Part 2 book “Gateway to success in surgery” has contents: Cervical lymphadenopathy, parotid swelling, inguinal hernia, paraumbilical hernia, femoral hernia, incisional hernia, testicular tumor, basal cell carcinoma, squamous cell carcinoma, upper limb ischemia,… and other contents.
Case 21 CASE 21 Cervical Lymphadenopathy Cervical Lymphadenopathy My patient Ranvir, a 30 year old male, resident of Haryana, presented with multiple swelling both side, of his neck for last months He noticed a single swelling in his left side of neck first graduate multiple swelling appeared both side of his neck Swelling are gradually progressive, and painless So he did not care about it initially but gradually he has got his history of weight loss, loss of appetite for last months and Fever for last months The fever with swelling stay for 5-7 days and followed by a period of apyrexia History of Abdominal pain and swelling in the lower limb (IVC obstruction) Features suggestive of TB like evening rise of temperature History of Exposure [to exclude sexually Transmitted Disease (STD)] History of Salivary gland swelling, conjunctivitis, dyspnea, cough, to no preauricular swelling (for Sarcoidosis)] GENERAL SURVEY: Patient is anaemic; pallor look, like white -coffee poorly/averagely nourished On local Examination-There are multiple ovoid Swellings, more in the posterior triangle of neck, no swellings, moves with deglutition No dental caries, oral hygiene Waldeyer’s ring appear normal On palpation-The swellings are 2-4 cm in size nontender, discreate, rubbery in consistency, smooth surface mobile, free from overlying skin and underlying structure, Axillary, Inguinal lymph nodes not enlarged Systemic Examination • GIT- There is splenomegaly and hepatomegaly Spleen is 14 cm on its axis • Liver is cm enlarged on mid clavicular line • No abdominal hymphadenopathy noticed • Both testis appear normal, (to exclude testicular malignancy) • Others examination are essentially normal So my provision diagnosis is - this is a case of Hodgkin's lymphoma but I like to put differential diagnoses for this case It may be Tubercular Lymphadenopathy Secondary syphilis Chronic pyogenic lymphadenitis Secondary metastatic lymph node Why is you considering Hodgkin's lymphoma as your first diagnosis? Sir my patient is a Young male, presents with slowly growing painless lymph nodal mass in the neck-especially in the posterior triangle He has been having fever for last months which occurs in a periodic fashion and he has got the history weight loss, anorexin, night sweats, etc On exam patient is anaemic, the pallor is like whitecoffee The cervical lymph nodes are ovoid, smooth, discreate these are solid, firm and rubbery in consistency nontendor, mobile (rarely may be fixed occasionally the lymph nodes may be matted in late stages called pseudo matting) There is hepatosplenomegaly also So this is clinically a case of Hodgkin's lymphoma [Differential Diagnoses (i) tubercular lymphadenopathy • It may occur at any age (but common in children) • persistent enlargement of lymph node and this most common cause of cervical lymphadenopathy in our country • Feature of tuberculosis along with -like evening rise of temperature, weight loss, anaemia, cough etc On Examination: the enlarged lymph nodes are firm in feel and initially discrete but later it's become matted (due to periadenitis) Often slightly tender • Evidence of Tuberculosis may be present in the lung 193 Gateway to Success in Surgery Short Cases ii Chronic pyogenic lymphadenitis • History of chronic infection in oral cavity like Dental caries • Painless, persisting for along • Lymph nodes are firm, tender not matted • Antibiotics reduce the size of the lymph node again it appears Non Hodgkins lymphoma • Common in younger • Lymph nodal involvement is from centripetal, i.e involvement is from periphery to towards centre • Rapidly growing swelling • Constitutional symptoms like weight loss, anorexia, fever, night sweats are present in 25%, cases iii Secondary Syphilis: • Young age (20-30 yrs) • History of exposure present • Ulcer may present in mouth, genitalia, – Fever, arthritis, various skin rashes (pleomorphic) – On Exam-Mucocutaneous lesion may be present ulcer in dorsum of tongue angular fissure, condyloma • Generalized enlargement of superficial group, firm, desecrates and shotty, non tender most characteristically there is enlargement of epitrochlear and suboccipital groups On examination- Lymph nodes are variegated consistency, soft, firm or hard Extranodal site of origin is common 10-35% iv Metastatic lymphadenopathy • Common in elderly male, few cancers like papillary Carcinoma thyroid occurs in young adults • Patients present with painlessly enlarged swellings enlarged in the neck Slowly progressive • General symptoms like anorexia, weight loss, and weakness may be present along with primary lesion • Metastatic nodes are common in the nodes of anterior triangle These are deep to the anterior edge of the sternomastoid (sternocleidomastoid) On examination-Lymph nodes are stony hard, mobile, may be fixed, non tender, usually at initial stage nodes are smooth and discreate and variable sizes, later on it has got irregular or bosselated surface • Primary lesion almost always presents example, head and neck cancer, carcinoma oral cavity ca oesophagus, lung, stomach, pancreas, testes breast etc • Presence of enlarged metastatic lymph nodes in left supra clavicular fossa is called Virchow's gland It is usually associated with abdominal malignancy and called Torisier's sign Other causes of lymphadenopathy are: • Non Hodgkin's lymphoma • Chronic lymphatic leukemia • Sarcoidosis etc 194 CML (chronic lymphatic Leukemia) • Above 50 years commonly in mates • Presence of constitutional symptoms like fever, gross weakness, weight loss, recurrent upper respiratory tract infection • Lmph node enlargement is slowly growing painlessly progressive cervical lymphadenopathy On Exam-Anaemia ++ • Lymph nodes discreate, firm, mobile, nontender • Skin thickening or nodules may present (due to leukaemic tissue infiltration) • Hepatosplenomegaly- firm smooth nontender Sarcoidosis: • Young adult and middle aged person • May present with enlarged superficial group of cervical lymph node with variable constitutional symptoms like fever, bone pain paroxysmal dyspnea, pain full eyes, etc On examination Superficial group of cervical lymph nodes are enlarged more characteristically Pre auricular groups These are firm, discreate, nontender • Parotid gland enlargement • Facial nerve palsy, uveitis, conjunctivitis may be present How will you proceed in this case of cervical lymphadenopathy? Sir, I will confirm my diagnosis first I will FNAC/ Excision biopsy of lymph node Lymph node biopsy confirms the diagnosis [Macroscopically cut section shows fish flesh appearance Microscopically-Red stern berg's giant cells-Pleomorphism of cellular tissue is characteristic feature] Case 21 Cervical Lymphadenopathy Chest X Ray- may show enlarged mediastinal shadow with pleural effusion • Chest and abdomen to stage the disease CT Scan may show • Mediastinal, Retroperitoneal lymphadenopathy, liver spleen enlargement • Sometime exploratory laparotomy may be required for retroperitoneal lymphadenopathy and involvement of liver, spleen, particularly where CT scan not adequate or not available Blood test-Anaemia, Pancytopenia, Leucocytosis with lymphocytopenia eosinophilia Bone marrow Examination- to stage the disease How will you differentiate between Hodgkin’s's and Non Hodgkin’s's Lymphoma? S no HODGKIN'S HODGKINS N O N - Site of Origin Nodal Extranodal 10- 35% (most common site by GI Tract) Nodal distribution Centrifugal Centripetal (periphery (centre to periphery) to central) Nodal spread Contiguous Non contiguous Lymph cells affected B-Lymphocytes characterized by the Reed-Sternberg's giant cell's B-Lymphocytes T Lymphocytes and NK Cells Liver involvement Uncommon Common > 50% Bone marrow involvement Uncommon 50% Role of chemotherapy Curable Not curable How will you classify Hodgkin's disease? • • An Artor classification since 1971 The Cotswolds modification in 1988 Principal stage• Stage I Involvement of single lymph node region (I) or single extralymphatic site (Ie) • Stage II Involvement of two or more lymph nodal regions on the same side of the diaphragm (II) of one lymph node region and a contiguous extra lymphatic site (II e) • Stage III Involvement of lymph node regions on both sides of the diaphragm which may include spleen (III s ) and or limited contiguous extralymphatic organ or site (IIIe or IIIes) • • • • • Stage IV- Disseminated involvement of one or more extralymphatic organs Modifications A and B- The absence of constitutional symptoms is denoted by adding an A to the stage, the presence is denoted by adding B to the stage E: is used if the disease is extranodal or has spread from lymph node to adjacent tissue X: is used if the largest deposit is > 10 cm (bulky disease) or whether the mediastinum is wider than 1/3 rd of the chest (on chest X Ray) Type of staging-CS-Clinical stage and PS-Pathological stage What are the adverse prognostic factors in a case of Hodgkin's lymphoma? The international studies of prognostic factors are Age> 45 years, Male > female Stage IV disease Hemoglobin < 10.5 gm% Lymphocyte < 600/cnmm or 15,000/cnmm Albumin < mg% How will you treat the patient? Sir, the treatment depends on the stage i In early stage (IA and II A) -Radiotherapy is very effective treatment Chemotherapy may be given ii In late stage (III, IV A or IV B)-combined chemotherapy alone iii Hodgkin's lymphoma at any stage if there is mass in chest that is usually treated with combined chemotherapy and radiotherapy What chemotherapy regime is the gold standard for treatment of Hodgkin’s's disease? Currently ABVD chemotherapy is the gold standard for treatment of Hodgkin's lymphoma • A-Inj Adriamycin 25 mg/m2 • B-Inj Bleomycin 10 mg/m2 • V-Inj Vinblastin mg/m2 • A-Inj Dacarbazine 37 5mg/m2 On D1-D15 weekly X cycles Over 85% Hodgkin's lymphoma cases are curable with this regimen Why it is called Hodgkin's lymphoma Formerly this lymphoma was known as Hodgkin’s lymphoma cases are has been described by Thomas Hodgkin in 1832 195 su Gateway to Success in Surgery What is the subtypes of classic Hodgkin’s lymphoma (CHL) i Nodular Sclerosis- most common subtype world wide ii Lymphocytic predominant-relatively uncommon but has better prognosis Short Cases iii Lymphocyte depleted- Uncommon subtype Bad prognostic iv Mixed Cellularity-This most common in Indian and it and most common subtype world wise wide SHORT NOTES ON CERVICAL LYMPHADENOPATHY Lymph nodes are arranged in the neck in two groups Superficial groups-these are few and scattered superficial to investing layer of deep cervical group Deep group [ vertical group/Circular group] • • Vertical group-Level I to level VI [as described in Neck nodes management] Circular group-anterior to posterior– Submental – Submandibular – Pre auricular – Post-auricular – Occipital CERVICAL LYMPHDENOPATHY CAUSE: A ACUTE B CHRONIC A -Acute (i) acute pyogenic lymphadenitis (ii) Acute lymphatic leukemia (iii) Acute Infectious mononucleosis B -Chronic Inflammatory: • Chronic pyogenic lymphadenitis • Tubercular lymphadenopathy • Secondary syphilis • Sarcoidosis • Brucellosis • Blastomycosis II NEoplastic Primary • • • • Hodgkin's lymphoma Non Hodgkin's lymphoma Chronic lymphatic leukaemia Burkit's lymphoma Secondary • Metastatic lymphadenopathy III Autoimmune disorders • • SLE (Systemic Lupus Erythematosus) Still disease (Juvenile rheumatoid arthritis) CAUSE OF GENERALIZED LYMPHADENOPATHY • • • • • • • Tubercular lymphadenopathy Hodgkin's and Non Hodgkin's lymphoma Secondary Syphilis Chronic lymphatic leukemia (CML) Metastatic lymphadenopathy Sarcoidosis HIV with generalized lymphadenopathy TUBERCULOUS LYMPHADENITIS Different levels of neck nodes 196 Characteristics of lymph node enlargement • Cervical group is involved initially common in upper deep cervical group (Jagulo-di-limapulu) Case 21 • • • • • Cervical Lymphadenopathy The lymph nodes are firm in consistency and discrete initially but gradually with the passage of time lymph nodes become matted (due to periadenitis) May be slightly tender Tonsils may be studded with tubercles Stage of tuberculous Lymphadenitis – Stage (i) Infection and lymphadenitis – Stage (ii) Periadenitis with matting – Stage (iii) Caseating necrosis and formation of cold abscess – Stage (IV) Formation of collar stud abscess – Stage (v) Discharging sinus formation which discharges yellowish caseating material look for associated pulmonary TB always LYMPH NODE'S PATHOLOGY • • Macroscopically looking solid, matted and cut section shows yellowish caseating material Microscopically-caseating material at the centre surrounded by epithelioid cells and then Langhan's type of giant cells INVESTIGATIONS • • • • Hematocrit/ ESR FNAC from lymph node and smear for AFB (Acid fast Bacilli) Chest X Ray PA view to exclude pulmonary Tuberculosis PCR (Polymerase chain Reaction) and KP 90 are useful method for detecting tuberculosis If HIV is suspected, ELISA and Western blot test TREATMENT Different stages of tubercular lymphadenopathy If the diagnosis is established start Antitubercular drugs Tab Rifampicin 10-15 mg/kg body weight (450-600 mg/ day) Before breakfast OD Tab INH (Isoniazid) 5-10 mg/kg body Weight OD after breakfast (300 mg to 450 mt./day) Tab ethambutol mg /kg body weight (800 mg/day) OD after breakfast Tab Pyrazinamide 20-30 mg/kg body weight OD after breakfast (1500 mg/day) Tab pyridoxine 10 mg OD along with INH to reduce neuritis • Duration of treatment is usually 6-9 months • All tablets are to be taken for first months • Next only Rifampicin and INH along with Pyridoxine long OD for 6-9 months depends on the extensiveness of the disease Side effects of antitubercular drugs • • • • • • Rifampicin, Hepatitis is a major adverse effect Flu like Syndrome chills fever headache Cutaneous syndrome-flushing, pruritus + rash, Respiratory syndrome'-breathlessness shock Abdominal syndrome-Abdominal cramps with or without- diarrhoea, nausea, vomiting Urine and secretions may become orange-red but this is not harmful .INH+ Peripheral 197 Gateway to Success in Surgery • • – Neuritis and variety of neurological manifestationsparesthesia, numbness, mental irritation etc – Hepatitis is a major adverse effect .Ethambutol - Loss of visual acuity /color vision, field defects due to optic neuritis – GI intolerance, fever, rash, few neurological changes Pyrazinamide-Hepatotoxicity is most important dose related side effect – Arthalgia, flashing, rash, loss of diabetic control etc – Second line antitubercular drugs are: – Thiacetazone – Para amino salicylic Acid (PAS) – Ethionamide – Cycloserine – Kanamycin – Amikacin – Capreomycin The newer Antitubercular drugs are • Ciprofloxacin • Ofloxacin • Clarithromycin • Azythromycin • Rifabutin Management of cold Abscess Cold Abscess Antigravity aspiration (Needle to put in a nondependant site along a 'z' Track in a zigzag pathway to prevent sinus formation) If it recurs To be drained all the caseating material (Through a non dependant incision) Wound to be closed without any drain Role of Surgery for removal of tubercular Lymph node There are few indications for removal of tubercular lymph node Lymph nodes to be removed if there is no local response to drugs In case of persisting sinus Procedure-Skin flap to be raised and remove all lymph nodes along with caseating material 198 Short Cases SECONDARIES IN NECK LYMPH NODES • Common primary sites are: – Oral cavity, tongue, tonsil – Salivary glands – Pharynx-nasopharynx – Larynx, oesophagus – Lungs, GI+, Thyroid – Testes • Feature of secondaries in neck – Commonly in elderly male – Commonest presentation Usually slowly progressing, painless swelling in the neck May progress rapidly like Non Hodgkin's lymphoma On exam- Hard in consistency, nodular surface and often fixed at presentation though it would be initially mobile Exception-secondaries from papillary carcinoma thyroidusually occurs in young adults and secondaries can be soft cystic – Evidence of primary growth may be there at above mentioned sites – Different symptoms to be clarified like – Dysphagia-carcinoma posts 1/3 rd of tongue, pharynx, and oesophagus Hemoptysis, cough, dyspnea – carcinoma lung Hoarseness-Carcinoma larynx, thyroid Ear pain, deafness, nasopharyngeal carcinoma • Spinal accessory nerve involvement-drooping of shoulder • Involvement of Hypoglossal nerve-Tongue deviates to the same side with wasting of tongue muscles • Sympathetic chain-Involvement – Horner's syndrome consisting of i Miosis (due to contraction of pupil owing to paralysis of the dilator papillae) ii Anhidrosis (absence of sweating in face, neck of that side) iii Ptosis (dropping of upper eyelid due to paralysis of the levator palpebrae superiors) iv Enophthalmos (regression of eye ball due to paralysis of muller's muscle) v Loss of celio - spinal reflex Types of Secondaries in the neck Secondaries in the neck with known primary • The name it self suggests that primary has been identified along with secondaries in any of the above mentioned sites Case 21 • • • • Biopsy from the primary site and FNAC from the secondaries to be done Treatment primarily depends upon the stage, surgery/ chemotherapy, radio therapy or combine therapy as required For Nodes-It mobile, operable MRND otherwise palliative chemo/radio therapy Cervical Lymphadenopathy Hodgkin's disease • • • • Bimodal incidence curve First being young adult 20-35 yrs Second being over 60 years All verities are more common in male except nodular sclerosis variant which is more common in female Secondaries in Neck with unknown primary also called CUPS (Carcinoma Unknown Primary Sites) • Where primary sites has not been identified clinically • FNAC from secondaries to confirm the metastasis • Look for primary sites by various investigations like i Triple endoscopy Nasopharyngoscopy Laryngoscopy Bronchoscopy Esophagoscopy ii Biopsy from suspected occult primary sites like: Pyriform fossa, Nasopharynx, Base of tongue, Subglotic Other sites are: fossa of Rosenmuller, lateral wall pharynx, thyroid, Para nasal sinus, Bronchus, oesophagus etc iii .CECT scan face, neck, chest, and abdomen Symptoms and signs Treatment- If primary site is detected treatment is surgery, chemotherapy and or radiotherapy as per pre planned treatment protocol Secondaries are to be treated either by Modified radical Neck Dissection or chemo/radio therapy whichever is suitable for the patient Non Hodgkin's lymphoma Secondaries in Neck with an occult primary • Occult primary sites which can cause secondary in neck are mentioned above • Here the secondaries are confirmed by FNAC but primary has not been identified by various investigations as mentioned above So it is called occult primary • This variety is usually less aggressive and relatively has better prognosis • Here initial treatment is MRND If MRND type (spinal accessory is spared only) done in one side and other side minimum type II MRND to be done because along with spinal accessory one sided Internal jugular vein to be preserved • Regular follow up at months interval is mandatory to reveal the primary site as early as possible • Once primary site is identified biopsy to be performed to confirm the diagnosis there after treatment will depend upon the stage of the disease (Details treatment written in the chapter of carcinoma oral cavity and management of neck nodes) i Painless, progressive lymphadenopathy in a centrifugal manner ii Systemic symptoms (B symptoms) like fever, night sweets, weight loss, pruritus, fatigue, bone pain may be present Bone pain may be induced/ enlarged by drinking alcohol Fever with or without rigors occurs in a periodic fashion Period of High grade pyrexia (fever) for 7-10 days alternating with nearly a similar period of apyrexia which may continue for several months called Pel-Ebstein fever iii Hepatosplenomegaly Diagnosis, types, classification, prognostic factors are described in question and answers part NHLs are tumors originating from lymphoid tissues, mainly of lymph nodes NHL represents a progressive clonal expansion of B cells or T cells and/or natural killer cells 85% NHLs are B-cells origin Male: female= 1.4:1, i.e incidence is slightly higher in male Age > 50 years Clinical feature—slowly progressive • • • • • • Painless peripheral adenopathy Centripetal in distribution is the most common presentation B' symptoms (fever) > 38o c, night sweats, weight loss > 10% from base line within months occurs in 30% cases More than 1/3rd of patients present with extra nodal involvement The commonest site is GI Tract Others involvements are skin, bone marrow, sinuses, genitourinary tract, CNS, thyroid etc Hepatosplenomegaly with bone narrow involvement also common >50% cases Investigations • Complete blood count, Hb% platelet count may show Anaemia, secondary to bone narrow infiltration, 199 Gateway to Success in Surgery • • • autoimmune hemolysis, bleeding and anaemia due to chronic disease Elevated LDH (Lactate dehydrogenase) - related with increased tumor burden Abnormal LFT- secondary to hepatic involvement Imaging studies – Chest X-ray- PA view – USG abdomen and pelvis – CT scan neck, chest Abdomen and pelvis to see the extent of the disease – Bone scan is indicated in patients with bone pain and or elevated alkaline phosphatase MRI—If primary CNS lymphoma, lymphomatous meningitis, para spinal lymphoma How to perform bone narrow aspirate and biopsy In a case of Non-Hodgkin's lymphoma • Bone narrow aspirate and biopsy should be performed on both the side, i.e bilaterally as bone narrow involvement is patchy 200 Short Cases • • Neoplastic cell infiltrate in a focal, interstitial Or diffuse pattern Biopsy of extramural sites: approximately 30-35% patients with NHL, the extra nodal sites are the primary presenting sites and the most common site is GI tract Treatment Chemotherapy is the main stay of treatment CHOP is the main regime • C -Cyclophosphamide • H -Hydroxydaunorubicin • O -Oncovin • P -Prednisolone Other option is:-• Stage I and II NHL-treated with involved field (if) radiation • Whole body radiation (WBR) is used if field therapy is failed • Stage III and IV-chemotherapy is the treatment of choice Case 22 CASE 22 Parotid Swelling Parotid Swelling My patient Sandhya, a 40 years old lady presented with history of swelling around her left ear lobule for last years Since last years my patient having the swelling below front and back of her left ear lobule which is • Slowly progressive • It is painless • attains its present size approximate × cm from its initial size of a peanut [Keep in mind the following negative history but not utter except very important relevant points] There is no history of • Trismus • No history of sudden increase in size • No history of facial weakness • No history of dysphasia • Or recurrent snoring • Paresthesia Metastases • Hoarseness of voice No other swelling found in the face or neck, floor of mouth etc No features suggestive of facial nerve involvement On Examination General survey Essentially normal Local examination • • • • • There is a x cm swelling in the left parotid region There is obvious loss of left submandibular furrow Left lobule lifted up Overlaying skin approximate normal No facial deformity / asymmetry noticed – The lump is non tender, local temperature not raised firm in consistency – Mobile, well defined margin, smooth surface – – – – – Not fixed to the masseter/SCM or overlying skin No paresthesia over the face/ ear lobule Facial nerve's function is intact Parotid duct -NAD Bidigital palpation reveals the involvement of superficial lobe only, not the deep lobe – No other lump or lymph nodes are palpable in the neck Clinically my diagnosis is Left parotid tumor most probably benign [Remember• Mixed parotid tumor, i.e pleomorphic adenoma or parotid carcinoma is typically around the ear lobule, i.e in the parotid region • Adenolymphoma (Warthin's tumour)- usually arises from the lower pole of the gland and lies at or below the angle of mandible • Accessory parotid tumor arises at the region of cheek also.] Why you say it is a benign parotid tumour? • • • • It is a slowly progressive tumour ON examination well defined margins, smooth surface underlying muscle or overlying skin is not involved Facial nerve is not involved Mixed parotid tumor is the most common benign parotid tumour How can you say it is a parotid tumour? Sir, i ii iii iv The swelling is in the parotid region The ear lobule is pushed upwards Retromandibular furrow is obliterated The swelling cannot be moved above the zygomatic bone ‘curtain sign’ These are typical findings of parotid swelling 201 Gateway to Success in Surgery What you mean by parotid region? The parotid region is bounded by i Anteriorly, the posterior border of mandible ii Posteriorly, the mastoid process and attached sternocleidomastoid muscle iii Superiorly the zygomatic arch iv Inferiorly, posterior belly of digastric muscle What are the other possibilities of this type of swelling? Sir, from history and clinical examination I will keep benign parotid tumor as my provisional diagnosis But I will keep in mind the following differential diagnosis • Adenolymphoma of parotid • Chronic sialoadenitis • Carcinoma parotid • Cervical lymphadenopathy - Tubercular, Metastatic, Lymphoma Pre auricular lymphadenopathy Features of i Adenolymphoma (Warthin's tumour, papillary cystadenoma lymphomatosum) • Elderly patient mean age of 60 years • M:F ratio 4:1 • Usually arises from lower pole of parotid and lies at the level or below angle of mandible • It is often bilateral • Slow growing, soft, cystic, and smooth and fluctuant swelling Investigations • Adenolymphoma, produces a 'hot spot' in 99 technetium pertechnetate scan (due to high mitochondrial content)it is diagnostic FNAC-> it composed of double layer of columnar epithelium • Right adenolymphoma does not turn into malignancy Anatomical relations of parotid gland 202 Short Cases ii Chronic Sialoadenitis: Calculi are more common in submandibular gland 80% because • The gland secretion is viscous • Contains more calcium • Non dependent drainage • Stasis – Pain is more during mastication due to stimulation – Gland size is increased during mastication owing to increase salivary secretion – Firm, tender swelling is palpable bidigitally – In submandibular salivary gland, the stones are multiple with inflammation of gland (sialoadenitis) Investigations: • Intra oral X-ray (dental occlusion films) to look for radio opaque stones • FNAC of the gland to rule out other pathology iii Carcinoma Parotid: • Mucoepidermoid tumor is the commonest malignant salivary gland tumour (In major salivary gland) • It is slowly progressive, often attains a big size and may spread to neck lymph nodes • Facial nerve involvement is only in few advanced cases, usually facial nerve not involved commonly • Swelling is usually hard, nodular, irregular margins • It often involves skin and lymph nodes iv Cervical and preauricular lymphadenopathy: Tubercular- Common in upper deep cervical (jaugulodigastric group of lymph nodes 54%) Next common is post triangle lymph node 22% • Swelling is firm, matted • Features of lymphadenitis- matting - cold abscess-> collar stud abscess-> sinus formation • Tonsils may be studded with tubercles • Pulmonary TB may be associated with Metastatic " Common in elderly people • Presenting with rapidly increasing -painless lump in the neck • Nodular, hard in consistency, in advanced stage it may be fixed • Features of adjacent structure involvement like skin changes, sympathetic chain involvement causing Horner's syndrome, etc • Dysphagia, hemoptysis, dyspnea, hoarseness of voice, ear pain are the features depending on the primary site Gateway to Success Surgery in Surgery Paediatrics Cases Care must be taken to ensure that the two components of the stapler are correctly fitted back together and that the jejunum is held up against the proximal end of the stapler thereafter the stapler can be fired After removal of the stapler the enterotomy wounds can be closed with a serosubmucosal continuous PDS suture as described previously Key Points • • The spike of a circular stapling device is shown emerging through the anti-mesenteric border of the jejunum at the proposed site of an esophagojejunal anastomosis • When using stapling devices ensure you are familiar with their assembly and function Careful preparation and meticulous set up of the anastomotic site is as essential when stapling as when suturing Ensure that you select the correct sized instrument for the task required Jejuno-Jejunostomy The final stage of the reconstruction is to join the proximal divided jejunum to the jejunal loop To ensure that there is adequate biliary diversion this should be 45-50 cm distal to the esophagojejunostomy The enterotomy site used for the insertion of the staple gun is a suitable site for the anastomosis The proximal jejunal loop should be brought to lie adjacent to the existing enterotomy It may be useful to insert stay sutures both at the site of the enterotomy and distally An enterotomy is made on the proximal loop of jejunum and a linear stapling device inserted into the two limbs of jejunum Side-to-side jejunostomy using a linear cutting stapler Case 47 KNOW FEW IMPORTANT THINGS ABOUT SUTURE MATERIALS Ideal Suture Material-Criteria • • • • • • • • Adequate tensite strength Minimal tissue reaction Good knotting capacity Nonallergic, noncarcinogenic Easy handling quality Less memory Easily available Relatively cheaper Classification A Absorbable i Natural ii Synthetic B Nonabsorbable i Natural ii Synthetic Examples of different sutures: i Natural a Plain Catgut b Chromic Catgut ii Synthetic a Polyglactic acid (Vicxyl) b Polyglycocolic acid (Dexon) c Polydioxanone suture (PDS) d Polyglecaprone (Monocryl) e Glycomer (Sisyn) f Polyglyconate (maxon) Note: Catgut is synthesized from the submucosa of sheeps intestine or serosa of beefs intestine, not cats intestine plain catgut is treated with 20% chromic acid called chromic catgut Uses of Absorbable Suture • • • • • • In bowel anastomosis, cholecystojejunostomy, choledochojejunostomy, pancreas jejunostomy, etc To suture muscosa, subcutaneous tissue muscle, fascia, peritoneum Base of the appendix, stump of the appendix Chosure of subcostal incision rectus sheath, external, oblique aponeurosis In ligating pedicles In circumcision Notes on Stapler, GI Stapler Congenital and Sutures Hernia (Remember—absorbable suture should not be used in vascular anastomosis, vessels, tendon and nerve) Nonabsorbable suture: a Natural i Silk ii Linen iii Cotton b Systhetic i Polypropylene (Prolene) ii Polyethylene (Ethylene) iii Polymide iv Steel v Polyester (Ethybond) vi Nylon, etc Uses of nonobsorbable suture: • Closuer of abdomen • In herniorrhaphy for repairing posterior wall of inguinal ligament • Repaire of incisional heria • In tendon injury • Vascular anastomoses • Suturing of skin • Posterior seromuscular suture in small gut anastomosis,gastrojejunostomy, pancreas ticojejunostomy, etc Monofilament and Polyfilament Suture Monofilament Suture is made of a single strand of fiber So the surface of this suture is smooth Usually these suture are strong and chance of bacterial contaminations are less but knot holding capacity is poor So 4/5 knot to be tied Examples polypropylene, polymide catgut, polyglecaprone (Monocryl), etc Polyfilaments—Surture is made of multiple srrands of fibers Surface is not smooth but knot holding capacity is excellent chance of bacterial contaminations is more due to presence of crevices So infections Example—Silk, linen, polyglactin (Vicryl), Polyglycocolic acid (Dexon), Braised polymide, braises, polyester suture Numbering of Suture Materials - Thick suture 1, 0, 1-0, 2-0, 3-0, 4-0, 6-0, 7-0, 8-0, 9-0 No - is used usually for pedicle ligation - , Gateway to Success Surgery in Surgery 2-0, 3-0 for bowel suturing 5-0, 6-0 for vascular anatomosis, nerve repair etc 9-0 is used under microscopic vision Usually used in ophthalmic surgery The number indicates thickness of the suture Higher the number, thicker is the suture When o is used suffixed , higher the number, finer the sutures Example - 4,0 is thinner than 3,0 sutures Mechanism of Absorption of Suture Absorbable Suture These suture get absorbed in the tissue, either enzymatic digestion or by phagocytosis except polyglactin (Vicryl), Polyglecaprone—Which digested by (Monocryl) hydrolysis So the sutures leave behind the scar mark over the skin For this why absorbable suture usually is not used in cosmetic area like face, neck, etc Nonabsorbable suture remain in the tissue for indefinite period for this why it is used for Henia repair In body surface Paediatrics Cases it is removed at face at days, neck 4-5 days, abdomen 7-10 days, upper limbs 10-12 days and lower limbs 12-14 days Example of Tensile Strenghth Polygloctin (Vicryl) Vicryl Rapid Polyglecaprone (Monocryl) Tensile strength 28-30 days 10-12 days 18-21 days Absorbed by 80-90 days 40-45days 90-120 days PDS (Polydioxanone suture) - It maintains tensile strength for a longer period, i.e, about 56 days At weeks tensile strength 5% maintained At weeks -50% maintained At weeks 25% maintained At weeks it loses its all tensile strength Atraumatic Suture When the suture is attached with an eyeless needle called atraumatic suture Chance of tissue injury is less here Case 47 THE CARE WORLD • Brings colours to life World Population Control (WPC) Population growth is the change in population overtime and can be qualified as the change in the uumber of individuals in a population using 'per unit time" for measurement Over population has a negative impact on the environment due to pollution and over crowding The more people are there, more resources they use and the more pollution that results Notes on Stapler, GI Stapler Congenital and Sutures Hernia • Air pollution is due to increased fossil fuel emissions from vehicles • Land or water pollution due to increased amounts of waste Population increased as people are born or immigrate into a country and decrease as people die or emigrate Rate, of population growth, usually expressed as a percentage, very greatly Our aim to control world population by preventing unwanted new born and make the world a more happier place for ever Index Page numbers followed by f refer to figure and t refer to table A Abdomen 11, 71, 77, 86 inspection 26 scaphoid 26 soft 26 Abdominal cocoon 40 examination 27, 125 lumps lymphadenopathy 108 pain 33 tuberculosis 38, 40 Abductor digiti minimi 320 Absorbable suture 392 Acquired causes 356 immunodeficiency syndrome 282 Action of ECRL 317 pancreatitis 54 physical and chronic health evaluation 57 Adductor hallucis 306 Adenocarcinoma 82 Adenolymphoma 202 Adenomatous polyp 91 Adequate staging laparotomy 35 Adjuvant therapy 69 Adnexal mass 127 Adrenal mass Adson’s test 289, 291 Advantages of surgical stapling 370 Aggravated after meal 238 AK Henry’s approach 233 Alcohol causes pancreatitis 58 Alcoholic and red meat eater 92 Alkaline phosphate 20 Allen’s test 290, 291 Alpha fetoprotein 244 Alveolus 339 Ambulatory venous hypertension 154, 157 Amelioration of symptoms 22 Aminoglycoside 242 Ampulla of Vater carcinoma 62 Ampullary carcinoma 13 Amputated stump 309 Anaplastic variety of carcinoma 263 Anastomosis 370 end-to-end functional 371 Anatomical relations of lower abdominal structures 220 Anatomy and lymphatic drainage of tongue 139f femoral hernia 234 inguinal canal 225f Anatomy of breast 171f extraperitoneal space for TEP hernia 227 hepatobiliary tree 17f hydatid cyst 64f inguinal canal 224f region 219f inguinofemoral region 233f liver segments 68f penis on cross-section 264f retroperitoneal space 112f tongue parts and papillae 139f Aneurysm of popliteal artery 332 Angell’s sign 355 Ankle brachial pressure index 146 Annular pancreas 54 Ant pituitary 190 Anterior gastrojejunostomy 102 Anterolateral neck dissection 142 Anterosuperior iliac spine Antibiotic prophylaxis 16 Aortic aneurysm 5, 49 Aortoiliac occlusive disease 150 Appendicular lump Approaches for kidney tumor 80 Area of lip cancer percentage wise 138f Arnold Chiari syndrome 365 Arterial or plexiform hemangioma 275 supply and lymphatic drainage of colon 97f of rectum and anal canal 97f occlusive disease 146 Ascaris 22 Assessment of liver 94 Atraumatic suture 392 Auscultation 11 Autoimmune disorders 196 Autonomous zone of nerve supply 324 Axillary tail of spence 171f B B cell lymphoma 107 Baid test 5, 27, 48 Baker’s cyst 334f develops 332 Balanitis xerotica obliterans 265 Ball valve mechanism 225 Ballooning of calyx 88 Barium meal 101 study 39 Barley water like 252 Basal cell carcinoma 264, 269, 270 and bone 270 arises 269 spreads 270 Base inguinal ligament 263 Basic defect in congenital hernia 362 Bassini’s operation 222 Bazin’s ulcer 308 Before palpation 11 Beger procedure 57, 58f, 60 Below knee amputation 311 Benign or malignant mass 126 ovarian mass 127 parotid tumor 201 stricture 22 Berry ligament 182 picking 183 sign 183 Bilateral hydronephrosis 87 orchidectomy 263 Biliary obstruction 18 Bilirubin level 14 metabolism 17 Bilocular hydrocele 256 Bimanually palpable 32 Bipartite cleft palate 344 Bladder mass Bleeding per rectum 33 Bleomycin 209 Blood carcinoembryonic antigen 93 supply 54 of left colon 95f of stomach 102f Blumer self’ palpable 11 Blumers self 78 Borrmann classification 105 Boundaries of inguinal canal 224 Boundary of inguinal pelvic dissection 263 Bow sign 258 positive 257 Bowel complaints 29 Bowen’s disease 280 Gateway to Success Surgery in Surgery Boyd’s classification 145 perforators 157 Brachial plexus formation 321f injury 320 Bradley’s procedure 58 Brain tumors 356 Branchial cyst 208 and branchial fistula 213 Breast conserving surgery 168, 169 Breslow’s classification 287 Brodie-Trendelenburg test 152, 159 Budd-Chiari syndrome 121 Buerger’s disease 144-148 Buerger’s postural test 289 Burkitt’s lymphoma 196 Bursae around the knee joint 333 Buschke Lowenstein tumor 262 Bypass procedures in colonic carcinomas 96f C Ca breast 168, 169 buccal mucosa 139 penis 280 Calculus 22 Callous or chronic ulcer 307 Cancer debilitating illness 159 Carcinoma breast 165, 166 cecum colon 9, 29, 93, 97 gallbladder 4, 11, 71, 73, 74 spreads 73 head of pancreas 60 left breast 166 oral cavity 137, 140f pancreas 15 parotid 202 penis 262 stomach 103, 104 thyroid 180, 187 transverse colon Card test 318 Cardiac toxicity 170 Cardiovascular symptoms 184 Carnett’s test 8f, 241 Caroli’s disease 22 Carotid body tumor 215 Carpal bones 316 Case of bleeding esophageal varices 116 Buerger’s disease 146 Carcinoma oral cavity 135 penis 263 396 Paediatrics Cases cervical lymphadenopathy 194 diabetic foot 299 metabolic alkalosis 104 operable gastric cancer 103 radial nerve injury 313 scrotal swelling 251 tubercular knee joint 335 Wilms’ tumor 359, 360 Cattle’s operation 242 Cauliflower like lesion 262 Causalgia 323 Causes of claw hand deformity 319 effusion in joint 335 exophthalmos 184 gastric outlet obstruction 103 pseudocyst 53 trophic 304 Causing basal cell carcinoma 269 Cavalier’s sign 158 Cavernous venous hemangioma 275 CECT abdomen 12, 72, 93, 101, 112 scan 20 Celiac axis 15 trunk 112 Cells of peyer 38 Cellular dysoxia 329 Central cleft 343 compartment neck dissection 142 Cephalosporium 242 Cerebrospinal fluid 356 Cervical and preauricular lymphadenopathy 202 dermoid 211 lymphadenopathy 193, 196 rib 292 Characteristics of Marjolin’s ulcer 326 Charcot’s triad 19 Chemical sympathectomy 147 Chemodectoma/potato tumor 215 Chemotherapeutic agents 103 Chemotherapy in carcinoma colon 95 penis 264 Chest 166 X-ray and barium 39 Child Pugh’s score 68 grading of hepatic reserve 70 Chimney sweep cancer 280 Chlamydia trachomatis 129 Chocolate cyst 126, 129f formed 128 Cholecystectomy 74 Cholesterol crystal 210 Chromophilic 82 Chromophobic 82 Chronic and critical limb ischemia 149 balanoposthitis 264 critical limb ischemia 147 limb ischemia 147 lymphatic leukemia 194 myeloid leukemia 115 pancreatitis 51, 59 pyogenic lymphadenitis 194 sialoadenitis 202 smoker 132 or tobacco chewer 132 venous disease 158 insufficiency 151 Chung law 19 Chvostek-Weiss sign 189 Chylocele 252 Chylolymphatic cyst 28 Circular stapling device 387f Circumflex scapular artery 316 Cirrhosis of liver 67 Cirrhotic PHT 121 Clark’s level of melanoma 287f Classification of carcinoma breast 168 chronic limb ischemia 150 pancreatitis 59 goiter 190 PHT 119 Claw hand 319 deformity 318 develops 319 Clear cell most common 82 Cleft lip and cleft palate 339 repair 340 cleft palate 340 Cleft palate 344 Cloquet’s hernia 235 lymph node 231 CNS system examination 125 Coagulation defects 19 profile 20 Cock’s peculiar tumor 273 Cold abscess in neck 208 nodules and hot nodules 188 Collagen granules 310 Collecting duct 82 Colloid goiter 191 formed 186 Colon cut off sign 55 Case 47 Colonic cancer 91 carcinoma 92, 95 lump 81 mass tumor 95 Coloproctectomy with ileal “J” 384 Color Doppler flow imaging 78, 298 Colorectal surgery 383 Common causes of ulnar nerve injury 319 channel hypothesis 58 peroneal nerve injury 322 sites of basal cell carcinoma 269 gastric cancer 105 trophic ulcer 304 varicosities 156 Communicating veins 157 Compensatory PAOD 148 Complete inguinal hernia 220f Complication of amputation 312 chronic pancreatitis 59 cystic hygroma 209 hypospadius repair 348 meningocele and meningomyelocele 366 multinodular goiter 186 orchiopexy 352 parotid surgery 206 post burns contracture 325 sclerotherapy 154 thyroglossal cyst 213 thyroidectomy 189 transhepatic intubation 24 undescended testis 352 varicocele surgery 259 varicose vein 158 Comprehensive neck dissection 142 Concept of the variceal grades 118 Conditions of thyroid 181 Condyloma acuminata 263 Congenital causes 87 hernia 362 hydrocele 254, 257, 363 inguinal hernia 363 nonhemolytic anemia 24 varicose veins 158 Conical bearing stumps 311 Conjugated hyperbilirubinemia 25 Conservative management of Baker’s cyst 333 treatment in varicocele 261 Contrast enhanced CT scan of abdomen 78 Controversial still 276 Conventional orchiopexy 351 Cooley shunt 124 Congenital Hernia Index Coronal hypospadius 347 Coronocaval shunt 117, 124 Correct nasal deformity 340 palate cleft 340 Cotswold staging classification of lymphoma 36 Course of branchial fistula 214f femoral hernia 234 fistulous tract 214 thoracic duct 15, 16 Courvoisier’s law 19 Coverings of inguinal hernia 225 Criles method 181 Criteria’s for ideal stump 310 of cystic hygroma 209 Critical limb ischemia 150 Crohn’s disease 6, 37, 91, 98 Cronkhite Canada syndrome 98 Cross-section of nerve 323f Cryptorchidism 353 CT colonography 93 CT findings of pseudocyst of pancreas 50f Cullen’s sign 55 Culp-deweerd spiral flap 90 Curative surgery 24 Curtain sign 201 Cystic hygroma 210 lump abdomen 26 swelling in the neck cystic hygroma 208 D Dead loss limb 310 Decompensatory PAOD 148 Deep branch of radial nerve 317 vein thrombosis 159 venous system 157 Defect in mucosal layer 134 Deficiency in mandible 134 Define extent of disease 67 Definition urethral groove 349 Deformity in ulnar nerve palsy 319 Degree of necrosis 56 Delaire’s technique 340 Deming’s sign 354 Demonstrate gustatory sweating 206 Denis Browne’s technique 349 Depth of burns 328f tumor 74 Dercum’s disease 274 Dermatomes of both upper and lower limbs 324f Dermoid cyst 126, 128, 271 Description of ulcers 302 Determine hepatic remnant function 67 Developing thyroid malignancy 182 Development of contracture 325 face 342f urethra 349 Diabetic foot 298 ulcer 299, 308 Diagnosis of parotid swelling 205 primary gastric lymphoma 107 Diagnostic laparoscopy 350 Diethylenetriamine pentaacetic acid 87 Dietl’s crisis 86, 88 Difference between embolism and thrombosis 293t indirect and direct sac 217f inguinal and femoral hernia 218f, 234f Raynaud’s disease and Raynaud’s syndrome 291 Different edges of ulcers 306f incisions of breast surgery 176f levels of neck nodes 196f parts of an ulcer 307f types of cleft lip 343f cleft palate 344f hernia repair 221 naevi 286f Diffuse gastric cancer 105 Digital rectal examination 31, 92, 114 subtraction angiography 290 Dilated biliary canaliculi 18 tree 20 Direct hernia 219 Disadvantages of porta caval shunt 123 Dismembered pyeloplasty 89 Dissect pelvic lymph nodes 263 Disseminated intravascular coagulation 330 mets 85 Distal lienorenal shunt 124 nature of disease 146 splenorenal shunt 117 selective 124 Distant metastasis 111, 168 Distention of abdomen 26, 98 Division of duodenum 387, 387f, 388f Doted line area of hemimandibulectomy 134f Double contrast barium enema 34, 93 duct sign 15 397 Gateway to Success Surgery in Surgery Drill biopsy 281 Duval procedure 60 Dysphagia 132 Dyspnea 132 E E coli 129 Early Ca breast 170 Early gastric cancer 104 Echinococcus 22, 64 Echosclerotherapy 156 Economy class syndrome 159 Ectopic left kidney 29 Ectopic sites of thyroid 213f Ectopic testis 353 Edge/wedge biopsy 281 Effect of gastric outlet obstruction 103 Effects of biliary obstruction 18 Effects of varicocele on testis 261 Elephantiasis neurofibromatosis 276 Elevated carcinoembryonic antigen 75 Eliminate infection 299 Embolism and thrombosis 292 Empyema GB Encysted hydrocele 252 of cord 254 tubercular peritonitis 27, 127 Endocrine dysfunction 59 factors 347 Endoscopic biopsy 106 drainage 52 of pseudocyst 52 pyelolysis 88 retrograde cholangiopancreatography 14, 22, 75 sclerotherapy 118 technique 24 USG 20 variceal ligation 116 Endotoxemia 19 Endovascular procedures 150 End-to-side ileocolostomy 372 Enroth sign 184 Enterogenous cyst 28 Enucleation for pleomorphic adenoma 203 Enzyme deficiency 347 Epidermal cyst 219, 271 Epididymal cyst 25, 258 Epididymal cyst and hydrocele 252 Epigastric hernia 238-239f lump 48, 53 Epigastrium Epithelial ovarian tumor 127, 129 398 Paediatrics Cases ERB-Duchenne paralysis 321 Esophagojejunal anastomosis 389 Evaluation of neck 143 Evan’s formula 330 Everted edge 307 Evolution of neck dissection 142 Example of tensile strenghth 392 Except extensor carpi radialis longus 313 Excision biopsy 110 Exocrine dysfunction 59 Expansile cough impulse 216 Exposure to PUJ 89 Extended left hemicolectomy 94 radical cholecystectomy 73 RND 142 SOHND 142 Extensor digitorum 313 muscle 317 muscles of wrist joints 313 Extent of hernia 219 lymphadenectomy 267 External iliac Extrahepatic portal venous obstruction 120 Extrarenal pelvis 87 Extremity sarcoma 110 Extrinsic compression 22 Eye signs in toxic goiter 184 F Face 325 Factors for recovery of nerve function 315 Familial adenomatous polyposis 91, 98 Fascicle 322 Fate of duct 212 Features of hypospadias 346 trophic ulcer 304 Fecal occult blood test 96 testing 33 Fegan’s method 152 Fegan’s test 159 Femoral hernia 218, 231 Fibroid uterus 126 Fibular free flap 139 Field fire cancer 269 Fine niddle aspiration cytology 281 Flank pain 83 Flap valve mechanism 225 Flexor accessories 306 compartments muscles of forearm 320 digiti minimi 320 brevis 306 digitorum profundus 319 hallucis brevis 306 Floor of mouth 138 Fluctuation test 256 Fluid maintenance therapy 330 Fluoxetine 297 Fogarty’s catheter 296 Foley’s Y-V plasty 90 Follicular adenoma and follicular carcinoma 181 carcinoma 191 thyroid 182f Fordyce’s disease 274 Fore arm–ulnar nerve supplying 319 Formal hernia operation 233 Formation of branchial cyst and fistula 213, 213f Roux-en-Y loop 387 sequestration demoid 272f Forming cold abscess 28 Forms of femoral hernia 235 Fortner’s regional pancreatectomy 62 Fouchet’s test 13 Fowler Stephen’s technique 351 Fox sign 55 Frey’s procedure 60 syndrome 206, 207 Froment’s sign 318, 319 Frontonasal process 342 Frozen section biopsy 168 Functional cyst 126 limb ischemia 150 neck dissection 142 ovarian cysts 128 Funicular hydrocele 254 G Gaint hemangioma 64 Gaiter’s zone 155 Gallbladder lump 11 mass Gallstones cause pancreatitis 58 Gamma glutamyltransferase 20 Gastric cancer 104 lymphoma 107 outlet obstruction 10 surgery 376 tetany 104 Gastroduodenal reconstruction 376 Gastrointestinal stromal tumors 106, 111 General survey 26 Generalized lymphadenopathy 30, 196 Germ cell 129 Case 47 GI stapling techniques 386 symptoms 92 Giant condyloma acuminata 262 naevus 287 prosthetic reinforcement of visceral sac 222 Gibbon’s hernia 226 Gifford sign 184 Gilbert classification of hernia 221 Gingivobuccal sulcus with gingiva 136 Gives stool color 17 Glassgo scale 57 Gonococcus 129 Grade encephalopathy 118 intermittent claudication 145 muscle power 314 Gray turner sign 55 Gritti Stokes amputation 312 Group staging of TNM 245 Gubernacular tails of lockwood 354f Guidelines by tumor stage 75 Guillotine amputation 312 Guttering of veins 148 Gynecological surgery 160 H Halsted test 291 Harvey’s sign 289 HBV and HCV 67 Head circumference of body 365 Healing ulcer 154, 307 Helicobactor pylori 105 Hematocele 252 Hematopoietic progenitor cell antigen 106 Hematuria 83 in case of Wilms’ tumor 358 Hemicolectomy 94 Hemithyroidectomy 183 Hemobilia 22 Hemodynamic changes 19 Hemolytic prehepatic 12 Hepatic mass 63 metastasis 65 resection 68 transplantation 69 Hepaticojejunostomy 24f Hepatobiliary tree and blood supply 16f Hepatocellular 12 cancer 67 carcinoma 64 Hepatomegaly in obstructive jaundice 14 Hereditary papillary renal cell carcinoma 82 Congenital Hernia Index Hernia en glissade 226 recurrence after mesh repair 223 Hesselbach’s triangle 216 hernia 235 High grade fever 29 inguinal orchidectomy 246 median nerve injury 320 History of cryptorchidism 244 present illness 10, 26, 71 smoking 149 surgical stapling 369 Hodgkin’s and non Hodgkin’s lymphoma 195, 196 disease 195 lymphoma 193, 195, 196 Homan’s sign 148, 161 Horner’s syndrome 322 Horny cell layer 281 Hose pipe 39 Human chorionic gonadotropins 244, 352 papilloma virus 262 Hurthle cell carcinoma 192 Hutl’s stapling principles 369 Hybrid procedures 150 Hydatid cyst 4, 64 of kidney 87 Hydrocele 251 develops 254 -en-bisac 256 of femoral hernia 233 of neck 210 Hydrocephalus 356 Hydronephrosis 86, 360 Hydrosalpinx 126, 129f Hyperbaric oxygen therapy 299 Hyperglycemias 301 Hypernoma 274 Hypersplenism 116 Hyperthyroidism for surgery 184 Hypertrophic scar 277 Hypogastrium Hypospadias 346 Hypothenar muscles 320 Hypotonic duodenography 15, 20 I Ian-Aird test 156 Ideal suture material-criteria 391 Ileocecal tuberculosis 37, 38 Iliac crest Ilizarov technique 146 Immediate postoperative management 315 Immunotherapy and hormonal therapy 70 Importance of Doppler ultrasonography 127 Incarcerated hernia 220 Incidental renal tumors 84 Incision for thyroid operation 183f Incisional biopsy 133, 167 hernia 24, 241-243 operation 242 Indications of adjuvant treatment 135 mesocaval shunt 123 Indirect hernia 219 inguinal hernia 216, 225 Indocyanine glue 68 Infantile hydrocele 254 Infection with ulcer 302 Infrainguinal occlusive disease 150 Inguinal canal in child 362 hernia 216-218, 257 lymph node 263 Inlay graft 243 Inner and outer Waldeyer’s ring 35f circle surrounding larynx 140 Inokuchi shunt 124 Intermittent claudication 145 Internal jugular vein 142 Interosseous muscles 306 Interstitial stromal tumor 247 gastric cancer 105 Intra-abdominal soft mass 27 Intravenous urogram 87 urography 31 Intubated ureterotomy 90 Involvement of urethra 262 Ischemic ulcer 302 Isolated regional perfusion 111 Isotope renogram 87 IUSG abdomen 109 J Jaboulay’s operation 252 Japanese classification 105 for early gastric cancer 105f Jaundice 11, 12 patient 19 Jejuno-jejunostomy 390 Jellinec K’s sign 184 Jod Basedow thyrotoxicosis 185 Jofroy’s sign 184 399 Gateway to Success Surgery in Surgery Jugular neck dissection 142 Juvenile rheumatoid arthritis 196 K Kang cancer 280 Kaposi’s sarcoma 282 Keel operation 242 Kettey Torek procedure 351 Kidney 18 mass Kind of ulcers 309 Kippel Trenaunay syndrome 151 Kistner’s valvuloplasty 155 Klippel-Trenaunay syndrome 158 Klumpke’s paralysis 319, 321, 322 Knee amputation 311 elbow position test 8f Kocher’s method 181 Krukenberg amputation 312 tumor 106 Kuster perforators 157 Laparoscopic hernia repair 226 surgery in colonic carcinoma 95 L Laplace rule 96 Lateral border 263 cleft 343 direct hernia 225 neck dissection 142 swellings 211 Lattice or darning procedure 243 Laugier’s femoral hernia 235 Lauren classification 105 Left and right hemicolectomy 96 breast 165 flank 114 gastric–caval shunt 117 hypochondrial mass hypochondrium iliac fossa 3, 29 lump 29 mass lobe of liver mass lower limb 144 lumbar sided bowel malignancy 33 isolated portal hypertension 115 PHT 121 tumors 98 upper abdomen 114 400 Paediatrics Cases Leg lifting test 8f Leriche’s syndrome 147 Lesion in gallbladder 72 Leukemic tissue infiltration 194 polyposis 98 Levels of axillary’s lymph nodes 171 neck nodes 140f Leydig cell carcinoma 247 Life-threatening infections 303 Ligation of mesenteric vessels in continuity 388f testicular vein 258 Limb salvage surgery 111 threatening infection 303 Linear stapler and cutting device 386f Lip 138 Littre’s hernia 226 Liver 18 function tests 12, 61 derangements 68 mass 4, 53 transplantation 116, 124 Lockwood operation 232 theory regarding ectopic testis 353 Locoregional lymph nodes 96 Long saphenous vein 157 and tributaries 160f Lord’s operation 253f Losartan 297 Loss of skin 134 soft tissue 134 Lotheissen’s operation 233 in femoral hernia 233 Low anterior resection with end-to-end anastomosis 384 Lower abdominal wall and inguinal region 224f brachial plexus injury 319 median nerve injury 320 part of descending Lumbar puncture 357 Lumbrical muscles 306 Lump 271 abdomen lower abdomen 125 of hepatic flexure of colon Lung metastases 283 Lymph nodal mass 5, 7, 29, 54 node involvement 75 nodes assessment 94 dissection 102 involve in nurse’s root of mesentery 44 varix 257 Lymphatic drainage from different parts of tongue 136 of breast 177f of colon 97f Lymphocyte depleted 196 Lymphocytic predominant 196 Lymphoma 34, 92 M Magnetic resonance cholangiopancreatography 75 Maintain hydration 16 Male exposure to sunray 269 Malgaigne’s bulging 219 Malignancy develops in penis 264 Malignant fibrous histiocytoma 111 melanoma 287 spread 283 mesenchymal tumor 111 obstruction 22 ovarian mass 128 tumor 79 Mallet Guys sign 59 Management of burns 330 chronic limb ischemia 150 ESCHAR 331 meningomyelocele 368 Marginal mandibulectomy 136f Marjolin’s ulcer 280, 307, 309, 326 Mary Joseph’s nodule 104 Mass in different regions of abdomen 7f epigastrium hypogastrium pelvoabdominal 126 right and left lumbar region umbilical region Mass upper abdomen 59 Maxillary process 342 Maydl’s hernia 226 May-Husni operation 162 procedure 159 Mayo’s operation 242 McFee incision for modified radical neck dissection 143 Measure portal pressure 121 Mechanism of absorption of suture 392 Medial border 263 Case 47 direct hernia 225 malleolus 151 meniscus injury 335 Median nerve injury 320 supplying 319 Medicolegal and ethical aspect in burns 331 Medullary carcinoma thyroid 182f Melanoma 282 topic 270 Meleney’s ulcer 308 Mènètrier’s disease 105 Meningocele 365 Meningomyelocele 365 Mesenteric cyst 27, 49 lymph node biopsy 7, 45f lymphadenitis 45f lymphadenopathy 81 Metastatic disease of carcinoma thyroid 188 lymphadenopathy 194 workup 79 Microvascular occlusion 329 Midline swelling in neck 211 Mild jaundice 59 pallor 91 Millard’s position 340 procedure 339 Ming’s classification 105 Mirault blair procedure 340 Mirizzi syndrome 25 Mixed cellularity 196 parotid tumor 203, 205 Modified RND 142 Moebius sign 184 Moh’s micrographic surgery 267 Molluscum sebaceum 278 Monofilament and polyfilament suture 391 Morrant Baker’s cyst 332 Morrissey’s cough impulse test 152, 159 Moses sign 148, 161 MR angiography 116 MS or DNB examination Muir and Burclay regime 330 Muller’s muscles 322 Multidrug resistant 69 Multinodular goiter 180 develops 186 Multiorgan dysfunction syndrome 329 Multiple tourniquet test 159 Musculoskeletal system 166 Mycobacterium tuberculosis 129 Myopectineal orifice of Fruchaud 226 Congenital Hernia Index N Nafziger’s sign 184 Napkin lesions 39 Natural history of PHT 120 porto systemic shunt 119 Neck 325 dissection 138 nodes management in carcinoma oral cavity 134 swelling 210 Necrosectomy 58 Needle biopsy 360 Neoadjuvant therapy 68, 113 Neourethra formation 348 Nephroblastoma 358 Nephron sparing surgery in RCC 80 Nerve conduction velocity 314, 315 from distal to proximal 315 function 315 in parotid gland 205 injury 322 after blunt trauma 315 sparing RPLND I 249 II 249 III 249 supply 54 Nerves used for nerve grafting 315 Neuhof’s sign 148, 160 Neural tube defects 366, 367 Neuroblastoma 360, 361 Neurofibroma 276 Neurogenic ulcer 305 Neurogenic/neuropathic ulcer 304 Neurolipomatosis 274 Neuropathic ulcer 302 Nevin’s staging of carcinoma gallbladder 74 Nifedipine 297 Nodal status 73 Nodular sclerosis 196 Nodule thyroid 183 Nonhealing ulcer 309 Nonseminomatous germ cell tumor 244 Noncirrhotic portal fibrosis 119, 120 Nongynecological causes of pelvic mass 127, 131 Non-Hodgkin’s lymphoma 107, 194 Nonobstructive hydronephrosis 87 Nonrespectability in carcinoma oral cavity 135 Nonseminoma 248 Nonsurgical ablative therapies 69 N-regional lymph nodes 84 Numbering of suture materials 391 Nuttall’s procedure 242 Nyhus classification of groin hernia 221 O Oblique hernia 219 Obstructed congenital inguinal hernia 363 jaundice 12, 118 symptoms 108 Occult carcinoma 187 Ochsner’s clapsing test 320 Ombredanne’s procedure 351 Omental cyst 27, 28 Oncologic relevance of lymph node levels 141 Onlay transverse prepucial skin tube repair 348 Operable carcinoma stomach 103 positive neck nodes 134 Operations for incisional hernia 242f Opponen’s pollicis 320 digiti minimi 320 Origin of kidney tumors 80 Ormond’s disease 87 Orthopedic deformity 302 Oschsner’s clasping test 320 Outer circle of superficial nodes 140 Ovarian cysts/tumors 29, 33 malignancy 127 mass from fibroid uterus 126 tubo-ovarian mass stage malignancy 129 tumors on histopathology 129 P Pad sign 61 Paget’s disease 264 Pain control in carcinoma pancreas 62 epigastric region 59 in lower abdomen 125 Palliative nephrectomy 81 surgery 24 treatment of advanced disease 76 Palma operation 159 Palmaris brevis 320 Palmo’s method 259 operation in varicocele 258 Palpable lump 98 Pancost’ tumor lung 321 401 Gateway to Success Surgery in Surgery Pancreatic cyst mass 54 Pancreaticojejunostomy 61 and gastrojejunostomy 24f Pandered syndrome 185 Pantaloon hernia 226 Papillary carcinoma 191 cystadenoma lymphomatosum 202 serous cystadenoma 130f Parathyroid insufficiency 185 Paradoxical aciduria 104 embolism 293 Paralysis of adductor pollicis brevis 320 Paraneoplastic syndrome 77 Paraovarian cysts 129 Paraumbilical hernia 236 Parietal swellings 32 Parotid gland 205 lymph node swelling 204 region 202 swelling 201 tumor 201, 203 Partial thyroidectomy 183 Parts of hernia 218, 218f Parts of ulcer 307 Patchy dermatocele 276 Patellar tendon bearing prosthesis 312 Pathway of CSF flow 367f CST 356 testicular descent 353f Patient of leukoplakia 137 thyrotoxicosis 184 varicocele 259 Peacock’s regimen 147 Pectoralis major myocutaneous 134 Pedal edema 30 Pelvic mass 125 veins 160 Pemberton’s sign 185 Penile conservative therapy 267 tumor 264 Per speculum examination 126 Per vaginal examination 31 Per vaginum examination 126 Percutaneous drainage 52, 57 ethanol injection 69 transhepatic biliary drainage 23 cholangiogram 22 402 Paediatrics Cases transluminal angioplasty 150 Perforating veins 157 Periampullary carcinoma 11, 13 Peripheral arterial thrombosis 293 artery occlusive disease 144 nerve injury 313 vascular disease venous constriction 329 Perthes’ test 152 Petti’s hernia 226 Peutz-Jeghers syndrome 98, 288 Peyer’s patches 38 Phantom hernia 226 Pharmacotherapy 117 in PHT 121 Pharyngeal pouch 214 Physiology of thyroid gland 190 venous dinage in lower limb 156 Pierre-Robin syndrome 343 Pigmentation occurs in venous ulcer 155 Pirogoff’s modification 312 Plain X-ray abdomen 83 Plexiform neurofibromatosis 276 Pointing index 320 test 320 Polycystic kidney 361 disease 87 Poor penile hygiene 265 Popliteal fossa 334f swellings 332 Portal decompression 117 hypertension 114, 115, 118 incidence 120 vein 15 Ports for TAPP repair 227f TEP repair 228f Port-wine stain 275 Position of branchial cyst and fistula 213f Positron emission tomography 143 Post burns contracture and Marjolin ulcer 325 Postoperative period after amputation 312 Post Whipple’s 61 Posterior circumflex humerus vessels 316 interosseous nerve 317 Posterolateral neck dissection 142 Postoperative thrombosis 160 Pouch and ileoproctostomy 384 Pratt’s test 159 Precancerous lesions in oral cavity 136 Precent of cancers stomach at different sites 106f Pregnancy and postpartum period 159 Prehn’s sign 354 Premalignant conditions of colonic carcinoma 98 of penis 263 lesions 265 Prevent diabetic foot ulcer 299 Prevention of DVT 162 Previous adenoma 67 Primary goals of surgical techniques 369 hydrocele 251, 254 survey and resuscitation 330 varicosities 156 Principles of hypospadius repair 347 Princkle cell layer 281 Processus vaginalis 254 Proctosigmoidoscopy/colonoscopy 31 Profundoplasty 146 Prognosis of Wilms’ tumor 359 Prognostic factor of Wilms’ tumor 359 in SCC 279 Prothrombin time 12, 14 Provisional diagnosis 126 Proximal splenorenal shunt 123, 123f Pruritis 22 Pseudomatting 193 Pseudomesenteric cyst 28 Pseudopancreatic cyst 27f Pseudo-pseudopancreatic cyst 52 Psoas abscess 29 PTC pictures in various diseases 22 Punch biopsy 281 Push back palatoplasty 340 Pyeloplasty for symptomatic PUJ obstructions 89 Q Quadrangular space 317f R Radial nerve and profunda brachialis artery 316 directly supplying 313 injury 313, 314 supplying 314 Radical cholecystectomy 73 mastectomy 169 neck dissection 142 nephrectomy with ureterectomy 80 orchidectomy 248 Radioiodine scan 188 Radiofrequency ablation 69 Radiotherapy in carcinoma stomach 103 Raised and beaded 307 Ranson score for gallstone pancreatitis 57 Case 47 Rare causes 27 lesions 29 Rarely white 307 Ray amputation 312 Raynaud’s disease 296 phenomenon 291, 296 syndrome 291, 296 Reconstructions after Whipple’s procedure 24f Recurrence after incisional hernia repair 243 and cirrhotic decompensation 68 Recurrent testicular cancer 250 Refluo technique 351 Regional lymph nodes 99, 111 Relations of thyroid 189f gland 189 Remove in lumbar sympathectomy 147 Renal angiography 359 cell carcinoma 77, 81, 82 lump 77, 79, 81, 92 transplant causes 86 vesical calculus 77 Repair nerve 315 Residual hydronephrosis 87 vericosities 154 Respiratory system 78, 101, 133 examination 125 Rest pain 145 Resuscitation in children 330 Retromolar trigone 140 Retroperitoneal cystic lump 27 lump 108 lymph node dissection 7, 29, 248 lymphadenopathy 81 mass 54 met 247 sarcoma/teratoma soft tissue tumor 92 tumor 6, 29, 32, 109 Reynold’s pentad 19 Richter’s hernia 226 Right hemicolectomy 96, 383 hypochondrial mass hypochondrium iliac fossa mass 6, 37 kidney lump lower limb 151 lumbar lymphatic duct 16 sided colonic carcinoma 98 Congenital Hernia Index Rising test 8, 8f Rive’s Stoppa’s technique 223 prosthetic repair of inguinal hernia 222 Rocker bottom 303 Rodent ulcer 269 Role of adjuvant chemotherapy 103 beta-blockers in PHT 117 color Doppler 146 hormonal therapy 352 laparoscopic surgery 99 laparoscopy in carcinoma stomach 104 MRI in oral carcinoma 133 nephron 85 orchiopexy to reduce malignancy 352 preoperative percutaneous biliary drainage 23 radiotherapy in Marjolin’s ulcer 326 renal angiography in renal tumor 79 retrograde pyelography 88 surgery in a diabetic foot 300 Buerger’s disease 146 thyroglobulin in Ca-thyroid 188 Rolled out edge 307 Rose thorn 15 Rosenbach’s sign 184 Rotation advancement flap operation 339 Rounding of calyx 88 Rules of nines 327f Ruptured Baker’s cyst 160 S S shaped incision for parotidectomy 204f Salvage regimens 250 Saphena varix 155 Scalene triangle 294f Scanlon’s procedure 170 Scardino-prince vertical flap 90 Schwartz test 152, 159 Sclerotherapy and banding 122 Second look operation 95 Secondary hydrocele 256 surgery for cleft lip and cleft palate 345 Seddon’s classification 322 Selective neck dissection 142 Sensation test 299 Sensory neuropathy 299 supply of median nerve 319 ulnar nerve 318f, 319 Sentinel lymph node biopsy 264, 284 node 177f biopsy 284 mapping 143 Sequestration dermoid 271 formation 271 Sertoli cell carcinoma 247 Serum albumin 20 amylase 55 bilirubin 19 Sex cord stromal 130 Sharma and Jhawer technique 253 Short saphenous vein 157, 159 Shouldice repair of hernia 222 Shutter mechanism of internal oblique 225 Sick cell syndrome 330 Side-to-side gastrojejunostomy 370 ileocolostomy 383 Sigmoid colon 29 Signs of healing 307 triangulation 363 Silber procedure 351 Silk glove sign 362, 363 Simple cyst of kidney 87 mastectomy 169 nontoxic goiter 190 Sites of basal cell carcinoma 270f carotid body tumor 215, 215f direct and indirect femoral hernia 218f distribution of colonic cancer 98f porta systemic anastomoses 119f radial nerve injury 315 thyroglossal cyst 212 Sjögren’s syndrome 296 Skew flap 311 Skin adnexal tumor 278 stapler: staple formation 376f Sliding femoral hernia 233 Slit valve mechanism 225 Small bowel 97 Soft tissue sarcoma 108, 110, 112 Solid ankle cushion heel 312 Solitary cyst 361 neurofibroma 276 nodule thyroid 180, 181 simple cyst 208 Souba bifida aperta 367 Space of bogros 227 retzius 227 Spermatocele 251 Spina bifida cystic 367 occulta 367 Spinal accessory nerve 142 403 Gateway to Success Surgery in Surgery Spiral CT angiography 116 Splenectomy in portal hypertension 116 Splenic mass 81 Split skin graft 325 Spreading ulcer 307 Spurious diarrhea 96 and tenesmus 33 Squamous cell carcinoma 262, 278, 279, 326 arises 280 in situ 264 Stage of epigastric hernia 239 local cyanosis 297 local syncope/pallor 297 red engorgement 297 tuberculous lymphadenitis 197 Stage testicular malignancy 245 Stages of tubercular lymphadenopathy 197f Staging laparotomy 35 of cervical nodal metastases 143 of colorectal cancer 34 of testicular tumor 245 Standardizing neck dissection terminology 142 Stauffer syndrome 79 Stellate sign 38 Stellwag’s sign 184 Steps of staging laparotomy 128 Sternocleidomastoid muscle 142 Stewart incision in breast cancer 171f Stierlin’s sign 39 Stomach mass Stool for occult blood 12 Stoppa’s procedure 222 for hernia repair 222 Straight X-ray abdomen 28 Strangulated femoral hernia 232 hernia 220 Structure in the midline of neck 212f Structures of kidney 80 nerve 322 popliteal fossa serially 333 Structure of tests 260f Sturge Weber syndrome 275 Subacute and chronic upper limb ischemia 290 Subclavian steal 292 Submucous cleft palate 341 Subtotal thyroidectomy 183 Sunderlands’ classification 323 Superficial parotidectomy 203 venous system 157 Superior mesenteric artery 112 Supraclavicular scalenectomy 295 Supraomohyoid neck dissection 142 404 Paediatrics Cases Suprapatellar bursa 333 Suprarenal tumor Surgery for basal cell carcinoma 270 carcinoma kidney 80 oral cancers in different subsets 138 Surgery in a nodular goiter 186 PUJ obstruction 88 Surgery operable cases 61 Surgical anatomy of femora hernia 234f indirect hernia 217f neck 210 complications of hydrocele 253 obstructive jaundice 10, 12 Suspicion of gallbladder cancer 75 Swelling 271 in neck 210 in popliteal fossa 332 Symphysis pubis Synchronous lesions 33, 133 Syringomyelocele 368 Systemic examination reveals 101 examinations 92 inflammatory response syndrome 328 lupus erythematosus 196 T Tackle locoregional recurrent melanoma 284 Tanner’s slide 222 operation 222 Tapping in hydrocele 253 Teale’s hernia 235 Tear cancer 269 Techniques of mesh repair 223 Tendon of flexor hallucis longus 306 peroneus longus 306 tibialis posterior 306 Tenesmus 96 Tensor of flexor digitorum longus 306 Teratomatous cyst 28 Test position and vibration sense 314 Testicular descent 353 tumor 108, 244, 247 classification 247 Testis in scrotum during orchiopexy 351 Thenar and hypothenar muscles 320 Therapeutic embolization 80 Thoracic outlet syndrome 294, 296 Thromboangiitis obliterans 149 Thyriod 190 acropathy 184 cyst 212 hormone synthesis 190 malignancy 182 paradox 182 steal 188 swelling 182, 192 Thyrotoxicosis factitia 185 Tillard’s triad Tissue hypoxia 329 plasminogen activator 291 TNM classification 84 of colonic cancer 98 staging in carcinoma thyroid 188 of carcinoma stomach 104 of oral cancer 133 Tongue 138 Tooth bearing area 339 Torsion ovarian cyst 128 testis 355f Tortion of testis 354 Total gastrectomy with Roux-en-Y anastomosis 381 parenteral nutrition 331 Tourniquet test 152 Trangular space 317f Transaxillary excision of first rib 295 Transcatheter arterial embolization 69 Transitional cell carcinoma 83 Transminases 20 Transmitted disease 193 Transtubercular line Transverse colon mass 5, 54 Travelers thrombosis 160 Treadmill test 146 Treat diabetic foot 299 venous ulcer 155 Treatment for retroperitoneal sarcoma 110 modality of testicular tumor 246 of delayed recovery of radial nerve 317 of Hodgkin’s disease 195 of keloid 276 of metastatic RCC 81 Trendelenburg operation 155 test 152, 153 Triad of Wilms’ tumor 358 Triangle of doom 227, 259 Triangles of neck 141f, 210, 211f Triangular spaces 316 Tripartite cleft palate 344 Trivex method 154 Troisier’s sign 104, 106 Case 47 Trophic ulcer 304 Tropical splenomegaly 115 Trousseau’s sign 61, 106, 189 Tru cut biopsy 109, 281 Tubercular lymphadenopathy 193 Tuberculosis 10 Tuberculous lymphadenitis 196 Tumor 271 grades 111 Turcot’s syndrome 98 Turnbull’s no touch technique 95 Types of amputation 311 basal cell carcinoma 269 biopsy 281 brachial plexus injury 321 chronic ulcer 309 cancer 98 colonic carcinoma 99f edges in various ulcers 306 gangrene 310 hernias 219, 226 hydrocephalus 356 hydronephrosis 87 hypospadias 346 jaundice 12 laparoscopic inguinal hernia repair 223 melanoma 283 naevus 286 neoplastic polyps 98 nerve repair 315 porta systemic shunts 117 surgical staplers 375 swelling 202 trophic ulcer 305 undescended testis 353 varices 155 varicocele 260 Wilms’ tumor 359 U Ulcer classification 303 Ulcerative colitis 98 Ulnar nerve injury 318 paradox 319 Ultrasound abdomen 28 Ultraviolet radiation 265 Congenital Hernia Index Umbilical region Unascended left kidney 32 Unascending kidney Unconjugated hyperbilirubinemia 24 Undermined edges 306 Undescended left testis 29 testes 32 testicular mass testis 350, 353 Unilateral and bilateral recurrent laryngeal nerve 187 Unilateral cases 360 hydronephrosis 87 Unresectable tumor 73 Upper GI endoscopy 12, 28, 116, 117 and biopsy 101 tract 108 limb 325 ischemia 289 Ureterocalycestomy 90 Urethral groove 349 plate 349 Urinary bilirubin and urobilinogen 20 disturbance or GI symptoms 114 Urine color 17 Urogenital cyst 28 Uses of absorbable suture 391 USG abdomen 12, 61, 93, 101, 112 with color Doppler 115 Usual sites for cystic hygroma 209 Uterine mass V Vaginal hydrocele 254 Variceal bleeding 121 ligation 123 Varices at splenic hilum 115 Varicocele 257 Varicos veins 151, 153, 156 vein surgery 156 Various tumor markers 127 Vascular and neurogenic claudication 145 endothelial growth factor 146 examination to exclude vasculopathy 302 Vasculopathy 301 Venography 153 Venous claudication 155 closure method 156 disease 150 drainage of testis 259 relationship in parotid gland 205 ulcer 154, 155 Vericose vein surgery 154 veins ablation 154 Verrucous carcinoma 280 Vertical line Viral markers 115 Virtual colonoscopy 34, 93 von Graefe’s sign 184 von Hippel-Lindau disease 82 von Langen back 340 von Reckling-Hausen’s disease 276 W Wegener classification 299, 303 Waldeyer’s ring 35 Wallace’s rule of 327 Wardill-Kilner-Veau four flap technique 340 Warren’s DSRS selective 124 shunt 124 Warthin’s tumor 202, 206 Wedge biopsy 133 Weir Mitchell’s skin 323 Whipple’s operation 16 procedure 60 Whitaker test 88 White swelling of knee 335 Wilms’ tumor 358, 360 metastases 359 Wolf-Chaikoff effect 185 World population control 393 Wound healing 19 Z Zieman’s test 221 technique 218, 231 405 ... Examination: First examine in the standing position and then in the supine position On Inspection: There is a swelling in the right inguinoscrotal region extending from right inguinal region to. .. appendicectomy causing ilioinguinal nerve damage mated to inguinal hernia • Smoking, collagen vascular disorders are other causes Anatomy of Inguinal Canal INGUINAL CANAL [Remember: In infant superficial... and indirect hernial sacs are present Anatomy of inguinal region According to extent of Hernia: i Bubonocele is an incomplete inguinal hernia in which hernial sac is confined within the inguinal