Chapters use Sample personal For - scholar.harvard.edu

Sample Chapters

For personal use only

Review of Surgeryfor Students

AUTHORS

Dr. Krishna Adit Agarwal, MBBS

Alumnus of Vardhman Mahavir Medical College and

Safdarjung Hospital, New Delhi, India

Founder, I-MediSTARInnovation in Medical Science, Technology and Research

www.IMediSTAR.com

AND

Dr. Avantika Singh, MBBS

Alumna of Vardhman Mahavir Medical College and

Safdarjung Hospital, New Delhi, India

Founder, I-MediSTARInnovation in Medical Science, Technology and Research

www.IMediSTAR.com

PEEPEEPUBLISHERS AND DISTRIBUTORS (P) LTD.

Sample Chapters


Review of Surgery for Students

Published byPawaninder P. Vij and Anupam VijPeepee Publishers and Distributors (P) Ltd.Head Office: 160, Shakti Vihar, Pitam PuraDelhi-110034 (India)

Correspondence Address: 7/31, First Floor, Ansari RoadDaryaganj, New Delhi-110002 (India)Ph: 65195868, 23246245, 9811156083

e-mail: [email protected]



www.peepeepub.com

© 2014 Peepee Publishers and Distributors (P) Ltd.

All rights reserved

No part of this publication may be reproduced or transmitted in any form or by any means, electronic, mechanical,photocopy, recording, translated, or any information storage and retrieval system, without permission in writing fromthe editor and the publisher.

This book has been published in good faith that the material provided by authors/contributors is original. Every effortis made to ensure accuracy of material, but publisher and printer will not be held responsible for any inadvertenterrors. In case of any dispute, all legal matters to be settled under Delhi jurisdiction only.

First Edition : 2014

ISBN: 978-81-8445-167-2

Sample Chapters


FOREWORD

Healthcare delivery in India is at a tipping point requiring major interventions. Even if investments are made available tocreate the necessary infrastructure, the big challenge of creating skilled manpower remains an uphill task.

For a country with a population of 1.21 billion, we might have the largest number of medical colleges producing 50,000doctors, yet, today we have only 18,000 surgeons in the country, i.e., one surgeon for 67,000 people!

Due to the vast gap in demand and supply of post-graduate seats, entry into higher medical education has remainedelusive to majority of MBBS graduates. In spite of large number of medical graduates, we are contending with only2,030 post-graduate seats in General Surgery.

With the scenario tough and competitive, the aspirants for General Surgery course need well-organized material forpreparation and better outcomes in the entrance tests. In this direction, the book ‘Review of Surgery for Students’by Dr. Krishna Adit Agarwal and Dr. Avantika Singh should come handy.

With well classified and clearly laid out content, the effort of the young authors in their maiden publication deservesadmiration. I am sure they will be able to enrich subsequent editions with valuable feedback from students and facultyalike.

I wish the authors as also the students a resounding success.

Dr. Devi Prasad Shetty

Dr. Devi Prasad ShettyChairman and FounderNarayana Health

Sample Chapters


Sample Chapters


INTRODUCTION TO THE AUTHORS

Dr. Krishna Adit Agarwal

Krishna is a recent medical graduateof Vardhman Mahavir Medical Collegeand Safdarjung Hospital, New Delhi.He aspires to specialize in the field ofRenal Medicine and has been offereda position at the prestigious Beth

Israel Deaconess Medical Center (a teaching affiliate ofHarvard Medical School) as a Research Fellow fromAugust 2014.

He has consistently performed well in his medical schoolexaminations and displayed the ability to approachacademic and practical problems in a logical, analyticaland systemic manner.

He has also undertaken several initiatives for the medicalstudents like envisioning and organizing the MedicalStudents’ International Conference (MEDSICON) at VMMC.As the founder of the first MEDSICON conducted in 2011,Krishna aimed at providing undergraduate (bio) medicalstudents an opportunity to showcase their researchpotential and take their research ideas forward. It hasgrown over the past three years and now receives ahandsome international and national participation.

Krishna has also been a co-founder of Innovation in MedicalScience, Technology and Research (I-MediSTAR) whichis an organization providing medical students andgraduates with various opportunities to hone their clinicaland research skills. He has also been instrumental insetting up of the ‘Journal of Young Medical Researchers’(JYMR), an open access journal providing an exclusiveavenue for young researchers to publish their work.

Krishna is a highly intellectual, dedicated and practicalthinking doctor who excels in thinking beyond theboundaries of the fixed academic curriculum.

Dr. Avantika Singh

Avantika is a recent medical graduatefrom Vardhman Mahavir MedicalCollege and Safdarjung Hospital, NewDelhi. She aspires to specialize in thefield of Neonatal Medicine and hasbeen offered a position at the

prestigious Boston Children’s Hospital (a teaching affiliateof Harvard Medical School) as a Research Fellow fromAugust 2014.

Avantika has excelled in her medical school, winningnumerous accolades. She topped the University in thethird and final professional examinations. She was awardedgold medals in Community Medicine and Obstetrics andGynecology, silver medals in Pediatrics, Surgery,Ophthalmology and ENT, and bronze medal in InternalMedicine besides a distinction in Pharmacology.

Besides excelling in academics, she has founded anorganization – Innovation in Medical Science, Technologyand Research (I-MediSTAR). The organization providesmentorship to medical students and graduates seekingto sharpen their clinical and research skills. It conductsvarious skill-based hands-on workshops to help studentslearn the science and art of medicine.

Avantika has also been the co-founder of MedicalStudents’ International Conference (MEDSICON) andorganized it at VMMC for the past three years. Theconference provided the much-needed platform to youngresearchers to share their research ideas with the medicalcommunity. She is also the Student Editorial BoardCoordinator at the Journal of Young Medical Researchers(JYMR).

Avantika is a brilliant doctor, who strives to excel in life.She is compassionate and caring towards her patientsand has the ability to make the best possible medicaldecisions.

Prof. Dr. Renuka SharmaProfessor, Dept. of Physiology

VMMC and SJH, New Delhi

Sample Chapters


Sample Chapters


Review of Surgery for Students is aimed at providing the most concise and high-yielding information to undergraduate

students preparing for their surgery final professional examination in India and abroad. There are a lot of surgery

textbooks available in the market but no review book was so far available to help the students properly revise what they

have learnt at their medical school. Our book is based on the Indian examination pattern and features a point-wise

approach to topics. It is a book that has been written keeping in mind the last minute examination stress faced by

students and it strives to help them retain the matter and answer well in the examinations. Only the must-know line

diagrams have been included in the book. These diagrams are easy to remember as well as draw in the exam and will

help achieve higher scores.

We have consulted the standard surgery textbooks, Bailey and Love’s Short Practice of Surgery (26th Ed.) and

Manipal Manual of Surgery (3rd Ed.) alongwith various online resources in preparing this review book. Although, we

have tried our best to include the latest guidelines and management protocols but these guidelines are continuously

being updated and we encourage our readers to keep themselves up-to-date with the future advances in surgery.

Being the first edition, there might be some inadvertent errors in the book. We request our readers to kindly email us

any corrections, suggestions and contributions in the form of latest protocols, line diagrams, newer topics asked in

exams etc. to [email protected] . We welcome your feedback and will surely incorporate it in the next edition

of this book.

“Let the young know they will never find a more interesting,

more instructive book than the patient himself”

- Giorgio Baglivi

Most importantly, attend your clinics and listen to the patient, for the patient teaches you far more than any book ever

can!

Dr. Krishna Adit Agarwal

Dr. Avantika SinghNew Delhi, India

PREFACE

Sample Chapters


Sample Chapters


We are thankful to…

Gods in Heaven

Gods on Earth, Our Parents

Our Gurus, Guides and Mentors

Dr. Jayashree Bhattacharjee

Dr. Chintamani, Dr. Harish Chellani

Dr. Renuka Sharma, Dr. Rajeev Tiwari

Dr. Sugandha Arya, Dr. Harpreet Singh

Our great friends, especially Manmohan

for igniting the spark to write this book

Our Dear Readers

and

The awesome team at Peepee Publishers andDistributors Pvt. Ltd.

for their wonderful work with this book.

ACKNOWLEDGEMENTS

Sample Chapters


Sample Chapters


CONTRIBUTING AUTHORS

Joyutpal BiswasVardhman Mahavir Medical College and Safdarjung Hospital, New Delhi

Arteries, Veins & Lymphatics and Burns

Akriti SinhaVardhman Mahavir Medical College and Safdarjung Hospital, New Delhi

Miscellaneous Questions asked in exams

Arushi DevganVardhman Mahavir Medical College and Safdarjung Hospital, New Delhi

Paediatric Surgery

Aditya RanotVardhman Mahavir Medical College and Safdarjung Hospital, New Delhi

Oral Cavity and Oropharynx and Salivary Glands

Nayan AgarwalUniversity College of Medical Sciences and G.T.B. Hospital, New Delhi

Trauma Care

Shivani SharmaVardhman Mahavir Medical College and Safdarjung Hospital, New Delhi

Fluid & Electrolyte Balance, SIRS and MODS

CREATIVE TEAM

Shashank SinghVardhman Mahavir Medical College and Safdarjung Hospital, New Delhi

Vinay KumarVardhman Mahavir Medical College and Safdarjung Hospital, New Delhi

Kaveri PanditVardhman Mahavir Medical College and Safdarjung Hospital, New Delhi

Sachin GoelVardhman Mahavir Medical College and Safdarjung Hospital, New Delhi

Sample Chapters


xii Review of Surgery for Students

Dr. Rohan KhandelwalMS, MRCS (Edin.), FIBD

Oncoplastic Breast SurgeonEditor-in-Chief: Journal of Young Medical Researchers

Dr. Megha TandonMS, DNB, MRCS Ed.,FICS,FIAGES

Instructor for ATLS (American College of Surgeons)

Dr. Mayank MehrotraMBBS, MD Anaesthesiology (Gold Medallist)

Senior Resident, Department of AnaesthesiologyVMMC and Safdarjung Hospital, New Delhi

REVIEWERS

Sample Chapters


Section 1: Gastrointestinal Surgery

Chapter 1. Hernias 1

Chapter 2. Oesophagus 6

Chapter 3. Stomach and Duodenum 15

Chapter 4. Liver and The Biliary System 26

Chapter 5. Pancreas and Spleen 46

Chapter 6. Small and Large Intestines 57

Chapter 7. Intestinal Obstruction 73

Chapter 8. Rectum and Anal Canal 81

Chapter 9. Bariatric Surgery 90

Section 2

Chapter 10. The Breast 93

Section 3

Chapter 11. Thyroid and Parathyroid Glands 111

Section 4

Chapter 12. Adrenal Gland 129

Section 5

Chapter 13. Oral Cavity and Oropharynx 131

Section 6

Chapter 14. Salivary Glands 137

Section 7: Urology

Chapter 15. Kidney and Ureter 142

Chapter 16. Urinary Bladder and Urethra 153

Chapter 17. The Prostate Gland 161

Chapter 18. Penis, Testis and Scrotal Sac 167

CONTENTS

Sample Chapters


xiv Review of Surgery for Students

Section 8: Arteries, Veins and Lymphatics

Chapter 19. Arterial Disorders 177

Chapter 20. Venous Disorders 186

Chapter 21. Lymphatic Disorders 191

Section 9: Trauma Care and Burns

Chapter 22. General Principles 193

Chapter 23. Head Trauma 195

Chapter 24. Chest Trauma 201

Chapter 25. Abdominal Trauma 204

Chapter 26. Burns 208

Section 10

Chapter 27. Paediatric Surgery 213

Section 11

Chapter 28. General Surgery 222

Section 12

Chapter 29. Fluid and Electrolyte Balance, SIRS and MODS 242

Section 13

Chapter 30. Post-Operative Fever 247

Section 14

Chapter 31. Principles of Anaesthesiology 250

Section 15

Chapter 32. Miscellaneous Questions Asked in Exams 260

Section 16

Chapter 33. Surgical Instruments 268

Sample Chapters


OESOPHAGUS

Chapter

2

ZENKER’S DIVERTICULUM

A.k.a. Pharyngoesophageal diverticulum, hypopharyngeal

diverticulum, pharyngeal pouch.

• A diverticulum arises by two mechanisms:

o Pulsion diverticulum: Push from inside thelumen increases intraluminal pressure and resultsin an outpouching, e.g., Upper and loweroesophageal diverticuli.

o Traction diverticulum: Pull from outside resultsin an outpouching, e.g., Middle oesophagealdiverticulum.

• Diverticuli can be of 2 types:

o Congenital diverticuli: Full thickness, mucosa toserosa, e.g., Meckel’s diverticulum.

o Acquired diverticuli: Partial thickness, muscles

are not involved, e.g., Zenker’s diverticulum.

• Zenker’s diverticulum results from an uncoordinated

swallowing associated with cricopharyngeal muscle

spasm and delayed muscle relaxation which cause

increased intrapharyngeal pressure and outpouching

of the mucosa at the weakest point of the pharyngeal

wall – Killian’s dehiscence.

• Killian’s dehiscence is a weak area of the pharynx

lying below the inferior constrictor muscle and above

the cricopharyngeus muscle.

• Clinical Presentation:

o Dysphagia.

o Lumpiness.

o Regurgitation of swallowed food.

o Halitosis.

o Cough.

Fig. 2.1: Zenker’s diverticulum

SECTION 1 : GASTROINTESTINAL SURGERY

07/08/2014 These are only sample pages from multiple chapters. Not complete chapters. FREE SAMPLE COPY

NOT TO BE REPRODUCED OR SOLD.

www.IMediSTAR.com

Sample Chapters


Oesophagus 7

• Diagnosis:

o Barium swallow.

o Water soluble contrast and CT.

o Endoscopy is usually not performed for the risk of

perforation.

• Treatment:

o Diverticulectomy and cricopharyngomyotomy:

Excise the diverticulum and reduce the tone of

cricopharyngeus muscle to prevent recurrence.

o Diverticulopexy: Reverse the direction of

diverticulum and fix it so that it can drain and

gradually reduce in size.

o Botulinum toxin injection into the crico-

pharyngeus: Maximum relief of 6 months.

o Dohlman’s procedure: Double-lipped oesophago-

scope is used for cutting and stapling.

o Medical management in patients unfit for

surgery: Can use calcium channel blockers or

nitrates.

GASTRO-OESOPHAGEAL REFLUX DISEASE(GERD)

GERD is a chronic condition characterized by reflux of

acidic stomach contents back into the oesophagus, causing

damage to the mucosal lining of the oesophagus.

• Pathophysiology: The most important factor causing

reflux is abnormal lower oesophageal sphincter.

Normally, this sphincter stays closed and relaxes only

during swallowing. In acid reflux disease, this

sphincter loses its tone and remains open, allowing

acidic contents of the stomach to go back into the

oesophagus and damage its mucosal lining.

• Other Important Factors:

1. Lower oesophageal sphincter.

2. Oesophageal motility.

3. Gastric emptying.

4. Angle between the stomach and oesophagus

(Angle of His).

• Causes:

1. Idiopathic.

2. Obesity.

3. Hiatal hernia.

4. Hypercalcemia.

5. Zollinger-Ellison syndrome.

6. Scleroderma or systemic sclerosis.

7. Visceroptosis a.k.a. Glenard syndrome.

8. Chronic steroid use.


1. Heartburn (retrosternal burning pain).

2. Regurgitation.

3. Pain while swallowing (odynophagia).

4. Water brash.

5. Coughing (due to laryngeal irritation).

• Diagnosis:

1. 24-hour ambulatory monitoring of pH is theinvestigation of choice.

o pH is measured 5 cm above and below thegastro-oesophageal junction.

o Patient maintains a symptom diary also.

2. Manometry.

3. Upper GI endoscopy.

• Treatment:

1. Lifestyle modification

o Weight reduction.

o Sleep hygiene.

o Avoidance of heavy meals before lying down.

o Stopping smoking and alcohol.

o Moderate exercise.

2. Medications

o Proton Pump Inhibitors (PPI), e.g.,Pantoprazole, Rabeprazole, Omeprazole.

o H2-Receptor blockers, e.g., Ranitidine,Famotidine.

o Antacids, e.g., Sucralfate, Aluminium

hydroxide etc.



www.IMediSTAR.com

Sample Chapters


8 Review of Surgery for Students

3. Surgery

o Nissen’s fundoplication: The upper stomach is

wrapped around the oesophagus to strengthen the

lower oesophageal sphincter and prevent reflux.

It is a 360 degree wrap.

o Belsey’s fundoplication: Partial 270 degree wrap.

o Hill’s repair.

o Laparoscopic fundoplication.

• Complications:

1. Oesophageal stricture.

2. Oesophageal ulcer.

3. Barrett’s oesophagus: Metaplasia of the normal

stratified squamous epithelial lining of the lower

oesophagus to the intestinal simple columnar

epithelium with goblet cells. It is a pre-malignant

condition, strongly associated with the develop-

ment of adenocarcinoma of the oesophagus.

HIATUS HERNIA

It is an abnormal protrusion of the stomach into the thorax

through a weakness or defect in the diaphragm.

• Types of hiatal hernias:

1. Type I a.k.a. Sliding Hernia: Occurs due to a laxity

of the phrenico-oesophageal ligament resulting in

dislocation of the upper stomach into the posterior

mediastinum.

2. Type II a.k.a. Rolling or Paraoesophageal Hernia:

Occurs when the fundus of the stomach herniates

alongside a normal oesophagus.

3. Type III: Mixed variety.

(See Fig. 2.2)

• Associated Risk Factors:

1. Increased intra-abdominal pressure due to violent

coughing, chronic constipation, pregnancy,

obesity etc.

2. Congenital diaphragmatic weakness.

3. Smoking.


1. Rolling hiatal hernia usually presents with

dysphagia or symptoms of obstruction.

2. Sliding hiatal hernia usually presents with

symptoms of heartburn and regurgitation.

• Diagnosis:

1. Upper GI endoscopy.

2. Barium swallow in erect position.

3. Plain X-rays – Might show an abnormal air fluid

level in the thorax.

Fig. 2.2: Hiatus hernia



www.IMediSTAR.com

Sample Chapters


Oesophagus 9

• Treatment

1. Lifestyle modification.

2. PPIs, H2-blockers, antacids to reduce acid

production.

3. Nissen’s fundoplication.

4. Laparoscopic fundoplication.

5. Hill’s repair.

BOERHAVVE SYNDROME

It is a full-thickness tear in the left distal oesophagus (a

few centimetres away from the stomach) due to forceful

vomiting or retching against a closed glottis.


o Usually patient has a history of severe retching or

vomiting followed by severe abdominal or chest

pain.

o Odynophagia, tachycardia, tachypnoea, cyanosis

and shock may develop.

o Mackler’s triad: Classical presentation seen in less

than 20% of cases comprises chest pain, vomiting

and subcutaneous emphysema.

o Subcutaneous emphysema may be audible as

Hamman’s crunch or Hamman’s sign.

• Investigations:

o Gastrograffin oesophagogram (water soluble

contrast).

o Plain X-ray.

o CT scan.

• Treatment:

o IV rehydration.

o Antibiotics to prevent mediastinitis.

o Surgery – Left thoracotomy with lavage and

primary repair within 48 hours.

o Controlled fistula may be otherwise used.

MALLORY-WEISS SYNDROME

A.k.a. Gastro-oesophageal laceration syndrome.

It is a partial thickness mucosal tear at the gastro-

oesophageal junction due to retching or vomiting. The

initial vomitus does not contain blood, but the subsequent

vomitings contain blood from the bleeding laceration.


o Usually presents as hematemesis following a severe

episode of vomiting or retching.

o May also present as melena.

• Investigations:

o Upper GI endoscopy is the investigation of choice.

• Treatment:

o Bleeding usually stops within 2-3 days.

o Endoscopic cauterization may be used to stop the

bleeding if it persists.

TRACHEO-OESOPHAGEAL FISTULA

A fistula is defined as a tract open at both ends, connecting

two epithelial lined cavities. The trachea-oesophageal

fistula refers to an abnormal communication between the

trachea and oesophagus. It is generally a congenital

abnormality but it may also occur following laryngeal

surgeries.

• During the development of the trachea and

oesophagus, normally a septum divides them in a

cranio-caudal direction. But if the septum develops

in a cranio-dorsal direction then a trachea-oesophageal

fistula results.

• Pressure necrosis due to an indwelling tracheostomy

tube might also cause an abnormal communication

between the trachea and oesophagus.

• Types:

Table 2.1: Types of tracheo-oesophageal fistula

Type Remarks

Type A Second-most common type

Type B

Type C Most common type

Seen in 80-87% of the cases

Type D

Type H



www.IMediSTAR.com

Sample Chapters



• TOF is commonly associated with Down’s syndrome.

• Other congenital anomalies often present in

association with TOF–VACTERL anomalies:

1. Vertebral anomalies.

2. Anorectal anomalies (Most common association).

3. Cardiac anomalies (PDA, VSD, Tetralogy of

Fallot).

4. Tracheo-oesophageal fistula.

5. Renal anomalies.

6. Limb anomalies (Radial hypoplasia being the most

common).

• Polyhydramnios is seen in 50% of the mothers with

a TOF-afflicted foetus.


1. The newborn often has excessive drooling from

the mouth, followed by choking on his own

secretions and cyanosis.

2. A red-rubber tube cannot be passed beyond

8-10 cm in the oesophagus.

3. Child chokes with each feed because the milk goes

into the trachea and causes choking and cyanosis.

4. Other complications like pneumonitis and lung

abscess may occur.

• Investigations:

1. Inability to pass a nasogastric tube.

2. Plain X-ray shows coiling of the nasogastric tube

at the fistula site.

3. Water soluble contrast may be given, which does

not go beyond the fistula site.

• Treatment:

1. A right posterolateral thoracotomy is done from

the 4th intercostal space to repair the defect.

2. Waterston’s criteria takes into account the birth

weight (BW) and presence or absence of pneumonia

into account while deciding on surgery:

o BW>5.5 lbs and pneumonia absent – Surgery

can be performed immediately.

o BW<4 lbs and pneumonia severe –

Gastrostomy should be done to feed the child

and definitive surgery performed a few weeks

later.

OESOPHAGEAL WEB

Table 2.2: Types of oesophageal webs

Congenital Acquired

• Rare • More common than the

congenital variety

• Common in lower • Common at the upper end of

oesophagus oesophagus, at the level of

cricopharyngeus

• Common in post- or peri-

menopausal women

• An asymmetrical mucosal web

• Associated with iron deficiency

anaemia (Plummer-Vinson

Syndrome / Paterson-Brown-

Kelly Syndrome)

• Can cause dysphagia in some

cases, therefore a.k.a

Sideropenic dysphagia

Fig. 2.3: Tracheo-oesophageal fistula



www.IMediSTAR.com

Sample Chapters




www.IMediSTAR.com

Sample Chapters


THE BREAST

Chapter

10

RELEVANT ANATOMY

Mammary glands are modified sweat glands. They are

located in the superficial fascia anterior to the pectoral

muscles and the anterior thoracic wall. Retromammary

space is a layer of loose connective tissue separates the

breast from the deep fascia.

The connective tissue stroma condenses in certain

regions forming well defined ligaments called ‘the

suspensory ligaments of Cooper’. These are continuous

with the dermis of the skin and support the breast.

Axillary tail of Spence perforates the deep fascia and

extends into the axilla through the foramen of Langer.

Physiology

Oestrogen is responsible for initiating ductal development.

Progesterone plays a role in differentiation of epithelium

and lobular development; it stimulates TDLU formation

and expansion during puberty and pregnancy. (Aid to

remember: DOPE-L:Ductal development–Oestrogen;

Progesterone: Epithelial differentiation, lobular development).

Prolactin is responsible for lactogenesis.

Oxytocin is released by suckling reflex, responsible

for expulsion of milk into ducts.

Arterial Supply

• Upper Part: Superior thoracic artery andAcromiothoracic artery (Branches of axillary artery).

• Lateral Part: Lateral thoracic artery (branch of axillaryartery).

• Medial Part: Perforating branches of internal thoracicartery.

Venous return is parallel to the arteries.

Innervation• Anterior and lateral cutaneous branches of 2nd-6th

Intercostal nerves.

• Nipple is innervated by the 4th intercostal nerve.

LYMPHATIC DRAINAGE OF THE BREASTLymphatic vessels pass to the axillary, supraclavicular,parasternal and abdominal lymph nodes as well as to theopposite breast. Cutaneous lymphatics of one breastcommunicate with the cutaneous lymphatics of the

opposite breast across midline.

Superficial Lymphatics

• Drain the nipple and areola.

SECTION 2



www.IMediSTAR.com

Sample Chapters



• Form a ‘subareolar plexus of Sappey’.

• Communicate with deeper lymphatics within breastparenchyma.

Deeper Lymphatics• Located in the parenchyma of the breast.

• Drain predominantly into:

1. Internal Mammary LN/Para-sternal LN

• Found in the first 3 intercostal spaces along theinternal mammary vessels deep to the plane ofcostal cartilages.

2. Axillary Lymph Nodes: (75% drainage)

• Six groups: Out of which apical group of lymphnodes receive the efferents of all the other groups.

• These are in continuity with the supraclavicularLN felt in the posterior triangle above the clavicle.They drain into the subclavian trunk. This entersthe great veins directly or via the thoracic duct orjugular vein.

(See Fig. 10.1 and Table 10.1)

TRIPLE ASSESSMENTIn any patient who presents with breast lump or othersymptoms suspicious of carcinoma, the diagnosis is madeusing triple assessment. The PPV (positive predictivevalue) exceeds 99%:

1. Clinical History and Examination.

2. Radiological Studies:• Predominant component of breast in non-lactating

women is FAT and in lactating women is

GLANDULAR TISSUE. For younger patients

(denser breasts) ultrasound is a better investigation

Central group of Axillary LN

Anterior, Posterior, Lateralgroup of axillary LN

Apical group of Axillary LN

Supraclavicular group (Lowestgroup of Deep Cervical LN)

Right Lymphatic Duct or thethoracic duct on the left side

Table 10.1: Levels of axillary lymph nodes

Level Position Lymph node groups

I Lateral to pectoralis minor • Anterior (Pectoral): Located along lateral thoracic vessels

• Posterior (Subscapular): Located along subscapular vessels

• Lateral (Humeral): Located along the axillary vein

II Along pectoralis minor • Central: Situated in the floor of axilla

• Interpectoral (Rotter’s): Lie between P. major and P. minor muscles

III Medial to pectoralis minor • Apical (Infraclavicular)

since in mammography both dense tissue andtumours show up as solid white areas. Mammo-graphy is more useful for older patients with lessdense tissue.

• Mammogram:

o Performed in all patients above 35: Involution ofbreast has usually started by this age, breaststroma is replaced by radiolucent fat makingsensitivity of mammogram greater.

o BI-RADS (Breast Imaging, Reporting and Data

System) scoring is used (Table 10.2).

Fig. 10.1



www.IMediSTAR.com

Sample Chapters


The Breast 95

• Ultrasound:

o Useful in young women and in pregnant

women.

o Helps distinguish cysts from solid lesions. Helps

localise impalpable areas of breast pathology.

• MRI:

o Helps to distinguish scar from recurrence in

women who’ve had BCS.

o Useful for women with breast implants.

3. Pathological Studies:

• Current evidence suggests that 14-gauge (14G) core

biopsy, properly carried out, provides better

sensitivity and specificity than FNAC.

• Types of biopsy procedures:

o Fine needle aspiration cytology (FNAC): A very

thin needle (21G - 30G) attached to a syringe

to withdraw (aspirate) a small amount of tissue

from the suspicious area.

– Advantage: Least invasive for cell

diagnosis, rapid, very accurate.

– Disadvantage: False negatives (mainly due

to sampling error), invasive cancer cannot

be distinguished from in situ disease.

o Core Biopsy: It is now the standard of care. A

spring loaded core needle biopsy device (hollow

needle) is used (12G-18G).

– Advantages:

♦ Histology gives important oncological

information including tumour type and

grade.

♦ Tells receptor status (imp before

neoadjuvant therapy).

♦ Facilitates definitive diagnosis of

benign lesions.

♦ Differentiates between DCIS and

invasive disease.

Table 10.2: BI-RADS assessment categories

Category Assessment Remarks and likelihood of cancer Next step

0 Incomplete Cloudy X-ray/Difficult to read/Patient moved Need additional imaging evaluation

when image was taken (Mammography/USG) or Prior

mammograms for comparison

1 Negative No evident signs of cancer Continue routine screenings

2 Benign No apparent cancer, but other findings (such as cysts) Continue routine screenings

are described in the report

3 Probably Benign > 0% but < 2% likelihood of malignancy Repeat mammogram in six months. If

family/personal history of breast cancer,

you may opt to do more tests now rather

than wait

4 Suspicious > 2% but < 95% likelihood of malignancy Tissue diagnosis (e.g. Core biopsy)

Category 4A: Low suspicion for malignancy (> 2% to < 10%)

4B: Moderate suspicion for malignancy (> 10% to < 50%)

4C: High suspicion for malignancy (> 50% to < 95%)

5 Highly Suggestive > 95% likelihood of malignancy Tissue diagnosis (e.g. Core biopsy)

of Malignancy

6 Known Biopsy- N/A Surgical excision when clinically

Proven Malignancy appropriate



www.IMediSTAR.com

Sample Chapters



♦ Microcalcifications, asymmetry and

architectural distortion can be studied

well.

Vacuum assisted core biopsy (VACB) is

done using systems like ‘Mammotome’.

Ultrasound guided biopsies or stereotactic

needle biopsies (mammogram from two

angles) are also done.

o Surgical (Open) Biopsy:

– Incisional biopsy: Only part of thesuspicious area, enough to make a diagnosisis removed.

– Excisional biopsy: Entire abnormal areawith or without a rim of normal breasttissue margins are removed.

BENIGN BREAST DISEASE

Benign breast diseases can be subdivided into three

categories:

1. Congenital.

2. ANDI (Aberrations of normal breast developmentand involution).

3. Non-ANDI.

Congenital Causes1. Accessory breast tissue and nipples (Polymazia and

supernumerary nipples). Incidence: 1% of women.These can occur anywhere along the milk lines with

most common site being axilla (for accessory breast)

and below the breast (for accessory nipples). These

undergo cyclical and lactational changes. They are

also prone to any benign or malignant disease.

Treatment involves reassurance or excision.

2. Breast hypoplasia: It presents with breast asymmetry

if it is unilateral. Poland syndrome is a condition

which occurs commonly in males and is characterised

by amastia, absent/partial pectoralis muscle and

syndactyly.

3. Athelia: Absence of nipples.

4. Micromastia: Postpubertal underdevelopment of

breast tissue.

ANDI (Aberrations of Normal Developmentand Involution)

It refers to the aberration of the physiological processes

which occur in the breast from menarche till menopause

(Table 10.3).

BREAST LESIONS (Fig. 10.2)

Fig. 10.2: Location of various breast lesions



www.IMediSTAR.com

Sample Chapters


The Breast 97

Dupont and Page Classification of BreastChanges (3 groups)

1. Non-Proliferative Changes:

a. 70% of all changes are non-proliferative.

b. Risk of cancer: Nil i.e. Relative risk is same as

general population (1:1).

c. These changes include:

i. Mild epithelial proliferation

ii. Cystic changes

iii. Apocrine changes

iv. Duct papilloma

2. Proliferative Changes Without Atypia:

a. 26% of all changes.

b. Risk of cancer: 1.5-2 : 1 as compared to general

population.

c. These changes include:

i. Florid epithelial hyperplasia.

ii. Sclerosing adenosis.

iii. Papillomatosis.

Table 10.3: Aberrations of normal development and involution

Normal Breast development Cyclical changes Involution*

physiologic

process →

Age Puberty- 25 years 25-40 years 35-55 years

Site Stromal Lobular Stromal Lobular Ductal

Aberration Juvenile Fibroadenoma Cyclical mastalgia, Sclerosing Macrocysts Duct ectasiahypertrophy cyclical nodularity lesions

(Previously calledFibroadenosis)

Clinical Excessive Discrete, highly Generalised or discrete May present Smooth, tense Nipple discharge,features breast mobile lobulated lumps, diffuse, irregular with a mass or cysts which Bilateral ordevelopment mass lumpiness in breast. mimic a cancer on feel firm on central nipple

Can be multiple/single/ mammogram palpation, may retraction (Note:unilateral/ bilateral cause pain, Unilateral nipplePremenstrual multifocal and retraction could bemastalgia bilateral cancer)

Investigation USG (Guided biopsy Mammogram USG to ensure nomay be done if >25 + biopsy solid componentyears)

Malignancy Rarely–Sarcoma Carcinoma if epithe-liosis is present

Treatment Reassurance, Conservative: Surgical excision Aspiration, F/U HadfieldExcision if rapid 1. Firm breast support to exclude to ensure resolution. operationgrowth, giant 2. Vit E malignancy Excise if recurs (Cone excisionfibroadenomas 3. Oil of Evening after 2 aspirations of the major(>5 cm) and if Primrose ducts)patient desires 4. Analgesics and

Diuretics (to reduce congestion)5. Danazol6. Tamoxifen (used in UK)

USG:Ultrasonography

*Involution: For normal involution of the lobule, it is important that specialised stroma should be continually present around it. If the stroma disappears too early, the lobules are unable to involute properly and the epithelial acini remain. These may then form cysts.



www.IMediSTAR.com

Sample Chapters



3. Proliferative Changes with Atypia:

a. 4% of all changes.

b. Risk of cancer: 4-5 : 1 as compared to generalpopulation.

c. If these changes are detected on FNAC: Surgicalexcision is always done.

d. These changes include:

i. Atypical Ductal Hyperplasia.

ii. Atypical Lobular Hyperplasia.

Fibroadenoma

• Epidemiology:

o Most common benign breast tumour in women

<40 years old, incidence declines with increasingage.

o Develops in 50% women who receive cyclosporineafter renal transplant.

• Clinical Features:

o Painless (mostly) or painful swelling.

o May spontaneously disappear or involute during

menopause (partially hormone-dependent).

o Giant Fibroadenoma: >5 cm in size OR occupies>1/3rd of the breast.

• On Examination:

o Discrete (well-defined), smooth, round bordered.

o Firm to hard in consistency non-tender/tender

lump.

o Highly mobile within the breast tissue (also calledbreast mouse).

o Multiple lesions may be present (10-15%). Theymay also be bilateral.

• Diagnosis: Triple assessment is needed for all breastlumps:

o Clinical Examination (as mentioned above).

o Imaging: Ultrasonography is preferred in patientswho are younger than 30 years or pregnant. Both

mammography and ultrasound are useful inpatients older than 30 years (and not pregnant).

• Ultrasound:

o Circumscribed, homogeneous, hypoechoic masses

which may have gentle lobulations and a thinpseudocapsule.

• Mammography:

o Circumscribed oval or round masses whichoccasionally have coarse calcifications.

o Large lobulated “pop-corn” calcifications may bepresent.

o Fibroadenoma does not contain adipose tissue,hence appears DENSER than the surroundingnormal tissue.

• Pathology:

o Fine needle aspiration or core biopsy.

o Shows a benign tumour with two components:Epithelial and mesenchymal (fibroblastic/connective tissue). Duct epithelium is non-neoplastic, fibroblastic component is neoplastic(monoclonal). The connective tissue proliferationenvelops the acini (terminal duct) and compressesthem into clefts (now called ‘canaliculi’).

o Types: (Mixed forms are the rule!)

A. Intracanalicular fibroadenoma: If mesen-chymal proliferation invades the canaliculi, itcompresses the ducts, which are irregular,reduced to slits (Mesenchyme predominates).

B. Pericanalicular fibroadenoma: Mesenchymeproliferates around the ductal spaces, so thatthey remain round or oval, on cross section(Glandular/epithelial tissue predominates).

• Malignant Potential:

o Risk of malignant transformation in fibroadenomais low. But risk of developing cancer in the breastparenchyma is elevated among women withfibroadenomas.

o Patients with fibroadenoma are 2.17 times morelikely than women in the general population todevelop invasive breast cancer.1 However, newerstudies do not support these findings.

o Risk is higher in case of complex fibroadenoma(Relative risk is 3.10) and positive family history

of breast cancer.1

Reference: 1. Dupont WD, Page DL, Parl FF, et al. Long-termrisk of breast cancer in women with fibroadenoma. N Engl J Med1994; 331:10-15.



www.IMediSTAR.com

Sample Chapters


The Breast 99

Complex fibroadenomas are those with cysts >3

mm in diameter, sclerosing adenosis, epithelial

calcifications etc.

• Treatment:

o Observation: If triple assessment is negative for

cancer and consistent with a fibroadenoma then

conservative follow-up can be offered. Inform the

patient about the limitation of the tests and assess

promptly if there is symptomatic or clinical

change.

o If fibroadenoma is rapidly growing, giant (>5 cm),

causing physical deformity, discomfort or

emotional distress:

– Open excision (Enucleation).

– Ultrasound guided percutaneous excision (<4

cm in largest diameter).

– Cryoablation (<4 cm in largest diameter).

Phyllodes Tumour

(Also called Cystosarcoma Phyllodes/SerocysticDisease of Brodie)

Phyllodes tumours are considered to be on a spectrum of

disease that consists of fibroadenoma on one end and

malignant form of phyllodes tumours on the other end.

• Epidemiology:

o Tumour of adult women: Most common between

40-50 years of age, i.e., prior to menopause (about

15 years after the typical age of presentation of

fibroadenoma).

o Account for less than 1% of all breast neoplasms.

• Clinical Features:

o Large fast growing painless breast lump which

increases in size within just a few weeks.

• On Examination:

o Firm, mobile, well-circumscribed, non-tender

breast mass (i.e., similar to fibroadenoma) with a

smooth and lobulated surface.

o Large tumour with an average size of 5 cm.

o Overlying skin may have a shiny appearance and

be translucent enough to reveal underlying breast

veins.

• Diagnosis: Triple Assessment is Needed for all Breast

Lumps:

o Clinical Examination (as mentioned above).

o Imaging: Unreliable since it cannot differentiate

benign cystosarcoma phyllodes from the malignant

form or from fibroadenomas.

o Pathology:

– Fine-needle aspiration is usually inadequate.

Core biopsy is more reliable.

– Definitive method for diagnosing phyllodes

tumours are:

♦ For smaller lesions: Open excisional breast

biopsy.

♦ For large lesions: Incisional biopsy.

– Shows a fibroepithelial tumour composed of

an epithelial and a cellular stromal component.

Cleft like spaces lined by epithelium with

stroma projecting into these in a leaf-like

fashion (phyllodes = leaf). Can be benign,

borderline, or malignant depending on

histologic features like stromal cellularity,

infiltration at the tumour’s edge, mitotic

activity etc.

• Malignant Potential:

o All forms of phyllodes tumours are regarded as

having malignant potential.

o 85-90% of phyllodes tumours are benign and 10-

15% are malignant.

o Although the benign tumours do not metastasize,

they have a tendency to grow aggressively and can

recur locally.

o The malignant forms metastasize hematogenously.

o Most common metastatic site: Lungs followed by

skeleton, heart, liver.

• Treatment:

o Best treatment: Complete excision (wide local

excision), with accurate histologic examination

and continued follow-up care.



www.IMediSTAR.com

Sample Chapters




www.IMediSTAR.com

Sample Chapters


Chapter

22GENERAL

PRINCIPLES

Assessment of a trauma patient should follow the ATLS

system (Advanced Trauma Life Support):

1. Airway and Cervical Spine Protection

• Ensure proper cervical spine immobilization in

all trauma patients. This can be achieved with in-line immobilization techniques or with atraditional neck collar, sandbag or tape.

• Next, check for the patient’s vocal response. Ifthe patient can speak, then his/her airway is not

immediately compromised.

• Clear the mouth and airway of any obvioussecretions and foreign bodies.

• Manoeuvres to open the airway include a jawthrust and/or chin lift.

• Consider nasopharyngeal airway if airway tendsto repetitively close after these manoeuvres.

• If the GCS</= 8, a definitive airway like anendotracheal tube is warranted.

2. Breathing and Ventilation

• All trauma patients should receive 100% high flow

oxygen through a mask or ET tube if it is in place.

• Examine the chest for adequate ventilation byinspection, percussion and auscultation on the

front and back of the chest by log-rolling

manoeuvres.

Primarysurvey and

resuscitation

Secondarysurvey

Definitivemanagement

Primary Survey and Resuscitation

• The rapid primary survey and resuscitation go hand

in hand with each other.

• ABCDE of primary survey and resuscitation

Table 22.1: ABCDE of primary survey and resuscitation

A Airway and cervical spine protection

B Breathing and ventilation

C Circulation and bleeding control

D Disability, i.e., neurological assessment

E Exposure – Assess for other injuries after undressing

the patient

SECTION 9 : TRAUMA CARE AND BURNS

Fig. 22.1: General ATLS trauma protocol



www.IMediSTAR.com

Sample Chapters



• Evaluate for the “deadly dozen” of chest trauma,

specially the life-threatening ones.

• Decompress a tension pneumothorax by a needle

thoracostomy in the 2nd intercostal space midcla-

vicular line.

• Insert a chest tube for other conditions like

pneumothorax and haemothorax.

• Control active bleeding from any vessel.

3. Circulation and Control of Bleeding

• Check the patient’s conscious level, skin colour

and pulse for evidence of hypovolemia.

• Secure 2 large-bore IV cannulas, take samples and

start aggressive fluid resuscitation.

• Titrate fluids against the patient’s initial response

to a fluid challenge and his/her vital signs.

• Evaluate for internal bleeding and treat accordingly.

4. Disability

• This includes rapid assessment of the patient’s

neurological status.

• Monitor pupils for size and reaction.

• Calculate the Glasgow coma score.

• Evaluate periodically to observe any changes.

• Exclude causes of altered consciousness like head

injury, hypovolemia, hypoglycaemia, alcohol and

drug abuse.

5. Exposure

• Expose the patient completely and examine the

front and back by log-rolling manoeuvres.

6. Adjuncts to the ABCDE of Primary Survey

• Take blood samples for biochemical and

haematological tests.

• Blood grouping and cross-match should be done.

• ECG, BP monitoring and pulse oximetry.

• ABG sampling.

• Urinary catheter.

• Nasogastric tube.

• Trauma radiography series.

Secondary Survey

• Secondary survey is undertaken only after the

completion of primary survey and initial stabilization

of the patient.

• It consists of reviewing the patient history and

carrying out a thorough head-to-toe examination of

the patient.

• Review the history (AMPLE)

o A – Allergy history.

o M – Medication and vaccination (TT) history.

o P – Past medical history.

o L – Last meal timings and contents.

o E – Events of the accident.

• Examination

o Examine the front of the patient and then perform

a log-roll to examine the back.

o Head and face – Head injuries, fractures, ENT

bleeds, inspection of mouth, foreign bodies and

airway compromise.

o Neck – Cervical spine, subcutaneous emphysema.

o Chest – Complete chest examination.

o Neurological–Periodic GCS calculations, complete

neurological examination.

o Abdomen and pelvis – Complete abdominal

examination, signs of peritonism, pelvic fractures,

perineal injuries, rectal and vaginal examination.

o Extremities – Limb injuries are not immediately

life-threatening, therefore, focus on the ABCDE

first. Then later observe for limb injuries, align

the fractured bone and evaluate distal neurovascular

function before and after the intervention.

Definitive Management

• Should be reached to as soon as possible after the

primary and secondary surveys are complete.

• If the patient is to be transferred to another hospital,

he/she should be hemodynamically and cardio-

vascularly stable and accompanied by an experienced

trauma care doctor.



www.IMediSTAR.com

Sample Chapters




www.IMediSTAR.com

Sample Chapters


Chapter

33 SURGICAL

INSTRUMENTS

Name 5 mm Trocar Sheath

Illustration

Features • Laparoscopic instrument.

• Placed in the patient's abdomen to serve as a port for

insertion of various other laparoscopic instruments.

5 mm trocar sheath

SECTION 16



www.IMediSTAR.com

Sample Chapters


Surgical Instruments 269

Name Allis Tissue Holding Forceps

Illustration

Features • Has sharp teeth.

• Used to hold tough tissues like fascia of the breast.

• Grasping/Holding bowel tissues to be resected.

• Can cause trauma to the tissues.

Name Aneurysm Needle

Illustration

Features • Has an eye in the hook of the instrument.

• Used to hold a vessel.

• Used to place a ligature around the vessel.

• Can also be used for blunt dissection.

Aneurysm needle

Allis tissue holding forceps



www.IMediSTAR.com

Sample Chapters




www.IMediSTAR.com

Sample Chapters


Sample Chapters


Chapters use Sample personal For - scholar.harvard.edu

Documents