid process T-siX
-Parotid surgery- a) Deviation of angle- Marginal mandibular nerve T10 Umbilicus Umbilicus is round
like 0
b) Anaesthesia at angle- Great auricular nerve(C2-C3) Submandibular injury d/t T12 Inguinal ligament
Sialolithiasis surgery/
c) Frey- Auriculotemporal nerve(gustatory sweating) Wharton duct involvement
- Lingual nerve
-Submandibular surgery- Marginal mandibular nerve
-Hernia surgery-
a) Loss of sensation over lateral thigh Lat. cut. n. of thigh(MC n. # in Lap.
Hernia Sx)
b) Loss of sensation over suprapubic region Iliohypogastric n.
(Mesh entrapment assd. #)
c) Loss of sensation over root of penis Ilio-inguinal n.(MC # in Open hernia
(Vowels stick together) repair)
d) Loss of Cremasteric reflex Genito-femoral n.(both afferent & efferent of reflex)
-Thymectomy Phrenic nerve Retrograde ejaculation
Lateral Cut. N. of Thigh #
-Rectal Ca Surgeries (IMA ligation)Superior hypogastric plexus # (Sympathetic • Meralgia paraesthetica
• Hernia surgery(MC in Lap. Hernia Sx)
-Pelvic dissection Nervi-erigentes #(leads to Impotence) fibre) • Extreme lithotomy/McRobert’s position
during management of Shoulder dystocia
SUTURES Monofilament : weaker but lesser r/o infection
Polyfilament : stronger but higher r/o infection

Absorbable Non - Absorbable

Mechanism:
Hydrolysis

Synthetic Natural Synthetic Natural

SILK
Monocryl: CATGUT
Nylon-Polyamide/ Ethilon
Polygycaparone

PDS: Polydiaxonone Microsurgical suture

Prolene – Polypropylene

Vicryl: Polygalactin
Novafil - Polybutester

Dexon: Polyglycolic acid Polyester- Ethibond

 Everted edges desired in skin sutures
SUTURES Inverted edges desired in bowel sutures
Purse string sutures
Simple continuous suture RECTAL PROLAPSE
Perineal-TAD bit too easy
Thiersche cerclage
Altemier’s procedure
Simple interrupted sutures Delorme procedure
Abdominal-
• Cervical incompetence Ripstein rectopexy
• Herniotomy for Congenital
hydrocele Wells
• Rectal prolapse

JENKIN’S RULE:
Subcuticular sutures Length Of Suture Should Be 4 Times The Length Of Wound
Angle Of Entry Of Suture Needle, IM injection: 90
Verees Needle Angle, SC Injection: 45
Horizontal mattress suture
ID injection:10-15
Verees needle(Bevelled margins to reduce trauma) : Pneumoperitoneum creation
CO2 MC used for insuffalation because : for Lap. Sx
Vertical mattress sutures CO2 :
• soluble in blood(no risk of air embolism)
15-20mmHg • Non-combustible(cautery can be used safely)
pressure, Only theoretical risk of hypercarbia therefore avoided in
<2L volume
COPD patients(use Room air/Helium/N2O)
*Peritoneal stretching d/t CO2 may lead to bradycardia via J-reflex
INSTRUMENTS
Blade number :
10. 11. 12. 15.

Bard-
Parker
handle Granny’s
Square/Reef
Surgeon’s knot knot(slips,
Skin/muscle I&D Suture Precise incision/ knot(secure
cutting removal minor OT proc
(Secure knot) not secure)
knot)
SUTURE KIT

Hold needle @ junction of post.(Swayed end) Scissors

Needle holder 1/3rd & ant.(pointed end)2/3rd of needle
Short & thick

Mayo
Long & slim

Adson’s tissue Metzenbaum

holdingForceps
FORCEPS
Transverse Transverse striations
striations ~ Single tooth
traumatic + transverse Multiple
striations teeth

Hemostasis
& ARM LSCS
Kocher’s
Kelly’s hemostatic Mixter’s right Allis’ forceps Green armytage
forceps
Artery forceps angled forceps forceps

Longitudinal No lock
Rampley’s striations ~
sponge Atraumatic
Ovum Desjardin’s Mayo’s
Babcock’s holding
Intestinal forceps choledocho- towel
forceps forceps
clamp (for lithotomy clip
RPOC) forceps
RETRACTORS
CZerney’s retractor
Doyen’s
retractor(for
bladder in
LSCS)

Daever’s retractor
Lagenback’s
retractor(narrow Morrison’s retractor Balfour’s self-
blade) (wide blade) retaining retractor
Joll’s thyroid
retractor
8 teeth 6 teeth

Makes a P

Jensen’s retractor Perkin’s retractor

Mollison’s retractor (6 letters)
(8 letters)
Mastoid retractors
 Time of drain removal : A) Thyroidectomy - w/in 24 hrs In sepsis/infections,

BAGS AND DRAINS B) GI anastomosis - 3-5 days

C) T tube - 2-3 weeks
remove drains after
infection subsides

ICD bag/Chest drain bag JP drain

Romovac(thoracic DJ stent
(underwater seal line) (abdominal drain)/
Abdominal Adequacy of tube placement : drain/
Hemovac(larger
drain bag oscillating water column Minivac(smaller
capacity variant) capacity variant)
Excessive bubbling : suspect
Types of drains :
Broncho-pleural fistula
A. Open(gravity & passive drainage)
Pigtail catheter eg. corrugated tube drain
Malecot’s catheter B. Closed :
i) Suctioned : Active drain(negative
pressr. via suction) eg. Romovac/JP
drain
ii) Non-suctioned : passive
drain(capillary action & gravity) eg.
Abscess drainage Kehr’s T tube urinary catheter, NGT
 HEMOSTATIC DEVICES

Linear
stapler(Zenker’s
CUSA(Cavitatory diverticulum)
Ultrasound Surgical
Aspirator)
Monopolar cautery Bipolar cautery • Ligature : pressure
• NS/RL not used • NS/RL can be used induced heat
• Distilled water
coagulation
used(r/o
• Harmonic scalpel :
hyponatremia) Circular stapler
oscillation induced
OR Glycine 1.5% (Hemorrhoids)
heat coagulation
• Blue :
• Thunderbeat :
Coagulates(Blue is
pressure +
glue)
oscillation induced
• Yellow : Cuts
heat coagulation
Surgical safety checklist
Before induction of Before skin incision Before patient leaves
anesthesia operating room OT ZONES
Sign In Time Out Sign Out
Zone 1:
q PATIENT HAS CONFIRMED q CONFIRM ALL TEAM MEMBERS Nurse verbally confirms with the
• IDENTITY HAVE INTRODUCED team: -Protective reception,
• SITE THEMSELVES BY NAME AND waiting, trolley bay, change
• PROCEDURE ROLE q The name of the procedure
• CONSENT recorded rooms
q SITE MARKED/NOT q Surgeon, anesthesia
q That instrument, sponge and Zone 2:
needle counts are correct (or
APPLICABLE professional and nurse verbally
not applicable) -clean area –preoperative,
confirm
• Patient
q How the specimen is labelled recovery, plaster room,
(including patient name)
• Site staff lounges, stores
• Procedure
Zone 3:
q ANAESTHESIA SAFETY Anticipated Critical Events
CHECK COMPLETED -Disposal area –dirty utility,
disposal corridor
q PULSE OXIMETER ON PATIENT Has antibiotic prophylaxis been q Surgeon, anesthesia
AND FUNCTIONING given within the last 60 minutes? professional and nurse review
the key concerns for recovery
DOES PATIENT HAVE A:
and management of this patient
KNOWN ALLERGY?
DIFFICULT AIRWAY? Cefazolin i.v. 30-60
RISK OF >500ML BLOOD LOSS? minutes before incision
Post - Op Fever
Timing Etiology Prevention Mnemonic
Anytime Drug reactions, - Wonder Incentive spirometer
malignant drugs
hyperthermia
POD 1-3 MCC ON D1- Incentive spirometry, Wind
Atelectasis early mobilization
antibiotics
POD 3-4 MCC OVERALL- Shot-term foley use Water
UTI
POD 4-5 Deep venous Early mobilization, Walking
thrombosis LMWH, sequential
compression socks

POD 7+ Surgical site infection Dressing changes, Wound

preoperative antibiotics
 SSI
SSI definition- within 30 days of Surgery/1 yr of implant Southampton wound grading score

BURST ABDOMEN
Day- D6 Salmon colored
Pathognomic sign: serosanguinous
Mx- Bagota bag/Urobag fluid
Laparotomy

Intra-abdominal abscess
MC site: Supine- Hepato Overall/ Ambulatory- Pelvis/
IOC CECT renal POD
TOC Pigtail pouch
drainage
Criterion ASEPSIS score
A Additional Treatment
S Serous discharge
E Erythema
P Purulent exudates
S Separation of deep tissues
I Isolation of bacteria Induration is not a
S Stay in hospital prolonged over 14 days part of the score
Types of surgery
-Gross purulence or existing infection? Class IV-Dirty /Infected
-Perforated viscera˃ 4 hours old? Yes e.g. surgical management of
-Traumatic wound open ˃4 hours? abscess, repair of perforated
-Penetrating injury ˃4 hours old? bowel
NO

-Acute, non-purulent inflammation? Class III- Contaminated

-Unplanned entrance into GI/GU/ respiratory Yes e.g. non –sterile debris in field,
tracts? cholecystectomy with bile spillage
-Major break in sterile technique? or acute inflammation, Open
cardiac massage
NO
Elective

Yes
Controlled/international entry into the GI,GU, Class II- Clean-Contaminated
or respiratory tracts? e.g. hysterectomy, lobectomy,
laryngectomy, small bowel
resection, TURP, LSCS

NO Class I- Clean
e.g. mastectomy, hernia repair,
thyroidectomy, TKR, THR, CABG
 qSOFA score ~ Revised Trauma score(RTS)
White THR(SBP not a component)
SIRS –2 or more +:
Core Temperature ˂36oC or ˃ 38oC
HR >90bpm
RR ˃20/min or Pco2 ˂32 mmHg GCS RR BP
White blood cell count ˃12,000 /μL,
<4000/μL, 10% bands

CO SVR CVP

Cardiogenic

Hypovolemic

Obstructive
Hyperdynamic
Neurogenic shock(spinal) : all parameters decrease
Distributive
SHOCK + WARM EXTREMITIES + MV02 >70%: state
Shock index- HR/SBP Septic shock
Neurogenic
Modified shock index- HR/MAP

-Best clinical indicator of adequacy of resuscitation: Urine output

ADULT: >0.5mL/kg/hr CHILDREN: >1mL/kg/hr INFANTS:>2mL/kg/hr
-Best indicator to estimate fluid required for resuscitation: CVP(Rt. Atrial Pressr.)
-Best lab parameter to monitor tissue perfusion: Lactate/Base deficit
Trauma-Basics
TRIAGE: PRIMARY SURVEY:
Immediate: immediately life-threatening injuries A Airway w/ C-spine stabilisation
Delayed: injuries requiring treatment within 6 hours B Breathing w/ Ventilation
Minimal: walking wounded
Dead C Circulation
D Disability - neurological assessment
Primary survey Identify what
(W/in is killing the patient
6hrs)
ADJUNCTS: E Exposure w/ environmental control
CXR/Pelvic X-ray/eFAST
Field: cABCDE where c = control of
Resuscitation Treat what is killing the patient
haemorrhage/exsanguinating bleed
Secondary survey Identify other possible injuries
CT scan Definitive : oral ET
Definitive care Make a management plan intubation
failure OR C/I to
intubate
eg. maxillofacial #)

Immediate :
Jaw thrust Head tilt- Cricothyroidotomy

f
Definitive :
C-spine # Chin lift Tracheostomy
CHEST TRAUMA
Flail chest not included
Triage level : RED

TENSION MASSIVE CONSOLIDATION / CARDIAC

PNEUMOTHORAX HEMOTHORAX CONTUSION TAMPONADE

TYPE OF SHOCK
Obstructive Hypovolemic - Obstructive
JVD Increase Decrease Normal Increase
TRACHEAL SHIFT
C/L C/L No shift No shift
BREATH SOUNDS /
VOCAL FREMITUS
Decrease Decrease Increase Normal
PERCUSSION
Hyper-resonant Dull Dull Dull(Ewart sign)
HEART SOUNDS Normal Normal Normal Muffled
Beck’s triad of CT : Muffled
heart sounds + Raised JVP +
Obstructive shock
Management of Cardiac tamponade: Emergency Pericardiocentesis f/b Thoracotomy
 Triangle of safety : P.major(ant.), Insert tube along Upper border of Lower rib as

CHEST TRAUMA Latissimus dorsi (post.) & 5th ICS(floor) with

axillary apex as apex
neurovascular bundle is present around lower
border of upper rib
Inferior rib notching seen in Coarctation of aorta(Rosler’s sign)

Air fluid levels

in a spherical
cavity : Lung
abscess

Seashore sign ~ Normal

M-mode USG

Air fluid levels in Xray : Diaphragm injury :

Haemothorax Pneumothorax Hydropneumothorax fundal air bubble in
A. Stable/unstable A. Stable managed by ICD Managed by ICD(no role thorax
managed by ICD in triangle of safety of needle ICD is C/I
B. No role of Needle B. Unstable(Tension) decompression )
placement managed by Needle f/b ICD Barcode/Stratosphere
sign ~ Ptx
Indications of Thoracotomy MC in Penetrating trauma
-IOC:Diagnostic laparoscopy > CECT
-Mx: Surgical repair
-Triad:Bergiust triad : Diaphragm #
+ rib # + spine/pelvis #
Shock
Parameter Class I Class II Class III Class IV
(Mild) (Moderate) (Severe)
Blood loss ˂15% 15-30% 31-40% ˃40%
<500mL 500-1000mL 1500-2000mL >2000mL
Heart rate ↔ ↑ ↑ ↑↑
Blood pressure ↔ ↔ ↓ ↓
Pulse pressure ↔ ↓ ↓ ↓
Respiratory rate ↔ ↔ ↑ ↑
Urine output ↔ ↔ ↓ ↓↓ Tranexamic acid
Glasgow coma ↔ ↔ ↓ ↓
scale score
Base deficit* 0 to -2mEq/L -2 to -6mEq/L -6 to -10 m Eq/L -10mEq/L or
less
Need for blood Monitor Possible Yes Massive Any pt. with
products Transfusion SBP < 110
OR
HR > 110

Mx of hypovolemic patients in shock (ATLS):

Min Cannula- 18G Fluid type- Isotonic Fluid volume- 1Ltr. prewarmed bolus(if
(green) crystalloid <40kgs then 20mL/kg)
 DAMAGE CONTROL SURGERY

• Primary Emergency Surgery

Metabolic Acidosis • Hemostasis Drainage of septic contamination
Stage
(pH<7.2) • Temporary abdominal closure
I
• (Bogota Bag, skin closure, Negative Pressure
Abdominal Closure Covers)

Trauma Stage • Resuscitation and ICU care: 24-48 hours

triad of II
death
Coagulopathy Hypothermia • Definitive Surgery
(<35 C) Stage • Full gastrointestinal repair
III • (Resection, Anastomosis, abdominal closure –
temporary or permanent )

• Abdominal Closure
Stage
• Patients on whom abdominal closure was not
IV
performed during definitive surgery
 ABDOMINAL TRAUMA

Subxiphoid SR pouch

eFAST +ve Seatbelt injury :

Free fluid in peritoneal space a. Mesenteric injury
Thorax b. Chance #
HR/ Morrison pouch Pelvis

-MC organ injured in BTA: Spleen

-MC organ injured in PTA: Liver > Stomach
-MC organ injured in GSW: Small intestine
-Kehr sign Left shoulder tip pain - splenic #
-Balance sign Dull note in LUQ - splenic #
eFAST: Extended Focused Assessment Sonography in Trauma
Sensitivity: ~100mL
LIMITATIONS: Retroperitoneal hematoma, Meseteric-bowel injury
ABDOMINAL TRAUMA
BLUNT TRAUMA

Unstable Stable
eFAST eFAST

Explorative Laparotomy CECT Observe

IOC : to localise injury
Grade : AAST

PENETRATING TRAUMA

-Unstable Local exploration Stable

-Gunshot (if stab wound)
-Peritoneal breach eFAST
-Impaled object
-Bleeding via orifice
-Evisceration Take to OT
CECT
 RP TRAUMA
Zones Contents Management
Zone I Central vascular structures Exploration
such as aorta and IVC Left medial visceral rotation:
Mattox Visualise Aorta
Right medial visceral:Visualise
Kocher’s/ Cattle Brasch IVC
Zone II Kidneys and adrenal glands Observation

Zone III Retroperitoneum associated External pelvic compression

with pelvic vasculature and fixation
Binder/Bedsheets
Zone IV Retro hepatic IVC and Observation
hematoma behind portal
vein
Sustained ACP >20mmHg w/ new onset MODS is ACS
Abdominal compartment pressure > 30mmHg =
indication of fasciotomy
Abdominal compartment IOC: Intravesical pressure
Anuria: Decompression
GU Trauma
AAST
-IOC for renal trauma in stable: CT Urography • Grade I: Subcapsular hematoma or contusion
-IOC for renal trauma in unstable: Single shot IVP • Grade II
-IOC for bladder injury: CT Cystography o Superficial laceration ≤1 cm depth not involving the collecting
-IOC for urethral injury:Retrograde Urethrogram(RGU) system
o Perirenal hematoma confined within the fascia

Mgt. : • Grade III

o Laceration >1 cm not involving the collecting system
Surgery o Vascular injury or active bleeding confined within the perirenal
fascia

• Grade IV
o Laceration involving the collecting system with urinary
Mgt. : extravasation Leaking
Foley’s contrast Urinoma +ve
catheter

o Vascular injury to segmental renal artery or vein

o Segmental infractions without associated active bleeding
o Active bleeding extending beyond the perirenal fascia

Dome rupture o Grade V

o Shattered kidney
Intraperitoneal Extraperitoneal
o Avulsion of renal hilum or laceration of the main renal artery or
bladder rupture bladder rupture(MC) vein: Devascularised kidney with active bleeding
 Distal urethral rupture : Straddle # - Penile/Bulbar Urethra #
URETHRAL TRAUMA Proximal urethral rupture : Pelvic # - Membranous/Prostatic urethra #

C/F: Inability to void + High riding prostate

on DRE(not done
+ nowadays d/t r/o
Bloods at meatus aggravating trauma)

Wait & watch if bladder

IOC: RGU not palpable for SPC

Normal RGU
Thigh(only up to Holden’s line if at all)

Supra-pubic Cystostomy(SPC) Q. A 14 year old boy presents to

the ED after a straddle injury
and rupture of bulbar urethra.
Delayed Extravasated urine can be seen
Urethroplasty in:
(after 4-6 wks) a) Scrotum
Buccal mucosal graft b) Thigh
c) Ischiorectal fossa
d) Deep perineal space
Bulbar Urethral rupture
 HEAD TRAUMA NCCT is IOC for head trauma except DAI(IOC : MRI)
Alcoholic-fall H/o RTA H/o RTA H/o RTA, GCS-9
Intraparenchymal
Star of death
Microbleeds : Blooming pattern
bleed/Contusion d/t
coup-countercoup #

Acute SDH Acute EDH Acute SAH Gold std. - DSA Diffusely Axonal
Thunderclap headache Injury
(Worst headache of life)
• Bridging veins • Artery Ant. div. of • Trauma> Aneurysm • NCCT Normal/
IOC : CTA
• Trivial trauma • RTA MMA • MC site: petechial
Circle of Willis TOC : Endovasvular
• Sutures: Can cross • Sutures: X hemorrhage
• Midline X • Midline Can cross ACA - ACOM jn. Coiling • IOC: MRI/SWI
Adam’s classification:
1 - GM-WM 2 - Corpus callosum
3 - Brainstem
HEAD TRAUMA
Transtentorial herniation

Base of
mandible

MC injured
Most accessible

Cricoid

Suprasternal
notch
3rd CN # Mount Fuji sign Max. mortality
Chronic SDH EDH
Tension
Swirl sign pneumocephalus
Active bleed is an
indication of I/L dilated pupil Penetrating neck trauma = Breach of platysma
Decompression using (Hutchinson pupil) • Expanding or pulsatile hematoma
Craniectomy/Burr • Active bleeding
I/L hemiplegia(d/t
• Shock
hole compression of C/L • Airway compromise
crus cerebri(false • Massive subcutaneous emphysema
localising sign) • Neurologic deficit
• ZONE 2
 TRAUMA SCORES
E4V5M6 Mangled Extremity Severity Score (MESS) ELISA
Type Characteristic Injury Point
Energy of injury s
1 Low energy Stab wound, simple closed fx, small-caliber 1
GSW
2 Medium
3 energy Open/multilevel fx, dislocation, moderate 2
4 High energy crush shotgun, high-velocity GSW 3
Massive crush 4
Logging, railroad, oil rig accidents
Shock Group Shock
Decerebrate 1 Normotensive BP stable 0
Transiently
Decorticate 2 Hypotensive BP unstable in field but responsive to fluid 1
Prolonged SBP ˂90mmHg in field and responsive to IV
3 hypotension fluids
2
In OR
Ischemia Group Limb Ischaemia
1 None Pulsatile, no signs of ischemia 1
Always score the better response 2 Mild Diminished pulses without signs of ischemia 2
No Doppler able pulse, sluggish cap refill,
3 Moderate Paresthesia, diminished motor activity 3

Max score : 15 GCS - P : Max score - 15 4 Advanced Pulseless, cool, paralyzed, numb without cap 4
refill
Min score : 3 Min score - 1 Age Group Age
Intubated patient : VNT(non-testable) 1 ˂30y/0 0
2 ˃30 ˂ 50 1
 BURNS
Depth Histology Appearance Sensation Healing
Fist-degree Epidermis only Erythema; blanches with Intact; 3-6 days without scarring
pressure mild to KEEP OPEN
moderate pain
Second degree
Superficial Epidermis and superficial Erythema, Blisters, moist, Intact; 1-3 weeks without scarring
dermis; skin appendages intact blanches with pressure severe pain DRESSING: Paraffin dressing
Deep Epidermis and most dermis; White, dry, waxy, reduced Decreased; ＞3 weeks, Scarring and
most skin appendages blanching to pressure less painful contractures
destroyed Hydrocolloid/ Collagen
dressing retains moisture
EXCISION AND GRAFTING
Third – Epidermis and all of dermis; White, charred, dry and Anesthetic; Does not heal;
degree destruction of all skin leathery; does not blanch not painful severe scarring and
appendages contractures
ESCHAROTOMY
EXCISION AND GRAFTING

MCC of death in burns: IV Fluids Latest ATLS:

-Immediate: Asphyxia > Neurgenic Fluid of choice in adults- R/L Adults: 2mL x wt. x %TBSA
-Early: Hypovolemic shock shock Fluid of choice in children- R/L + 5% <14yr: 3mL x wt. x % TBSA
-Late/ Overall: Sepsis Time: dextrose Electrical injury:4mL x wt. x %TBSA
-Organism: Pseudomonas 1/2 - 8hrs 1/2 - 16hrs Increased r/o Rhabdomyolysis
From time of burn
 Lund & Browder’s chart - Most accurate
Rule of 9-MANAGEMENT Berkley’s chart

Silver sulfadiazine: active against Pseudomonas but decreased

18% penetration
9% Silver nitrate: active against Pseudomonas, black
discolouration
18% 18% Mafenide acetate Causes metab. acidosis
9% 9% 9% 9% Cerium nitrate Best option(increases CMI)
18%
18%
1%
Cooling burn- NOT ICE
14% 14%
Effective upto: 1 hr
18% 18%
Ideal temp: 15 C

Adults Child FROSTBITE COOLING: Gradual rewarming(40-42 C)

Jackson’s staging

Laryngeal edema
Soot
Singed hair

Reduced perfusion
Immediate intubation

Increased perfusion
THYROID
-MC associated with RT, TGC: Papillary Ca
-Most common, Best prognosis, Lymphatic mets:
-Hematogenous mets:
Follicular Ca
-MC in iodine deficient areas, MNG:
-MC in MEN2 (RET point mutation): Medullary Thy. Ca Lahey’s Gille’s method
Pizillo’s
-RET/PTC (t 10;17): Papillary Ca method method
-RAS GOF, PAX8-PPARG(t2;3): Follicular Ca
-Worst prognosis: Anaplastic Ca
-GNAS mutation: Toxic nodular goitre
-Wolf chaikoff: Iodine induced Hypothyroidism
-Jod Basedow: Iodine induced Hyperthyroidism Pemberton method Berry’s test
(SVC syndrome OR Mediastinal CCA
invasion of thyroid)
Thyroglossal cyst
MC location: Infrahyoid
Management: Sistrunk procedure
 Thyroid Eye signs
Stellwag sign (STAREwag sign)

No creases on
Joffroy sign Joffrey’s head)

Orphan Annie eye Eosinophilic extracellular

nuclei amyloid Superior eye folds जल
Coffee bean nuclei A-Calcitonin Jellnick sign (जल-nick) के hyperpigmented
Psammoma bodies Medullary Thy. Ca
Papillary Ca Thyroid cancer w/ assd.
Diarrhoea(d/t 5HT), CEA+ve Hurt-hoge then lat. eyebrows are lost
Hertoge sign

का DaKo(डाकू)
Dalrymple sign UP
Retracted(Retarded)

Von Graffe sign

Granuloma Möbius sign
DeQuervian’s Thyroiditis Black thyroid d/t Kocher’s sign :upper lid retraction on fix gaze
Painful gland + h/o URTI Minocycline Enroth/Vigoroux sign : Eyelid swelling
(VS Lymphocytic Eyes swell Gifford sign : difficulty everting upper lid
Thyroiditis - painless) Vigorously when
Abadie sign : LPS spasm with lid retraction A-BADdIE’s LiPS spasm
EnRAGEd
Graves Disease LATS/TSI +ve

Thyroid Eye ds
Coca-cola sign
IMSLOw
IR MR SR LR s/iO
Sequence of involvement

No coca-cola sign in
orbital pseudotumour
Beefy Red/Pink Scalloping of Pachydermo- Pretibial
OR colloid periostitis a.k.a myxedema Class 0: No signs or symptoms
Angry Thyroid Acropachy (GAGs Class 1: Only signs (lid retraction, stare ±lid lag)
NOSPECS
deposited) Class 2: Soft tissue involvement Classification of
Management of Graves Class 3: Proptosis Thyroid
Ophthalmopathy
Class 4: Extraocular muscle involvement
RADIO-IODINE DRUGS SURGERY
Class 5: Corneal involvement
ABLATION I-131 Pregnancy : Severe TED
Class 6: Sight loss (optic nerve involvement)
Mainstay(B+r) PTU in T1 (Decompression Sx)
C/I : pregnancy, Methimazole in Thyroid hormone: Osteopenia
severe TED T2/3 High Osteoclast- High resorption
S/Es :
PTU : Agranulocytosis
Methimazole : Agranulocytosis, Choanal atresia, Cutis aplasia
APPROACH TO STN

TSH LOW TSH HIGH

RADIOLOGICAL IOC:

IOC:
FNAC can’t distinguish Follicular
Bethesda grading adenoma from carcinoma(IOC :
Thyroiditis OR Factitious Cant distinguish: Surgical biopsy)
hyperthyroidism/
Exogenous thyroid OR
Struma Ovarii
(Diffusely low uptake)
THYROID SURGERY
(1 lobe +
Baehr’s triangle:Max. r/o Upward extension prevented by: -Hemithyroidectomy: isthmus
CCA-ITA-RLN RLN # Sternothyroid & Sternohyoid muscles resected)
(4 gms tissue
Downward extension into -Subtotal: left in each lobe)
Triangle of concern: ITA # mediastinum is prevented by:
Berry ligament-RLN-Trachea Ligament of Berry -Near total: (4 gms tissue
Thyroid moves during deglutition: left in 1 lobe)
Pretracheal fascia

Chvostek sign Trosseau’s sign(obstetrician’s hand)

COMPLICATIONS HypoCalcemia d/t
PTH adenoma : MCC of MCC- ITA # ass. Necrosis HypoPTH
MACIS : Completeness of surgery C/F time- 48-72 hrs
Post-op score hypercalcemia
IOC : SPECT > Tc99
Inability to extubate- B/L RLN #
Sestamibi
MCC of intra-op thyroid storm:
MIAMI CRITERIA: >50% decline in 10minutes Inadequate patient preparation
MCC of hypercalcemia in hospitalized patient: Malignancy
MEN
Inheritance Gene Manifestations
Prophylactic
thyroidectomy:
MEN 1 = 1. Pituitary adenoma(MC Prolactinoma)
AD Menin MEN2A : 5 years
Wermer 2. Parathyroid hyperplasia > adenoma
Chr 11 MEN2B/3 : 1 year
3. Pancreatic neoplasm(Gastrinoma MC)
MEN2a= 1. Parathyroid adenoma
Sipple RET
AD 2. Medullary thyroid cancer
Chr 10
3. Pheochromocytoma
MEN2b=3 1. MTC 4. Mucosal neuroma
RET 2. Pheo 5. Megacolon
AD Chr 10 3. Marfanoid 6. Medullated
habitus corneal n. fibre
Non - > Insulinoma Passaro’s triangle :
MC Pancreatic NET:
functional jn. of D2-D3, Jn. of CHD & Cystic
MC NET in MEN1: Gastrinoma
Refractory ulcers, Diarrhea, ZES duct & Jn. Of Head & neck of pancreas
IOC :DOTANOC PET scan(Somatostatin Rc)
Most Panc.NETs lie in this triangle. NETs
of MEN syndrome however mostly present
outside this triangle & have poorer prognosis