SRB Bedside Clinic

SRB’s
Bedside Clinics in
SURGERY
SRB’s
Bedside Clinics in
SURGERY
Sriram Bhat M MS (General Surgery)
Associate Professor in Surgery
Kasturba Medical College, Mangalore
Karnataka, India
e-mail: meera_sriram2003@yahoo.com
Foreword
Thangam Verghese Joshua
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SRB’s Bedside Clinics in Surgery

© 2009, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form
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author and the publisher.
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case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition : 2009

ISBN 978-81-8448-581-3
Typeset at JPBMP typesetting unit
Printed at
This book is dedicated to
all my students
Foreword
Sriram Bhat M, author of SRB’s Bedside Clinics in Surgery is known for his innovative works,
writing books related to his profession, collecting all clinical and operative photographs.
He has already authored SRB’s Manual of Surgery; SRB’s Surgery for Nursing Students, SRB’s
Surgery for Dental Students and Jaypee Gold Standard Mini Atlas Series: Surgical Diseases.
This new innovation of his, SRB’s Bedside Clinics in Surgery is of different type with
illustrations, clinical methods, X-rays, discussion on surgical pathology and basic surgical
procedures. It is more of clinical and practical book by which undergraduate and surgical
postgraduate students will be benefited. It will also be useful in the process of learning
to any practitioner who still has the zeal to learn.
I am proud of the fact that a student of mine has reached such heights of excellence
and I feel privileged to be given the honor of penning the foreword for this special book.
I wish him success in all his endeavors which I am sure will be an inspiration for every
young aspiring surgeon.
Thangam Verghese Joshua MS MCh

Head, Department of Surgery
Kasturba Medical College
Mangalore 575 001
Karnataka, India
Preface
It is observed that students, especially undergraduates, often find difficult to prepare
themselves for clinical examination after theory papers. They need to know basic clinical
methods with relevant discussion of the specific cases; X-ray discussion; surgical specimens;
instruments; basic operative procedures and principles. Keeping this in mind, this book SRB’s
Bedside Clinics in Surgery has been brought out to go through quickly prior to clinical
examinations. This is also useful to surgical residents and postgraduates, especially for
instruments and surgical pathology, which are of great importance to them.
Many a times, students need to refer to SRB’s Manual of Surgery, 3rd edition (whenever
required) and other specific books for detailed theory aspects of many topics. I hope this
book will earn its value in its own way in student circle.
I thank everybody including publishers who are backbone of this title. Any criticisms
are well accepted.
Sriram Bhat M
Acknowledgements
I am happy to bring out this new book of clinical and practical importance SRB’s Bedside Clinics
in Surgery, first edition. This is due to constant help and support of many.
I thank our Chancellor Dr Ramdas M Pai, Pro-Chancellor Dr HS Ballal, Vice-Chancellor of MAHE
Prof Rajashekaran Warrier, our beloved Dean Prof CV Raghuveer, our Vice-Deans Prof Anand Kini
and Prof Venkatraya Prabhu for their academic support.
I thank Prof Thangam Varghese, Head of Department of Surgery, KMC, Mangalore, for her
constant encouragement in academic work and progress.
I always remember my senior teachers, Prof CR Ballal and Prof Suresh Kamath for their constant
help.
Surgical unit heads in our college Prof K Prakash Rao, Dr BM Nayak, Dr Jayaram Shenoy,
Dr Jayaprakash Rao, Dr Harish Rao, Dr Ramachandra Pai, Dr Alfred Augustine and Dr Shivananda
Prabhu are always supportive for my work and are worth to be remembered always.
I am grateful to all my teachers and colleagues in Surgery Department who directly or indirectly
helped me to bring out this edition.
I appreciate District Medical Officer and Resident Medical Officer of Government Wenlock
Hospital, Mangalore for their kind help.
I thank very much to the faculty, Department of Surgery and Paediatric Surgery, JJMMC, Davangere
for providing the needed photographs.
I sincerely thank Prof Navin Chandra Shetty, Head of Radiology Department, KMC, Mangalore
and also other faculty of the department for their help in providing and guiding me in X-rays, CT
scans and imaging methods.
I acknowledge Prof Kishore Chandra Prasad, Head of Department of ENT for his help, guidance
and encouragement in bringing out this book.
I thank Dr Shivaprasad Rai, Dr Ahfaque Mohammed, Dr Kalpana Sridhar, Dr Yogish Kumar,
Dr Ramesh, Dr K Akbar, Dr Keshava Prasad, Dr Kishore Reddy, Dr Achaleshwar Dayal, Dr Raghav
Pandey, Dr Rupen, Dr Ashwini Mallya, Dr Praveen, Dr Ashok Hegde, Dr Rajesh Ballal, Dr Devidas
Shetty, Dr Venkatesh Sanjeeva, Dr Sunil, Dr Shanbogh, Dr Harish Nayak, Dr Subraya Kamath,
Dr Venkatesh Shanbogh, for their help in various aspects.
I sincerely appreciate Dr Raghavendra Bhat and Dr Ravichandra, consultants in Radiology
Department, Yenepoya Medical College, Mangalore for their contribution and affectionate help.
I will never forget my close associates Dr Ganapathy MD, Mangala Hospital, Kadri, Mangalore
and Dr Ashok Pandit, MCh (Urologist) for their affectionate help and encouragement in all my
endeavours. They always stood with me in my difficulties.
I thank my friend Dr Jagadish MDS for his contributions to X-ray.
My wife Dr Meera Karanth helped me day and night in editing this new book and without her
help this could not have been possible. My beloved daughter Ananya helped me in drawing new
diagrams artistically. I enjoy her love and affection towards me.
I remember my students Dr Ravi CR, Dr Ashwini Polnaya; Dr Ishwara Keerthi and Dr Sudesh
for their special contributions.
I thank all my students especially postgraduates of Surgery Department who were helping
regularly in bringing out this book.
Words are not sufficient to remember all my patients who are the main material for the book.
I pray for their good health always.
I appreciate Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (Director-
Publishing) and all staff of the Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, for doing
appreciable work in their respective field of printing and publishing.
Sriram Bhat M
Contents
1. Surgical Long Cases ................................................................................................................ 1
• Introduction and Writing Case Sheets of Surgical Cases (Basic Pattern of
Case Sheet Writing) ............................................................................................................. 2
• Hernia ..................................................................................................................................... 7
• Vascular Diseases ............................................................................................................... 40
• Varicose Veins ..................................................................................................................... 73
• Breast .................................................................................................................................... 91
• Thyroid ............................................................................................................................... 132
• Differential Diagnosis of Mass Abdomen .................................................................. 181
2. Surgical Short Cases ........................................................................................................... 209
3. Surgical Pathology .............................................................................................................. 289
4. X-rays ....................................................................................................................................... 357
5. Newer Imaging Modalities ............................................................................................... 429
6. Instruments ............................................................................................................................ 447
7. Surgical Principles and Procedures ................................................................................ 501
• Preoperative Preparations .............................................................................................. 502
• Surgical Procedures .......................................................................................................... 511
8. Miscellaneous ....................................................................................................................... 545
• Definitions of Common Terminologies in Surgery .................................................. 546
• Most Commons in Surgery ............................................................................................ 561
Index .............................................................................................................................................. 577

2 SRB's Bedside Clinics in Surgery
INTRODUCTION AND WRITING CASE SHEETS OF SURGICAL CASES

(BASIC PATTERN OF CASE SHEET WRITING)
A case sheet comprises a detailed history of a particular Then come to the next complaint, if it is
patient admitted to the hospital, has to be written swelling, mode of onset, whether there is recent
carefully and neatly without any spelling mistakes. increase in size, pain, its relation to activities,
Two important aspects of a case sheet are— etc. Then the next complaint, if it is fever, mention
• Detailed history. in detail the type, time of onset, whether
• Physical examination. associated with chills, sweating.
Once the chief complaints are elaborated, only
relevant questions in respect to symptoms
HISTORY pertaining to other systems should be asked and
Particulars of the patient— mentioned.
1. Name. • GIT: history of haematemesis, melaena, heart
2. Age. burn, flatulence, weight loss, appetite, details
3. Sex. of bowel habits, (frequency, nature, bleeding),
4. Religion. jaundice.
5. Occupation. • Respiratory system: H/O chest pain, cough,
6. Address. haemoptysis, breathlessness.
7. Date of admission. • Cardiovascular system: H/O chest pain,
8. Hospital number. palpitation, breathlessness on exertion
• Urinary system: Details of urinary habits
Chief Complaint (frequency, dysuria, urgency, hesitancy),
Should be mentioned in brief, and if multiple, haematuria, burning micturition
in chronological order of appearance • Neurological: H/O of head ache, vomiting,
e.g. difficult speech, walk, weakness in limbs, etc.
• Pain in the right knee joint—15 days.
• Swelling in the right knee joint—7 days. Past History
• Fever since 2 days.
• Do not simply mention ‘nothing significant’.
All minor complaints should not be listed; only
• History of any other major illness, pulmonary
2-3 appropriate complaints must be noted.
Koch’s been treated, epilepsy (treated or on
History of Present Illness treatment), hypertension, jaundice, diabetes,
psychiatric illness, autoimmune disorder.
Write in detail about the complaints, along with
• History of surgery in the past, nature of illness,
mentioning other minor ailments also.
type of surgery, emergency/elective, type of
Begin with an opening statement such as the
anaesthesia used, mode of recovery, any
‘patient was apparently normal’ (not perfectly
complication, any blood transfusion given.
or absolutely normal) before this episode of
illness, e.g.
Personal History
If the chief complaint is pain, then write in
detail about the site, nature, duration, mode of Following aspects must be looked into—
onset, radiation, shifting of pain, aggravating • Dietary habits.
and relieving factors, its relation to food/sleep/ • Addiction (alcohol; drugs/cigarettes/
physical activities, whether associated with tobacco, betel nut chewing).
vomiting. • Sleep (disturbed or normal).
Surgical Long Cases 3
• Bowel habits, micturition (if not mentioned Systemic Examination
in the h/o presenting complaints). All other systems which has not been included
• Socioeconomic status, marital status.
in local examination has to be examined and
• Menstrual history in females (nature of the
written.
cycle, duration of flow, obstetric h/o, LMP,
postmenopausal bleeding in old women).
Abdomen
Family History Inspection:
Ask for history of any illness in the parents, • Shape of abdomen (normal/obese scaphoid/
siblings, spouse and children. distended).
• Position of umbilicus (central/deviated/
Treatment History pushed up or down).
• History of treatment received for the present • Movements of abdomen.
illness. • Skin over the abdomen ( scar/pigmentation/
• History of receiving treatment for any other venous engorgement).
illness. • Hernial sites (look for expansile impulse on
cough).
History of Allergy to Drugs and Food • External genitalia.
Palpation:
PHYSICAL EXAMINATION Done for—
Done under three main categories— • Swelling, if palpated, its relation to abdominal
quadrants has to be mentioned, mobility,
General Examination tenderness, consistency is noted.
Level of consciousness, degree of cooperation, • Tenderness both deep and superficial is
build, facies, nutrition decubitus, anaemia, elicited; any rebound tenderness with
jaundice, cyanosis, clubbing, oedema neck guarding and rigidity is noted.
veins, lymph nodes. • Liver, spleen, kidneys are palpated for
Pulse— enlargement, their consistency, tenderness,
Mention the rate, regularity, volume of blood flow, nodularity if any is noted.
vessel wall, and palpate all the peripheral pulses
Percussion:
(radial, brachial, temporal, dorsalis pedis).
• General note all over the abdomen.
Blood pressure— • Shifting dullness.
Respiratory rate— • Free fluid thrill.
• Upper border of liver dullness.
Temperature—
Pigmentation— Auscultation:
• Bowel sounds, nature intensity, abnormality
Local Examination is noted.
Site of disease has to be thoroughly examined • Any added sounds-bruit.
in detail under 4 heading ( inspection, palpation,
percussion, auscultation), e.g., Perrectal Examination
Examination of inguinal region in hernia.
Examination of breast in breast disease. Pervaginal Examination (in women)
Respiratory System b. Urine routine.

c. Stool for routine (ova/cyst/parasite).
Inspection: Shape, movement of chest, respiratory d. Chest X-ray.
rate is noted. e. ECG.
Palpation: Position of trachea, tenderness over Special investigation—based on clinical findings
ribs and costochondral junction, vocal fremitus. and provisional diagnosis.
Percussion
DIFFERENTIAL DIAGNOSIS
Auscultation: Breath sounds, any crepitus/
rhonchi, vocal resonance. Can be mentioned in order of significance.
Cardiovascular System IMPORTANT POINTS OF

Inspection: Shape of precordium, apex beat, any GENERAL PHYSICAL
pulsation. EXAMINATION
Palpation: Apex beat, parastenal heave, thrill. Anaemia
Auscultation: 1st and 2nd heart sound in all the It is qualitative or quantitative reduction in RBC
areas. or HB% in relation to standard age or sex.
Murmur It is assessed by presence of pallor at the
lower palpebral conjunctiva, tip and dorsum of
Examination of Nervous System tongue, nail beds skin over palms and soles.
• Higher functions: Consciousness, speech,
alertness, cooperation noted.
• Gait examined.
• Cranial nerves examined.
• Motor system: Tone, power of upper and lower
limb muscles must be mentioned.
• Sensory system: Pain, touch, temperature
over arms, chest, back and lower limbs;
vibrations and reflexes are checked.
• Cerebellar sign ± noted.
Examination of Cranium and Spine
PROVISIONAL DIAGNOSIS
Fig. 1.1: Anaemia
A complete diagnosis has to be given.
e.g—Carcinoma right breast with mobile axillary
Jaundice
lymph nodes—T2NIM0.
Yellowish discolouration of sclera, skin and
mucous membrane due to excess bilirubin in
INVESTIGATION SUGGESTED blood.
Base line investigations— Normal serum bilirubin—0.2mg% to 0.8mg%
a. HB%, TC, DC, ESR, blood for sugar, blood Jaundice is looked for in day light over sclera
urea, creatinine. by asking the patient to look down and retracting
the upper eye lid, over soft palate and under • Pitting on pressure becomes evident only
surface of tongue, skin over palms and soles. when the circumference of limb increases by
10%.
Cyanosis • In non-ambulant patient, it is checked by
Bluish discolouration of skin and mucus pressing over the sacrum.
membrane due to increased amount of reduced
Hb in circulation (> 5 gm%).
Types
• Peripheral: Periphery (tip of nose, tips of finger
and toes, palms, soles, ear lobule) is blue due
to sluggish circulation or vasoconstriction
leading to more oxygen desaturation at
capillary bed.
• Central: Excessive oxygen desaturation of
central arterial blood (in severe VSD, tetrology
of Fallot), looked for in the undersurface of
tongue, and inner aspect of lips. Here
periphery is also blue.
Clubbing
It is increase in anteroposterior and transverse
curvature of nail leading to bulbous enlargement
of the terminal phalanges. The angle between
nail and nail bed is obliterated.
Degrees of Clubbing
Fig. 1.2: Oedema should be looked
1st: Increased fluctuation of nail bed (looked for for in both feet
at the base of the nail with two index fingers).
Lymph Nodes
2nd: Fluctuation associated with increased
anteroposterior and transverse curvatures. Cervical Lymph Nodes
3rd: Above changes associated with increased Level 1: Submental group in submental triangle;
pulp tissue in terminal phalanges producing submandibular group in submandibular triangle—
parrot beak or drum stick appearance. Palpated with pulp of fingers after flexing
the neck to the same side.
4th: In addition to above changes there is
Level 2: Upper jugular group, situated along the
hypertrophic osteoarthropathy (subperiosteal
thickening of wrist and ankle bones). upper third of the internal jugular from carotid
bifurcation to base of skull.
Oedema Level 3: Middle jugular group, situated along the
• Due to excessive of fluid collection in extra- middle third of internal jugular.
vascular compartment. Level 4: Lower jugular group, situated along the
• In ambulant patient, medial surface of tibia, lower third of internal jugular.
2.5 cm above the ankle is pressed for 5-10 Level 2, 3, 4 are palpated along the jugular
seconds. with the pulp of finger.
Level 5: Posterior triangle group palpated in • Radial artery is ideally and conveniently used
posterior triangle, and also includes supraclavi- to palpate for pulse against the lower end
cular group which is palpated in supraclavicular of radius above the wrist joint.
fossa by asking the patient to shrug the shoulder. Normal pulse rate: 60-100/minute; < 60/mt—
bradycardia; > 100/mt—tachycardia.
Level 6: Anterior compartment, includes peri-
laryngeal, pericricoid, peritracheal nodes from Not only rate-noting the rhythm is also
hyoid bone above to suprasternal notch below important. Rhythm is appearance of successive
and to medial border of sternomastoid laterally. pulse wave with time, regular if successive pulse
The number of nodes, consistency, mobility/ beat appears at definite interval, irregular if it
fixity to underlying structures, tenderness,has is not appearing at regular interval.
to be noted.
Respiration
Axillary Group of Nodes Normal respiration is abdominothoracic, normal
Pectoral group: Situated behind the anterior fold rate 18-20/min.
of axilla, palpated with pulp of fingers of right
hand for left side, with examiners fingers Temperature
insinuated behind the pectoralis major, and with Normal body temperature: 98-99 degree Farenheit.
patient’s arm made to rest over the examiners Pyrexia: >99° Farenheit
forearm.
Hyperpyrexia: >106° Farenheit.
Brachial group: Lies on the lateral wall of axilla Pyrexia of unknown origin (PUO): It is fever
along the cephalic vein, left hand is used for of >101° Farenheit persisting for more than
left side, with palm directed laterally towards 2 weeks with cause remaining obscure in spite
the upper end of humerus. of intensive investigation.
Subscapular group: Lies along the posterior fold
of axilla, palpated standing behind the patient, Blood Pressure
keeping the arm in semi-flexed position. Recorded is done in lying down supine position
Central group: This group is palpated in the apex and sitting position, with sphygmomanometer
of the axilla, left side with examiners right hand. cuff tied firmly around the left arm, one inch
above the elbow joint. The cuff is inflated till
Apical group: This group is palpated higher than the radial pulse disappears. The diaphragm of
the above nodes. stethoscope is placed over the brachial artery.
The pressure reading at which there is a clear
Inguinal Group tapping sound on deflating the cuff is the systolic
Both horizontal and vertical group must be blood pressure and the reading which corres-
examined. ponds to complete disappearance of sound is
the diastolic pressure.
Pulse
• It is lateral expansion of arterial wall by a Pigmentations
column of blood forced by the contraction Looked in face, oral cavity, tongue, palmar
of heart into the peripheral circulation. creases and general body skin.
HERNIA
Hernia is an important clinical topic for • Any changes in the size and extent of the
undergraduate as well as postgraduate students swelling on standing/walking/straining/
in surgery. It is a long case for undergraduate lying down.
student and a short case for postgraduate • Whether swelling is reducible on lying
students in surgery. It is the one of the commonest down/partially reducible or irreducible on
surgical entity that surgeons come across and lying down or needs any manoeuvre to
so detail knowledge of the subject is mandatory reduce it. History of gurgling sound in the
to both undergraduates and postgraduates. scrotum signifies enterocele.
Writing a case sheet for hernia is important • If swelling is irreducible, then whether it
as a long case. is painful or any abdominal distension
vomiting should be asked.
METHOD OF WRITING A CASE Pain

• Site of pain—whether it is in the groin or
SHEET FOR INGUINAL HERNIA in the scrotum.
Patient’s name. • Duration of pain.
Age. • Severity of the pain, type of pain—dull aching
Sex. or severe pricking type.
Occupation. • Aggravating or relieving factors. Aggravated
by straining/walking/weight lifting; relieved
Elderly people are more prone for hernia. Men by lying down.
with strain full occupation like manual labourer,
sportsmen, weight lifters, etc. are more prone for History Relevant to Precipitating Factors
hernia. • Chronic cough, tuberculosis, bronchial
asthma or other respiratory diseases.
Chief Complaints • Constipation, altered bowel habits, tenesmus,
• Swelling in the groin, right or left or both bloody stool—in relation to anorectal stric-
sided for....durations; or swelling in right/ ture/carcinoma.
left/both inguinoscrotal region for....dura- • Dysuria/urgency/hesitancy/altered
tions. stream/night frequency/retention of urine/
• Pain over the swelling for....durations. burning urine/haematuria—in relation to
benign prostatic hyperplasia/urethral
History stricture.
History of Present Illness
Past History
Swelling • Past history of hernia surgery—same side/
• Duration of the swelling. opposite side. Type of surgery whether mesh
• Mode of onset of the swelling—spontaneous used or repair done.
or on straining. • History of appendicectomy earlier and if so
• Site of the first appearance of the swelling detail about the surgery (can cause right direct
in the groin or in the scrotum. hernia).
• Progress and extent of the swelling, whether • Past history suggestive of irreducibility/
it limits only to the groin or extends to the obstruction and treatment for that conser-
scrotum. vative/surgical.
Personal History direct inguinal hernias are in inguinal region.

• Smoking- duration, number per day, whether Complete indirect inguinal hernia (rarely
beedi or cigarette. Pan chewing/alcohol complete direct inguinal hernia) is inguino-
intake. scrotal extending down into the bottom of
• Appetite and altered weight. the scrotum. Swelling extends from the
proximal part of the inguinal canal towards
Treatment History the scrotum below.
Any previous treatment given. • Both transverse and vertical dimensions of
the size should be mentioned.
General examination • Shape of the swelling is pyriform in indirect
Examine for general built and nutritional status, inguinal hernia and globular in direct
pallor, clubbing, cyanosis, jaundice, lympha- inguinal hernia.
denopathy, oedema feet, pulse and blood • Expansile impulse on coughing over the
pressure. swelling is diagnostic. It is better seen than
felt.
Local Examination • Surface smooth/uneven.
Inguinoscrotal region should be examined in • Margin—well-defined/ill-defined.
standing position as swelling commonly reduces • Visible peristalsis over the swelling should
and disappears in lying down position. be noted if present. It means it could be
enterocele.
• Scar/dilated veins/discolouration/redness
over the swelling.
• On inspection, whether testis is seen sepa-
rately from the swelling or covered by the
swelling all over.
Fig. 1.3: All hernias should be

inspected initially on standing.
Inspection
Inspection in standing position— A B
• Mention the side of the swelling.
Figs 1.4A and B: Expansile impulse on coughing is better
• Extent of the swelling is important. Incomp- seen than felt. It should be inspected with patient standing
lete indirect inguinal hernia and usually and examiner sitting beside the patient.
reduction of contents of the scrotum by gentle
manipulation by flexion and rotation of hip join.
• Zieman’s test is done to find out over which
finger cough impulse is felt and so which
type of hernia it could be whether femoral/
direct inguinal or indirect inguinal.
• Deep ring occlusion test: When deep ring is
occluded, if impulse on coughing is absent
then it is indirect inguinal hernia; if impulse
on coughing is still present then it is direct
inguinal hernia.
• Finger invagination test: Size of the superficial
ring is noted and site of the impulse felt is
observed whether it is in the tip of the finger
or on the pulp.
Fig. 1.5: Inguinal hernia is reduced in lying down position • Palpation of testis, epididymis and spermatic
with elevation of scrotum and flexion and rotation of the cord should be done without fail. Relation
hip—taxis. of swelling to testis also should be noted.
• Bulbar urethra is palpated by lifting the
Palpation scrotum and feeling in the midline. (To look
• Temperature and tenderness over the swelling for thickening and button like depression-
• Whether get above the swelling is possible or a feature of stricture urethra).
not- purely scrotal swelling one can get above • Opposite inguinal region, opposite testis,
the swelling but in inguinoscrotal swelling epididymis and spermatic cord should be
one can not get above the swelling. examined. Presence or absence of impulse
• Position and extent of the swelling. on coughing on opposite side should be
• Size in vertical and transverse directions. mentioned.
• Margin well defined or ill-defined.
• Surface smooth/lobular/tense.
• Consistency is soft and elastic in enterocele;
doughy in omentocele.
• Location of the swelling—swelling is above
and medial to pubic tubercle in inguinal hernia
and below and lateral to pubic tubercle in femoral
hernia.
• Reducibility of the swelling is checked by
different methods.
Whether it is reducible spontaneously while
lying down and gets reduced completely or
partially.
In enterocele, it is difficult to reduce the first
part but last part gets reduced easily. In Fig. 1.6: Bulbar urethra should be palpated by raising
omentocele it is difficult to reduce the last the scrotum in midline posteriorly. Any stricture urethra
is felt as thickening/button like depression. Gonococcal
part but first part gets reduced easily.
urethritis and trauma are the commonest causes of stricture
• Whether swelling needs any manipulation urethra. Bulbar urethra is the commonest site of stricture
to get reduced like taxis. Taxis is gradual urethra.
Percussion
Without reducing contents of the swelling,
percussion is done over the surface. If it is
resonant, it is enterocele. If it is dull on percussion,
then it is omentocele.
Auscultation
Bowel sounds may be heard over the swelling
if it is enterocele.
Fig. 1.8: Clinically per-rectal examination is a must in
Perabdomen examination hernia to look for prostate enlargement, and rectal stricture
• Abdomen muscle tone should be checked by which are precipitating factors.
head raising test, leg raising test and Valsalva
manoeuvre. It should be inspected for
Malgaigne bulging and should be palpated
to check whether the tone is adequate (firm)
or inadequate (supple).
• Any scar over the abdomen (appendicectomy
scar may cause right-sided direct inguinal
hernia); ascites or mass per abdomen should
be mentioned.
Fig. 1.9: Respiratory system should be examined to find

out the precipitating causes for hernia like bronchitis,
tuberculosis or asthma.
A B
Other Systems
Cardiovascular system, nervous system including
Figs 1.7A and B: Head raising and valsalva manoeuvre
tests are needed to check the tone of abdominal muscle
spine and cranium for any neurological problems
in hernia. are examined for management of hernia.
Digital Examination of the Rectum Diagnosis

Digital examination of the rectum (P/R) must Diagnosis should be written complete with
be done in all hernia cases to look for prostate mentioning of side, type,whether complicated or
enlargement in elderly and rectal/anorectal not.
strictures. For example, left sided indirect incomplete
uncomplicated inguinal hernia-enterocele.
Examination of Respiratory System
Examination of respiratory system for altered Investigations
breath sounds (rhonchi, bronchial breathing), • All case sheets for long case should mention
effusion, etc. to find out any precipitating the investigations required for that particular
causes. case.
• Relevant investigations required for inguinal Expansile impulse on coughing is also felt by
hernia are chest X-ray, haematocrit, blood placing the thumb in front, middle and index
sugar, serum creatinine, ultrasound abdomen fingers behind the root of the scrotum and asking
depending on the age/suspected cause of the the patient to cough.
hernia.
Note: Presentation of the case should be in order When in a hernia impulse on coughing
as mentioned above. One cannot alter the order will not be there?
of presentation like presenting percussion first Strangulated hernia will not show impulse on
and later palpation or likewise in a haphazard coughing.
manner.
Students should strictly follow the proper order What is the meaning of the ‘get above the
of presentation in clinical methods. swelling’?
Root of the scrotum is palpated between the
Discussion thumb in front, index and middle fingers behind.
In examination, discussion is usually in question In purely scrotal swelling like vaginal hydrocele,
and answers method. A provisional discussion fingers and thumb meet each other well without
often done after a presentation is given here. any additional structure other than cord in
between (one can get above the swelling). In case
Why clinically it is inguinal hernia? of inguinoscrotal swelling thumb and fingers
Patient presented with swelling in the left groin, do not meet each other properly because of the
gradually increased in size which often descends descent of hernial contents down (one cannot get
into the scrotum and gets reduced on lying down. above the swelling). It occurs in funicular and
It increases on straining, coughing or walking. complete type of inguinal hernia not in
Expansile impulse on coughing is present and bubonocele.
reduces on lying down or by taxis.
Why it is indirect inguinal hernia?
It is pyriform in shape. It descends obliquely in the
groin. On occluding the internal ring in ring
occlusion test, swelling does not appear later on
coughing. On ring invagination test, impulse is felt
at the tip of the invaginating finger. Zieman’s test
confirms the impulse over the index finger.
If it is direct inguinal hernia, then what A
are the differentiating features?
Direct inguinal hernia is globular in shape. After
occluding the deep ring, swelling still appears
on coughing on the medial side of the inguinal
region. Impulse is felt on the pulp of the finger
in invagination test and over the middle finger
in Zieman’s test.
How expansile impulse on coughing is
clinically demonstrated? B
Expansile impulse on coughing is seen on Figs 1.10A and B: In inguinoscrotal swelling
inspection when patient is asked to cough. one cannot get above the swelling.
ring occlusion test/invagination test/Zieman’s

test if hernia is irreducible.
How is finger invagination test done?

Patient is asked to lie down. Contents are reduced
completely. Using the little finger, scrotal skin
is invaginated from below upwards near upper
part of the testis. Finger is reached towards the
superficial inguinal ring/external ring. Normally
external ring does not admit the tip of the little
finger. Finger is rotated inwards so that nail is
towards the cord side. Patient is asked to cough.
Fig. 1.11: Ring occlusion test is done to find out whether If the impulse is felt on the tip of the finger, then
hernia is direct or indirect. If after occluding the ring swelling it is indirect inguinal hernia. If impulse is felt
appears on the medial side, it is direct hernia. If swelling on the pulp then it is direct inguinal hernia.
does not appear on occlusion and coughing it is indirect
In case of complete inguinal hernia or funicular
hernia.
hernia external ring is patulous which can be
very well-assessed by invagination test. Index
What is ring occlusion test? finger can also be used for the test.
It is the most important test in inguinal hernia. Invagination test should be done very gently,
Deep/internal ring is located 1.25 cm above the otherwise it will be very painful. It cannot be
mid-inguinal point. Mid-inguinal point is mid- done in children.
point between the anterior superior iliac spine
and pubic symphysis. (Note: Mid point of the
inguinal ligament is center point between anterior
superior iliac spine and pubic tubercle). Patient
is asked to lie down to reduce the hernial contents.
Thumb is placed over the mid-inguinal point.
Patient is asked to cough. If there is expansile
impulse on coughing on the medial side of the
A
thumb, in spite after deep ring occlusion, it is
then direct inguinal hernia. If there is no impulse
on coughing then patient is asked to stand with
thumb occluding the deep ring. Patient is once
again asked to cough; impulse on the medial
side of the occluded thumb is looked for to rule
out the direct inguinal hernia. If there is no
impulse even on standing, it is indirect inguinal
hernia. The occluded thumb is removed and
patient is asked to cough to show the swelling
and impulse due to indirect inguinal hernia.
What is the prerequisite to do ring-

occlusion test? B
Hernia should be reduced completely prior to Figs 1.12A and B: Ring or little finger is
do deep ring occlusion test. One cannot do deep used to do invagination test.
How is Zieman’s test done? What are the boundaries of the inguinal canal?
Reduce the hernial contents. Index ring is placed
Boundaries
over the deep ring. Middle finger is placed over
In front: External oblique aponeurosis and
the superficial ring and ring finger over the
conjoint muscle laterally.
femoral ring. Patient is asked to cough.
Behind: Inferior epigastric artery, fascia trans-
If impulse touches—
versalis and conjoint tendon medially.
Index finger it is indirect inguinal hernia
Middle finger it is direct inguinal hernia Above: Conjoint muscle (Arched fibres of internal
Ring finger it is femoral hernia. oblique).
Below: Inguinal ligament.
Fig. 1.14: Anatomy of the inguinal canal. IL—Inguinal

Ligament. SIR—Superficial Inguinal Ring. DIR—Deep
Inguinal Ring. CT—Conjoint Tendon. ASIS—Anterior
Superior Iliac Spine. IEA—Inferior Epigastric Artery.
What is inguinal defence mechanism?

B It is the natural mechanism to maintain the
Figs 1.13A and B: Zieman’s test—done on both sides. strength of the inguinal canal.
Three fingers are used to do Zieman’s test. It is by
• Obliquity of the inguinal canal.
How inguinal hernia is differentiated from • Arched conjoined tendon.
femoral hernia? • Shutter mechanism of internal oblique.
Inguinal hernia is above and medial to the pubic • Ball valve mechanism of the cremaster.
tubercle. Femoral hernia is below and lateral to • Slit valve mechanism of the intercrural
the pubic tubercle. fibres of the superficial inguinal ring.
What are the differences between indirect inguinal and direct inguinal hernias?
Indirect inguinal hernia Direct inguinal hernia
Can occur from childhood to adult. Common in elderly.

Occurs in a pre-existing sac. Always acquired.
Protrusion through the deep ring. Herniation through posterior wall of the
Herniation occurs later. inguinal canal.
Pyriform/oval in shape. Globular/round in shape.
Descends obliqulely and downwards. Descends directly forwards as a bulge.
Can become complete by descending. Descends down into the scrotum is rare.
down into the scrotum.
Neck of the sac is narrow and lateral to Neck of the sac is wide and medial to inferior
inferior epigastric artery. to epigastric artery.
Sac is anterolateral to the cord. Sac is posterior to the cord.
Ring occlusion test does not show any Test shows impulse even after occluding the deep ring.
impulse after occluding the deep ring.
Invagination test shows impulse on Impulse is felt over the pulp of the little finger.
the tip of the little finger.
Zieman’s test shows impulse Test shows impulse on the middle finger.
on the index finger.
Commonly unilateral but can be bilateral. Commonly bilateral.
Obstruction/strangulation are common. Rare but can occur.
Sac should be opened during surgery. Sac is not necessarily opened unless—
obstruction is present.
Fig. 1.15: Diagrammatic representations of direct and indirect sacs.
How clinically is enterocele and omentocele differentiated?

In enterocele In omentocele (epiploecele)
First part is difficult to reduce but First part is easier to reduce but last part is
last part is easier There will be gurgling difficult. Has a doughy feeling.
sound on reduction.
Resonant on percussion. Dull on percussion.
Peristalsis is seen. No peristalsis seen.
Bowel sounds may be heard. Bowel sounds not heard.
Fig. 1.16: Bilateral direct hernia. Note the medial location

of the hernia. Direct hernia occurs through Hesselbach’s
triangle.
Fig. 1.18: Direct sac on table during surgery.
Fig. 1.17: Large bilateral direct hernias. Note, on right

Fig. 1.19: Irreducible hernia with bowel as well as omentum
side it has descended into the scrotum to become complete.
as contents. Note the change in colour of the bowel.
Usually direct hernia will not descend into the scrotum
but long standing direct hernia can descend down and
become complete.
A B
Figs 1.20A and B: Hernial sac with small bowel (enterocele) as content.
What is Hesselbach’s triangle?

It is bounded by inferior epigastric artery
laterally, lateral border of rectus muscle medially
and inguinal ligament below. Direct hernia
protrudes out through this triangle.
Fig. 1.22: Anatomy of Hesselbach’s triangle. LUL—Lateral

Umbilical Ligament. CT—Conjoint Tendon. ASIS—Anterior
Superior Iliac Spine. IEA—Inferior Epigastric Artery.
A
hernia or femoral hernia or Maydl’s hernia. Taxis
should be done very gently.
How is tone of abdominal muscle checked

and why?
Abdominal muscle tone is checked by head rising
(without supporting the elbows) or leg rising
tests. It is initially inspected for any bulges in
the abdominal wall which signifies Malgaigne
bulgings. Later abdomen should also be palpated
for muscle tone. Firmness signifies adequate tone
whereas suppleness signifies poor muscle tone.
Poor muscle tone indicates that patient needs
B
hernioplasty using mesh. Abdominal muscle tone
is also checked by Valsalva manoeuvre.
Figs 1.21A and B: Direct hernia aries through Use five fingers of the hand to complete all tests
Hesselbach’s triangle for hernia’
• Thumb for deep ring occlusion test.
What is taxis? • Index, middle and ring fingers for Zieman's
Taxis is a method used to reduce the complete test.
inguinal hernia. Hip and knee are flexed and • Little finger for superficial ring invagination
thigh is adducted. One hand held near the fundus test.
of the sac in the bottom of the scrotum, other
hand adjacent to external ring, contents are gently Rules of hernia examination
reduced towards the proximal side. Often patient • Never forget to check expansile impulse on
himself does this technique in a better way. coughing and reducibility.
It is contraindicated in obstructed/strangulated • Never forget to examine opposite side.
• Never forget to do perrectal examination. What are the types of indirect inguinal hernia?
• Never forget to examine bulbar urethra. It can be incomplete wherein sac does not reach
• Never forget to check abdominal muscle tone. to the bottom of the scrotum. It can be complete
wherein sac descends completely up to the bottom
What are the differential diagnoses for of the scrotum. Incomplete type can be bubonocele
groin swelling? where hernia limits to inguinal region without
• Indirect/direct inguinal hernia. passing through the superficial inguinal ring
• Hydrocele—vaginal/encysted. or can be funicular where sac reaches up to the
• Femoral hernia. level of the upper part of the testis into the scrotum
• Lipoma of the cord. across the external ring.
• Inguinal lymphadenopathy.
• Groin abscess.
A B
Fig. 1.23: Parts of hernia—neck, body and fundus. C

Figs 1.24A to C: Types of indirect inguinal hernia.
What is groin hernia? (A) Bubonocele (B) funicular (C) Complete
It is hernia occurring through a myopectineal
orifice. It can be indirect inguinal hernia/direct
inguinal hernia or femoral hernia.
What is Fruchaud’s myopectineal orifice?

It is an osseomyoaponeurotic tunnel.
It is bounded—
– medially by lateral border of rectus sheath.
– above by the arched fibres of internal
oblique and transverse abdominis muscle.
– laterally by the iliopsoas muscle.
– below by the pectin pubis and fascia
covering it.
It is through this tunnel all groin hernias Fig. 1.25: Complete inguinal hernia is one where
occur. hernia descends completely into the scrotum.
What are the newer classifications of groin

hernias?
Gilbert classification(1987)
Type I: Hernia has got snug internal ring through
which a peritoneal sac passes out as indirect
sac.
Type II: Hernia has a moderately enlarged
internal ring which admits one finger but lesser
than two finger breadth. Once reduced it protrude
during coughing or straining.
Type III: Hernia has got large internal ring with
defect more than two fingerbreadth. Hernia
descends into the scrotum or with sliding hernia.
A Once reduced it immediately protrudes out
without any straining.
Type IV: It is direct hernia with large full blow
out of the posterior wall of the inguinal canal.
The internal ring is intact.
Type V: It is a direct hernia protruding out through
punched out hole/defect in the transversalis
fascia. The internal ring is intact.
Type VI: Pantaloon/double hernia.
Type VII: Femoral hernia.
B
Type VI and VII are Robbin’s modifications.
Nyhus classification
Type I: Indirect hernia with normal deep ring.
Type II: Indirect hernia with dilated (patulous)
deep ring.
Type III: Posterior wall defect.
a. Direct hernia, sliding hernia.
b. Pantaloon hernia.
c. Femoral hernia.
Type IV: Recurrent hernia.
Bendavid classification
Type I: Anterolateral defect (indirect).
Type II: Antero medial (direct).
C
Type III: Posteromedial (Femoral).
Figs 1.26A to C: Diagram and photos of indirect inguinal
hernial sac. IL—Inguinal Ligament. SIR—Superficial Inguinal
Type IV: Posteriorprevascular hernia.
Ring. DIR—Deep Inguinal Ring. ASIS—Anterior Superior Type V: Anteroposterior defect (Inguino-femoral
Iliac Spine. IEA—Inferior Epigastric artery hernia).
What are the precipitating causes for How local anaesthesia is given for
inguinal hernia? inguinal hernia surgery?
• Smoking. Around 50-60 ml of xylocaine 0.5% is used. Plain
• Obesity. xylocaine 0.5% or xylocaine 0.5% with adrenaline
• Respiratory causes like bronchial asthma, can be used. Plain xylocaine dose is 2 mg/kg
tuberculosis, bronchitis. body weight. Xylocaine with adrenaline is
• Ascites. 7 mg/kg body weight.
• Previous surgery like appendicectomy which
Two methods are used—
causes direct inguinal hernia.
a. Nerve block method (point block)
• Chronic constipation due to anorectal
• 10 ml of xylocaine is infiltrated 2 cm above
strictures. Rectal stricture may be due to
and medial to anterior superior iliac spine
chronic proctitis (amoebic), tuberculosis of
to block the iliohypogastric nerve.
anorectum, previous anorectal surgery, rectal
• Midinguinal point is infiltrated with
carcinoma or stricture due lymphogranuloma
10 ml xylocaine.
venereum.
• Pubic tubercle place is infiltrated with
• Urinary problems like benign prostatic
10 ml xylocaine.
hyperplasia (BPH), urethral stricture.
• 10 ml of xylocaine is infiltrated just below
• Straining.
the inguinal ligament lateral to femoral
• Multiple pregnancies.
artery to block the genital branch of
genitofemoral artery.
How patient with hernia is evaluated for
• Line of skin incision is infiltrated with
treatment?
10 ml of xylocaine.
• Routine investigations like haemoglobin, total
• Later neck of the hernial sac is infiltrated
count, blood urea, serum creatinine.
with 10 ml of xylocaine.
• Blood sugar
b. Field block method (Shouldice method)
• Specific investigations like chest X-ray,
• Skin of around 4 cm wide area is infiltrated
U/S abdomen to confirm BPH.
into the subcutaneous plane as first layer
from anterior superior iliac spine to pubic
What is the treatment? symphysis. Skin, subcutaneous and two
• Initially precipitating causes should be
layers of superficial fascia (Camper and
treated. Asthma, tuberculosis and bronchiec-
Scarpa’s) are incised.
tasis are treated by proper drugs, broncho-
• Area deep to external oblique aponeurosis
dilators, respiratory physiotherapy.
is infiltrated with 10 ml of xylocaine.
• Later definitive surgical treatment is under-
External oblique aponeurosis is incised.
taken.
• Exposed inguinal canal and hernial sac
• Commonly used procedure at present is
is infiltrated with 10 ml of xylocaine to
hernioplasty using prolene mesh. Modified
continue with the dissection.
Bassini’s repair is done in young individual
with indirect hernia. Shouldice repair is also What is modified Bassini’s repair?
used in some centers. It is strengthening of the posterior wall of the
inguinal canal by approximation of the conjoint
What is the anaesthesia used for inguinal tendon to inguinal ligament using monofilament
hernia repair? nonabsorbable suture material. Absorbable
General/spinal/epidural or local anaesthesia suture material like catgut should not be used
can be used to do inguinal hernia repair. as 50% of the tensile strength will be lost in
7 days. It takes 6 months to achieve more than

80% of tensile strength in repaired hernial
wound; and so non-absorbable suture material
has to be used here to maintain the same adequate
tensile strength in these period. Multifilament
suture material like silk may precipitate infection
because of the crevices in the suture material
and tensile strength is not as good as
monofilament suture material. Commonly used
suture material is either polypropelene (prolene
(blue in colour)) or polyethylene (ethylon (black
in colour)). Continuous sutures compromise the
blood supply and interfere with proper healing;
and strength will not be as adequate as
interrupted sutures. So always interrupted
sutures are used.
Earlier, commonest surgery done for groin
inguinal hernia is modified Bassini’s repair. But
now hernioplasty is the commonly done
procedure for both direct and indirect sac.
In direct hernia, sac is usually not opened but Fig. 1.27: Cord holding forceps is used to
in indirect hernia, sac is always opened. hold cords in inguinal hernia surgery.
What is herniotomy?
Herniotomy is done for indirect sac, where the
sac is dissected, neck of the sac is ligated and
redundant sac is excised.
What are the steps in inguinal hernia

surgery? What are the different
modifications?
1. Herniotomy
Procedure
After cleaning and draping, skin is incised
1.25 cm above and parallel to the medial two/
third of inguinal ligament. Two layers of
superficial fascia (outer Camper’s fascia and
inner Scarpa’s fascia) are incised. External
oblique aponeurosis is incised. Upper leaf is
reflected above and lower leaf is reflected
downwards to visualise and expose the inguinal
ligament. Ilioinguinal nerve is safeguarded.
Fig. 1.28: Twisting the sac after exposing and dissecting
Cremasteric muscle is opened. Cord structures the indirect sac. Sac should be twisted after opening so
are dissected. Sac which is anterior and lateral as to avoid any content from coming back into the sac
to cord is identified and is pearly white in colour. during transfixation of the sac.
2. Modified Bassini’s herniorrhaphy
Conjoint tendon and inguinal ligament are
approximated using interrupted nonabsorbable
monofilament sutures [polypropylene (prolene,
blue in color)]; medial most stitch is taken from
the periosteum of pubic tubercle (called as key
or Bassini’s stitch); external oblique is closed and
other layers are closed. 1-0 polypropylene suture
material is used for repair.
Lytle’s repair
Often internal ring is narrowed by placing
Fig. 1.29: Bassini’s repair interrupted sutures over the medial side of the
ring to the transversalis fascia using either thread
or silk (To narrow the ring and push the cord
Dissection is usually started from the fundus laterally).
and extended towards the neck which is
identified by extraperitoneal fat. The neck is Shouldice repair
narrow and is lateral to the inferior epigastric Eventhough transversalis fascia is thin, it is a
artery. Sac is opened at the fundus. Finger is tough layer and so double breasting of this fascia
passed to release any adhesions. Sac is twisted using continuous sutures (with nonabsorbable
so has to prevent the contents from coming back. material) strengthens the posterior wall of the
It is transfixed using absorbable suture material inguinal wall.
(vicryl or chromic catgut 2-0) and is excised It is a multilayered repair. It was originated
distally. at Shouldice clinic in Toronto where it was usually
A B C
D E F
Figs 1.30A to F: On table pictures of inguinal hernia surgery from cleaning, incision, exposure of external
oblique, opening of external oblique and identification of the cord before dissecting the sac.
A B C
D E F
G H I
J
Figs 1.31A to J: Steps in herniorrhaphy (modified Bassini’s repair) identification of sac, dissection of sac, opening
of the sac, herniotomy, exposure of conjoint tendon and inguinal ligament, placing interrupted, approximating sutures
between conjoint tendon and inguinal ligament and putting the knots of repair.
Fig. 1.33: Tanner's slide operation—relaxing incision placed

over the lower medial aspect of the rectus sheath to
reduce the tension after modified Bassini’s repair.
Darning (Abrahamson nylon darning)

Continuous intervening network of non-
Fig. 1.32: Lytle’s repair absorbable sutures are placed between conjoint
tendon and inguinal ligament to give good
done under local anaesthesia. After doing support to posterior wall inguinal wall.
herniotomy as in any other inguinal hernia,
transversalis fascia is incised along the line of
the wound from deep ring to pubic tubercle.
Lower flap of fascia is sutured to posterior part
of the upper flap. Upper flap is sutured to the
inguinal ligament. It causes double-breasting of
the transversalis fascia. Then conjoint tendon
and inguinal ligament is further approximated
by two layers of continuous sutures. External
oblique aponeurosis is sutured in two layers
(double-breasting) in front of the cord. Hence
the original Shouldice repair is 6 layered
procedure. First two layers of transversalis fascia,
next two layers of conjoint tendon and last two Fig. 1.34: Darning of the posterior wall of inguinal canal
layers of external oblique aponeurosis. Suture using nonabsorbable suture material either polypropylene/
material used here is fine steel wire 34 gauge polyethylene.
(in original Shouldice repair) or polypropylene
or polyethylene. Recurrence rate is 1%. Kuntz‘operation
In old people after taking consent, orchidectomy
Berliner modified shouldice repair: Involves double- is done along with removal of full cord, testis
breasting of the transversalis fascia like in and total closure of posterior inguinal wall by
Shouldice repair and single layer closure of the repair so as to reduce the recurrence.
external oblique aponeurosis without any
additional two-layered repair of conjoint Removal of cord at inguinal region
tendon to inguinal ligament. Cord is removed from the inguinal canal by
ligating both at external and internal ring. But
Tanner’s slide operation testis is retained (for psychological reason) and
To reduce the tension in the repair area, relaxing closure of inguinal canal by repair is done.
incision is placed over the lower rectus sheath
so that conjoint tendon is allowed to slide Andrew’s operation
downward. Overlapping the external oblique aponeurosis.
A B
Figs 1.35A and B: Hernia truss. Note the position where sac is supported.
It is not commonly used now as it may precipitate strangulation.
Macvay operation (Cooper’s ligament repair)

Suturing the conjoined tendon to Cooper’s
ligament.
Conservative treatment
1. Taxis: Patient lying in supine position,
with flexion of hip and knee, and internal
rotation of hip, contents are pushed with
one hand directing with other hand
2. TRUSS: Rat-tailed sprung truss is used.
Measurement is taken from the tip of
greater trochanter to third piece of sacrum.
Complications are discomfort, ulceration,
strangulation, inflammation
It may be used in old people who are not
fit for anaesthesia and surgery Fig. 1.36: Bilateral inguinal hernia-operated. Postoperative
Conservative treatment should be avoided wound infection has occurred on left side.
in hernia as much as possible
What are the complications of the inguinal What is hernioplasty?

hernia surgery? It is strengthening of the posterior wall of the
inguinal canal using synthetic material like
Complications of inguinal hernia surgery prolene mesh, or Dacron. Earlier natural materials
• Haemorrhage, haematoma, haematocele. like tensor fascia lata, temporal fascia were being
• Infection 1-5% used. Now prolene mesh is commonly used.
• Postherniorrhaphy hydrocele, lymphocele It is placed in front of the conjoint tendon between
• Hyperaesthesia over the medial side of conjoint tendon and inguinal ligament. It is
inguinal canal due to injury to ilioinguinal sutured using nonabsorbable suture material
nerve below to the inguinal ligament and above to the
• Injury to iliohypogastric nerve, vas deferens, conjoined tendon. Prolene suture material is white
urinary bladder, intestine in colour.
• Recurrence Size of the mesh should be 1.5 cm wider than
• Testicular atrophy, rarely oedema of the the defect. Adequate haemostasis and prevention
penis of infection is important. Mesh should overlap
• Osteitis pubis over pubic tubercle adequately.
• Inlay mesh repair by placing mesh deep to
conjoint tendon.
• Lichtenstein tension free mesh repair (1993)
with encircling the cord with mesh which
is often done under local anaesthesia.
• Nyhus pre-peritoneal mesh repair. It is done
through suprainguinal horizontal incision.
Mesh is placed in the preperitoneal space
deep to the cord, conjoined tendon, and
transversalis fascia. Below, it is folded deep
to the iliopectineal ligament of Cooper and
sutured to it using two or three interrupted
non-absorbable sutures. It is sutured to
transverse abdominis above and transversalis
Fig. 1.37: Mesh repair. Prolene mesh is reinforced fascia from deep.
between conjoint tendon and inguinal ligament. • Rives preperitoneal mesh repair is pre-
peritoneal mesh repair through transinguinal
What are the different types of hernioplasty? approach. Here mesh is folded and sutured
Hernioplasty is becoming the prime treatment for below to iliopectineal ligament, above to the
inguinal hernia. transverse abdominis in deeper plane. Often
transversalis fascia opened earlier is sutured
Different types are back using nonabsorbable suture material
• Onlay mesh repair by placing mesh in front. in front of the placed mesh.
A B C
D E F
Figs 1.38A to F: Hernial sac should be dissected up to the neck of the sac. It is then twisted and
transfixed using catgut or vicryl and redundant sac is excised.
A B C
D E
F G
Figs 1.39A to G: Placement of prolene mesh in inguinal hernia repair.

i.e Inlay-Lichtenstein mesh repair.
• Stoppa’s giant prosthesis reinforcement of

visceral sac (GPRVS). It is done in large
hernias, hernias in elderly, bilateral hernias,
recurrent and re-recurrent hernias, hernia
with very lax abdomen. Horizontal length
(size) of the mesh is 2 cm less than distance
between two anterior superior iliac spines
and vertical length (size) is distance between
the umbilicus and pubic symphysis. Large
mesh is placed between peritoneum and
lateral, inferior, anterior abdominal wall
which stretches in the lower abdomen and Fig. 1.40: Mesh after hernioplasty got infected with
pelvis. It is done through lower midline or wound Dehiscence. It needs removal of mesh.
Pfannensteil incision. Usually such large only in case of nonavailability of TURP or very
mesh is placed without any anchorage. large BPH.
• Gilbert mesh repair: after herniotomy, internal
ring is plugged by cone-shaped piece of
prolene mesh. Later onlay/inlay mesh repair
of posterior wall of the inguinal canal is done.
• Transabdominal preperitoneal laparoscopic
mesh repair (TAPP repair): becoming popular.
• Totally extraperitoneal laparoscopic mesh
repair (TEP): becoming popular.
Case
A 65 years old male patient presents with bilateral
direct inguinal hernia with features of prostatism
with night frequency, burning micturition, and
incomplete urination. Fig. 1.41: Left-sided complete inguinal hernia in a patient
with Benign Prostatic Hyperplasia (BPH) who is on Foley’s
catheter. He needs trans urethral résection of prostate
How will you manage the case? (TURP) with hernioplasty.
Patient is having bilateral inguinal hernia with
benign prostatic hyperplasia (BPH). Digital Recurrent Hernia
examination of the rectum (P/R) should be done. What are the causes of recurrent hernia?
Patient is evaluated with ultrasound exami- • Infection—most common—50%.
nation, serum acid phosphatase and PSA • Haematoma in the wound.
(Prostate specific antigen). Residual urine should • Early straining.
be assessed. Normal value is 30 ml. More than • Retained indirect sac, after repair of a direct
50 ml is abnormal. More than 200 ml signifies sac (Pantaloon hernia).
severe obstructive uropathy which needs surgical • Smoking, constipation, obstructive uropathy,
intervention. old age, nutritional deficiencies.
• Altered tension in repair site. Altered collagen
What surgery is done to this patient? synthesis.
TURP (Transurethral Resection of Prostate) with
hernioplasty either Lichtenstein or preperitoneal
mesh repair should be done. Both surgeries are
done at single sitting usually under spinal
anaesthesia.
If TURP facility is not available what other

options are there?
Open prostatectomy, either transvesical or
retropubic can be done, which also can be com-
bined with hernioplasty. But many advocate
hernioplasty 12 weeks after open prostatectomy.
Incidence of open prostatectomy has drastically Fig. 1.42: Recurrent hernia on table. Note the
come down because of advent of TURP. It is done defect on the medial aspect.
What are the recent approaches for

inguinal/groin hernias?
Transabdominal preperitoneal mesh repair (TAPP)
using laparoscope. This is used in large indirect
hernia or irreducible inguinal hernia. 10 mm
umbilical port is used for laparoscope. 5 mm
ports on pararectal point at the or above the level
of the umbilicus one on each side so that to
achieve adequate triangulation.
Contents of the hernia are reduced. Hernial
sac is dissected in preperitoneal plane after
making horizontal incision at the upper part of
Fig. 1.43: Sac in a case of recurrent hernia.
the sac opening. Vas, gonadal vessels, pubic
bone, inferior epigastric vessels are identified.
Once sac is dissected and excised, a prolene/
Recurrence rate
vipro/ultrapro mesh of 15 × 10 cm sized is placed
• Bassini’s repair—10%
in preperitoneal space. It is fixed to pubic bone
• Shouldice repair—1%
using tacks. Peritoneum is closed with
• Hernioplasty—1 to 3%
continuous prolene sutures.
• Other methods—1 to 5%
Totally extra peritoneal repair (TEP repair) using
What are the types of recurrent hernias? laparoscope—This technique is gaining more
True or false recurrence—based on type of popularity than TAPP. Through subumbilical
recurrence—whether inguinal recurrence after incision (10 mm) extraperitoneal space is reached.
inguinal hernia repair (true)/femoral hernia or After CO2 insufflation, another 5 mm port is
obturator or other rare types after inguinal hernia inserted 4 cm below the first port in the midline.
repair (false). But presently hernia is classified Third 5 mm port is inserted in the same line
grossly as groin hernias and so all recurrences 4 cm below or in the right iliac fossa. Dissection
are true recurrences. is carried out downwards carefully, then medially
up to the pubic tubercle, iliopectineal ligament,
laterally to iliac vessels, inferior epigastric
How is patient with recurrent hernia
vessels. Once adequate space is dissected 15 ×
investigated?
15 cm mesh is placed and spread. Care should
Patient is investigated by chest X-ray, pulmonary
be taken not to have any folding in the mesh.
function tests, U/S abdomen for BPH, uroflow-
Mesh may be sutured to iliopectineal ligament.
metry, etc.
Displacement of mesh is not common. Other side
also can be done together.
How such patient is treated?
Treatment is always by surgery—always by Anatomical Considerations
hernioplasty. Ideally preperitoneal mesh repair Preperitoneal space is a potential space in front
is done either Rives or Nyhus or giant prosthetic of the peritoneum and behind the transversalis
reinforcement of visceral sac (Stoppa’s GPRVS). fascia and anterior rectus muscle. Below in front
Technically dissection is difficult because of the of the urinary bladder it is called as space of
distorted anatomy of the inguinal canal and Retzius (medially), laterally it is called as space
scarring. Orchidectomy may be added in old of Bogros. Median umbilical fold is formed
people only after taking formal consent. by urachus in the midline. Medial umbilical
ligament is formed by obliterated umbilical
arteries. Lateral umbilical fold by inferior
epigastric vessels. Three fossae are lying in
relation to these folds—supravesical and medial
fossae are medial to lateral umbilical fold which
are sites of direct hernia whereas lateral fossa
is lateral to lateral umbilical ligament is site of
indirect hernia.
In 1956, Fruchaud described his myopectineal
orifice bounded medially by the lateral border
of rectus abdominis, laterally by iliopsoas,
superiorly by conjoined tendon and inferiorly
by pectin pubis. This area is the site of groin
hernia which should be covered by mesh of
adequate size to strengthen the defect and to
prevent the recurrence. Iliopubic tract is analogue
of the inguinal ligament extends from Cooper’s
ligament to anterior superior iliac spine which
divides endoscopic view of preperitoneal space Fig. 1.44: Ports used for TEP (red colour) and
into superior compartment (contains inferior for TAPP (yellow colour).
Fig. 1.45: Diagrammatic representations of TEP and TAPP.

epigastric artery, Hesselbach’s triangle, cord replacing its pubic branch travels across Cooper’s
structures and site of indirect inguinal hernia) ligament, which during fixation of mesh can
and inferior compartment (contains femoral canal, cause torrential haemorrhage—circle of death.
iliac vessels, iliopsoas muscle, genitofemoral Triangle of pain is formed by gonadal vessels
nerve, lateral femoral cutaneous nerve). External medially, iliopubic tract laterally and peritoneal
iliac vessels lie in a triangle formed by gonadal reflection below. Genitofemoral nerve and lateral
vessels laterally, vas deferens medially and cutaneous nerve of thigh traverse this triangle.
peritoneal reflection inferiorly (triangle of doom). Injury to these nerves either by dissection or by
Aberrant obturator artery which is an tacks cause postoperative pain. Tacks/staplers
occasional branch of inferior epigastric artery should not be placed in this triangle.
Indications for TEP Contraindications for TEP

• Recurrent hernia • Obstructed/strangulated inguinal hernias
• Bilateral hernia • Ascites
• Indirect/direct/femoral hernia • Bleeding disorders
Landmarks to be identified in TEP Principles in TEP
• Pubic bone midline • Head-down supine position
• Inferior epigastric artery • Surgeon standing opposite side of hernia
• Cooper’s ligament • Camera person placed at opposite side of hernia
• Iliopubic tract • Monitor at foot end
• Cord and vas deferens • Catheterise/empty the bladder properly
• Psoas muscle and nerves in relation prior to TEP
• Adequate wide space creation
• Careful dissection of cord and sac
• Ligate indirect sac
• Mesh should not be fixed laterally
• Size of mesh is 15 × 15 cm
• Two point fixations—one at pubic bone other at
Cooper’s ligament by tacks/staplers
Difficulties and complications in TEP repair

• Difficulty in dissecting indirect sac cord/vas injury
• Inadvertent opening of the sac/peritoneum and creation of pneumoperitoneum.
• Injuries to major structures like iliac vessels—0.5-1.0%
• Displacement of mesh or erosion into the structures like urinary bladder—rarely may occur.
• Nerve injury
• Formation of seroma/haematoma
• Infection
• Recurrence
Advantages of TEP repair

• Approach is totally extraperitoneal
• Small incision
• Proper placement of mesh in right space that is preperitoneal space
• Peritoneal cavity is intact and not opened
INCISIONAL HERNIA and skin should be palpated. The defect in the
abdominal wall must be assessed. It is done after
• Incisional hernia is a hernia occurring
reducing the hernial content with patient in lying
through a weak scar.
down position. Fingers are placed horizontally
• Writing case sheets, taking detailed history
over the hernial defect and patient is asked to
is similar to inguinal hernia.
raise the head with arms folded over the chest
Additional history to be collected in history of (to contract the abdominal wall muscles) so that
present illness— the defect is felt clearly. Its size, extent can be
• Details of surgery patient has undergone assessed well. Assessment can also be done by
earlier. After how long incisional hernia has raising the legs instead of head.
occurred? Gap cannot be assessed in an irreducible hernia.
• History of wound infection, wound
dehiscence, whether surgery done was an Factors Responsible for Development of
emergency or elective, and tension sutures Incisional Hernia
placed or not. • Vertical incision has got higher chances of
• History of pain, irreducibility and details of
incisional hernia than horizontal incision.
precipitating factors to be asked.
• Layered closure of the abdomen has got higher
• Other precipitating factors similar to inguinal
chance than single layer.
hernia like smoking, urinary/respiratory/
• Continuous closure has got higher chances
abdominal symptoms.
than interrupted closure.
• Use of absorbable suture material has got
higher chances of hernia than nonabsorbable
sutures.
• Emergency surgical wound has higher
chances than elective surgical wound.
• Laparotomy for peritonitis, acute abdomen,
and trauma can commonly cause incisional
hernia.
• Drainage through the main laparotomy
wound may precipitate formation of inci-
sional hernia.
• Chronic cough, smoking, obstructive uro-
Fig. 1.46: Lower abdominal incisional
pathy, constipation can precipitate incisional
hernia adherent to skin. hernia.
• Diabetes, old age, malnutrition, malignancy,
Local Examination (Abdomen) anaemia, hypoproteinaemia, jaundice,
Inspection ascites, liver disease, uraemia, steroid
Scar, its extent and location, whether healed therapy, immunosuppressive diseases are
primarily or secondarily, skin over the scar and other precipitating factors.
swelling is noted. Details of the swelling with
expansile impulse on coughing and examination Type of defects in incisional hernia
both in lying down and standing are done. • Small defect
• Large and wide defect
Palpation • Very large defect
Palpation is like for inguinal hernia. Size, extent, • Massive/diffuse
impulse on coughing must be confirmed; scar • Multiple defects
Note: fistula formation but it is found to be safer.

• Size of the defect is important to decide the Laparoscopic preperitoneal mesh placement
type of surgical closure in incisional hernia. also done for smaller defects. Now dual mesh
• Midline hernia expels the content more (PTFE) or four layered mesh are available.
outwards due to contraction of rectus muscles In this mesh is placed under the peritoneum
on both sides. deep to the defect after reducing the contents.
Mesh is fixed with sutures and tacks. In four
Treatment Strategy for Incisional Hernia layer mesh, deepest 1st layer is absorbable
• When the defect is less than 3 cm, and if cellulose which allows new peritoneum to
the patient is having adequate abdominal creep underneath. Second layer is PDS mesh
muscle tone then layer by layer anatomical 3rd layer is polypropylene mesh last 4th layer
repair is done using monofilament non- is again PDS mesh. It is ideal but costly.
absorbable suture material like polypropylene/ • Keel’s operation is done in large defect. Scar
polyethylene with ideally interrupted sutures. is excised and sac is dissected beyond the
Sac should be dissected, ligated and excised margin of the defect. Sac is never opened
prior to repair. Peritoneum and posterior unless there is obstruction of the content. Sac
rectus sheath is apposed as first layer and in inverted using continuous/interrupted
anterior rectus sheath as second layer. inverting nonabsorbable sutures, layer-by-
• Double breasting of the rectus sheath using layer until the defect margins are apposed
interrupted nonabsorbable sutures using together which is then again sutured with
monofilament suture material. It is over- interrupted sutures. Keel is inverted beam of
lapping the rectus sheath in two layers with the ship.
two rows of sutures. • Nuttall’s operation is done for lower midline
• Mesh repair of the incisional hernia defect incisional hernia. Recti attachments are
is always better and ideal with less chances detached from the pubic bones and are
of recurrence. Adequate sized mesh is placed crossed over to fix to opposite pubic bones
either outer to peritoneum (inlay), or outer so as to create a firm abdominal wall support
to musculoaponeurotic abdominal layer by crossed recti muscles.
(onlay/overlay), or occasionally combined
inlay and onlay mesh placement, both deep
to peritoneum and outer to musculoapo-
neurotic layer. Rive’s Stoppa’s mesh placement
for incisional hernia is placing mesh between
posterior rectus sheath and rectus muscle.
Commonly polypropylene mesh is used.
Other materials used are Dacron, poly-
tetrafluroethylene (PTFE) mesh, polyglycolic
mesh (vicryl mesh) or combined polypro-
pylene and polyglycolic acid mesh (vipro
mesh). Drain (suction drain) must be placed
after surgery.
• Laparoscopic mesh repair is done for Figs 1.47A and B: (A) Keel's operation is inverting rectus
incisional hernia by placing a mesh under sheath layer by layer using nonabsorbable monofilament
suture material so as to appose the defect. (Keel of a
the defect laparoscopically in intraperitoneal
ship). (B) Nuttall's operation—rectus muscle detached
plane. The only problem of this underlay from its attachment from the pubic bone and sutured
placement is chances of adhesion and GI to opposite pubic bone.
Preoperative Preparations for Incisional
Postoperative management in incisional
Hernia Surgery
hernia
• Reduction in weight and control of obesity.
• Early ambulation
• Nutrition, control of anaemia.
• Nasogastric aspiration
• Treatment for diabetes, hypertension, cardiac
• Antibiotics, analgesics
diseases, respiratory problems. • Fluid management
• Treating the precipitating causes. • Catheterisation
• Chest X-ray, U/S abdomen to be done. • Drain should be kept until drainage becomes
• Massive incisional hernia after reduction minimal
might cause IVC compression, paralytic ileus • Abdominal binder is used to support abdo-
and diaphragmatic elevation with respiratory minal wall during recovery period
embarrassment (abdominal compartment
syndrome). It is prevented by prior increasing Additional Problems in Large Incisional
the capacity of peritoneal cavity by creating Hernia
the pneumoperitoneum using CO2 so as to • While reducing the bulky contents like bowel
increase the peritoneal pressure by 12-15 cm and omentum, inadequate intra-abdominal
of H2O, daily for 3-6 weeks. Later definitive capacity leads to increased intra-abdominal
surgery is done. pressure causing IVC compression, mesen-
teric oedema following stasis of splanchnic
bed, paralytic ileus, diaphragmatic elevation
Different Types of Mesh Repair for and respiratory distress (abdominal compart-
Incisional Hernia ment syndrome), urinary and bowel distur-
• Outer to peritoneum is ideal method. Large-sized bances. Abdominal capacity can be raised
mesh is placed in preperitoneum. It need not by regular pneumoperitoneum over the period
be fixed as abdominal pressure keeps it in of 3-6 weeks.
position. • Lordosis and back pain may be presenting
• Under the peritoneum, directly over the content. feature.
Now it is accepted but there are chances of • Sac and contents may get adherent to the
adhesions/fistula formation. It is used in thin skin over the summit of the hernia leading
laparoscopic repair. to skin ulceration and occasionally fistula
• Overlay mesh placed outer to musculoapo- formation.
neurotic layer. • Often might need resection of the adherent
• Combined inlay and overlay with two layers bowel segment.
of mesh. • Large mesh placement is required.
• Rive’s Stoppa’s method of placing mesh
What is paraumbilical hernia?
between posterior rectus sheath and rectus
It is midline herniation above or below the
muscle.
umbilicus. It often attains large size and sags
downwards. Neck may be narrow with omen-
Surgeries for incisional hernia tum/small bowel as contents. Obstruction/
• Layer-by-layer closure—Cattell’s operation. strangulation tend to occur. It is commonly asso-
• Mesh repair—commonly done and ideal. ciated with obesity and multiple pregnancies.
• Double breasting of the rectus sheath It is common in females. Swelling, impulse on
• Keel's operation—not commonly used now. coughing, dragging pain and reducibility are
• Nuttall’s operation—not commonly used usual presentations. It is common with flabby,
now. pendulous abdomen.
A B
C D
Figs 1.48A to D: Epigastric hernia. It is fatty hernia through a gap in the decussation of the linea alba. Initially,
it is sacless but later develops peritoneal sac with contents. Pain is the common feature of the epigastric hernia.
Condition may be associated with peptic ulcer and so gastroscopy should be done. Treatment is surgical repair.
Large mesh should be used to correct the hernia (in preperitoneal position).
How is paraumbilical hernia treated? is large. Additional lipectomy (panniculectomy)

It is treated by transverse elliptical incision, may be done in case of pendulous abdomen.
dissection and ligation of sac followed by closure
of defect with interrupted nonabsorbable sutures What is Mayo’s operation?
when it is less than 4 cm size; mesh repair should It is done for umbilical and paraumbilical hernia.
be done using polypropylene mesh if the defect Once lower flap or umbilicus is raised above,
Fig. 1.49: Paraumbilical hernia.
sac is identified, dissected and opened. After Fig. 1.51: Incision for umbilical hernia
reducing the contents sac is transfixed using
vicryl. Rectus sheath is repaired with double
breasting using nonabsorbable sutures. Skin flap complications are indications for surgery. It is
is closed often with a drain. Infection, recurrences operated through an infraumbilical incision;
are known complications. defect is closed with interrupted sutures after
ligating the sac.
What is umbilical hernia?
It is herniation through a weak umbilical cicatrix. What is Richter’s hernia?
It is common in infants and children. It is It is herniation of a portion of circumference of
hemispherical in shape with defect felt during intestine usually small bowel leading into
crying. It can cause obstruction and strangu- gangrenous change. But patient presents with
lation. 95% of umbilical hernias disappear in features mimicking gastroenteritis without any
2 years. If it persists beyond 2 tears, and if the signs of intestinal obstruction. Eventually it leads
defect is more than 2 cm in size or presence of to perforation and peritonitis. It is common in
femoral hernia. It is treated by resection and
anastomosis and repair.
Fig. 1.50: Umbilical hernia Fig. 1.52: Richter’s hernia.

and its content is usually small bowel. Posterior

wall should not be separated from the sac. Sac
is excised only partially and then is pushed into
peritoneal cavity. Mesh repair is done afterwards.
What is pantaloon hernia?

Inguinal hernia containing both direct and
indirect sacs is called as pantaloon hernia but
it presents as direct hernia. It is also called as
double hernia, saddle hernia or Romberg hernia.
So in all cases of direct hernia, indirect sac
should be looked for. Condition is one of the
causes for recurrence.
What are the problems of

strangulated hernia?
It is due to compromised blood supply of the
contents of the hernia like bowel/omentum
causing toxicity, tenderness at the site. There is
Fig. 1.53: Richter’s hernia with gangrene of part of the no impulse on coughing, and is irreducible and
circumference of the bowel with perforation in a case tense. Features of intestinal obstruction are
of femoral hernia. present if the content is bowel. Narrow neck and
adhesions are the causes of strangulation. It is
What is sliding hernia? treated by emergency surgery. Exploration is done
Posterior wall of the sac is formed by parietal through groin incision. Contents are not allowed
peritoneum and also by sigmoid colon/caecum/ to spill or to get reduced. Toxic fluid is removed
urinary bladder. It occurs exclusively in males using suction. Bowel is checked for viability.
and common on left side. It attains large size If not viable resection and anastomosis is done.
Groin is repaired by herniorrhaphy. Mesh is not
used in strangulated hernia. Drain is kept to
the wound. Adequate antibiotic coverage is a
must.
Fig. 1.55: In strangulated hernia, if the content is stran-

gulated omentum, then omentum is excised and repair
Fig. 1.54: Sliding hernia. is done. Mesh is usually not used in strangulated hernia.
A B
Figs 1.56A and B: Strangulated enterocele with irreducibility, absence of impulse on coughing,
signs of acute inflammation, tense and tender with features of intestinal obstruction. Bowel
strangulation is obvious during surgery.
Fig. 1.57: Incision used for strangulated inguinal hernia. Fig. 1.58: Strangulated hernia with toxic
It is placed in the inguinal region extending into the scrotum fluid and site of obstruction.
downwards.
What is Maydl’s hernia? reducible or irreducible hernia. Patient himself

Here bowel loop in the form of ‘W’ lies in the does it properly. It is dangerous in case of
hernial sac and centre of the portion of the W obstructed hernia, Maydl’s hernia, femoral
is strangulated. It may get reduced ‘en-masse’. hernia, strangulated hernia and sliding hernia.
Strangulation of centre part is common.
What are the clinical features of
What is ‘taxis’? femoral hernia?
Taxis is reducing hernia by flexing and medially Femoral hernia is herniation through the femoral
rotating the hip. It is done in case of partially ring over medial most part of the femoral canal.
cases. It is below and lateral to pubic tubercle

whereas inguinal hernia is above and medial
to pubic tubercle. Impulse on coughing, pain,
reducibility are the usual features. It should be
differentiated from inguinal hernia, lymph node
mass, lipoma, psoas bursa, femoral aneurysm
and saphena varix.
Fig. 1.59: Maydl’s ‘W’ hernia.
B
Figs 1.61A and B: Femoral hernia is common in females.
It occurs below and lateral to pubic tubercle. Herniation occurs
through femoral ring- medial most part of the femoral canal.
How is femoral hernia treated?

It is treated by surgical approach. Different app-
roaches like Lockwood-low approach, McEvedy-
High vertical approach (for strangulated femoral
hernia), Lotheissen’s inguinal approach or supra-
pubic approach are used. After sac dissection
Fig. 1.60: Anatomical locations of femoral and inguinal
hernia. Inguinal hernia is above and medial to pubic tubercle.
and ligation, repair is done by approximating
Femoral hernia is below and lateral to pubic tubercle. inguinal ligament to iliopectineal ligament or
Also note the location of the obturator hernia below in by approximating conjoint tendon to ilio-
Scarpa’s triangle. pectineal line (Lotheissen’s repair). Polypropylene
mesh can be buttressed into the femoral canal
Femoral ring is bounded by inguinal ligament, to close the defect. A K Henry’s approach is
iliopectineal ligament, lacunar ligament and suprapubic transverse extra peritoneal approach
septum separating femoral vein. It is retort-shaped for bilateral femoral hernias. Laparoscopic mesh
hernia, more prone for strangulation. It is repair of femoral hernia is also a good method
common in females and it is bilateral in 20% which is done using large mesh like TAPP/TEP.
Fig. 1.64: Different approaches for femoral hernia.

Fig. 1.62: Diagramatic representation of location of inguinal,
1. Lockwood low approach is below the inguinal ligament
femoral and obturator hernias. Obturator hernia occurs
parallel to it. 2. McEvedy high approach is vertical incision
through obturator canal, commonly presenting with features
extending above and below the inguinal ligament. It is
of intestinal obstruction. Often radiating pain to knee joint
used in strangulated femoral hernia. 3. Lotheissen's
through geniculate branch of the obturator nerve called
approach is inguinal approach through inguinal canal.
as Howship-Romberg sign may be the presentation.
4. A K Henry's approach is horizontal lower abdominal
Obturator hernia is common in elderly females.
approach for bilateral femoral hernia repair with extra-
peritoneal approach.
Fig. 1.63: Femoral hernia repair. Repair of femoral hernia Fig. 1.65: Right-sided hernia in a child. Only herniotomy
is done either by approximating inguinal ligament to ilio- is done for inguinal hernia in children. Repair/mesh are
pectineal ligament or by approximating conjoint tendon not used. Herniotomy is also done for hydrocele in children
to iliopectineal ligament or by plugging the mesh to femoral through inguinal approach. Hydrocele in children is due
opening. to patent processus vaginalis.
VASCULAR DISEASES
EXAMINATION OF A CASE OF
ARTERIAL DISEASES
Arterial diseases can occur in lower limb
commonly and also occasionally upper limb.
Often both lower and upper limbs may get
involved.
It is often classified as lower limb ischaemia
and upper limb ischaemia. But wherever the
disease detailed examination of both lower limb
and upper limb vessels is required in all patients.
Name:
Age:
Sex:
Occupation:
Address:
Atherosclerosis occurs in old age usually.
Thromboangiitis obliterans (Buerger’s disease)
occurs in young males. Raynaud’s disease is
common in young/middle-aged females. Fig. 1.66: Rest pain in a TAO patient. Observe the
way patient holding the foot to relieve the pain.
Chief Complaints
by transmission of temperature from holding
• Pain in the limb right/left/both—its duration.
hand into the part) or to hang the leg down
• Intermittent claudication—its duration.
to relieve the pain or by applying the warmth.
• Blackish discoloration/ulceration.
• Pain, discomfort, colour changes when
exposed to cold.
History
History of Present Illness Ulceration
• Whether precipitated by trauma/spon-
Pain taneously.
• Site of pain, type of pain—severe burning/ • Pain in the ulcer/type/duration/aggravating
aching/deep persisting. or relieving factors.
Whether pain radiates or not. • Discharge-type—serous-purulent-bloody.
• Intermittent claudication—duration, grade/ • Progression.
distance how much patient can walk/
whether pain subsides after stopping walk Gangrene
or after continuous walk/whether patient is • Site of gangrene/its onset/progression/pain.
able to walk in spite of pain/change in the • History of difficulty in walking/altered gait.
claudication distance eventually/site of • Mode of onset—in atherosclerosis/Buerger’s
claudication—foot/leg/thigh/buttock. disease process is spontaneous and gradual.
• Presence of rest pain—its location/severity/ Gangrene due to embolism is sudden in onset,
whether patient has to hold the limb/foot/ rapidly progressive.
leg/toes to relieve pain little bit (probably • History of fever.
• History of impotence—its duration. • Colour proximal to gangrene area/ischaemic
• History of tingling/numbness/weakness in area (usually ischaemic area is pallor).
the limbs. • Limb deformity.
• History of syncope/blackouts/loss of • Gangrene of toe/toes/foot/leg: Its extent,
consciousness/blurred vision. discharge from area, type of gangrene—dry
• History of chest pain/cough or cardiac related or wet, line of demarcation—type/level/
symptoms. depth, colour of gangrenous area—black/
• History of abdominal pain/bloody diarr- purple/greenish black (in gas gangrene).
hoea/abdominal angina. • Ulceration if any—its extent/discharge/size/
• History of paraesthesia over the skin. shape/floor/surrounding area.
• History suggestive of superficial thrombo- • Patchy ulcers proximal to gangrenous area-
phlebitis like swelling/redness/pain along skip lesions which are usually black patchy
the line of superficial vein. lesions.
• Muscle wasting in the foot/leg/thigh should
Past History and Treatment History be observed. It should be compared and also
• Similar history earlier. should be measured using a tape from a fixed
• History of drug intake earlier for similar bony point keeping equal distance in both
conditions like vasodilators/drugs to increase limbs.
the perfusion. • Features of ischaemia—shiny thin skin/loss
• History of earlier surgery like/sympathec- of subcutaneous fat/hair loss- its extent/nail
tomy/omentoplasty/their results or effects. changes—brittle nail/transverse ridges in the
nail.
Personal History • Plantar aspect of the foot for infective focus/
History of smoking—beedi or cigarettes/ abscess/callosities/skin changes/superficial
duration/number per day/stopped now or ulcers in heel/malleoli/toes.
continuing/since when stopped smoking. • Buerger’s postural test: Patient in supine
position is asked to raise his legs one after
Family History other with knee keeping straight. In normal
Any family history suggestive of atherosclerosis limb even after 90° elevation limb remains
or vascular diseases. pink without any palor. Diseased limb after
elevation shows marked palor (overfoot) with
General Examination empty-guttered veins. The angle with which
• Pulse-rate/rhythm/character/condition of palor develops (between limb and ground)
vessel wall. is called as Buerger’s vascular angle of
• Blood pressure of both arms and if possible insufficiency. In severe ischaemia, this angle
of both lower limbs. will be less than 30°. If foot does not become
• Attitude of limbs. palor or doubtful, then repeated ankle flexion
and extension is done until it becomes palor
Local Examination empty-guttered veins on the dorsum of foot
Inspection and after lowering the foot cyanotic conges-
• Inspect both lower limbs keeping side-by-side tion appears in the foot.
as comparison is needed during clinical • Oedema in the foot/feet/legs.
examination. • Status of the superficial veins—normally
• Change in colour is very important sign of filled veins or pale/discoloured/guttered
ischaemia. veins as seen in ischaemic limb.
• Capillary filling time: Initially elevated limbs rapidly for 5 minutes. Normal individual can
are made to hang down the bed. Limb will do this without any discomfort and pain.
remain normal pink in elevated as well as Patient with thoracic outlet syndrome
down position because of rapid capillary develops pain, fatigue, paraesthesia of
filling time. In ischaemia, limb becomes palor forearm with tingling and numbness of
in elevation and only gradually becomes fingers. Patient will not be able to complete
purple-red and then pink in more than the test for 5 minutes. This test can also
20 seconds. Purple pink colour is due to differentiate thoracic outlet syndrome from
deoxygenated blood. Prolonged capillary time cervical disc prolapse disease.
signifies severe ischaemia. • Roos test: Patient is asked elevate and abduct
• Venous refilling time: Elevated limb when laid
the shoulders 90° with external rotation of
horizontal in the bed normal venous refilling
arms to keep it for 5 minutes. Patient feels
occurs within 5 seconds. It is delayed in
fatigue in the diseased side.
ischaemic limb.
• Costoclavicular compression manoeuvre: While
Palpation feeling radial pulse of the patient, he is asked
• Temperature of the skin is important factor to place his shoulder backwards and
in ischaemic limb. Extent of cold and proxi- downwards (exaggerated military position)
mally where exactly limb/part become causing absence/feeble radial pulse and
warmer also should be assessed. while auscultating the supraclavicular region
• Tenderness: Site/extent/severity should be a bruit may be heard. This is due to com-
assessed. pression of subclavian artery between clavicle
• Gangrenous area to be palpated for extent/ and first rib.
whether it is dry and shriveled or whether • Hyperabduction manoeuvre (Halsted test): While
it is wet and oedematous. Crepitus in palpating the radial pulse, arm on the
gangrenous present or not should be checked. diseased side is passively hyperabducted
• Limb above the gangrenous area should be causing feeble or absence of radial pulse. This
palpated. is due to compression of artery by pectoralis
• Capillary filling: Tip of the nail or pulp of minor tendon (pectoralis minor syndrome).
the finger or toe is pressed to blanch it and An axillary bruit may be heard on auscul-
pressure is released (in 2 seconds) to make tation.
it to become pink. Time taken from blanched • Adson’s test: While feeling the radial pulse
area to turn into pink is capillary filling time. of the affected side of the patient, patient is
It is prolonged in ischaemic limb. asked to take deep breath and to turn his
• Harvey’s venous refilling test: Two fingers are neck/head towards the same side so as to
placed over the vein. Pressure is elicited over
compress the thoracoaxillary channel. Pulse
the vein. Proximal finger is moved proximally
becomes feeble or absent in positive Adson’s
for about 5 cm without releasing the pressure.
test in thoracic outlet syndrome/scalenus
Vein between the fingers gets emptied
anticus syndrome. While taking deep breath
completely and becomes flat. Distal finger is
released now to see the flow of the blood thoracic cage moves upwards and narrows
and its refilling is observed whether it is good the space causing aggravation of compres-
or poor. It is poor in ischaemic limb. sion of subclavian artery by scalenus anterior
• Elevated arm stress test (EAST): Both shoulders muscle. Contraction of scalenus anterior
are abducted 90° with arms fully externally further aggravates the feature (by turning neck
rotated. Patient will open and close the hands towards same side).
clinching) and holds it tightly. After 1 minute,
clinch is released to open the palm of the
hand which looks pale. Pressure on the radial
artery in wrist is released to see area of
distribution of the radial artery. Normally,
it becomes flushed with pink colour. If there
is radial artery block area will remain white.
Test is repeated again. This time pressure
on the ulnar artery is released to check the
patency of ulnar artery. Area will be pale
and blanched after releasing in case of ulnar
artery block. Otherwise in normal individual
it becomes pink after release.
A • Cold and warm water test: It is commonly done
to confirm Raynaud’s phenomena. Patient
is asked to dip hands in cold water to
precipitate the vasospasm and Raynaud’s
syndrome.
• Crossed-leg test (Fuchsig’s test): Patient is asked
to sit with the legs-crossed one above the
other so that the popliteal fossa of one leg
B
will lie against the knee of other leg.
Oscillatory movements of foot can be observed
Figs 1.67A and B: Adson’s test synchronous with the popliteal artery
pulsation. If the popliteal artery is blocked
• Branham’s/Nicoladoni’s sign: In arteriovenous oscillatory movements will be absent.
fistula, pressure over the artery proximal to • Disappearing pulse syndrome: Exercise the limb
fistula will cause reduction in pulse-rate and after feeling the pulse. Pulse will disappear
size of the swelling with pulse pressure once patient develops claudication. It is
becoming normal and disappearance of because of vasodilatation and increased
bruit. vascular space occurring due to exercise
• Allen’s test: It is used in hand to find out the wherein arterial tension can not be kept
patency of radial and ulnar arteries. Both adequately and so pulse will disappear
radial and ulnar arteries of the patient is felt (unmasking the arterial obstruction).
and pressed firmly at the wrist. Patient • Buerger’s postural test: Patient lying down on
clinches his hand firmly (often repeated his back is asked to raise the leg forward
A B C D
Figs 1.68A to D: Allen’s test
significantly. Release and assess the time of

appearing of red flush in skin which signifies
the reactive hyperaemia time. Normal time
is 2 seconds. It is delayed in ischaemia.
Palpation of Blood Vessels

Dorsalis pedis artery is felt just lateral to the
extensor hallucis longus tendon at the proximal
end of first web space, felt against the navicular
and middle cuneiform bones. It is absent in 10%
cases.
A B
Figs 1.69A and B: Crossed-leg test—checking
oscillatory movements.
for two minutes. In normal individuals, limb

(plantar aspect of foot) will remain pink even
after raising to 90°. Ischaemic limb, when Fig. 1.70: Palpation of dorsalis pedis artery pulsation.
elevated shows marked pallor and empty
veins. The angle in which pallor develops Posterior tibial artery is felt against the calcaneus
is called as Buerger’s angle of vascular insuffi- just behind the medial malleolus midway
ciency. Less than 30° angle indicates severe between it and tendo-Achilles.
ischaemia. Ischaemic height of the heel in
relation to the sternal angle where palor
develops in heel signifies the severity of the
disease. This height in centimeter is equal
to the arterial pressure in the foot in mmHg.
After that patient is asked to keep the legs
below the bed to fill the vessels. Time taken
to become leg pink colour is capillary filling
time. Filling time more than 30 seconds
suggests severe limb ischaemia.
• Guttering of vein while raising the leg for 15°
is observed in ischaemic limb due to complete
collapse of the veins whereas in normal
individual veins are only partially collapsed
while raising the leg. Fig. 1.71: Palpation of posterior tibial artery.
• Reactive hyperaemia time test: Inflate the
sphygmomanometer cuff around the limb up Anterior tibial artery is felt in the midway
to 250 mmHg for 5 minutes to appear palor anteriorly between the two malleoli against the
lower end of tibia just above the ankle joint lateral be felt in supine position with knee flexed
to extensor hallucis longus tendon. 90-130° to relax the popliteal fossa so as to feel
the pulsation against tibial condyles.
Femoral artery in the groin is felt just below the
inguinal ligament midway between anterior
superior iliac spine and pubic symphysis (mid-
inguinal point). Often hip has to be flexed for
about 10-15° to feel it properly.
Fig. 1.72: Palpation of anterior tibial artery
Popliteal artery is difficult to feel. It is palpated

better in prone position with knee flexed about
90-130° to relax popliteal fascia. It is felt in the
lower part of the fossa over the flat posterior
surface of upper end of tibia. In upper end of
the fossa, artery is not felt as bony area in Fig. 1.74: Palpation of femoral artery.
intercondylar region is not present. It can also
Radial artery is felt at the wrist on the lateral
aspect against lower end of the front of radius.
Fig. 1.75: Palpation of radial artery
Ulnar artery is felt at the wrist on the medial

end against lower end of the front of ulna.
B
Figs 1.73A and B: Palpation of popliteal artery both in
supine and prone positions. Prone position is better. Fig. 1.76: Palpation of ulnar artery.
Brachial artery is felt in front of the elbow just Common carotid artery is felt medial to
medial to biceps brachii tendon. sternomastoid muscle at the level of thyroid
cartilage against carotid tubercle (Chaissagne
tubercle) of transverse process of 6th cervical
vertebra (in carotid triangle).
Fig. 1.77: Palpation of brachial artery.
Axillary artery is felt in lateral aspect of the axilla

against upper end of the shaft of the humerus
with raised and elevated arm.
Fig. 1.80: Palpation of common carotid artery.
Facial artery is felt against body of mandible at

the insertion of masseter.
Fig. 1.78: Palpation of axillary artery.
Subclavian artery is felt against first rib just above

the middle of the clavicle in supraclavicular fossa Fig. 1.81: Palpation of facial artery.
while patient is lifting the shoulder to relax deep
fascia. Superficial temporal artery is felt just in front of
the tragus of the ear against zygomatic bone.
Fig. 1.79: Palpation of subclavian artery. Fig. 1.82: Palpation of superficial temporal artery.
All pulsations should be written in a tabular form right and left side.
Pulse Right Left

Dorsalis pedis Should be mentioned as Should be mentioned as
Posterior tibia present/absent/feeble present/absent/feeble
Anterior tibial
Popliteal
Femoral
Radial
Ulnar
Brachial
Axillary
Subclavian
Carotid
Superficial temporal
Condition of the vessel wall, thrill and any

tenderness on the artery should be mentioned.
Ulcer if present should be examined for different
features like tenderness/mobility/fixity/base/
induration.
Limb muscle wasting assessment is important
to find out the severity of the ischaemia. It is
done by inspection of muscle bulk; prominent
bony prominences; by measurement of the limb
Fig. 1.84: Muscle power should be checked

against resistance to find out the grade.
B
Figs 1.83A and B: Measurement of girth is important
to find out the wasting. It should be compared to opposite
side and measured at a specific distance from a bony Fig. 1.85: Wasting of muscles of right hand because of
prominence. ischaemia. Note also colour difference between two hands.
girth (circumference is measured using a tape, the artery. It signifies localised stenosis causing
15 cm away from the bony point). turbulence flow. Machinery bruit/murmur also
Muscle power is also should be checked and heard in AV malformations/fistulas.
graded as—Grade 0—complete paralysis; Grade
1—flicker of contraction, no movement; Grade Neurological Examination
2—movement with the elimination of gravity; Muscle tone/power at ankle, knee and hip,
Grade 3—movement against gravity, not against sensory examination for touch, pain and
resistance; Grade 4—movement against partial temperature, reflexes at ankle and knee and
resistance; Grade 5—normal movement against plantar response should be checked when
full resistance. associated neurological conditions are suspected
(like tabes dorsalis, syringomyelia, hemiplegia,
Auscultation transverse myelitis).
Auscultation over the artery for bruit is done
using bell of the stethoscope placing gently over
Fig. 1.87: Sensation should be checked for neurological

deficit especially in upper limb (cervical rib).
Systemic Examination
A
Abdomen should be examined for the presence
of abdominal aortic aneurysms. It presents as
pulsatile mass above the umbilicus, vertically
placed, smooth, soft, nonmobile, not moving with
respiration, resonant on percussion. Expansile
pulsation is confirmed by placing the patient
in knee-elbow position.
Figs 1.86A to C: Auscultation over the major vessel

like femoral/carotid for bruit is important. It signifies stenosis Fig. 1.88: Examination of abdomen for aortic pulsation/
and turbulence flow of blood. aneurysm; old sympathectomy scar are important.
Cardiovascular system: CVS is essential part The site of pain depends on site of arterial
of the arterial system for any associated or occlusion.
causative causes to find out. There may be • Commonest site is calf muscles.
embolic focus in heart like fibrillation/endo- • Pain in foot is due to block in lower tibial
carditis, etc. and plantar vessels.
• Pain in the calf is due to block in femoro-
popliteal site.
• Pain in the thigh is due to block in the
superficial femoral artery.
• Pain in the buttock is due to block in the
common iliac or aortoiliac segment, often
associated with impotence and is called as
Leriche’s syndrome.
Pain commonly develops when the muscles
are exercising. Cause for pain is accumulation
of substance ‘P’ and metabolites. During exercise
increased perfusion and increased opening of
collaterals wash the metabolites.
Fig. 1.89: Cardiovascular system examination is also

equally important for mitral stenosis/endocarditis, etc. Boyd’s classification of claudication
Grade I: Patient complains of pain after walking,
Other systems like skeletal and respiratory and distance in which pain develops is called
systems should be examined in detail. as ‘claudication distance’. If patient continues
to walk metabolites causing pain are washed
away in the circulation due to increased blood
flow in muscle and so pain subsides by opening
of the collaterals
Grade II: Pain still persists on continuing walk;
but can walk with effort
Grade III: Patient has to take rest to relieve the
pain
Neurogenic claudication is pain in the leg

during walking due neurological causes. It often
mimics vascular claudication but arterial pulses
Fig. 1.90: Palpation of abdominal aortic pulsation
are normal in this. It is common in spinal cord
in epigastrium, above the umbilicus, midline.
stenosis.
Intermittent Claudication Claudication distance is distance at which
Claudio means ‘I limp’ a Latin word. It is a crampy claudication appears. It is better assessed using
pain in the muscle seen in the limbs. Due to a treadmill.
arterial occlusion, metabolites like lactic acid and Claudication is not that common in upper
substance P accumulate in the muscle and cause limb but can occur during writing or any upper
pain. limb exercise.
Rest Pain Wet Gangrene

It is continuous aching in calf or feet and toes It is due to both arterial and venous block with
or in the region depending on site obstruction. superadded putrefaction and infection. It spreads
It is ‘cry of dying nerves’ due to ischaemia of the proximally and there is no line of demarcation.
somatic nerves. It signifies severe decompensated It spreads faster.
ischaemia. Pain gets aggravated by elevation and Organs in which gangrene can develop are
is relieved in dependant position of the limb. appendix, bowel, gall bladder, testis and
Pain is more in the distal part like toes and feet.
pancreas.
It gets aggravated with movements and pressure.
Hyperaesthesia is common association with rest
Necrosis
pain. Rest pain is more during night time as
It is microscopic cell death.
there is reduced heart-rate and blood pressure
during night (sleeping time).
Sequestrum
Fontaine classification of limb ischaemia Sequestrum is dead bone in situ.
Stage 1: No clinical symptoms
Stage 2: Intermittent claudication Slough
2a: Well-compensated Slough is dead soft tissue.
2b: Poorly-compensated
Stage 3: Rest pain Line of Demarcation
Stage 4: Gangrene, ischaemic ulcer It is a line between viable and dying tissue
indicated by a band of hyperaemia. It also
indicates that disease is well-localised. Final
Critical Limb Ischaemia separation between healthy and gangrenous tissue
It is persistently recurring ischaemic rest pain occurs by development of a layer of granulation
or ulceration or gangrene of the foot or toes with tissue in between. It is hyperaesthetic due to
an ankle systolic pressure < 50 mmHg or toe exposed nerve endings.
systolic pressure < 30 mmHg.
Type of separation
• Separation by aseptic ulceration-seen in dry
Pregangrene
gangrene.
It is the changes in tissue which indicates that
• Separation by septic ulceration-seen in
blood supply is inadequate to keep the tissues
alive and presents with rest pain, colour changes, infected cases and wet gangrene.
oedema, hyperaesthesia with or without
ischaemic ulceration.
Features of ischaemia
• Marked pallor, purple blue cyanosed
Gangrene appearance
It is macroscopic death of tissue in situ with or • Thinning of skin
without putrefaction. • Diminished hair
• Loss of subcutaneous fat
Dry Gangrene • Brittle nails, with transverse ridges
It is dry, dessicated, mummified tissue caused • Ulceration in digits
by gradual slowing of blood stream. There is • Wasting of muscles
a line of demarcation and is localised. • Tenderness and temperature (cold)
• Doppler to find out the site of block.
• Duplex scan: It is combination of B mode
ultrasound and Doppler study. Difference in
transmitted beam of the ultrasound and
reflected beam is called as Doppler shift which
is assessed and converted into audible
signals. To study the site, extent, severity of
block, and also about collaterals. Audible
sound—with normal flow and sound is
important. Turbulence is heard with stenosed
partially blocked artery. Audible sound will
be absent, if there is complete block. Using
Fig. 1.91: Ischaemic ulcers in both Doppler probe blood pressure at various
upper and lower limbs
levels can be assessed. Pulse wave tracing
along the artery is also important.
Features of severe ischaemia • Plethysmography.
• Systolic ankle pressure less than 50 mmHg • Ankle-brachial pressure index (ABPI):
• Systolic toe pressure is less than 30 mmHg Normally, it is 1. If it is less than 0.9, it means
• Ankle brachial index is less than 0.3 ischaemia is present. If it becomes 0.3 or below
• Burger’s angle of insufficiency is less than then it signifies severe ischaemia with gangrene.
20° It may be normal at rest in early mild ischaemia
• Capillary filling time more than 30 seconds but alters (reduces) during exercises.
• Delayed reactive hyperaemia time
• Presence of ischaemic ulcers, gangrene Angiography
Retrograde transfemoral Seldinger angiography:
Aortoiliac block causes claudication in both It is commonly done. It is done only when
buttocks, thighs, and calves; absence of femoral femorals are felt. If femoral pulsation is not felt,
and distal pulses; bruit over aortoiliac region. then angiogram is done either transbrachially (left
Impotence occurs due to defective perfusion through brachial artery), or transaortic.
internal iliac arteries and so into the penis causing
erectile dysfunction (Leriche’s syndrome). Indications for angiogram
Iliac artery obstruction causes claudication in • TAO
thigh and calf; bruit over iliac arteries with • Atherosclerosis
absence of femoral and distal pulses. • Raynaud’s phenomenon
Femoropopliteal obstruction causes claudication • A-V fistulas
in calf with absence of distal pulses but with • Haemangiomas
palpable femoral. • Thoracic outlet syndrome ( e.g. cervical rib)
Distal obstruction shows absence of ankle • Aneurysms,
pulses with palpable femoral and popliteal • Neoplastic conditions
pulses.
Other angiograms are carotid angiogram,
INVESTIGATIONS FOR ARTERIAL celiac angiogram, superior mesenteric angiogram,
coronary angiogram.
DISEASES
Femoral artery is cannulated with a guide
• Blood tests: Hb%, blood sugar, lipid profile, wire. Through that Seldinger arterial catheter is
peripheral smear, platelet count. passed proximally in retrograde direction and
water soluble iodine dye (Sodium diatrizoate)

is injected. X-rays are taken to see the block, its
extent in the affected limb. In TAO cork screw
appearance is characteristic. Distal run off through
collaterals is also important. If catheter is passed
still proximally angiogram of opposite side is
possible. Seldinger technique can also be used
(to study) to do renal angiogram, renal artery
stenosis, renal carcinomas, renal anomalies
(vascular).
Complications of retrograde angiogram
• Bleeding
• Dissection of vessel wall
A B
• Haematoma formation
• Thrombosis Figs 1.92A and B: DSA showing aortoiliac block left-
• Infection sided. Second film is DSA after balloon angioplasty causing
adequate dilatation of the left-sided aortoiliac segment.
• Anaphylaxis
• Direct aortic angiogram, practiced earlier, is DISEASES OF THE ARTERIES
discouraged at present because of the risk
of aortic dissection and paraplegia due to 1. Atherosclerosis:
blockage of anterior spinal artery.
Risk factors for atherosclerosis
Digital Subtraction Angiography (DSA) • Hypercholesterolaemia, hypertriglyceridae-
• Here vessel (artery) is delineated in a better mia and hyperlipidaemia
way by eliminating other tissues through • Cigarette smoking
computer system. A-V fistulas, haemangio- • Hypertension
mas, lesion in circle of Willis, vascular • Diabetes mellitus
tumours, other vascular anomalies are well- • Age—elderly
made out. • Common in males
• Dye is injected either to an artery or vein. • Sedentary life
Injecting into a vein is technically easier but • Family history
larger dose of dye is required. Injecting into
2. Thromboangiitis obliterans. TAO: (Buerger’s
an artery is technically difficult but small
disease.)
dose of dye is sufficient.
3. Raynaud’s disease.
• Advantages: Only vascular system is
visualised; other systems are eliminated by 4. Conditions causing Raynaud’s phenomenon:
computer subtraction. Small lesion, its Like Scleroderma, Rheumatoid arthritis, SLE,
location and details are better observed with Granulomatosis, vasculitis of other causes.
greater clarity. 5. Embolus.
• Disadvantages: Cost factor and availability. 6. Aneurysms.
• Complications: Anaphylaxis, bleeding,
Thromboangiitis Obliterans (TAO)
thrombosis.
syn. Buerger’s disease - Leo Buerger, 1908
U/S abdomen (Professor of Urology, 1879-1943).
To see abdominal aneurysm or nature of aorta It is a disease exclusively seen in males of young
and other vessels. age group (Not seen in females due to genetic
Once collaterals open up, through these
collaterals, blood supply is maintained to the
ischaemic area.
↓
It is called as compensatory peripheral vascular
disease.
↓
If patient continues to smoke, disease progresses
into the collaterals, blocking them eventually,
leading to severe ischaemia and is called as
decompensatory peripheral vascular disease.
↓
It is presently called as critical limb ischaemia.
A B
It causes rest pain, ulceration and gangrene.
Figs 1.93A and B: X-ray abdomen AP and
lateral view showing calcified aorta. Smoking = Number of cigarettes × Number of years
index (SI) smoked per day of smoking
reason). It is seen only in smokers and tobacco
SI > 300 is a risk factor
users. Always starts in lower limb, may start
on one side and later on the other side. Upper Pack Years = Number of packets × Number of years
limb involvement occurs only after lower limb Index (PYI) cigarettes per day of smoking
is diseased. It is a panvasculitis.
PYI > 40 is a Risk factor
Pathogenesis
Smoke contains carbon monoxide and nicotinic acid Shianoya’s criteria for Buerger’s disease
↓ • Tobacco use. Only in males
Causes initially vasospasm and hyperplasia • Disease starts before 45 years
of intima • Distal extremity involved first without
↓ embolic or atherosclerotic features
Thrombosis and so obliteration of vessels occurs. • Absence of diabetes mellitus or hyper-
Commonly medium sized vessels are involved. lipidaemia
↓ • With or without thrombophlebitis
Panarteritis is common.
Usually involvement is segmental.
↓ Investigations
Eventually artery, vein and nerve are • Hb%. Blood sugar.
together involved. • Arterial Doppler and Duplex scan (Doppler
↓ + B mode U/S).
Nerve involvement causes rest pain. • Transfemoral retrograde angiogram through
↓ Seldinger technique—
Patient presents with features of ischaemia – Shows blockage—sites, extent, severity.
in the limb. – Cork screw appearance of the vessel due
↓ to dilatation of vasa vasorum.
Once blockage occurs, plenty of collaterals open – Inverted tree/spider leg collaterals.
up depending on the site of blockage either – Severe vasospasm causing corrugated/rippled
around knee joint or around buttock. artery.
A B C
D E F
G H
Figs 1.94A to H: Different types of ischaemic ulcers. Also note wasting,

loss of hair, shininess and other features of ischaemia.
• Distal run off is amount of dye filling in 4. Amputations are done at different levels
the main vessel distal to the obstruction depending on site, severity and extent of
through collaterals. If distal run off is good vessel occlusion. Usually either below- knee
then ischaemia is compensated. If distal or above—knee amputations are done.
run off is poor then ischaemia is decom- 5. Ilzarov method of bone lengthening helps in
pensated. improving the rest pain and claudication by
• Transbrachial angiogram: If femorals are not creating neoosteogenesis and improving the
felt, then transbrachial angiogram (Through overall blood supply to the limb.
left side brachial artery—left subclavian artery 6. Gene therapy: Intramuscular injection of
– and so to descending aorta) should be done. vascular endothelial growth factor (VEGF)
• Ultrasound abdomen which is an endothelial cell mitogen which
• Vein, artery, nerve biopsies. promotes angiogenesis.
Treatment
Stop smoking. Opt for either smoke or limb but
not both.
Drugs
• Vasodilators, e.g. nifedepine.
• Pentoxiphylline increases the flexibility of
RBC’S and helps them reach the micro-
circulation in a better way so as to increase
the oxygenation.
• Low dose of aspirin—antithrombin activity
• Prostacyclins, Ticlopidine, Praxilene.
Fig. 1.95: Below-knee amputation stump is still infected
• Clopidogrel 75 mg, atorvastatin 10 mg, par- in a TAO patient. This patient might require an above-
vostatin 40 mg knee amputation.
• Cilostazole 100 mg bid—is a phosphodies-
terase inhibitor which improves circulation.
All drugs act at the collateral level than at
the diseased vessel.
Buerger’s exercise, Buerger’s position, heel raise,
analgesics, care of feet (Chiropady), proper footwear
are advised.
Surgery
1. Lumbar sympathectomy to increase the
cutaneous perfusion so as to make the ulcer
to heal.
2. Omentoplasty to revascularise the affected Fig. 1.96: Below-knee amputation with
limb. long posterior flap.
3. Profundaplasty is done for blockage in
profunda femoris so as to open more Raynaud’s Phenomenon
collaterals across the knee joint. (It often makes It is an episodic vasospasm, i.e. arteriolar spasm.
better perfusion to the knee joint and flap It leads to sequence of clinical features called
of below knee amputation). as Raynaud’s syndrome.
Raynaud’s syndrome Esophageal defects, Sclerodactyly, Telangiec-

It is sequence of clinical features due to tasia).
arteriolar spasm.
1. Local syncope: It is due to vasospasm, causing Types of Raynaud’s Phenomenon
white and cold palm and digits along with Vasospastic.
tingling and numbness Obliterative.
Type is identified by angiogram of palm,
2. Local asphyxia: It is due to accumulation
Doppler, Duplex scan.
of deoxygenated blood as the result of
Other investigations required are X-ray of the
vasospasm causing bluish discolouration
part, specific tests for autoimmune diseases.
of palm and digits with burning sensation.
(it is due to accumulated metabolites)
Treatment
3. Local recovery: It is due to relief of spasm
• Treat the cause.
in the arteriole, leading to return of blood
• Avoid the precipitating cause.
to the circulation causing flushing and pain • Vasodilators, Pentoxiphylline.
in digits and palm. (Pain is due to increased • Small dose of aspirin (100 mg daily).
tissue tension) • Cervical sympathectomy.
4. Local gangrene: If spasm persists more than
ischaemic time (more than one hour in Treatment of Arterial Diseases
upper limb), then digits go for ulceration
Medical
and gangrene. Does not occur regularly but
is an occasional phenomenon in the cycle General measures
• Stop smoking.
• Reduction of weight.
Causes for Raynaud’s Phenomenon • Change in life style.
• Raynaud’s disease: • Exercise.
– It is seen in females, usually bilateral. • Care of feet.
– It occurs in upper limb with normal • Control of diabetes and hypertension.
peripheral pulses. • Buerger’s position and exercise—regular
– It is due to upper limb (hand) arteriolar graded exercises upto the point of clau-
spasm due to abnormal sensitivity to cold. dication improves the collateral circulation.
Patient develops blanching, cyanosis and
Drugs: Nifedepine, praxilene, pentoxiphylline,
later flushing as Raynaud’s syndrome. small dose of aspirin, prostacycline, dipyridamole,
Occasionally, if spasm persists it result ticlopidine, atorvastatin, cilostazol 100 mg.
in gangrene. Symptoms can be precipi-
tated and observed by placing hands in Surgery
cold water.
• Working with vibrating tools: Like pneumatic 1. Transluminal balloon angioplasty/percutaneous
road drills, chain saws, wood cutting, and transluminal balloon angioplasty/PTA): Through
fishermen traveling in machine boats. transfemoral Seldinger approach, initially
• Collagen vascular diseases: Like scleroderma, angiogram is done. Then under guidance (fluoro-
Rheumatoid diseases causing vasculitis scopic) stenosed area is approached. Balloon of
(All autoimmune diseases). the angioplasty catheter is inflated at stenosed
• Other causes: Cervical rib, Buerger’s disease, area for one minute and repeated if required.
Scalene syndrome. Catheter is withdrawn. It is useful in cases of
It is often associated with CREST syndrome. localised stenosed areas.
(Calcinosis cutis, Raynaud’s phenomenon, Complications: Thrombosis, bleeding, sepsis.
2. Atherectomy: It is removal of atheroma from thrombus if present, is removed. Opening is
the wall of the artery either through open surgery widened using either venous or synthetic (Dacron
or by percutaneous route of medium sized vessels. or PTFE) grafts. This procedure allows collaterals
across the knee joint through profunda femoris
3. Thrombectomy: It is removal of thrombus
and so gives good blood supply below-knee level
through an arteriotomy of larger vessels. It is
and may prevent patient going in for above-knee
done in aortoiliac, femoropopliteal region.
amputation.
4. Endarterectomy: It is removal of thrombus along (May be able to save knee joint with below-
with diseased intima through an arteriotomy. knee amputation with better prosthesis).
Fig. 1.97: Endarterectomy technique. Both thrombus and

diseased intima are removed through an arteriotomy. Often
ring stripper is used to remove the atheromatous plaque.
Fig. 1.99: Profundaplasty for deep femoral block.
7. Reverse saphenous vein graft: In case of

femoropopliteal block, saphenous vein is dissected
out, reversed and sutured above to the femoral
artery and below to popliteal segment so as to
bypass the blood through reverse saphenous vein
graft. Saphenous vein is reversed to nullify the
action of valves so as to allow easy flow of blood.
Fig. 1.98: Exposing femoral artery 8. In-situ saphenous vein graft: It is arterialisation
for endarterectomy technique. of saphenous vein. Saphenous vein intact in same
position is sutured above and below the blocked
5. Intraluminal stent placement.
femoropopliteal region to bypass the blood
6. Profundaplasty: It is done when there is across. Venous valves are removed through
localised block in opening of profunda femoris valvulotomy instrument so as to allow the blood
(deep femoral). Profunda femoris is opened, to pass.
9. Arterial/venous grafts:
Synthetic:
• Dacron woven graft.
• Dacron knitted graft.
• PTFE—Poly tetra fluoroethylene graft.
Natural:
• Internal mammary artery.
• Long saphenous vein either reverse or in situ.
Grafts of different length and size are
available.
Different procedures:
• Aorto-femoral bypass graft.
• Ileo-femoral bypass graft. Fig. 1.101: On table picture of aorto-femoral
• Femoro-femoral bypass graft. arterial graft.
• Femoro-popliteal graft.
• Femoro-distal graft.
Problems with grafts: Leak, infection, thrombosis,
cost factor, availability, re-block.
Fig. 1.100: Aorto-femoral bypass graft

(End to Side). Fig. 1.102: Femoro-popliteal bypass graft.
10. Cervical sympathectomy:
Indications
Cervical rib with vascular manifestations—
Useful
Raynaud’s phenomenon—Useful
A B
Hyperhydrosis—Very useful
Figs 1.104A and B: Patient underwent cervical sym-
Upper limb vasospasm due to other causes—
pathectomy left-side for ischaemic gangrene index finger
Useful tip which has healed now. Note the sympathectomy scar.
Acrocyanosis—Useful In another patient typical ptosis after sympathectomy is
Causalgia—Very useful seen.
Sudeck’s osteodystrophy
b. Transthoracic approach (Hedley Atkins): This
gives better visibility and easier removal of
rami, lower down compared to supracla-
vicular approach.
c. Endoscopic sympathectomy is the choice and
popular approach at present.
Advantages are better visibility with
magnification, less trauma of access (wound),
faster recovery, and precise.
11. Lumbar sympathectomy
Indications:
• Peripheral vascular disease like TAO.
• To promote healing of cutaneous ulcers.
A B
• To change level of amputation and to make
Figs 1.103A and B: Upper limb ischaemia left-side
flaps to heal better after amputation.
showing wasting, gangrene of digits.
• Causalgia of lower limb (it is common in
Approaches: upper limb).
a. Supraclavicular approach: Through an incision • Hyperrhidrosis.
in supraclavicular region, sternomastoid,
Principle: It increases the cutaneous blood supply
omohyoid, scalenus anterior muscles are
and so ulcer healing and healing of skin flaps
divided. Phrenic nerve is displaced medially;
in amputations is better. It will not improve
subclavian artery is pushed downwards;
intermittent claudication.
suprapleural membrane is depressed, stellate
ganglion is identified in the neck of the first Procedure: Under general or spinal anaesthesia,
rib. All rami communicanting from second ganglia are approached through a transverse
and third ganglia are divided and Kuntz nerve incision in the loin at the level of umbilicus,
is also divided. through extraperitoneal approach, by dividing
Complications: Bleeding, injury to subclavian external oblique, and splitting internal oblique,
artery and nerves, pneumothorax and and transverse abdominis muscles. Inferior vena
haemopneumothorax, Horner’s syndrome cava on right side, aorta on left side are identified.
with ptosis, miosis, anhydrosis, enophthal- Sympathetic chain is identified by its rami. L2,
mos. L3, L4, L5 Ganglia are removed. L2 is identified
by its size (Larger) and more number of rami. 13. Omentoplasty.

L1 is retained on one side in bilateral cases. It Indications:
is under the crus of the diaphragm. L4 is under 1. Peripheral vascular disease—To improve
iliac vessels. Sympathetic chain is deeply placed circulation.
in front of the vertebra with firm tense cord like 2. For lymphoedema it helps by providing
feeling with ganglia at different levels. After lymphatics and so to drain lymph from the
removal, chain should be sent for histology. Chain limb.
3. It is also tried for revascularisation of pharynx,
may be missed for genitofemoral nerve.
cranial cavity.
Lymphatics and lymph nodes are also can be Omentum is supplied by omental vessels.
missed for sympathetic chain. Chain has got grey
Coeliac artery
rami communicantes from spinal cord to the
↓
chain and ganglia; and white rami communi-
Right gastric artery Splenic artery
cantes begins at ganglia and enters the peripheral ↓ ↓
nerves. If it is removed it will lead on to failure Gastroduodenal artery Left gastro-epiploic
of ejaculation and so sterility. ↓ ↓ artery
Complications: Right gastro-epiploic artery → Omental vessels
1. Injury to IVC or aorta. Four layers of omentum have got omental
2. Bleeding lumbar veins. arcades of vessels. Omentum is also rich in
3. Spinal vessel spasm and so ischaemia of lymphatics. It has got adhesive property. By
spinal cord and paraplegia. retaining one of the pedicles, omentum can be
4. Injury to bowel and ureter. mobilised so as to reach the limb to maintain
5. Wound infection and abscess formation. the circulation. It can also be mobilised up to
Its effects are only temporary (3-4 wks). Long the ankle. It promotes ulcer healing, reduces the
pain, and controls the features of ischaemia. It
term results are doubtful. It can be combined
can be used in upper limb ischaemia. But if
with omentoplasty.
patient continues to smoke, disease spreads to
It can also be done along with below- knee these omental vessels also. Often it can be used
amputation to increase the blood supply of skin for both limbs.
flap so as to have better healing.
Complications of omentoplasty:
Limb will become warmer immediately after • Abdominal sepsis.
sympathectomy. • Incisional hernia, where omental pedicle is
12. Chemical sympathectomy tunneled into the limb from the abdomen.
It is done in lateral position using a long spinal • Adhesions and intestinal obstruction.
needle under local anaesthesia. Position is Procedure:
confirmed by injecting dye under fluoroscopy. Under general anaesthesia, abdomen is opened
Later 5 ml of phenol in water or absolute alcohol with upper midline incision. Omental vessels
are identified. Omentum with its blood supply
(1: 16) is injected lateral to the vertebral bodies
is carefully mobilised to get a adequate length.
of second and fourth lumbar vertebrae. Care
Lengthened, mobilised omentum is brought into
should be taken to see that the needle does not the subcutaneous plane through abdominal wall,
enter IVC or Aorta. Procedure is contraindicated lateral to the lower part of rectus muscle. Later
in patients with bleeding disorders and in patients this pedicle is mobilised in the subcutaneous
who are on anticoagulants. tunnel across the leg, burried in the deep fascia.
A B
Fig. 1.106: Incisional hernia in omentoplasty patient. Patient

also has failure of omentoplasty and underwent above
knee amputation because of gangrene.
Other treatment methods:

D Amputations at different levels depending on
extent of gangrene, site of block, amount of
collaterals.
F
Fig. 1.107: Amputated 2nd toe (ray amputation)—healing
well-done for toe gangrene. It was dry gangrene.
Subclavian Steal Syndrome

Following obstruction of the first part of
subclavian artery, vertebral artery provides
collateral circulation to the arm by reversing its
G blood flow. This causes cerebral ischaemia with
syncopal attacks.
Figs 1.105A to G: Omentoplasty technique. Mobilization
of greater omentum with its arterial arcade and bringing Visual disturbances, diminished blood
down to the limb up to the ankle. pressure in the affected limb.
3. Acute compartment syndrome.

4. During femoral or brachial arterial catheteri-
sation, either diagnostic or therapeutic
procedures.
Clinical features: H/o trauma, pain, swelling at the
site, pallor, pulselessness, cold limb
Investigation: Duplex scan, angiogram.
Fig. 1.108: Forefoot amputation – it is not an ideal procedure
for vascular disease. In this patient wound is granulating Treatment: Wound is explored and tear in the
well after amputation. It is probably due to good number artery is identified. It is sutured using non-
of opened collaterals in the foot. absorbable monofilament material, polypropylene
6-0. Often venous or dacron graft is required for
Symptoms will be aggravated by arm exercise. interposition.
Investigations: Duplex scan and angiogram. DSA Proper antibiotics and heparin are required
is useful. to prevent thrombosis of the vessel. Later patient
is advised to take oral warfarin for maintenance.
Treatment: Transluminal balloon angioplasty/
endarterectomy or bypass graft. Compartment syndrome: Is common in anterior
compartment leg and in front of forearm. Here
because of the closed compartment, pressure
increases following fracture, haematoma which
compresses over the vessel. It leads to blockade
of vessel causing acute ischaemia of the limb
presenting with severe pain, pallor, pulse-
lessness.
Treatment: Immediate decompression by longitudinal
fasciotomy, is the treatment of choice, where in
deep fascia is cut adequately to relieve the
compression. Otherwise limb may go for severe
ischaemia, gangrene and may land with
amputation.
Associated fractures, haematoma, vessel tear
has to be managed accordingly.
Fig. 1.109: Subclavian steal syndrome.
Embolism
Acute Arterial Occlusion It is due to a solid material which is floating
Causes and traveling in the blood stream, eventually
1. Trauma. blocking the vessel on its pathway.
2. Embolism. Arterial emboli: Source-due to mural thrombus
following—
Traumatic Acute Arterial Occlusion • Myocardial infarction.
Causes • Mitral stenosis.
1. Thrombus due to trauma. • Atrial fibrillation.
2. Subintimal haematoma. • Aortic aneurysms.
• Cervical rib causing poststenotic dilatation and agents are injected intraarterially through
of subclavian artery. the arterial catheter.
Venous emboli are due to DVT causing
Drugs used are:
pulmonary embolism.
• Streptokinase (here lysis occurs in 48 hours).
– Fat embolism.
– Air embolism. • Urokinase.
• Tissue plasminogen activator. (TPA)— Here
Effects of Arterial Embolism lysis occurs in 24 hours.
• Brain: Blockage at middle cerebral artery • TPA pulse- spray method – here lysis occurs
causes hemiplegia, transient ischaemic in 6 hours.
attacks (TIA), visual disturbances. Contraindications for thrombolysis: Stroke, bleeding
• Blockage at central retinal artery causes diathesis, pregnancy.
amaurosis fugax, or permanent blindness. Heparin should not be used concomitantly
• Blockage at mesenteric vessels causes with fibrinolysins.
intestinal gangrene.
• Blockage at renal artery lead to haematuria,
loin pain.
• Blockage at limb vessels causes pain, pallor,
pulseless, paraesthesia, paresis, ulceration,
gangrene.
Commonest site of arterial emboli is common
femoral artery.
Investigations for Arterial Embolism

• Emergency Doppler, ECG and echocardio-
graphy, angiogram.
• Relevant tests for origin of emboli.
Treatment
1. Embolectomy: It is done as early as possible
as an emergency operation. Under fluoroscopic
guidance, Fogarty catheter (interventional
radiology) is passed beyond the embolus and
balloon is opened. Catheter is pulled out gently
with embolus. Procedure has to be repeated until
embolectomy is completed and bleeding occurs.
Angiogram is repeated to confirm the free flow. Fig. 1.110: Embolectomy technique.
Postoperatively initially heparin and later oral
anticoagulant are used. Procedure is done under Saddle Embolus
general anaesthesia. It is an embolus blocking at bifurcation of aorta.
Open arteriotomy and embolectomy can be done
Causes:
by direct approach and later the arteriotomy has
• Mural thrombus after myocardial infarction.
to be sutured. Postoperatively, anticoagulants,
• Mitral stenosis with atrial fibrillation.
antibiotics should be given.
• Aortic aneurysm.
2. Intraarterial thrombolysis using fibrinolysins: The embolus which blocks at aortic
After passing arterial catheter, angiogram is done bifurcation is usually large.
Treatment:
• Initially, heparin is given intravenously -
10,000/ units and later 5,000 units/-
subcutaneously 8th hourly.
• Embolectomy can be done using Fogarty
catheter.
• Open arteriotomy and embolectomy can also
be tried.
• Antibiotic prophylaxis has to be given to
prevent infection.
Fat Embolism
Fig. 1.111: Fogarty catheter. It is 80 cm in length with
It is commonly seen after fracture femur, tibia, or
4 to 7 French size. It is used for embolectomy. Note multiple fractures and occasionally following
the inflated balloon at the tip. electro convulsive therapy, usually occurs in
24-72 hours.
It is due to aggregation of chylomicrons,
derived from bone marrow, causing fat embolism.
It is often a fatal condition.
Features:
• Cerebral: Drowsy, restless, disoriented,
constricted pupils, pyrexia, coma.
• Pulmonary: Cyanosis, tachypnoea, right heart
failure, froth in mouth and nostrils, fat
droplets in sputum, eventually respiratory
failure.
• Cutaneous: Petechial haemorrhages in the skin.
• Retinal artery emboli is the earliest sign to appear,
causing striae haemorrhages, fluffy exudates
confirmed on fundoscopic examination.
• Kidney: Blockage in renal arterioles results
in fat droplets in urine.
Treatment: Oxygen, heparinisation, low mole-
cular weight dextran, ventilator support and
Fig. 1.112: Saddle embolus blocking the ICU management.
bifurcation of abdominal aorta.
Air Embolism
Clinical features:
• Features of ischaemia in both lower limbs. Causes:
• Gangrene of both lower limbs. • Through venous access like IV cannula.
• Associated infection and its features. • During artificial pneumothorax.
• During surgeries of neck and axilla.
Investigations: • Traumatic opening of major veins sucking
• Arterial Doppler. air inside, causing embolism.
• Aortic angiogram. • During fallopian tube insufflation.
• U/S abdomen. • During illegal abortion.
Amount of air required to cause air embolism Types
is 50 ml. • Fusiform
When the air enters the right atrium, it gets • Saccular
churned up forming foam which enters the right • Dissecting
ventricle and then blocking the pulmonary artery.
Treatment:
Patient has to be placed in Trendelenburg
position. By passing a needle, the air has to be
aspirated from the right ventricle. Often requires
life saving open thoracotomy to aspirate the
excess air causing the block.
Therapeutic Embolisation
Indications:
Fig. 1.113: True and false aneurysms. In true type, all
• Haemangiomas,
layers are intact. In false type all layers breached with
• AV fistulas, haematoma having a false capsule.
• Malignancies like renal cell carcinoma,
hepatoma,
• Craniovascular problems.
• To arrest haemorrhage from GIT, urinary and
respiratory tract.
In bleeding duodenal ulcer or gastric ulcer,
embolisation is used to occlude gastroduodenal
artery or left gastric artery respectively. It also
useful in bleeding oesophageal varices,
secondaries in liver (mainly due to carcinoids),
hepatoma.
Materials used
- Blood clot - Human dura
- Gel foam - Plastic microspheres
- Balloons - Ethyl alcohol
- Quick setting plastics - Wool
- Stainless coils. Fig. 1.114: Fusiform and Saccular types of aneurysms.
Causes
Aneurysms • Atherosclerosis.
It is dilatations of localised segment of arterial • Syphilis.
system. • Traumatic.
• True aneurysm contains all three layers of • Collagen diseases like Marfan’s syndrome.
artery.
• False aneurysm contains single layer of Mycotic Aneurysm
fibrous tissue as wall of the sac and it usually It is a misnomer. It is not due to fungus but
occurs after trauma. due to bacterial (commonly Staphylococcus,
Streptococcus) infection. Origin of bacteria may Differential diagnosis:

be from any site of infection in the body. 1. Pyogenic abscess: Abscess has to be always
confirmed by aspiration ; especially in axilla,
Sites:
popliteal region, groin.
• Aorta.
2. Vascular tumours.
• Femoral.
3. Pulsating tumours: Sarcomas, pulsating
• Popliteal.
secondaries.
• Subclavian.
4. Pseudocyst of pancreas mimics aortic
• Cerebral, mesenteric, renal, splenic arteries
aneurysm.
• Commonest is true, fusiform, atherosclerotic,
5. A-V fistula.
aortic aneurysms.
Investigations:
Doppler study, duplex scan, angiogram , DSA.
Tests relevant for the cause, like blood sugar,
lipid profile, echocardiography.
Treatment:
• Reconstruction of artery using arterial grafts.
• Arterial endoaneurysmorrhaphy—MATA’S.
• Therapeutic embolisation,
• Clipping the vessel under guidance (e.g.
cranial aneurysms).
Abdominal Aneurysms
Abdominal aortic aneurysm is the commonest aortic
aneurysm. It has got 2% incidence.
Causes:
Fig. 1.115: Thoracic aortic aneurysm. Atherosclerosis: 95%.
Others: Syphilis, dissecting, traumatic, collagen
Berry’s aneurysms are multiple aneurysms diseases.
occurring in circle of Willis. Classification I:
Clinical features of aneurysms: • Infrarenal—Commonest. 95%.
• Swelling at the site which is pulsatile, • Suprarenal 5%.
(expansile), smooth, soft, warm, compressible, Classification II
with thrill on palpation and bruit on auscul- 1. Asymptomatic: Found incidentally either on
tation. Swelling reduces in size when pressed clinical examination or on angiography or
proximally. on ultrasound. Repair is required if diameter
• Distal oedema due to venous compression. is over 5.5 cm on ultrasound.
• Altered sensation due to compression of 2. Symptomatic without rupture: Present as back
nerves. pain, abdominal pain, mass abdomen which is
• Erosion into bones, joints, trachea or smooth, soft, nonmobile, not moving with
oesophagus. respiration, vertically placed above the
• Aneurysm with thrombosis can throw an umbilical level, pulsatile both in supine as
embolus causing gangrene of toes, digits, well as knee-elbow position with same
extending often proximally also. intensity, resonant on percussion. GIT,
urinary, venous symptoms can also occur.
Complications
Hypertension, diabetes, cardiac problems
• Haemorrhge
should be looked for and dealt with.
• Colonic ischaemia
Investigations: • Renal failure
Blood urea, serum creatinine. • Sexual dysfunction
U/S, aortogram. • Aorto-duodenal fistula
DSA, CT scan, MRI. • Graft Leak, graft thrombosis, graft failure
• Aorto venacaval fistula
Treatment:
• Spinal cord ischaemia
If aneurysm is more than 5.5 cm then surgery
is the choice.
Options are
• Open surgical aneurysm repair using PTFE
or dacron graft.
• Endoluminal stent graft procedure using
interventional radiology with Seldinger's
technique. Adequate amount of blood is
required for surgery.
Symptomatic Ruptured Aortic Aneurysm

Risk of rupture is 1%, if diameter is within
5.5 cm in size. Risk increases to 20% once the
diameter = 7 cm. It may be anterior rupture (20%)
into the free peritoneal cavity causing severe shock
and death very early; or posterior rupture (80%)
with formation of retroperitoneal haematoma of large
size causing severe back pain, hypotension,
shock, absence of femoral pulses and with
palpable mass in the abdomen.
Management of ruptured aneurysm:
• Immediate diagnosis by ultrasound. Fig. 1.116: Chest X-ray showing aortic aneurysm.
• Resuscitation.
• Massive blood transfusions ( 10-15 bottles).
• Emergency surgery is the only life saving
procedure in these cases.
Patient has to be shifted to the operation
theatre. Abdomen is opened. Vascular clamps or
bull dog clamps are applied to the aorta above
and below the aneurysm. Adventitia is opened
and the clot is removed. Aneurysm is excised
and the arterial graft PTFE (Polytetra fluoro-
ethylene), knitted dacron graft, or woven dacron graft
is placed. The graft is sutured to the vessel above
and below using monofilament, nonabsorbable
suture material, polypropelene 5-zero. Fig. 1.117: Abdominal aortic aneurysm ultrasound picture.
• Cystic medial necrosis.

• Marfan’s syndrome and collagen diseases.
• Trauma.
• Weakening of the elastic layers of the media
due to shear forces.
Features:
• It is always seen in thoracic aorta, common
in ascending aorta. (70%).
• It is uncommon in other part of aorta or other
Fig. 1.118: Infra-renal aortic aneurysm repair. It is vessels.
the commonest site of aortic aneurysm.
• It can occur in aortic arch or thoracic
descending aorta.
Peripheral Aneurysms • This dissected aortic channel gets lined by
Popliteal aneurysm endothelium, often re-opens distally into the
• Is commonest (70%). aorta causing double-barreled aorta which in
• 65% are bilateral. fact prevents complications.
• 25% cases are associated with abdominal • It is commonly associated with aortic
aortic aneurysm. insufficiency.
• 75% causes complications in 5 years.
Presentations
• Swelling in popliteal region which is smooth,
soft, pulsatile, well localised, warm, and
compressible, often with thrill and bruit. It
may mimic a pyogenic abscess.
• Thrombosis and emboli from popliteal
aneurysm can cause distal gangrene which
may be spreading proximally and may lead
to amputation.
• Rupture may cause torrential haemorrhage.
Investigations
• Duplex scan, angiogram.
• CT scan/CT angiogram.
• MRI/MR angiogram.
Fig. 1.119: Dissecting aneurysm.
Treatment
• Repair with arterial graft using PTFE, dacron.
• Endoluminal stenting. Dissecting aneurysm is a misnomer. It is only
• Aneurysmorrhaphy. aortic dissection.
Atherosclerosis is not a usual cause for
Dissecting aneurysm: It is the dissection of media dissecting aneurysm.
of the aorta after splitting through intima creating
a channel in the media of the vessel wall. Classification (DeBakey’s):
Causes: Type I: Dissection begins in ascending
• Hypertension (It is associated in 80% of aorta extends into descending thoracic aorta
dissecting aneurysms). (70%).
Type II: Dissection origins and extends only up Cyanosis which is persisting may aggravate by
to the origin of the major vessels.it is safer type exposure to cold. It may be associated with
with less complications. endocrine dysfunction.
Type III: Dissection begins in the descending Treatment: Vasodilators, cervical sympathectomy
thoracic aorta beyond the origin of the left (Effective).
subclavian artery.
Gangrene
Dissecting aneurysm can be
It is macroscopic death of tissue in situ (in continuity
• Acute.
with adjacent viable tissue) with or without
• Chronic.
putrefaction.
• Healed dissecting aneurysm which communi-
It can occur in—limbs, appendix, bowel,
cates distally again to aorta as double
testes, gall bladder.
barreled aorta.
Complications:
Acute: Rupture into the pericardium or pleura
- dangerous type.
Chronic: Blockage of coronary vessels, major
vessels like carotid, subclavian arteries with
aortic insufficiency.
Clinical features:
• Pain in the chest, back which is excruciating.
• Features of ischaemia due to blockage of
different vessels.
Investigations:
• Chest X-ray shows mediastinal widening.
• Arterial Doppler.
• Angiogram.
Treatment: Antihypertensives.
Surgery: Using Dacron graft reconstruction of Fig. 1.120: Gangrene of toes and
aorta has to be done with cardio-pulmonary by- ischaemic changes in the foot.
pass.
Causes
Indications for surgery: Secondary to arterial obstruction like athero-
• Progressive disease sclerosis, emboli, diabetes, TAO, Raynaud’s
• Significant ischaemia disease, ergots, etc.
• Impending rupture.
Infective: Boil, carbuncle, gas gangrene, Fournier’s
Acrocyanosis gangrene, cancrum oris.
It is persistent, painless cyanosis seen in fingers Traumatic: Direct, indirect.
and often in legs with paraesthesia and chilblains
affecting young females. It is chronic persistent Physical: Burns, scalds, frostbite, chemicals,
arteriolar constriction with slow rate of blood irradiation, electrical.
flow. Trophic changes, ulcerations are not seen. Venous gangrene.
Clinical Features Investigations

1. Colour changes: Pallor, greyish, purple, • Hb%, blood sugar.
brownish black due to disintegration of • Arterial Doppler, angiogram (Seldinger's
haemoglobin to sulphide. technique).
2. Absence of pulse, loss of sensation, loss of • U/S abdomen to find out the status of aorta.
function,
3. Line of demarcation between viable and dead
tissue by a band of hyperaemia and
hyperaesthesia with development of a layer
of granulation tissue.
In dry gangrene separation occurs by aseptic
ulceration with minimum infection and
gangrene is dry, and mummified.
In moist gangrene separation takes place by
septic ulceration. Often demarcation is vague
with skip lesions more proximally and so
landing with higher level of amputations.
Even after amputation skin flap may show A
die back process, leading to failure of taking
up of flap of amputation and so require still
higher level of amputation.
4. Proximal ischaemic features may be present with
rest pain, colour changes, hyperaesthesia—
pregangrene.
B
Types of Gangrene Figs 1.122A and B: Gangrene both in lower and
Dry gangrene is due to slow gradual loss of blood upper limbs. Note all features of gangrene.
supply to the part causing dry, desiccated,
wrinkled, mummified part with proper line of
Treatment
demarcation.
Wet gangrene is due to infection with put- Limb saving methods:
refaction, causing oedematous, swollen, • Drugs: Antibiotics, vasodilators, pentoxiphyl-
discolouration, spreading proximally, with vague line, praxilene, dypyridamole, small dose of
line of demarcation. aspirin, ticlopidine.
• Care of feet and toes:
• The part has to be kept dry.
• Any injury has to be avoided.
• Proper footwear is advised (Microcellular
rubber footwear, MCR).
• Measures for pain relief is taken.
• Nutrition supplementation is done.
• The limb should not be heated.
• Pressure areas has to be protected.
• Localised pus has to be removed.
Fig. 1.121: Dry gangrene of leg. Patient needed • Cause has to be treated.
above knee amputation. • Diabetes has to be controlled.
• Surgeries to improve the limb perfusion: • Osteomyelitis of different bones of foot like
Lumbar sympathectomy, omentoplasty, metatarsals, cuneiforms, calcaneum.
profundaplasty, femoropopliteal thrombec- • Diabetic gangrene.
tomy or endarterectomy, arterial graft bypass • Arthritis of the joints.
are done according to the need.
Pathogenesis of Diabetic Foot/Gangrene
Life saving procedures: • High glucose level in tissues is a good culture
Amputations may have to be done occasionally. media for bacteria. So infection is common.
Level of amputation has to be decided on skin • Diabetic microangiopathy causes blockade of
changes, temperature, line of demarcation and microcirculation leading to hypoxia.
Doppler study. • Diabetic neuropathy: Due to sensory neuro-
• Below-knee amputation is a better option as BK pathy, minor injuries are not noticed and so
prosthesis can be fitted better and also the infection occurs. Due to motor neuropathy,
movements of knee joint are retained. There dysfunction of muscles, arches of foot and
is no need of external support and limp is joints, and loss of reflexes of foot occurs
absent. causing more prone for trauma, abscess, etc.
• In above-knee amputation range of movements Due to autonomic neuropathy, skin will be
is less, limp is present and often requires dry, causing defective skin barrier and so
third (stick) support to walk. more prone for infection.
• Different amputations done are Ray ampu- • Diabetic atherosclerosis itself reduces the blood
tation, below-knee amputation (Buerges’s supply and causes gangrene. Thrombosis can
amputation), Gritti-Stokes transgenial ampu- be precipitated by infection causing infective
tation, above-knee amputation. gangrene. Blockage occurs at plantar, tibial,
Lisfranc’s, Chopart’s, Symes‘, Modified and dorsalis pedis vessels.
Symes‘ amputations are not commonly used in • Increased glycosylated haemoglobin in blood
ischaemic limb as flaps will not survive. causes defective oxygen dissociation leading
to more hypoxia. At tissue level there will
Diabetic Foot and Diabetic Gangrene be increased glycosylated tissue proteins,
Foot is a complex structure with many layers which prevents proper oxygen utilisation and
of muscles, ligaments, joints, arches, fat, thick so aggravates hypoxia.
plantar fascia, vascular arches, neurological
system which maintains weight bearing, gravity, Clinical Features
normal walk (swing, and stance phases). • Pain in the foot.
• Ulceration.
Problems in Diabetic Foot • Absence of sensation.
• Callosities, ulceration. • Absence of pulsations in the foot (Posterior
• Abscess and cellulitis of foot. tibial and dorsalis pedis arteries).
• Loss of joint movements.
• Abscess formation.
• Change in temperature and colour when
Meggitt’s classification of diabetic foot:
gangrene sets in.
Grade 0: Foot symptoms like pain, only.
Grade 1: Superficial ulcers.
Investigations
Grade 2: Deep ulcers.
• Blood sugar, urine ketone bodies.
Grade 3: Ulcer with bone involvement.
• Blood urea and serum creatinine.
Grade 4: Forefoot gangrene.
• X-ray of part to see osteomyelitis.
Grade 5: Full foot gangrene.
• Pus for culture and sensitivity.
• Doppler study of lower limb to assess arterial Ainhum

patency
• Angiogram to see proximal blockage
• U/S abdomen to see status of abdominal
aorta.
Treatment
Foot can be saved only if there is good blood
supply.
• Antibiotics—decided by pus C/S.
• Regular dressing.
• Drugs: Vasodilators, pentoxiphylline,
dipyridamole, small dose of aspirin.
• Diabetes has to be controlled by insulin only.
• Diet control, control of obesity.
• Surgical debridement of wound.
• Amputations of the gangrenous area. If blood
supply is not present, then below knee or
above knee amputation may be required. Level
of amputation has to be decided by skin and
temperature changes or Doppler study.
• Care of feet in diabetic:
– Any injury has to be avoided.
Fig. 1.123: Typical Ainhum. Note it is bilateral. Note the
– MCR foot wears must be used. constriction ring in the little toe. It may go for autoamputation.
– Feet has to be kept clean and dry, It needs Z plasty.
especially the toes and clefts.
– Hyperkeratosis has to be avoided. • Commonly affects males (can also occur in
females)
Frostbite
• Common in blacks, in Negroes.
• It is due to exposure to cold wind or high
• History of running barefoot in childhood is
altitude.
common.
• It is common in old age during cold spells.
• Damage to vessel wall causes oedema, • Fifth toe is commonly affected. A fissure
blistering, gangrene formation. develops in interphalangeal joint which
• Part is painless and waxy. becomes a fibrous band that encircles the digit
• Treatment: Gradual warming is done. Part causing necrosis. (Gangrene of little toe).
should be wrapped with cottonwool and • Often it is bilateral.
rested. Warm drinks, analgesics, paraverte- • Treatment: is early ‘Z’ plasty. Amputation is
bral injections to sympathetic chain, hyperbaric often required later. Commonly auto-
oxygen are effective. amputation occurs.
VARICOSE VEINS
due to long saphenous vein varicosity; on

WRITING A CASE SHEET FOR
the lateral aspect is due to short saphenous
VARICOSE VEINS (LONG CASE) vein varicosity.
Name: Address: Age: • Discharge from ulcer: Its type, smell, quantity
signifies the severity of the infection.
Occupation: Varicose veins are more common in • Itching and bleeding in the ulcer bed are also
people who stand for long hours like bus important.
conductors, nurses, doctors, manual labourers,
watchmen, traffic policemen, etc. History of trauma: Often minor trauma precipi-
tates ulcer formation in patients with varicose
Chief Complaints vein.
• Pain in the leg/thigh/foot with the duration History of swelling around the ankle.
of pain and side.
• Swelling/dilated veins in the leg and its History of pain/lump in the abdomen.
duration. History of urinary/bowel symptoms.
• Pigmentation/ulceration in the leg with
duration. History of similar complaints on the other leg—
Varicose veins are often bilateral.
History
History of Present Illness Past History
• History suggestive of earlier deep vein
Pain
thrombosis like pain, calf swelling and fever.
• Pain in the leg/foot/or thigh with duration.
• History of immobilisation, hospitalisation.
Origin of pain, its severity, nature of onset
• History of any previous surgery.
whether acute or insidious has to be asked.
• Character of pain: Dull aching or cramping
Treatment History
should be asked. Whether pain gets aggra-
• History of previous surgery for varicose vein,
vated by walking/standing should be noted.
drug intake like warfarin for DVT, injection
Dull aching pain along the line of the vein
therapy—sclerotherapy, wearing stockings/
is typical and usually aggravates in the
crepe bandages.
evening and gets relieved by lying down. Pain
in calf of short duration, may be due to co-
Personal History
existing deep vein thrombosis (DVT).
• In females, history of pregnancy, delivery and
• Pain also can be due to ulcer/periostitis/
postdelivery period, oral contraceptive
infection.
intake.
Pigmentation • Smoking/alcohol/working pattern.
• It is due to stasis and release of chemicals
and usually occurs around ankle region. Family History
• It is associated with itching and often Family history relevant of varicose veins.
ulceration. • Often varicose veins are familial, which are
Ulcer bilateral and severe, observed in young
• History: Mode of onset, duration, site of onset. individuals. There are absent/defective
Ulcer on the medial aspect of the ankle is valves in these patients.
Local Examination
Examination of lower limbs—symptomatic limb
should be examined first.
Inspection
Examination of veins in standing position is the
first method in varicose veins.
B
A B
Figs 1.124A and B: Inspection of varicose veins should be Figs 1.125A and B: Bilateral varicose.
done on standing. Long saphenous veins on both sides should
be inspected along medial aspect in standing position. Short • Brodie-Trendelenburg test
saphenous vein should also be inspected from behind. Vein is emptied by elevating the limb and
milking the vein in lying down position; a
• Limb is looked for dilated long saphenous tourniquet is tied just below the sapheno-
vein on the medial side and for short saphe- femoral junction (or saphenofemoral junction
nous vein on posterior and lateral side. Other can be occluded using a thumb). Saphenous
communicating veins are also looked for. opening is located 3.5 cm below and lateral
• Beginning of the varicosity in the foot, later to the pubic tubercle. Pubic tubercle is
its extent above also should be examined. palpated along the adductor longus tendon
Great saphenous vein tortuosity often extends which is identified by adducting the thigh
into the thigh whereas short saphenous vein against resistance. Patient is asked to stand
varicosity ends at popliteal region. quickly. When tourniquet or thumb is
• Always limb is looked for skin changes, released, rapid filling from above signifies
pigmentation, oedema, ankle flare, and ulcer. sapheno femoral incompetence. This is
Cough impulse at saphenous opening Trendelenburg test I.
(Morrisey’s) may be significant. In Trendelenburg test II, vein is emptied again
• Extent, size, shape, margin, edge and in lying down position and tourniquet is
discharge in an ulcer should be noted. applied at sapheno-femoral junction. After
standing without releasing the tourniquet,the
Palpation limb is observed. Filling of blood from below
• Ulcer, if present should be described with upwards rapidly can be observed within
tenderness, induration, warmness, mobility, 30-60 seconds. It signifies perforator incompe-
fixity to the underlying bone, etc. tence.
A B
Figs 1.126A and B: Long saphenous vein varicosity. Note the prominent of veins and blow outs.
Note the diagrammatic representation of varicose veins.
Figs 1.127A to C: Emptying of the superficial varicose vein is important in all tourniquet
tests for varicose veins. It is done in lying down position with elevating and milking the
vein. Emptying is not done in modified Perthes’ test. Note the marking of the saphenofemoral
junction before applying the tourniquet.
3. Another below knee level.

4. Additional tourniquets often may be
applied at below-knee and above ankle
level.
A
Patient is asked to stand; filling of veins and
site of filling is looked for. Then tourniquets are
released from below upwards to look again for
incompetent perforators. Individual perforators
may be tested by repeating the procedure.
B
Figs 1.128A and B: Note the site of applying the tourniquet
at sapheno-femoral junction. It is 3.5 cm below and lateral
to pubic tubercle.
Fig. 1.129: Tourniquet test. After emptying the vein by

elevating the leg and milking, tourniquet is applied. Patient
is asked to stand, tourniquet is released immediately and
saphenous vein is observed. Rapid filling of vein from
above signifies LSV varicosity with sapheno-femoral
incompetence.
• Three/multiple (Oschner’s Mahoner’s test)

tourniquet test: To find out the site of
incompetent perforator, three tourniquets are C
tied after emptying the vein—
1. At sapheno-femoral junction.
2. Above knee level.
• Schwartz test: In standing position, when lower
part of the vein in leg is tapped, impulse is
felt at the saphenous junction or at the upper
end of the visible part of the vein. It signifies
continuous column of blood and valves
between two fingers are incompetent due to
valvular incompetence. It signifies continuous
column of blood and also signifies. Positive
test is usually found in gross venous varicosity.
• Pratt’s test: Esmarch bandage is applied to
the leg from below upwards with a tourniquet
D tied at saphenofemoral junction. The bandage
is released after that to see the ‘blow outs’
as perforators.
• Fegan’s test: Line of varicose vein is marked.
On standing, the site where the perforators
enter the deep fascia bulges and these points
are also marked. In lying down, button like
depressions (crescentric gaps) in the deep
fascia are felt at the marked out points which
confirms the perforator site.
• Ian-Aird test: On standing, proximal segment
of long saphenous vein is emptied with two
fingers. Pressure from proximal finger is
released to see the rapid filling from above
which confirms saphenofemoral incompe-
tence.
• Perthes' test: The affected lower limb is wrap-
ped with elastic bandage and the patient
E F is asked to walk around and exercise.
Development of severe crampy pain in the
calf signifies DVT.
• Modified Perthes' test: Tourniquet is tied just
below the sapheno femoral junction without
emptying the vein. Patient is asked to do a
brisk walk which precipitates bursting pain
in the calf and also makes superficial veins
more prominent. It signifies DVT.
DVT is contraindicated for any surgical
intervention of superficial varicose veins. It is
also contraindicated for sclerosant therapy.
• Homan’s test is dorsiflexion of the foot to elicit
pain in the calf and Mose’s sign is squeezing
G H
the relaxed calf muscles sidewards to elicit
Figs 1.130A to H: Note the different phases of pain. Both tests signify deep vein thrombosis
multiple tourniquet tests. (DVT).
Point to be remembered is that in case Venous Doppler in varicose veins

of acute DVT, Homan’s/Mose’s tests should not • To find out DVT- very important
be done as it will precipitate the dislodgement • To find out sapheno-femoral, sapheno-
of the clot and embolism. popliteal incompetence
• Bone thickening in the shin (tibia and ankle) • To find out perforator incompetence
is important which signifies periostitis.
• Measurement limb length and girth is needed 2. Duplex scan is a highly reliable U/S Doppler
especially in arterio-venous malformation imaging technique (Here high resolution B
with varicose veins and also to find out mode ultrasound imaging and Doppler
deformities. ultrasound is used) which along with direct
visualisation of veins, gives the functional
Auscultation and anatomical information, and also colour
Auscultation of the vein for bruit/venous hum. map. Examination is done in standing and
lying down position and also with valsalva
Other Examinations maneuver. Hand held Doppler probe is
Examination of peripheral pulses are important placed over the site and visualised for any
(dorsalis pedis/anterior tibial/posterior tibial/ block and reversal of flow. DVT is very well-
popliteal/femoral). identified by this method.
Regional lymph nodes Vertical inguinal nodes
and external iliac nodes (above and medial aspect
of the inguinal ligament) are palpated.
Ankle Joint movements (plantar and dorsi-
flexion) are checked for any restriction.
Examination of the other limb both in standing
and lying down position should not be forgotten.
Abdomen should be examined for any mass
which might be compressing the inferior vena
cava (IVC) or iliac veins causing varicose veins.
Examination of other systems also should be
done.
INVESTIGATIONS FOR
VARICOSE VEINS
Fig. 1.131: Doppler machine used for varicose
Specific Investigations veins and DVT.
1. Venous Doppler: With the patient standing;
the Doppler probe is placed at sapheno- 3. Venography
femoral junction and later wherever required. • Ascending venography was a very common
Basically by hearing the changes in sound, investigation done earlier to Doppler period.
venous flow, venous patency, and venous A tourniquet is tied above the malleoli
reflux can be very well-identified. and the vein of dorsal venous arch of foot
5. Ambulatory venous pressure.
6. Arm-foot venous pressure (Foot pressure is
not more than 4 mmHg above the arm
pressure).
7. U/S abdomen, peripheral smear, platelet
count, and other relevant investigations are
done depending on the cause of the varicose
veins. If venous ulcer is present, then the
discharge is collected for culture and
sensitivity, biopsy from ulcer edge is taken
to rule out Marjolin’s ulcer, plain X-ray of
the part is taken to find out periostitis.
Routine Investigations
Fig. 1.132: Doppler showing DVT in leg. Deep vein • Haematocrit, blood urea, serum creatinine,
thrombosis is contraindicated for varicose vein surgery. blood sugar.
• Chest X-ray, ECG.
It is done mainly to prepare the patient for
surgery—for anaesthesia purpose.
TREATMENT FOR VARICOSE VEINS

Conservative Treatment
1. Elastic crepe bandage application from below
upwards or use of pressure stockings to the
Fig. 1.133: U/S showing IVC thrombosis. limb.
2. Diosmin therapy which increases the venous
is cannulated. Water soluble dye injected, tone.
flows into the deep veins (because of the 3. Elevation of the limb.
applied tourniquet). X-rays are taken below
and above knee level. Injection sclerotherapy (Fegan’s technique)
Any block in deep veins, its extent, By injecting sclerosants into the vein, complete
perforator status can be made out by this. sclerosis of the venous walls can be achieved.
Note: In the presence of Duplex scan
ascending venography is not necessary Indications
investigation. • Uncomplicated perforator incompetence
If DVT is present, surgery or sclerotherapy • In the management smaller varices
are contraindicated. • Recurrent varices
• Descending venogram is done when ascending • Short saphenous vein-uncomplicated
venogram is not possible and also to visulalise
incompetent veins. Here contrast material is
injected into the femoral vein through a Sclerosants
cannula in standing position. X-ray pictures • Sodium tetradecyl sulphate 3% (STDS)
are taken to visulalise deep veins and • Sodium morrhuate
incompetent veins. • Ethanolamine oleate
4. Plethysmography. • Polidocanol
Contraindications
Mechanisms of action of sclerosant
1. Sapheno-femoral incompetence.
• Causes aseptic inflammation leading to 2. Varicose veins with venous ulcer.
thrombosis 3. DVT.
• Causes perivenous fibrosis leading to block
• Causes approximation of intima leading to Advantages
obliteration 1. It can be done as an out patient procedure.
2. It does not require anaesthesia.
After emptying a 23 gauge needle is inserted Disadvantage: Inadvertent subcutaneous injection
into the vein with the patient sitting down, with can cause skin necrosis or abscess formation.
the legs kept horizontal. 0.5 ml of sclerosant is
injected into the vein and immediately compres- Foam sclerotherapy: STD 3% is taken in a syringe
sion is applied on the vein (to prevent the entry and is passed rapidly into another syringe which
of blood which may cause thrombosis, which contains air to form foam. This can be injected
into larger area of the vein and also long
later gets re-canalised and further worsens the
saphenous or short saphenous veins. Air gets
condition) so as to allow the development of
absorbed and endothelial destruction and
sclerosis and proper endothelial apposition.
sclerosis occurs.
Usually injection is started at the ankle region
and then preceded upwards along the length Echosclerotherapy: Sclerotherapy is done under
of veins at different points. Later pressure ultrasound duplex image guidance.
bandage is applied for three weeks. Often injection
may have to be repeated after a week. Surgery
a. Trendelenburg operation: It is juxta-femoral
Microsclerotherapy: Very dilute solution of flush ligation of long saphenous vein (i.e.
sclerosing agent like STDS, Polidocanal is injected flush with femoral vein), after ligating named
into the thread veins and reticular veins followed (superficial circumflex, superficial external
by application of compression bandage (30 G pudendal, superficial epigastric vein) and
needle). Dermal flare will disappear well by this unnamed tributaries. All tributaries should
method. be ligated otherwise recurrence occurs and
retained stump of the vein becomes tortuous
and dilated (saphena varix).
Fig. 1.135: Incision for Trendelenburg operation is on

Fig. 1.134: Note the typical ankle flare—dilated dermal below and medial aspect of the inguinal ligament at the
and reticular veins. Microslerotherapy is useful to these level of the sapheno-femoral junction. Long saphenous
veins. vein is identified and ligated flush with femoral vein.
b. Stripping of vein: Using Myer’s stripper vein
is stripped off. Stripping from below upwards
is technically easier. Immediate application
of crepe bandage reduces the chance of
bleeding and haematoma formation. A
C
Figs 1.137A to C: Note the stripper in place inside
the vein and stripped vein entangled to stripper.
Figs 1.136A and B: Myer’s stripper.

Note the stripper and olive tip.
Complication: Injury to saphenous nerve

causing saphenous neuralgia.
Stripping is not usually done for the veins
in the lower part of the leg. Fig. 1.138: Diagrammatic representation of stripping vein.
c. Subfascial ligation of Cockett and Dodd technologies Inc; Sunnyvale, CA, USA) (by
Perforators are marked out by Fegan’s method. Goldman 2000): This procedure is done under
Perforators are ligated deep to the deep fascia general or regional anaesthesia. A RFA
through incisions in antero-medial side of catheter is passed into long/short saphenous
the leg. vein near sapheno-femoral or sapheno-
d. Ligation of short saphenous vein at sapheno- popliteal junction under guidance. 85°C
popliteal junction. Stripping of the short temperature is used for longer period of time
saphenous vein is better. It is done using a to cause endothelial damage, collagen
rigid stripper. denaturation and venous constriction.
e. Removal of superficial varicose veins by hook Phlebectomy is done while withdrawing the
phlebectomy. catheter.
f. Linton’s approach is vertical skin incision • TRIVEX method—By subcutaneous illumi-
approach in the calf to do perforator ligation nation, a large quantity of fluid is injected
subfascially. percutaneously to identify the superficial
Contraindication for surgery: Deep vein veins. Superficial veins are removed using
thrombosis (DVT). suction.
• Subfascial endoscopic perforator ligation
surgery (SEPS)—is becoming popular.
• Endo-venous laser ablation (EVLA): It is done
as an OP procedure or as day- care surgery.
Patient lies supine with diseased leg flexed,
hip externally rotated and knee flexed. With
aseptic precaution, under U/S guidance LSV
is cannulated above the knee and a guide
wire is passed beyond SFJ and 5-French
Fig. 1.139: Cockett and Dodd catheter is passed over guide wire and tip
operation. Note the multiple small is placed 1 cm distal to the junction. 200 ml
transverse incisions. Perforators
are ligated deep to deep fascia.
of 0.1 % lignocaine is infiltrated along the
length of the LSV. Laser fibre is inserted up
to the tip of the catheter and catheter is
withdrawn for 2 cm and laser fibre protrudes
for 2 cm. Laser fibre is fired step by step using
diode laser one second withdrawal in 2
seconds. Once procedure is over catheter is
removed and pressure bandage is applied
for 2 weeks. Heat produced (729°C at tip)
by the laser produces steam bubbles with
Fig. 1.140: Linton’s incision and approach thermal damage of endothelium leading into
for perforator ligation. It is vertical incision occlusion of the vein.
in mid-calf region. Incision is deepened
upto the muscle plane by cutting the
deep fascia. All perforators are easily
Complications of varicose vein surgery
identified and ligated. • Infection
• Haematoma formation
Newer Methods Available for Treating • DVT
Varicose Vein • Saphenous neuralgia
• Radiofrequency ablation (RFA) method • Recurrence
(VNUS closure method) (VNUS medical • Pain along the stripped vein area
What are the aetiologies for varicose veins?
Varicosities are more common in lower limb.
Because of erect posture long column of blood
has to be supported which can lead to weakness
and incompetence of valves leading to
varicosities.
a. Primary varicosities are due to—
Fig. 1.141: After any intervention for varicose veins, – Congenital incompetence or absence of
crepe bandages should be applied for 3-6 weeks.
valves.
– Weakness or wasting of muscles.
Complications of varicose veins
– Stretching of deep fascia.
• Haemorrhage: Venous haemorrhage can
b. Secondary varicosities are due to—
occur from the ruptured varicose veins or
– Recurrent thrombophlebitis.
sloughed varicose veins, often torrential, but
– Occupational—standing for long hours.
can be controlled very well by elevation and – Obstruction to venous return like abdo-
pressure bandage minal tumour, retroperitoneal fibrosis,
• Eczema and dermatitis lymphadenopathy.
• Periostitis causing thickening of periosteum – Pregnancy (due to progesterone hormone).
• Venous ulcer – A-V malformations—congenital or
• Marjolin’s ulcer acquired.
• Lipodermatosclerosis – IVC/Iliac vein thrombosis.
• Ankylosis of the ankle joint
• Talipes equino varus What is the definition of the varicose veins?
• Deep venous thrombosis It is dilated, tortuous and elongated superficial
• Calcification vein with reversal of blood flow due to
incompetence of valves.
Discussion
What are the sites where varicosities can
What are the usual presentations of occur?
varicose veins?
• It is more common in females (10:1). It is much Sites where varicosities can occur
more common in females with a family • Lower limb
history. • Pampiniform plexus of veins-varicocele
• Often it is familial. • Vulva
• Familial varicose veins begin in younger age • Sites of portosystemic anastomosis (piles)
group and are seen bilaterally, involve all
veins including deep veins. Venous Ulcer
• Visible dilated veins in the leg with pain, It is the complication of varicose veins or deep
distress, nocturnal cramps, feeling of vein thrombosis.
heaviness, pruritus.
• Pedal oedema, pigmentation, dermatitis,
ulceration, tenderness, restricted ankle joint
movement.
• Bleeding, thickening of tibia occurs due to
periostitis.
• Positive cough impulse at the sapheno-
femoral junction. Fig. 1.142: Venous ulcer—typical site around the ankle.
Pathogenesis of Venous Ulcer Treatment

Varicose veins or DVT which are recanalised,
eventually causes chronic venous hypertension Bisgaard method of treating venous ulcer
around ankle. • Elevation
• Massage of the indurated area and entire
↓ calf
Causes hemosiderin deposition in the subcuta- • Passive and active exercise
neous plane from lysed RBC’s, Eczema
↓
Dermatitis and lipodermatosclerosis • Pressure bandage (crepe bandage). Multilaye-
↓ red (four) pressure bandage with pressure
Fibrosis—Anoxia of 45 mmHg is also very useful. This optimum
pressure promotes the ulcer healing without
↓ injuring the leg.
Ulceration
• Care of ulcer by regular cleaning with
povidone iodine, H2O2.
• Area where venous ulcer commonly develops is
around and above the medial malleoli because • Dressing with EUSOL. (EUSOL is Edinburgh
of presence of large number of perforators university solution of lime containing boric
which transmit pressure changes directly into acid, hypochlorite, and calcium hydroxide).
superficial system. This area is called as • Antibiotics depending on C/S of the dis-
Gaiter’s zone. It can be seen on both malleoli. charge.
• Ulcer is often large, nonhealing, tender, • Once ulcer bed granulates well, split skin
recurrent with secondary infection. Vertical graft (SSG, Thiersch graft) is placed.
group of inguinal lymph nodes are usually • Specific treatment for varicose veins should be
enlarged and tender. undertaken—Trendelenburg's operation,
• Often it leads to scarring, ankylosis, Marjolin’s stripping of veins, perforator ligation.
ulcer formation. Slough from the ulcer bed
may give way causing venous haemorrhage.
• Periostitis is common which also prevents ulcer Note:
from healing. 50% of venous ulcer occurs as a result of
• Due to regular walking on toes so as to get recanalisation of DVT, and the leg is commonly
relief from pain causes contraction and called as post phlebitic limb (leg). It presents with
extra-articular fibrosis of Achilles tendon. all complications of venous diseases like eczema,
Proper exercise is the remedy – talipes equino
ulceration, lipodermatosclerosis, and venous
varus.
ulcers.
Investigations Here surgery for superficial varicose veins
• Discharge from the ulcer for C/S. is contraindicated. Venous valve repair ( Kistner’s
• X-ray of the area to look for periostitis. valvuloplasty) or drugs like Stanazolol which
• Biopsy from the ulcer edge to rule out reduces the fibrous tissue in turn increases the
Marjolin’s ulcer. oxygenation are beneficial.
What are the types of varicose veins?
1. Long saphenous vein varicosity.
2. Short saphenous vein varicosity.
3. Varicose veins due to perforator incompe-
tence.
A B
Figs 1.143A and B: Typical site of venous ulcer. When

ulcer granulates well-split skin grafting is done. Definitive
treatment for varicose veins should be done.
Complications of venous ulcers

• Haemorrhage
• Marjolin’s ulcer
• Infection
• Talipes equino varus
• Periostitis is common over the tibia A B
• Disability
Figs 1.145A and B: Tortuous, elongated dilated
• Calcification long saphenous vein.
• DVT
Fig. 1.144: Stockings should

be worn for 3 months after
therapy. It should be worn from A B
toes to knee joint.
Figs 1.146A and B: Photo of short saphenous vein
varicosity and its diagrammatic location.
4. Thread veins (dermal flares): Are small varices Inappropriate activation of trapped leucocytes
in the skin usually around ankle which look release proteolytic enzymes which cause cell
like dilated, red or purple network of veins. destruction and ulceration—White cell trapping
<3 mm in size. theory.
5. Reticular varices: Are slightly larger than
thread veins located in subcutaneous region. What are different types of perforators?
>3 mm in size. • Ankle perforators (May or kuster).
• Lower leg perforators I, II, III (of Cockett).
6. Combinations of any of above.
• Gastrocnemius perforators (of Boyd).
• Mid thigh perforators (Dodd).
What is lipodermatosclerosis? What are the
• Hunter’s perforator in the thigh.
theories of the problems of varicose veins?
Fibrin deposition, scarring and tissue hypoxia What is CEAP classification?
due to chronic venous hypertension around It is the classification used for lower extremity
ankle joint is called as lipodermatosclerosis. It is venous diseases.
irreversible change in the soft tissue which
eventually leads into ulceration. C—Clinical signs (grade 0-6); (A) for asymp
tomatic or (S) for symptomatic presentation.
Two theories E—Aetiological classification (congenital,
1. Fibrin cuff theory primary, secondary)
2. White cell trapping theory A—Anatomic distribution (Superficial, deep
or perforator)
Incompetence of venous valves P—Patho-physiologic dysfunction (reflux or
↓ obstructive)
Stasis of blood
↓ Grading of clinical signs
Chronic ambulatory venous hypertension 0—no visible or palpable signs of venous
(Pressure up to 80-100 mmHg) diseases
↓ 1—Telangiectases, reticular veins or malleolar
Defective microcirculation flare
↓ 2—Varicose veins
RBC’s diffuses into tissue planes 3—Oedema without skin changes
↓ 4—Skin changes due to venous diseases like
Lysis of RBC’s pigmentation, eczema or lipodermato-
↓ sclerosis.
Release of haemosiderin, pigmentation 5—Skin changes as above with healed
↓ ulceration
Dermatitis 6—Skin changes as above with active ulcera-
↓ tion
Capillary endothelial damage
↓ Physiology of Venous Blood Flow in
Prevention of diffusion and exchange of nutrients Lower Limb
↓ Veins are thin walled vessels with collapsible
Severe anoxia walls that assume an elliptical configuration in
↓ collapsed state and circular configuration in the
Chronic venous ulceration. (Fibrin cuff theory). filled state.
Venous valves are abundant in the distal 6. Postoperative thrombosis: Common after the
lower extremity and the number of valves age of 40 years. Incidence following sur-
decreases proximally, with no valves in superior geries is 30%. In 30% of cases both legs
and inferior vena cava. are affected. Usually seen after prostate
surgery, hip surgery, major abdominal sur-
Venous Return geries, gynaec surgeries, cancer surgeries.
1. Arterial pressure across the capillary Bedridden for more than 3 days in the
increases the pumping action of vein. postoperative period increases the risk of
2. Calf musculovenous pump: During contraction DVT.
phase of walking, pressure in the calf muscles 7. Spontaneous thrombosis is common in
increases to 200-300 mmHg. This pumps the visceral neoplasm like carcinoma pancreas
blood towards the heart. During relaxation or carcinoma stomach. It is often migrating
phase of walking, pressure in the calf falls type.
and so it allows blood to flow from superficial 8. Thrombus may start in a venous tributary
to deep veins through perforators. Normally which eventually may extend into the main
while walking, pressure in the superficial vein causing DVT.
system at the level of ankle is 20 mmHg. 9. Axillary vein thrombosis can occur
3. During walking, foot pump mechanism spontaneously, following compression by
propels blood from plantar veins into the leg. cervical rib, by various causes of thoracic
4. Gravity. inlet syndrome, or arm being in the hyper
abduction state for prolonged period (e.g
Factors responsible for venous return: painting the ceiling), after axillary lymph
• Negative pressure in thorax node block dissection, after radiotherapy
• Peripheral pump—calf muscle to axilla, occasionally as a complication
• Vis-a–tergo of adjoining muscle of venous cannulation.
10. Polycythaemia vera, thrombocytosis.
• Nonrefluxing valves in course of veins
11. Deficiencies of antithrombin III, protein C,
protein S.
Deep Vein Thrombosis (DVT) Sites
Aetiology 1. Pelvic veins: Common.
Factors— 2. Leg veins: Common in femoral and popliteal
veins—(Common on left side).
Virchow’s triad: 3. Upper limb veins: Not uncommon (Axillary
• Stasis. vein thrombosis).
• Hypercoagulability.
• Vein wall injury. Phlegmasia alba dolens:
It is DVT of femoral vein (deep femoral vein
commonly) causing painful congestion and
Causes
oedema of leg, with lymphangitis, which further
1. Following childbirth.
increases the oedema and worsens the situation.
2. Trauma.
(White leg).
3. Muscular violence.
4. Immobility. Phlegmasia caerulea dolens:
5. Debilitating illness, obesity, bed rest, preg- It is extensive DVT of iliac and pelvic veins
nancy, puerperium, oral contraceptives, and causing blue leg with either venous gangrene
estrogens. or areas of infarction.
Clinical Features (It should not be given when patient is on

1. Fever—earliest and common symptom. heparin).
2. Pain and swelling in the calf and thigh (often). 5. Venous thrombectomy is done using
Commonly associated with fever. Pain is often Fogarty venous balloon catheter.
so severe that the patient finds difficult to 6. Thrombotic emboli is prevented from
flex (or move) the leg. reaching the heart by filtering it at IVC level
3. Leg is tense, tender, warm, pale or bluish using Kim ray Greenfield filter, suture sieve
with stretched and shiny skin. plication, stapler plication, vena caval
4. Positive Homan’s sign: Passive forceful ligation, Mobin Uddin umbrella filter.
dorsiflexion of the foot with extended knee 7. Palma operation: In iliofemoral thrombosis,
will cause tenderness in the calf. common femoral vein below the block is
5. Mose’s sign: Gentle squeezing of lower part communicated to opposite femoral vein
of the calf from side to side is painful. through opposite long saphenous vein.
Gentleness is very important otherwise it may 8. May-Husni operation: When blockage is in
dislodge a thrombus to form an embolus. popliteal vein, popliteal vein below the
6. Neuhof’s sign: Thickening and deep tender- block is anastomosed to long saphenous
ness is elicited while palpating deep in calf vein (end to end) so as to by pass the blood
muscles. across popliteal block.
7. Most often, DVT is asymptomatic and presents
suddenly with features of pulmonary
embolism like chest pain, breathlessness and
haemoptysis.
Investigations
1. Venous Doppler.
2. Duplex scanning.
3. Venogram.
4. Radioactive I125 fibrinogen study.
5. Haemogram with platelet count.
Treatment
1. Rest, elevation of limb,bandaging the whole
limb with crepe bandage.
2. Anticoagulants: Heparin, warfarin, phenin-
dione.
3. For fixed thrombus: Initially high dose of
heparin of 25,000 units/day for 7 days has
to be given. Later patient is advised to
continue with warfarin for 6 months. Low
molecular heparin can also be used. Dose
is controlled by assessing Activated Partial Fig. 1.147: Palma operation.
Thromboplastin Time (APTT). Duration of
heparin treatment is usually for 5 days. Prevention of DVT
4. For free thrombus: Fibrinolysins-Strepto- 1. Care has to be taken to see for proper posi-
kinase or urokinase or tissue plasminogen tioning of legs with no pressure on the calf
activator are used to dissolve thrombus muscles.
2. Pressure bandage to the legs has to be applied • It does not cross placental barrier and not
during major surgeries, laparoscopic surge- secreted in breast milk.
ries. During postoperative period, elevation,
massaging, pressure bandage, early ambu- Indications
lation, maintaining hydration are essential • As prophylaxis in major surgeries, post-
measures. operative period, puerperium.
3. Low dose heparin is given in suspected cases, • As therapy in DVT.
in major surgeries and continued during post
operative period till the patient is ambulated. Dose
5000 units is given subcutaneously 2 hours • For prophylaxis: 5,000 units/SC ly. 8th
before surgery. hourly.
4. Various measures like graduated static • For therapy: 10,000 units/IV ly. 6th or 8th
compression, elastic stockings, electrical hourly. Later change to subcutaneous dose.
stimulation of calf muscles, pneumatic • In severe cases, 5000 units to 20,000 units
compression are used to prevent sluggish is given daily through IV infusion at a rate
flow of blood. of 1000 units per hour. Daily dose should
5. Intravenous dextran 70, 500 ml during surgery not exceed 25,000 units.
and another 500 ml postoperative period in Note: Heparin should not be given intramus-
24 hours can also be used to prevent DVT. cularly and should not be combined with
streptokinase or urokinase.
Effects and sequelae of DVT Heparin is not given orally.
• Pulmonary embolism. Heparin administration should always be
• Infection. monitored with APTT.
• Venous gangrene.
• Partial recanalisation, chronic venous Complications
hypertension around the ankle region Allergy, bleeding, thrombocytopenia.
causing venous ulcers.
• Recurrent DVT. Low Molecular Weight Heparin (LMWH)
• Propagation of thrombus proximally. It is a commercially prepared heparin with a
molecular weight of 4000 to 6500.
Anticoagulants
Advantages
Heparin • They are absorbed more completely.
• It is a natural anticoagulant, a mucopolysacc- • Have a longer duration of action.
haride. • Have a better anticoagulant effect.
• It prevents clotting of blood both in vivo and • Less interaction with platelets.
in vitro by acting on all three stages of • Less antigenic.
coagulation. It prolongs clotting time and • Usage is easier and acceptable.
activated thromboplastin time in specific (by
1.5–2.0 times the control). Disadvantages: They are expensive.
• Heparin also causes hyperkalaemia. Presently LMWH are becoming very popular.
• Commercial heparin is derived from lung and Enoxaparin, dalteparin, parnaparin, reviparin.
intestinal mucosa of pigs and cattle.
• The onset of action is immediate after Heparin Antagonist
administration and lasts for 4 hours. 50 mg of 1% protamine sulphate solution is given
• It is metabolised in the liver by heparinase. slow intravenous.
Oral Anticoagulants Indication

They are given orally and are slow acting. • In DVT, for maintenance therapy after
cessation of heparin.
Types • After valve replacement surgery.
1. Coumarin derivatives: Bishydroxycoumarin
(Dicoumarol)— First coumarin drug derived
from sweet clover. Side Effects
Warfarin sodium: Commonest oral anticoagu- 1. Bleeding: It may require blood transfusion to
lant used. control.
2. Indandione derivative: 2. Cutaneous gangrene.
Phenindione. 3. Fetal haemorrhage and teratogenicity.
Anisindione. 4. Alopecia, urticaria, dermatitis.
5. Drug interactions: With NSAIDs, cimetidine,
Mode of Action of Oral Anticoagulant Therapy omeprazole, metronidazole, cotrimoxazole,
• By suppressing synthesis of prothrombin, erythromycins, barbiturates, rifampicin,
factors VII, IX, and X. griseofulvin.
• By inhibiting carboxylation of glutamic acid
through vitamin K. Warfarin Sodium
Features Warfarin Sodium (Wiskonian Alumini Research
• Oral anticoagulant does not have in vitro Foundation + coumARIN derivative) is the
action. commonest drug used. It has got lesser side
• They are slow acting, and long acting. effects. It has got cumulative action and so given
• Control of oral anticoagulant therapy is by in tapering dose.
monitoring prothrombin time. Dose is 5 mg once a day.
• PT comes to normal only 7 days after cessation
of the drug. It should be discontinued 7 days before any
• They cross placental barrier and known to surgery like tooth extraction and prothrombin
cause teratogenicity when given in 1st time should return to normal level. During surgery
trimester. if excess bleeding occurs, blood transfusion may
• They are secreted in breast milk. be given.
BREAST
WRITING A CASE SHEET IN A History of changes in nipple: Like retraction

(depression), deviation, destruction, displace-
CASE OF BREAST LUMP ment, discolouration, duplication and discharge
History Taking is noted. Recent history of changes signifies
carcinoma. Often retraction may be congenital,
Chief Complaints
since birth.
• Swelling in the right/left breast/both breasts;
its time duration. History of alteration in size and symmetry of
• Pain in the breast with duration. the breasts with duration.
• Ulceration in the breast with duration.
History related to swelling in the axilla/neck
• Discharge from nipple.
and their details like duration, progress, pain,
• Ulceration over the breast/swelling.
ulceration, etc. is noted.
• Swelling in the axilla/neck.
History related to respiratory problems has to
History of Present Illness be asked like chest pain/breathlessness/cough/
haemoptysis—signifies the secondaries in lung
Swelling: Duration, its progression whether
from carcinoma breast.
slowly increasing in size or rapidly increasing
has to be asked for. Swellings of short duration History of abdominal pain, loss of appetite,
are most probably due to carcinoma. But most decreased weight, jaundice, abdominal disten-
often, after noticing the swelling the patient sion which signifies liver secondaries has to be
immediately consults a doctor for opinion and asked for.
so duration may not be clearly obtained. Swelling
History related to bone secondaries: Like bone
in the opposite breast is also important. In 2 %
pain, low back pain, altered sensation like sense
of cases, breast carcinomas are bilateral; and
of position and vibration, lower limb weakness,
fibrocystadenosis is commonly bilateral.
features of paraplegia, loss of control over
Pain: In the breast, it is often called as mastalgia. urination and defaecation is asked for.
It is common in fibrocystadenosis and acute History of convulsions, loss of consciousness,
mastitis. There will be associated fever in vomiting, limb weakness, headache, visual
mastitis. Carcinoma breast is painless to begin disturbances, behavioural changes (psycho-
with but eventually becomes painful following logical like features) and localisation changes.
infiltration or development of tumour necrosis
or skin ulceration/fungation. Pain in fibro- Past History
adenosis is more prior to menstruation (cyclical),
and may disappear during pregnancy and after Past history of any surgeries of breast (recurrence
menopause. Duration of pain, type, timing, site can occur after excision of fibroadenoma,
and relation to menstruation has to be noted. conservative breast surgery may cause recurrent
carcinoma breast) or drug therapies like for
Nipple discharge: Duration of discharge, its type fibroadenosis.
whether serous/purulent/bloody/serosan-
guinous/milky/greenish has to be asked for and Menstrual History, Obstetric History and
noted. Bloody discharge is often seen in duct Family History
papilloma, carcinoma. Serous and greenish This is important in breast diseases. Family history
discharge is seen in fibroadenosis. of carcinoma of breast (in mother, grandmother,
aunt, cousins, 1st and 2nd degree relatives),

ovarian tumour or other tumours has to be noted.
Breast carcinoma can be familial. Often multiple
tumours can occur. History of menarche,
menstrual cycles, number of pregnancies, breast
feeding, lactation, menopause, last child birth
and usage of contraceptives/postmenopausal
HRT are very important.
Personal History and Treatment History

History of smoking, alcohol intake, dietary habits
is noted. History of any drug intake at present
A
is important.
General Examination
Like for any other long case, patient should be
examined for palor, jaundice, oedema feet,
clubbing. Pulse and blood pressure should be
checked.
Local Examination of Breasts B

Inspection Figs 1.149A and B: Examination of breast is done
For proper inspection, both breasts should be in sitting position with arms beside.
exposed properly including axillae. Initially
examination is carried out with the patient sitting
with 45° semi recumbent position. Later
examination is done in lying down position.
During inspection, the clinician should stand
in front and later on the side of the patient. Usually
normal breast should be first examined.
B
Figs 1.150A and B: Examination with both arms
Fig. 1.148: Accessory nipple is not an uncommon condition. raised above the shoulder and with leaning forward.
Fig. 1.151: Examination with 45° semi-recumbent position
Inspect both breasts: Note the size, shape and

symmetry. Asymmetry can be seen in breast
B
lumps. Inspect both breasts while leaning
forward to see whether both breasts fall forward Figs 1.152A and B: Nipple deviation and retraction
should be looked for in breast lumps.
or not. In carcinoma, if the breast is fixed to
underlying chest wall, it will not fall forward.
itching and vesicles, with normal nipple. It is
Both breasts should be inspected while the arms
common during lactation. Paget’s disease of
are raised upwards to see whether breast is/
breast is unilateral, without vesicles and itching,
breasts are adherent to chest wall.
with a hard lump underneath, often with
Inspection of nipple: Look for symmetry/ destruction of nipple.
asymmetry, pushed up/down, displacement, Skin over the breast is inspected for retraction,
retraction, size/shape of nipple, discharge/ pigmentation, redness/shining, dimpling,
ulceration in the nipple, discolouration, puckering, Peau d’ orange, nodules, ulceration,
duplication, cracks/fissures. Many of these fungation, and scar. Any dilated veins over the
changes occur in carcinoma. Fissuring and cracks skin and cancer-en-cuirasse is looked for.
can occur in breast feeding mothers during Involvement of the ligament of Cooper causes
lactation. Nipple retraction may be due to dimpling and puckering of skin over the breast.
infiltration of lactiferous duct by carcinoma. Oedema of skin is due to blockade of cutaneous
Areola should be inspected for any changes lymphatics causing burial of sweat glands and
in color, size, ulceration, eczema/eczema like hair follicles giving the appearance of orange
changes. Both areolas should be inspected. peel (Peau d’ orange). When ulcer is present, its
Areola is pink in colour in young girls, dark position, size, shape, margin, floor, edge should
coloured in adults, brownish during pregnancy be noted. Cancer-en-cuirasse is extensive
and lactation. Ulceration of nipple can occur in involvement of the skin over the breast and chest
carcinoma and Paget’s disease of breast, a localised wall with multiple nodules and ulceration by
type of carcinoma breast. It should be differen- the carcinoma. It looks like armor coat.
tiated from eczema. Eczema is commonly bilateral Swelling in the breast is an important finding
without any nodule underneath, associated with to be inspected. Its location in relation to the
quadrants of the breast, extent, size, shape, from internal mammary nodes or through
margin, surface, skin over it should be examined. cutaneous lymphatics.
Examination of arms for venous oedema or
Palpation lymphoedema. Venous oedema may be due to
Normal breast should be palpated first. Palpation axillary vein compression by nodal mass.
should be done by the palmar aspect of the fingers. Lymphoedema may be due to lymphatic block
During palpation one should look for raise in following nodal involvement. Lymphoedema is
temperature over the breast ( observed in mastitis mainly distal. It is gradual in onset and
but also can occur in vascular tumours like progressive. Venous oedema is sudden in onset,
medullary carcinoma and sarcoma), tenderness, with bluish discolouration over the skin, uniform
nature of the swelling—its size, shape, extent, in both distal and proximal aspect of the upper
surface, margin, consistency (carcinoma is hard/ limb (forearm and arm).
stony hard and irregular), fixity to breast tissue Examination for mediastinal node involve-
(swelling will not have independent/differential ment—it is done by percussion. Initially percus
mobility), fixity to skin (by pinching the skin), for liver dullness. Then percussion is done one
fixity to pectoral fascia (by tethering), fixity to space above from lateral to medial, to widened
pectoralis major muscle/serratus anterior mediastinal border. Mediastinal nodes are
muscle/latissimus dorsi muscle. Palpate ulcer— common in middle mediastinum.
look for tenderness, its edge and base for Examination of respiratory system for
induration, bleeding on palpation. Nipple and secondaries— altered breath sounds, features of
areola should be palpated for tenderness, consolidation or pleural effusion are looked for.
eversion, induration and discharge.
Fig. 1.153: Normal breast should be palpated first.

It should be palpated for mass, its location, shape, size,
surface, consistency, mobility and fixity.
Examination of ipsilateral, regional axillary

lymph nodes. Anterior/pectoral, central/medial, Fig. 1.54: Look for pleural effusion and altered
breath sounds for secondaries in lungs.
posterior, lateral, apical lymph nodes should be
examined. Examination of abdomen—to look for
Supraclavicular lymph nodes should be palpable nodular liver, Krukenberg ovaries in
examined. menstruating age group, and ascites. It is
Opposite axillary nodes are also examined. completed with digital examination of rectum
It may get involved through retrograde spread (P/R), and per vaginal examination.
Ideally done once a month, just after the
menstruation, as during this time breasts are less
engorged. In postmenopausal age group it is done
regularly at monthly intervals (fixed day of the
month).
• Examine both breasts.
• American cancer society recommends
monthly BSE after 20 years of age.
• Remind the patient that 90% of breast lumps
are not cancer.
Fig. 1.155: Always examine abdomen for liver enlargement, • Better way is in lying down position with
ascites or Krukenberg's tumour (in premenopausal age) arm raised with a mattress support behind.
• Palpation is done over all quadrants of the
Examination of pelvis, spine, long bones for
breast using the fingers.
any swelling/tenderness/pathological fracture/
• If any doubtful swelling is palpable, consult
restricted movements of spine, hips, etc.
the surgeon.
Examination of central nervous system to look
• Nursing mother should perform BSE just after
for any neurological deficits following metastatic
feeding the baby.
disease in the brain.
Diagnosis
Complete diagnosis with side and staging should
be given/written in case sheet. TNM staging is
used.
Example: Carcinoma left breast stage II-T1,
N1, M0.
Discussion
Breast is examined in different positions to elicit
different clinical features.
Different positions are—

• Sitting position with arms by the side Fig. 1.156: Self-examination of breast is
• 45° semirecumbent position is very much done in lying down position.
convenient
• Sitting position with leaning forward
• Sitting position with arms over the waist
Assessment of Nipple Deviation
• Sitting position with arms rising above the
Nipple changes are assessed by inspection,
shoulder—to see fixity to chest wall and
palpation and measurement. Displacement of
changes in nipple.
nipple is assessed by measuring distance
• Lying down position for self-examination
between mid-clavicular point to the nipple. This
reveals any upward/downward displacement
Breast self examination (BSE) has got a of nipple. Outward/inward displacement is
major role in early detection of the carcinoma assessed by measuring the distance of nipple
breast. from mid-line.
Fixity of the lump to breast tissue is checked

Quadrants of breast
by holding the breast tissue in one hand and
• Quadrants of breast are marked by drawing
moving the lump in other hand. If lump is fixed
two lines, vertical and horizontal along the
to breast tissue, then breast tissue moves along
nipple.
the lump.
• Upper outer quadrant (includes axillary tail
Skin tethering can be demonstrated by moving
also)—commonest site for carcinoma
the lump one side. It is due to inward puckering
• Lower outer quadrant
of the skin following involvement of the elastic
• Upper inner quadrant
Cooper’s ligament which becomes inelastic.
• Lower inner quadrant—close to medias-
Dimpling of skin appears which can be
tinum
demonstrated by raising the arms above the
• Central quadrant—nipple and areola region
shoulder level. When skin tethering occurs lump
can be moved in the arc anywhere without
moving the overlying the skin where as lump
cannot be moved at all without moving the skin
in skin fixation.
Fig. 1.158: Peau d' orange appearance of skin in carcinoma

breast. It is due to blockade of dermal lymphatics.
Fixity to pectoralis major muscle is checked

in sitting position. Patient is asked to keep her
hands on her waist. Lump is moved along the
direction of the muscle and also perpendicular
to the direction of the muscle. Patient is asked
to hold the hands tight and pressed over the
waist to contract the pectoralis major muscle
(action of the muscle is flexion of the shoulder)
which is confirmed by feeling the taut muscle.
Lump is again moved along the direction and
B perpendicular to the direction of the muscle.
Mobility will be restricted, if lump is adherent
Figs 1.157A and B: Quadrants of breast. Carcinoma
is more common in upper outer quadrant as more breast
to the pectoralis major muscle. It becomes T3
tissue is located in this quadrant. stage.
A B
C D
Figs 1.159A to D: Checking for fixity to pectoralis major muscle. Muscle is made taut
by keeping the patient’s hands over the waist and lump mobility is checked both in relaxed
and contracted status of the muscle. Taut muscle should be confirmed by palpating the
muscle in anterior axillary fold.
Fixity to latissimus dorsi muscle is checked resistance with elbow flexed 90° to contract the
in sitting position with examiner by the side of latissimus dorsi. If now mobility of the lump
the patient. Latissimus dorsi is an extensor of is restricted, then it confirms that lump is fixed
the shoulder joint. Initially mobility of the lump to latissimus dorsi muscle.
is checked and then arm is extended against Fixity to serratus anterior muscle is checked
by checking the mobility of the lump before and
after contracting the serratus anterior. Contraction
of serratus anterior is achieved by pushing the
outstretched both hands against resistance over
the wall and checking for restriction of mobility
of the lump. It signifies involvement of chest
wall—T4.
Chest wall fixity can be assessed by absence/
presence of mobility of the mass; and breast with
mass will not fall forward if it is fixed to
underlying chest wall; and on raising the arm
above shoulder breast with mass will not raise
upward. Chest wall fixity means fixity to ribs
and intercostals muscles.
Palpation of axillary lymph nodes is an
Fig 1.160: Fixity to latissimus dorsi muscle is checked
by checking the mobility of the mass while extending important step in examination of carcinoma
the arm against resistance. breast.
Anterior/pectoral group of nodes are

commonly involved nodes. Patient will be in
sitting position. Raise the patient’s arm high and
inspect the axilla. Place the patient’s forearm
over examiners forearm. Palpate the relaxed axilla
over pectoralis major muscle for any lymph
nodes. Examiner will use his left hand to examine
the nodes (of right axilla) and his right hand
will be over patient’s left shoulder to support.
Fig. 1.163: Examination of pectoral group of

lymph nodes.
B
Interpectoral nodes (Rotter’s) are also
Figs 1.161A and B: Fixity to serratus anterior is checked
by checking the mobility of the lump while pushing the palpated similarly by insinuating the fingers
outstretched both hands of the patient, over the wall against between the two pectori. It signifies retrograde
resistance. spread of the tumour. It is often difficult to
palpate.
Central/medial group of nodes are palpated
in similar way like pectoral nodes but hand in
Fig. 1.162: Inspection of the axilla with raised

arm is very important clinical method. Fig. 1.164: Examination of central group of lymph nodes.
the axilla is directed medially over the lateral shoulder and supraclavicular region of the same
chest wall and with gentle rolling movements. side of the axilla. It is often difficult to palpate.
Lateral/humeral group of nodes are palpated
with examiner’s right hand (for right axilla) with
left hand placed over same side shoulder.
Fig. 1.167: Examination of apical group of

lymph nodes.
Supraclavicular nodes are palpated using

Fig. 1.165: Examination of lateral group of fingers over supraclavicular fossa by standing
lymph nodes. behind the patient who is asked to shrug the
shoulder.
Posterior/subscapular nodes are palpated
with patient in sitting position and examiner
standing behind the patient. By raising the arm
and forearm of the patient from opposite side
the posterior axillary fold is palpated between
thumb and fingers.
Fig. 1.168: Examination of supraclavicular

group of lymph nodes.
Fig. 1.166: Examination of posterior group of Axillary nodes on opposite side are also
lymph nodes. examined. Opposite axilla can be examined by
examiner standing on the same side by leaning
Apical nodes are palpated (for right axilla) over the patient or can be examined by standing
with left hand of the examiner placing high in on the opposite side. Its involvement signifies
the axilla with right hand supporting over the stage IV disease. It is confirmed by FNAC.
Levels of the axillary nodes

Level I: Below and lateral to the pectoralis minor
muscle—anterior, lateral, posterior
Level II: Behind the pectoralis minor muscle—
central
Level III: Above and medial to pectoralis minor
muscle—apical
Fig. 1.170: Axillary tail of Spence.
block; and severe excruciating pain along the

distribution of the median and ulnar nerves (rare
in radial nerve) with often significant sensory
and motor deficits due to tumour infiltration of
Fig. 1.169: Surgical levels of lymph nodes in the the cords of brachial plexus (medial cord often
axilla draining from breast.
lateral cord).
Note: Cystic swellings of the breast
• Spread restricted to Level I nodes carries • Blood good cyst.
better prognosis • Breast abscess.
• Spread to Level II has poor prognosis • Hydatid cyst.
• Spread to Level III indicates worst prognosis • Galactocele.
• Serocystic disease of Brodie
Axillary tail of the Spence is the extension • Cystic necrosis in carcinoma breast.
of the upper outer quadrant of breast across • Lymph cyst.
foramen Langer deep to deep fascia. Foramen • Haematoma in breast.
Langer is an opening in deep fascia over outer
aspect of the breast which allows part of breast Mastitis
tissue to extend under deep fascia, otherwise • Mastitis of infancy (Witches milk) is due to
rest all breast tissue is in subcutaneous plane. maternal hormone in infant blood. It usually
Axillary tail is located adjacent to outer border subsides but may cause suppuration.
of the pectoralis major muscle. When it is involved • Mastitis of puberty is common in boys, is
by carcinoma it should be differentiated by invariably unilateral with tender, swollen
pectoral node enlargement. Axillary tail will move and inflamed breast.
along with main breast tissue whereas pectoral • Mastitis of mumps is usually unilateral and
node will not move when breast is moved but can occur in both sexes.
it has got independent mobility. Axillary tail often • Bacterial mastitis is seen in adult women
extends over the lateral edge of the pectoralis commonly lactating and is due to Staphylo-
major muscle up to axilla. cocci infection.
Fixed enlarged axillary nodes can cause • Subareolar mastitis is due to infection of
lymphoedema due to lymphatic block; venous gland of Montgomery or due to areolar
thrombosis and venous oedema due to venous furuncle.
Differences between Paget’s disease and eczema of nipple
Paget’s disease (Jame’s Paget-1874) Eczema

• Unilateral Bilateral
• Edges are distinct Edges are indistinct
• Itching absent Itching present
• Seen in menopausal women Occurs during the time of lactation
• Vesicles absent Vesicles present
• Nipple is usually destroyed Nipple is usually intact
• Underlying lump is usually present No underlying lump
Discharges from the nipple

Blood
• Carcinoma
• Ectasia
• Papilloma
Serous
• Fibrocystic disease
• Ectasia
Greenish A
• Ectasia
• Fibrocystic disease
Purulent
• Infection
• Sometimes malignancy
Milk
• Lactation (Physiological discharge)
• Galactorrhoea
Serosanguinous
• Carcinoma
• Infection B
Figs 1.171A and B: Paget’s disease of the breast.

In Paget’s disease, there will be a hard nodule
just underneath the areola, which later ulcerates
and also causes destruction of nipple.
Histologically it contains large, ovoid, clear
Paget’s cells with malignant features.
Causes of lymphoedema in carcinoma breast

• Involvement and fixation of the axillary
nodes level I, II and III
• After levels I, II and III dissection
• After radiotherapy to axilla
Fig. 1.172A: Subareolar carcinoma with destruction
• Recurrent axillary disease of nipple-areolar complex.
Treatment of lymphoedema of arm

Elevation of limb
Elastic stockings
Pneumatic compression
Drugs like diuretics and benzopyrones
Features of lobular carcinoma in situ

• Predominantly premenopausal
• Need not be detected by mammography
• It is an incidental pathological entity
• Multifocal and bilateral
• Clinically, it do not form a lump
• Does predispose to invasive cancer
• 50% cancers can develop in the contralateral
breast Fig. 1.174: Carcinoma breast over the commonest site—
upper outer quadrant—more visible on raising the arm.
Fig. 1.172B: Carcinoma breast with rib secondaries.
Fig. 1.175: Carcinoma breast with

extensive skin involvement.
Fig. 1.173: Ulcerated carcinoma breast with Peau‘ d Fig. 1.176: Recurrent carcinoma of breast. Note the
orange. Note the lymph node enlargement. recurrent tumour nodules.
Staging of Carcinoma Breast (Manchester and TNM Staging)
Manchester Staging
1. Tumour in the breast, not involving pectoral or deeper plane. Skin involvement if present,
it is lesser than the size of tumour. Lymph nodes are not palpable
2. Same as stage I but with mobile, discrete lymph nodes palpable in the ipsilateral axilla
3. Tumour fixed to pectoral muscle or skin involvement more than the tumour size or ipsilateral
axillary lymph nodes adherent to each other
4. Tumour fixed to the chest wall, ‘cancer-en-cuirasse’, skin involvement wider than that of the breast
or ipsilateral or contralateral side supraclavicular lymph nodes or opposite breast or opposite
axillary lymph nodes or spread to bone, lung, liver or inflammatory carcinoma of breast
TNM Staging
Tumour
1. T1—Tumour size <2 cm in greatest diameter (T1a—0.1-0.5 cm, T1b—0.5-1.0 cm, T1c—1-2cm).
2. T2—Size 2-5 cm
3. T3—Size >5 cm
4. T4—Tumour fixed to chest wall or skin (T4a—fixed to chest wall, T4b—fixed to skin, T4c—
T4a+T4b, T4d—inflammatory carcinoma breast)
Node
N0—No nodes
N1—Axillary nodes mobile
N2—Axillary nodes fixed to one another and other structures
N3—Supraclavicular nodes. Oedema of arm and internal mammary lymph nodes
Metastasis
Mo—No metastasis
M1—Distant metastases
The Columbia Classification (Haagsen, Cooley and Stout)
Grave signs
Oedema of skin Stage A—only tumour. No grave signs
Skin ulceration Stage B—tumour + axillary lymph nodes < 2.5 cm
Fixity to chest wall Stage C—tumour + any one of five grave signs
Axillary lymph nodes >2.5 cm Stage D—two more Grave signs
Fixed axillary lymph nodes Supraclavicular lymph node involvement
Distant metastasis.
Stage A — No skin oedema, ulceration, or fixation to chest wall.
Axillary nodes are not clinically involved.
Stage B — Clinically involved axillary nodes less than 2.5 cm in diameter.
Not fixed.
Stage C — Grave signs of comparatively advanced carcinoma.
Oedema of skin, skin ulceration, fixation to chest wall
Massive axillary involvement with nodes > 2.5 cm in diameter
Axillary fixation.
Stage D — Advanced carcinoma including two or more signs in stage C.
In addition satellite nodules, supraclavicular nodes.
Inflammatory cancer, arm oedema or distant metastasis.
Causes of massive enlargement of breast

• Benign hypertrophy usually bilateral.
• Giant fibroadenoma.
• Serocystic disease of Brodie.
• Sarcoma.
• Carcinoma often when extensively involved.
• Filariasis of breast.
Changes that can occur in nipple

• Destruction
• Depression (retraction).
• Discoloration.
• Displacement. Fig. 1.178: Carcinoma right breast with ulceration in
• Deviation. the primary with axillary lymph node secondaries.
• Discharge.
• Duplication
Causes of hard swellings in the breast

• Carcinoma breast.
• Antibioma breast.
• Traumatic fat necrosis.
• Calcified haematoma.
• Fibroadenoma—hard variety.
Fig. 1.179: Advanced carcinoma left breast involving

entire breast with nodularity.
One has to remember that differential

diagnosis for carcinoma breast is same as all
conditions which are benign diseases of the
Fig. 1.177: Carcinoma right breast with retraction of breast (Refer table).
nipple and areolar changes.
Differential diagnosis for carcinoma breast
• Fibroadenosis.
How carcinoma breast is suspected? • Traumatic fat necrosis
Any lump in the breast can be malignant unless • Tuberculosis of breast.
proved otherwise. But one has to remember that • Bloodgood cyst
every breast lump need not be always malignant. • Filariasis breast.
Duration, progression, nodal status, hard • Mastitis.
consistency, often irregular surface and late • Antibioma.
features like fixity, ulceration/fungation and • Galactocoele
distant spread are the features to consider • Mondor’s disease.
carcinoma breast. • Cystosarcoma phylliodes.
Fig. 1.182: Mammogram.
B
Figs 1.180A and B: Fungating carcinoma breast.
Note the extension of fungation into the chest wall.
Fig. 1.183: Medio-lateral and cranio-caudal mammographic

pictures showing microcalcification, spiculations and
irregularity.
Dose of radiation is 0.1 Gy, a low dose. So

it is a safe and effective procedure.
Fig. 1.181: Cancer-en-cuirasse with malignant
nodules in chest wall and skin. Findings
• Microcalcifications signify malignancy
• Soft tissue shadow may be smooth and
What are the investigations done for regular in benign conditions or irregular
breast lump? in carcinomas
Investigations in carcinoma breast— • Size and location of mass lesion is assessed
with nipple and skin change (thickness).
1. Mammography • Spiculations
It is plain X-ray of soft tissue of breast using • Mammary duct distortion
low voltage and high amperage X-rays. Two films
are taken. Breast imaging reporting and data system
Cranio caudal from above downward. (BI-RADS) has got its own categories, assessment
Mediolateral from side to side. and recommendations.
Digital mammography is computerised Doppler will show high frequency signals

electronic image of the breast with enhanced with continuous flow.
magnified pictures. • Benign lesions are smooth, rounded with
Digital spot-view mammography allows well-defined margins with weak internal
faster and more accurate stereo tactic biopsy. echoes and compressibility.
• Disadvantage is lesions less than 1 cm may
Indications
not be identified.
• For screening purpose it is done after 40 years.
• FNAC can be done under U/S guidance.
Early screening is indicated when there is
• It is cheaper, easily available and there is
family H/o carcinoma breast or histological
no risk of radiation.
risk factor. Mammography before 25 yr of age
• It is preferred method of screening in
is usually not done unless there is a lump
pregnancy and early lactation.
or a strong family history.
• In obese patients. 3. FNAC
• To find out spread or de novo tumour in the FNAC is very useful in diagnosing the carcinoma
opposite breast. breast. FNAC is also done under U/S guidance.
• Mastalgias. But negative results are difficult to interpret
• Mammography guided biopsy can be done. because it may be due to sampling errors and
• Evaluation and follow up in benign breast so requires further diagnostic methods. FNAC
disease with malignant potential. of opposite breast, lymph nodes, opposite axillary
• Follow up mammography after conservative lymph nodes are also often required. It is done
breast surgery. with 23 gauge needle using FNAC aspiration
Mammography is usually not done before special syringe. With the lump held firmly, the
the age of 25 yr, unless there is a strong family
history or any suspicious lump.
Xeromammography is same as above, but here
a photoconductor is used to produce a final image
on a Selenium paper rather than on X-ray film.
Advantages: Edge enhancement effect,
therefore useful in dense breasts.
Disadvantage: Exposure to high radiation dose
and selenium plate is needed. A
The condition when lump is clinically not
palpable but mammogram shows identifiable
carcinoma is ideal for breast conservative surgery
like quadrantectomy/QUART therapy.
2. Ultrasound of breast
• To look for whether the lesion is solid or
cystic, margin of the lesion, internal echoes,
retro-tumour acoustic shadowing, compressi-
bility, dimensions.
• Irregular margin, irregular internal echoes,
irregular posterior shadowing, non-compres-
sibility, ratio between antero-posterior to
width (lateral/horizontal) dimensions more B
than 1 are the features of carcinoma. Figs 1.184A and B: FNAC of breast lump
needle is passed into the lump and with negative 8. Radioisotope bone scan to look for secondaries
pressure continuous aspiration is done until in bone in advanced cases. It is not done routinely
adequate material comes through the needle. in early carcinoma of breast.
Needle with syringe is removed without negative
pressure. Material is collected on a slide; a smear Indications for whole body bone scan in
is made using 100% alcohol. Cytology is studied carcinoma breast
after staining it under microscopy. • T3, T4 advanced disease
• Advanced nodal disease
Advantages:
• Bone pain, bone swelling, pathological
FNAC is least painful, can be done on OP basis,
fracture
reliable and cheaper. Malignant deposits will
• Chest/liver secondaries
not occur along FNAC track (only contraindi-
cation for FNAC is testicular tumour).
9. Estrogen receptor study
FNNAC is Fine Needle Non-Aspirating
• They are estrogen sensitive receptors, which
Cytology.
are cytosolic glycoprotein present in the breast
and tumour tissue .It is an important indicator
Reliability of FNAC and mammography
of prognosis of carcinoma breast.
FNAC Mammography • Tissue for receptor study is sent in low
Sensitivity temperature in ice flasks. It is assessed by
(true positivity) 90-98% 90% quantitative analysis. (Frozen –70°).
Specificity (without • If value is more than 10 units (Femto mols)
false positive) 98-100% 90%
False negative 2-10% 10%
per ng gram tissue it is called as ER +ve status.
False positive Near 1-5%10% If value is 5-9 it is borderline and if it is less
than 5 femtomoles per nanogram tissue it
4. Frozen section biopsy is called as ER –ve status.
If FNAC fails even after two trials or in cases In ER +ve status
of negative FNAC, then on table frozen section biopsy – Prognosis is good.
is done for diagnosis. It is often difficult to diffe- – Hormone therapy including Tamoxifen
rentiate between severe atypia and carcinoma is very beneficial.
by frozen section and so its validity and use – Response to treatment is better.
is under debate. In such situation excision biopsy In ER –ve status
is better. While doing excision biopsy incision – Prognosis is poor.
is placed in such a way that it can be included – Hormone therapy is not very beneficial
in eventual mastectomy. Trucut biopsy is also (but used) as compared to ER +ve patients.
used nowadays in many centers. – Response to treatment is not good.
5. Chest X-ray: To look for pleural effusion, ER positivity is common in post-menopausal
cannon ball secondaries in lungs, mediastinal women (60%) compared to premenopausal
lymph nodes, secondaries in rib. CT chest is more women (30%).
reliable method to see lung secondaries. Progesterone receptor (PR status) study and
Her 2 neu receptor status are other studies done
6. Ultra sound abdomen: To look for liver at present to plan the therapy and assess the
secondaries, ascites, and ‘Krukenberg’ tumour. prognosis.
7. X-ray spine or MRI spine/pelvis shows 10. Study of discharge from the nipple
osteolytic secondaries in the bone like vertebra Nipple discharge is usually unilateral in
and pelvic bones. carcinoma breast. Ductal lavage may be useful
in some patients. Micro-catheter of 1 cm length tumour (peritumour area). Marker will pass
is introduced gently into the ductal opening. through the sentinel node which can be detected
10 ml saline is infused through the catheter. Fluid visually as blue staining or with a hand held
is withdrawn into the syringe and cytological gamma camera; and is biopsied with a small
analysis is done. incision directly over it. If there is no involvement
11. MRI of breast and MRI of spine (in case of suspected of sentinel node by tumour, then further axillary
spine secondaries) dissection is not required as skip lesions (skipping
• To differentiate scar from recurrence. sentinel node) occur only in less than 3% cases.
• To image breasts of women with implants. Note: Facility for SLNB is not available in
• To evaluate the axilla and recurrent disease. many centers.
• Both pre contrast and post contrast MRI are SLNB is done in—
done. T1 and T2 weighed images are taken • Carcinoma breast.
• Irregular mass with spiculations, changes in • Carcinoma penis.
skin and nipple, lymphoedema are the • Malignant melanoma.
findings in carcinoma breast.
12. Edge biopsy: Done only when there is skin
involvement—ulceration and fungation.
Diathermy should be avoided in incision biopsy
as it may distort the histology of tumour and study
of hormone receptor status may not be possible.
13. Tumour markers are used mainly during follow
up period. CA 15/3 is commonly done when
needed.
14. Sentinel node biopsy (SLNB):
The first axillary (SLN) node draining the breast
(by direct drainage) is designated as the sentinel
node. SLN is first node involved by tumour cells
and presence or absence of its histological
Fig. 1.185: Sentinel lymph node biopsy (SLNB) of breast.
involvement, when assessed will give a predictive Note: Spread by skipping the sentinel node is less than
idea about the further spread of tumour to other 3%.
nodes. Involvement of other nodes without SLN
is less than 3% and so if SLNB is negative nodal Axillary sampling is often done with an
dissection can be avoided but regular follow up adequate axillary incision. 10-15 nodes are
is needed. SLNB is done in all cases of early removed for sampling. It is not commonly
breast cancers, T1 and T2 without clinically practiced now. (Minimum 10 nodes should be
palpable node. It is not done in clinically palpable removed—level I nodes).
axillary node as there is already distortion of
15. CT scan of chest, abdomen and brain whenever
lymphatic flow due to tumour. It is also not done
needed. CT is said to be more useful to detect
in multifocal and multicentric tumours, as there
secondaries in these regions.
is involvement of many lymphatic trunks from
different places of breast, chances of false negative 16. Triple assessment:
is high. Sentinel node is localised by pre-operative Includes—
(within 12 hours) or peroperative injection of 1. Clinical assessment.
patent blue (Isosulfan vital blue dye) or 99m Tc 2. Radiological imaging.
radioisotope labeled colloid albumin near the 3. Cytological or histological analysis.
17. Ductography
It is contrast study of ducts of breast in case
of unilateral nipple discharge. Fine cannula is
passed under vision carefully through the duct
opening into the duct and 0.2 ml of dilute water-
soluble contrast media is injected into the duct.
Craniocaudal and mediolateral X-ray films are
taken. Contrast irregular filling defect may be
observed.
18. Thermography is not very sensitive test (50%).
Malignant tumours are hypervascular and so
A
transmitted temperature is detected through
different thermographic methods.
What is the treatment for early breast cancer?

In early breast cancer, aim of the treatment is—
to achieve cure, to conserve breast form and
function, to prevent recurrence and distant
spread.
In early cancer, breast conservative surgery like
quadrantectomy, axillary dissection (levels I and
II) and postoperative radiotherapy (to the breast)
is used which prevents the disfigurement and
psychological trauma of mastectomy to the patient.
Principles of conservative breast surgery B
• Curvilinear nonradial incisions (Do not place
Figs 1.186A and B: Curvilinear incision should be placed
radial incisions, as if there is a need to convert in conservative breast surgeries. Never place wrong radial
into total mastectomy, then incision plan may incisions. If conversion to total mastectomy is needed
be difficult). placement of incision will be difficult if radial incision is
• Separate incision for axillary dissection. placed. In conservative breast surgery for axillary dissection
separate incision in the axilla should be placed.
Breast conservative surgery

Indications Contraindications
• Lump < 4 cm • Tumor > 4 cm
• Clinically negative axillary nodes • Positive axillary nodes > N1
• Mammographically detected lesion • Tumour margin is not free of tumour after
• Well differentiated tumour with low S phase breast conservative surgery
• Adequate sized breast to allow proper • Poorly differentiated tumour
RT to breast • Multicentric tumour
• Breast of adequate size and volume • Earlier breast irradiation
• Feasibility of axillary dissection and • Tumour/breast size ratio is more
radiotherapy to intact breast • Tumour beneath the nipple
• Intraductal carcinoma extensive
• Try to avoid undermining of the skin flap (5000 cGy) and axilla (1000 cGy). First it is started
• Confirm tumour clearance by frozen section. by Umberto Veronesi from Milan.
It may be often difficult and so tumour is
cut and only margin which is close and What is skin sparing mastectomy (SSM)?
doubtful is advocated for frozen section. • It is like a key-hole surgery of breast
• Radiotherapy is a must to breast and chest • Skin sparing/limited skin excision (5-10%)
wall region (locally) will not alter/affect the recurrence rate.
• Indications are— central tumour/multi-
What is QUART therapy? central/extensive intraductal/T1/not
It is quadratectomy, axillary dissection of level feasible for conservation.
I and II nodes with separate axillary incision • Excision of nipple—areola complex with very
and postoperative radiotherapy to breast limited skin removal.
Figs 1.187A to C: Skin sparing mastectomy for carcinoma breast—different approaches. Skin sparing
mastectomy (SSM) does not affect the recurrence rate.
• Marginal skin excision over the tumour/ Axillary sampling is done by separate curved
biopsy site. incision between the outer border of pectoralis
• Total glandular mastectomy. major and latissimus dorsi 6 cm below the apex
• Axillary dissection using either same of axilla. About 10-15 nodes (level I) are sampled.
(extension of SSM incision) or separate Axillary sampling is now not advocated
incision in the axilla. anywhere.
When total mastectomy is done in early What are axillary dissection/axillary

breast cancer? clearance?
• When tumour is more than 4 cm. It is removal of axillary nodes with fat, fascia
• Multicentric tumour. of the axilla. Different levels of nodes are
• Poorly differentiated tumour. removed.
• Tumour margin is not clear of tumour after
breast conservative surgery. What are the problems with axillary
dissection?
How axillary nodes are treated when • Injury/thrombosis of axillary vein
clinically not palpable? • Seroma—50%.
Sentinel lymph node biopsy (SLNB) is done. If • Shoulder dysfunction 10%.
node is positive for tumour, then axillary • Pain (30%) and numbness (70%).
dissection is done. But facility for SLNB is not • Flap necrosis/infection.
available in most of the centers and so axillary • Lymphoedema(15%) and its problems
dissection is done. Usually level I and II nodes • Axillary hyperesthesia (0.5-1%).
- below the axillary vein are dissected. • Winged scapula.
Why axillary dissection is Which levels? Technical principles

done?
• For staging • Level I- 60% • Any incision but caudal hair-line

• To assess the prognosis- • Level I, II- 20-25% incision is preferred
number of nodes/size • Level I,II,III- 15- • Safeguard nerve to serratus anterior/
of the node 20% thoraco-dorsal nerve
• As a treatment- regional • Level I and II • Retain medial and lateral pectoral
control of the disease dissection –Low nerves when done with the mastectomy
• To plan adjuvant axillary dissection • Drain should be kept to the area
therapy irradiation/ – less chances of • After surgery specimen should be
chemo/hormone lymphoedema dissected for all lymph nodes properly,
labeled and sent for histological study.
Usual number of nodes in axilla are
20-32. So minimum of 10 nodes should
be dissected, identified and sent for
study. Nodes can be easily identified
if fat dissolving agents are used over
them.
Taxanes
They are newer chemotherapeutic drugs which
act by G2/M phase of cell cycle. It is commonly
used in metastatic carcinoma of breast. Drugs
are paclitaxel and docetaxel. Taxanes have no
cross resistance with anthracyclines and so can
be used sequentially or concurrently with
anthracyclines.
Indications for chemotherapy-

• All node positive patients
• Node negative patients but having other
poor prognostic factors
Fig. 1.188: Post mastectomy lymphoedema.

Note the mastectomy scar.
Adjuvant therapy after surgery in early breast

cancer
• Radiotherapy
• Chemotherapy—CMF, CAF regime
commonly used. Taxanes are also used.
• Endocrine manipulation-
• Ablation
• Tamoxifen (receptor antagonist)- 20 mg/
Fig. 1.189: Alopecia after chemotherapy
day for 5 years to carcinoma breast.
• Aromatase inhibitors- blocks estrogen
production. –Letrozole 2.5 mg OD- What are different types of surgeries for
• LHRH agonists- Goserelin 3.6 mg/28 carcinoma breast?
day’s cycle for 2 years. 1. Simple (total) mastectomy: Along with the tumour,
• Monoclonal antibodies (Trastuzumab/ entire breast, areola, nipple, skin over the breast,
herceptin) including axillary tail are removed. There is no
Drugs Used for Chemotherapy
Anthracycline regimes
CMF regime CAF regime MMM regime
Cyclophosphamide 600 mg/sq m. Cyclophosphamide Methotrexate.

Methotrexate 40 mg/sq m Adriamycin 50 mg/sq m Mitomycin C.
5-Fluorouracil 500 mg/sq m 5-Fluorouracil Mitozantrone.
CMF is commonly used.

All regimes are given in monthly cycles/3 weekly for 6 months.
Toxic effects are: Alopecia, bone marrow suppression, cystitis, megaloblastic anaemia, GIT disturbances, and nephritis.
axillary dissection. Often the patient is later
subjected to radiotherapy (external) to axilla.
2. Simple mastectomy with axillary clearance:
Commonly used procedure. Total mastectomy
is done along with removal of axillary fat, fascia
and lymph nodes.
3. Modified radical mastectomy (MRM)
a. Patey’s operation: Commonly done. Here
along with tumour, entire breast, overlying
skin, nipple, areola, fat, fascia and level I, Fig. 1.191: Gray incision for mastectomy in
carcinoma breast which extends to opposite side.
II and III lymph nodes of axilla are removed.
Pectoralis minor is divided from its origin
or removed completely, (so as to have good
assess to the upper part of axilla and also
to clear the interpectoral nodes of Rotter,
which are commonly involved) but pectoralis
major is retained so as to have better cosmetic
result.
b. Scanlon’s operation: Is a modified Patey’s
operation wherein instead of removing
pectoralis minor, it is incised to approach
the affected Level III lymph nodes.
c. Auchincloss operation: Here pectoralis minor
muscle is left intact and level III lymph nodes
are not removed. Fig. 1.192: Greenough's incision for mastectomy.
Fig. 1.193: Other incision often used for total

Fig. 1.190: Stewart incision for mastectomy. mastectomy—horizontal incision.
4. Halsted Radical Mastectomy.*[Complete

Halsted)[R M):
In radical mastectomy (Halsted)-

Structures removed are:
• Tumour
• Entire breast, nipple, areola, skin over the
tumour with margin
• Pectoralis major and minor muscles
• Fat, fascia, lymph nodes of axilla
• Few digitations of serratus anterior.
Structures retained are
• Axillary vein,
Fig. 1.194: Kocher’s incision for mastectomy. • Bells nerve (nerve to serratus anterior)
• Cephalic vein.
*Not commonly done at present.
Complications are lymphoedema and
eventual lymphangiosarcoma (after 3 to many
years later) of the limb.
Fig. 1.197: Note the original Halsted and modified

Halsted incision.
Fig. 1.195: Orr incision for mastectomy.
Fig. 1.198: Other incision used for radical and often modified
radical mastectomy. Note the extension of the incision
Fig. 1.196: Rodman's incision for mastectomy. into the anterior axillary fold.
Fig. 1.199: Complete Halsted operation—radical mastectomy with removal of fat, lymph nodes, pectoralis
major, pectoralis minor, entire breast with tumour and skin over the breast, nipple and areola.
5. Conservative breast surgeries: Tumour is removed from medial aspect of the second and third
with a rim of 1 cm of normal tissue. It may be intercostals space enclosing the nipple, areola
a. Wide excision. and tumour extending laterally into the axilla
b. Lumpectomy. along the anterior axillary fold. Upper and lower
c. Quadrantectomy as part of Quart Therapy- skin flaps are raised. Breast with tumour is raised
Entire segment of the involved breast is from the medial aspect of the pectoral major
removed along with axillary dissection (done muscle. Dissection is proceeded laterally with
through a separate incision in the axilla, level ligating pectoral vessels. Once dissection reaches
I and either level II or level III removal) and axilla, lateral border of pectoralis major muscle
radiotherapy. is cleared with level I nodes. Pectoralis minor
is divided from coracoid process to clear level
6. Toilet mastectomy: In locally advanced tumour,
II nodes. Medial and lateral pectoral nerves
tumour with breast tissue and whatever possible
should be preserved (otherwise atrophy of
is removed to prevent further fungation. But its
pectoralis major muscle occurs). Later from the
use and significance is under question.
apex of axilla level III nodes are cleared. Nerve
7. Extended Radical Mastectomies: It includes to serratus anterior, nerve to latissimus dorsi,
Radical mastectomy + removal of internal intercostobrachial nerve, axillary vein, cephalic
mammary lymph nodes of same side with or vein and pectoralis major muscle are preserved.
without opposite side. It is not done at present. Wound is closed with a suction drain.
What is Patey’s modified radical How mastectomy specimen is sent and for
mastectomy? what all examinations?
It is total mastectomy along with clearance of • Specimen is sent in formalin for histology.
all levels of axillary nodes and removal of • It is sent in saline in low temperature for
pectoralis minor muscle. It is enblock dissection ER/PR/Her 2 neu status study (histo-
of breast and axilla. An elliptical incision is made chemistry).
B E
Figs 1.200A to E: Different steps of Patey’s mastectomy with incision, flap raise, dissection in breast and
axilla and specimen after surgery.
• Tumour grading, tumour clearance, nodal • Occasionally it causes bone pain associated
involvement—its number and capsular with hypercalcaemia, particularly in patients
breach are assessed histopathologically. with bone metastasis.
• It increases the incidence of endometrial
What is tamoxifen? cancer.
• It is an antiestrogen. It blocks cytosolic
estrogen receptors. Advantages:
• Dose is 20 mg daily for 5 years. • It reduces the recurrence rate by 25%.
Adverse effects: • It improves the prognosis.
• Tamoxifen flare—flushing, tachycardia, • It is used presently in all age group, ER +ve
sweating. and ER –ve patients; even though it is more
effective in ER + ve patients and perimeno- common. It is observed in younger age group
pausal age group. usually pregnancy or lactating period. There
• Cheap, easily available, less toxic effects, very will be extensive skin involvement with pain.
effective. It often mimics mastitis of lactation. FNAC
• It is equally effective in carcinoma male breast. or incision biopsy concludes diagnosis. It is
Note: It is also used for certain benign diseases treated by initial chemotherapy or radio-
of breast (ANDI, Cyclical mastalgia), desmoid therapy; later if tumour reduces in size then
tumour, and male infertility. total mastectomy with axillary clearance can
be done. But most often it is inoperable. After
Selective Estrogen antagonists surgery, chemotherapy and tamoxifen is
• Do not cause endometrial hyperplasia or given. 5 year survival for inflammatory
endometrial carcinoma. carcinoma of breast is 25-30%.
• Drugs include Raloxifen, Tormefin.
What is letrozole?
Locally advanced carcinoma of breast (LACB) • It is a non-steroidal competitive inhibitor of
• It means locally advanced tumour with the enzyme ‘aromatase’. This enzyme
muscle/chest wall involvement, extensive converts adrenal androgens to estrogen
skin involvement or fixed axillary nodes. (aromatization). So it is an aromatase
It will be T3, T4a, T4b, T4c or T4d or N2 inhibitor.
or N3. • Other aromatase inhibitors are anastrozole
• It is investigated by FNAC of tumour, and exemestane.
mammography of opposite breast, chest CT, • Letrozole is used as an adjuvant endocrine
CT abdomen or whole body bone scan. therapy in post-menopausal women with
• Treatment of LACB is always palliative by hormone sensitive breast cancer. (In pre-
simple mastectomy, chemotherapy and menopausal women this will cause rise in
hormone therapy using tamoxifen. gonadotrophins and ovarian aromatase is
• Palliation is to control pain, to prevent
not well suppressed). It can also be used in
fungation or bleeding.
metastatic and recurrent cases. It slows down
• In inoperable fixed tumour initial chemo-
and stops the growth of estrogen sensitive
therapy is given. Later, after 3-4 cycles of
breast tumours. It reduces estrogen level by
chemotherapy, when tumour size reduces and
98%. Its half-life is 45 hours. It decreases the
becomes operable, total mastectomy is done.
bone density.
• Postoperative radiotherapy is given to breast
• Dosage of letrozole is 2.5 mg once daily.
field and axilla.
• It is given for 5 years or for 2 years following
• Usually axillary dissection is not necessary
3 years of tamoxifen.
in LACB.
• Side effects of letrozole are vaginal dryness,
• Only chemotherapy and radiotherapy to
breast and axilla (without palliative mastec- night sweats, hot flushes, vaginal bleeding,
tomy) also can be used in LACB. cardiovascular problems and osteoporosis.
• There is no role of breast conservative surgery
for LACB. Note
• 5 year survival is 40% and 10 year survival • Tamoxifen interferes with oestrogen receptors
is less than 25%. • Letrozole interferes with oestrogen produc-
• Inflammatory carcinoma is T4d LACB. It is tion
also called as mastitis carcinomatosis or • Transtuzumab (Herceptin) interferes with
lactating carcinoma of breast. It is 2% HER-2 neureceptors
What is transtuzumab? (Herceptin) spine involvement, and advanced axillary

• It is a monoclonal antibody that blocks HER- nodes.
2/neu receptors thereby preventing growth • Hormone therapy has got important role.
of cancer cells. It is a new drug. It is presently • Blockage of over expression of epidermal
marketed as herceptin. It is ErbB2 inhibitor. growth factor (EGF)/transforming growth
• It has very little effect on HER-2/neu negative factor alpha (TGF-alpha) which are related
cancers. to ErbB1/ErbB2 receptors in relation to
• It is useful only in HER-2/neu positive aggressive carcinoma factor.
cancers. It is currently approved by FDA for • Palliative surgeries done are total/toilet
use only in metastatic disease. It is given as mastectomy, fixation of bones in case of
intravenous infusion. pathological fractures, lung resection in case
• Studies have shown that substantiate of localized secondaries, bilateral oophorec-
improvement in disease free and overall tomy.
survival can occur. • Trastuzumab (herceptin) is monoclonal
• It has got cardiac side effects. antibody used in cancers with good results.
It blocks the Her-2/neu and erbB2 receptors.
What is metastatic carcinoma of breast?
It is blood spread into different places like bone, Surgical endocrine ablations
lungs and pleura, liver, soft tissues, brain and • Bilateral oophorectomy (Beatson—1896).
adrenals. It is evaluated by FNAC/incision • Bilateral adrenalectomy.
biopsy, chest CT, LFT, U/S abdomen, CT • Pituitary ablation.
abdomen, whole body bone scanning, CT brain,
tissue study for ER/PR/HER-2 neu receptor Hormone Therapy in Carcinoma Breast
status. Includes:
• Estrogen receptor antagonists - Tamoxifen.
Treatment concept in metastatic carcinoma of breast
• Ovarian ablation by surgery (Bilateral oopho-
• To improve quality of life.
rectomy) or by radiation.
• To relieve pain of secondaries like bone, lungs.
• LHRH agonists. (Medical Oophorectomy).
• To relieve neurological problems like con-
Goserelin causes reversible ovarian ablation
vulsions, space occupying cranial problems.
by suppressing gonadotrophin release. It acts
• Other symptomatic relief.
at hypothalamo-pituitary axis via tachyphy-
Treatment strategy in metastatic carcinoma of breast laxis causing reversible chemical castration
• Chemotherapy—CMF, CAF, Taxanes in (ovarian ablation). 3.6 mg/28 days cycle for
combination. 2 years.
• High dose of chemotherapy using cyclophos- • Oral aromatase inhibitors for post menopausal
phamide, cisplatin, carmustine, melphalan women. Letrozole and anatrozole are recent
is tried in view to get high response rate of aromatase inhibitors available.
55-70% along with bone marrow transplant. • Adrenalectomy or pituitary ablation.
But toxic effects are often life threatening. • Progesterone receptor antagonist.
• Haemopoietic growth factor also used along • Androgens. – Inj Testosterone propionate
with chemotherapy to enhance the cell kill 100mg IM three times a week.
with less bone marrow toxicity. It also may • Aminoglutethimide - blocks the synthesis of
allow multiple high dose chemotherapy to steroids by inhibiting conversion of choles-
increase the response rate. terol to pregnenolone - medical adrenalectomy.
• Radiotherapy is used in bone metastasis, • Progestogens, e.g. medroxyprogesterone
brain secondaries, to prevent paraplegia in acetate.
Drug Mechanism of Dose Advesrse effects

action
Tamoxifen Antiestrogen 20 mg Nausea, weight gain, hot flushes,
vaginal bleeding, bone pain,
amenorrhoea
Medroxyprogesterone Progestogen 400 mg Nausea, flushing, vaginal bleeding
Amino glutethimide Aromatase 250 mg Rash, dizziness, lethargy,
inhibitor QID Cushing facies
Arimidex Aromatase 1mg Lethargy, GI upset
Letrozole, anatrozole inhibitors 2.5g mg
OD orally
Zoladex (Goserelin) LHRH agonist 3.6 mg Amenorrhoea, nausea. It is
monthly expensive.
Diethyl stilboestrol Ostrogen 15 mg Fluid retention, vomiting,
daily thrombosis hypercalcaemia.
Fluoxymestrone Androgen 30 mg daily Masculinization, nausea
Hormone therapy for carcinoma breast. Indications

In pre-menopausal women- • Patient who undergoes conservative breast
• Tamoxifen-antiestrogen. surgery—breast is irradiated after surgery
• Ovarian ablation by surgery/by Goserelin/ using external radiotherapy.
by radiation • After simple mastectomy—external irradia-
• Progestogens—Medroxyprogesterone 400 mg tion is given to axilla.
• Androgens—Fluoxymestrone • Patients with higher risk of local relapse after
surgery:—a) Invasive carcinoma. b) Extensive
In post-menopausal women- in situ carcinoma. c) Patients under 35 years.
• Tamoxifen d) With multifocal disease.
• Aromatase inhibitor like letrozole 2.5 mg OD • In bone secondaries—to palliate pain and
• Progestogens swelling. If there is pathological fracture in
• Androgens the bone, internal fixation has to be done
• Medical adrenalectomy using aminoglute- along with external irradiation.
themide (Mitotane) as major source of • Inflammatory carcinoma of breast.
oestrogen after menopause is adrenal gland. • In atrophic scirrhous carcinoma of breast, as
Cortisone supplement is also needed to a curative radiotherapy.
prevent feedback rise of ACTH which may • As preoperative radiotherapy— to reduce the
block effect of aminoglutethemide. tumour size and to downstage the tumour,
so that the operability is better.
Radiotherapy in Carcinoma Breast • In conditions where there are more than 4
• RT reduces the local recurrence of tumour and positive axillary nodes, pectoral fascia
in the axillary region; and improves the involvement, positive surgical margins,
quality of life. extranodal spread or axillary status not
• But survival benefit?—Not proved. known/not assessed.
Radiotherapy in carcinoma breast

To chest wall To axilla • RT is a MUST after
• T3 tumour > 5 cm • 4 or more nodes +ve conservation of breast
• Residual disease-LABC • Extranodal spread • Local as well as to axilla
• Positive margin/close • Axillary status not • Tangential fields 50 Gy/25
surgical margin of < 2 cm known/not assessed fractions/5 weeks
• After conservative surgery • Another 10 Gy to tumour bed
• Higher risk group
• Inflammatory carcinoma
External radiotherapy is given to breast, axilla, • It is common in nulliparous woman. Early

and internal mammary and supraclavicular area. child bearing and breast feeding reduces the
Total dosage is 5000 cGY units. 200 cGY units incidence of malignancy. Breast carcinoma
daily 5 days a week for 6 weeks. is directly related to oestrogen level increase.
Early menarche and late menopause has got
Common sites of distant spread in carcinoma higher risk probably due to increased
breast oestrogen level.
• Bones—70% (lumbar vertebrae, pelvic • It is more common in obese patient.
bones, long bones). • Breast cancer relative risk is qualified as
• Lungs and pleura—20-30% Relative Risk (RR). RR 2.0 means risk is twice
• Soft tissues—5-15% the normal population. If RR is 0.5 means
• Liver—10-12% risk is 50% less than normal population.
• Brain—2-5% • In males, occasionally gynaecomastia turns
• Adrenals—2-5% into carcinoma.
• Benign breast diseases with atypia,
What are the aetiologies for carcinoma hyperplasia and epitheliosis have got higher
breast? risk in a patient with family history of
Aetiology: carcinoma breast.
• Carcinoma breast is more common in • Mutation of tumour suppressor genes BRCA
developed western countries. In African- 1 and BRCA 2 has got high risk of carcinoma
American women, it is more aggressive. It breast. BRCA 1 has got more risk (35-45%).
is less common in Japan. It is located in long arm of chromosome 17.
• It is second most common carcinoma in It is also associated with ovarian carcinoma.
females. Incidence is 19-34%. Median age is BRCA2 is located in long arm of chromosome
47 years. 13. It is also associated carcinoma male breast.
• It is more common after middle age, but do Occasionally mutation of BRCA3 and p53
can occur at any age group after 20. suppressor gene is also involved.
• It is familial in 2-5% cases. • Cowden’s syndrome and Li-Fraumen’s
• Carcinoma in one breast increases the risk syndromes are associated with carcinoma
of developing carcinoma on opposite breast breast.
by 3-4 times. Incidence of bilateral carcinoma • Presently carcinoma breast is considered as
is 2%. systemic disease. Halsted concept of spread
• Diet low with phytoestrogens and high is sequential spread. Breast—axillary lymph
alcohol intake. node—systemic spread. Fischer concept is early
to begin with itself, only then there is distant Risk of lymph node spread in DCIS is less
blood spread because of micrometastasis than 4%. So axillary dissection is not necessary.
without nodal disease. Only tumour lesser Sentinel Lymph Node Biopsy and proceed is the
than 1 cm size can be sequential. preferred method (if facility is available).
• Prior diagnosis of uterine/ovarian/colonic
cancers. Nottingham Prognostic Index (NPI) - (0.2 X
Tumour size in cm) + Lymph node stage +
Incidences in carcinoma breast Tumour grade.
• 30% of all female cancers NPI score < 3.4 Good prognosis with
• 20% of cancer related deaths in females 80% survival
• 2-4% bilateral (15 years).
• 2-5% hereditary NPI score 3.4-5.4 Moderate prognosis
• Lump in the breast-commonest presentation with 40% survival.
(75%). NPI score > 5.4 Poor prognosis with
• 10% presents with pain 15% survival.
• 35-45% with mutation of BRCA1 gene
• 70% blood spread occurs to bones Which is the commonest pathological type
of carcinoma breast?
What is duct carcinoma in-situ? (DCIS) Scirrhous type of carcinoma breast is the com-
It is intraductal carcinoma without any invasion monest pathological type of carcinoma breast.
in to the basement membrane. It is whitish, hard, and gritty/cartilaginous in
It is 5-20% common. consistency without any capsule.
It can be:
• Solid. What is medullary carcinoma of breast?
• Comedo with necrosis is high grade with It is also called as encephaloid carcinoma because
increased chances of micro invasion. of its soft consistency. It contains malignant cells
• Cribriform. with lymphocytic infiltration. It has got better
• Papillary. prognosis than scirrhous carcinoma of breast
• Micropapillary. because of more lymphocytes.
It is associated with high expression of
C–erb2 gene (80%). Which has got worst prognosis and which
Nipple discharge and often-small swelling has got best prognosis?
are main presentations. Inflammatory carcinoma has got worst prognosis.
U/S assisted FNAC and mammography are Atrophic carcinoma (in post-menopausal
the needed investigations. women) has got best prognosis.
Van Nuy’s prognostic index for DCIS:

Score 1 2 3
Size in mm < 15 mm 15-40 mm > 40 mm
Clearance in mm > 10 mm 1-10 mm < 1 mm
Grade and necrosis Not high grade Not high grade High grade
– No Necrosis Necrosis present. Necrosis present
Total score is 9
Score 3-4 Conservative breast surgery (wide local excision)
Score 5-7 Conservative surgery + Radiotherapy
Score 8-9 Total mastectomy
How is carcinoma breast classified? • Tumour grade, growth factor and oncogene
factors. ErbB2 –Her-2/neu positive has got
Classifications
poor prognosis. ErbB1 with over expression
I. Ductal carcinoma.
of epidermal growth factor (EGF) and TGF
Lobular carcinoma.
alpha has got poor prognosis.
II. (a) In situ carcinoma
• DCIS (Ductal carcinoma in situ). • DNA flow aneuploid status has got poor
• LCIS (Lobular carcinoma in situ). prognosis. Low S phase fraction has got good
(b) Invasive. prognosis.
• Invasive ductal carcinoma.
• Invasive lobular carcinoma. It is What are the specialities of bone
commonly multifocal and often secondaries in breast?
bilateral.
III. Unilateral. Bone secondaries in carcinoma breast
Bilateral. 2-5% common. • Commonest site of blood spread (70%)
IV. Unifocal. • Common in lumbar vertebrae, femur, pelvis
Multifocal. • Pathological fracture can occur
IV. Multifocal—tumour tissues within the same • Can present with spinal compression and
quadrant. paraplegia
Multicentric—tumour tissues within the • Radiotherapy, internal fixation, spinal
breast but in different quadrant. decompression is required
• Biphosphonates 1600 mg/day
What are the prognostic factors for
carcinoma breast?
• Spread to axillary nodes is the most important
prognostic indicator. More than 2 in number
of nodes and nodal size more than 2.5 cm
carries poor prognosis. More than 4 nodes/
level III (apical nodes) involvement has got
worst prognosis (5 year survival is 30%) and
also decides for radiotherapy to axilla.
• Age: Younger the age worse the prognosis.
• Sex: Carcinoma male breast has got worse
prognosis compared to female breast, because
of early spread in carcinoma male breast.
• Stage I and II has got better prognosis.
• Atrophic scirrhous has got best prognosis.
• Medullary carcinoma has got better
prognosis than scirrhous carcinoma because Fig. 1.201: X-ray showing typical osteolytic bone
of lymphocytic infiltration. secondaries in pelvis in carcinoma breast.
• Invasive carcinoma has got worse prognosis.
• Inflammatory carcinoma breast has worst What are the features of pleural effusion
prognosis. due to secondaries?
• ER +ve tumours has got better prognosis. Malignant pleural effusion as secondaries from
• Differentiation also decides prognosis. carcinoma breast—
• Presence of elastic fibers in histology has • It signifies terminal event.
got better prognosis. • It has got poor prognosis.
• HRCT is ideal diagnostic tool.
• Respiratory distress and failure is the main
feature.
• Treated by
– Intercostal tube drainage.
– Pleurodesis using talc/tetracycline.
– Chemotherapy.
A B
How carcinoma breast in pregnant woman
is managed? Fig. 1.202: LD flap (A) Donor area (B) Recipient area.
Carcinoma breast in pregnancy
• Incidence is 3%.
• Treatment is modified radical mastectomy
(MRM).
• Chemotherapy can be given in 2nd trimester
with care.
• Radiotherapy has no role.
• As commonly ER negative, hormone therapy
is not used.
• When distressing secondaries are present
termination of pregnancy may be required.
• Women with breast cancer can become pregnant
2 years after the completion of therapy, as
recurrence is more common in 2 years.
Breast Reconstruction
Fig. 1.203: Latissimus dorsi flap (LD FLAP) placed after
Types of Reconstruction mastectomy. It is based on thoracodorsal artery.
• Immediate reconstruction.
• Delayed reconstruction.
Types of Materials for Reconstruction

• Silicon gel implant under pectoralis major
muscle.
• Expandable saline prosthesis with prior tissue
expansion.
• If there is less skin or after radiotherapy-
Latissimus dorsi musculocutaneous flap (LD
flap) or contra lateral transversus abdominis
muscle flap (Tram flap).
Note:
• Breast reconstruction is done in young
patients with early stage disease.
• Skin sparing mastectomy with removal of
nipple areola complex may be better for
Fig. 1.204: Transverse rectus abdominis myocutaneous
reconstruction. flap. Note the blood supply of the flap.
A C
B D
Figs 1.205A to D: Different operative steps in TRAM flap.
• Symmetry is the most important factor in a full thickness graft is applied to reconstruct
breast reconstruction. the areola.
• External breast prosthesis which fits within Areola pigmentation is created using (it is done
the bra is a simpler cosmetic method. 3 weeks after nipple creation)—
• Full thickness skin graft from non hairy skin
Nipple is created using— lateral to labia majora, as the pigmentation
• Local breast flaps 3 months after breast of this graft matches that of the areola.
reconstruction. • From contralateral areola if reduction
• Nipple sharing from contralateral nipple mammoplasty is done on that side.
using composite graft. • Tattooing – Colour tends to fade with time
• Skate flap: Local flap with deepithelialised and may need to be repeated.
donor site around the periphery over which • SSG from retroauricular area or from thigh.
LD flap TRAM flap
• Myocutaneous flap based on • Transverse rectus abdominis myocutaneous
subscapular artery flap based on superior epigastric artery
• Easy to perform • It gives the bulk needed for reconstruction
• Reliable flap, well vascularised and so implant is not needed
• Can be placed over prosthesis • Donor site morbidity and fat necrosis can
• Low complication rate occur
• But causes unsightly donor area • Free TRAM flap into internal mammary/
on the back thoracodorsal axis can be done
Other flaps used for reconstruction
Carcinoma of male breast
• Superior gluteal flap based on superior gluteal
• It is less than 1% of cases of breast cancers
vessels.
• Gynaecomastia and excess estrogen are said
• Ruben’s flap using soft tissue pad overlying
to be the etiological factors
the iliac crest based on deep circumflex iliac
• Commonly it is infiltrating duct carcinoma.
vessels.
Commonly ER positive
• Presentation, spread, behavior are same as
What are breast implants?
carcinoma of female breast. Investigations
They are synthetic non-reactive materials placed
and treatment are same as carcinoma female
under the breast to give breast contour.
breast
• Technically simple.
• Tamoxifen is very useful in carcinoma male
• Achieves symmetry easily.
breast
• Implant in submuscular plane is better
• LHRH agonists are next option.
whenever muscle has not been removed
• Earlier bilateral orchidectomy was the
during surgery.
preferred choice. Now not commonly done
• If muscle is removed like during radical
mastectomy, then subcutaneous implant is
placed.
• Silicon gel implants are used.
Complications of breast implants

• Pain, exposure of implant and rupture
• Displacement, extrusion
• Infection
• Capsular contraction
Fig. 1.207: Carcinoma male breast in a pre-existing

gynaecomastia. Note Gynaecomastia on opposite side.
What is fibroadenoma?
It is a benign encapsulated tumour occurring
commonly in young females of 15-25 yrs age
group.
B Presently it is considered as hyperplasia of
Figs1.206A and B: Typical breast implant and its placement.
a single lobule of the breast (may be classified
It can be placed in subcutaneous or submuscular plane. under ANDI).
Fig. 1.208: Carcinoma male breast showing mass,

puckering and retraction.
Fig. 1.209: Circumareolar (Webster’s) and
submammary (Galliard Thomas) incisions.
Types
Points to be remembered
Gross
• Size of giant duodenal ulcer is > 2 cm
• Soft.
• Size of giant gastric ulcer is > 3 cm
• Hard.
• Size of giant fibroadenoma is > 5 cm
• Giant ( >5 cm in size).
• Diameter of transverse colon in toxic
Microscopy megacolon is > 6 cm
• Intracanalicular—small and hard—mainly • Giant naevus is size > 20 cm
fibrous.
• Pericanalicular—large and soft—mainly Fibrocystadenosis (Fibrocystic disease of
cellular. the breast/mammary dysplasia)
Clinical features It is due to Aberration of Normal Development
• It presents as a painless swelling in one of and Involution (ANDI) of breast causing.
the quadrants, which is smooth, firm, non
tender, well localized and moves freely within • Fibrosis
the breast tissue (‘mouse in the breast’). • Cyst formation
• Axillary lymph nodes are not enlarged. • Glandular proliferation (Adenosis)
• Hyperplasia (Epitheliosis)
Investigations • Papillomatosis
• Mammography (well localized smooth
regular shadow). • It is an estrogen dependent condition. One
• FNAC. of the cysts may get enlarged to become a
• Ultrasound (to confirm solid nature). clinically palpable well localized swelling
Treatment - bluedome cyst of Bloodgood.
Excision through a circumareolar incision • Diffuse, small, multiple cysts in fibrocystade-
(Webster’s) or sub mammary incision (‘Galliard nosis is called as Schimmelbusch’s disease.
Thomas incision’) is done. • Disease is common in upper outer quadrant.
Clinical features • Depending on mitotic index and degree of
• Presentation is during menstruating age pleomorphism they are graded as low grade
group as a bilateral, painful, diffuse, granular, to high grade tumours.
tender, swelling which is better felt with
palpating fingers (poorly felt with palm).
• Not fixed to skin, muscle or chest wall.
• Pain and tenderness are more during
menstruation (Cyclical mastalgia).
• It subsides during pregnancy, lactation and
after menopause.
• Discharge from the nipple when present will
be serous or greenish.
Investigations A
• FNAC (Epitheliosis, when florid is
undoubtedly premalignant).
• Ultrasound, mammography.
Treatment
I. Conservative line of management is preferred.
• Reassurance.
• Oil of evening primrose (capsules): Contains
gamolenic acid which reverses the
saturated fatty acids to unsaturated fatty
acids.
• Gamolenic acid — 120mg.
• Bromocriptine. B
• Vitamin E and B6. Figs 1.210A and B: Cystosarcoma phylloides of right
• LHRH agonist. and left breasts in two different patients. Note the dilated
• Danazol. veins. Tumor occupies the entire breast. Post-surgery
specimen signifies enormous size of the tumour.
• NSAID’S.
• Tamoxifen—antiestrogen. Gross
II. Surgery: Subcutaneous mastectomy with Large capsulated area with cystic spaces and
prosthesis placement. cut surface shows soft, brownish, cystic areas.
Microscopy
Indications for surgery in fibroadenosis
• It contains cystic spaces with leaf like
• Intractable pain
projections, hence the name.
• Florid epitheliosis
• Cells show hypercellularity and pleomor-
• Blood good cyst
phism.
• It may be a variant of intracanalicular
Phylloides Tumour (Cystosarcoma
fibroadenoma of breast.
phylloides/Serocystic disease of Brodie)
• They are not simply giant fibroadenoma. Clinical features
• They show a wide spectrum of activity, • They occur in premenopausal women (30-
varying from almost a benign condition to 50 years).
a locally aggressive and sometimes metastatic • It is usually unilateral, grows rapidly to attain
tumour. a large size.
• Swelling is smooth, non tender, soft, fluctuant dilatation of lactiferous sinus. It contains milk
with necrosis of skin over the summit due to within. It is a retention cyst due to blockage of
pressure. single duct which begins under the areola.
• Recurrence is common.
Features
• Lump in the lower quadrant of the breast
which is usually unilateral, large, soft, fluctuant,
with smooth surface and nontender. It is a retention
cyst — subareolar type.
• It may get precipitated, inspissated, or get
calcified.
Fig. 1.211: Recurrent cystosarcoma phylloides.
• When it is calcified it mimics carcinoma breast.
Investigations • If it gets infected it will form an abscess.
U/S, FNAC, mammography and chest CT. • U/S and FNAC are used to diagnose.
Treatment • Treatment is excision (by submammary
• Excision or subcutaneous mastectomy is done. incision). Abscess when formed should be
• If malignant (sarcoma), total mastectomy is drained under general anaesthesia under
indicated. Sarcoma may spread to lungs and cover of antibiotics.
so chest X-ray/chest CT has to be taken.
Traumatic Fat Necrosis

It may be due to either direct or indirect trauma
(most often trauma may not have been noticed
or forgotten).
Pathogenesis
Capillary ooze causes triglyceride in the fat to
dissociate into fatty acids. It combines with cal-
cium from the blood resulting in saponification
which causes inflammatory reaction and later
presents as a nonprogressive swelling in the
breast.
Fig. 1.212: Galactocoele. Note the block at the
Features opening of the duct.
• Painless swelling in the breast which is
smooth, hard, nontender and adherent to breast Mastitis
tissue. (D/D-Carcinoma). It is nonprogressive. Types
• FNAC shows chalky fluid with fat globules. • Subareolar.
• Mammography is done to rule out malig- • Intramammary.
nancy. • Retro mammary (Submammary).
• It often mimics carcinoma breast.
• Treatment is excision. a. Subareolar mastitis
• It is the infection under the areola due to
Galactocoele cracks in the nipple or areola.
It is seen in lactating women. It is due to the • Red, inflamed, oedematous areola with tender
blockage of lactiferous duct resulting in enormous swelling underneath.
• Differential diagnosis is Paget’s disease of
the nipple.
• Treatment is under cover of antibiotics pus
is drained of by making a sub areolar incision.
b. Intramammary mastitis
a. Lactational abscess of the breast
Commonly seen in lactating women.
Mode of infection
Bacteria (Staph aureus) enter the breast during
sucking through the cracked nipple. Occasionally A
it can be haematogenous. Gram-negative and
other bacterial infection can supervene later.
Features
• Pain in the breast and fever.
• Diffuse redness, tenderness, and induration
in the breast.
• Purulent discharge from the nipple.
• Full breast may get involved eventually.
• Differential diagnosis is inflammatory
carcinoma of breast.
B
Treatment
Antibiotics—Cephalosporins. Figs 1.213A and B: Typical look of breast
Drainage under general anaesthesia, a counter abscess/mastitis.
incision may be needed.
It is not advisable to wait till the formation
of abscess.
Complications
• Antibioma formation.
• Sinus formation.
• Recurrent infection.
b. Non-lactational abscess of the breast
It commonly occurs in duct ectasia and
periareolar infections. Common organisms are
bacteroides, anaerobic streptococci, enterococci
and gram-negative organisms. It is commonly
recurrent with tender swelling under the areola.
Treatment
• Antibiotics.
• Repeated aspirations.
• Drainage and later cone excision of the duct Fig. 1.214: Incision and counter incision for breast
is done. abscess.
• Investigations are FNAC, mammography and

U/S breast.
• Treatment is excision (Submammary
incision). Later antibiotics are given.
Duct ectasia
• It is dilatation of lactiferous ducts due to
muscular relaxation of duct wall with
periductal mastitis (Plasma cell mastitis). Many
ducts are commonly involved.
• Greenish discharge from the nipple.
• Indurated mass under the areola which is
Fig. 1.215: Placement of often tender.
drain in breast abscess.
• Retraction of nipple which occurs at later
c. Retromammary mastitis stage of the disease.
It is due to tuberculosis of the intercostal lymph • Eventually it forms an abscess, and fistula.
nodes or ribs beneath or suppuration in the • Often they are bilateral and multifocal.
intercostal lymph nodes. • Differential diagnosis is carcinoma breast.
Breast is normal. • Investigations are — discharge study and
mammography.
Investigations
• Chest X-ray, FNAC, ESR. • Treatment is cone excision of involved major
• Peripheral smear. ducts (Hadfield operation) with antibiotics.
• CT chest.
Mondor’s Disease
Treatment • Mondor’s disease is thrombophlebitis of the
• Cause has to be treated. Antibiotics are used. superficial veins of the breast and anterior
• Drainage under general anaesthesia with sub- chest wall.
mammary incision reaching submuscular • Presents as a thrombosed subcutaneous cord
plane. which is attached to the skin.
• Often may need intercostal tube drainage in • It is often a self limiting disease without any
specific causes. recurrence, complication or deformity.
• It mimics the lymphatic permeation of
Antibioma carcinoma breast.
If intramammary mastitis is not drained but only
treated by antibiotics, pus localizes and becomes Duct Papilloma
sterile (flaques) with a thick fibrous tissue cover, • It is usually single, from a single lactiferous
it is called as antibioma. duct.
• It is the commonest cause of nipple discharge.
Features • By blocking the duct it causes ductal dilata-
• Previous history of mastitis treated with tion.
antibiotics.
• Swelling which is painless, smooth, non Features
tender, hard, fixed to breast tissue without • Papilliferous swelling (projection), usually
involving the pectorals and chest wall. near the nipple orifice (4-5 cm from orifice).
• Differential diagnosis is carcinoma breast. • Blood stained discharge from the nipple is
(Scirrhous carcinoma breast). common.
• But serous or serosanguinous discharge can
also occur.
• Single papilloma is not premalignant.
• But multiple papillomas in many ducts can
be premalignant
• Study of discharge and ductogram may be
needed.
• Treatment—Microdochectomy: Probed lacti-
ferous duct is opened with excision of the Fig. 1.216: Gynaecomastia – right side breast. Compare
papilloma using tennis racquet incision. to opposite side to note the difference in size.
Causes
Galactorrhoea
• It is secretion of milk not related to pregnancy • Idiopathic.
or lactation. • Teratoma testis.
• Primary galactorrhoea is due to stress and other • Ectopic hormonal production in bronchial
factors. Reassurance is the treatment. carcinoma.
• Secondary galactorrhoea is due to enhanced • Anorchism, after castration.
dopamine activity. • Adrenal and pituitary disease.
– By drugs (haloperidol, methyldopa, • Leprosy, because of bilateral testicular
chlorpromazine, metoclorpramide), atrophy.
– Hyperprolactinaemia due to tumours. • Drugs: Stilboestrol, Digitalis, Cimetidine,
• Treatment—bromocriptine/cause has to be Spironolactone.
treated. • Liver diseases and liver failure.
Witch milk is secretion of milk in both male • Klinefelter’s syndrome. (XXY Trisomy).
and female infants due to maternal hormonal Investigations are relevant to the cause.
effects in foetus which lasts for 3 weeks after Example: Liver function tests, DNA study,
child birth. Hormone assay. Often gynaecomastia may turn
into carcinoma.
Gynaecomastia
Treatment
• It is hypertrophy of male breast more than
• When symptomatic or large or long standing,
usual, often attaining features of female breast.
excision through circumareolar incision is
• It can be unilateral or bilateral.
done.
• Often subcutaneous mastectomy is needed.
Presentations
• Diffuse enlargement of breast occupying all Mastalgia
quadrants or as a well localized, small, firm It is pain in the breast.
or hard nodule under the areola which is Types
often painful and tender. • Cyclical • Noncyclical
Cyclical mastalgia Noncyclical mastalgia
• Pain related to menstrual cycle • Pain due to causes other than ANDI like periductal
• Seen in Andi like fibrocystadenosis mastitis, malignancy, cervical root pain,
• Treatment is like for fibrocystadenosis musculoskeletal pain, previous surgery, Tietze’s
syndrome (costochondritis of 2nd costal cartilage,
commonly seen in females)
• It is unilateral, chronic, burning/dragging pain occurs
in pre and post menopausal age group
THYROID
WRITING A CASE SHEET IN History

CASE OF THE THYROID History of Present Illness
DISORDERS Swelling: Its duration, onset sudden or insidious.
Origin of the swelling, its progress- gradual
Name: (benign), rapidly progressive (malignancy) or in
Address: an existing swelling rapid increase recently
Residential place may be important in certain (benign turning into malignancy) or sudden
goitres. Iodine deficiency endemic goitre is rapid increase may be seen in haemorrhage.
common in interior areas, mountain areas like Thyroglossal cyst may be present since childhood.
Vindhyas, Himalayas. Goitre is more common Swelling may be single/multiple or occupying
in south India than north India. It was also one lobe, or both lobes or isthmus.
common in Middle East and European countries, Any thyroid of any size or any duration or
North America, in Bulgaria near river Struma any consistency or in any age group can be
which eventually reaches Aegean Sea. Follicular malignant unless proved otherwise.
and anaplastic carcinoma may be more in iodine Pain: Its duration, character like dull aching/
deficiency areas but papillary carcinoma is not pricking, site of pain, radiation, factors which
related to iodine deficiency. alters the pain. Usually goitres are painless.
Occupation: Thyroiditis may be painful. Malignancy is
initially painless but later becomes painful. Infil-
Age: tration into surrounding structures/necrosis/
Simple goitre is seen often in puberty in girls. haemorrhage makes it painful and tender.
Dyshormonogenesis goitre occurs in younger age
group. Physiological goitre occurs when there Pressure symptoms: Dysphagia (oesophageal
is increased metabolic demand of the hormone compression), dyspnoea (tracheal compression),
like in puberty, pregnancy. Solitary nodule, stridor (infiltration into trachea), hoarseness of
colloid goitre, papillary carcinoma and primary voice (recurrent nerve compression) and Horner’s
thyrotoxicosis are seen between 20-40 years. syndrome (infiltration of cervical sympathetic
Multinodular goitre, follicular carcinoma and chain – ptosis, loss of sweating, in face same
Hashimoto‘s thyroiditis are seen in middle aged side, miosis and enophthalmos). Their duration,
women. onset and progression.
Features of toxicity: Increased appetite/loss of
Chief Complaints weight/diarrhoea/chest pain aggravated by
• Swelling in front of the neck and its duration exercise/palpitation/amenorrhoea/irritability/
• Pain in the swelling and its duration nervousness/sleeplessness (insomnia)/hand
• Hoarseness of voice due to recurrent laryngeal tremors/increased sweating/cold preference/
nerve palsy. heat intolerance/proximal muscle weakness in
• Difficulty in swallowing or breathing the thigh or arm like in getting down steps or
• Tremor in the hands lifting weight using arms (myopathy) due to
• Generalized weakness difficulty in isometric contraction and increased
• Palpitation muscle metabolism/wasting of muscles/visual
• Loss of significant weight disturbances with bulging of the eyes.
Features of hypothyroidism/myxoedema: Muscle myxoedema. Patient may be cachexic in
weakness/lethargy/weight gain/poor appetite/ thyroid carcinoma which is advanced.
facial swelling/cold intolerance/menorrhagia/ • Exophthalmos should be looked for in toxic
constipation/superciliary madarosis in lateral patient. Irritable/agitated tensed face with
half of the eye brows/loss of hairs in scalp/ eye signs is seen in toxic thyroid.
change in voice due to vocal cord oedema/dry • Myxoedema face is typical. It is expression-
skin. less, mask-like puffy face. Patient will be dull
with low intelligence.
Past history: Irradiation history for carcinoma
• Hasty—rapid gait is seen in hyperthyroid
thyroid. Irradiation to head and neck region for
and slow—lethargic gait in hypothyroidism.
benign lesions like adenoids, tonsillitis, thymus,
• Pulse—its character, whether tachycardia,
acne vulgaris or hamangiomas or malignancy in
collapsing or pulsus paradoxus or ectopic
younger age groups like of lymphomas. Chernobyl
or fibrillation has to be looked for.
nuclear disaster in Ukraine in 1986 caused
• Blood pressure may be high in toxic thyroid.
increased incidence of papillary carcinoma of
• Sleeping pulse rate is checked at late night
thyroid in children. Previous history of having
or early morning for three consecutive nights
Thyroglossal cyst which might have infected
and average is taken. Sedation like diazepam
causing fistula either due to spontaneous burst or
or phenobarbitone to be given to check sleep-
after surgical drainage of an infected cyst. Previous
ing pulse rate prior to sleep is a controversial.
surgery for thyroid in recurrent thyroid swelling
Sleeping pulse rate is graded as Crile’s
or earlier surgery for thyroglossal cyst in case of
grading.
thyroglossal fistula should be asked for.
Personal history: Smoking, alcohol intake or any
drugs which may cause alteration in thyroid
function. Patient may be on thyroxine or on
antithyroid drugs or beta blockers or other drugs
like lithium, PAS or sulphanylureas which alter
the thyroid function. Dietary habits should be
asked. Brassica family vegetables like cabbage, kale
and rape are goitrogens. Type of salt used in the
family iodized/home rock salt is also important.
Family history: Dyshormonogenesis, medullary
carcinoma of thyroid can be familial (MEN
syndrome). Endemic goitre and Grave’s disease
can occur in families. Altered thyroid function
may be cause for infertility.
Menstrual History
Fig. 1.217: Palpation of radial pulse for its count, volume,
Treatment history: History of undergoing investi-
variations should be done in thyroid diseases.
gations or treatment relevant to thyroid disease.
Crile’s grading Sleeping pulse rate/minute
General Examination
I Up to 90
Like any other long case.
II 90-110
• Thyrotoxic patient is anxious/thin and
III > 110
undernourished. Obesity is seen in
• In toxic thyroid, patient will be thin and Tremor of the hands and tongue
underweight. In hypothyroidism, patient will Hand tremors observed by outstretching the
be obese and overweight. In metastatic thyroid hands and fingers forward to see tremors of the
cancer patient is cachexic. fingers. Often small object like pen may be kept
• Agitated stressful facial expression is to watch the tremor better. Fine tremor is observed
observed in toxic thyroid. Puffy, expression- in toxic thyroid. It is due to diffuse irritation
less, dull and mask-like face is seen in of the gray matter. Tongue twitching can be
myxoedema. observed by opening the mouth and carefully
• Rapid aggressive gait is seen in toxicity but observing the tongue.
lethargic and slow gait is observed in
hypothyroidism. Assessment of voice change
• Skin is wet and warm in hyperthyroidism • Pitch of the voice—whether raised/lowered
(moist palm while shaking hands). or pitch locked
• Ankle (Achilles tendon) reflex is prolonged • Breath support during speaking is adequate
with delayed relaxation in hypothyroidism or not
and it is shortened and brisk in hyperthy- • Ability to alter the rapidity of speech – slow/
roidism. fast/medium
• Both legs and ankle region in front should • Altered laryngeal and neck muscle tension
be inspected for pretibial myxoedema. It is • Indirect laryngoscopy—with tongue pulled out
a feature of primary thyrotoxicosis. It is due using gauze, warmed ILS is placed into the
to deposition of myxomatous tissue. oral cavity to see vocal cords. Patient is asked
to say ‘e’ to see the vocal cord movements
Local Examination
Inspection
Swelling: Its location/size (both vertical and
horizontal dimensions of each lobe and isthmus
or if it is one mass dimensions as a single
swelling)/shape (butterfly shape if both lobes
are involved)/extent (from posterior border of
sternomastoid laterally to midline in one sided
gland enlargement or from one side to opposite
sternomastoid if both lobes are enlarged)/ upper
extent is usually up to thyroid cartilage/lower
margin is clearly visible or not or visible during
deglutition/movement upwards with deglutition
(thyroid moves upwards during deglutition due
to attachment of the condensed vascular
pretracheal fascia (Berry’s ligament) which is
attached above, medially and behind to cricoid
cartilage and also pretracheal fascia is attached
to larynx, trachea and inferior constrictor muscle
Fig. 1.218: Pretibial myxoedema is seen which moves upwards)/scar or dilated veins
in primary thyrotoxicosis. (in toxic goitre, carcinoma thyroid, venous
A B C
D E F
Figs 1.219A to F: Tremor of the hands outstretched and tongue
should be checked properly in toxic thyroid.
A B
Figs 1.220A and B: Simple goitre. Inspection of goitre is very

important.
compression, retrosternal goitre) or pigmentation

on the skin over the swelling/pulsation over the
swelling (toxicity, malignancy)/surface on
inspection (smooth or nodular).
Fig. 1.221: Thyroid moves upwards with deglutition. Often

it is better to give a glass of water to the patient to drink. B
Figs 1.222A and B: Large carcinoma of thyroid

Swellings which move upwards with which is vascular. Note the dilated veins.
deglutition
• Thyroid swelling Occasions wherein thyroid swelling may not
• Sub hyoid bursa move upwards with deglutition-
• Thyroglossal cyst • Anaplastic carcinoma thyroid – often
• Pretracheal/prelaryngeal lymph nodes • Carcinoma thyroid with extensive local
• Swelling from larynx/trachea infiltration into soft tissues, trachea/larynx
and posterior muscles
In some occasions swelling whether moves • Intrathoracic retrosternal extension with
with protruding the tongue or not should be infiltration/impaction
looked for. Thyroglossal cyst moves upwards • Riedel’s thyroiditis with encasement of
with protrusion of tongue. Patient is asked to trachea
open the mouth and then swelling/cyst is held • Massive thyroid wherein movement
firmly. Now patient is asked to protrude the upwards is difficult to observe and
tongue to feel an upward movement of the appreciate
swelling with a typical ‘tug’ in the swelling.
Any other swelling in the neck should be Palpation
seen like for lymph nodes. Lymph nodes can Swelling: Temperature over swelling (swelling
be involved commonly in papillary carcinoma may be warm in toxic thyroid, malignancy,
of thyroid occasionally in follicular carcinoma thyroiditis)/tenderness (haemorrhage, thyroi-
of thyroid. ditis, tumour necrosis can cause tenderness)/
A B C
Figs 1.223A to C: Examination of thyroid from behind with patient is sitting in a stool comfortably and neck
flexed. Careful palpation for nodules should be made.
A BB
C
Figs 1.224A to C: Contraction of sternomastoid one side/both sides
to confirm that thyroid is deep to deep fascia
Fig. 1.226: Skin should be pinched to confirm

swelling is not adherent to skin.
Digastric muscle depresses and retracts the

chin. Infrahyoid muscles (strap muscles) contract
and get tensed to prevent ascent of hyoid bone
when the digastric is in action.
B Thrill is checked in the upper pole of the
Figs 1.225A and B: Lower border should be assessed gland as superior thyroid artery is superficial
in case of thyroid enlargement to rule out possible
retrosternal extension.
and enters the gland in front upper pole. Thrill
signifies toxicity or increased vascularity.
extent/position/shape/size (should be measu-
red in centimetre both vertically and horizon-
tally)/movement of the swelling upwards with
deglutition/surface (smooth or nodular)/
consistency (soft or firm or hard or variable and
if so different locations of different consistencies
should be mentioned)/margin (well defined or
diffuse, lower margin which is most important)/
independent mobility of the swelling/plane of
the swelling (it is checked by contracting the
sternomastoid muscles by placing examiner’s
hand under the chin of patient and patient has
to flex the neck against resisting hand) (single
side gland relation to sternomastoid muscle is
checked by contracting the muscle by turning
the chin against resistance of the examiner’s Fig. 1.227: Superior pole of thyroid should be
palpated for thrill which signifies vascularity.
hand)/skin is free or not.
Method of palpation of thyroid gland: Thyroid gland of the gland. It is mainly useful in solitary nodule
is palpated from behind with patient is sitting of thyroid. Examiner should stand in front of
in a stool with neck partially flexed. Both thumbs the patient. If right lobe is needed to palpate,
of the examiner are kept over the cervical spine left lateral lobe is pushed towards right to make
and fingers will be in front to feel the gland- posterior aspect of the right gland more promi-
both lateral lobes and isthmus for all features. nent as gland gets pushed and rotated towards
right side. Posterior becomes posterolateral or
Crile’s method of palpation of gland: It is the
lateral which is felt for any nodules. Left lobe
palpation of the nodule/swelling in front using
posterior aspect is palpated by pushing the right
the pulp of the thumb.
lobe towards left side.
Fig. 1.228: Criles method of palpation

using thumb for any nodules. Fig. 1.230: Lahey’s test.
Pizzillo’s method of palpation: It is the method of Kocher’s test: It is the test for tracheal compression.
palpation of thyroid gland in short neck and Patient is asked to see straight. With fingers and
obese individuals. Patient is asked to keep her/ thumb both lateral lobes of the thyroid gland
his both hands over the occiput and gland are gently compressed directing postero-
becomes prominent which will be palpated from medially. If patient develops stridor-Kocher’s test
front or behind. is positive. If no stridor means it is negative.
Fig. 1.229: Pizzillo’s method of examination.
Lahey’s method of examination: It is the method

used to palpate the any nodules in posterior part Fig. 1.231: Kocher’s test.
In a long standing goitre and large goitre, because • Dyspnoea at night during lying down or neck
of constant pressure tracheal rings get weakened extended.
which get narrowed/collapsed during compres- • Rarely recurrent nerve palsy can occur.
sion. Goitre itself because of forward traction
keeps trachea patent. But after thyroidectomy no
support to trachea causes tracheomalacia—
weakening of the tracheal rings. Such patients
need tracheostomy after thyroidectomy. It is
usually temporary tracheostomy for 2-3 weeks
by then tracheal rings regain their strength to
maintain the patency of the trachea.
Confirmation of retrosternal extension:
• Lower margin of the swelling/goitre is not
visible-even on deglutition.
• Lower margin is not palpable on deglutition.
• Dilated veins over neck or chest wall may
be visible.
• Normal resonant note becomes dull over the
sternum on percussion.
• Pemberton’s sign—patient is asked to raise the
both arms above the shoulder so as to touch Fig. 1.233: Retrosternal extension of
the ears and made to keep like that for 3 thyroid—diagram.
minutes. Patient will develop dilated veins
and cyanosis in the neck and upper chest Retrosternal goitre is defined as having
wall, puffiness in face and respiratory distress > 50% goitre below the suprasternal notch.
and rarely dysphagia. It means sign is positive • Primary is rare—1%. Primary retrosternal
signifying retrosternal extension of goitre. goitre arises from ectopic thyroid tissue from
mediastinum. It gets its blood supply from
mediastinum itself, not from the neck. And
also it is not related to the existing thyroid
in the neck.
• Secondary is common. It is extension from the
enlarged thyroid from the neck.
Commonly retrosternal goitre arises from
lower pole of a nodular goitre. It is more observed
in short neck people. Due to negative intrathoracic
pressure nodule gets drawn into the superior
mediastinum. Sometimes it may be also ectopic
thyroid tissue.
Retrosternal goitre may be substernal (part
of the nodule in the neck-palpable) or plunging
goitre (intrathoracic goitre forced into the neck
occasionally by increased intrathoracic pressure)
A B
or intrathoracic goitre with normal neck. It can
Figs 1.232A and B: Pembertones sign for be toxic/non-toxic nodules/malignancy.
retrosternal goitre.
Retrosternal goitre is confirmed by CT scan
and radioiodine study. It is treated by complete
surgical removal usually through neck approach,
occasionally through median sternotomy. Radio
active iodine therapy is not used for retrosternal
goitre. Surgical removal should be complete
because recurrent retrosternal goitre is very
difficult to re-operate.
Stridor due to compression of tracheo-bron-
chial tree by retrosternal goitre is very dangerous
because it is often not possible to clear the airway
either by intubation or by tracheostomy.
Position of trachea is checked by palpation using
A
three fingers from below. Middle finger is kept
just above the suprasternal space and index and
ring fingers are placed over sternal heads of the
sternomastoid muscles on each side. Middle
finger is run upwards along the trachea to feel
the position-central or deviated. In solitary
nodule or disease of only one lateral lobe trachea
will be usually deviated towards opposite side.
In both lobes enlargement trachea will be usually
central. Other features are absence of hollowness
on the side of the deviation (trail sign), on
auscultation hearing of breath sounds on the
side of the deviation.
B
Figs 1.235A and B: Method examination of trachea

to find out deviation using three fingers.
Superior border of the isthmus of the normal thyroid

gland is inferior to cricoid cartilage. Isthmus is
felt over the tracheal rings below. Bare tracheal
rings are observed in ectopic thyroid (which
means in normal location thyroid tissue is not
present) and also in absence of isthmus (rare).
Carotid pulsation should be checked. It is normally
felt at the level of the upper border of thyroid
cartilage over medial aspect of the sternomastoid
muscle on the Chaissagne tubercle (carotid
tubercle) on the transverse process of C6 vertebra.
It may be deviated posteriorly/laterally in a large
Fig. 1.234: Trachea in central position. It is central when goitre. It may be absent in advanced carcinoma
both lateral lobes are enlarged. It is deviated to opposite thyroid due to infiltration of the carotid sheath
side in solitary nodule thyroid. by the tumour (Berry’s sign).
Examination of neck lymph nodes for secondaries.

It is common in papillary carcinoma of thyroid.
It is usually in level III and IV nodes. It could
be firm, hard or cystic. It is usually brownish
black in colour often with papillary projections.
Lymph nodes often can get enlarged in follicular
carcinoma thyroid and lymphoma. Lateral
aberrant thyroid is earlier thought as aberrant
thyroid in lateral part of the neck but actually
it is not so but it is secondary in lymph node
with primary being papillary carcinoma of
thyroid.
Fig. 1.236: Palpation of carotid artery (common carotid)

at the level of thyroid cartilage on the medial border of
sternomastoid muscle over Chaisagne tubercle in
transverse process of C 6 vertebra. In Berry’s sign it
is absent. It signifies advanced carcinoma of thyroid.
Sympathetic chain in the neck may get involved

in locally advanced carcinoma thyroid causing
Horner’s syndrome—enophthalmos due to
Muller’s muscle weakness:
• Drooping of upper eyelid (ptosis).
• Anhidrosis.
• Miosis due to paralysis of dilator pupillae.
• Absence of ciliospinal reflex.
• Flushing of face and nasal congestion.
Causes for Horner’s syndrome Fig. 1.237: Lymph node drainage of thyroid. Primary
It is due to interruption of sympathetic nerve and secondary nodes are drainage groups.
supply to head and neck. Preganglionic fibres
Percussion over the manubrium sterni is important.
arise from 1st and 2nd thoracic segments of
Dullness signifies retrosternal extension.
the spinal cord which synapses with three
Tenderness may signify the secondaries in
cervical sympathetic ganglia. Any disruption
sternum from follicular carcinoma of thyroid.
of preganglionic fibres or cervical ganglia or
their fibres will cause Horner’s syndrome. Auscultation over the upper pole of the gland for
• Posterior inferior cerebellar artery thrombosis bruit- in toxic thyroid severe cases and very
• Cervical sympathectomy vascular tumours.
• Pancoast’s tumour Cardiovascular system examination is important
• Secondaries in neck in thyrotoxicosis- commonly secondary type.
• Carotid artery aneurysm Tachycardia, ectopic, pulsus paradoxus,
• Spinal cord lesions extrasystoles, atrial fibrillation are the cardiac
• Injuries to lower root of brachial plexus presentations.
A
A
B B
Figs 1.238A and B: Percussion over the sternum is Figs 1.239A and B: Bruit over thyroid should be auscultated
important to rule out retrosternal extension. to find out increased vascularity over upper pole.
Respiratory system examination: Secondaries and In primary thyrotoxicosis exophthalmos and

pleural effusion can occur in follicular carcinoma all eye signs are looked for.
of thyroid. • Both the eyelids cover the bulbar sclera
partially in normal individual.
Abdomen examination: Hepatomegaly as
• Upper sclera is visible in only lid retraction—
secondaries in liver is known to occur in follicular
due to spasm of involuntary levator palpebrae
carcinoma of thyroid. Hepatosplenomegaly can
superioris muscle. Here lower eyelid is in
occur as part of Grave’s disease or Hashimoto’s
normal position. It does not indicate exoph-
disease.
thalmos.
Examination of skull and spine: Localized, warm, • In exophthalmos lower bulbar sclera is clearly
vascular, pulsatile secondaries can occur visible and lower eyelid is below and will
in skull commonly, rib and other bones not cover the bulbar sclera. In severe exoph-
occasionally as a spread from follicular thalmos sclera all over both above and below
carcinoma of thyroid. will be visible.
B
Fig. 1.240: Cardiovascular system is examined and
auscultated for cardiac problems in secondary Figs 1.243A and B: Palpation of spleen in a thyroid
thyrotoxicosis. enlargement patient.
Fig. 1.241: Hepatomegaly can occur in Graves’ and

Hashimoto’s diseases as part of the autoimmune disease.
Fig. 1.244: Palpation of skull in thyroid enlargement to

look for secondaries when primary is follicular carcinoma
Fig. 1.242: Abdomen is percussed for free fluid. of thyroid (pulsatile, vascular, warm, and localized).
• Exophthalmos is measured using exophthal- 1. Von Graefe‘s sign: Lid lag sign is inabitility
mometre. of the upper eyelid to keep face with eyeball
when looking downwards—lid lag. Place
the examiner’s left hand over the patient’s
Other eye signs head. Place examiner’s right index finger
Eye signs are common in primary thyrotoxicosis. near the level of eye and slowly bring it
Lid lag, lid spasm can occur in secondary down and patient is asked to see the
thyrotoxicosis also. downward moving finger. If sclera upward
is visible then it is positive lid lag sign.
Test is repeated few more times for
confirmation. Normally upper eyelid
follows the finger downwards properly but
in primary thyrotoxicosis lid lag is
observed.
2. Naffziger’s sign: While examiner standing
behind the patient, patient’s neck is
extended and examiner looks from behind
along the superior orbital margin of the
patient. Eyeball is seen beyond the superior
orbital margin in exophthalmos.
A 3. Dalrymple‘s sign: Upper eyelid retraction,
so visibility of upper sclera.
4. Stellwag‘s sign: Absence of normal blinking
- so starring look. First sign to appear.
5. Joffroy‘s sign: Absence of wrinkling on
forehead when patient looks up (frowns)
with the neck flexed. .
6. Moebius sign: Lack of convergence of eye
ball. Defective convergence is due to
lymphocytic infiltration of inferior oblique
and inferior rectus muscles in case of
primary thyrotoxicosis. There will be
diplopia. It may be an early sign of eventual
ophthalmoplegia. Examiner’s left hand is
placed over the patient’s head. Right index
finger from distance is brought towards
root of the nose between the eyes and patient
is asked to follow the converging finger
B
visually to look for convergence. If positive
patient will be unable to converge and
develops diplopia.
7. Jellinek‘s sign: Increased pigmentation of
eyelid margins.
8. Enroth sign: Oedema of eyelids (lower eyelid
specifically) and conjunctiva.
9. Rosenbach‘s sign: Tremor of closed eyelids.
10. Gifford‘s sign: Difficulty in everting upper
eyelid. Differentiates from exophthalmos
of other causes.
11. Loewi‘s sign: Dilatation of pupil with weak
adrenaline solution.
C 12. Knie‘s sign: Unequal pupillary dilatation.
Figs 1.245A to C: Lid lag check in primary 13. Cowen‘s sign: Jerky pupillary contraction
thyrotoxicosis. to consensual light.
14. Kocher‘s sign: When clinician places his

hands on patient eyes and lifts it higher,
patients upper lid springs up more quickly
than eyebrows.
15. Naffziger‘s sign: With patient in sitting
position and neck fully extended, protruded
eye ball can be visualized when observed
from behind.
16. Grove’s sign. Upper lid resistance to
downward traction. A
17. Rochin’s sign: Reduced amplitude of
blinking.
18. Boston’s sign: Uneven jerky movement of
the upper eyelid in inferior movement.
19. Mean’s sign: Eye globe lags behind upper
eyelid on upward gaze.
20. Griffith’s sign: Lower eyelid lags behind the
eye globe on upward gaze.
21. Sainton’s sign: Frontalis contraction after
cessation of levator activity.
22. Vigourox’s sign: Puffiness of lids.
23. Ballet’s sign: Ophthalmoplegia- paralysis
of more extraocular muscles.
B
24. Suker’s sign: Difficulty in maintaining
fixation in extreme lateral gaze. Figs 1.246A and B: Movements of the eye ball should
25. Wilder sign: Jerking of eyes on movement be checked in primary thyrotoxicosis with exophthalmos
to rule out involving eye ball muscle infiltration by
from abduction to adduction. macrophages, inflammatory cells
26. Trousseau’s/Payne’s sign: Dislocation of the
eye globe.
27. Reisman’s sign: Bruit over eyelid.
28. Snellen/Donder’s sign: Bruit over the eye.
29. Goldzieher’s sign: Deep injection of
conjuctiva.
• Lid retraction is higher upper eyelid with
normal lower eyelid with visible sclera
adjacent upper eyelid
• Lid lag is inability of the upper eyelid to
keep pace with the eyeball when it looks
downwards to follow the examiners finger
• Exophthalmos is visible sclera first below
(lower part) the lower edge of the iris and
later eventually upper part of sclera will
be visible. It is due to pushing of eyeball
forwards due to fat, oedema fluid, cells like
macrophages in retrobulbar space. Fig. 1.247: Moebius sign
Thyroid ophthalmopathy in Grave’s disease-

Werner’ abridged classification of ocular
changes with van Dyke’s modification
Class-grade Definition
0 No signs and symptoms
1 Eye signs only—refer table
below for eye signs
2 Soft tissue involvement
3 Proptosis more than 22 mm
4 Extraocular muscle
involvement
5 Corneal involvement—
ulceration
6 Loss of sight/vision due to optic
nerve and corneal involvement
Eye signs only
• Resistance to retro displacement of eye
• Oedema of conjuctiva and caruncle
• Lacrimal gland enlargement
• Injection of conjuctiva
• Oedema and fullness of lids
Exophthalmos
Fig. 1.248: Naffziger’s sign. • It is proptosis of the eye, caused by infiltration
of the retro bulbar tissues with fluid and
round cells, with visible lower bulbar sclera
Order of appearance of signs and with lid spasm of upper eyelid. (Lid
1. Stellwags sign - Mild spasm is spasm of levator palpebrae
First sign to appear superioris muscle which is partly innervated
2. Von Graefes sign - Mild by sympathetic fibres.)
3. Joffroys sign - Moderate • Sclera can be seen clearly below and often above
4. Moebius sign - Severe the limbus of the eye.
• Proptosis can be measured by exophthalmo-
meter.
Important signs to be remembered • Exophthalmos is often self limiting, but not
• Visible lower sclera- sign of exophthalmos always. Sleeping in propped up position and
• Naffziger’s sign lateral tarsorrhaphy will help to protect the
• VonGraefes sign-upper lid lag- contraction/ eye.
overactivity of the involuntary part of the Severe Exophthalmos
levator palpebrae superioris muscle – • Eyelid oedema, chemosis, conjuctival
Muller’s muscle injection.
• Joffroy’s sign • Diplopia, ophthalmoplegia (Complete weak-
• Moebius sign- most important-early sign of ness of all extraocular muscles and so no
ophthalmoplegia movements possible).
• Corneal ulceraion.
Treatment of severe exophthalmos
• Papilloedema soon develops.
• Steroids intravenously
• Finally it may also cause loss of vision.
• IV antibiotics
It is called as malignant exophthalmos. (Even
• Guanethidine, steroid, antibiotic drops
though it is neither malignant nor related to any
• Lateral tarsorrhaphy
malignancy).
• Orbital decompression
• Diuretics
• Dark spectacles, protective eye patches
• Eyelid surgeries
Remember—Antithyroid drugs may worsen

exophthalmos and so observe the patient once
antithyroid drugs are started as steroids may
require to be supplemented.
Grading of exophthalmos
Mild: Widening of palpebral fissure due to
lid retraction
Moderate: Orbital deposition of fat causing
bulging with positive Joffroy’s sign
Severe: Congestion with intraorbital oedema,
raised intra-ocular pressure and diplopia and
Fig. 1.249: Malignant exophthalmos.
ophthalmoplegia
Progressive: In spite of proper treatment
Treatment is emergency one, i.e. Large doses
progression of eye signs with chemosis, corneal
of systemic steroids (Prednisolone) are given
ulceration and ophthalmoplegia
along with orbital decompression, systemic
antibiotics, steroid drops, antibiotic drops.
Causes of dyspnoea/stridor in thyroid diseases

• Carcinoma thyroid causing infiltration of
recurrent laryngeal nerve/trachea
• Large, long standing goitre causing
tracheomalacia
• Retrosternal goitre
• Congestive cardiac failure in thyrotoxicosis
Recent rapid increase in thyroid swelling is

due to
• Previous MNG – malignant transformation
• Haemorrhage into a nodule
Fig. 1.250: Look of eyes in different conditions
including thyrotoxicosis.
• Anaplastic carcinoma of thyroid
Causes of exophthalmos Causes of pulsating exophthalmos

Endocrinal • Carotid-cavernous sinus A-V fistula
• Thyrotoxicosis – common • Cavernous sinus thrombosis
• Cushing’s syndrome, acromegaly-rare • Orbital vascular neoplasm
• Orbital haemangioma
Congenital deformities of skull
• Ophthalmic artery aneurysm
• Craniostenosis, oxycephaly, hypertelorism
Primary tumours
• Periorbital meningioma
• Optic nerve glioma
• Lymphoma
• Osteoma
• Pseudo tumour—granuloma
Secondary tumours
• Antral carcinoma, neuroblastoma
Inflammatory
• Orbital cellulites, frontal sinusitis
Vascular causes
• Cavernous sinus thrombosis/A-V fistula
Other eye causes
• Severe myopia
• Severe glaucoma-buphthalmos
Causes of pulsating exophthalmos
• Carotid-cavernous sinus A-V fistula
• Cavernous sinus thrombosis
• Orbital vascular neoplasm
In a case of thyroid disease following things Remember-

should be made very clear • Goitre is enlargement of the thyroid gland
• Functional status – hyperthyroid/euthy- • Solitary nodule is on clinical examination
roid/hypothyroid single palpable nodule without palpable
• Compression to trachea/recurrent nerve rest of the gland
• Neck lymph nodal status • Dominant nodule is single nodule with
• Tracheal deviation palpable enlargement of the remaining
• Carotid infiltration thyroid gland
• Retrosternal extension • Thyroid swelling is confirmed by its movement
• Systemic features like toxicity or malignant with deglutition due to attachment of enclosed
spread to different organs like bone/liver/ pretracheal fascia to inferior constrictor
lungs muscle which is attached to trachea and
cricoid cartilage and so moves with deglu-

tition. Berry’s ligament is condensed vascu-
larised pretracheal fascia postero-supero-
medially. It is important as it is close to
recurrent laryngeal nerve
• Any thyroid swelling can be malignant unless
proved otherwise
• U/S neck, FNAC, T3, T4, TSH are essential
investigations
• CT scan neck is needed in large goitre and
fixed or malignant thyroid.
• Radioisotope study I123 is done only in
selected cases like borderline toxicity, ectopic Fig. 1.251: U/S neck showing thyroid nodule.
thyroid, retrosternal goitre and in follicular
carcinoma thyroid after thyroidectomy to
see secondaries during follow-up period Role of FNAC in thyroid swelling
• Normal thyroid gland is usually not palpable. • Highly sensitive in papillary carcinoma of
thyroid and also its nodal spread
Investigations for Thyroid Diseases • Useful to differentiate between benign and
• T3, T4, TSH, Free T3, Free T4. malignancy
• U/S neck for thyroid and neck nodes. • Useful in lymphoma/anaplastic carci-
• FNAC thyroid and lymph node. noma/medullary carcinoma thyroid/
• Radioisotope study. Hashimotos thyroiditis
• CT neck in malignancies or large goitre. • It is not very useful in follicular carcinoma
• Trucut biopsy if two trials of FNAC are as it is difficult to differentiate it from
inconclusive. It can injure deeper structures follicular adenoma as main feature in
like recurrent laryngeal nerve and also can follicular carcinoma is capsular invasion/
cause haemorrhage. vascular invasion
• Frozen section biopsy on table and proceed
may be needed.
• Serum calcitonin, serum thyroglobulin esti-
mation in neoplasms of thyroid.
Role of ultrasound (U/S) in thyroid diseases
• To detect number, size, nature of the nodules
(cystic/solid/complex) (complex means
cystic and solid together—more suspicious
of carcinoma). Size up to 2 mm can be detected.
• U/S guided FNAC is very useful
• U/S at regular intervals is advisable to
observe a small nodule in thyroid
• To detect recurrent nodule
• To find out the invasion/spread/vascu-
larity/status of carotid artery and internal
jugular vein
Fig. 1.252: FNAC thyroid is an important
• To find out enlarged lymph nodes in neck investigation in thyroid diseases.
Note:
• On table frozen section biopsy is useful in
negative FNAC but doubtful cases. Definitive
procedure is undertaken once frozen section
report comes on table. But in frozen section
biopsy itself, 15% of follicular carcinoma
report may be inconclusive or negative which
causes difficulty in taking decision. In such
occasion hemithyroidectomy is done and
once histology report of follicular carcinoma
is obtained completion thyroidectomy is done
usually immediately within a week. If biopsy
report is delayed then completion thyroidec-
tomy is done after 6 weeks. A B
• Trucut biopsy gives tissue diagnosis but
danger of haemorrhage and injury to vital
structures like trachea, recurrent laryngeal
nerve, vessels are likely.
Solitary Thyroid Nodule

What is solitary nodule of thyroid?
It is a single palpable nodule in thyroid on clinical
examination, in an otherwise normal gland.
Causes
• Thyroid adenomas—
Colloid—commonest.
Hurthle cell.
C
Follicular.
• Papillary carcinoma of thyroid.
Figs 1.253A to C: Solitary nodule involving isthmus
• Only one nodule may be palpable in an
underlying multinodular goitre.
• Thyroid cyst.
Note:
Types: • Thyroid nodule in children and elderly can
1. Toxic solitary nodule. be malignant.
2. Nontoxic solitary nodule. • Rapid enlargement of thyroid nodule can be
malignant.
Based on radioisotope study: • Medullary carcinoma of thyroid commonly
1. Hot—Means autonomous toxic nodule. and 6% of papillary carcinoma of thyroid
2. Warm—Normally functioning nodule. can be familial.
3. Cold—Non-functioning nodule; may be • Recurrent laryngeal nerve palsy, fixity,
malignant-20% (need not be always). Cold stridor, presence of palpable neck nodes are
nodule may be due to malignancy, thyroiditis, usually features of carcinoma thyroid.
thyroid cyst or haemorrhage. • Follicular carcinoma causes pulsatile, locali-
4. Hot or warm in 99m technetium scan but cold zed, warm, vascular secondaries in skull bone.
in I123 scan—commonly they are malignant. • 30% of solitary nodules are cystic.
Features biopsy may be done but it can cause pain/

1. Single nodule palpable in one or other lobes bleeding/recurrent laryngeal nerve injury.
of the thyroid which is usually smooth, 5. T3, T4, TSH are done to find out the function
globular, well-defined margin and firm. Skin 6. Radioisotope study. (I123/I131/99mTc).
overlying is normal. 7. CT scan or MRI neck is done only in selected
2. Lahey’s test does not show any other nodules cases but not routinely. Large swelling/to
in posterior part of the gland. see vascularity/retrosternal extension are the
3. Tracheal deviation towards opposite side is indications.
common – confirmed by trail sign, three finger
test and auscultation.
4. U/S neck is very useful. FNAC is essential.
When FNAC is inconclusive Trucut needle
Fig. 1.255: Solitary nodule thyroid causes deviation

of trachea to opposite side.
Treatment
• If it is a nontoxic nodule due to any cause,
hemithyroidectomy with complete removal of
A lateral lobe and whole of the isthmus is done.
• If it is papillary carcinoma thyroid, then near
total thyroidectomy is done along with
suppressive dose of L-Thyroxine given 0.3
mg OD daily.
• If it is a toxic nodule, radioiodine therapy,
I 131 —5 milli curie is given orally, if the age
of the patient is more than 45 years.
• If age is less than 45 years, then initially
toxicity has to be controlled by antithyroid
drugs, always followed by surgery - Hemithy-
roidectomy.
• If FNAC is follicular adenoma, then hemi-
thyroidectomy is done. If histology becomes
follicular carcinoma (capsular and vascular
invasion) then completion total thyroidec-
tomy is done. Completion thyroidectomy is done
B usually within 7 days or after 3 weeks. If
Figs 1.254A and B: Solitary nodule right lateral
frozen section biopsy proves carcinoma then
lobe. It is a clinical entity. total thyroidectomy is done.
• If there is a nodule in the isthmus, isthmec- Possible features of suspected malignancy
tomy with excision of part of adjacent lateral in solitary nodule thyroid
lobes is done. • Any nodule can be malignant whether
• If FNAC is medullary carcinoma of thyroid, nodule is hard/firm/cystic/small/large/
then total thyroidectomy with bilateral neck asymptomatic
nodal dissection including central compart- • Rapid onset/rapid recent increase in size
ment is done. • Hoarseness of voice/dysphagia/stridor/
• Colloid nodule may response for conservative dysphagia
drug treatment using thyroxine orally in 50% • Fixity of the nodule
cases. If nodule reappears/enlarges progres- • Palpable significant neck nodes
sively significantly/causing cosmetic
problem then hemithyroidectomy is indicated Diffuse Hyperplastic Goitre
in colloid nodule. Initial persistent increase in TSH level causes
diffuse active lobules. In late stages of diffuse
hyperplasia, TSH stimulation decreases and
many follicles become inactive get filled with
colloid and it is called as colloid goitre. As diffuse
hyperplastic goitre is a reversible stage, l- thyroxine
is beneficial.
A Nodular Goitre
Pathogenesis
B
Figs 1.256A and B: Hemithyroidectomy specimen
done for solitary nodule thyroid
Indications for surgery in solitary nodule

thyroid
• Malignant nodule
• Follicular neoplasm
• Toxic nodule in young
• Nodules with obstruction
• Recurrent cystic nodule
• Complex cyst (both solid and cystic
component)
• Cosmetics
Fig. 1.257: Diagrammatic representation of

multinodular goitre. Fig. 1.259: Nodular thyroid involving
both lobes in a female.
• Recent increase in size signifies malignant

transformation or haemorrhage.
• Investigations are T3, T4, TSH, U/S neck,
FNAC, X-ray neck will show ring or rim
calcification.
Fig. 1.258: Large multi-nodular goitre.
Other factors involved are growth stimulating

immunoglobulins and growth prone cell clones.
Features
• It is a slowly progressive disease with many
years of history.
• Multiple nodules of different sizes are formed
in both lobes, also in isthmus, which is firm, Fig. 1.260: X-ray neck showing calcification in
nodular, non tender, moves with deglutition. thyroid with retrosternal extension.
Complications of MNG
• Secondary thyrotoxicosis. (30%)
• Follicular carcinoma of thyroid (10%)
• Haemorrhage in a nodule
• Tracheal obstruction
• Calcification
• Cosmetic problem
Treatment
Nodular goitre is an irreversible stage and so
surgery is the treatment.
• Total thyroidectomy is universally accepted A
method presently. Only problems are chances
of recurrent nerve palsy and postoperative
risk of patient developing hypocalcaemia
often severe.
• Subtotal thyroidectomy is done depending on
the amount of gland involved, amount of
normal gland existing and location of nodules.
• Hartley-Dunhill procedure is removal of one
entire lobe which is more affected with
subtotal removal of other gland.
• Partial thyroidectomy wherein gland behind
the tracheo oesophageal groove is retained
with removal of diseased glands in front.
Earlier it used to be a popular method.
Currently it is not well practiced.
• Postoperatively L-thyroxine is often given to B
prevent further fluctuation in TSH level. Figs 1.261A and B: Multi-nodular goitre specimen
and also cut section.
Thyroid cyst
• It is thyroid swelling which is cystic in Thyrotoxicosis and Hyperthyroidism
nature eliciting positive fluctuation Symptoms due to raised levels of thyroid
• Common cause is colloid degeneration hormones.
• 30% of solitary nodules are cystic Types
• 15% cystic swellings in thyroid are malignant 1. Diffuse toxic goitre—(Grave’s disease,
• Cyst formation is common in papillary Basedow‘s disease. Primary thyrotoxicosis).
carcinoma of thyroid 2. Toxic multi-nodular goitre (Secondary
• A cyst if contains both solid and cystic areas thyrotoxicosis.). (Plummer disease).
is called as complex cyst which is more 3. Toxic nodule.
likely malignant 4. Hyperthyroidism of rarer causes:
• FNAC may cause regression in simple cyst a. Thyrotoxicosis factitia- drug induced. Due
But after three repeated aspirations recur- to intake of L-thyroxine more than normal.
rence occurs, surgery is needed. b. Jod Basedow thyrotoxicosis - because of large
• Complex cyst and if cyst is more than 4 cm doses of iodides given to a hyperplastic
in size then surgery is indicated endemic goitre.
c. Autoimmune thyroiditis or de‘ Quervain‘s • Shortness of breath at rest or on minimal

thyroiditis. exertion.
d. Occasionally carcinoma thyroid. • Angina.
e. Neonatal thyrotoxicosis. It subsides in • Cardiac irregularity.
3-4 weeks as TsAb titres fall in the baby’s • Cardiac failure in the elderly (CCF).
serum.
Neuromuscular system
(Wolf-Chaikoff effect—iodides inhibit the further
• Undue fatigue and muscle weakness,
release of hormone causing hypothyroidism).
exaggerated tendon reflexes, myasthenia like
syndrome.
Clinical Features
• Tremor, hyperkinesias, increased sweating.
i. It is eight times more common in females.
ii. Occurs in any age group. Skeletal system
iii. Primary type is seen commonly in younger Increase in linear growth in children.
age group.
Genitourinary system
iv. Secondary is common in older age group.
• Oligo- or amenorrhoea.
• Occasional urinary frequency.
Integument
• Hair loss.
• Pruritus.
• Palmar erythema.
Psychiatry
• Irritability.
• Nervousness.
• Insomnia.
Sympathetic overactivity causes dyspnoea,
palpitation, tiredness, heat intolerance, sweating,
nervousness, increased appetite and decrease in
weight. Because of the increased catabolism they
are having increased appetite, decreased weight
Fig. 1.262: Thyrotoxicosis (primary). Note the

exophthalmos and also toxic thyroid enlargement.
Symptoms of Hyperthyroidism
Gastrointestinal system
• Weight loss in spite of increased appetite
• Diarrhoea (due to increased activity at
ganglionic level).
Cardiovascular system Fig. 1.263: Diffuse toxic goitre. Note the involvement
• Palpitations, chest pain. of both lobes bilaterally.
WAYNE‘S DIAGNOSTIC INDICES (CLINICAL)

Symptoms Present Absent
1. Dyspnoea on effort +1
2. Palpitation +2
3. Tiredness +2
4. Preference for heat +5 —5
5. Preference for cold (Heat intolerance)
6. Excessive sweating +3
7. Nervousness +2
8. Appetite increased +3
9. Weight decreased +3
Signs Present Absent
1. Bruit over thyroid +2
2. Exophthalmos +2
3. Lid retraction +2
4. Lid lag +1
5. Hyperkinetic movements +4 —2
6. Fine finger tremors +1
7. Hands Hot +2 —2
Moist +1 —1
8. Atrial fibrillation +4
9. Pulse rate 80/minute —3
80-90/minute 0
More than 90/minute +3
10. Palpable thyroid +3
< 11 points—non toxic 11-19—equivocal > 19 points—toxic goitre
and so also increased creatinine level which sig- 2. Cardiac Manifestations:

nifies myopathy (due to more muscle catabolism). 1. Tachycardia is common.
Fine tremor is due to diffuse irritability of grey Sleeping pulse rate is usually checked for
matter. three consecutive nights and average is
Thrill is felt in the upper pole of the thyroid taken as the value.
and also bruit on auscultation. It is because in
2. Ectopic.
upper pole, superior thyroid artery enters the
gland superficially, and so thrill and bruit can 3. Pulsus paradoxus.
easily be assessed. In lower pole inferior thyroid 4. Wide pulse pressure.
artery enters the gland from deeper plane and 5. Multiple extrasystoles.
so thrill cannot be felt. 6. Paroxysmal atrial tachycardia.
7. Paroxysmal atrial fibrillation.
Signs of Hyperthyroidism 8. Persistent atrial fibrillation (not responsive
1. Eye signs in toxic goitre (Refer above) to digoxin).
3. Myopathy: Cardinal signs of toxic thyroid

1. Weakness of proximal muscles occurs, i.e. • Palpable thyroid often with thrill and bruit
the front thigh muscles, or arm muscles. • Tremor of hands and tongue
2. Weakness is more when muscle contracts • Tachycardia
isometrically either while getting down • Exophthalmos
steps, or lifting a full bucket, etc.
3. Often when it is severe it resembles myas-
thenia gravis. Once hyperthyroidism is Toxic Nodule
controlled recovery occurs. • Is a solitary overactive nodule.
• There is an autonomous hypertrophy and
4. Pretibial myxoedema is often a feature of
hyperplasia of the part of the gland where
primary thyrotoxicosis (It is a misnomer)
there is a nodule. (It is not due to Thyroid
• It is usually symmetrical, shiny, red thickened
stimulating antibody (Ts Ab)).
skin, with coarse hair.
• Here high levels of circulating thyroid
• In severe cases skin of whole leg below the
hormones suppress TSH secretion, and so
knee with foot and ankle is involved.
normal thyroid tissue surrounding the nodule
• It is due to deposition of myxomatous tissues
is itself suppressed and inactive.
(mucin like deposits) in skin and subcuta-
• Once patient becomes euthyroid by drugs,
neous plane.
surgery (hemithyroidectomy) is done or
• It might or might not regress completely after
radioactive iodine therapy I131 in a therapeutic
treatment for toxicity
dose of 5mcurie is given orally.
• It is associated with exophthalmos with high
• Because normal gland is inactive, radioactive
levels of thyroid stimulating antibodies.
iodine affects only the autonomous nodule,
5. Thyroid acropachy is clubbing of fingers and allowing the normal gland to remain intact
toes in primary thyrotoxicosis. Hypertrophic which later gets activated and functions
pulmonary osteoarthropathy may develop. normally.
Differentiating points between Primary and Secondary hyperthyroidism

Primary thyrotoxicosis Secondary thyrotoxicosis
1. Symptoms appear first, then swelling 1. Swelling appears first
2. Goitre is diffuse, smooth, firm or soft, both 2. Swelling is large nodular, obvious
lobes are involved 3. Symptoms appear after long time, which is
3. There is thrill and bruit less severe and slowly progressive compared
4. Features are much more severe compared to primary toxicosis
to that of secondary toxicosis 4. Cardiac features are more common
5. Eye signs and exophthalmos are common 5. Eye signs are not common
6. As it is an autoimmune disease, there may
be hepatosplenomegaly
Histologically, there is hyperplasia of acini, lined
by columnar epithelium, often containing vacuolated
colloid
• Drugs are used initially, only for a temporary a. Carbimazole:
period to make the patient euthyroid. • It is the commonest drug used.
• Dose is 5-10 mg, exactly 8th hourly, (as T1/
Investigations 2 of carbimazole is 8 hours).
Thyroid function tests • Usually given for 12-18 months.
• Peak plasma level should be maintained in
Type of disease T4 T3 TSH optimum concentration to have a proper
Conventional increased increased undetectable
benefit.
hyperthyroidism • Often tri-iodo thyronine 20 micro gram 4 times
T3 hyper- → increased Undetectable
daily or Thyroxine 0.1 mg daily is given in
combination with antithyroid drugs, to
thyroidism
prevent iatrogenic thyroid insufficiency or to
Subclinical → → undetectable prevent the increase in size of goitre.
hyperthyroidism
• It acts by blocking thyroid hormone synthesis.
• Serum T3 and T4 levels are very high. TSH • Carbimazole also suppresses the auto-
is very low or undetectable. Some times, only immune process in thyroid in Graves‘ disease.
T3 level is increased and is called as T3 So thyroid stimulating antibody (TsAb)
toxicosis. Here in T3 toxicosis, free T3 estimation production diminishes.
is important.
• Radioisotope study by I131 (Diagnostic dose b. Methimazole: Similar like carbimazole. Dose
5 micro curie is used) will show more up is 5-20 mg daily.
take, i.e. hot nodules or hot areas. This is very
useful in autonomous solitary toxic nodule. c. Propylthiouracil:
• TRH estimation. 1. It acts by blocking thyroid hormone synthesis
• ECG—To look for cardiac involvement and as well as by blocking peripheral conversion
if required opinion from cardiologists‘ is taken of T4 to T3.
and cardiac problems are managed. 2. It also decreases the thyroid autoantibody
• Total count and neutrophil count are very levels.
essential base line investigations before 3. It can be given in hyperthyroidism in children
starting antithyroid drugs (as it may cause and pregnancy.
agranulocytosis). 4. Dose is 200 mg 8th hourly.
Antithyroid drugs are continued during and
Treatment after surgery, for 7-10 days and after radioactive
1. Antithyroid drugs.
iodine therapy for 6 weeks to 12 weeks.
2. Surgery.
Response to treatment and possibility of
3. Radio-iodine therapy.
relapse in primary thyrotoxicosis can be assessed
1. Antithyroid drugs by studying HLA status and TsAb level.
Indications for Antithyroid drugs Propranolol:
1. Toxicity in pregnant women—Propylthio- Dose is 40 mg tid.
uracil is preferred
It reduces the cardiac problems and also
2. Toxicity in children and young adults
blocks the peripheral conversion of T4 to T3, as
3. Before subtotal thyroidectomy, to make the
it is the T3 which is the principle active agent
patient euthyroid usually for 6-12 weeks
4. After radioactive I131 therapy for 6-12 weeks in periphery.
(Effects of Radiotherapy start only in 6-12 Contraindications are bronchial asthma, heart
weeks) block, cardiac failure.
Lugol‘s iodine (5% iodine + 10% potassium In autonomous nodule, hemithyroidectomy is

iodide): done – Entire lateral lobe with whole of isthmus
• It decreases the vascularity of the gland and is removed.
makes it more firm and easier to handle
Advantages: Rapid cure and high cure rate.
during surgery. Dose is 10-30 drops/day
Patient should be made euthyroid before
(minims) for 10 days prior to surgery.
doing surgery. (It should be confirmed by repeated
Potassium iodide tablets 60 mg tid also can
estimation of TSH, T3 and T4 levels).
be given instead of Lugol‘s iodine. But its
use at present is disqualified. Disadvantages:
(One minim = one drop. One ml = 16 drops). 1. Recurrent thyrotoxicosis (5%). It is treated by
radioiodine therapy or antithyroid drugs.
Advantages of antithyroid drugs
Resurgery is technically difficult.
1. Avoids surgery and its complications
2. Thyroid insufficiency (20-45%). It is revealed
2. Avoids radiotherapy.
in 6 months to 2 years and confirmed by
Clinical improvement occurs in 2 weeks.
doing T 3 and T 4 and TSH estimation.
Biochemical improvement occurs in 6 weeks.
Hypothyroidism is better than recurrent
Disadvantages thyrotoxicosis. It is treated by tab. L-thyroxine
1. Prolonged course of treatment for 18 months 0.1 mg daily (OD) for life long.
and inspite of this can not predict the 3. Complications of thyroid surgery itself.
remission or relapse. Relapse rate is 40%.
3. Radioiodine therapy:
2. Size of swelling may not regress.
3. It may lead to agranulocytosis and thrombocyto-
Indications
penia, liver damage, hair loss.
1. Primary thyrotoxicosis after 45 years of age
Sore throat is the earliest presentation of
2. In autonomous toxic nodule
agranulocytosis. If it is so, drug has to be stopped;
3. In recurrent thyrotoxicosis
total count has to be done. If it is less, agranulo-
cytosis is confirmed. High doses of injection
• Radioiodine destroys the cells and causes
benzyl penicillin 10-20 lakh, 6th hourly, IV has
the complete ablation of thyroid gland. It is
to be started to prevent infection. If required, blood
given only after the age of 45yrs, as the chances
transfusion has to be done. Patient usually
of genetic mutation (damage), leukaemia;
recovers by this. To control toxicity, Tab.
carcinomas are high in younger individual.
Propranalol 40 mg tid has to be started. Rarely
• Usual dose is 50-60 milli curie, or 160 micro
they need bone marrow transplantation.
curie/gm of thyroid. (300-600 MBq).
2. Surgery: • It takes 3 months, to get full response, and
so until then, the patient has to take anti-
Indications thyroid drugs. Often additional one or two
1. Failure of drug treatment in primary thyro- doses of radioiodine are required to have
toxicosis in young patients complete ablation. Eventually they go for
2. Autonomous toxic nodule hypothyroidism (80%) and so require
3. Nodular toxic goitre maintenance dose of l-thyroxine 0.1mg daily.
4. When malignancy can not be ruled out • To give therapeutic dose, patient should be
admitted and isolated for 7 days (Half life)
Surgery done is subtotal thyroidectomy—Both lobes
to prevent irradiation. It is given orally soon
with isthmus are removed and a tissue equivalent
after getting from the manufacturer without
to pulp of finger is retained in lower pole of
much delay to have optimal efficacy.
the gland on both sides.
Choice therapies
Condition Age Treatment

Diffuse toxic goitre:
a. Small goitre Antithyroid drugs for 18 months.
b. Large goitre Over 45 years Radioiodine therapy.
Under 45 years Surgery (Subtotal thyroidectomy).
Toxic nodular goitre: Surgery: (Subtotal thyroidectomy)
Initially antithyroid drugs are given to
make the patient euthyroid before surgery.
Toxic solitary nodule: Over 45 years Radioiodine.
Under 45 years Surgery: (Hemithyroidectomy).
Recurrent thyrotoxicosis Under 45 years Antithyroid drugs.
after surgery Over 45 years Radioiodine therapy.
Failure of antithyroid drugs Surgery.
or radio iodine therapy:
Advantages: initially antithyroid drugs are given until adole-

1. No surgery. scent period and then subtotal thyroidectomy
2. No prolonged drug therapy. is done.
Disadvantages:
1. Availability of facilities. Thyrocardiac
2. Proper follow-up is essential. Severe cardiac damage resulting from hyper-
thyroidism (may be partly or wholly due to same),
Toxic Thyroid in Pregnancy usually secondary type, requires proper opinion
• Radioiodine therapy is an absolutely contra- from cardiologists and treatment with propra-
indicated in pregnancy (High risk to foetus). nolol. Subtotal thyroidectomy is the treatment.
• Antithyroid drugs can be administered In a patient with thyrotoxicosis, with recent
carefully. onset of proptosis, early thyroidectomy has to
• But, the problem here is that both TSH and be avoided. Because early surgery may precipitate
antithyroid drugs crosses the placental barrier malignant exophthalmos. Here the patient has
and baby born may be hypothyroid and to be treated initially with antithyroid drugs and
.goitrous. if required with steroids, until the proptosis has
• Propylthiouracil is preferred in pregnancy. remained static for six months. Then subtotal
• Subtotal thyroidectomy can be done in second thyroidectomy is done.
trimester. Since half life of l-thyroxine is 7 days,
propranolol and antithyroid drugs has to be
Toxic Thyroid in Children continued for 7 days after thyroidectomy.
Radioiodine therapy is absolutely contraindicated T3 thyrotoxicosis should be suspected if the
in children because of high risk of developing clinical picture is suggestive of toxicosis, but
thyroid carcinoma. Recurrence rate is also very routine tests for thyroid function are within
high after surgery. So proposed treatment is, normal range.
Differential diagnosis of thyrotoxicosis d. Papillary adenoma—its existence is

• Anxiety neurosis- hands are cold and moist; doubtful. It is invariably low grade
sleeping pulse rate is normal; thyroid papillary carcinoma.
enlargement is not present. Malignant (Dunhill classification).
• Phaeochromocytoma.
• Malabsorption syndrome. a. Differentiated.
• Diabetes mellitus. 1. Papillary carcinoma (60%).
2. Follicular carcinoma (17%).
What are the different presentations of 3. Papillofollicular carcinoma behaves like
carcinoma thyroid? papillary carcinoma of thyroid.
• Any thyroid swelling can be malignant. It 4. Hurthle cell carcinoma behaves like
can be of short or long duration. It can be follicular carcinoma.
solitary/multinodular goitre. It can be solid/ b. Undifferentiated.
cystic/complex in nature. Anaplastic carcinoma (13%).
• Preexisting thyroid swelling with recent
history of rapid increase in size. c. Medullary carcinoma (6%).
• Palpable neck lymph nodes. d. Malignant lymphoma (4%).
• Recurrent laryngeal nerve palsy, dyspnoea,
stridor are other presentations. e. Secondaries in thyroid (rare) - from colon,
• Medullary carcinoma thyroid and papillary kidney, melanoma.
carcinoma thyroid (6%) can be familial.
Etiology of Thyroid Malignancy
Classification of thyroid neoplasm 1. Radiation either external or radioiodine can
cause papillary carcinoma thyroid. There is
A. Benign. increased incidence of thyroid carcinoma
a. Follicular adenoma. among children following exposure to
b. Hurthle cell adenoma. ionising radiation after the Chernobyl nuclear
c. Colloid adenoma—commonest. disaster in Ukraine in 1986. Irradiation to
head and neck region used to be the therapy
for benign conditions like adenoids, acne
Fig. 1.264: Carcinoma thyroid. Note the

superficial tissue infiltration. Fig. 1.265: Carcinoma thyroid showing vascularity.
vulgaris, thymus enlargement, haemangio- Types
mas which predisposed papillary carcinoma i. Occult (< 1.5 cm)
of thyroid. Radiotherapy for Hodgkin’s ii. Intrathyroidal
lymphoma in younger age group may cause iii. Extrathyroidal
papillary carcinoma of thyroid. iv. Micropapillary carcinoma is less than 1 cm
2. Preexisting multinodular goitre. It turns into in size or clinically not detectable.
follicular carcinoma of thyroid. Gross:
3. Medullary carcinoma thyroid is often familial. It can be soft, firm, hard, and cystic. It can be
4. Hashimoto’s thyroiditis may predispose to solitary or multinodular. It contains brownish
papillary carcinoma of thyroid and also NHL. black fluid.
Papillary Carcinoma Microscopy:

• It is 60% common. It shows cystic spaces, papillary projections with
• Common in females (3:1) and young age psammoma bodies, malignant cells with ‘Orphan
group. Annie eye’ nuclei (intranuclear cytoplasmic
inclusions). (Nuclear grooving).
Aetiology
• Radiation either external or radioactive Clinical Features
1. Soft or hard or firm, solid or cystic, solitary
iodine therapy.
or multinodular thyroid swelling.
– TSH levels in the blood of these patients
2. Compression features are uncommon in
are high. and so it is called as hormone
papillary carcinoma thyroid.
dependent tumour.
3. Often discrete lymph nodes in the neck are
– It is a slowly progressive and less
palpable.
aggressive tumour.
– It is commonly multicentric.
Diagnosis
– It spreads within the gland throgh intra- FNAC of thyroid nodule and lymph node. To
thyroidal lymphatics to other lobe, comes see psammoma bodies, nuclear changes
out of the capsule and spreads to lymph Radioisotope scan shows cold nodule.
nodes. TSH level in the blood is higher.
– Usually there is no blood spread.
Treatment
• Near total thyroidectomy or total thyroidec-
tomy
• Suppressive dose of L-Thyroxine 0.3 mg O.D
life long.
• Block dissection (modified radical neck dissection)
is required if lymph nodes are involved.
• Occasionally if small lymph nodes are
present, ‘Berry picking’ may be done. (Not
accepted now).
• Extrathyroidal type needs radioactive iodine
therapy also (I131).
Near total thyroidectomy (by Thomas) is
removal of both lobes of the thyroid and isthmus
Fig. 1.266: Papillary carcinoma of thyroid with lymph
with retaining a small tissue close to recurrent
nodal spread. laryngeal nerve and parathyroids.
Note: If tumour is unifocal, intrathyroidal, less Berry’s in thyroid

than 1 cm and well differentiated tumour in a • Berry ligament
patient with age less than 40 years, then • Berry sign
hemithyroidectomy is sufficient with regular, • Berry picking
proper follow-up.
Prognosis is good and it is one of the curable Lateral aberrant thyroid is a misnomer. It is
malignancies. actually secondaries in neck lymph nodes which
are palpable from an occult primary from
papillary carcinoma of thyroid (which is
clinically not palpable).
Thyroid paradox—Cellular tumours are soft, and
cystic tumours are firm or hard (tensely cystic).
It is observed in papillary carcinoma of thyroid.
Features of thyroid carcinoma

Any thyroid can be malignant of any size,
of any texture- solid/cystic, of any number-
single/multiple, in any age group
Features of infiltration
• Infiltration of strap muscles often with
sternomastoid muscle
• Infiltration of laryngotracheal complex
causing stridor and often haemoptysis
Fig. 1.267: Papillary carcinoma of thyroid specimen. • Infiltration of recurrent laryngeal nerve
causes hoarseness of voice
AMES scoring • Infiltration of oesophagus causes dys-
A: Age. Age less than 40 years has got better phagia/odynophagia (painful swallowing)
prognosis • Infiltration into carotid sheath causing
M: Distant metastasis absence of carotid pulsation- berry’s sign
E: Extent of the primary tumour • Infiltration of cervical sympathetic chain
S: Size of the tumour. Size less than 4 cm causing Horner’s syndrome
has got better prognosis • Rarely infiltration into cranial nerves or
brachial plexus can occur
AGES scoring
A: Age less than 4 cm has got better prognosis Features of lymph nodal spread
G: Pathologic Grade of the tumour • Discrete neck node involvement can occur
E: Extent of the primary tumour commonly in papillary carcinoma of thyroid,
S: Size of the primary tumour. Size less than often in medullary carcinoma and
4 cm has got better prognosis occasionally in follicular carcinoma. Lymph
node is often cystic (20%) and contains
Psammoma bodies are seen in brownish-black material in papillary
• Papillary carcinoma thyroid carcinoma
• Meningioma • Central neck (level VI) and mediastinal nodes
• Serous cystadenoma of ovary are also often can get involved in thyroid
malignancy. Primary nodes may be involved • It can also spread to lymph nodes in the neck
but clinically not palpable. Superior occasionally.
mediastinal nodes (level VII) can cause
compression of SVC, recurrent laryngeal Types
nerve with often dullness in the sternum. • Non-invasive-blood spread is not common.
These nodes can get involved without • Invasive- blood spread is common.
palpable neck nodes
• In the neck palpable nodes are commonly
levels – II, III and IV occasionally level V.
Secondary nodes – clinically palpable
• Only palpable neck node may be presentation
without clinically palpable thyroid – occult
secondary with primary (papillary) thyroid
carcinoma. FNAC of the node concludes the
diagnosis
• Central node dissection is the common
practice while doing total thyroidectomy in
carcinoma thyroid especially in medullary
carcinoma of thyroid
Features of blood spread

Fig. 1.268: Follicular carcinoma of thyroid in a male patient.
• Follicular carcinoma commonly spreads It involved mainly left lobe but it is extensive and spreading
through blood to bone, lungs, and liver. Bone to soft tissues adjacent to it.
secondary is typical. It is well-localized,
smooth, soft/hard, warm, non mobile,
vascular and pulsatile. It is common in the
skull bone – frontal/parietal bone. It can
occur in other bones also
• Lung secondaries present with chest pain,
dyspnoea and haemoptysis
• Liver secondaries cause hepatomegaly and
jaundice
• Blood spread also can occur in medullary
carcinoma of thyroid
Follicular Carcinoma
• It is 17% common.
• It is common in females.
• It can occur either denovo or in a preexisting
multinodular goitre. A B
• It is a more aggressive tumour. Figs 1.269A and B: Follicular carcinoma of thyroid causing
• It spreads mainly through blood into the lung, secondaries in skull. It is localized, vascular, smooth,
bones, liver. pulsatile, warm secondaries (in skull).
• Bone secondaries are typically vascular,
warm, pulsatile, localized, commonly in skull, Typical Feature
long bones, ribs. Angioinvasion and capsular invasion.
Clinical Features • Frozen section biopsy is very useful. But in

1. Swelling in the neck, firm or hard and 15% cases it shows negative results.
nodular. • U/S abdomen, Chest X-ray, X-ray bones are
2. Tracheal compression and stridor. the other investigations required.
3. Dyspnoea, haemoptysis, chest pain when
there are lung secondaries.
4. Recurrent laryngeal nerve involvement
causing hoarseness of voice, positive ‘Berry’s
sign’ signifies advanced malignancy.
(Infiltration into the carotid and so absence
of carotid pulsation).
5. Pulsatile, warm, well localized, vascular
secondaries in the skull (frontal/parietal
bones), long bones.
Investigations
• Most often FNAC is inconclusive, because
capsular and angioinvasion which is the
main feature in follicular carcinoma cannot
be detected by FNAC.
Fig. 1.271: CT scan of neck showing thyroid enlargement
in follicular carcinoma of thyroid with infiltration.
Treatment
• Total thyroidectomy is done, along with block
dissection whenever lymph nodes are enlarged.
• Maintenance dose of L-Thyroxine 0.1mg.O.D
is given lifelong.
• FNAC in 50% of follicular carcinomas are
inconclusive as it is difficult to differentiate
A between follicular adenoma and carcinoma.
In such occasions frozen section biopsy on
table may be useful. If on-table frozen section
biopsy is positive for malignancy then total
thyroidectomy is done.
• In 15% cases frozen section biopsy also may be
inconclusive or frozen section biopsy facility may
not be available in many places then initial
hemithyroidectomy is done. If later report comes
as follicular carcinoma of thyroid then
completion thyroidectomy is done. It is done
usually in 7 days of initial surgery otherwise
3 weeks after the first surgery.
B • When neck nodes are present in 10 % cases,
Figs 1.270A and B: X-ray skull showing modified radical dissection is done one or
secondaries from follicular carcinoma thyroid. both sides.
Follow-up Note:
It is by radioisotope I123 scan done at regular • Toothpaste colloid- follicular carcinoma.
intervals (6 months) to look for secondaries. • Chewing gum colloid papillary carcinoma.
Thyroglobulin estimation is a good follow- • Nuclear grooving papillary carcinoma.
up method to decide for Radioisotope study. • Psammoma bodies papillary carcinoma.
Normal value is 3-5 ng/ml. High value signifies • Amyloid—medullary carcinoma.
persistent/recurrent/metastatic disease. It • Follicular adenoma aneuploid and in
should be estimated once in 3 months. If fcdiploid—DNA ploid study.
thyroglobulin level is normal radioiodine study
is not necessary.
If it is high, radioiodine study is indicated.
Further Treatment
• If secondaries are detected therapeutic dose
Ra I131 is given. L-thyroxin has to be stopped
for 6 weeks prior to RT, and then required
dose of Ra I131 is given.
• Secondaries in bone are treated by external
radiotherapy. Internal fixation should be done
whenever there is pathological fracture.
• There is no role of chemotherapy for follicular
carcinoma thyroid.
Note:
• High dose of retinoic acid will make I131 to
concentrate in tumor cells (70mg/daily for
2 weeks). Fig. 1.272: Carcinoma thyroid with dilated veins
on the surface.
• Fertility should be avoided for 1 year after
I131 therapy.
• Avoid contrast CT in thyroid diseases as much
as possible because I131 study in later period
will be difficult.
• MRI is ideal when radioiodine therapy is
needed.
Hurthle cell carcinoma is a variant of follicular
carcinoma of thyroid which contains abundant
oxyphill cells. It spreads more commonly to
regional lymph nodes than follicular carcinoma
of thyroid. 99mTc sestamibi scan is very useful
for Hurthle cell carcinoma.
Differential diagnosis for carcinoma thyroid

• Multinodular goitre
• Solitary nodule of other causes
• Riedel’s thyroiditis Fig. 1.273: Total thyroidectomy specimen done
for follicular carcinoma of thyroid.
TNM staging for thyroid cancer

Tumour Nodes
Tx Primary not assessed Nx Nodes cannot be assessed
T0 No primary N0 No regional nodes
T1 < 1 cm limited to thyroid N1 Regional nodes present
T2 1-4 cm limited to thyroid N1a Same side neck nodes
T3 > 4 cm limited to thyroid N1b Bilateral, midline, mediastinal nodes
T4 Any size extending beyond capsule
Metastases
Mx Cannot be assessed
M0 No metastases
M1 Metastases presen
Under the age of 45 years only Stage I (any T/N and M0) and II (any T/N and M1). After the age
45 years, Stage I, II, III and IV. Anaplastic carcinoma is always stage IV.
Fig. 1.274: Carcimnoma thyroid with neck

secondaries. Fig. 1.275: Anaplastic carcinoma of thyroid with infiltration
through the capsule. It commonly encases the carotid
Anaplastic Carcinoma artery causing Berry’s sign positive.
• It is a very aggressive tumour of short
duration, presents with a swelling in thyroid
region which is rapidly progressive causing-
i. Stridor and hoarseness of voice.
ii. Dysphagia.
iii. Fixity to the skin.
iv. Infiltration into the carotid sheath-Berry’s
sign.
• Swelling is hard, with involvement of isthmus
and bilateral lateral lobes.
• FNAC is diagnostic.
• Tracheostomy and isthmectomy has got a role
to relieve respiratory obstruction temporarily. Fig. 1.276: Anaplastic carcinoma of thyroid.
• Treatment is external radiotherapy as usually 2. Diarrhoea, flushing.
thyroidectomy is not possible. 3. Hypertension, phaeochromocytoma and
• However prognosis is poor. mucosal neuromas when associated with
MEN II syndrome.
Follow-up in differentiated thyroid carcinoma 4. Sporadic and familial types occur in adult-
• Proper clinical examination in the neck for hood whereas cases associated with MEN
residual/nodal disease and for distant syndrome II occur in younger age groups.
spread.
• Whole body radioisotope scan after one Types
week of surgery to see residual tumour in 1. Sporadic: Usually solitary—70%.
the neck or metastases. 2. MCT with MEN II syndrome: MCT with MEN
• Estimation of thyroglobulin at regular inter- II B with phaeochromocytoma is most
vals is very important. aggressive
• Follow-up whole body radioisotope scan 3. Familial MCT: It is autosomal dominant with
at 3-6 months intervals. Thyroxine should proto-oncogene in chromosome number 10.
be stopped for 6 weeks. It is commonly done It is commonly multicentric.
if thyroglobulin level in the blood is signi-
ficantly high.
Investigations
• FNAC: Shows amyloid deposition with
Medullary Carcinoma of Thyroid (MCT)
dispersed malignant cells and ‘C’ cell
• It is uncommon (5%) type of thyroid
hyperplasia.
malignancy.
• Tumour marker: Calcitonin level will be higher.
• It is arises from the para follicular ‘C` cells
Normally, it is less than 0.08 ng/L.
which is derived from the ultimo bronchial
body (neural crest). They are part of APUD • U/S neck-thyroid region.
(Amine Precursor Uptake Decarboxylation) • Urinary VMA, urinary catecholamines,
cells. C cells are more in upper pole of the urinary metanephrine, serum calcium, serum
thyroid. parathormone estimation.
• It contains characteristic ‘amyloid stroma’ • CT neck and chest to evaluate nodal status
wherein malignant cells are dispersed. is a must.
• In these patients blood levels of calcitonin both • 111 Indium octreotide scanning is useful in
basal as well as that following calcium or detecting medullary carcinoma thyroid (70%
pentagastrin stimulation is high, a very useful sensitivity). It is also useful in postoperative
tumour marker. follow-up to find out residual/metastatic
• Tumour also secretes 5-H.T (serotonin), disease.
prostaglandin and vasoactive intestinal
polypeptide (VIP).
• It spreads mainly to lymph nodes (60%
common).
• It may be associated with MEN II syndrome
and phaeochromocytoma with hypertension.
• There may be mucosal neuromas in lips, oral
cavity.
Clinical Features
1. Thyroid swelling often with enlargement of
neck lymph node. Fig. 1.277: Medullary carcinoma of thyroid specimen.
Treatment Malignant Lymphoma

Surgery is the main therapeutic modality. • It is NHL type. Occurs in a pre-existing
• Total thyroidectomy with Central node dissection Hashimoto‘s thyroiditis (Not proved well).
(level 6) in all patients even if there are no • FNAC is useful to diagnose the condition.
nodes in the neck. + Maintenance dose of • Chemotherapy is the main treatment.
L-thyroxin. • Often total thyroidectomy is done to enhance
• Neck lymph nodes block dissection if lymph the results.
nodes are involved (bilateral modified radical
dissection of neck nodes). Later regular Hashimoto's Thyroiditis
(Struma Lymphomatosa)
U/S neck to detect early neck nodes.
• Also called as diffuse nongoitrous thyroiditis
• Adriamycin is the drug used as chemotherapy
• It is an autoimmune thyroiditis is common
with limited results.
in women.
• No role of suppressive hormone therapy or There is hyperplasia initially, then fibrosis,
radioactive iodine therapy. eventually infiltration with plasma cells and
• External beam radiotherapy for residual lymphocytic cells. Askanazy cells are typical (like
tumour disease. Hurthle cells).
• Somatostatin/octreotide for diarrhoea. The river struma arises in Bulgaria and flows
• If there is associated phaeochromocytoma it into Aegean Sea. Struma means goitre. Banks
should be treated surgically by adrenalectomy of this river are endemic goitre area.
first and later only total thyroidectomy is
done. Clinical Features
• All family members of the patient should be 1. Painful, diffuse, enlargement of usually both
evaluated for serum calcitonin and if it is high lobes of thyroid which is firm, tender and
they should undergo prophylactic total smooth (occasionally one lobe is involved).
thyroidectomy (Can also be assessed by genetic 2. Initially, they present with toxic features but
evaluation). If there is positive RET proto- later, they manifest with features of
oncogene in MCT with MEN II A and familial hypothyroidism.
MCT types, prophylactic total thyroidectomy Hyperplasia → Hyperthyroid.
is done at the age of 5 years. In positive RET → Euthyroid.
Fibrosis → Hypothyroid.
proto-oncogene in MCT with MEN II B
3. There may be hepatosplenomegaly.
prophylactic total thyroidectomy is done at
4. It is often associated with other autoimmune
the age of one year. diseases.
• MCT with associated parathyroid hyper- 5. In 85% cases significant rise in the thyroid
plasia (30%) in MEN IIA, total thyroidectomy antibodies (microsomal, thyroglobulin, or
with central nodal dissection with total colloid antibodies) is observed.
parathyroidectomy and autotransplantation 6. Papillary carcinoma may develop in
of half of gland in sternomastoid or non- Hashimoto‘s thyroiditis.
dominant forearm brachioradialis muscle. 7. Often condition may be associated with or
may predispose to malignant lymphoma. It is
Prognosis at present not well proved.
• Sporadic MCT and MCT with MEN II are
aggressive. Investigations
• Familial MCT not associated with MEN II FNAC, T3, T4, TSH. Thyroid antibodies assay.
has got better prognosis. Usually ESR is very high (over 90 mm/hour).
Treatment Treatment
1. L-thyroxine therapy. Isthmectomy is done to relieve compression on
2. Steroid therapy often is helpful. the airway. They require l- thyroxine replacement
3. If goitre is large and causing discomfort, then later, as hypothyroidism is common.
subtotal thyroidectomy is done.
THYROIDECTOMY
De-Quervain's Subacute Types

Granulomatous Thyroiditis 1. Hemithyroidectomy: Along with removal of one
It is due to viral aetiology either mumps or lobe, entire isthmus is removed. It is done
Coxsackie’s viruses causing inflammatory in benign diseases of only one lobe.
response with infiltration of lymphocytes, 2. Subtotal thyroidectomy commonly done in toxic
neutrophils, multinucleated giant cells. thyroid either primary or secondary and also
often for nontoxic multinodular goitre. Here
about 8 grams, or a tissue, size of pulp of
Clinical Features finger is retained on lower pole, on both sides
• Pain is diffuse, swelling in thyroid which and rest of the thyroid gland is removed.
is tender. 3. Partial thyroidectomy is removal of the gland
• Commonly seen in females. in front of trachea after mobilization. It is
• Initially, there will be transient hyperthyroi- commonly done in nontoxic multinodular
dism with high T3 and T4 but poor radioiodine goitre.
uptake. 4. Near total thyroidectomy: Here both lobes except
• It is usually a self limiting disease. the lower pole which is very close to recurrent
laryngeal nerve and parathyroid is removed.
It is done in case of papillary carcinoma of
Riedel's Thyroidis (0.5% common) thyroid.
• A very rare benign entity wherein thyroid 5. Total thyroidectomy: Entire gland is removed.
tissue is replaced by fibrous tissue which It is done in case of follicular carcinoma of
interestingly infiltrates the capsule into thyroid, medullary carcinoma of thyroid.
muscles, paratracheal tissues, carotid sheath.
• It is often associated with retroperitoneal and
mediastinal fibrosis (Woody Thyroiditis,
Ligneous Thyroiditis).
Clinical Features
Hard, fixed, swelling with stridor, often Berry’s
sign may be positive, i.e. absence of carotid
pulsation.
Differential Diagnosis
Anaplastic carcinoma of thyroid.
Investigations
• T3, T4 may be low due to hypothyroidism.
Fig. 1.278: Hemithyroidectomy—entire one lateral lobe
• Radioisotope scan will not show any uptake. and entire isthmus are removed retaining entire opposite
• FNAC to rule out carcinoma. lateral lobe. It is done in solitary nodule/toxic or nontoxic
adenoma in one lobe.
Fig. 1.281: Near total thyroidectomy is done in papillary

carcinoma of thyroid. Here most of the gland except lower
small tissue of 1 gram is retained to safeguard recurrent
laryngeal nerve and parathyroid gland. Tissue is retained
Fig. 1.279: Subtotal thyroidectomy—it is done in toxic/
either in or both sides.
nontoxic multinodular goitre. Most of the gland except
lower pole (4-8 gram) on both sides removed.
Fig. 1.282: Total thyroidectomy is done for follicular

carcinoma and medullary carcinoma of thyroid.
Fig. 1.280: Partial thyroidectomy—it is done in nontoxic

nodular goitre if there is adequate normal gland posteriorly.
Tissue in the tracheo-oesophageal groove is retained.
Isthmus and gland with nodules in front is removed. It
is not commonly done now.
Preoperative Preparation
• Blood grouping and cross matching. Keep
the required blood ready.
• Indirect laryngoscopy. Patient is asked to tell’
E’ to check the abduction of vocal cord.
• Serum calcium estimation—ionic calcium
• T3, T4, TSH.
• Thyroid antibodies. Fig. 1.283: Hartley Dunhill procedure. Here one entire
lateral lobe, isthmus, and most part of the opposite lateral
• ECG and cardiac fitness especially in toxic lobe except small quantity of tissue in the lower pole/
goitre. tracheo-oesophageal groove – subtotal/partial/one gram
is retained.
Procedure Skin and platysma are incised – upper flap
Position: Under general anaesthesia patient is raised up to thyroid cartilage, lower flap up to
put in supine position with neck extended by sternoclavicular joint. Deep fascia is opened
placing a sand bag under shoulder—with table vertically in the midline. Strap muscles are
tilt of 15 degree head up to reduce venous retracted or cut in between two Kocher’s forceps
congestion. (in the upper part as in lower part ansa cervicalis
Incision: Horizontal crease incision is done, two nerve is present which supplies the muscles).
finger breadth above the sternal notch, from one Pretracheal fascia is opened to mobilize the
sternomastoid to the other. thyroid. First, short stout middle thyroid vein
is ligated, and then superior thyroid pedicle is
ligated close to the gland so as to avoid injury
to external laryngeal nerve. Inferior thyroid artery
is ligated away from the gland so as to avoid
injury to recurrent laryngeal nerve. Mobilized
gland is removed. Bed is sutured with catgut
so as to prevent bleeding. Drain is placed. The
wound is close in layers.
Thyroid steal: Patient is taken to operation theatre
for few days before doing surgery so as to reduce
the anxiety of the patient.
Fig. 1.284: Note the incision for thyroid surgery.
Fig. 1.285: Reverse Trendelenburg position used for thyroid surgery.

Fig. 1.288: Suction drain is kept after thyroidectomy.
Complications of Thyroidectomy
1. Haemorrhage: May be due to slipping of
ligatures either superior thyroid artery or
other pedicles. It will cause tachycardia,
hypotension, breathlessness, and compres-
sion over the trachea may cause severe stridor,
A
respiratory obstruction. As a first aid,
immediate release of sutures including that
of deep fascia has to be done and pressure
over the trachea is released. Then patient is
shifted to operation theatre, and under general
anaesthesia exploration is done and bleeders
are ligated. Blood transfusion may be required.
2. Respiratory obstruction. It may be due to
B haematoma (if it is so, the haematoma has
to be evacuated), or due to laryngeal oedema.
Figs 1.286A and B: Anatomical relations of thyroid For laryngeal oedema, immediate emergency
should be clear for safe thyroid surgery
endotracheal intubation is done along with
steroid injections. Often emergency tracheo-
stomy may be required as a life saving
procedure.
3. Recurrent laryngeal nerve palsy: It can be
transient or permanent. Transient is 3%
common. They usually recover in 3 weeks
to 3 months. Often they require steroid
supplement and speech therapy. Permanent
paralysis is rare.
4. Hypoparathyroidism is rare 0.5% common.
Mostly it is temporary due to vascular spasm
of parathyroid glands, occurs in 2-5th
postoperative day. Present with weakness,
+ve Chvostek‘s sign, carpopedal spasm,
convulsions. Serum calcium estimation has
Fig. 1.287: Anatomical positions of vocal cord at
to done and then 10 ml of 10% calcium
different situations.
gluconate— is given IV eighth hourly, and
later supplemented by oral calcium 500 mg
8th hourly. After 3-6 weeks, patient is
admitted, drug is stopped and serum calcium
level is repeated.
Fig. 1.290: Note the location of parathyroid glands.
5. Thyrotoxic crisis (Thyroid storm): Occurs in

a thyrotoxic patient inadequately prepared
for thyroidectomy and rarely a thyrotoxic
patient presents in a crisis following an
unrelated operation or stress. They present
in 12-24 hours with severe dehydration due
to circulatory collapse, hypotension, hyper-
pyrexia, and often cardiac failure.
Treatment is injection hydrocortisone, oral
antithyroid drugs, tepid sponging of whole
body, beta blocker injection, oral iodides, large
amount of IV fluids for rehydration, digitoxin,
cardiac monitor, often ventilator support, and
B observation. It has got high mortality rate
with critical period of 72 hours. Fluid and
electrolyte management, cardiac management
Figs 1.289A and B: Anatomical location of recurrent
laryngeal nerve. Note the different variations of recurrent are important aspects to be monitored and
laryngeal nerve. treated.
6. Injury to external laryngeal nerve causes

weakness of cricothyroid muscle leading to
alteration in pitch of voice.
7. Hypothyroidism. Revealed clinically after 6
months.
8. Wound infection, stitch granuloma forma-
tion.
9. Keloid formation.
Treatment of thyroid crisis

• Injection hydrocortisone high dose—500-
1000 mg IV
• Rehydration with adequate IV fluids to
control circulatory collapse
• Injection sodium iodide IV
Fig. 1.292: Postoperative tetany
• Injection propranolol after thyroidectomy.
• Oral iodides
• Oral antithyroid drugs
• Tepid sponging
• Digitoxin
• Fluid and electrolyte management
• ICU care, ventilator support and cardiac
monitor
Fig. 1.291: Postoperative sinus formation

after thyroidectomy.
THYROGLOSSAL CYST B
Thyroglossal cyst is a swelling occurring in the Figs 1.293A and B: Recurrent nodule thyroid. Patient
neck in any part along the line of thyroglossal has undergone thyroidectomy once earlier. Note the scar
tract. It is a tubulodermoid. It is accumulation in the neck.
of the cystic fluid secreted by the portion of the
unobliterated part of the thyroglossal duct/tract.
Fig. 1.295: Thyroglossal cyst.
Fig. 1.296: Thyroglossal duct anatomy.
Possible sites for thyroglossal cyst

C a. Beneath the foramen caecum
b. In the floor of mouth
c. Suprahyoid
Figs 1.294A to C: Operated specimen of thyroid showing d. Subhyoid - commonest site
nodules, cut section showling cavities, haemorrhagic
areas.
e. On the thyroid cartilage
A B C
Figs 1.297A to C: Thyroglossal cyst examination to feel the ‘tug”
It is usually congenital wherein there will Investigations

be degeneration of a part of the tract causing a. Radioisotope study I131.
cystic swelling. Normal thyroid may be present b. U/S neck.
in the normal location (fossa). Sometimes, thyroid c. FNAC from the cyst.
may not be present in the normal site but may d. T3, T4 and TSH estimation.
be present in the wall of the thyroglossal cyst.
It contains gel like fluid. It is lined by columnar Differential diagnosis for thyroglossal cyst
epithelium surrounded by lymphoid tissues. • Subhyoid bursa
• Pretracheal lymph node
Clinical Features • Dermoid cyst
a. Swelling in the midline, towards the left. • Solitary nodule thyroid
b. Moves with deglutition as well as with the
protrusion of tongue. Patient is asked to open Treatment
the mouth and keep the lower jaw still. a. Sistrunk operation: Excision of cyst along with
Examiner holds the cyst between the thumb full tract up to the foramen caecum is done
and forefinger. When the patient is asked to along with removal of part of the body of
protrude the tongue, a ‘tugging sensation’ can the hyoid bone as the tract passes through
be felt. it. Anaesthetist should wear a glove and
c. Swelling is smooth, soft, fluctuant, (cystic), support and guide over the posterior third
nontender, mobile, often transilluminant. of the tongue while reaching the tract to
d. Thyroid fossa is empty, if there is no thyroid foramen caecum.
in normal location. b. If there is no normal thyroid gland after the
e. Thyroglossal cyst can get infected and may surgery, maintenance dose of l-thyroxine
form an abscess. 0.1 mg od is given life long.
f. Malignancy can develop in thyroglossal cyst If tract is not completely excised, it will result
(Papillary carcinoma). in thyroglossal fistula.
Thyroglossal Fistula Ectopic Thyroid
• It is not a congenital condition. Ectopic thyroid tissue may lie any where along
• It either follows infection of thyroglossal cyst the line of descent. Whole of the thyroid gland
which bursts open or after inadequate removal or residual thyroid lies in an abnormal position
of the cyst. either in the posterior part of the tongue, or in
• It is lined by columnar epithelium, discharges the upper part of the neck in midline, or
mucus, and is a seat of recurrent inflam- intrathoracic region. Radioisotope scan, CT scan
mation. ‘Hood sign’ is characteristic. for intrathoracic thyroid will confirm the
diagnosis.
Investigations
Radioisotope study and fistulogram.
Treatment
Sistrunk operation.
(Note: One more Sistrunk operation is done in case
of lymphoedema).
Fig. 1.299: Thyroid ectopic sites
Lingual Thyroid
It is a thyroid swelling in the posterior third
A B
of tongue, at the foramen caecum, presenting as
Figs 1.298A and B: Thyroglossal fistula. rounded swelling. It may be the only existing
thyroid tissue which may cause.
DYSHORMONOGENESIS a. Dysphagia.
• It is an autosomal recessive condition wherein b. Speech impairment.
there is either deficiency of thyroid enzymes c. Respiratory obstruction.
(either peroxidase or dehalogenase) or d. Haemorrhage.
inability to concentrate or to bind or to retain Any diseases which can occur in normal
iodine. thyroid can also occur in lingual thyroid, i.e.
• It may be familial and patient presents with nodularity, toxicity, malignancy.
large diffuse vascular goitre involving both
lobes. Diagnosis
• They respond very well to L-thyroxine and • Radioisotope study shows the uptake of iodine
may not require surgery at any time. by the lingual thyroid and also says the status
• Condition may be associated with congenital of the thyroid in normal fossa.
deafness which is being called as Pendred‘s • U/S neck has to be done to see the absence
syndrome. of thyroid in normal location.
Treatment Radioisotope study is done to see the

L-thyroxine is given daily orally. secondaries by doing whole body scanning (Total
Often requires surgical excision and is body scintygraphy). For diagnostic radioactive
technically easier. study Technetium 99 pertechnetate can also be
Radioisotope therapy for ablation is also used but it is not as good as I123.
given.
Therapeutic Uses
Radioactive iodine:
1. In primary thyrotoxicosis after 45 years.
It is used both as a diagnostic as well as a
2. In autonomous toxic nodule after 45 years,
therapeutic agent.
it is useful as remaining gland still will
1. I131—is used for radioactive iodine therapy
function adequately after radiotherapy (As
(beta rays).
during radiotherapy radioisotope will not be
2. I123 —is used for diagnostic studies (gamma
taken up by this retained normal gland as
rays).
it is suppressed in the presence of toxic
For diagnostic purpose I123 is given orally on
nodule which will function later adequately).
previous day. (Dose—5 microcurie; T1\2 (half-life)
3. In follicular carcinoma of thyroid, after total
of I 123 is 13 hours and so it is suitable for diagnostic
thyroidectomy, if there are secondaries
purpose). Patient should not take l-thyroxine for
elsewhere in the body, as in bone or lungs,
7 days prior to radioisotope study.
then radioiodine therapy is given. I131 is given
Thyroid treats this I123 similar to inorganic
as its half-life is 8 days. Patient should be
I . This I 123 enters the thyroid from the circulation
127
isolated for this period. It is given orally in
and get incorporated into T3, T4 and later released
a dose of 5 milli curies (160 micro curie/gm
into circulation as protein bound iodide (PBI).
of thyroid).
Normal value of PBI is 8 mg%.
Using Gieger Muller‘s gamma ray counter Dose of radioactive iodine
scanning of thyroid gland is done to visualise Diagnostic
gland. • For thyroid—5-50 micro curie
• Hot area suggests more uptake, • For whole body iodine scan—5-10 milli curie
• Warm area suggests normal uptake, in 72 hours
• Cold area suggests no uptake. Therapeutic
I123 radioisotope can be safely used in children • Residual thyroid ablation—50 m curie
and pregnancy for only diagnostic purpose • Bone secondaries from FCT—100-120 m
(5 microcurie) as the dose is low. curie
Indications for diagnostic radioactive iodine • Lung secondaries from FCT—180 m curie
study:
a. Doubtful toxicity. Half-life
b. Ectopic thyroid. I123 13 hours Oral
c. Autonomous toxic nodule. I125 60 days Oral
d. After total thyroidectomy, to look for I131 8 hours Oral
secondaries in follicular carcinoma thyroid. I132 2.3 hours Oral
e. Retrostrernal thyroid. Tc 99 scan 6 hours Intravenous
DIFFERENTIAL DIAGNOSIS OF MASS ABDOMEN
WRITING A CASE SHEET FOR Abdomen is divided in to nine regions by four lines.
1. Upper horizontal or transpyloric line is mid-
MASS ABDOMEN way between the suprasternal notch and
In a patient presenting with mass abdomen, symphysis pubis or line between tips of ninth
generally following clinical features should be costal cartilages on each side. It is often mid-
assessed carefully. way between xiphisternum and umbilicus.
• Pain: Site, nature, aggravating or relieving 2. Lower horizontal line is transtubercular line
factors, duration of pain, referred pain. at the level of two tubercles (5 cm behind
• Vomiting: Type, content, haematemesis, the anterior superior iliac spine along the
relation to food, frequency. iliac crest) on the iliac crest.
• Jaundice: It is an important factor in relation 3. Right vertical line is the line through the
to liver, gallbladder or pancreatic masses. midpoint of right anterior superior iliac spine
• Bowel habits: Constipation, diarrhoea, bloody and pubic symphysis. It is usually a line join-
diarrhoea, furious diarrhoea, tenesmus. ing midclavicular and midinguinal points.
• Decreased appetite and weight. 4. Left vertical line is the line thro‘ the midpoint
• Inspection of the mass: Anatomical location, of left anterior-superior iliac spine and pubic
margin, surface, movement with respiration. symphysis. It is usually a line joining
• Palpation of the mass: Site, extent, surface, midclavicular and midinguinal points.
tenderness, consistency, movement with
respiration, mobility, borders, plane of the
swelling (by leg rising test), presence of other
masses.
• Percussion is an important aspect of
examination in case of a abdominal mass.
Percussion over the mass is important to
predict the anatomical location of the mass.
If mass is dull, then it is in the anterior
abdominal wall or in front of the bowel intra-
abdominally like liver, spleen, gallbladder,
etc. If the mass is with a impaired resonant
note, then the mass is arising from the bowel
like stomach, colon, small bowel. If the mass Fig. 1.300: Different regions in the abdomen.
is resonant on percussion, then the mass is
probably in the retroperitoneal region. Other Regions in the abdomen
than this, liver dullness, free fluid in the 1. Right hypochondrium
abdomen should be elicited during 2. Epigastrium
percussion. 3. Left hypochondrium
• Per/rectal examination: It is done to look for 4. Right lumbar region
any secondaries in recto-vesical pouch, 5. Umbilical region
primary tumour or relation of lower abdomen 6. Left lumbar region
masses (pelvic masses). 7. Right iliac fossa
• Pervaginal examination is done to assess pelvic 8. Hypogastrium
masses. 9. Left iliac fossa
Quadrants in the abdomen are four in number History

formed by two lines — one is vertical midline History of Present Illness
through the umbilicus; another is horizontal line
passing through the umbilicus. Quadrants are Pain
— right upper, right lower, left upper and left • Site of origin of pain — onset (sudden/
lower. insidious); duration.
• Radiation of pain/referred pain.
• Type of pain — intermittent/persistent; dull,
severe pricking, colicky.
• Periodicity with an interval of free period —
ulcer pain has got often periodicity unless
it is complicated.
• Relation to food intake — more/less/not
related to meals.
• Relation to vomiting/induced vomiting.
• Aggravating/relieving factors.
• Pain in relation to bowel habits/urinary
habits.
Vomiting
• Duration, frequency, relation to food, (type
projectile/effortless).
• Vomitus – content (food/blood/bile), quan-
Fig. 1.301: Different quadrants in the abdomen.
tity, smell, colour – coffee ground/bloody/
yellow, taste.
Chief Complaints
• Relation to pain, details of haematemesis if
• Mass per abdomen – duration, progress, site,
present.
mass appearing/disappearing (like
• It is better to ask the patient to collect and
intussusception, Dietl’s crisis hydroneph-
keep the vomitus and clinician should
rosis kidney, and choledochal cyst).
personally observe it.
• Pain in the abdomen – region of pain to be
mentioned; duration of pain. Jaundice
• Vomiting – duration. • Duration, color–greenish yellow suggests
• Haematemesis, malaena – duration. obstruction, severity, progress – progressive/
• Satiety – sensation of fullness after taking intermittent/static/reducing.
food (early satiety signifies gastrointestinal • Presence of fever with jaundice – cholangitis.
pathology like carcinomas. • Association with pruritus, clay stool/silvery
• Yellowish discoloration of sclera – duration. stool.
• Loss of appetite and decreased weight –
Altered bowel habits
weight loss more than 10 kg in short period/
Duration, type, malaena, with distension of
6 months is significant.
abdomen.
• Altered bowel habits/constipation/
diarrhoea. Altered urinary symptoms
• Fever – its character like in abdominal tuber- • Frequency/urgency/haematuria/pyuria/
culosis, amoebic liver abscess, cholangitis, oliguria/painful urination/burning urine/
malignancy with tumour necrosis, infected difficulty in passing urine/hesitancy/
pseudocyst of pancreas. hiccough/oedema feet or face.
• Relation of urinary symptoms to pain, mass Local Abdominal Examination
in abdomen. Inspection
Other relevant history • Inspection of the abdomen is done in supine
Cough and haemoptysis, bone pain, etc. – position with exposure from midchest to
suggestive of metastases. midthigh region with arms extended.
Inspection is done from side of the bed as
Past History well as from foot end with eye level at the
Earlier surgery of abdomen – reason for surgery, level of the patient.
how long ago, whether earlier symptoms are
relieved or not, symptoms are similar now or
different, emergency or elective surgery, earlier
properly investigated or not, drain placed or not
– if placed when it was removed; what content
was coming through the drain, whether blood
transfusion was done during surgery or
postoperative period. A
Personal History
Alcohol intake, diet, smoking, etc.
Treatment History
Any relevant.
Family History B
Any relevant. Figs 1.303A and B: Proper exposure of the abdomen
is important from midchest to midthigh and position of
General Examination the patient for proper abdominal examination.
Palor/jaundice/clubbing/oedema feet/pulse/
blood pressure/genitalia/respiration.
A B
B
Figs 1.302A and B: Obstructive jaundice in a patient Figs 1.304A and B: Inspection of the abdomen should
with carcinoma head of pancreas. Note the sclera for be done at the level of the patient’s abdomen both from
discoloration. Severe itching is common in these patients. right side as well as from foot end.
• Shape–contour–normal/scaphoid/dis-
tended.
• Skin over the abdomen–stretched/
pigmented/presence of scar–healed
primarily or secondarily/site of scar/length
and width of scar; whether there is incisional
hernia or not.
• Dilated veins over the abdomen – caput medusae
– is radiating dilated veins from the umbilicus
– seen in portal hypertension. In inferior vena
cava obstruction, (lateral abdominal wall) A B
dilated veins are visible with their blood flow Figs 1.306A and B: Inferior vena caval obstruction causing
are from below upwards towards superior dilated veins over the lateral aspect of the flank with flow
vena cava. In superior vena cava obstruction of blood upwards.
dilated veins with blood flow from above
downwards. Dilated veins should be inspec- abdomen directing downwards and towards
ted in standing position and also direction right to umbilical region. It is stimulated by
of flow should be checked by placing two drinking glass of water or by massaging the
fingers apart over the vein and to release the epigastrium. It signifies gastric outlet
finger one by one to see the direction of blood obstruction. It may be absent in gastric outlet
flow. Normally, above the umbilicus abdomi- obstruction if gastric paresis develops and
nal wall drains to superior vena cava and stomach becomes dilated but silent without
below the umbilicus towards inferior vena any motility. Visible intestinal peristalsis (VIP)
cava—water shed area. is step ladder pattern in central abdomen
from left to right or vice versa in umbilical
region. Visible colonic peristalsis may be
obvious from right to left along the line of
colon.
• Inspection of the mass — its location (exact
location should be mentioned as in which
region and then its extension into the other
region should be mentioned later); extent;
approximate size; well defined or ill defined
(often mass is not clearly seen but fullness
is visible); margin whether clear or not or
Fig. 1.305: Superior vena caval obstruction causing dilated which part is clear and which part is not
veins in the neck chest wall and shoulder. Note the neck clear; mass movement with respiration
swelling extending into the mediastinum. present or not (upper abdomen mass like liver,
stomach, spleen, gallbladder, omental mass,
• Movements with respiration of regions. kidney mass moves with respiration). Mass
• Pulsations over the mass or any region – which is initially mobile once gets fixed to
patient should hold the breathing after full retroperitoneum or deeper plane may not be
expiration to see pulsations. mobile later. Mass initially not mobile once
• Inspection for visible peristalsis–Visible gastric gets attached to structures like omentum may
peristalsis (VGP) is seen in upper middle start moving with respiration occasionally.
region with waves beginning at left upper Lower abdominal mass, retroperitoneal mass
will not usually move with respiration. Mass • Umbilicus—position, everted/inverted.
which comes in contact with diaphragm Tanyol sign: Umbilicus is shifted upwards
closely will move with respiration. Composite in pelvic/ovarian mass and shifted
mass may move with respiration because of downwards in ascites.
its component like omentum, lymph nodes, • Hernial orifices and genitalia inspection –
bowel, etc. is a must.
Fig. 1.307: Visible large mass upper abdomen – could

be liver/pseudocyst of pancreas/retroperitoneal mass Fig. 1.309: Impulse on coughing should be seen
and also felt to confirm associated hernia.
• Carnett’s test – raising test (head or leg): It is
done to confirm whether mass is in the
abdominal wall or intra-abdominal. Mass is
seen initially and palpated and patient is
asked to raise his head and if mass
disappears, it is intra-abdominal; if becomes
more prominent it is in the abdominal wall.
Fig. 1.310: Loin should be
inspected from behind for
fullness and oedema.
Palpation
• While palpating the abdomen patient should
take deep breath with open mouth to relax
the abdomen otherwise it is difficult to get
proper finding. Hands should be warm and
Fig. 1.308: Head raising test should be done to find out Fig. 1.311: Checking the temperature of the
whether mass is intra-abdominal or in the abdominal wall. abdomen using dorsum of the hand.
Fig. 1.312: Palpation of abdominal mass using fingers.
Fig. 1.313: Lower abdominal mass–retroperitoneal

tumour/ovarian tumour/uterine mass.
forearm should be horizontal at the same level

as patient’s abdomen. Palpation is done with
ventral aspect of the fingers. Legs should be
partially flexed at hips and knees.
• Liver is palpated by placing flat of the hand
parallel to the right costal margin – initially
near right iliac fossa with fingers towards
upwards up to the margin of the right rectus.
Slowly with each phase of respiration fingers
should be moved upwards towards right
hypochondrium to feel the lower margin of C
the liver. Then feel the surface of the liver Figs 1.314A to C: Method of palpating the liver
for tenderness, nodularity, round/sharp right lobe and left lobe.
margin. Level of lower margin at should be
measured in centimeters from right costal
margin. In children below 3 years, liver is
3 cm below the right costal margin. Liver is
not palpable or just palpable in normal adult.
Whenever there is ascites liver is palpated
by ‘dip method’ (dipping fingers quickly so
as to displace the fluid).
• Gallbladder palpation—normally it is not
palpable. When enlarged its lower margin
may be in right side of umbilical region/right
lumbar region/right iliac fossa. It moves with
respiration, globular in shape, smooth and
soft, may be horizontally mobile but not
vertically, upper margin merges under the
liver when liver is enlarged or under the right
costal margin. It is usually in right hypo-
chondrium, just right of the right rectus Fig. 1.315: Succussion splash.
muscle.
Murphy’s sign is elicited in sitting position. over the epigastrium. Abdominal wall is
While palpating in gallbladder area during scratched using pencil or finger tip by radiating
summit of inspiration, patient winces with strokes from bell area towards left hypochon-
pain. During deep inspiration, inflamed drium, left lumbar and left and later towards
gallbladder comes down and touches the right part of the umbilical regions. Change in
gallbladder to cause tenderness. It is observed the note of the sound is marked at each stroke
in chronic cholecystitis. If it is elicited in lying line. All these marks are joined to get the greater
down position it is called as Moynihan’s sign. curvature of the stomach. Only greater curvature
• Stomach is palpated in the epigastrium. Entire is assessed. Reasons are only greater curvature
stomach may be dilated and palpable due dilates significantly when there is obstruction,
to gastric outlet obstruction. Succussion flash not lesser curvature and greater curvature is more
and auscultopercussion tests should be towards surface whereas lesser curvature is on
elicited in such occasion. deeper plane. Normal greater curvature is above
the umbilical level on surface marking. In gastric
Succussion splash: Patient should not take
outlet obstruction it will be below the level of
anything orally for 4 hours as gastric emptying
umbilicus.
time for liquid is 4 hours. If patient drinks fluid
Stomach mass is commonly carcinoma stomach
even stomach is not dilated succussion splash
but occasionally it is gastric lymphoma or
may be positive. Bell of the stethoscope is placed
leiomyoma of stomach. Carcinoma stomach mass
in the epigastrium. Two thumbs of the two hands
is in the epigastrium or upper part of umbilical
are placed over the bell and fingers of each hand
region – which moves with respiration; all
are placed on costal area on each side and shaken
borders well made out; mobile in all directions;
well to hear splashing sound. This can
nodular and hard; upper border well made out;
occasionally elicited by dipping the hand over
impaired resonant on percussion. If mass is close
the dilated stomach also.
to the fundus of stomach then upper border may
Auscultopercussion test: It is positive in gastric not be clearly felt and often patient should be
outlet obstruction. Bell of the stethoscope is placed examined in lateral position or after making the
patient to walk for few minutes so that to allow the

mass to come down to make it easily palpable.
Mass may be from the pylorus then there will be
features of gastric outlet obstruction and mass is
just above right of the umbilicus. Mass from the
body of the stomach is horizontally placed
commonly without features of obstruction and
extending towards the left hypochondrium. Often
a composite mass of carcinoma, lymph nodes,
omentum and part of the liver may be palpable
and attains a large size also. Carcinoma stomach
when it is fixed may not move with respiration
and may find it difficult to differentiate from
pancreatic mass eventhough carcinoma pancreas
is rarely palpable but palpable gallbladder and
progressive severe jaundice will suspect the
carcinoma pancreas. Often also carcinoma
A stomach can cause jaundice when there is secon-
daries in liver extensively in both lobes. In such
occasion along with stomach mass nodular
secondaries in liver with ascites can also be
evident. Mass near the oesophago gastric junction
presents as dysphagia. Linitis plastica (diffuse
type of carcinoma stomach in submucosal plane)
usually presents as loss of appetite and decreased
weight with reduced stomach capacity. It usually
does not present as mass abdomen. When mass is
palpably present, it is a composite mass of nodes,
omentum and stomach. It carries a poor prognosis.
Total gastrectomy is the treatment. Clinically
palpable carcinoma stomach (as mass) is advanced
carcinoma stomach as serosa involvement
B
according to definition is advanced. Without
serosal breach it is difficult to be clinically palpable.
But it could be surgically resectable.
A B C
C
Figs 1.317A to C: Different locations of carcinoma stomach.
Figs 1.316A to C: Ausculto percussion test (A) Pylorus (B) Body of stomach (C) Near OG junction.
B C
A
D E
Figs 1.318A to E: Carcinoma pylorus causes gastric outlet obstruction with palpable mass above the umbilicus.
Carcinoma body of stomach mainly presents as loss of appetite and decreased weight with horizontally placed
stomach mass. Carcinoma from fundus of the stomach presents as mass abdomen with loss of appetite and weight.
Carcinoma OG junction presents as dysphagia. Carcinoma stomach is one of the common causes of secondaries
in liver.
Palpation
Pancreatic mass is palpable in the epigas-
trium. It is deep, nonmobile, not moving with Palpation of spleen
respiration, with bowel in front. It is felt on deep Spleen normally is not palpable. When enlarged
palpation. Pseudocyst mass is having rounded more than 2½ times it is clinically palpable. Non-
lower margin with transmitted pulsation. palpable spleen still could be enlarged. Spleen
Pancreatic masses are usually resonant. enlarges towards right iliac fossa across umbi-
A B
C D
Figs 1.319A to E: Method of palpating spleen and also eliciting hook sign.
A B C
Figs 1.320A to C: Renal angle should be palpated and percussed in a kidney mass—in sitting position
lical region directing obliquely. It is palpated Murphy’s kidney punch is eliciting the
by placing fingers of right hand over right iliac tenderness in renal angle in sitting position from
fossa with left hand under left costal margin behind. In sitting position from behind loin
for support. Fingers of right hand are gradually should be inspected for any fullness. Renal angle
and gently moved towards left hypochondrium tenderness is elicited using thumb at the angle
during phases of respiration to feel the splenic (renal angle is between erector spinae muscle
lower margin often with a notch (notch need and 12th rib). Renal angle also should be
not be present always). Fingers cannot be percussed for change in note. Normally, it is
insinuated under the left costal margin. Spleen resonant because of the ascending/descending
moves with respiration, smooth, firm in colon but is replaced by kidney when enlarged
consistency and usually non-tender unless making it dull to percuss.
massively enlarged. Often patient need to be tilted
towards right side to have easier palpation of
spleen. It can be palpated from left side by hooking
the left costal margin – hook sign (Spleen is dull
on percussion).
Palpation of kidney
Kidney is palpated by placing right hand in front
and left hand behind the loin area. When kidney
is enlarged, it is palpable as bimanually palpable,
ballottable (left hand from behind is pushed
anteriorly and kidney coming forward and
touching/pushing the right hand in front can
be felt), moves with respiration (as it is related
Fig. 1.321: Palpation for kidney mass – for
to diaphragm), vertically placed with resonant ballottability and bimanual palpation.
colonic band in front because of medial and
anterior push of the colon by enlarged kidney. • Small bowel mass is felt as mobile, localized
It is smooth and soft in hydronephrosis; it is mass with resonant or impaired resonant note.
hard and nodular in carcinoma kidney; it is firm, It does not move with respiration. Intussus-
nodular and bilateral in polycystic kidney ception is sausage shaped mass with conca-
disease. Kidney may not move or may not be vity towards umbilicus. It appears and
ballottable if it is adherent due to infection or disappears; contracts under the palpating
advanced carcinoma. finger.
Fig. 1.324: Lower border of the mass is very important

in lower abdominal masses. Bladder should be emptied
Fig. 1.322: Renal bruit should be auscultated. or catheterised before palpation.
Fig. 1.323: Often abdominal mass also should be examined

in side position to get better feeling and findings.
A
• All masses in the lower quadrants should
be palpated after emptying urine or passing
a urinary catheter. Upper border is clearly
felt but not lower border which merges into
the pelvis. Mass also should be bimanually
palpated by placing fingers in rectum or per
vagina.
• External genitalia should be palpated for any
swelling/loss of testicular sensation,
secondary hydrocele.
• Often there will be many masses in the
abdomen. So once one mass is felt always
B
look for other relevant mass also.
• Retroperitoneal masses and pulsatile mass like Figs 1.325A and B: Intrinsic mobility of the mass
aneurysms should be examined in knee- should be checked in all abdominal masses.
Fig. 1.326: external genitalia should be

palpated for mass/hydrocele, etc.
elbow/knee – chest position. Retroperitoneal

mass will not fall forward whereas intra-abdo-
minal mass will fall forward. Aortic aneurysm
with expansile pulsation will retain its pulsa-
tion whereas mass with transmitted pulsation
will show reduced/absent pulsation in knee-
elbow position.
B
Percussion
• Liver dullness should be assessed by
percussion. It is done by percussion from
above downwards over right intercostal
spaces in midclavicular line. Liver span also
can be assessed by this.
• Percussion over the mass is very important. Mass
in front of the bowel is dull on percussion
like parietal/abdominal wall mass, liver,
spleen, gallbladder, etc. Mass from the
stomach/small bowel/colon shows impaired
resonance on percussion. Mass from retro-
peritoneum shows resonance on percussion.
• Percussion for free fluid is important. Patient
in supine position, initially percussion is
done over the epigastrium to confirm
resonance note. Then percussion is continued C
over one side flank until one gets dullness.
Figs 1.327A to C: Knee elbow position–palpation of
Patient is tilted towards opposite side to make retroperitoneal mass. Mass can be held to check mobility,
area of percussion outwards so as to displace relations, etc.
A
Fig. 1.328: Liver dullness should be assessed (upper
border of liver) by percussing from above in intercostal
spaces midclavicular line downwards until dullness is elicited
and space is marked.
Fig. 1.329: Percussion over the mass is essential to

say whether mass is anterior to bowel (dull); from the B
bowel (impaired resonant) or behind the bowel (resonant).
C
Fig. 1.330: Looking for minimal ascites in knee- Figs 1.331A to C: Massive ascites. Eliciting fluid
elbow position – Puddle sign. thrill in massive ascites.
the fluid from that side. After 1-2 minutes
(time to allow fluid to shift towards opposite
side) without removing the fingers same area
is percussed to get resonance note which
confirms the presence of fluid. For massive
ascites, fluid is confirmed by eliciting fluid
thrill. Patient’s side of the hand is placed
over the midline epigastrium firmly. Examiner A
should keep his one hand over one lumbar
region and with fingers of other hand on the
opposite lumbar region tapping is done to
elicit fluid movement as fluid thrill. Small
quantity of fluid can be elicited in knee elbow
position. In this position over the umbilical
site percussion is done to elicit dullness which
signifies positive puddle sign—signifying
minimal ascites.
• Percussion over renal angle for resonance
(normal) or dullness (abnormal).
• Auscultation for bowel sounds, bruit over the
renal artery just side of the umbilicus, over
the mass like liver which signifies vascularity,
over aneurysm for bruit.
• Left supraclavicular fossa between two heads B
of sternomastoid muscle should be palpated
for Virchow’s node enlargement – Troisier’s
sign—as secondary deposits.
• Examination of respiratory system for
effusion, altered breath sounds suggestive of
metastases.
• Examination of skeletal systems—sternum,
spine, skull and other bones for tenderness,
swelling, pathological fracture, neurological C
deficits.
• Digital examination of rectum (Per Rectal
examination/P/R): P/R must be done in all
abdominal mass cases. It is done in lateral
position towards left side of the patient with
right leg is flexed completely and left is
straight. After informing patient above the
technique and consent, procedure is done.
Xylocaine jelly is applied over the anus. It
is inspected for discharge, opening, skin
changes and swelling. Pulp of the gloved D
right index finger is gently pushed into the Figs 1.332A to D: Confirming ascites/free fluid in the
anorectum in the direction of the umbilicus. peritoneal cavity by percussion—classical method.
A B
Figs 1.333A and B: Spine and other skeletal system
should be examined in mass abdomen patient.
Sphincter tone is assessed. Posteriorly sacral

curvature, rectal mucosa are assessed. Finger
is turned towards front. Prostate, its texture,
size, median groove are felt. Rectum is
palpated for any growth, stricture or
secondary nodule in front above (as a hard
nodule with free rectal mucosa – Blumer shelf).
Gently finger is removed and finger tip should
be inspected for content staining – blood/
mucus/pus, etc. P/R is contraindicated in
acute fissure in ano.
B
Mass in the Right Hypochondrium

Liver Palpable as Mass in Right
Hypochondrium
• It is horizontally placed.
• It usually moves with respiration.
• Upper border is not felt.
• It is dull on percussion. (This dullness
continuous over liver dullness above).
• Fingers cannot be insinuated under right
costal margin.
Conditions where liver gets enlarged:
1. Soft, smooth, nontender liver—
• Hydrohepatosis. It is due to obstruction of
CBD causing dilatation of intrahepatic biliary C
radicles. Figs 1.334A to C: Digital examination of the rectum
• Congestive cardiac failure. is important (P/R; Per Rectal examination).
• Hydatid cyst of the liver — Here mass is well
localized in the liver with typical hydatid
thrill (Three fingers are placed over the mass
widely. When central finger is tapped fluid
movement is elicited in lateral two fingers).
2. Soft, smooth, tender liver:
• Amoebic liver abscess. Here liver often gets
adherent to the anterior abdominal wall and
will not move with respiration. Intercostal
tenderness, right sided pleural effusion are
common.
3. Hard, smooth liver:
• Hepatoma: (HCC): Here a large single hard
nodule is palpable in the liver. But occasio-
nally there can be multiple nodules when A
it is multicentric. Rapidly growing tumour
can be soft also. Hepatoma often can also
be tender due to tumour necrosis or stretching
of the liver capsule. Vascular bruit may be
heard over the liver during auscultation. It
mimics amoebic liver abscess in every respect.
• Solitary secondary in liver.
4. Hard, multiple nodular liver:
• Multiple secondaries in liver: Hard nodules
here are having umbilication which is due
to central necrosis.
• Macronodular cirrhotic liver.
Palpable Gallbladder in Right B

Hypochondrium Figs 1.335A and B: Multiple secondaries in liver with
• It is smooth and soft (Except in carcinoma umbilication. It is due to central necrosis. Secondaries
gallbladder). are the commonest malignant tumour of the liver. It could
• It is mobile horizontally (side-to-side). be from GIT or extragastrointestinal like from breast, lungs,
melanoma, thyroid, prostate, kidneys, etc. Patient with
• It moves with respiration. liver secondaries has got poor general condition. It should
• It is located right of the right rectus muscle, be differentiated from multicentric hepatoma. It is usually
below the right costal margin or below the treated by palliative chemotherapy. Solitary secondary
lower margin of the palpable liver. from carcinoma colon can be removed by segmentectomy.
• It is dull on percussion. It has got poor prognosis.
Conditions where gallbladder is palpable: 2. Hard gallbladder:

1. Soft, nontender gallbladder: Carcinoma gallbladder.
• Mucocele of the gallbladder.
• Enlarged gallbladder in obstructive Other masses in the Right Hypochondrium
jaundice due to carcinoma head of the Pericholecystic inflammatory mass: It is tender,
pancreas or periampullary carcinoma or smooth, firm or soft, not mobile, intra-abdominal
growth in the CBD. mass often with guarding.
Kidney mass arising from upper pole of the kidney:

• LFT, CT scan, raised AFP, liver biopsy are
It may be due to renal cell carcinoma or
the investigations.
hydronephrosis.
• Hemihepatectomy in early operable growth
Commonest benign tumour of liver is haemangioma. is the treatment.
• Hepatic artery ligation/intra-arterial chemo-
Hepatoma/hepatocellular carcinoma/HCC therapy/chemoembolisation/percutaneous
• Common etiologies are aflatoxins, hepatitis ethanol or acetic acid injection/radio-
B and hepatitis C virus infection, alcoholic frequency ablation/chemotherapy using
cirrhosis, haemochromatosis, smoking, adriamycin, carboplatin, gemcitabine are
hepatic adenoma, clonorchis sinensis, palliative procedures.
polyvinyl chloride.
• Unicentric and right lobe involvement is Amoebic liver abscess
more common. • It is due to Entamoeba histolytica infestation
• Fibrolamellar variant is common in left lobe, • It is more common in alcoholics and
not related to hepatitis or cirrhosis without cirrhotics.
AFP level raise. There is increased serum • Single abscess is common — 70%; common
vitamin B 12 binding capacity and in right posterosuperior lobe — 80%.
neurotensin levels. • Chocolate coloured Anchovy sauce pus is
• It can be multifocal/indeterminate/spread- classical.
ing/expanding – Okuda classification. • Secondary infection can occur – 30%; life
• Presents as large smooth hard liver mass threatening due to septicaemia.
– later jaundice, fever, pain and tenderness, • It can be acute or chronic; both mimics
ascites and bruit over mass. hepatoma.
• Spreads to lymphatics, blood and direct • Rupture into lungs – commonest site of
spread. rupture.
• Mimics amoebic liver abscess, secondaries, • Most dangerous rupture is into pericardium
hydatid cyst, polycystic liver disease. – left lobe abscess.
• Liver failure can develop in cirrhotic patient.
• Common in males (20:1), fever, pain, inter-
costal tenderness, tender liver – features.
• Mimics cholecystitis, subphrenic abscess,
hepatoma.
• Total count, LFT, prothrombin time, US
abdomen are relevant investigations.
• Chest X-ray may show right sided
sympathetic pleural effusion.
• CT scan to differentiate from hepatoma.
• Treatment – drugs like metronidazole,
injection dihydroemetine, chloroquin tablets,
diloxanate furoate; after controlling
prothrombin time using inj vitamin K or
FFP, US guided aspiration; if recurs
percutaneous guided drainage using pigtail
catheter; open laparotomy and drainage with
Fig. 1.336: Hepatocellular carcinoma/hepatoma. It is
common in right lobe, unicentric, attains large size.
placement of Malecot’s catheter.
drium, as nontender, globular, smooth, soft, dull
mass which moves with respiration and with
horizontal mobility.
Exceptions for the rule are:
• Absence of gallbladder
• Intrahepatic gallbladder
• Previous cholecystectomy
• Double impacted stone
• Large stone in Hartman’s pouch.
Surgical Jaundice
Causes
1. Biliary atresia.
Fig. 1.337: Anchovy sauce pus in amoebic liver
abscess. 2. Choledochal cyst.
3. CBD stones.
4. Ascending cholangitis.
5. Biliary strictures.
6. Sclerosing cholangitis.
7. Carcinoma of head and periampullary
region of the pancreas.
8. Cholangiocarcinoma.
9. Klat skin tumour (Carcinoma at the
confluence of hepatic ducts above the level
of the cystic duct and so will cause
hydrohepatosis without GB enlargement).
10. Extrinsic compression of CBD by lymph
nodes or tumours.
11. Parasitic infestations.
Classification of Causes of Obstructive

Jaundice
1. Congenital: Biliary atresia, choledochal cyst.
Fig. 1.338: Common location of amoebic liver 2. Inflammatory: Ascending cholangitis, sclero-
abscess–posterosuperior part of right lobe.
sing cholangitis.
3. Obstructive: CBD stones.
Courvoisier’s Law 4. Neoplastic: Carcinoma of head or periampul-
In a patient with jaundice if there is palpable lary region of pancreas, cholangiocarcinomas,
gallbladder, it is not due to stones. Klatskin tumour.
In obstruction due to CBD stone, gallbladder 5. Extrinsic compression of CBD by lymph nodes
does not distend because it is chronically or tumours.
inflamed, thickened and fibrotic.
In malignancy, like carcinoma of head of the Investigations for Obstructive Jaundice
pancreas or periampullary carcinoma, gall- 1. Serum bilirubin. Normal value is less than
bladder will be distended and palpable to the 1.0 mg%. Both direct and indirect are assessed.
right of rectus muscle in the right hypochon- Direct is increased in obstructive jaundice,
i.e. conjugated hyperbilirubinaemia. Vanden- • Mannitol 100-200 ml BD IV to prevent hepato-

berg test is done. renal syndrome.
2. Serum albumin, globulin and A: G ratio. • Repeated monitoring by doing prothrombin
Normal S. albumin is more than 3.5 gm%. time, electrolytes.
3. Prothrombin time. Normal value is 12-16 • Antibiotics like third generation cephalospo-
seconds. If more than 4 from the control or rins.
more than one and half times the control is • Calcium supplements as calcium chloride IV.
significant. It is corrected by injection vitamin
K 10 mg IM od for 5 days or by fresh blood Treatment of Obstructive Jaundice
transfusion. • CBD stones—ERCP stone removal, choledo-
4. Serum alkaline phosphatase, SGPT, SGOT, cholithotomy, transduodenal sphinctero-
5‘nucleotidase. plasty, choledochojejunostomy or Choledo-
5. U/S abdomen. choduodenostomy.
6. ERCP to visualize site of obstruction, brush • Carcinoma periampullary or head of
biopsy, bile sample for analysis. pancreas—Whipples operation or Triple
7. MRCP—Noninvasive diagnostic tool. bypass or ERCP stenting.
8. CT scan in case of tumours to assess operability. • Biliary stricture—Stenting, choledocho-
9. Urine tests: Fouchet’s test for bile pigments, jejunostomy, Roux en Y hepaticojejunostomy.
Hay’s test for bile salts and test for • Klatskin tumour—Radical resection or
urobilinogen in urine. palliative stenting.
• Biliary atresia—Kasai’s operation or liver
Fouchet’s test: 10 ml of urine + 5 ml of BaCl2 transplantation.
+ pinch of MgSO4 causes formation of BaSO4 • Choledochal cyst—Excision, hepatico-
which is filtered over a filter paper and few drops jejunostomy, mucosal resection.
of Fouchet’s reagent is added. Green or blue
colour signifies bile pigments in the urine. Postoperative Management
• Monitoring with prothrombin time, bilirubin,
Hay’s test for bile salt: Sprinkle sulphur to
albumin, creatinine, electrolyte estimation.
2 ml of urine. In presence of bile salts sulphur
• FFP or blood transfusion.
sinks to the bottom. • Antibiotics.
Ehrlich’s test: 5 ml of freshly voided urine + • Observation for septicaemia, haemorrhage,
1 ml of Ehrlich reagent (p-dimethyl amino pneumonia, pleural effusion, bile leak.
benzaldehyde) and wait for 5 minutes. Formation • Care of T tube and drains.
of red colour signifies presence of urobilinogen • T tube cholangiogram in 10-14 days.
in urine. Normally, it is present in traces, in • TPN, CVP line, nasogastric tube, urinary
obstructive jaundice it is absent and in haemolytic catheter.
jaundice it is in excess.
Portal Hypertension
Preoperative Preparation of Patient with Sustained raise of portal pressure more than 12
Obstructive Jaundice mm Hg.
• Proper diagnosis and assessment. Isolated splenic vein thrombosis causes left
• Injection Vitamin K IM 10 mg for 5 days. sided sinistral/segmental portal hypertension.
• Fresh Frozen plasma—often requires 6 bottles Causes are:
or more. • Prehepatic – portal/splenic vein thrombosis,
• Blood transfusion in case of anaemia. trauma, periportal inflammation, hypercoagu-
• Oral neomycin, lactulose. lable status, neonatal umbilical sepsis.
• Hepatic (80%) – cirrhosis, idiopathic, primary (Child’s grading is used for selecting patients
biliary cirrhosis, hepatitis, schistosomiasis, for surgery and predicting prognosis).
Wilson’s disease, haemochromatosis, Surgery is contraindicated in Child C.
congenital hepatic fibrosis.
Orthotopic liver transplant is ideal and best. If
• Posthepatic—Budd-Chiari syndrome,
patient is for liver transplant open shunt surgery
constrictive pericarditis, veno occlusive
is contraindicated as liver hilum should be kept
disease, congestive cardiac failure.
virgin for transplantation effectively.
Presentations: Oesophageal varices (haemate- Transjugular Intrahepatic porta Systemic
mesis/malaena), splenomegaly, ascites, Stenting TIPSS can be done in these patients.
jaundice, features of encephalopathy. TIPSS is a nonselective shunt.
Investigations: Gastroscopy, LFT, splenoporto-
Mass in the Epigastrium
graphy, US abdomen, CT abdomen, prothrombin
time, liver biopsy. Palpable Left Lobe of the Liver
• It is in the epigastric region.
Acute bleed is managed by pharmacotherapy • Its upper border cannot be felt.
(vasopressin, glypressin, octreotide, propranolol, • It moves with respiration.
Sengstaken Blakemore balloon tamponade, • It extends towards left hypochondriac region.
surgical ligation of varices by various approaches. • It is dull on percussion.
Further bleeding is prevented by endoscopic Conditions where left lobe of the liver is palpable:
banding for oesophageal varices; sclerotherapy; • Hepatoma.
endoscopic glueing for gastric varices. • Amoebic liver abscess in left lobe.
Shunt surgery is done if grading is Child’s grade • Left lobe secondaries.
A or B. Selective shunts like distal spleno renal • Hydatid cyst of the left lobe.
shunt (Warren’s shunt) or Inakuchi shunt
between left gastric vein and IVC. Portocaval, Features of Stomach Mass
mesentricocaval, proximal splenorenal shunts • It is in the epigastric region.
are nonselective shunts. • It moves with respiration. It is intra-
abdominal.
Indications for Shunt Surgery • It is resonant or impaired resonant on
Child’s Grades A and B. percussion.
Child A B C
Bilirubin < 2.0 mg 2.0-3.0 mg > 3.0 mg
Albumin > 3.5 3.0-3.5 < 3.0
Ascites None Controlled Uncontrollable
Mental status Normal Disoriented Coma
Nutrition Very good Good Poor
Score 5-6 7-9 10-15
P.T. Increase up to 3 Increase between 3 and 6 Increase > 6
(Pugh’s modification)
Figs 1.340: Hepatosplenomegaly is the common condition

(clinical entity). It is due to macronodular cirrhosis with
portal hypertension, lymphoma, autoimmune diseases,
congestive cardiac failure, hepatoma with portal
hypertension, haemolytic diseases, etc. There may be
ascites, supraclavicular palpable lymph node, pleural
effusion (right sided).
• Mass may be better felt on standing or on

walking.
• Mass is often mobile, unless it gets adherent
posteriorly.
• In pylorus mass, all margins are well felt
A which is mobile with features of gastric outlet
obstruction.
• Mass from the body of the stomach is
horizontally placed without any features of
obstruction.
• Mass from the upper part of the stomach near
the OG junction causes dysphagia.
• Mass from the fundus of the stomach is in
the upper part of the epigastric region towards
left side.
• Carcinoma stomach is nodular and hard. It
is commonest cause for stomach mass.
• Leiomyoma of stomach is smooth and firm.
Management of gastric carcinoma

• Early growth – pylorus – lower radical
gastrectomy with removal of tumour,
proximal 5 cm clearance, nodal clearance,
greater and lesser omentum, distal pancreas
B and spleen ( now not regularly removed;
Figs 1.339A and B: Different masses at different it is removed to clear splenic nodes – one
regions in the abdomen. of the node stations) and Billroth II
anastomosis or Roux-en-Y anastomosis is Pseudocyst of the Pancreas

done. Postoperatively adjuvant chemo- • Mass in the epigastric region. It is smooth,
therapy should be given – 5 fluorouracil, soft. It can be tender if it gets infected.
mitomycin, epirubacin, cisplatin • It does not move with respiration.
• Growth in body, proximal growth, diffuse • It is not mobile.
carcinoma and generalized linitis plastica • It has got transmitted pulsation. It is confir-
are the indications for total radical gastrec- med by placing the patient in knee-elbow
tomy with oesophagojejunal anastomosis. position.
• Neoadjuvant chemotherapy in advanced • Lower border is well felt. Upper border is
gastric cancer prior to surgery and later not clear.
gastrectomy • It is resonant on percussion.
• Instillation of mitomycin C impregnated • Baid test: Because stomach is pushed in front,
charcoal intraperitoneally to control lymp- Ryle’s tube when passed, can be felt per
hatic disease (Japan) abdomen on palpation.
• Palliative procedures like palliative partial Pseudocyst of the pancreas is quite common
gastrectomy, anterior gastrojejunostomy, condition. It has got a false capsule not true
Devine’s exclusion procedure, luminal capsule as there is no epithelial lining. It usually
stenting in proximal inoperable growths, occurs in 3 weeks after an attack of acute
chemotherapy are used in inoperable cases. pancreatitis. Lesser sac is the common site. It
• In early carcinoma proper lymph nodal also can occur in relation duodenum, jejunum,
clearance is important splenic hilum and colon. It can be communicating
and noncommunicating. It mimics often aortic
Lymph node stations in gastric carcinoma aneurysm, retroperitoneal cystic tumours,
– (Japan) – 18 stations are there cystadenocarcinoma of pancreas.
1. Right cardiac
2. Left cardiac
3. Nodes along the lesser curvature
4. Nodes along the greater curvature
a. Along short gastric vessels—4sa
b. Along left gstroepiploic vessels—4sb
c. Along right gastroepiploic vessels—
4sd
5. Suprapyloric nodes
6. Subpyloric nodes
7. Along left gastric artery
8. Along common hepatic artery
9. Along celiac axis
10. At splenic hilum
11. Along splenic artery
12. At hepatoduodenal ligament
13. Retroduodenal lymph nodes Fig. 1.341: Pseudocyst of pancreas – CT scan picture.
14. At root of mesentery
15. Around middle colic artery Cystadenocarcinoma of the Pancreas
16. Para-aortic nodes Mass is smooth, firm, does not move with
17. Around lower oesophagus
respiration, not mobile, resonant on percussion.
18. Supradiaphragmatic
Patient is also having back pain.
Investigations for pseudocyst of pancreas – Indications for intervention –

• Ultrasound–commonly done procedure • Size more than 6 cm
• CT scan ideal and choice • Formed thick walled pseudocyst
• LFT, serum amylase, prothrombin time • Infected pseudocyst
• ERCP to find out communications
• Barium meal–not done now–shows
widened vertebrogastric angle
Interventions – Complications
• Roux-en-Y cystojejunostomy is ideal • Rupture – 3%
• Cystogastrostomy – Jurasz procedure— • Infection – 20%
commonly done • Bleeding – torrential 7%
• Cystoduodenostomy • Cholangitis
• Cystogastrostomy with external drainage
if infected – Smith operation
• Endoscopic stenting
• Laparoscopic cystogastrostomy –
popular – safer
• Guided aspiration helps but high
recurrence rate of 70%
• Acute fluid collection – just fluid collection
• Acute pseudocyst with thin wall
• Chronic pseudocyst – thick walled
• Pseudopseudocyst – inflammatory mass of
bowel, omentum, etc. after acute pancreatitis
mimics pseudocyst
A B C
Figs 1.342A to C: Cystadenocarcinoma of pancreas from body and tail of pancreas–large extensive tumour.
Colonic Mass Left Renal Mass from Upper Pole of any Cause
• It is carcinoma of transverse colon. It has got features of renal mass.
• It is mobile, horizontally placed, nodular,
hard mass which does not move with Left Sided Adrenal Mass
respiration. Caecum will be dilated and • It does not move with respiration. It is not
palpable. mobile.
• It is resonant or impaired resonant on • It is deeply placed mass. Often it crosses the
percussion. midline.
• Patient will be having bowel symptoms, loss • It is resonant on percussion. It mimics kidney
of appetite and decreased weight. mass.
Para-aortic Lymph Node Mass Mass arising from the tail of the pancreas.
• Mass in the epigastric region which is deeply
placed, not mobile, not moving with respira- Mass in the Lumbar Region
tion. Palpable Kidney Mass
• It is vertically placed, above the level of the • There will be fullness in the loin which is
umbilicus and resonant on percussion. better observed in sitting position.
• Causes for enlargement are: Secondaries, • Mass moves with respiration. It is vertically
Lymphomas or Tuberculosis. placed.
• It is bimanually palpable. It is ballotable.
Aortic Aneurysm • Renal angle is dull on percussion (Normally
It is smooth, soft, pulsatile (expansile pulsation it is resonant due to colon).
which is confirmed by placing the patient in • There is a band of resonance in front due
knee-elbow position). to reflected colon.
It is vertically placed above the level of the • It does not cross the midline.
umbilicus, not mobile, not moving with respira-
tion and resonant on percussion. Conditions where Kidney Gets Enlarged
Mass in the Left Hypochondrium Hydronephrosis:
• It is smooth, soft, lobulated, nontender mass.
Enlarged Spleen
• Spleen has to enlarge three times to be pal- Pyonephrosis:
pated clinically. • History of throbbing pain in the loin, pyuria
• It enlarges towards the right iliac fossa from and fever with chills.
left costal margin. • It is smooth, soft and tender kidney mass.
• It moves with respiration, mobile, obliquely Polycystic kidney:
placed, smooth, soft or firm, with a notch • History of loin pain and haematuria.
on the lower margin. • Hypertension, anaemia and features of renal
• Fingers cannot be insinuated over the upper failure.
border. • Usually bilateral. But one side can present
• ‘Hook sign’ is positive, i.e. one cannot insinuate early than on the other side.
the fingers under the left costal margin. • Lobulated smooth surface.
• It is dull on percussion.
Renal cell carcinoma:
Left Sided Colonic Mass • History of mass in the loin, haematuria, fever
• It is mobile, nodular, and resonant. and dull pain.
• It does not move with respiration. • Mass is nodular and hard.
• It is commonly due to carcinoma colon. • It does not crosses the midline.
Mass from the Ascending Colon on Right Retroperitoneal Cysts

Side or Descending Colon on Left Side They are smooth and soft with the same features
• History of altered bowel habits with decreased as retroperitoneal tumours.
appetite and weight.
• Mass is nodular, hard which does not move Mass in the Umbilical Region
with respiration and is not ballottable. Usual masses are:
• It is resonant or impaired resonant on • Mesenteric cyst.
percussion. • Omental cyst.
• Renal angle is resonant. • Ovarian cyst (Pedunculated).
• Proximal dilated bowel may be palpable. • Small bowel tumours.
• Extension of masses from other region.
Adrenal Mass
• It is nodular and hard. Mesenteric Cyst
• It does not move with respiration. • Tillaux triad:
• It is not mobile and often crosses the midline. - Soft intra-abdominal umbilical region
• It is felt on deep palpation. mass.
• It is resonant in front. - Mobile in the direction perpendicular to
• It is not ballottable. the attachment of the mesentery.
- Resonant mass.
Retroperitoneal Tumours • May precipitate intestinal obstruction,
• They are not mobile, resonant and do not volvulus.
fall forward in knee-elbow position.
• They are deeply placed mass which are Omental Cyst
usually smooth and hard. • It is smooth, soft and nontender.
• They may be retroperitoneal sarcomas or • It moves with respiration. It is mobile in all
teratomas, etc. directions.
• It is dull on percussion.
Small Bowel Swellings

• Small bowel lymphomas.
• Small bowel carcinomas.
• Intussusception.
Intussusception
• Mass in umbilical region usually towards
left and above the umbilicus.
• Occasionally towards right side.
• Mass is intra-abdominal which is sausage
shaped, well-defined, smooth, firm and mobile.
• Mass does not move with respiration.
• Mass contracts under palpating fingers.
• Often mass disappears and mass reappears.
• Mass is resonant or impaired resonant on
percussion.
• ‘Red currant jelly’ stool with features of
Fig. 1.343: Retroperitoneal tumour. intestinal obstruction may be present.
Mass in the Right Iliac Fossa
• Appendicular mass or abscess.
• Carcinoma caecum.
• Ileo-caecal tuberculosis.
• Amoeboma.
• Psoas abscess.
• Lymph node mass either mesenteric or
external iliac lymph nodes.
• Bony swellings.
• Ectopic kidney.
• Undescended testis (Abdominal).
• Actinomycosis.
• Crohn’s disease.
• Iliac artery aneurysm.
• Ovarian swelling-ovarian cyst, tubo-ovarian Fig. 1.345: Percussion over the mass in right iliac fossa.
mass. Retroperitoneal mass is resonant. Bowel mass is impaired
resonant. Mass from abdominal wall is dull on percussion.
• Tubo-ovarian mass.
• Uterine mass: like pedunculated fibroid. Appendicular Mass
• It is smooth, firm, tender mass in the right iliac
fossa.
• It is not mobile. It does not move with
respiration.
• It is resonant on percussion. It is well localized
mass with distinct borders.
Appendicular Abscess
It is smooth, soft, tender and dull mass in the right
iliac fossa with indistinct borders.
Carcinoma Caecum
• It is nodular, hard mass in the right iliac fossa.
A • It does not move with respiration.
• It is mobile but mobility may be restricted
once it gets adherent to psoas muscle.
• Mass is resonant or impaired resonant on
percussion.
• Often features of intestinal obstruction may
be there.
Ileocaecal Tuberculosis
• Mass in the right iliac fossa which is smooth,
hard, resonant and nontender.
• It does not move with respiration and has
B
restricted mobility.
• Caecum may be pulled up to lumbar region
Figs 1.344A and B: Mass in the right iliac fossa. due to fibrosis.
Amoeboma
• H/O dysentery with pain in the right iliac
fossa.
• Smooth, hard, well-defined mass in the right
iliac fossa which is not mobile.
• It may or may not be tender.
Psoas Abscess
• It is localized; smooth, soft, nonmobile mass
in the right iliac fossa.
• Psoas spasm (flexion of the hip joint) is typical.
• Spine may show gibbus, tenderness, paraspinal
spasm. Spinal movements will be restricted.
Fig. 1.346: Ovarian cyst—large tumour on table finding.
Mass in the Left Iliac Fossa
• Carcinoma sigmoid or descending colon. In all regions parietal masses can occur:
• Bony masses. • Benign and malignant soft tissue tumours.
• Ovarian/uterine masses. Common one is lipoma.
• Psoas abscess. • Fatty hernia of linea alba, interstitial hernia
• Ectopic kidney. • Desmoid tumour.
• Lymph node mass. • Parietal wall abscess.
• Undescended testis.
Investigations for Mass Abdomen
Mass in the Hypogastrium • Haematocrit, liver function tests, renal
Bladder Mass function tests, stool/urine examination.
• It is in the midline. It is dull on percussion. • Ultrasound abdomen.
Lower border is not felt. • Endoscopies-Gastroscopy-Colonoscopy-
• It can be mobile in horizontal direction. Mass ERCP.
reduces in size after emptying the bladder. • Barium studies-Barium meal-Barium enema-
It can be felt on per-rectal examination. Barium meal follow through.
• It is either carcinoma bladder (common) or • CT scan – contrast CT is ideal for mass abdo-
leiomyoma or sarcoma bladder. men. It clearly gives idea about the origin
of mass, its extent and operability,
Uterine Mass vascularity, relation to major vessels.
• It is midline mass which is smooth, hard. Intravenous as well as oral water soluble
• Lower border is not felt which extends in iodine contrast agent should be given.
to the pelvis. • MRI, MRCP.
• It is felt on pervaginal examination. • Endosonography.
• Ascitic tap.
Ovarian Mass • Diagnostic laparoscopy.
• Pelvic soft tissue mass. • U/S guided/CT guided biopsy.
• In all lower abdomen masses P/R and or • IVU/RGP/Cystoscopy/Isotope renogram.
P/V is must. • Exploratory laparotomy.
EXAMINATION OF A SWELLING/ Personal history of alcohol consumption/

smoking/tobacco chewing/history of sexual
LUMP contact/dietary habits are also important.
Swelling/lump denotes enlargement or pro-
Family history suggestive of similar swellings is
tuberance in any part of the body due to
important. Neurofibromatosis is often familial.
congenital/inflammatory/traumatic or neo-
plastic causes. 2. General examination
Detailed general examination is a must.
1. History
Anaemia/oedema/jaundice/clubbing/lymp-
Duration hadenopathy/radial pulse/blood pressure/raise
Duration of onset is important in all swellings. in temperature/attitude of the patient/nutritional
Swelling which is present since birth could be assessment by skin texture, subcutaneous fat,
congenital like meningocoele. Swelling of short weight, body mass index/any other relevant
duration with pain may be inflammatory. Benign findings should be mentioned.
tumours are usually painless and of long
3. Local examination
duration. Malignant tumours are of short
duration, rapidly growing, initially painless (but Location of the swelling
can be painful later). Exact anatomical location of the swelling/its
Mode of onset size/shape—globular or hemispherical or oval
Swelling whether appeared after trauma or or pear-shaped or irregular or kidney shaped/
spontaneously. diffuse or well localized. Vertical and horizontal
Rapid progress or slow in progress- dimension should be assessed and should be
malignancy progresses rapidly whereas benign measured using a measuring tape.
swellings progress slowly. Dermoid cysts occur in midline/outer
Whether painful or not canthus of eye/or, along any line of fusion.
Lipoma can occur any where in the body.
Pain
When pain started? Location of pain/type of • Colour of the swelling
pain/severity/whether it interferes with work Blue colour of haemangioma/black colour of
or not. Inflammatory conditions are painful naevus or melanoma/blue colour of ranula are
whereas malignant conditions are painless to often diagnostic. Redness over the swelling
begin with but later it becomes painful. suggests inflammation.
Presence of fever— • Surface over swelling
Fever may be present in inflammatory condi- Smooth/irregular/nodular/cauliflower like:
tion. Certain malignancies also can present with • Number of the swellings—neurofibromas and
fever at later stage like in Hodgkin’s lymphoma sebaceous cysts can be multiple. Dermoid cyst
or renal cell carcinoma. is usually single.
• Edge of the swelling whether well-defined
Presence of other lumps/secondary changes in the
or ill-defined/whether pedunculated or
swelling like ulceration/fungation.
sessile should be looked for.
History of previous surgery • Pulsation over the swelling
Arterial swelling has got expansile pulsation.
Loss of function of part or as a whole.
It is checked by keeping two fingers over the
Loss of weight and decreased appetite may signify swelling. Swelling which is very close to artery
that swelling is related to malignant condition or adherent to it also can show pulsation but
and also probably advanced. it is transmitted pulsation.
Surgical Short Cases 211
• Reducibility—whether swelling gets reduced the deeper plane like bone is also checked.
while pressing and disappears. Hernia is Dermoid cyst commonly shows erosion into the
reducible. bone. In lipoma margin slips away from the
• Presence of expansile impulse on coughing finger-slip sign. In sebaceous cyst margin gets
signifies hernia or communication into the yielded by the finger.
deeper cavity like abdomen or thorax or
Surface of the swelling
cranium.
It is done using palmar surface of the fingers.
• Skin over the swelling should be inspected.
It may be smooth like in a cyst/nodular in lymph
Skin over the swelling may be tense, glossy
nodes/lobular in lipoma/matted in tuberculous
with prominent veins in sarcoma and malig-
nodes/irregular in carcinoma. It may be variable
nancy. It is red oedematous in inflammatory and if so which part is smooth and which part
swellings. Pigmentation, ulceration/fungation/ is nodular should be mentioned.
discharge from ulcer/bleeding from the
fungation should be inspected. Consistency
It may be soft (like consistency of lip)/may be
Scar—its size, features whether healed by primary firm (like consistency of nose)/may be hard (like
intention or secondary intention should be consistency of forehead). Lipoma, cystic swel-
mentioned. Linear and regular/broad, puckered lings, abscess are soft. Fibromas, neurofibromas,
and irregular. certain nodal enlargements are firm. Chondroma,
• Inspect the area and distally especially when osteomas are bony hard. Malignant swellings
swelling is in the limbs for pressure effects are stony hard. Variable consistency in one
and wasting. Wasting should be confirmed swelling may be observed. In such occasion
by proper measurement of the part from equal which area is soft, which area is firm or hard
distance from a bony point. should be confirmed properly. Variability may
4. Palpation be due to tumour necrosis/inflammation.
• Local raise of temperature is checked using back Swelling like sebaceous cyst or dermoid cyst
of fingers. It may be due to inflammation which contains pultaceous material or putty like
(infection) or due to tumours. material gets moulded.
• Tenderness is checked while palpating the Fluctuation
swelling by observing the face of the patient. Swelling is fixed usually by holding with both
Patient expresses the tenderness. Inflam- thumbs and middle fingers. With the index finger
matory conditions are tender. Neoplastic of one hand one side of the swelling is pressed
conditions are initially non-tender but later and index finger of other hand placed on
can become tender. diagonally opposite side feels the fluid movement
• Size is measured using tape; shape is and also a raise. Procedure should be repeated
confirmed and extent of the entire swelling in perpendi-cular direction to confirm fluctuation
and its anatomical location should be (two right angle planes). This is standard
mentioned properly. fluctuation. Positive fluctuation signifies presence
• Edge or margin of the swelling can be well- of fluid. Examples are hydrocele, cysts, etc. (Note:
defined (distinct) or ill-defined (indistinct). Often muscle gives fluctuation like feeling when
In acute conditions and deep swellings it is elicited in one direction but not in two
ill-defined. In superficial swellings it is well- perpendicular directions).
defined. Margin may be irregular in malig- In swelling which cannot accommodate two
nancy and may be regular in benign swellings. fingers to do standard fluctuation test, margin
Edge of the swelling is examined using pulp of the swelling is fixed using two fingers (index
of the index finger. Erosion of the margin into and ring) and using middle finger summit/centre
of the swelling is pressed/indented to feel dis- Transillumination test

placement of the fluid/to get yielding sensation. When light is illuminated over the swelling it
This test is called as Paget’s test of fluctuation. transmits light through it. It is called as
Fluctuation may be present in a cystic transillumination/translucency. It is positive means
swelling which contains fluid with two swelling illuminates to light. It means it contains
components on either sides of an anatomical clear fluid. It is negative when it contains blood,
barrier (across an anatomical barrier). It is called pus, pultaceous material. Torch light is placed
as cross fluctuation. Ranula (across mylohyoid on one side of the swelling and illumination
muscle), psoas abscess (across inguinal ligament), is observed on the diagonally opposite side using
compound palmar ganglion (across flexor a rolled paper or rolled X-ray.
retinaculum), bilocular hydrocele (across a band Lymph cyst, cystic hygroma, ranula, menin-
or superficial inguinal ring) are cross-fluctuant. gocele, hydrocele are transilluminant.
False fluctuation may be elicited in lipoma,
myxoma and vascular swellings. Reducibility
Swelling is pressed to see if it reduces completely
and disappears. Hernia is reducible.
Compressibility
On applying pressure swelling reduces in size
only partially and will not disappear completely and
on releasing the pressure swelling comes back
again to its original size and shape immediately.
Usually vascular and lymphatic swellings are
compressible. Example: haemangioma, lymphan-
gioma.
Pulsatility
A Two fingers are placed over the swelling with
adequate gap between two fingers. If fingers over
the swelling are raised and separated with each
beat of the artery it means pulsation is expansile.
If fingers are only raised but not separated then
pulsation of the swelling is transmitted. Pure
arterial swelling like aneurysm shows expansile
pulsation. Swelling which is close to the artery
may show pulsation because of its close
proximity and it is only transmitted pulsation.
Fixity to the skin
Mobility of the skin over the swelling is checked
or skin over the swelling is pinched to see
whether skin is free or attached to swelling
underneath. Sebaceous cyst has skin adherent
over the summit with a punctum (70%) often
B present. In dermoid cyst skin is always free. In
Figs 2.1A and B: Paget’s test is done for a small lipoma skin is usually free. In neurofibromas
swelling to elicit fluctuation. skin may be adherent but depends on from which
nerves neurofibroma arises, whether from deeper
plane or from cutaneous nerves.
Fig. 2.3: Mobility of swelling should be checked to

find out the plane of the swelling.
Fig. 2.2: Skin over the swelling should be pinched/ Auscultation

held to check swelling is adherent to skin or not. It is done to look for bruit over the swelling like
Fixity to deeper structures in A-V malformation, arterial stenosis,
If swelling is freely mobile it could be in aneurysms.
subcutaneous plane. Lipoma, sebaceous cyst, Joints above and below the swelling should
often neurofibroma are subcutaneous. be examined both for active and passive
If swelling is adherent to muscle underneath, movements.
then when muscle is contracted against
resistance mobility of the swelling is restricted Regional lymph nodes should be examined for
but it becomes more prominent. While muscle significant enlargement.
is relaxed swelling will be mobile. Relevant systemic examination is a must like
If swelling is arising from the muscle or deep respiratory, cardiac, skeletal and abdomen.
to muscle then size of the swelling decreases
Proper diagnosis of the swelling should be given.
in size (less prominent) when muscle is
contracted. Again mobility which is present Relevant investigations
initially will disappear completely during • FNAC, U/S of part, CT scan, MRI for bony
contraction of the muscle. Disappearance occurs and joint swellings, angiography and
much more significantly in swelling which is Doppler in vascular swellings, biopsy in soft
deeper to the muscle. tissue sarcomas.
Swellings arising from vessels or nerves will • Swelling may be congenital/traumatic/
move only horizontally/perpendicular to the line inflammatory/neoplastic. It may be benign
of nerve but will not show any mobility in or malignant. In malignancy it may be early
longitudinal direction. Example—neurofibroma, or advanced.
aneurysm.
Swelling arising from the bone is hard and Lipoma
absolutely fixed and cannot be moved separately • Lipoma is benign tumour arising from yellow
from the bone. fat. It is usually encapsulated.
Percussion over the swelling in relevant area • It is also called as universal/ubiquitous tumour.
like hernia should be done. • It can occur anywhere except brain.
B
Figs 2.4A and B: Swelling should be
inspected properly
Figs 2.6A to D: Eliciting fluctuation – in two directions.

Swelling should be fixed before eliciting fluctuation.
Fig. 2.5: Slip sign should be elicited using finger. Fluctuation cannot be elicited in intra-abdominal swelling
Lipoma slips between fingers. as it cannot be fixed.
A B
Figs 2.7A and B: Mobility of the swelling should be checked

in two directions perpendicular to each other.
• It can be subcutaneous, submuscular,

subsynovial, intra-articular, intracavitary,
retroperitoneum, submucosal, etc.
• Diffuse lipoma can occur in sole and palm.
• Lipoma is slow growing tumour which slips B
by the palpating finger; mobile with free skin, Figs 2.9A and B: Slip sign in lipoma
semifluctuant, nontransilluminating.
• Lipoma can turn into liposarcoma especially • Complications–malignant transformation,
in back, thigh, shoulder region and retro- intussusception occurs in submucosal
peritoneum. There will be rapid increase in lipoma in intestine, degeneration, saponi-
size; warmness, increased vascularity, fixity, fication, calcification.
often blood spread to lungs.
• Dercum’s disease is painful deposition of Papilloma
hypertrophied fat, occurs usually in thigh. It is warty swelling from the skin or often from
• Lipoma can be fibrolipoma, neurolipoma the mucous membrane.
(painful), naevolipoma. It has got a central axis of connective tissue,
• Lipoma is treated by excision. blood vessels and lymphatics.
1. True papilloma
It is a benign tumour with localized overgrowth
of the epidermis. It is commonly pedunculated
but rarely can be sessile.
Pedunculated papilloma is villous with a
central axis of connective tissues, blood vessels
and lymphatics.
2. Infective papilloma
It is a warty lesion due to infection, e.g.
condyloma acuminata.
Papilloma may be Single.
Fig. 2.8: Lipoma back region. Multiple.
Papilloma may be Pigmented. Cysts

Nonpigmented. Cyst is a collection of fluid in a sac lined by
epithelium or endothelium.
Word meaning of cyst is ‘bladder’ (Greek).
1. True cyst
• Cyst wall is lined by epithelium or
endothelium.
• If infection occurs cyst wall will be lined by
granulation tissue.
• Fluid is usually serous or mucoid derived
from the secretion of the lining.
2. False cyst
• It does not have epithelial lining.
• Fluid collection is result of exudation or
degeneration.
Examples:
Fig. 2.10: Diagram of papilloma.
• Pseudocyst of pancreas.
• Wall of cystic swelling in tuberculous
True papilloma may turn into squamous cell peritonitis.
carcinoma occasionally. There will be sudden • Cystic degeneration of tumour.
increase in size, bleeding or ulceration. • After haemorrhage, in a haematoma, RBC’s
are lysed and absorbed and fluid remains
Differential Diagnosis as a false cyst.
Amelanotic melanoma, pedunculated lipoma,
carcinoma. 3. ‘Apoplectic cyst’ is formed in brain as a result
• Papilloma occurring in the breast is called of ischaemia causing collection of fluid.
as duct papilloma which is the commonest
cause of bloody discharge from the nipple. Classification
• Papilloma can occur in mucus membrane like Congenital cyst
in oral cavity, urinary bladder (transitional • Dermoids: Sequestration dermoid.
papilloma), in the rectum (columnar), in the • Tubulodermoids: Thyroglossal cyst, postanal
larynx, in the gallbladder (cuboidal). dermoid, ependymal cyst, urachal cyst.
• Cysts of embryonic remnants: Cysts from
Treatment paramesonephric duct and mesonephric
• True papilloma is excised with its base along duct. Cysts of urachus and vitellointestinal
with surrounding 1 cm skin margin. duct.
• Infective warts can be treated by excision or Acquired cysts
CO2 snow or diathermy coagulation. • Retention cysts: They are accumulation of
secretion of a gland due to obstruction of a
Complications of papilloma
duct. E.g. Sebaceous cyst, bartholin cyst, cyst
• Bleeding
of pancreas, cyst of parotid, breast, epi-
• Malignant transformation didymis.
• Ulceration • Distention cyst: Lymph cyst, ovarian cyst,
• Mechanical disability like voice change colloid goitre.
when it occurs in vocal cord • Exudation cyst: Bursa, hydrocoele.
Cystic tumours: Dermoid cyst of ovary, cystade- Common sites are
nomas. 1. Forehead.
2. External angular dermoid.
Traumatic cyst: Due to trauma, haematoma 3. Root of nose.
occurs usually in thigh, loin, and shin. It 4. Sublingual dermoid.
eventually gets lined by endothelium containing 5. Any where in midline or in the line of fusion.
brown coloured fluid with cholesterol crystals. • Dermoids occurring in the skull may extend
Degenerative cyst: Due to cystic degeneration into the cranial cavity. When it occurs as
of a solid tumour (due to necrosis of tumour). external angular dermoid, it extends into the
orbital cavity. Or it can extend into any cavity
Parasitic cyst: Hydatid cyst, trichiniasis, cysti- in relation to its anatomical location (e.g.
cercosis. thorax, abdomen).
• Dermoid cyst contains putty like desqua-
Clinical Features of a Cyst mated material. It is lined by both dermal
• Hemispherical swelling which is smooth, and epidermal components.
fluctuant, nontender, well localised. Some
cysts are transilluminant.
• Presentation varies depending on its
anatomical location.
Effects of a Cyst
• Compression to adjacent structures: Choledochal
cyst compressing over the CBD.
• Infection.
A
• Haemorrhage.
• Torsion, e.g. Ovarian cyst.
• Calcification.
• Cachexia: In malignant ovarian cyst patient
goes for severe cachexia.
Swellings which are brilliantly

transilluminant
• Ranula
• Cystic hygroma and lymph cyst
• Hydrocoele
• Epididymal cyst [Chinese-lantern pattern)
• Meningocoele
B
Dermoids
Figs 2.11A and B: External angular dermoid
Sequestration Dermoid?
and postauricular dermoid
It occurs at the line of fusion due to inclusion
of epithelium beneath the surface which later Types of Angular dermoid
get sequestered forming a cystic swelling in the • External angular dermoid: It is a sequestration
deeper plane. dermoid situated over the external angular
process of the frontal bone. Outer extremity • It is common in fingers (common in tailors),
of the eyebrow extends over some part of the toes and feet.
swelling. This typical feature differentiates
it from the swelling arising from the lacrimal
gland. It may extend into the orbital cavity
also.
• Internal angular dermoid: It is a sequestration
dermoid near central position at the root of
the nose.
Clinical features
• Painless swelling in the line of fusion,
presents in the second or third decade
onwards, which is smooth, soft, nontender,
fluctuant (Paget’s test positive, i.e. swelling is
fixed with two fingers and summit is indented
to get yielding sensation due to fluid),
nontransilluminating, with free skin often
adherent into the deeper plane.
• There will be resorption and indentation of Fig. 2.12: Implantation dermoid
the bone beneath (Bony guttering). It is true Clinical features
cyst. • Swelling which is painless, observed after
Differential diagnosis minor trauma, slowly progressing in fingers
• Sebaceous cyst. or toes.
• Lipoma. • It is smooth, soft, mobile, tensely cystic,
nontransilluminating and is adherent to skin.
Investigations
• X-ray skull or part. Differential diagnosis
• CT scan head or part. • Lipoma.
Treatment • Bursa.
Excision is done under general anaesthesia. Treatment
Often formal neurosurgical approach is required • Excision.
by raising cranial osteocutaneous flaps.
Submental dermoid is sequestration dermoid Teratomatous Dermoid
arising from sequestration at the site of fusion • It arises from all germinal layers ecto, meso
of ectoderm of 1st and 2nd branchial arches. and endoderms.
• It occurs in ovary, testis, retroperitoneum,
Tubulodermoids mediastinum.
It arises from the embryonic tubular structures. • It contains hairs, teeth, cartilage, muscle.
Examples includes: • It can be benign or malignant.
• Thyroglossal cyst.
• Ependymal cyst.
Sebaceous Cyst (Wen, Epidermal Cyst)
• Postanal dermoid.
• It is a retention cyst. It is due to obstruction
Implantation Dermoid to the mouth of a sebaceous duct, causing
• Due to minor pricks or trauma, epidermis a cystic swelling.
gets buried into the deeper subcutaneous • It is common in face, scalp, and scrotum.
tissue which causes reaction and cyst • It is not seen in palms and plantar aspect
formation (Trauma is often forgotten). of foot (sole) as there are no sebaceous glands.
• Sebaceous cyst contains yellowish material
with fat, epithelium which has putty like
consistency, with a parasite in the wall of
the sebaceous cyst—demodex folliculorum.
• Its lining is only epidermal layer of squamous
epithelium.
Clinical Features
• Painless swelling which is smooth, soft,
nontender, freely mobile, adherent to skin
especially over the summit, fluctuant (positive
Paget’s test), nontransilluminating with
Punctum over the summit.
• It moulds on finger indentation. Content has
got unpleasant smell. Fig. 2.13: Sebaceous cyst face.
• Punctum is present over the summit in 70%
of cases because here sebaceous duct directly
opens into the skin which gets blocked.
Punctum is depressed black coloured spot
over the summit of the sebaceous cyst. It is
black in colour because of the denuded
squamous epithelium (keratin). In 30% cases
sebaceous duct opens into the hair follicle Fig. 2.14: Incision for sebaceous cyst excision –
and so punctum is not seen. elliptical which includes punctum.
Complications
• Infection and abscess formation. Sites
• Surface gets ulcerated with discharge and • Cranial.
is called as—Cock’s peculiar tumour—often • Spinal.
resembles epithelioma. • Peripheral.
• Sebaceous horn.
Types
Treatment • Nodular neurofibroma presents as single
• Excision including skin adjacent to punctum smooth, firm, tender (often) swelling which
using elliptical incision. moves horizontally or perpendicular to the
• Incision and avulsion. direction of the nerve, not in the direction
• If abscess is formed, then drainage initially of the nerve. There is pain and hyperaesthesia
and later excision. in the distribution of the nerve.
• If capsule is not removed properly the cyst • Plexiform neurofibroma commonly occurs
will recur. along the distribution of 5th cranial nerve
in the skin of the face. It often occurs in the
Neurofibroma cutaneous distribution of the peripheral
• It is tumour arising from connective tissue nerve. It attains enormous size with thicke-
of the nerve. ning of the skin which hangs downwards.
• It can be single or multiple. Neurofibromas It causes erosion into the bone, orbit and
may be associated with pheochromocytomas, deeper structure. It may cause myxomatous
scoliosis, hypertension and few syndromes. degeneration also. It causes cosmetic problem.
• Generalised neurofibromatosis (von- 2. Haemorrhage into the tissues.

Recklinghausen’s disease): 3. Spinal and cranial neurofibromas can cause
– It is an inherited autosomal dominant neurological deficits.
disease wherein there will be multiple 4. Erosion into deeper planes, bone, orbit.
neurofibromas in the body.
– It may be cranial, spinal or peripheral. Treatment
– It is associated with pigmented spots • Excision
(coffee coloured) in the skin, commonly Indications:
seen on the back, abdomen, thigh (café – Symptomatic neurofibroma.
au‘ lait spots). – Cosmetically problematic lesion.
– Elephantiatic neurofibromatosis: It is of – Recent increase in size.
congenital origin. Skin of the limb is greatly – Malignant transformation.
thickened and coarse.
Neurilemmoma (Schwannoma)
Complications • It arises from Schwann (neurilemmal cells)
1. Sarcomatous changes: When it occurs it shows cells. They are lobulated, encapsulated, soft,
rapid enlargement, warmness, more vas- and whitish in appearance. They displace
cularity with dilated veins. Secondaries in the nerve from which they arise and can be
lungs can occur through blood spread. removed. They are common in acoustic nerve
but do can occur in a peripheral nerve. Often
they are multiple.
• Presentation is pain along the distribution
of the nerve, hyperaesthesia, and tenderness.
• Treatment is excision.
• Recurrent Schwannoma could be malignant.
Ganglion
It is a cystic swelling occurring in relation to
tendon sheath or synovial sheath or joint capsule.
It contains clear gel like fluid.
Common Sites
1. Dorsum of wrist.
2. Flexor aspect of wrist.
3. Around ankle joint—occasionally.
A
Pathogenesis
• Cystic degeneration of the tendon sheath.
• Leakage of synovial fluid through joint
capsule.
• There are small islets of microspaces in
synovial sheath which often fuses together
or one of them gets enlarged to form ganglion.
B
Clinical Features
Figs 2.15A and B: Multiple neurofibromatosis with Café
au' lait spots. More than 5 in number with each more
• Well localised, smooth, soft, cystic, or tensely
than 1.5 cm in size – significant. cystic, (Paget’s test is +ve), nontender,
transilluminant, swelling which is mobile but • Pressure compression (people used to place
mobility is restricted when tendon is bible over it to have pressure on it).
contracted against resistance.
• Occasionally it is communicating with joint Bursae
capsule. • Bursa is a sac like cavity containing fluid
• Often pain, tenderness and restricted joint within, which in normal location prevents
movement may be the presentation (but rare). friction between tendon and bone.
• Minor injuries and pressure leads in to
bursitis, which will present as a swelling at
the site.
• Inflammation of this bursa due to friction
causes bursitis, which commonly presents
as swelling, pain, and restricted movements.
Fig. 2.16: Ganglion over the wrist.
Fig. 2.18: Bursa near elbow joint
Fig. 2.17: Ganglion in flexor aspect of the

wrist—transilluminant.
Differential diagnosis: Lipoma, lymph cyst, Fig. 2.19: Adventitious bursa over lateral aspect of
sebaceous cyst. foot—a common site.
Treatment Different Types

• Excision. Usually under local anaesthesia It can be anatomical or adventitious.
(lignocaine plain 2%).
– Patient should be explained of high recur- Anatomical
rence rate (30%). • Subhyoid bursa—A horizontally oval swelling
– After excision, always it should be sent situated below the hyoid bone and in front
for histopathology. of the thyrohyoid membrane.
• Subacromial bursa: In front and lateral to

humeral head in relation to supraspinatus
tendon between acromion and greater
tuberosity of humerus.
• Bicipito radial bursitis.
• Olecranon bursitis (Student’s elbow) (Miner’s
elbow).
• Psoas bursa: A tensely cystic swelling beneath
Fig. 2.20: Parts of an ulcer
and below the inguinal ligament on the lateral
aspect of the femoral triangle. But it will not
extend above the inguinal ligament in to the
iliac region (unlike in psoas abscess which
extends above and is cross fluctuant).
• Prepatellar bursitis (Housemaid’s knee).
• Infrapatellar bursitis (Clergyman’s knee).
• Semimembranosus bursitis.
• Bursa anserina: Under the tendons of Guy ropes
( sartorius, gracilis and semitendinosus
tendons) (Goose’s foot).
• Retrocalcaneum bursitis between calcaneum
and tendo-Achilles.
Fig. 2.21: Ulcer edges
Adventitious bursa
• Adventitious bursa occurs in an unusual site
Different edges are:
like in hallux valgus (bunion) over first
Sloping edge: It is seen in healing ulcer.
metatarsal, over lateral malleolus (tailor’s
• Its inner part is red because of red, healthy
bursa), between tendo-Achilles and skin
granulation tissue.
(retro-Achilles bursitis) or over gluteal
• Its middle part is white due to scar/fibrous
tuberosity. It occurs due to friction or pressure.
tissue.
• It often mimics soft tissue tumour.
• Its outer part is blue due to epithelial
• Management: X-ray of the part and often FNAC proliferation.
are required. Later excision of the bursa is
done. Undermined edge is seen in tuberculous ulcer.
Disease process advances in deeper plane (in
Ulcer subcutaneous tissue) whereas (skin) epidermis
Definition proliferates inwards.
An ulcer is a break in the continuity of the covering Punched out edge is seen in gummatous
epithelium either skin or mucus membrane due (syphilitic) ulcer and trophic ulcer.
to molecular death. It is due to end arteritis.
Parts of an Ulcer Raised and beaded edge (pearly white) is seen

• Margin: It may be regular or irregular. It may in rodent ulcer (BCC). Beads are due to
be rounded or oval. proliferating active cells.
• Edge: Edge is the one which connects floor Everted edge (rolled out edge): It is seen in
of the ulcer to the margin. carcinomatous ulcer due to spill of the
proliferating malignant tissues over the normal • Diabetic ulcer.
skin. • Ulcers due to leukaemia, polycythaemia,
• Floor: It is the one which is seen. Floor may jaundice, collagen diseases, lympho-
contain discharge, granulation tissue. edema.
• Base: Base is the one on which ulcer rests. • Cortisol ulcers are due to long-term appli-
It may be bone or soft tissues. cation of cortisol (steroid) creams to certain
skin diseases. These ulcers are callous
Classification ulcers lasting for long-time and requires
excision and skin grafting.
Classification I (Clinical)
• Spreading ulcer: Here edge is inflamed and
Different discharges in an ulcer: (as well as
oedematous.
from a sinus)
• Healing ulcer: Edge is sloping with healthy
Serous: In healing ulcer
pink/red granulation tissue with serous
Purulent: In infected ulcer
discharge.
Staphylococci: yellowish and creamy
• Callous ulcer: Floor contains pale unhealthy
Streptococci: bloody and opalescent
granulation tissue with indurated edge/base.
Pseudomonas: greenish colour
Ulcer has no tendency to heal. It lasts for
Bloody: Malignant ulcer, healing ulcer from
many months to years.
healthy granulation tissue
Classification II (Pathological) Sero-purulent
1. Specific ulcers: Sero-sanguinous: Serous and blood
• Tuberculous ulcer. Serous with sulphur granules: Actinomycosis
• Syphilitic ulcer: It is punched out, deep, Yellowish: Tuberculous ulcer
with ‘wash-leather’ slough in the floor
and with indurated base.
• Actinomycosis. Examination of an Ulcer
• Meleney’s ulcer. An ulcer is break in continuity of the covering
2. Malignant ulcers: epithelium of skin or mucus membrane.
• Carcinomatous ulcer.
• Rodent ulcer. History
• Melanotic ulcer. • Mode of onset.
3. Non-specific ulcers: • Duration.
• Traumatic ulcer: It may be mechanical, • Pain—its time of onset, progress, severity.
physical, chemical. • Discharge from ulcer.
• Arterial ulcer: Atherosclerosis, TAO. • History suggestive of associated disease/
• Venous ulcer (Gravitational ulcer, post- treatment history.
phlebitic ulcer). Local examination of an ulcer
• Trophic ulcer.
• Infective ulcers: Pyogenic ulcer. Inspection
• Tropical ulcers: It occurs in tropical • Site of ulcer.
countries. It is callous type of ulcer, e.g. • Size of ulcer.
Vincent’s ulcer. • Shape of ulcer.
• Ulcers due to chilblains and frostbite. • Number.
(cryopathic ulcer). • Margin whether regular/irregular/well-
• Martorell’s hypertensive ulcer. defined/ill-defined.
• Bazin’s ulcer. • Edge of ulcer.
A B C
Figs 2.22A to C: Inspection of ulcer for its site, size, shape, margin, edge, floor and surrounding area.
• Floor of the ulcer—floor is the one what is

seen. It rests on the base (Base is not seen;
it is only felt).
• Discharge from ulcer bed may be serous, sero-
sanguinous, bloody, purulent; colour of
discharge – greenish in pseudomonas
infection.
• Surrounding area to be examined for inflam-
mation, oedema, eczema, scarring.
• Inspection of the entire part/limb.
Palpation
A B
• Tenderness over edge and base and sur-
rounding area. Figs 2.23A and B: Checking the temperature in surrounding
area and comparing opposite/normal area.
• Warmness over surrounding area.
• Edge palpation for induration.
• Palpation of base for induration/fixity.
• Depth of ulcer—trophic ulcer is deep with
bone as its base.
• Bleeding on palpation and touching.
• Palpation of deeper structures and its relation
to ulcer.
• Surrounding skin.
Examination of regional lymph nodes is essential.
Examination of arterial pulse peripherally in
relation to ulcer.
Examination for varicose veins in standing
position.
Examination of spine and neurological system like Fig. 2.24: Palpating the edge for
sensation and muscle power. tenderness and induration.
A B
Fig. 2.25: Palpation may cause bleeding on touch in healthy
granulation tissue or carcinoma. Base of an ulcer also Figs 2.27A and B: Bone thickening should be felt by
should be palpated for tenderness and induration. palpation over proximal and distal part of the ulcer. Here
ulcer is in ankle region and so thickening of tibia and
calcaneum should be checked.
Fig. 2.28: Joint near the ulcer area should be checked

for its change in movement. Fibrous ankylosis and total
A loss of joint movement can occur.
Granulation Tissue
It is proliferation of new capillaries and
fibroblasts intermingled with RBC’s and WBC’s
with thin fibrin cover over it.
Types:
• Healthy granulation tissue: It occurs in a
healing ulcer. It has got sloping edge. It bleeds
on touch. It has got serous discharge. Skin
grafting takes up well with healthy granu-
lation tissue. Streptococci growth in culture
should be less than 105/gram of tissue before
skin grafting.
B • Unhealthy granulation tissue: It is pale with
purulent discharge. Its floor is covered with
Figs 2.26A and B: Mobility of an ulcer should be checked.
If free mobility is present it means that it is not fixed slough. Its edge is inflamed and oedematous.
to bone. If is absent then it could be fixed to bone. It is spreading ulcer.
• Unhealthy, pale, flat granulation tissue: It

is seen in chronic nonhealing ulcer (callous
ulcer).
• Exuberant granulation tissue (Proud flesh):
It occurs in a sinus wherein granulation tissue
protrudes out of the sinus orifice like a
proliferating mass. It is commonly associated
with a retained foreign body in the sinus
cavity.
• Pyogenic granuloma: It is a type of exuberant
granulation tissue.
Here granulation tissue from an infected
wound or ulcer bed protrudes out presenting
as well localised, red swelling which bleeds
on touching.
Differential diagnosis: Papilloma, skin adnexal
tumours.
Treatment: Antibiotics, excision and should
be sent for biopsy.
Fig. 2.29: Regional lymph nodes should be palpated for

enlargement. In lower limb ulcer, vertical superficial group
of inguinal nodes are palpated. External iliac nodes are
also need to be checked above and on medial aspect
of the inguinal ligament. Its enlargement signifies severity
of the disease.
Fig. 2.31: Ulcer with healthy granulation tissue

ready for split skin grafting.
Induration in an ulcer is due to carcinomatous

ulcer or long standing ulcer due to fibrosis.
Investigations for an Ulcer

• Study of discharge: Culture and sensitivity,
AFB study, cytology.
• Edge biopsy: Biopsy is taken from edge because
edge contains multiplying cells. Usually two
biopsies are taken. Biopsy is not taken from
the centre because of central necrosis and
biopsy may be inadequate.
• X-ray of the part.
• FNAC of the lymph node.
Fig. 2.30: Systemic examination like of abdomen,
respiratory, cardiovascular system, spine, neurological
• Chest X-ray, Mantoux test in suspected case
examination is a must. of tuberculous ulcer.
Trophic Ulcer Clinical features:
It is due to— • Painless ulcer which is punched out.
• Impaired nutrition. • Ulcer is nonmobile with base formed by bone.
• Defective blood supply.
• Neurological deficit. Investigations: Study of discharge, biopsy from
the edge, X-ray of the part, X-ray spine, blood
It usually occurs— sugar.
• In the heel.
• in relation to heads of metatarsals. Treatment:
• buttocks. • Cause should be treated.
• over the ischial tuberosity. • Nutritional supplement.
• sacrum. • Rest, antibiotics, slough excision, regular
• over the shoulder. dressings is done.
• occiput. • Once ulcer granulates well flap cover or skin
– Because there is neurological deficit grafting is done.
trophic ulcer is called as neurogenic ulcer/ • Excision of the ulcer and skin grafting.
neuropathic ulcer.
– Initially, it begins as callosity due to Ulcer due to Chilblains
repeated trauma and pressure which
It is due to exposure to intense cold causing
suppurates and gives way through a
blisters and ulceration in the feet.
central hole which extends into the deeper
These ulcers are superficial.
plane as perforating ulcer (penetrating ulcer).
It is due to excessive cutaneous arteriolar
constriction.
The condition is also called as perniosis.
Ulcer due to Frostbite

• It is due to exposure of the part to wet cold
below the freezing point.
• There is arteriolar spasm, denaturation of
proteins and cell destruction.
• It leads on to gangrene of the part.
• Ulcers here are always deep.
Fig. 2.32: Bedsore in sacral region— Martorelle’s Ulcer

it is a trophic ulcer. • It is seen in hypertensive patients often with
Neurological causes are: atherosclerosis.
• Diabetic neuropathy • It is seen in calf. Often it is bilateral. It is painful.
• Peripheral neuritis • Necrosis of calf skin with sloughing away
• Tabes dorsalis occurs with formation of deep, punched out
• Spina bifida ulcer extending into the deep fascia.
• Leprosy • There is sudden obliteration of the arterioles
• Spinal injury of the calf skin.
• Paraplegia • All peripheral pulses are present.
• Peripheral nerve injury • It takes months to heal.
• Syringomyelia. • Treatment is once ulcer granulates well, skin
Bedsores are trophic ulcers grafting with lumbar sympathectomy.
Bairnsdale Ulcer • X-ray of the part.

• It is a chronic, irregular, undermined ulcer • Arterial Doppler of the limb.
due to Mycobacterium ulcerans infection.
Treatment
• Discharge study will show acid-fast bacilli.
• Control of diabetes using insulin.
• Antituberculous drugs resolve the ulcer
• Antibiotics.
usually. Skin grafting may be required later. • Nutritional supplement.
• Regular cleaning, debridement, dressing.
Diabetic Ulcer • Once granulates well it is covered with skin
grafting or flap
Causes:
• Increased glucose in the tissue precipitates Meleney’s Ulcer
infection • It is an acute rapidly spreading ulcer with
• Diabetic microangiopathy which affects gangrene of skin and subcutaneous tissues.
microcirculation
• Increased glycosylated haemoglobin Aetiology:
decreases the oxygen dissociation • It is common in old age and immuno-
• Increased glycosylated tissue protein suppressed individuals.
decreases the oxygen dissociation • It is caused by microaerophillic streptococci
• Diabetic neuropathy involving all sensory, and anaerobes.
motor and autonomous components • Site: It begins in scrotum or perineum and
• Associated atherosclerosis spreads to groin and lower abdominal wall
rapidly. It can occur in other areas of skin
also.
• Infection is severe with endarteritis of the
skin leading on to ulcer and gangrene.
Clinical features:
• Toxic features.
• Spreading ulcer with skin gangrene with foul
smelling discharge.
Management
• Blood sugar is checked and if diabetic it is
controlled.
• Antibiotics.
• Blood transfusion.
Fig. 2.33: Diabetic ulcer foot with ischaemia. • Adequate excision of dead tissues until it
bleeds.
Sites • Once healthy granulation occurs skin grafting
• Foot-plantar aspect is the commonest site. is done.
• Leg.
• Upper limb, back, scrotum, perineum, etc. Lupus Vulgaris
Diabetic ulcer may be associated with • It is cutaneous tuberculosis which occurs in
ischaemia. Ulcer is spreading and deep. young age group.
Investigations • Commonly seen on face, starts as typical
• Blood sugar both random and fasting. apple-gelly nodule with congestion of face
• Urine ketone bodies. around. Eventually ulceration occurs with
• Discharge for culture and sensitivity. scarring, necrosis and undermined edge.
• Often lesion extends into nose and oral cavity Sinus
involving mucosa. It is a blind track lined by granulation tissue
• Due to lymphatic obstruction oedema of face leading from an epithelial surface into the
can occur. surrounding tissues.
• Long standing lupus vulgaris can turn into Sinus means ‘hollow’ or ‘a bay’ (Latin).
squamous cell carcinoma.
Investigation
ESR, discharge study, biopsy, chest X-ray.
Treatment
• Antituberculous drugs.
• If complete healing does not occur, then
excision and skin grafting is required.
Bazin’s Disease
• It is also called as Erythema induratum.
• It is localised area of fat necrosis affecting
adolescent girls.
Fig. 2.34: Sinus
• Symmetrical purple nodules develop in the
calves which eventually break down forming Fistula
indolent ulcers with pigmented scars. It is an abnormal communication between the
• It may be due to tuberculosis. lumen of one viscus to another or the body surface
• Antitubercular drugs and sympathectomy are or between the vessels. Fistula means ‘flute’ or
the treatment. ‘a pipe or tube’.
Management of an ulcer
• Cause should be found and treated
• Correct the deficiencies like anaemia, protein
deficiency, and vitamins
• Transfuse blood if required
• Control the pain
• Investigate properly
• Control of infection and rest to the part
• Care of the ulcer by debridement (wound
excision), ulcer cleaning and dressing
• Removal of the exuberant granulation tissue
• Topical antibiotics for infected ulcers only
like framycetin, silver sulphadiazine,
mupirocin
• Antibiotics are not required once healthy
granulation tissues are formed
• Once granulates, defect is closed with
secondary suturing, skin graft, flaps Fig. 2.35: Fistula
Types Compound Palmar Ganglion

Congenital Acquired
• It is chronic tenosynovitis of flexor tendon
sheaths due to tuberculosis (tuberculous
Preauricular sinus Ruptured abscess tenosynovitis) or rheumatoid arthritis.
Branchial fistula Tuberculosis • It can be unilateral or bilateral.
Tracheo-oesophageal fistula Actinomycosis
Congenital A-V fistula Chronic osteomyelitis
Fistula in ano Pathology
Acquired A-V fistula • Flexor tendon sheath on either side of the
wrist is involved, i.e. both in the volar surface
Clinical Features of palm and lower forearm.
• Discharge from the opening of sinus. • Swelling contains fluid with typical melon
• No floor. seed bodies.
• Raised indurated edge, indurated base, • Condition is often bilateral in case of
nonmobile. rheumatoid arthritis.
• Often sprouting granulation tissue is seen over
the sinus opening. Clinical Features
• Swelling in the palm and lower forearm which
Causes of Persistence of a Sinus is smooth, soft, nontender, fluctuant and
or Fistula cross-fluctuant across flexor retinaculum,
1. A foreign body or necrotic tissue may be non-transilluminating.
present underneath, e.g. suture, sequestrum. • Wasting of hand and forearm muscles.
2. Insufficient or nondependent drainage. • Matted axillary lymph nodes may be palpable.
3. Persistent obstruction in the lumen. E.g. in • Primary focus may be present in lungs.
faecal fistula, biliary fistulas (distal obs-
truction). Investigations
4. Lack of rest. • ESR.
5. Walls get lined with epithelium or • Chest X-ray.
endothelium. • FNAC of axillary lymph node and swelling
6. Dense fibrosis prevents contraction and itself.
healing.
7. Specific infections: Tuberculosis, actinomy- Hamartomata
cosis. Hamartano means ‘I miss’ (Greek). Or ‘fault’ or
8. Presence of malignant disease. ‘misfire’ or ‘error’.
• It is a benign lesion with aberrant differen-
tiation producing a mass of disorganised but
Investigations
mature specialised cells or tissue indigenous
• Fistulogram/sinusogram using ultrafluid
to the particular site and is called as
lipidol or water soluble iodine dye.
hamartomata.
• Discharge for C/S, AFB, cytology, staining
• It is tumour like overgrowth of tissue or tissues
• Biopsy from the edge.
proper to that part.
• Chest X-ray. • It may be single lesion or multiple lesions.
• ESR. • Haemangiomas, lymphangiomas, A-V
malformations, neural malformations are the
Treatment examples.
• Treat the cause.
• Excision of sinus or fistulas. Always specimen Problems with Hamartomas
should be sent for histology. • Pressure symptoms locally.
• Bleeding.
• Infection.
• Gigantism.
• Cosmetic problem.
Treatment
• Depends on site, type, extent.
• Cryotherapy, ligation of feeding vessels,
sclerotherapy, excision.
Haemangioma
• It is the commonest Hamartoma (a congenital
malformation).
• They are not true tumours.
• Commonly seen in skin and subcutaneous
tissue, but can occur anywhere in the body
like in liver, brain, lung or other organs. Fig. 2.36: Capillary haemangioma.
Classification
1. Capillary.
2. Cavernous (venous).
3. Arterial: Is a type of congenital arteriovenous
fistula.
Capillary Haemangioma
Types
1. Salmon patch: Present at birth. Usually on
face, scalp, limb. Often involves wide area
of skin. With age it goes for spontaneous
regression and disappears completely. Hence,
Masterly inactivity is adviced.
2. Port wine stain (Naevus flammeus): Present Fig. 2.37: Capillary haemangioma-port wine stain. It
at birth and persists throughout life without persists throughout the life.
any changes. No spontaneous regression. It
presents as reddish blue, warm area • History of bleeding after minor trauma.
commonly on face. Often it is nodular. It • It involves skin, subcutaneous tissue and often
requires cosmetic coverage, excision and muscle also.
grafting or laser ablation. • After one year of age, it slowly involutes and
3. Strawberry haemangioma: Child is normal by 7-8 years it disappears completely
at birth. Between one and three weeks it (commonly).
appears as red mark which rapidly increases
in three months to form strawberry or Treatment
raspberry haemangioma which contains • Allow for spontaneous regression.
immature vaso formative tissues. • Otherwise by laser therapy.
• It is clinically warm, compressible, and • CO2 snow therapy.
bluish in colour. • Sclerosant therapy.
Cavernous Haemangioma Investigations

• It is present at birth and consists of a multiple • U/S.
venous channels. • Doppler.
• Its size increases gradually and may cause • Angiogram to find out feeding vessel.
problems. • Platelet count.
• It often contains feeding vessels which is of
Treatment
surgical importance.
• Ligation of feeding artery.
• Therapeutic embolisation.
• If small in accessible area then excision.
• Sclerosant therapy.
• Laser ablation.
Associated Syndromes
• Klippel-Trenaunay-Weber syndrome: Naevus
flammeus + osteohypertrophy of extremities
+ AV fistula
• Kasabach-Merritt syndrome: Capillary hae-
mangioma + DIC (Disseminated intravas-
cular coagulation)
• Sturge-Weber syndrome: Haemangiomas +
hemiplegia and epilepsy (Calcified vascular
Fig. 2.38: Cavernous haemangioma in tongue. cerebral and meningeal deposits) +
It is one of the causes for macroglossia.
glaucoma
Sites • Maffucci syndrome: Cavernous haeman-
Face, limbs, liver and other internal organs. gioma + dyschondroplasia
Clinical features
• Smooth, bluish, well localised, soft, com-
Cirsoid Aneurysm
pressible, warm swelling from skin and
• It is a rare variant of capillary haemangioma
subcutaneous tissue.
occurring in skin, beneath which abnormal
• Compressibility of a swelling is checked by
artery communicates with the distended
gently and gradually pressing the swelling
veins.
so as to reduce it partially and pressing finger
• Commonly seen in superficial temporal artery
is released. After release swelling reappears
and its branches.
to attain its original size. It is called as
• Often the underlying bone gets thinned out
compressibility. Vascular and lymphatic
due to pressure.
swellings are compressible. Examples are –
• Sometimes extends into the cranial cavity.
haemangioma; cavernous haemangioma;
• Ulceration is the eventual problem which will
often arteriovenous malformations.
lead on to uncontrollable haemorrhage.
Complications
• Haemorrhage. Clinical Features
• DIC. Pulsatile swelling in relation to superficial
• Thrombosis. temporal artery, which is warm, compressible,
• Infection and septicaemia. with arterialisation of adjacent veins and with
• Erosion into the adjacent bone. bone thickening (due to erosion).
Investigations
• Doppler study.
• CT scan.
• Angiogram.
• X-ray of the part.
Treatment
• Ligation of feeding artery and excision of
lesion, often requires preliminary ligation of
external carotid artery.
• Intracranial extension requires formal
neurosurgical approach.
Fig. 2.39. Hypertrophic changes due to AV malformation
Arteriovenous Fistula (AVF) in index finger. Auscultation reveals a continuous bruit/
murmur over it.
It is a type of arteriovenous malformations.
Types
• Congenital.
• Traumatic.
Congenital AVF
During developmental period AV communica-
tions occur.
Sites
• Limbs either part or whole of the limb. Part
may be in toes or fingers.
• Lungs.
• Brain in circle of Willis.
• Other organs like bowel, liver.
Clinical Features A
Structural changes in the limb.

• Limb is lengthened due to increase in blood
flow since developmental period.
• Limb girth is also increased.
• Limb is warm.
• Continuous thrill and continuous machinery
murmur all over the lesion.
• Dilated arterialised varicose veins are seen
due to increased blood flow and due to B
valvular incompetence.
Figs 2.40A and B: Congenital AV malformation of right
• Often there will be bone erosion or extension upper limb with increased length, girth, and warmness.
of AVF into the bone as such. There is also right side facial hypertrophy.
Physiological changes: Because of the hyper- 2. After vascular surgical intervention for major
dynamic circulation, there will be increased vessels.
cardiac output and so often congestive cardiac 3. Therapeutic: For renal dialysis, AVF is created
failure. (cimino fistula) to achieve arterialisation of
Complications veins and also to have hyperdynamic
• Haemorrhage. circulation. It allows easy adequate venous
• Thrombosis. assess for long term haemodialysis. Common
• Cardiac failure. sites are wrist, brachial, and femoral region.
Investigations Pathophysiology
• Angiogram. • Physiological changes: Cardiac failure due
• Doppler study. to hyperdynamic circulation.
• X-ray of the part. • Structural changes:
– Changes at the level of fistula: Blood
Treatment
flows from high pressure artery to low
• Avoid injury.
pressure vein causing diversion of most
• Ligation of feeding artery.
of the blood. Between the artery and vein,
• Sclerosant therapy.
at the site of fistula, dilatation develops
• Therapeutic embolisation.
with fibrous sac formation called as
• Amputation when required (only) as life
aneurysmal sac. This presents as warm,
saving procedure.
pulsatile, smooth, soft, compressible
swelling at the site with continuous thrill
Acquired AVF
and continuous machinery murmur. It
Causes is warm at the site.
1. Trauma in – Changes below the level of the fistula:
a. Femoral region. Because of diversion of arterial blood
b. Popliteal region. distal part becomes ischaemic. Because
c. Brachial region. high pressure veins become arterialised,
d. Wrist. valvular incompetence occurs causing
e. Aorta venacaval. varicose veins.
f. Abdomen: It may be following road traffic – Changes proximal to the fistula: Hyper-
accidents, penetrating wounds, Cock- dynamic circulation causing cardiac
fights injury (common in South India). failure.
If pressure is applied to the artery proximal
to the fistula, swelling will reduce in size, thrill
and bruit will disappear, pulse rate and pulse
pressure becomes normal. This is called as
Nicoladoni’s sign or Branhan’s sign.
Cardiac failure may be very severe in
traumatic AVF (Often resistant to drug therapy).
Investigations
• Doppler.
• Angiogram.
• ECG.
Fig. 2.41: Acquired arteriovenous fistula. • Echocardiography.
Treatment • Dye might not have reached the required area.
• Excision of fistula and reconstruction of • Time consuming and invasive procedure.
artery and vein with graft.
• In emergency situation, quadruple ligation, Lymphangiographic Classification of
i.e. both artery and vein above and below Lymphoedema
should be ligated without touching the fistula • Congenital hyperplasia (10%).
and sac. Patient recovers well from cardiac • Distal obliteration (80%).
failure. • Proximal obliteration ( 10%).
• Therapeutic embolisation may be tried.
Hunter’s ligation should be avoided. It is used Isotope Lymphoscintigraphy
as life saving measure because it invariably causes Radioactive Technetium labelled antimony
limb ischaemia and gangrene even though patient sulphide colloid particles are injected into the
recovers from cardiac failure. It is ligation of both web space using fine needle. These particles are
artery and vein proximally so as to make cardiac specifically taken up by lymphatics. Using
function normal. But it invariably steals the blood gamma camera, limb and inguinal region is
from the limb leading to gangrene. exposed to visualise the lymphatics and inguinal
lymph nodes. In 3 hours it reaches para-aortic
Lymphangiography lymph nodes, other abdominal lymph nodes and
liver . Later thoracic duct also can be visualized.
Indications It can be compared to the take up on the other
• Congenital lymphoedema like aplasia, limb.
hypoplasia, hyperplasia.
• Lymphomas, it shows reticular pattern. It is Advantages
also useful to assess the response to treatment. • It is more sensitive.
• Secondaries in lymph nodes, especially iliac • Technically easier and faster compared to
and para-aortic lymph nodes. lymphangiography.
• Thoracic duct, other lymph nodes and liver
Technique can be visualized.
Patent blue dye or 1 ml Isosulphan blue is injected
subcutaneously between toes. Dye will be taken
up by lymphatics which will be visualised clearly. EXAMINATION OF LYMPHATIC
After making incision, one of the lymphatic SYSTEM
vessels is dissected and 30G needle is passed.
Lymphatic system is important in relation to
Ultra fluid lipiodol which is an oily contrast
many diseases like lymphoma, tuberculosis,
medium is injected slowly using pressure pump
at a rate of 1 ml in 8 minutes (total quantity secondary deposits, nonspecific infections,
is 7 ml). Slowly in 24 hours, it passes through lymphatic leukaemia, AIDS.
the lymphatics and reaches the iliac and para- In generalised lymphadenopathy a thorough
aortic lymph nodes. Radiographs taken will help examination is needed.
to visualise both lymphatic vessels as well as 1. History
lymph nodes. • Duration, progress, site/sites.
Secondaries in lymph nodes cause filling • Fever.
defects. Lymphomas show enlarged nodes which • Jaundice.
have foamy or reticular appearance. • Loss of appetite and weight.
• Pruritus.
Disadvantages • Cough, haemoptysis, dyspnoea.
• Technically difficult. • Bone pain.
• Extravasation of dye can occur. • History of exposure.
2. General examination: Clubbing, jaundice, Note: In modification, following additions are there.
fever, anaemia, built, respiration. • Single extralymphoid site is IE.
3. Lymphatic system examination • An extralymphoid site with one or more
• Oral cavity – tonsils and inner Waldeyer lymph nodes same side of diaphragm is II
ring. E.
• Neck nodes – superficial and deep; outer • An extralymphoid site with lymph nodes on
Waldeyer ring. both sides of diaphragm III E.
• Axillary nodes. • An extralymphoid site with spleen and
• Epitrochlear nodes – above and medial lymph nodes on both sides of diaphragm
to medial epicondyle. III SE.
• Mediastinal widening for mediastinal • Spleen with lymph nodes on both sides of
nodes. diaphragm is III S.
• Inguinal/iliac nodes. N – Nodes, H—Liver, S—Spleen, L—Lung, M—
• Para-aortic nodes. Marrow.
• Hepatosplenomegaly/ascites. P—Pleura, O—Bone, D—Skin.
• Popliteal nodes. Stage III (1) is nodes above renal vein level and
Bone tenderness, sternal tenderness.
(2) is below it.
Spine tenderness.
Respiratory system examination for pleural
Hodgkin’s Lymphoma (HL)
effusion and altered breath sounds.
• It is the commonest type of lymphoma.
Lymphomas • Grossly lymph nodes are fleshy, pinkish grey,
They are progressive neoplastic condition of and rubbery in consistency.
lymphoreticular system arising from stem cells. • Microscopically contains cellular infiltration
with lymphocytes, reticulum cells, histiocytes,
Types fibrous tissue and Reed-Sternberg cells.
• Hodgkin’s lymphoma (HL). (Reed-Sternberg cells are giant cells with two
• Non-Hodgkin’s lymphoma (NHL). large mirror image nuclei).
WHO modified REAL classification (Revised

European American Lymphoma) of lymphoma:
1. B cell neoplasms
I. Precursor B cell neoplasm—ALL, LBL.
II. Peripheral B cell neoplasm—It includes
all B cell related Non-Hodgkin’s lymphomas
2. T-cell and putative NK cell neoplasms
I. Precursor T cell neoplasms—ALL and
LBL T cell related.
II. Peripheral T cell and NK cell neoplasm—
It includes all T cell related Non-
Hodgkin’s lymphomas.
3. Hodgkin’s lymphoma
I. Predominant HL—Nodular lymphocyte
type
II. Classical HL
Nodular sclerosis
Lymphocyte rich
Mixed cellularity
Lymphocyte depletion
Fig 2.42: Hodgkin’s lymphoma in a boy.
Rye’s classification Ann—Arbor clinical staging
1. Lymphocytic predominance. Has got good Stage 1: Confined to one group of lymph node.
prognosis. Stage 2: More than one group of lymph nodes
2. Mixed cellularity. on one side of the diaphragm.
3. Nodular sclerosis. Stage 3: Nodes involved on both sides of the
4. Lymphocytic depletion has got bad prog- diaphragm.
nosis. Stage 4: Extranodal involvement like liver, bone
Reed-Sternberg cells are also seen occasionally marrow.
in certain other conditions like glandular fever.
Suffix ’S’—Spleen involved
Clinical Features
Suffix ‘B’—Presence of constitutional
• It is more common in males.
symptoms.
• It has got bimodal presentation. It is seen
Suffix ‘A’—Absence of constitutional
in young and adolescents (20-30 yr) as well
symptoms.
as in elderly (> 50 yr).
• Painless progressive enlargement of lymph
nodes. They are smooth, firm, nontender, Differential Diagnosis
typically of India rubber consistency. • Tuberculosis.
• NHL.
Site • HIV.
• Cervical lymph nodes commonest. 82% (lower • Chronic lymphatic leukaemia.
deep cervical group in posterior triangle). • Nonspecific lymphadenitis.
• Others include axillary, mediastinal, inguinal, • Sarcoidosis.
abdominal. • Secondaries in lymph nodes.
Specific Features Investigations

• Nodular sclerosis is most common type. • Blood: Hb%, ESR, peripheral smear, blood
• Consecutive group of lymph nodes are urea, serum creatinine.
involved. • FNAC of lymph nodes.
• Splenomegaly is very common (45%). • Excision biopsy of lymph nodes. Full lymph
• Hepatomegaly with jaundice—jaundice is node has to be excised to retain the
due to haemolysis or due to diffuse liver architecture of the lymph node. It is important
involvement. to grade the tumour.
• Constitutional symptoms like fever, malaise, • Chest X-ray to see mediastinal lymph nodes,
pruritus, weight loss may be present pleural effusion.
which signifies stage ‘B’, which has got • U/S abdomen—to see for the involvement
poor prognosis. Stage ‘A’ is absence of of liver, spleen, abdominal lymph nodes.
these symptoms which signifies better • CT scan of mediastinum and abdomen.
prognosis. • Lower limb lymphangiography to see the
• Mediastinal lymph node involvement may pelvic and retroperitoneal lymph nodes.
cause compression features like SVC • Bone marrow biopsy to stage and also to see
obstruction. the response to treatment.
• Occasionally bone may get involved, like • Staging laparotomy:
vertebrae. But it is not common in NHL. • Open the abdomen. Do splenectomy
• Anaemia, pancytopaenia. mainly to remove the tumour bulk, as
spleen is commonly involved and also Non-Hodgkin’s Lymphoma (NHL)

to avoid irradiation to splenic area which • It occurs in middle aged and elderly. It is
often causes unpleasant pulmonary more aggressive than HL.
fibrosis. Take biopsies from both lobes of • It involves asymmetrical group of lymph
the liver (needle biopsy) from para-aortic, nodes.
mesenteric, iliac nodes. In females ovaries • General condition is poor.
are fixed behind the uterus to prevent • Inner-Waldeyer ring, epitrochlear lymph
radiation oopheritis (oopheropexy). nodes, peripheral lymph nodes are commonly
involved.
Treatment for HL • Spleen is not commonly involved.
• Stages I and II • Hepatomegaly is common.
1. Mainly radiotherapy—external high • Vertebral involvement is common; paraplegia
cobalt RT. can occur.
• Above the diaphragm -‘Y’ field therapy, • Secondary infection, cachexia and immuno-
covering cervical, axillary, mediastinal suppression is more common.
lymph nodes.
• Below the diaphragm, mantle or Types
inverted ‘Y’ field therapy, covering para- • Nodular (follicular)
aortic and iliac nodes. • Diffuse lymphocytic
2. Chemotherapy is also often used. • Undifferentiated
• Stage III and IV: Mainly chemotherapy. • Histiocytic type
Drugs used includes:
— Mustine. M. (Mechloroethamine). Rappaport Working
— Oncovine. O. (Vinca alkaloids). classification: classification:
— Procarbazine. P. 1. Nodular a. Low grade
— Prednisolone. P. 2. Diffuse b. Intermediate grade
Other regimens available — MVPP, ABVD. c. High grade
Prognosis: 5 years survival rate is 80%. Treatment
Mainly chemotherapy
Prognostic factors Various regimens available include:
1. Stage I and II has got better prognosis. • ChOPP—Chlorambucil, Oncovin, Pro-
2. Lymphocytic predominance has got better carbazine, Prednisolone.
prognosis. • ABVD—Adriamycin, Bleomycin, Vincri-
3. Stage‘A’ without constitutional symptoms stine, Dacarbazine.
has got better prognosis. • ABVP—Adriamycin, Bleomycin, Vincri-
stine, Prednisolone.
Differences between HL and NHL • Combinations of above.
HL NHL
Age Young and elderly Middle age and elderly

Pattern of involvement Symmetrical and consecutive Asymmetrical
Cervical lymph node Commonly involved Any group can be involved
Splenomegaly Common Not common
Peripheral lymph node involvement Not common Common
(e.g. epitrochlear nodes)
Treatment Mainly radiotherapy Mainly chemotherapy
Chemotherapy (MOPP regime)
Prognosis Better Poor
Role of radiotherapy in NHL: When vertebra is Skin Adnexal Tumours
involved. • They are tumours arising from accessory skin
Prognosis is poor compared to HL. structures like sebaceous glands, sweat
glands, hair follicles, etc.
Burkitt’s Lymphoma (Malignant Lymphoma • It is not uncommon. It may be benign or
of Africa) malignant.
• It is common in South Africa and New- • It presents as protruding well-localised
Guinea. swelling in the skin.
• Epstien-Barr virus may be the aetiological agent. • Malignant skin adnexal tumour forms a
It is common in children. nodular, hard, indurated swelling in the skin,
• It is associated with infectious mononucleo- often with involvement of hard, nodular
sis. regional lymph glands.
• It is common in malaria endemic area. • It mimics squamous cell carcinoma of skin.
• The tumour is multifocal, rapidly growing,
painless. Differential Diagnosis
• Different groups of lymph nodes can also • Squamous cell carcinoma of skin.
be affected. • Dermatofibrosarcoma protuberans.
Microscopy Diagnosis
Primitive lymphoid cells with large clear • Biopsy.
histiocytes—starry night (starry sky) pattern. • FNAC of lymph node.
Site Treatment
It is common in jaw either lower or upper. • Excision for benign tumour.
Abdominal presentation and renal involvement • Wide excision and regional lymph node
is common (75%). block dissection when required.
Renal involvement often may be bilateral.
In females ovaries are commonly affected. Dermatofibroma (Sclerosing Angioma or
Subepithelial Benign Nodular Fibrosis)
Investigation • It is a benign tumour arising from skin.
• FNAC and biopsy confirms the diagnosis. • It is formation of firm, single or multiple
• X-ray jaw shows osteolytic lesions. nodules occurring commonly in extremities
• U/S abdomen to see involvement of kidneys. (limbs).
• Blood urea and serum creatinine estimation • It can be red, brownish yellow (due to lipid),
is done. or bluish black (due to haemosiderin).
Treatment
Radiotherapy.
• Squamous cell carcinoma of skin.
Chemotherapy: Cyclophosphamide, Metho-
• Melanoma.
trexate, Orthomelphalan.
• Basal cell carcinoma.
Surgery is usually not indicated unless it is
• Skin adnexal tumour.
localised or in case of involvement of ovaries.
Prognosis Treatment
Prognosis is good. Excision.
Dermatofibrosarcoma Protuberans • It presents as a rapidly growing painless

• It is a low grade fibrosarcoma which grows single swelling in the skin with central brown
slowly but persistently. area.
• Occurs in the limb, abdominal wall, back, etc. • It grows usually for 4 weeks and later shows
• It is not a rare entity, often attains a large spontaneous regression in 4 months.
size with multiple, nodular, hard, swelling • During regression phase, central area
with often involvement of lymph nodes. separates from the lesion leaving a deeply
• Rarely does it spread into lungs through seated scar.
blood. • Mobile, hard painless, nontender, lump with
• It mimics squamous cell carcinoma of skin, a central brownish area.
and skin adnexal tumour. • No lymph nodes are enlarged.
• It is totally benign.
Differential diagnosis—squamous cell
carcinoma
Treatment is excision. Always send the tissue
for histopathological study.
PREMALIGNANT CONDITIONS OF
THE SKIN
• Bowen’s disease of skin: It is an intradermal
precancerous condition. It presents as
brownish induration with a well-defined
edge. Microscopically it contains large clear
cells. Eventually it will turn into carcinoma.
• Paget’s disease of nipple.
• Leukoplakia.
• Senile or solar keratosis: It is multiple, dry,
Fig. 2.43: Malignant dermatofibrosarcoma
hard, scaly, lesions in face and backs of hands
due to exposure to sunlight, occurs after
Diagnosis
middle age. Squamous cell carcinoma occurs
• Biopsy of the lesion.
later.
• Chest X-ray.
• Radiodermatitis.
• FNAC of the lymph node.
• Chronic scars develop into Marjolin’s ulcer.
• Xeroderma pigmentosa wherein there is
Treatment
defective DNA excision repair mechanism.
• Wide excision and follow up.
It turns into malignant melanoma.
• Recurrence is common.
• Chronic lupus vulgaris.
• Prognosis is good.
• Prolonged irritation of skin by various
chemicals like dyes, tar, soot, etc.
Keratoacanthoma (Molluscum Sebaceum)
• It is a overgrowth and subsequent spon- Squamous Cell Carcinoma (Epithelioma)
taneous regression of hair follicle seen • It occurs in premalignant conditions like
commonly in adults. Bowen’s disease, chronic scars, chemically
• Cause is unknown. It may be self limiting induced chronic irritation, radiodermatitis,
benign neoplasm of viral origin. senile keratosis. For example, Khangri cancer
in Kashmir. Chimney scrotal cancer; Kang • Verrucous carcinoma is a squamous cell
cancer in Tibetians. carcinoma, commonly occurring in mucus
• It is arising from squamous layer of the skin. membrane or mucocutaneous junction
without lymph node spread. It is dry
Clinical Features exophytic warty indurated growth. It has got
• An ulcerative or ulceroproliferative lesion. good prognosis. It is curable malignancy.
• Raised and everted edge.
• Indurated. Histology
• Bloody discharge from the lesion. Malignant whorls of squamous cells with
• Regional lymph nodes are commonly epithelial or keratin pearls are characteristic.
involved with hard, nodular features, initially
mobile but eventually fixed to underlying Broder’s Classification
structures. I. Well differentiated. > 75% keratin pearls.
• Usually no blood spread. II. Moderately differentiated: 50-75% keratin
pearls.
III. Poorly differentiated: 25-50% keratin pearls.
IV. Dedifferentiated: <25%. keratin pearls.
BCC, melanoma, keratoacanthoma, skin adnexal
tumours.
Investigations
Edge biopsy, FNAC from lymph node.
Fig. 2.44: Squamous cell carcinoma in foot. Note
the cauliflower like lesion. Treatment
• Radiotherapy using radiation needles, moulds,
etc.
• Wide excision.
• Amputation with one joint above.
• For lymph nodes, block dissection of the
regional lymph nodes is done.
• Advanced cases with fixed lymph nodes,
palliative external radiotherapy is given to
palliate pain, fungation and bleeding.
• Chemotherapy is given using methotrexate,
vincristine, bleomycin. (Unstable scar of long
duration).
Marjolin’s Ulcer
Fig. 2.45: Squamous cell carcinoma in the arm with It is a well differentiated squamous cell carcinoma
enlarged axillary lymph nodes. which occurs in chronic scars like burn scar,
scar of venous ulcer (unstable scar of long
Varients duration).
• Marjolin’s ulcer which occurs in chronic scar • Because it develops in a scar due to chronic
is a type of squamous cell carcinoma without irritation and there are no lymphatics in scar
lymph node spread. tissue, it will not spread to lymph nodes.
Fig. 2.46: Marjolin’s ulcer occurring in a chronic long

standing scar/ulcer–burns scar, venous scar.
• Because scar is relatively avascular it grows

slowly. As scar does not contain nerves it
is painless. Fig. 2.47: Basal cell carcinoma near
eye brow–common site.
• Once it reaches the normal skin it may behave
like any other squamous cell carcinoma, i.e.
it will spread to lymph nodes. • It is only locally malignant. It does not spread
through lymphatics nor through the blood.
• History of pre-existing venous ulcer or burn.
But it erodes deeply into local tissues
• Indurated, painless, nontender, ulcer with
including cartilages, bones causing extensive
raised and everted edge.
local destruction. Hence, the name ‘rodent
• Biopsy from the edge confirms the diagnosis.
ulcer’.
• Treatment:
– Wide excision.
– If large ulcer, amputation is required.
– Radiotherapy should not be given as it may
turn into poorly differentiated squamous
cell carcinoma.
• It is curable malignancy.
Basal Cell Carcinoma (Rodent Ulcer)

• It is low grade, locally invasive, carcinoma
arising from basal layer of skin or muco-
cutaneous junction. It does not arise from
mucosa.
• It is common in white skinned people than
blacks.
• Common in places where exposure to UV
light is more (Australia).
• It is common in males, common in middle
Fig. 2.48: Common site of basal cell carcinoma — above
aged and elderly. the line drawn between angle of mouth and ear lobule
• Common site is face – above the line drawn
between angle of mouth and ear lobule. Types
• It is called as tear cancer because it is commonly • Nodular.
seen in area where tears roll down. • Cystic.
• Often can occur in mucocutaneous junctions. • Ulcerative.
• Multiple, often associated with syndromes Treatment
and other malignancies. • It is radiosensitive. If lesion is away from vital
• Pigmented BCC — mimics melanoma. structure (like away from eyes), then curative
• Geographical or field fire or forest fire BCC radiotherapy can be given. Radiotherapy is
is wide area involvement with central not given once it erodes to cartilage or bone.
scabbing and peripheral active proliferating • Surgery: Wide excision (2 cm clearance) with
edge. skin grafting or flap is the procedure of choice.
• Basisquamous BCC— behaves like squamous • Laser surgery, cryosurgery, MOHS (Microsco-
cell carcinoma with spread into lymph nodes. pically Oriented Histographic Surgery).
BCC which has not been treated for long-
time can turn into basisquamous carcinoma. Indications for Surgery
• Rodent ulcer eroding into cartilage or bone.
Microscopic Types • BCC close to the eye.
• Superficial type. • Recurrent BCC.
• Morphia type.
It contains malignant cells arranged as outer NAEVI
palisading columnar cells with central polyhedral • It is a hamartomata of melaocytes due to
cells without prickle cells or keratinisation. excessive stimulation.
• It may present during birth or appear later
Clinical Features in life.
• Ulcer on the face in a middle aged man which
is nontender, dry slowly growing, nonmobile, Types
with raised and beaded edge with central • Hairy mole is a mole with a hair growing
scab. on its surface.
• Site of beading signifies the area of active • Nonhairy mole.
proliferating cells. In between beaded areas • Blue naevus: It is seen in children. It is located
dormant nonactive cells are present. deep in the dermis, hence appears blue. It
• No lymph node or blood spread. is common in buttock (Mongolian spot), hand,
feet.
• Junctional naevus: It is located centered in
the junctional layer (basal layer) of the
1. Squamous cell carcinoma.
epidermis as clusters. It is immature, unstable
2. Melanoma.
and premalignant. Microscopically, there is
3. Keratoacanthoma.
proliferation of melanocytes at the epidermal
junction. Features of malignant transfor-
Investigations
mation are change in the size, colour, bleeding,
Edge biopsy, X-ray of the part.
ulceration, crusting, and satellite spots.
TNM staging of skin cancer other than melanoma

Tumour Node Metastasis
T0—No tumour found N0—No nodes M0–No distant spread
Tis Tumour in situ N1—Regional nodes ++ M1–Distant spread ++
T1 Tumour < 2 cm
T2 Tumour 2-5 cm
T3 Tumour > 5 cm
T4 Spread to cartilage, muscle or bone.
• Compound naevus: It is combination of ulceration, increased colour, halo around the

intradermal and junctional naevus. intra- naevus are the features of malignant
dermal part is inactive but junctional part transformation.
is potentially malignant. • Clark’s staging; Breslow’s grading are the
• Juvenile melanoma: It is appearance of classifications used.
junctional like mole before puberty. It is seen
Clark’s levels
in children in face.
• Level 1: Only confined to epidermis.
• Hutchinson’s freckle: It is seen in elderly with
• Level 2: Extension into papillary dermis.
large area of dark pigmentation. In the
• Level 3: Filling of papillary dermis completely.
macular stage it is smooth and brown. In
• Level 4: Extension into reticular dermis.
the tumour stage it is dark and irregular. It
• Level 5: Extension into subcutaneous tissue.
can turn into melanoma commonly.
Treatment
Excision: Always specimen should be sent for
histopathology
Melanoma
• Melanoma is most aggressive cancer of the
skin. It also can occur in mucosa, Fig. 2.50: Clark’s staging of melanoma.
mucocutaneous junction. It arises from the
melanocytes. Breslow’s Classification
• It often occurs denovo in skin or in a pre- Based on thickness of invasion measured by
existing naevus- commonly junctional type. optical micrometer.
• Recent increase in size, bleeding, itching, • I: Less than 0.75 mm.
• II: Between 0.76 and 1.5 mm.
• III: 1.51 to 4 mm.
• IV: more than 4 mm.
Superficial spreading type is the commonest
type. It spreads through lymphatics as well as
blood. It can spread to brain, lungs, and liver.
It causes massive enlargement of liver.
Incision biopsy is contraindicated in
melanoma. Excision biopsy, sentinel node biopsy,
CT scan brain, chest are the investigations.
Treatment is wide excision/amputation/
radical block dissection of regional nodes/
isolated limb perfusion/chemotherapy/immu-
notherapy. It has got poor prognosis.
Please refer chapter Surgical Pathology for
detail.
EXAMINATION OF ORAL CAVITY

1. History
• Swelling—in detail.
Figs 2.49A and B: Melanoma in sole – pigmented lesion.
Black lymph nodes in block dissection specimen.
• Ulcer—detail.
• Pain. 5. Relevant systemic examinations should be
• Type of pain, radiation to ear (through done.
lingual and auriculotemporal nerves) or
other places, severity.
• Fever.
• Excessive salivation is common in
carcinomas.
• Difficulty in speech.
• Voice change—in carcinoma larynx.
• Halitosis—foul smelling breath.
2. Personal history
Smoking history, chewing pan and keeping pan/
quid in the cheek, alcohol intake, spicy diet,
trauma by teeth.
3. Examination A
i. Inspection
• Site of lesion/type/extent/edge/margin/
floor/mouth opening (trismus) is adequate
or not/gums/dentition/floor of mouth/
tongue/palate/tonsils/lips/leukoplakia
present or not.
• Skin over the check also should be inspected
for swelling/oedema/ulceration/discolora-
tion.
• Tongue depressor is needed for proper
inspection of the oral cavity.
ii. Palpation
• Lesion is palpated after wearing a glove for
B
tenderness/extent/induration/mobility/
fixity/bleeding on touch/palpation of
different parts of the oral cavity.
• Bone thickening is checked using two fingers.
– thickening/tenderness/irregularity/
evidence of fracture site (pathological).
• All parts of the oral cavity should be palpated
properly.
4. Neck is examined for significant lymph
nodes of different groups and levels. Submandi-
bular nodes are checked with neck flexed and
tilted towards same side. It should be differen- C
tiated from submandibular salivary gland by
Figs 2.51A to C: Carcinoma cheek stage IV disease
bidigital palpation. Lymph gland is not and carcinoma angle of mouth lip and extending into cheek
bidigitally palpable whereas salivary gland is – inspection from outside is important. Inspection also
bidigitally palpable. should be done properly inside the oral cavity also.
A B C
D E
Figs 2.52A to E: Neck nodes should be examined in carcinoma oral cavity. Same side and opposite side
submandibular and upper deep cervical lymph nodes should be examined.
B
Figs 2.53A and B: Trismus should be assessed by passing Fig. 2.54: Oral cavity should be examined and
fingers sidewise through the teeth into the mouth. palpated in oral cavity cancers.
A
Fig. 2.57: Oral cavity is examined using tongue depressor
to see posterior third of the tongue, tonsils, etc.
Figs 2.55A and B: Bone should be palpated bidigitally

as well as from outside in oral malignancies – tenderness,
pathological fracture, bone thickening should be looked
for. A
Fig. 2.56: Bidigital palpation for submandibular salivary B

glands and palpation of all parts of the oral cavity is
important – vestibule, lip, floor of the mouth, tongue, cheek, Figs 2.58A and B: Proper palpation for induration,
tonsils, palate, etc. tenderness, bleeding on touch should be done.
Leucoplakia Incidence of leucoplakia in those who smoke

It is a white patch in the mucosa of the oral or chew pan is 20%, where as incidence in non
cavity that cannot be characterized clinically or smokers is 1%.
pathologically to any other disease. It is a Incidence of it turning into malignancy is
premalignant condition. 2-4%. It increases with age, duration of the pan
chewing, smoking.
Types
Histology: Parakeratosis with widening of rete pegs.
1. Homogenous.
2. Nodular—more potentially malignant.
Histological Staging
3. Speckled—more potentially malignant.
• Acanthosis.
• Parakeratosis.
• Widening of retepegs.
• Dyskeratosis.
• Dysplasia.
• Carcinoma in situ.
Biopsy confirms the diagnosis as well as rules
out the carcinoma.
Treatment
• Pan chewing and smoking has to be stopped.
• Excision, if required skin grafting has to be
done.
• Regular follow-up is necessary.
Erythroplakia
• It is red velvety appearance of the mucosa
Fig. 2.59: leucoplakia cheek. which cannot be characterised as any
recognized condition.
Clinically the lesion appears as white or • It is 17-20 times more potentially malignant
greyish coloured, well localised patch in the than leucoplacia.
cheek, tongue, palate or other areas of the oral • Histologically parakeratosis with severe
cavity. epithelial dysplasia is the typical feature.
• Diagnosis is by taking biopsy.
Common Causes • Treatment: Biopsy and surgical excision.
• Smoking.
• Spirit. Oral Submucosal Fibrosis
• Sepsis. • It is a progressive fibrosis deep to the mucosa
• Superficial glossitis. of the oral cavity which causes trismus and
• Syphilis. ankyloglossia.
• Spices. • The mucosa of cheek, gingivae ,palate and
• Sharp tooth. tongue shows a mottled/marbled pallor
• Susceptibility. • It is common in Asians and Indians.
• Pan chewing using areca, tobacco, slaked lime • Etiology: Hypersensitivity to chilli, betel nut,
• Chronic hypertrophic candidiasis (long tobacco and vitamin deficiencies probably
standing Candida infection.). alter the collagen metabolism leading to
juxtaepithelial fibrosis, epithelial atrophy and • Occasionally it can be adenocarcinoma
dysplasia. arising from the minor salivary glands or
• 30-33% of oral submucosal fibrosis can turn mucus glands. Rarely it can also be
into malignancy. melanoma.
• Treatment: Precipitating factors has to be
avoided. Precipitating Factors
• Surgical excision when required followed by All ’S’—Smoking, Spirit, Syphilis, Sharp tooth,
skin grafting has to be done. Sepsis.
Retromolar Trigone Premalignant Conditions

Retromolar trigone is the anterior surface of the • Leucoplakia.
ascending ramus of the mandible .It is triangular • Erythroplakia.
in shape with the base being superior and apex • Submucosal fibrosis.
inferiorly behind the third molar tooth. • Hyperplastic candidiasis.
Betel nut chewing (Pan, with pan quid kept
Premalignant conditions of oral cavity in cheek pouch for a long time) is an important
• Leucoplakia causative factor of carcinoma cheek.
• Erythroplakia
• Chronic hyperplastic candidiasis Types:
• Oral submucosal fibrosis 1. Ulcerative
• Syphilitic glossitis 2. Proliferative (exophytic)
• Sideropenic dysphagia 3. Verrucous
• Oral lichen planus
• Discoid lupus erythematosus Verrucous Carcinoma
• Dyskeratosis congenita • It occurs as a superficial proliferative
exophytic lesion with minimal deep invasion.
Carcinoma Cheek • Lesion has got white, dry, velvety or warty,
• Squamous cell carcinoma is the most common keratinised surface.
• It is of low grade, very well-differentiated
carcinoma of the cheek.
squamous cell carcinoma, which is locally
malignant without any lymphatic spread.
• It is a curable malignancy.
• After biopsy treatment is wide excision.
Radiotherapy is not given as it may lead to
anaplastic transformation.
Biological Behaviour of Carcinoma Cheek

• Carcinoma cheek is common in posterior half
of cheek than anterior.
• It spreads into the deeper plane to involve
buccinator, pterygoids; into the retromolar
trigone, base of the skull, pharynx.
• It spreads outwards to involve the skin
causing fungation, ulceration, orocutaneous
fistula formation.
Fig. 2.60: Carcinoma cheek extending into lip and • Mandible is commonly involved either by
outer aspect–locally advanced stage IV disease direct extension or through subperiosteal
lymphatic plexus which communicates freely • Eventually it causes fungation and

with oral lymphatics. bleeding from major vessels—-carotid
• Lymph nodes commonly involved are blow out.
submental, submandibular, deep cervical and
often lateral pharyngeal groups. Staging
• Infection of the tumour area and soft tissues TNM Staging.
around is common, causing fever, foul T1 - Tumour size < 2cm.
smelling ulcer, halitosis. T2 - Tumour size 2-4 cm.
• Respiratory infection is common in these T3 - Tumour > 4 cm.
patients. T4 - Tumour is of any size involving bone, soft
• Once tumour extends into the retromolar tissues, muscles.
region, soft palate, pharynx, dysphagia will N1 - Lymph node size < 3 cm.
occur. N2 - Lymph node size 3-6 cm or bilateral lymph
nodes.
Clinical Features N3 - Lymph node size > 6 cm.
1. Ulcer in the cheek which gradually increases
in size in a patient with H/O chewing pan,
Features of Advanced Carcinoma Cheek
smoking.
1. Involvement of retromolar trigone.
2. Pain occurs when it involves the skin, bone
2. Extension into the base of skull and pharynx.
or if secondarily infected. Referred pain into
the ear signifies involvement of lingual nerve. 3. Fixed neck lymph nodes.
3. Involvement of retromolar trigone indicates that 4. Extension to the opposite side.
it is a advanced disease, as the lymphatics
here communicate freely with the pharyngeal Investigations
lymphatics. • Edge biopsy usually taken from two sites.
4. Everted edge, induration are the typical features Biopsy has to be taken from the edge as it
of the ulcer. contains active cells; not from the centre as
5. Mandible is examined bidigitally, for it is the area of necrosis.
thickening, tenderness, and sites of fracture. Malignant squamous cells with epithelial pearls
6. Trismus and dysphagia signifies involvement (Keratin pearls) are the histological features.
of pterygoids, or posterior extension. Broder’s histological grading:
7. Occasionally it may extend into the upper 1. Well-differentiated—> 75% epithelial pearls,
alveolus and to the maxilla causing swelling, 2. Moderately differentiated—50-75%
pain and tenderness. epithelial pearls.
8. Submandibular lymph nodes and upper deep 3. Poorly differentiated—25-50% epithelial
cervical lymph nodes are involved which are pearls.
hard, nodular, and initially mobile and later 4. Differentiated—< 25% epithetial pearls.
get fixed to each other and then to deeper
• FNAC from lymph nodes. (No biopsy from
structure.
lymph nodes).
• Once lymph nodes get fixed it may infil-
• CT scan—to assess the extension of tumour
trate into hypoglossal nerve (tongue will
deviate towards the same side), spinal and its secondaries.
accessory nerve (defective shrugging of • Orthopantomogram to look for the involve-
shoulder) and cervical sympathetic chain ment of mandible— destruction and fracture
(Horner’s syndrome). sites.
• Compression over external carotid artery
causes absence of superficial temporal Treatment
artery pulsation. Treatment may be curative or palliative.
Treatment Strategy involvement: Wide excision of primary tumour
• Surgery—Wide excision, hemimandibulec- and radical neck lymph node dissection on
tomy, neck lymph node block dissection. same side are done. Mandible is not removed.
• Radiotherapy—Curative or palliative; • Fixed primary tumour or advanced neck lymph
external or brachytherapy. node secondaries: Only palliative external radio-
• Chemotherapy—Intra-arterial, IV or orally. therapy is given to palliate (pain, fungation
• Early growth without bone involvement: and to prevent anticipated torrential
1. Curative radiotherapy using 137Caesium haemorrhage).
needles or 192Iridium wires, i.e. Brachy- • Preoperative radiotherapy is often used in fixed
therapy. lymph nodes to downstage the disease so as
Advantages are that surgery is avoided; to make it operable.
no surgical mutilation and parts are • Postoperative radiotherapy is given in T3 and
retained—as it is squamous cell T4 tumours; N2 and N3 nodal status to reduce
carcinoma, primary is radiosensitive. the recurrence and to improve the prognosis.
2. Other option is wide excision with 3 cm • Prophylactic block dissection has become popular.
clearance. Often, the approach to the
• Reasons are eventhough clinically, lymph
tumour is by raising the cheek flap
nodes are negative there may be microscopic
(outside). After the wide excision, the flap
involvement of lymph nodes (25-65%).
is placed back. (Patterson operation).
Clinically detectable disease in lymph nodes
3. Presently advanced technology in radio-
of the patient signifies extracapsular spread
therapy, facilitates the use of external
which has got poor prognosis. Recurrence
radiotherapy also. The incidence of
rate is less after prophylactic block compared
dreaded complication like osteoradione-
to block dissection with clinically positive
crosis of mandible has reduced due to better
nodes because there is no extracapsular
RT methods.
spread in the former even if there is
• Growth with mandible involvement: Here along microscopic spread of tumour in many cases.
with wide excision of the primary tumour, Block dissection is an acceptable surgery as
hemimandibulectomy or segmental resection there is negligible mortality and less
of the mandible or marginal mandibulectomy morbidity.
(using rotary electric saw) is done.
• If growth is extending to upper alveolus: Partial
• Operable growth with mandible involvement and maxillectomy or total maxillectomy may be
mobile lymph nodes on same side: (confirmed required.
by FNAC): Along with wide excision of the • Role of chemotherapy
primary, hemimandibulectomy and radical
– Drugs used are Methotrexate, Vincristine,
neck lymph node dissection is done.
Bleomycin, and Adriamycin.
[Commondo like operation).
– Often it is given intra-arterially through
• Operable growth with mandible involvement;
external carotid artery using arterial
mobile lymph nodes on same side and
pump or by increasing the height of the
opposite side: Along with wide excision of
drip more than 13 ft. so as to attain a
the tumour, hemimandibulectomy, radical
pressure more than systolic pressure.
neck lymph node dissection on same side Chemotherapy can also be given IV or
and functional block dissection on opposite orally.
side are done, retaining the internal jugular
vein, sternomastoid, spinal accessory nerve. Reconstruction after Surgery
• Operable primary tumour with mobile lymph • Split skin graft.
nodes on same side but without mandibular • Deltopectoral cutaneous flap.
• Forehead flap.
• Pectoralis major myocutaneous flap.
• Mandible reconstruction by cortical bone graft
or rib, fibula or synthetic material.
Problems with Surgery

• (Surgical) Mutilation.
• Anaesthesia complications.
• Requirement for reconstruction.
• Mortality.
• Morbidity.
Problems with Radiotherapy

• When mandible is irradiated, chances of the
Fig. 2.61: Carcinoma lower lip
dreaded problem of osteoradionecrosis are
high which requires the removal of mandible.
• Loss of taste and dryness. • Usually it is a well-differentiated squamous cell
• Infection. carcinoma.
• Skin excoriation. • Differential diagnosis
• Trismus may get aggravated. Keratoacanthoma
• Can itself cause dysphagia, laryngeal oedema. Basal cell carcinoma
Minor salivary gland tumours.
Problems with Chemotherapy Often carcinoma of lip is an extension from
• Bone marrow suppression. carcinoma of cheek.
• Megaloblastic anaemia. • Diagnosis: Edge biopsy, FNAC of lymph nodes.
• GIT symptoms. • Treatment:
• Hepatotoxicity and renal toxicity. – If lesion is less than 2 cm, then curative
• Alopecia. radiotherapy, either brachytherapy or
external beam radiotherapy. It gives a
Neoplasm of Lip good cure.
Minor salivary gland tumours are common in upper If tumour is more than 2 cms, wide
lip. They are usually pleomorphic adenomas. excision is done. Excision of lower lip up
to one third can be sutured primarily in
Carcinoma Lip layers keeping vermillion border in proper
• It is common in men . Common in lower lip apposition without causing any
(90%); upper lip 5%. microstomia.
• Commonly due to exposure to sunlight – Excision of more than one third of the
(ultraviolet rays). lip requires reconstruction using different
• Initially starts as a red, granular dry lesion flaps.
which eventually gets ulcerated and forms
an ulcero-proliferative lesion. Occasionally Methods
it occurs at the angle of mouth. 1. Estlander’s rotating flap from the upper lip
• Causes: U\V rays, smoking. based on upper labial artery.
2. Fries‘ modified Bernard facial flap-recons-
• It spreads to submental nodes and later to
truction using lateral facial flaps.
other neck nodes on both sides.
– Lymph nodes are dealt with by radical Histologically
neck dissection on one side and functional • Squamous cell carcinoma—commonest.
block or suprahyoid block dissection on • Adenocarcinoma may be from minor salivary
other side. glands or mucus glands.
– Postoperative radiotherapy is given if • Melanomas.
tumour is large or if lymph nodes are
involved. Sites
• Prognosis: Good. 5 year survival is 70%. 1. Lateral margin—Commonest—47-50%.
2. Posterior third—20%.
Differential diagnosis for tongue ulcers. 3. Dorsum—6.5%.
Dental ulcers 4. Ventral surface—9%.
Aphthous ulcers
Ulcers in lichen planus
Sphilitic ulcers
Tuberculous ulcers
Malignant ulcers
Benign Tumours of the Tongue

1. Papilloma.
2. Fibroepithelial polyp.
A
3. Haemangioma and lymphangioma.
4. Neurofibroma.
5. Lipoma.
6. Granular cell myoblastoma.
CARCINOMA TONGUE
Incidence is equal in both sexes. Presently its
incidence is increasing in females due to increase
in number of female smokers.
Aetiology
• Leucoplakia.
B
• Erythroplakia.
• All’S. Figs 2.62A and B: Carcinoma tongue is more
Premalignant conditions mentioned earlier. common in lateral aspect of the tongue.
Types Clinical Features

• Pain in the tongue due to infection or
Gross ulceration or due to the involvement of lingual
1. Papillary. nerve (pain is referred to ear). Pain on
2. Ulcerative or ulceroproliferative. swallowing, in case of carcinoma of posterior
3. Fissure with induration. third of tongue.
4. Lobulated, indurated mass. • Excessive salivation.
• Dysphagia either due to fixed tongue or due Treatment

to the involvement of genioglossus or growth Surgery, Radiotherapy, Chemotherapy.
in the posterior third of the tongue. Surgery
• Visible ulcer in anterior two thirds of tongue. • Early growth < 2 cm in size requires, wide
Growth or ulcer in posterior third, is usually excision and growth >2 cm in size requires
not visible hemiglossectomy.
• Ankyloglossia. • Larger primary tumour can be given
• Inability to articulate. preoperative radiotherapy, and then later
• Foetor (Halitosis). Due to infection and hemiglossectomy is done.
• Same side palpable, mobile lymph nodes are
necrosis in the oral cavity.
removed by radical neck block dissection.
• Change in voice: Occurs in posterior third • Bilateral mobile lymph nodes are dealt with
tumours. Tumour in posterior third area is one side radical block and other side
more aggressive. functional block dissection with essentially
• Palpable lymph nodes in the neck which are retaining internal jugular vein (on opposite
hard, nodular and may get fixed in advanced side) to maintain the cerebral venous blood
stages. flow. Other option is same side radical neck
• Features of bronchopneumonia. dissection and on opposite side suprahyoid
block dissection can be done.
Spread of Carcinoma Tongue • Wide excision when growth is in the tip.
• Posterior third growth can be approached
• Local spread: In case of anterior two thirds by lip split and mandible resection, so as
of tongue, the spread occurs to genioglossus to have total glossectomy.
muscle, floor of the mouth, opposite side and • When mandible is involved hemimandibu-
mandible. In case of posterior third of tongue lectomy is done.
it spread locally to tonsil, side of pharynx, • The procedure that involves wide excision
soft palate, epiglottis, larynx and cervical or hemiglossectomy, hemimandibulectomy
spine. and radical neck dissection together is called
• Lymphatic spread: From tip of tongue it spreads as Commando Operation.
to submental nodes. From lateral margin it • Reconstruction of tongue and other area after
surgery: By deltopectoral flap, forehead flap,
spreads to submandibular lymph nodes and
pectoralis major muscle flap, skin grafting.
later to deep cervical lymph nodes. • Prophylactic block dissection is becoming
Lymphatics in the tongue are freely popular at present.
communicating, and so involvement of
bilateral neck lymph nodes is common. From Postoperative management:
posterior third it spreads to pharyngeal nodes • Control of infection
• Oedema
and upper deep cervical lymph nodes.
• Regular mouth wash
• Maintaining the airway
Investigations • Prevention of aspiration.
1. Edge biopsy.
2. FNAC of lymph nodes. Radiotherapy
3. Indirect and direct laryngoscopy to see 1. In small primary tumour—Curative radio-
posterior third growth. therapy (Brachytherapy using caesium or
4. CT scan to see the extension of posterior third iridium needles).
growth, or to see the status of advanced 2. Large primary tumour—Initial radiotherapy
secondaries. is given to reduce the tumour size so that
5. Chest X-ray to see bronchopneumonia. the resection will be better later.
3. Advanced primary as well as secondaries Prognostic Factors
in the neck can be controlled by palliative • Size of the tumour.
external radiotherapy. • Site of tumour (Posterior third has got poor
4. Postoperative radiotherapy is given in large prognosis).
tumours to reduce the chances of relapse. • Tumour crossing the midline.
• Lymph nodes status.
5. In case of growths in the posterior third of
• Differentiation
tongue, radiotherapy is of curative as well
• Bone involvement.
as palliative mode.
Complications of radiotherapy: Nasopharyngeal Carcinoma
• Loss of sensation like taste. • Nasopharynx lies above the level of the soft
• Trismus and ankyloglossia. palate which divides it from oropharynx
• Infection. below.
• Pharyngeal and laryngeal oedema. • It is also called as postnasal space or
• Dermatitis and skin infection. epipharynx. Eustachian tube opens on its
antero-lateral wall. Fossa of Rosenmuller is
Chemotherapy located above and behind the opening of the
• Given in postoperative period and also for Eustachian tube as a small depression.
palliation.
• Price-Hill regimen is commonly used. Drugs Clinical Features
are Methotrexate, Vincristine, Adriamycin, • Epistaxis, nasal speech, postnasal discharge
Bleomycin and Mercaptopurine. and nasal obstruction.
• It is given either intra-arterially, as regional • Pain in the ear with unilateral deafness due
chemotherapy through external carotid artery to compression of eustachian tube with fluid
using arterial pump or through IV. It can also collection in the middle ear.
be given orally. • Elevation and immobility of soft palate on
the same side.
• Complications: • Pain in the area of distribution of trigeminal
— Megaloblastic anaemia, nerve due to direct infiltration of the nerve
— Bone marrow suppression. at foramen lacerum.
— Alopecia. 5. Palpable secondaries in upper deep cervical
lymph nodes (70%).
— Sepsis.
For Melanoma, Melphalon and DTIC are Trotter’s triad
used. • Unilateral deafness
Terminal events: • Immobile elevated soft palate
• Inhalational bronchopneumonia. • Pain in the distribution of trigeminal nerve
• Haemorrhage from erosion of lingual artery.
In posterior third of the tongue, erosion of Differential Diagnosis
• Lymphoma.
internal carotid artery can occur.
• Lympho-epithelioma.
• Cancer cachexia.
• Minor salivary gland tumour.
• Asphyxia due to pressure on air passages
or due to oedema glottis. Investigations
• Biopsy from the primary site.
Prognosis • FNAC from the neck lymph nodes.
5 years survival for females is 50%, for males • X-ray of the skull to visualize erosions.
is 25%. CT scan skull.
Histological Type • Ranula has a delicate fibrous capsule and

Squamous cell carcinoma. is lined by a layer of macrophages.
• It contains clear fluid.
Treatment
• External irradiation for primary. Treatment
• Radical block dissection of cervical lymph • Marsupilisation can be done initially and later
nodes. once the wall of the ranula is thickened it
• Chemotherapy: Methotrexate, Vincristine. is excised.
• If ranula is small it can be excised.
Ranula
[Rana = Frog, Ranula looks like belly of frog, Differential Diagnosis
hence the name.) • Lymph cyst
• Ranula is an extravasation cyst arising from • Sublingual dermoid.
sublingual gland or mucus glands of Nuhn
or glands of Blandin in the floor of the mouth. Sublingual Dermoids
They are sequestration dermoids lined by squamous
epithelium containing keratin.
Types
1. Median sublingual dermoid: It is derived from
epithelial cell rests at the level of fusion of
two mandibular arches. It is located between
two genial muscles, above the level of
mylohyoid muscle. It is a midline swelling
which is smooth, soft, cystic, nontender,
nontransilluminant.
Treatment is excision through per oral
approach.Complication is abscess formation.
2. Lateral sublingual dermoid: It develops in
relation to submandibular duct, lingual nerve
and stylohyoid ligament. It is derived from
Fig. 2.63: Ranula first branchial arch. It forms a swelling in the
lateral aspect of the floor of the mouth.
Clinical Features Treatment: Small one is removed per orally.
• As a bluish smooth, soft, fluctuant, brilliantly Larger one is excised through submandibular
transilluminant swelling in the lateral aspect incision.
of the floor of the mouth.
• It often extends into the submandibular region
through the deeper part of the posterior
margin of mylohyoid muscle and is called
as plunging ranula.
Clinical features of ranula

• Bluish swelling in the floor of the mouth
• Laterally placed and nontender
• Fluctuant and cross fluctuant
• Brilliantly transilluminant
Fig. 2.64: Sublingual dermoid
Jaw Tumours Cysts arising in relation to dental epithelium:
Classification • Dental cyst.
• Dentigerous cyst.
Swelling arising from the gums (Epulis):
• Congenital epulis. Swelling arising from the mandible or maxilla:
• Fibrous epulis. • Osteoma and osteoblastoma.
• Pregnancy epulis. • Torus palatinus and mandibularis.
• Giant cell epulis. • Fibrous dysplasia.
• Myelomatous epulis. • Osteoclastoma.
• Sarcomatous epulis. • Osteosarcoma.
• Secondaries.
Swelling arising from the dental epithelium
(Odontomes): Surface tumours:
• Ameloblastoma. Tumours from the surface which extend into the
• Compound odontoma. jaw.
• Enameloma.
• Cementoma. Epulis
• Dentinoma. Swelling arising from the gums.
• Odontogenic fibroma and myxoma.
Congenital Epulis
• It is a benign condition seen in a newborn
arising from gum pads.
• It is a variant of granular cell myoblastoma
originating from gums.
• It is more common in girls. It is more common
in upper jaw.
• It is not a malignant condition.
Clinical features:
Well localized swelling from the gum which is
firm and bleeds on touch.
Treatment:
Excision.
Fibrous Epulis
• It is a benign condition, can occur in any
individual with caries tooth.
• It is seen in the gum, adjacent to the caries
tooth.
Clinical features:
• Painful, well-localized, hard, tender swelling
in the gum which bleeds on touch.
• Caries tooth adjacent to the lesion.
Differential diagnosis:
Squamous cell carcinoma from the gum.
Investigations:
• X-ray jaw.
Figs 2.65A and B: Jaw tumours both lower • Orhtopantomogram.
and upper jaws in two different patients. • Biopsy from the lesion.
Treatment: Investigations
Excision with extraction of the adjacent tooth. • Orthopantomogram (OPG) shows multilocu-
lated lesion.
Pregnancy Epulis • Biopsy from the swelling.
• It occurs in pregnant women due to inflammatory
gingivitis usually during 3rd month of preg- Treatment
nancy. • Segmental resection of the mandible. OR
• Clinically it resembles fibrous epulis or pyo- • Hemimandibulectomy with reconstruction of the
genic granuloma. mandible.
• It usually resolves after delivery. Otherwise • Curettage and bone grafting should not be
it should be excised. done.
It is a curable condition.
Myelomatous Epulis Recurrent adamantinoma can spread
• It is seen in leukaemic patients. through blood.
Investigated for leukaemia by peripheral smear,
bone marrow, biopsy. Dentigerous Cyst (Follicular Odontome)
• It is a unilocular cystic swelling arising in
Treatment: For leukaemia. relation to the dental epithelium from an
unerupted tooth.
Ameloblastoma (Adamantinoma, Eve’s • Common in lower jaw, but can also occur
Disease, Multilocular Cystic Disease of the Jaw) in upper jaw.
• It arises from the dental epithelium probably • It occurs over the crown of unerupted tooth.
from the enamel. Commonly seen in relation to premolars or
• It occurs commonly in mandible or maxilla. molars.
• Occasionally it is seen in the base of the skull • It causes expansion of outer table of the
in relation to Rathke’s pouch or in tibia. mandible.
• Histologically it is a variant of basal cell
carcinoma.
• It is a locally malignant tumour.
• It neither spreads through lymph node nor
through blood. Hence it is curable.
• It is usually unilateral.
• It can occur in a pre-existing dentigerous cyst.
Clinical Features
• Swelling in the jaw usually in the mandible
near the angle which attains a large size.
• It is gradually progressive, painless, smooth
and hard with intact inner table.
• Lymph nodes are not enlarged.
Differential Diagnosis Fig. 2.66: Dentigerous cyst

• Osteoclastoma of the mandible: Here inner
table is not intact. Clinical Features
• Dentigerous cyst. Painless swelling in the jaw which is smooth
• Dental abscess. and hard.
• Adamantinoma.
• Dental cyst.
• Osteoclastoma.
Complication
It can turn into adamantinoma.
Investigations
Orthopantomogram.
Fig. 2.68: Dental cyst
Complication
It can cause osteomyelitis of the jaw.
Dentigerous cyst.
Fig. 2.67: Orthopantomogram showing dentigerous cyst
Investigation
Treatment Orthopantomogram.
• If it is small, excision of the cyst is done.
• If it is large, initial marsupilisation and later Treatment
excision is done. • Antibiotics.
• Unerupted tooth should be extracted. • Drainage or excision of the cyst with
extraction of the infected tooth is done.
Dental Cyst (Radicular Cyst, Periapical Cyst)
• It occurs under the root of the chronically
infected dead erupted tooth. Curable malignancies
• It is lined by squamous epithelium derived • Adamantinoma
by epithelial debris of Mallassez. • Basal cell carcinoma
• Verrucous carcinoma
Clinical Features • Papillary carcinoma thyroid
As a smooth, tender swelling in the jaw in relation • Marjolin’s ulcer
to caries tooth which causes expansion of the • Carcinoma colon
jaw bone.
Differences between dental cyst and dentigerous cyst

Dental cyst Dentigerous cyst
Site of occurrence Erupted tooth under the root. Over the crown of an unerupted tooth.
Infection Common Not common
Complication. Osteomyelitis Adamantinoma
Treatment Excision and extraction of tooth Marsupilisation, excision and
then extraction of tooth
EXAMINATION OF SALIVARY • All features of facial nerve palsy—inability

GLAND to close eye/difficulty in blowing/altered
nasolabial groove/clinching of teeth
1.History • Neck nodes should be examined
• Swelling-duration-progress. • Examination of other salivary glands should
• Pain- duration/type/severity/radiation. be done
• Fever. • Relevant findings should be elicited in case
• Difficulty in opening mouth. of submandibular salivary gland enlargement
• Excess salivation during meals/more pain
during meals/swelling become more Features of facial nerve palsy
prominent during meals. • Difficulty in chewing food as food accumu-
• Recent increase in size. lates in vestibule due to buccinator weakness
2. Examination • Deviation of angle of mouth while talking,
laughing, blowing, whistling due to
i. Inspection paralysis of orbicularis oris
• Swelling in detail.
• Failure of closure of eyelids or easy opening
• Deep lobe of parotid enlargement is checked
of the eyelids after closure – paralysis of
by inspecting the oral cavity for any bulge
orbicularis oculi
in the tonsil and lateral wall of pharynx.
• Absence of furrows while looking upwards–
• Stenson’s parotid duct should be inspected
opposite 2nd upper molar. paralysis of frontal belly of occipitofrontalis
• Skin over the swelling should be inspected. • Absence of corrugation in the forehead
during frowning – paralysis of corrugator
Features of parotid swelling supercilii
• Ear lobule raise • Deviation of angle of mouth towards
• Swelling in parotid region opposite side – paralysis of levator anguli
• Swelling occupying the groove between oris
posterior part of the mandible and mastoid • Loss of contraction of platysma in the neck
process while stretching the neck – paralysis of
• Moves upwards upto zygomatic bone— platysma
Curtain’s sign • Inability to blow the air by the check and
on palpation reduced tone of buccinator –
ii. Palpation paralysis of buccinator
• Tenderness/temperature/extent/size/ • Inability to whistle – paralysis of orbicularis
surface/consistency/mobility/fixity/plane oris
of the swelling/masseter involvement/facial
Proper diagnosis and investigations should
nerve involvement/skin over the swelling
be mentioned.
• Parotid duct palpation – by rolling the finger
across the masseter muscle while patient is
clinching the teeth to make masseter taut. Salivary Neoplasms
Terminal part of the duct is palpated Classification
bidigitally using index finger inside and a. Epithelial:
thumb outside. 1. Adenomas
• Palpation of oral cavity/bidigital examina- - Pleomorphic adenoma.
tion for deep lobe with one finger inside the - Monomorphic adenomas.
mouth behind the tonsillar fossa and the other • Adenolymphoma (Warthin’s tumour).
outside in parotid region. • Oxyphil adenomas.
Fig. 2.69: Deviation of angle of mouth towards opposite

side while clenching the teeth—paralysis of levator anguli
oris
A
B
Fig. 2.70: Loss of contraction of platysma in the neck Figs 2.72A and B: Palpation of deep
while stretching the neck—paralysis of platysma lobe of the gland
2. Carcinomas
- Mucoepidermoid carcinoma —
Commonest malignancy.
- Acinic cell carcinoma.
- Adenoid cystic carcinoma. — Very
aggressive.
- Adeno carcinoma.
- Squamous cell carcinoma.
- Carcinoma in ex. Pleomorphic
adenoma.
- Undifferentiated carcinoma.
b. Nonepithelial:
• Haemangioma - commonly seen in infants,
usually in parotids. Spontaneous
regression is common.
• Lymphangioma.
Fig. 2.71: Absence of corrugation in the forehead • Neurofibromas and neurilemmomas.
during frowning—paralysis of corrugator supercilii c. Malignant lymphomas.
A B C
Figs 2.73A to C: Failure of closure of eyelids or easily opening of the eyelids after closure—paralysis of
orbicularis oculi
Fig. 2.74: Inability to whistle—paralysis of

orbicularis oris
A B
Figs 2.75A and B: Checking the mobility and skin fixation of the parotid swelling
B B
Figs 2.76A and B: Stenson’s parotid duct should Figs 2.77A and B: Palpation of neck nodes—
be examined opposite 2nd upper molar submandibular and upper deep cervical
Incidence
• 75-80% salivary neoplasms are in the
parotids of which 80% are benign.
• 80% of these are pleomorphic adenomas.
• 15% of salivary tumours are in the submandi-
bular salivary gland. Of which 60% are benign.
• 95% of these are pleomorphic adenomas.
• 10% of salivary neoplasms are in the minor
salivary glands—palate, lips, cheeks, and
sublingual glands. Of these only 40% are
benign.
Pleomorphic Adenomas (Mixed salivary

tumour)
• Commonest of the salivary gland tumour.
• It is 80% common.
• More common in parotids.
• It is mesenchymal, myoepithelial and duct
reserve cell origin. Fig. 2.78: Facial nerve palsy
• There may not be any visible swelling in the

preauricular region.—Dumb bell tumour.
• This tumour is in relation to styloid process,
mandible, stylohyoid, styloglossus,
stylopharyngeus muscles.
Clinical Features
• 1:1 male to female ratio. 80% common
• Occurs in any age group. Usually unilateral.
• Present as a single painless, smooth, firm
lobulated, mobile swelling in front of the
Fig. 2.79: Parotid gland enlargement in young boy. parotid with positive curtain sign (As the deep
fascia is attached above to the zygomatic bone,
• Grossly: It contains cartilages, cystic spaces, it acts as a curtain, not allowing the parotid
solid tissues. swelling to move above that level. Any
• Histologically: It shows swelling superficial to the deep fascia will
- Epithelial cells.
move above the zygomatic bone).
- Myoepithelial cells.
• The ear lobule is lifted.
- Mucoid material with myxomatous
• When deep lobe is involved, swelling is
changes
commonly located in the lateral wall of
- Cartilages.
pharynx, posterior pillar and over the soft
• Eventhough it is capsulated, tumour may
palate.
come out as pseudopods and may extend
• Facial nerve is not involved.
beyond the main limit of the tumour tissue.
• Long standing pleomorphic adenoma may
When disease occurs in parotid, commonly
turn into carcinoma (carcinoma in pleomor-
it involves superficial lobe or superficial and
phic adenoma).
deep lobe together. But sometimes only deep
lobe is involved and then it presents as Its features are—
swelling in the lateral wall of the pharynx, – Recent increase in size.
soft palate and posterior pillar of the fauces. – Pain and nodularity.
– Involvement of skin.
– Involvement of masseter.
– Involvement facial nerve — Lower facial
nerve palsy –(Difficulty in closing eyelid,
difficulty in blowing and clenching teeth)
– Involvement of neck lymph node.
Investigations
• FNAC is very important and diagnostic.
• CT scan to know the status of deep lobe.
Treatment
• Surgery—1st line treatment.
• If only superficial lobe is involved, then
Fig. 2.80: Raised ear lobule is important superficial parotidectomy is done wherein
sign of parotid enlargement. parotid superficial to facial nerve is removed.
• If both lobes are involved, then total conser- Facial nerve involvement is rare or very late
vative parotidectomy is done by retaining in mucoepidermoid carcinoma of parotid.
facial nerve.
• Enucleation is avoided as the recurrence is Clinical Features
high. • Swelling in the salivary (parotid or submandi-
bular) region, slowly increasing in size,
Adenolymphoma (Warthin’s Tumour, eventually attaining a large size, which is
Papillary cystadenolymphomatosum) hard, nodular, often with involvement of skin
• It is a benign tumour that occurs only in and lymph nodes.
parotid, usually in the lower pole. • Facial nerve is usually not involved.
• Common in males. It is often bilateral.
• It is said to be due to trapping of jugular Adenoid Cystic Carcinoma
lymph sacs in parotid during developmental • It is common in minor salivary glands.
period. • It consists of myoepithelial cells and duct
• It composed of double layered of columnar epithelial cells with cribriform or lace like
epithelium, with papillary projections into appearance.
cystic spaces with lymphoid tissues in the • It involves facial nerve very early, spreads
stroma. through the perineural sheath and infiltrates
into the perineural tissues and bone marrow
Clinical Features over a long distance more proximally.
• It presents as a slow growing, smooth, soft, • It also invades periosteum and bone medulla
cystic, fluctuant swelling, in the lower pole, early and spreads extensively.
often bilateral, and is nontender. • Prognosis is poor.
• It is common in males. It is 10% common.
Acinic Cell Tumour
Investigations • It is a rare, slow growing tumour that occurs
• Adenolymphoma produces a ‘hot spot’ in almost always in parotid and is composed
99
Technetium pertechnetate scan—it is of cells alike serous acini. It is more common
diagnostic. in women. It occurs in adult and elderly.
• FNAC. • It can involve facial nerve or neck lymph
Adenolymphoma does not turn malignant. nodes.
• Clinically it is of variable consistency with
Treatment soft and cystic areas.
Superficial parotidectomy.
General Features of Malignant Salivary
Mucoepidermoid Tumour Tumours:
• It is the commonest malignant salivary gland • Fixation
tumour (in major salivary glands) • Resorption of adjacent bone
• It is slowly progressive, often attains a large • Pain and anaesthesia in the skin and
size, and spreads to neck lymph nodes. mucosa
• It contains malignant epidermoid and mucus • Muscle paralysis
secreting cells. • Skin involvement and nodularity
• Involvement of jaw and masticatory muscle.
Types • Nerve involvement (facial nerve in parotid
• Low grade. or hypoglossal nerve in submandibular
• High grade. salivary gland).
TNM staging of malignant salivary tumours

T — Tumour N —Lymph node
TX —Tumour cannot be assessed Nx —Nodes not assessed
T0 —No evidence of primary tumour N0 —Regional nodes not involved
T1 —Tumour <2 cm without extraparenchymal spread N1 —Single ipsilateral node <3 cm
T2 —Tumour 2-4 cm N2a —Single ipsilateral node 3-6 cm
T3 —Tumour 4-6 cm N2b —Multiple ipsilateral nodes < 6 cm
—or with extraparenchymal spread N2c —Bilateral or contralateral nodes
—but no facial nerve spread <6 cm
T4 —Tumour >6 cm N3 —Single node spread >6 cm
—or facial nerve spread M —Metastases
—or base of skull spread M0 —No blood spread
M1 —Blood spread present.
Submandibular salivary gland tumours: – Diagnosis is by FNAC of primary tumour

• Benign tumours commonly pleomorphic and of lymph nodes when involved, CT
adenomas are smooth, firm or hard, bidigitally scan and OPG.
palpable, without involving adjacent muscles – Treatment: Wide excision, with removal
or hypoglossal nerve or mandible bone. of adjacent muscle, soft tissues, and
– Diagnosis is by FNAC, Orthopantomo- mandible.
gram (OPG), and CT scan. – If lymph nodes are involved, block
– Excision of both superficial and deep lobes dissection of neck (Classical neck
of the gland is done. dissection) is done.
• Malignant tumours of submandibular
salivary gland: Management of Malignant
– They are hard, nodular, often fixed to skin, Salivary Tumours
muscles, hypoglossal nerve, and mandible. Specific Investigations
• FNAC.
• CT scan to see the deep lobe of the parotid;
to look for the involvement of bone, extension
into the base of the skull; relation of tumour
to internal carotid artery, styloid process etc.
• OPG
• Blood grouping and cross matching ; required
amount of blood is keep ready.
• FNAC of lymph node.
• MRI shows better soft tissue definition than
CT scan.
Sialogram is not useful in assessment of
tumour.
Fig. 2.81: Submandibular salivary gland tumour. Here
oral cavity should be examined for deep lobe (bidigitally Treatment
with one finger in the floor of the mouth); Wharton’s duct
In parotid:
(on either side of the frenulum of tongue); mandibular
bone for thickening; hypoglossal nerve and lingual nerve • Surgery: Radical parotidectomy is done which
palsy; neck nodes for spread. includes removal of both lobes of parotid,
soft tissues, part of the mandible with facial Indications for radiotherapy in malignant
nerve. salivary gland tumours
– Facial nerve is reconstructed using greater • All adenoid cystic and adenocarcinomas.
auricular nerve, or sural nerve. • T3 and T4 tumours
– Often lateral tarsorrhaphy or temporal • Recurrent tumours
sling reconstruction is done. • Poorly differentiate tumours
• Tumours with lymph node involvement
• As preoperative radiotherapy
• Recurrent benign pleomorphic adenomas
• Spillage during surgery in case of pleo
morphic adenomas.
Minor Salivary Gland Tumours

• It is 10% of salivary tumours.
• It is common in - palate (40%).
- lip
- cheek
Fig. 2.82: Facial nerve on table - sublingual glands.
look during parotidectomy • Palate is the commonest site.
• 10% are benign—commonly pleomorphic
Complications of surgery: adenomas.
1. Haemorrhage. • 90% are malignant—Commonly adenoid cystic
2. Infection. carcinomas.
3. Fistula. • They present as swelling with ulcer over the
4. Frey’s syndrome. summit.
5. Facial nerve palsy. • If it is malignant, then extension into the
• Postoperative radiotherapy is quiet useful to palate, maxilla, pterygoids can occur often
reduce the chances of relapse.Usually external with involvement of lymph node.
radiotherapy is given. It is given in all
carcinomas, but more useful in adenoid cystic Differential Diagnosis
and squamous cell carcinomas. Squamous cell carcinoma of oral cavity.
• Chemotherpy is also given. Drugs given here
depend on tumour type. Intrarterial chemo- Investigations
therapy is beneficial. 1. Incision biopsy.
• Preoperative radiotherapy is given in large 2. CT scan
tumours to reduce the size and make it better 3. X-ray maxilla.
operable. i.e. to down stage the disease. 4. FNAC of lymph node.
• If lymph nodes are involved, which is confirmed
by FNAC, radical neck dissection is done. Treatment
• Wide excision often with palatal excision or
In submandibular salivary gland: maxillectomy is done.
• Wide excision is done, with removal of • Reconstruction by dental plates, skin grafting,
mandible, and soft tissues around. If lymph or flaps are done.
nodes are involved, then block dissection of • Lymph node block dissection of the neck is
the neck is done. done if involved.
• Salivary gland tumours are usually benign Parotidectomy

in adult Types
• It is rare in children but when it occurs, 1. Superficial parotidectomy: It is the removal of
it is commonly malignant superficial lobe of the parotid (superficial to
• Clinical and FNAC are diagnostic methods facial nerve.). It is done in case of benign
• Open biopsy is contraindicated diseases of superficial lobe of the parotid.
• Sialogram is not useful in salivary tumours 2. Total conservative parotidectomy: It is done in
• CT or MRI are often needed benign diseases of parotid involving either
• Nerve should be preserved in benign lesions only deep lobe or both superficial and deep
• Nerve can be sacrificed to achieve clearance lobes. Here both lobes are removed with
in malignancies preservation of facial nerve.
3. Radical parotidectomy: Both lobes of parotid
Frey’s Syndrome (Auriculotemporal are removed along with facial nerve, fat,
Syndrome) fascia, muscles, and lymph nodes. It is done
• Occurs in 10% of cases. in case of carcinoma parotid. Later facial nerve
• It is due to injury to the auriculotemporal reconstruction is done using hypoglossal or
nerve, where in postganglionic parasympa- greater auricular nerve.
thetic fibres from the otic ganglion become
united to sympathetic nerves from the
superior cervical ganglion (Pseudosynapsis).
Causes
• Surgeries or accidental injuries to the parotid.
• Surgeries or accidental injuries to temporo-
mandibular joint.
Features
• Flushing, sweating, pain and hyperaesthesia
in the skin over the face innervated by the
auriculotemporal nerve, whenever salivation
is stimulated (i.e. during mastication).
• Condition causes real inconvenience to the
patient.
• Starch iodine test will show the area blue
Treatment Fig. 2.83: ’S’ shaped incision towards parotidectomy

• Initially conservative and reassurance. Most
of the time they recover. Complications of Parotidectomy
• Occasionally they require surgical division 1. Facial nerve injury.
of the tympanic branch of the glossopharyn- 2. Haemorrhage.
geal nerve below the round window of middle 3. Salivary fistulas.
ear (i.e. Intratympanic parasympathetic 4. Infection.
neurectomy, Jacobsen nerve). 5. Frey’s syndrome.
• Injection of botulinum toxin to the affected Conservative surgeries are becoming popular
skin for malignancy but they are not universally
• Antiperspirants like aluminium chloride accepted.
Cervical Rib Compression of C8 and T1 will cause tingling
Definition and numbness along its distribution, i.e. in the
• It is an extension of transverse process of little finger, medial side of hand and forearm.
C7 vertebra more than 2.5 cm (normal).
• Syndrome caused by it is called as cervical
Clinical Features
rib syndrome, thoracic inlet syndrome, thoracic
outlet syndrome, scalene syndrome. Majority of patients are asymptomatic.
• It is 0.46% common, common in females, more 1. Vascular manifestations:
frequently on right side. - Pain is due to ischaemia in the muscle. It
• It can be unilateral or bilateral; can be is more during work, exercise and is relieved
asymptomatic or symptomatic.
by rest.
Types • Roos test is raising the arm above the
1. Complete bony: Cervical rib is radio-opaque, shoulder. The side where cervical rib is
anteriorly ends over the first rib or manubrium. present, patient cannot continue and so
2. Fibrous: Cannot be demonstrated radio- drops the hand down.
logically. • EAST- Elevated arm stress test (Modified Roos
3. Combined: Partly bony partly fibrous. test): Arm is elevated above the shoulder,
4. Partial bony: With free end expanding as bony with elbow stretched fully. Rapid
mass.
movements of fingers will cause fatigue
Pathology on the side where cervical rib is present.
Cervical rib narrows the scalene triangle • Adson’s test: The hand is raised above after
(bounded by scalenus anterior, scalenus medius feeling the radial pulse. The patient is
and first thoracic rib below) asked to take a deep inspiration and turn
↓ the head to the same side. Any change
Compression of subclavian artery; in pulse, i.e. either becoming feeble or
C8 and T1 nerve roots due to cervical rib. absent is noted.
↓ • Modified Adson’s test is same as Adson’s,
Angulation of subclavian artery occurs but neck is turned towards the opposite
↓
side.
Causes constriction of artery at the site
- Wasting of thenar, hypothenar and forearm
where artery crosses the cervical rib
muscles.
↓
- Often digital gangrene.
‘Eddie’s current’ created in the blood flow causes
sudden release of pressure distal to the narrowing - Limb is colder and pallor than the opposite
↓ side.
Poststenotic dilatation due to spasm of vasa 2. Neurological features: is due to compression
vasorum of localized segment of the artery-Venturi of T1 and C8 causing tingling and numbness in
phenomenon the little finger, medial side of hand and forearm.
↓
Stasis of blood occur 3. Features in the neck:
↓ a. Hard, fixed, bony mass in the supraclavicular
Thrombosis →Embolus region.
↓ ↓ b. Palpable thrill above the clavicle in the
Features of ischaemia in the hand and subclavian artery.
forearm. Later digital gangrene occurs. c. Bruit on auscultation.
Differential Diagnosis Branchial Cyst

1. Cervical spondylosis—to differentiate, X-ray It arises from the remnants of second branchial
neck—lateral view should be taken. cleft. Normally 2nd, 3rd, 4th clefts disappear to
2. Carpal tunnel syndrome. form a smooth neck. Persistent 2nd cleft is called
3. Tumours or swellings compressing over the as cervical sinus which eventually gets sequestered
vessel or nerves in the neck. to form branchial cyst.
Investigations Features
• Chest X-ray PA-view and lateral view • Swelling in the neck beneath the anterior
including neck- only (radio-opaque) bony rib border of upper third of the sternomastoid
can be identified. muscle.
• It is smooth, soft, fluctuant, often transillu-
• Nerve conduction studies to confirm neuro-
minant.
logical compression and also to rule out
• It contains cholesterol crystals.
carpal tunnel syndrome or cervical spon-
• Histologically, it is lined by squamous epithe-
dylosis. lium.
• Arterial doppler of subclavian artery and of • Differential diagnosis: Cold abscess, lymph
the upper limb. cyst.
• Subclavian angiogram • It may get infected to form an abscess.
• FNAC shows cholesterol crystals.
Treatment
1. In symptomatic cervical rib without arterial Treatment
compression of subclavian artery, along with • Excision under G/A.
scalenotomy (cutting scalenus anterior Cyst is in relation to carotids, hypoglossal
muscle), extraperiosteal resection of cervical nerve, glossopharyngeal nerve, and spinal
rib with often resection of first rib is done accessory nerve, posterior belly of digastric
to increase the thoracoaxillary channel and and pharyngeal wall. Medially it is close to
so as to reduce RE compression. the posterior pillar of tonsils. During
2. In symptomatic cervical rib with significant dissection, all these structures should be taken
subclavian artery, compression of along with care off.
scalenotomy, extraperiosteal resection of
cervical rib, resection of first rib, subclavian Branchial Fistula
artery reconstruction with or without a graft • It is a persistent second branchial cleft with
has to be done. a communication outside to the exterior .It
3. Along with scalenotomy, extraperiosteal is commonly a congenital fistula. Occasio-
resection of cervical rib, resection of first rib, nally the condition is secondary to incised,
reconstruction of subclavian artery, cervical infected branchial cyst. Often it is bilateral.
• External orifice of the fistula is situated in the
sympathectomy has to be done to improve
lower third of the neck near the anterior border
the circulation to the ischaemic upper limb.
of the sternomastoid muscle. Internal orifice
is located on the anterior aspect of the posterior
Approaches pillar of the fauces, just behind the tonsils.
1. Supraclavicular approach: Mainly when Sometimes fistula ends internally as blind
there is need for vascular reconstruction. end. Track is lined by ciliated columnar
2. Transaxillary approach: Through axillary epithelium with patches of lymphoid tissues
crease, rib is approached and removed. beneath it, causing recurrent inflammation.
3. Thoracotomy approach. Discharge is mucoid or mucopurulent.
• Investigations: Discharge study, fistulogram. Treatment
• Treatment: Always surgery: Under G/A after Antibiotics has to be started.
passing a probe, fistula is excised across its Pharyngeal pouch is excised by an oblique neck
full length, upto its internal opening. Care incision (approach from neck). As there is
should be taken to safeguard carotids, jugular cricopharyngeal spasm, cricopharyngeal myotomy
vein, hypoglossal nerve, glossopharyngeal (i.e. cutting of cricopharyngeal circular muscle
nerve, and spinal accessory nerve. Track should fibres without opening mucosa) is done to prevent
be excised fully. the recurrence.
Pharyngeal Pouch Complications

• It is a protrusion of mucosa through Killian’s 1. Infection either mediastinitis or lung infection
dehiscence, a weak area of the posterior (Pneumonia or lung abscess).
pharyngeal wall between thyropharyngeus 2. Pharyngeal fistula.
3. Abscess in the neck.
(oblique fibres) and cricopharyngeus (transverse
fibres) of the inferior constrictor muscle of the
Laryngocele
pharynx.
• It is a unilateral narrow necked, air containing
• Imperfect relaxation of the cricopharyngeus
diverticulum resulting from herniation of
increases the pressure in the pharynx, mainly laryngeal mucosa.
during swallowing which leads to protrusion • It is situated in the anterior third of the
of mucosa through the Killian’s dehiscence laryngeal ventricle, between the false cords
causing pharyngeal pouch. The potrusion is and thyroid cartilage, herniates through the
usually towards left. thyrohyoid membrane.
• It occurs in professional trumpet players, glass
Stages blowers, and in people with chronic cough.
1. Small diverticulum. • Swelling in the neck in relation to larynx
2. Large, globular diverticulum causing regur- adjacent to thyrohyoid membrane which is
gitation, cough, dysphagia, respiratory smooth, soft, resonant and is more prominent
infection. while blowing.
3. Large pouch which is visible in the neck as • Infection is quite common in the sac of
a globular swelling often tender, smooth and laryngocele, leading to the blockade of
soft. They present with dysphagia, features opening of the sac causing an abscess.
of respiratory infection like pneumonia and • Pus often may be discharged into the pharynx
lung abscess, weight loss and cachexia. Pouch repeatedly.
may itself get infected and may form an • Diagnosis: Clinical features, X-ray neck,
abscess. Often the pouch descends downward laryngoscopy, CT scan.
and enters the superior mediastinum. • Treatment: Excision through neck incision.
Neck of the sac should be ligated.
Clinical Features Cystic Hygroma (Cavernous
• Pain, dysphagia, recurrent respiratory Lymphangioma)
infection, swelling in the neck on the left side • It is a cystic swelling due to sequestration
which is smooth, soft and tender. of a portion of jugular lymph sac from the
lymphatic system, during the developmental
Investigations period in utero.
• Barium swallow—lateral view shows pharyn- • Present during birth and so may cause
geal pouch. obstructed labour. Occasionally present in
• Chest X-ray shows pneumonia. early infancy.
Sites Treatment
1. Posterior triangle of the neck—commonest site. • Aspiration of the contents .Later once the sac
Eventually may extend upwards in the neck. or capsule gets thickened by fibrous tissue,
2. Cheek. it is excised.
3. Axilla. • When it causes respiratory obstruction,
4. Tongue—lymphangiogenetic macroglossia. aspiration and tracheostomy has to be done.
5. Groin. • Under proper antibiotics coverage, drainage
6. Mediastinum. of abscess is done. Later sac is excised
7. Often multiple sites.
Complications
Pathology 1. Respiratory distress.
It contains aggregation of cysts looking like soap
2. Infection → Abscess → Septicaemia.
bubbles. Cysts have mosaic appearance with larger
3. Surgery itself may cause torrential haemor-
cysts near the surface and smaller cysts in the
rhage.
deeper planes . Each cyst contains clear lymph
with endothelial lining.
Carotid Body Tumour (Potato Tumour,
Clinical Features Chemodectoma, Nonchromaffin Para-
• Swelling is present since birth in the posterior ganglioma)
triangle of neck causing obstructed labour. • It arises from the carotid body, which is
• Swelling is smooth, soft, fluctuant (cystic), located at the bifurcation of the carotid artery.
compressible, brilliantly transilluminant. • Cells of the carotid body are sensitive to the
• Swelling may rapidly increase in size causing changes in pH and temperature of the blood.
respiratory obstruction- dangerous sign. • They are commonly locally malignant
• It may get infected forming an abscess which tumours, but in 20% cases spread can occur
is a tender, warm, soft swelling. It may cause to the regional lymph nodes.
septicaemia which may be life-threatening. • Blood supply to the tumour is from external
carotid artery. Tumour does not secrete
epinephrine or any endocrine substances.
• They can be familial.
Clinical Features
• Usually unilateral, more common in middle
age.
• Swelling in the carotid region of the neck
which is smooth, firm, and pulsatile (due to
pulsatile vessel overlying its surface) and
moves only side to side but not in vertical
direction.
• Features of transient ischaemic attacks due
to compression over the carotids.
• Thrill may be felt and bruit may be heard.
Often tumour may extend into the cranial
cavity along the internal carotid artery as
Fig. 2.84: Cystic hygroma dumbbell tumour.
Investigations Differential diagnosis for neck lymph node
• Doppler. enlargement
• Angiogram to see the ‘tumour blush’. • Tuberculous lymphadenitis
• CT scan.
• Secondaries in lymph nodes
• No FNAC: No partial excision.
• HIV infection
Differential Diagnosis • Lymphomas
• Carotid aneurysm. • Chronic lymphatic leukaemia
• Soft tissue tumour [Sarcoma). • Nonspecific lymphadenitis
• Lymph node enlargement. • Infectious mononucleosis
• Sarcoidosis
Treatment
• If it is small, it can be excised easily as the Cold Abscess
tumour is in the adventitia. • It is due to tuberculosis. It is commonly
• When it is large, as commonly observed, observed in neck in relation to caseating
complete excision has to be done followed
by placing a vascular graft.
• Carotid body tumour is not radiosensitive.
Sternomastoid Tumour
• It is due to birth injury to the sternomastoid
muscle.
• It is a misnomer. It is not a tumour.
Pathogenesis
During child birth injury to sternomastoid muscle
causes haematoma in the muscle which gets
organized to form sternomastoid tumour.
Clinical Features
• It is seen in infants of 3-4 weeks age.
• Swelling in the sternomastoid muscle which
is smooth, hard, nontender and adherent to
the muscle.
• Chin pointing towards opposite side. Head
towards same side (Scoliosis capitis).
• In later age groups it causes hemifacial atrophy
due to less blood supply because of the
compressed external carotid artery by
sternomastoid tumour.
• Compensatory cervical scoliosis.
• Compensatory squint.
• Differential diagnosis: Other causes for
torticollis.
• Treatment: Division of the lower end of the
sternomastoid muscle or excision of the Fig. 2.85: Staging of tuberculous lymphadenitis
muscle.
tuberculous cervical lymphadenitis. It can • Investigations are—ESR, chest X-ray, FNAC

occur in relation to spine, like psoas abscess, shows epithelioid cells and Langhans’ giant
paraspinal region or any other area. In cells, X-ray spine
tuberculous lymphadenitis– there are five • Treatment–antitubercular drugs, nondepen-
stages – stage of lymphadenitis; stage of dent aspiration, nondependent incision and
matting; stage of cold abscess formation; stage drainage with closure of the wound without
of collar stud abscess formation and stage placing a drain.
of sinus formation. • Complications are—sinus formation, syste-
• Cold abscess does not show any signs of mic spread, secondary infection, resistance
acute inflammation. It will be soft, smooth, tuberculosis.
nontender well localized swelling. Relevant (Please refer chapter surgical pathology for detail)
lymph nodes, oral cavity/tonsils, cervical/
thoracic spines, lungs should be examined. Secondaries in Neck Lymph Nodes
Levels in Neck Nodes (Memorial Sloan–
Kettering cancer center leveling of neck
nodes).
Level I—Submandibular lymph nodes and
submental lymph nodes.
Level II—Lymph nodes in upper deep cervical
region. (It extends from base of skull to hyoid
bone and from lateral margin of sternothyroid
to posterior margin of sternomastoid muscle.
Level III—Lymph nodes in middle cervical region.
(From hyoid bone to omohyoid muscle or
cricothyroid membrane).
Level IV—Lymph nodes in lower cervical region.
A (From omohyoid muscle to clavicle).
Level V—Lymph nodes in posterior triangle
including supraclavicular region.
Level VI—Lymph nodes in the midline neck—
pretracheal and prelaryngeal.
Level VII—Lymph nodes in the mediastinum.
Common sites of primary

• Oral cavity, tongue, tonsils
• Salivary glands
• Pharynx—nasopharynx
• Larynx
• Oesophagus
• Lungs
B • GIT
Figs 2.86A and B: Cold abscess in a young girl. • Thyroid
Collar stud abscess in an old lady.
• It is commonly from squamous cell carcinoma, Features of Secondaries in Neck
but can be from adenocarcinoma, or • Nodular surface, hard, often fixed when it
melanoma. is advanced.
• Squamous cell carcinoma is mainly from oral • Secondaries from papillary carcinoma of thyroid
cavity, pharynx. can be soft, cystic and contains brownish
• Adenocarcinoma is usually from GIT, com- black fluid.
monly involving left supraclavicular lymph- • Secondaries can infiltrate into carotids,
nodes. sternomastoid, posterior vertebral muscles,
spinal accessory nerve (shrugging of
shoulder is affected), hypoglossal nerve
(tongue will deviate towards the same side),
cervical sympathetic chain (Horner’s
syndrome).
• Secondaries spread into adjascent soft tissues
and also to the skin causing fungation and
ulceration. Often because of tumour necrosis,
softer area develops in the hard node.
• In advanced cases tumour may infiltrate into
the major vessels like carotids, or branches
of external carotid artery causing torrential
haemorrhage.
A
Types of Secondaries in the Neck
1. Secondaries in the neck with known primary:
• Here secondaries are present and primary
has been identified clinically in the oral cavity,
pharynx, larynx, thyroid, or other areas.
• Biopsy from the primary and FNAC from the
secondaries has to be taken.
• Primary is treated accordingly either by
curative radiotherapy or by surgery (wide
excision).
• Secondaries when mobile are treated by
B radical lymph node block dissection in the
neck.
2. Secondaries in the neck with clinically unidentified
primary:
• Hard, neck lymph nodes are the secondaries,
but primary has not been identified clinically.
• FNAC of the neck node has to be done and
secondaries have to be confirmed .Then
search for the primary has to be done by
C various investigations.
Figs 2.87A to C: Different types of
They are:
secondaries in neck. a. Nasopharyngoscopy.
b. Laryngoscopy. Treatment
c. Oesophagoscopy. • Primary has to be treated depending on the
d. Bronchoscopy. site, either by wide excision (surgery) or by
e. Blind biopsies from the fossa of Rosen- curative radiotherapy. Then the secondaries
muller, lateral wall of pharynx, pyriform have to be treated.
fossa,larynx. • Secondaries when are mobile are treated by
f. FNAC of thyroid and suspected areas. radical neck dissection.
g. CT scan. • When fixed it is inoperable. Palliative external
Once the biopsy confirms the primary, it radiotherapy has to be given to palliate the
is treated either by surgery or by curative pain and to prevent the anticipated bleeding.
radiotherapy. • Sometimes initially, external radiotherapy has
Secondary in the neck is treated by radical to be given to downstage the disease so that
neck dissection. it becomes operable and later classical block
dissection can be done.
3. Secondaries in the neck with an occult primary:
• Here secondaries in the neck lymph nodes Types of Block Dissection
are confirmed by FNAC, but primary has not
been revealed by any available investigations. 1. Classic radical neck dissection:
• When all the investigations mentioned above It is resection of lymph nodes, fat, fascia,
are done do not show any evidence of sternomastoid muscle, strap muscles, internal
primary, only then it is called as occult primary. jugular vein, accessory nerve, submandibular
• Initially the secondaries in the neck are treated salivary gland, lower part of parotid - ‘en-block’
by radical neck dissection, then regular follow (Criles‘ operation).
up is done (at three monthly intervals) until Incision that is commonly made is Mc‘Fee
the primary reveals. incision which are two parallel incisions, one
• Once primary is revealed it is confirmed by at submandibular region, another at supracla-
vicular region. Blood supply of the flap remains
biopsy and treated accordingly, either by
intact and so healing will be better without flap
curative radiotherapy or by wide excision
necrosis.
depending on location of revealed primary.
• This type is usually less aggressive and has 2. Conservative functional block dissection:
got better prognosis. Primary branchiogenic (Modified radical neck dissection; MRND).
carcinoma may be a differential diagnosis for this. It is done only in selected cases where tumour
is very well-differentiated and less aggressive.
Investigations for Secondaries in Neck Structures preserved here are sternomastoid
1. FNAC of secondary. muscle, internal jugular vein and spinal
2. Biopsy from primary. accessory nerve.
3. Blind biopsies from suspected areas. • Only spinal accessory nerve is preserved—
4. Nasopharyngoscopy, laryngoscopy, bron- MRND type I.
choscopy, oesophagoscopy. • Acessory nerve and sternomastoid are
5. CT scan. preserved—MRND type II.
• Accessory nerve, sternomastoid and internal
Differential Diagnosis jugular veins are preserved—MRND type III.
1. Lymphomas. 3. Suprahyoid block
2. Tuberculous lymphadenitis. Only fat, fascia, lymph nodes, muscles,
3. Nonspecific lymphadenitis. submandibular salivary gland, with dissection
above the omohyoid muscle is done. Done only • It occurs in younger age group compared to
in selected individuals with well-differentiated carcinomas.
tumour and involvement of few submandibular • They can arise from bone (osteosarcoma) or
lymph nodes. ( Levels I,II, III are removed). from any soft tissues (soft tissue sarcomas).
4. Bilateral neck dissection: (Mesenchymal tissue).
Internal jugular vein has to be preserved on one • They are much more aggressive compared
side. Always the side where the vein is preserved to carcinomas.
is operated first. (If both the jugulars are ligated, • They are rapidly growing tumours with fleshy
cerebral congestion occurs leading to cerebral appearance.
oedema which is dangerous. During surgery if • They are not encapsulated but are having
it occurs, the patient has to be kept in propped pseudocapsule.
position; antibiotics, diuretics, steroids are given, • They spread through blood especially to lungs
repeated CSF taps are done to control the cerebral often also to other organs.
oedema). • Lymphatic spread is not common with
certain exceptions.
5. Commando operation (Combined mandibular • They are not radiosensitive.
dissection and neck dissection). • Main method of treatment is surgery, i.e. wide
It is en-block removal, which includes wide excision, amputation.
excision of primary tumour with hemimandibu-
• In inoperable cases debulking is the accepted
lectomy and neck block dissection (e.g. in tongue)
method of treatment.
• Chemotherapy is the adjuvant therapy.
Complications of block dissection
• Commonest sarcoma of bone is osteosarcoma.
• Haemorrhage
• Commonest soft tissue sarcoma is liposar-
• Infection
coma.
• Lymph ooze
• Usual clinical features are: Diffuse swelling
• Carotid blow out
which is smooth, hard, warm and very
vascular.
Other Treatment
Chemotherapy
Important features of sarcoma
• Drugs used are— Methotrexate, Vincristine,
• More aggressive
Bleomycin, Adriamycin.
• Rapidly spreading
• It can be given by intra-arterial route- through
• Not very much radiosensitive
external carotid artery. (Never through internal
• Blood spread
carotid as it will cause cerebral damage).
• Painless soft tissue mass is the presentation.
• Site of arterial catheter should be confirmed by
• Very vascular
Doppler and angiogram. Drug is usually
administered through an arterial pump. Other Soft tissue sarcoma
method is to increase the height of the drip stand • 1% of adult malignancy
to get a pressure above the level of the systolic • 15% of paediatric malignancies
pressure of the patient. (i.e. more than 13 ft). • Incidence
• Drugs can also be given IV or orally. – 35% occurs in lower limb (commonest
site)
SARCOMAS – 15% upper limb, 15% retroperitoneum
– 10% trunk, 10% viscera, 10 % other areas.
Features • Soft tissue tumour > 5 cm should be biopsied
• Sarcomas are much lesser in incidence in suspicious of sarcoma.
compared to carcinomas.
Aetiology • MRI is the investigation of choice as it

• Genetic determines the vascularity, relation to vessel
– Von-Recklinghausen disease and fascial planes.
– Gardner’s syndrome • Chest X-ray is done to look for secondaries.
– Tuberous sclerosis • CT chest is ideal to see early lung secondaries.
– Basal cell naevus syndrome It is done in all deep seated, high grade tumour
– Li-Fraumeni syndrome and tumour more than 5 cm in size.
• Chemicals—PVC, tetrachlorodibenzodioxin, • Angiogram may be required to find out the
arsenic tumour vascularity.
• Viral—HIV in Kaposi’s sarcoma. • Radionuclide scintigraphy (Gallium-67)
• Ionizing radiation—Malignant fibrous histio- • p-MRS (p-Magnetic Resonance Spectroscopy)
cytoma (p53) and FDG (Fluor-2-Deoxy Glucose) PET are
done to assess the metabolic activity of tumour.
Clinical Features of Soft Tissue Sarcoma
• Painless swelling of short duration with Incision biopsy for soft tissue sarcoma
progressive increase in size—soft tissue mass. • It is the ideal tool to conclude sarcoma
• Compression of adjacent structures histologically
• Smooth, hard, warm and vascular • Incision should be placed in such a way
• Features of secondaries in lung—cough, that it can be included in wide tumour
haemoptysis and chest pain. excision at later period
• Incision should be longitudinal in limbs
• Injury to vessels and nerves should be
avoided
• Flaps should not be undermined
• Adequate haemostasis is needed, as
tumours are vascular
• Immunohistochemistry and cytogenetics are
possible
FNAC is less useful for sarcomas. Core/

Trucut biopsy can be done but not equal to
incision biopsy.
Staging of the soft tissue tumour is done
depending on the tumour size, nodal status,
metastasis and histological grading of the tumour.
(GTNM staging).
Fig. 2.88: Chondrosarcoma leg. It was removed by
wide excision as a limb salvaging procedure Grading of sarcomas
Low Desmoid, dermatofibrosarcoma,
Investigations liposarcoma
• Incision biopsy is the main method of High Synovial, rhabdomyosarcoma,
diagnosis. angoisarcoma
Malignant fibrous histiocytoma,
• Excision biopsy is done if the tumour size
Extraosseous chondrosarcoma
is <3 cm. Undetermined Fibrosarcoma, leiomyosarcoma
• CT scan or MRI of the part to see the extent
and invasion.
TNM staging of soft tissue sarcoma

Grade (G) Tumour (T)
Gx Can not be assessed Tx Cannot be assessed
G1 Well-differentiated T0 No primary
G2 Moderately differentiated T1 Size < 5 cm or 5 cm (maximum dimension)
G3 Poorly differentiated T1a: Superficial T1b: Deep tumour
G4 Undifferentiated T2 Size > 5 cm
T2a: Superficial T2b: Deep tumour
Regional lymph nodes (N) Distant spread (M)
Nx Nodes cannot be assessed Mx Cannot be assessed
N0 No nodes M0 No distant spread
N1 Nodes present M1 Distant spread present
Note: Superficial tumour is outside the superficial fascia. Deep tumour is deep to superficial fascia or
any tumour invading the superficial fascia.
• Debulking surgery is useful in large advanced

Differential diagnosis for soft tissue sarcoma tumours like retroperitoneal sarcomas.
• Haematoma • Preoperative radiotherapy or chemotherapy
• Abscess followed by wide excision.
• Aneurysm • Postoperative radiotherapy is commonly
• Myositis used because of less tumour burden and less
wound problems. Titanium clips are placed
Treatment during surgery at high risk areas to identify
• Wide excision is the treatment of choice with the site to concentrate proper RT.
3-5 cm clearance with adequate depth. – Brachytherapy is very effective in local
• Compartment resection is a radical limb control of the tumour. Initially precise
saving procedure. Here muscle group of one mapping of the area is done in the
compartment (anterior, posterior or medial) operation theatre. Loading catheters are
is resected entirely from its origin to insertion placed in surgical field peroperatively.
with the tumour. It is done only when tumour Later these catheters are loaded with
is intracompartmental. It is not suitable when iridium 192.
tumour is extracompartmental or many – Permanent radioactive sources also can
compartments are involved or encased to be placed to the area.
major neurovascular bundle. – Palliative external radiotherapy can be
• Amputation is done in large tumours of upper given to prevent bleeding, fungation and
or lower limbs. to reduce pain in advanced cases. It is
also used in secondaries in brain, bone.
Indications for amputations in soft tissue • Primary radiotherapy alone (radical) is of less
sarcoma: beneficial in soft tissue sarcoma.
• Major neurovascular encasement • Chemotherapy drugs—VAC (Vincristine,
• Bone involvement Adriamycin, Cyclophosphamide) are commonly
• Multiple compartment involvement used. Other drugs ifosamide, dacarbazine are
• Limb itself is diseased like lymphoedema used in combination with above drugs. Mesna
• Recurrence with multicentricity. is used as a protection for haemorrhagic
cystitis. Chemotherapy is used when tumour
is more than 5 cm or high grade. Usually 1. History:

postoperative chemotherapy is given. Age—Epididymo-orchitis is common in younger
• Neoadjuvant chemotherapy is used to make the age group. Torsion testis is common in younger
primary tumour better operable. age group.
• Isolated limb perfusion using cytotoxic drugs and
Pain—It is important feature in scrotal swelling.
tumour necrosis factor with hyperthermia is
Pain may be in the testis, in the epididymis, in
also often used.
the vas deferens. In funiculitis, pain is in the
• Pulmonary metastasis can be treated with
groin. In tuberculosis which involves epididymis
wedge resection, segmentectomy, lobectomy,
(not commonly testis) pain is in groin. In torsion
pneumonectomy. Surgery is done only when
testis sudden pain is seen in scrotum which
primary is well-controlled. Radiotherapy and
radiates upwards towards umbilicus. It may
chemotherapy are also tried. More than 3
mimic appendicitis in right testicular torsion.
number metastases in lung signify poor
Dragging pain is seen in varicocele.
prognosis.
Swelling—Duration, progress, reducibility
Prognostic factors especially on lying down are important. Hernia
• Size >5 cm gets reduced on lying down. Varicocele also
• High grade disappears slowly in lying down. Scrotum may
• More than one compartment involvement. be empty in undescended testis and history of
• Deep tumours and multicentric swelling in the groin since childhood signifies
• Neurovascular invasion undescended testis.
• Lung secondaries
Fever—is often seen in acute epididymo-orchitis,
pyocele, and infected hydrocele.
Sarcomas which also spread through lymph
nodes 2. Local examination
• Synovial sarcoma
Inspection
• Lymphangiosarcoma
• It is done initially in standing position later
• Rhabdomyosarcoma—alveolar type
in lying down position.
• Ewing’s sarcoma
• Position and extent of the swelling above/
• Angoisarcoma
below.
• Epitheloid sarcoma
• Skin over the swelling.
• Carcinosarcoma of uterus
• Impulse on coughing should be checked for
hernia.
EXAMINATION OF SWELLING IN Palpation

• Position and extent is confirmed.
GROIN AND SCROTUM, AND • Impulse on coughing.
OTHER COMPLICATIONS • Warmness, tenderness, skin over the swelling
• Get above the swelling—in scrotal swelling one
Hydrocele can get above the swelling. Root of the scrotum
Hydrocele is a common disease seen in clinical is held between thumb in front and other
practice. It is usually kept as a short case in fingers behind. Cord structures are felt. If only
undergraduate clinical examination. It should cord structures are felt and not any other
be differentiated from hernia and other swellings structures like hernial sac or content that
in groin and scrotum. means one can get above the swelling. It is
purely scrotal. In hydrocele, it is possible to
get above the swelling. In hernia/ — Hydrocele is collection of fluid in the
inguinoscrotal swelling one can not get above scrotum between two layers of the tunica
the swelling. vaginalis testis. It can be primary
• Size, surface, consistency, margin of the idiopathic, secondary due to filarial
swelling. infection, trauma, tuberculosis, syphilis
or malignancy.
• Presence of scrotal oedema should be
— Hydrocele fluid is amber colored which
confirmed. contains water, salt, albumin and
• Fluctuation should be elicited. The scrotum fibrinogen. Fluid per se does not clot but
is fixed using hand and fingers, swelling is if comes in contact with the blood it gets
fixed and made prominent. With one index clotted.
finger one side of the swelling is pressed to — Primary vaginal hydrocele occurs in
indent and fluid movement is felt by the other middle age.
finger placed on the opposite direction. It — Hydrocele is smooth, soft, fluctuant and
should be repeated in diagonally often transilluminant. When root of the
scrotum is held only cord structures are
perpendicular direction. One should
felt, nothing else. There is no impulse on
remember that fluctuation should always be
coughing. It is by this method hydrocele
done in two directions (not in just one
is differentiated from inguinal hernia. In
direction). Hydrocele is fluctuant.
hernia one cannot get above the swelling
• Transillumination test –It is checked by lighting
and there is impulse on coughing.
a pen torch on side and front part of the
swelling side wards (not from behind as testis
prevents passage of light); illumination is
observed on opposite side in front using a
scotoscope. Often red glow is visible.
Hydrocele and epididymal cyst are
transilluminant.
• Reducibility—Hydrocele is not reducible
except congenital hydrocele which com-
municates into the peritoneal cavity.
• Palpation of testis—For size, surface, consis-
tency and testicular sensation. It is felt by
applying pressure sensation over the testis A
and patient feels sickening sensation in
epigastric region. It is absent in malignancy,
syphilis, leprosy, chronic haematocele.
• Palpation of epididymis/vas deferens/groin
lymph nodes are important.
• Palpation of epigastrium for para-aortic nodes
and supraclavicular region for lymph nodes
• Traction test – Apply traction on the testis
by holding it and pulling downwards. In
encysted hydrocele of the cord, mobility of
swelling gets restricted. B
• Opposite side examination.
Figs 2.89A and B: Hydrocele is scrotal swelling. Get
• Examination of abdomen and lungs are also above the swelling is the clinical method used to differentiate
equally important. from hernia.
A B
C D
Figs 2.90A to D: Hydrocele is usually transilluminant. Thickened dartos,
thick sac, infected fluid makes it nontransilluminant.
3. Types Secondary Hydrocele

• Vaginal hydrocele limits to only scrotum.
Causes
• Congenital hydrocele communicates to
Infection: Filariasis.
peritoneal cavity.
Tuberculosis of epididymis.
• Infantile hydrocele—Here tunica and
Syphilis.
processus vaginalis (hydrocele) are distended
Injury: Trauma, Postherniorrhaphy hydrocele
up to internal ring, but sac has no connection
Tumour: Malignancy.
with the general peritoneal cavity.
It is usually small, lax and testis is usually
• Encysted hydrocele of the cord— It is a
palpable (unlike primary hydrocele). Exception
smooth, oval, swelling associated with the
is secondary hydrocele due to filariasis.
spermatic cord. On gentle traction to the testis,
the swelling becomes less mobile (traction test). Filarial Hydrocele and Chylocele
• Hydrocele en bisac: (Bilocular hydrocele): • Occurs commonly in coastal region and in
• Hydrocele has got two intercommunicating and around the Equator.
sacs, one above and one below the neck of • Usually occurs after repeated attacks of filarial
the scrotum. epididymitis.
• Hydrocele is usually of large size and the • Skin, dartos, external spermatic fascia,
sac is thickened. internal spermatic fascia are incised.
• Fluid contains fat , rich in cholesterol, derived Bluish hydrocele sac is identified (i.e.
from ruptured lymph varix into the tunica. parietal layer of the tunica vaginalis of the
• It is often difficult to differentiate from primary testis).
hydrocele. Fluid is evacuated using trocar and
cannula. Sac is opened.
Complications of hydrocele • If the sac is small, thin and contains clear
• Infection fluid, either Lord’s plication ( i.e. tunica is
• Pyocele bunched into a ‘ruff’ by placing series
• Haematocele of multiple interrupted chromic catgut
• Atrophy of testis sutures so as to make the sac to form
• Infertility fibrous tissue) (it is relatively avasular
and so haematoma will not occur).
• Or evacuation and eversion of the sac behind
the testis (after eversion, everted sac is
sutured with chromic catgut by conti-
nuous sutures) is done.
• If the sac is thick, in large hydrocele and
chylocele, subtotal excision of the sac is done
(as tunica vaginalis is reflected on to the
cord structures and epididymis poste-
riorly, total excision leads to orchidectomy
with division of cord.).
• Aspiration must be avoided as much as possible
as it is only a temporary measure
(recurrence occurs very early) and chances
of haematocele, and infection are higher.
• A drain is placed near the root of the
scrotum on the lateral aspect because it
Fig. 2.91: Hydrocele–could be primary becomes the most dependent portion once
vaginal hydrocele
Treatment for Hydrocele: Surgery

1. Subtotal excision. Radical cure—Hydrocelec-
tomy.
2. Partial excision and eversion Jabouley’s
3. Evacuation and eversion.
4. Lord’s plication.
5. Sharma and Jowar’s procedure.
Procedure
• Under G/A or spinal or L/A, after cleaning
and draping, vertical incision of about 6-8
cm in length is made over the scrotum, Fig. 2.92: Hydrocele sac is blue in color.
anteriorly 1cm lateral to the median raphe. Content is amber coloured fluid.
scrotal support is given. Scrotal support • Swelling contains barley water like fluid which
is given to reduce the scrotal oedema for contains spermatozoa.
10 days. • It is soft, cystic and transilluminant. It is often
• Wound is closed in layers. considered by the patient like having
• Drain is removed in 48 hours. additional testis.
• Aspiration cytology confirms the diagnosis.
Complications of surgery • Treatment: It can be left alone. If it is large,
• Reactionary haemorrhage excision is done.
• Haematocele • Differential diagnosis: Epididymal cyst,
• Infection hydrocele.
• Pyocele
• Sinus formation Varicocele
• Recurrent hydrocele. • It is dilatation and tortuosity of the
pampiniform plexus of veins and so also the
Cyst of the Epididymis testicular veins. Normally there will be plenty
• It is due to the cystic degeneration of: of plexus of veins (pampiniform) in the scrotum,
1. Paradidymis (organ of Geraldes)—is the which all join together to form about 4-8 veins
commonest cause. in the inguinal canal. Above, in the abdominal
2. Appendix of the epididymis. cavity, in the posterior abdominal wall all join
3. Appendix of the testis to form a single testicular vein. On left side, it
4. The vas aberrans of Haller. drains into the left renal vein; on the right side
• Even though it is of congenital origin, it occurs it drains in to the inferior venacava.
in middle age. • Varicocele is common in tall, thin young men.
• It is tensely cystic, contains clear fluid. • More common on the left side, but often can
• They are often bilateral. be bilateral.
• They are aggregation of number of small cysts • Commonly it is idiopathic, may be due to
and so multiloculated. absence or incompetent valve at the junction of
• They feel like ‘bunch of tiny grapes’ situated left testicular vein and left renal vein causing
behind the body of the testis. inefficient drainage of blood.
• Because of numerous septae they are finely • Other reason is, due to perpendicular (right
tessellated and so are brilliantly transillumi- angle) entry of the left testicular vein into the
nant, appear like ‘chinese lantern pattern’. left renal vein.
• In left sided renal cell carcinoma, tumour
Differential Diagnosis proliferates into the left renal vein and blocks
• Spermatocele the entry of left testicular vein causing varicocele
• Encysted hydrocele of the cord. on left sided which is irreducible.
• Varicocele causes increased temperature in
Treatment the scrotum which depresses the spermato-
• Avoid excision as much as possible as it will genesis and so causes infertility (correctable
result in infertility due to blockage. infertility).
• In old age, excision can be done.
Clinical Features
Spermatocele • Swelling in the root of the scrotum.
• It is a unilocular acquired retention cyst derived • Dragging pain in the groin and scrotum.
from some portion of the sperm conducting • ‘Bag of worms’ feeling.
mechanism of the epididymis. It is situated • Impulse on coughing.
in the head of the epididymis, above and • On lying down it gets reduced (except in renal
behind the body of the testis. cell carcinoma).
Grading of Varicocele Pathology
I Small. 1. Infiltrating type occurs in a pre-existing
II Moderate. leuckoplakia.
III Large. 2. Papilliferous type eventually attains a large
IV Severely tortuous. size forming fungating foul smelling lesion
which often gets infected.
Differential Diagnosis 3. Ulcerative type
• Hydrocele. Glans penis is the commonest site (coronal
• Inguinal hernia. sulcus for basal cell carcinoma).
Investigations Spread
• Venous Doppler of the scrotum and groin. • Through lymphatics it spreads to the
• U/S abdomen to look for kidney. horizontal group of inguinal lymph nodes
• Semen analysis. which become nodular and hard. Lymph
nodes on both sides can get involved. Later
Treatment external iliac group are involved (above and
• Palamo’s operation — Supra inguinal extra on medial aspect of the inguinal ligament).
peritoneal ligation of the testicular vein. • Once inguinal lymph nodes are fixed it causes
• Inguinal approach: Easier and safer. severe excruciating pain and lymphoedema.
Fixed lymph node status indicates the
• Scrotal approach: In case of grade IV, veins
advancement of the disease. It may erode into
have to be excised through this approach.
the femoral vessels causing torrential
• Laparoscopic approach – Presently accepted
haemorrhage and death.
good approach.
• Carcinoma from penis and glans spread to
inguinal lymph nodes and then to external
Indications for Surgery iliac lymph nodes. From glans it also spreads
1. Pain to Cloquet lymph node which is located in
2. Oligospermia—Usually in 6-12 weeks oligo- femoral canal.
spermia improves very well and also the • Carcinoma from shaft of penis can spread
conception rate. directly to the external iliac lymph nodes.
• It spreads proximally to the body of penis
Carcinoma Penis causing induration.
It is commonly squamous cell carcinoma, but • Urethral meatus may get involved causing
melanoma, adenocarcinoma from Tyson’s gland, alteration in urinary stream. It is a locoregional
basal cell carcinoma and secondaries may also malignant disease.
occur. • Blood spread is rare.
Etiology Clinical Features

1. Chronic balanoposthitis. • In an adult, recent onset of phimosis should
2. Sexually transmitted diseases. arise the suspicion of carcinoma penis.
3. Leuchoplakia of glans. • Lesion is painless initially but later becomes
4. Long standing genital warts. painful due to secondary infection often
5. Paget’s disease of penis (Erythroplasia of accompanied by discharge which is foul
Querat is persistent rawness of glans penis). smelling, purulent and irritating.
• Altered urinary stream.
Circumcision during infancy confers total • Fungation and induration, often extending
immunity against carcinoma penis. into the body of penis.
• Partial amputation of penis with bilateral

inguinal block dissection is called as Young’s
operation.
• When scrotum is removed along with total
amputation of penis then it is called as Piersey
Gold operation.
• In early carcinoma prepuce, after
circumcision, curative radiotherapy using
penile mould is tried so as to retain the penis.
• In ilio-inguinal block dissection, inguinal
lymph nodes, external iliac lymph nodes, fat,
fascia in inguinal region, saphenous vein are
removed en-block.
• Primary inguinal block means block
dissection is done within 4 weeks of surgery
for primary lesion.
Fig. 2.93: Carcinoma penis. • Secondary inguinal block means block
dissection is done after 4 weeks of surgery
for primary lesion.
• Palpable hard, nodular inguinal lymph nodes
on both sides may be present. External iliac
Complications of inguinal block dissection
lymph nodes may be palpable.
• Haemorrhage
• Pain , oedema, tenderness, redness develops
• Lymphorrhoea
once infection occurs.
• Lymphoedema
• Infection
Investigations
• Flap necrosis common
• Edge biopsy from the lesion shows squamous
cell carcinoma with epithelial pearls. • Postoperative radiotherapy to inguinal region
Broder’s classification: Grading: is often given.
– Well-differentiated (75% epithelial pearls) • In advanced fixed inguinal lymph nodes
– Moderately differentiated (50-75%) palliative external radiotherapy is given to
– Undifferentiated (25-50%).
palliate pain and anticipated erosion into the
– Dedifferentiated < 25% keratin pearls.
femoral vessels.
• Only FNAC of lymph node. (No open biopsy
• Chemotherapeutic drugs are 5 FU, Bleomycin,
for lymph nodes).
Vincristine.
• U/S abdomen to see external iliac lymph
• Topical 5FU cream or Nd: YAG Laser photo-
nodes.
irradiation is useful in carcinoma in situ cases.
Treatment Prognosis
• If growth is involving only glans without
Stage I: Only glans and or prepuce are involved.
extending into the body of the penis, then
5-year survival is 90%.
partial amputation of penis is done.
• If induration extends into the body of penis Stage II: Body of penis 70%.
then total amputation of penis is done with
Stage III: Only inguinal lymph nodes are
perineal urethrostomy.
involved—50%.
• In case of mobile inguinal lymph nodes
bilateral inguinal block dissection is done. Stage III: With external iliac nodes 20%.
Stage IV: Fixed lymph nodes or scrotal extension
of primary tumour or distant spread: < 5%.
(Please refer chapter surgical pathology for detail)
Buschke-Lowenstein Tumour
It is verrucous carcinoma of penis (5-15%
common).
• It is a curable malignancy
• It is locally destructive, locally invasive
• It is often large, exophytic, dry, verrucae like
growth
• Neither spreads through lymphatics nor
blood.
• After biopsy and confirmation, surgical Fig. 2.94: Patient underwent earlier total amputation of
excision or partial amputation is the penis. Now he has developed secondaries in inguinal
treatment of choice lymph nodes which has ulcerated and fungated – advanced
• Radiotherapy should not be given. disease.
Surgical pathology is indeed important and

interesting aspect, to know how exactly a
diseased area looks like and also to think its
possible causes and prognosis. Specimen
should be sent properly, labeled with markers.
Suspected area should be marked. Whenever
nodes are removed it should be sent by mention-
ing in detail of its location and nature. In many
centers specimen moulds/keeping trays are used A
for particular organs. Detailed history and
clinical findings should be sent to the patho-
logists.
SPECIMEN OF APPENDIX
Commonest anatomical position of appendix is
retrocaecal (75%). Rarest site is preileal (1%).
Second common position is pelvic (21%).
Appendicitis is more common in white
races, young males, and in people with meat
rich intake.
It can be non-obstructive or obstructive type.
• Non obstructive type commonly responds to
drug treatment. But recurrent, non-obstructive B
type may eventually turn into obstructive type
of appendicitis. Gangrene and perforation is
initially rare in non-obstructive appendicitis.
• Obstructive type results in collection of pus
in the lumen and later infective thrombosis
of appendicular artery and gangrene –finally
leading to perforation and peritonitis. Usually
pneumoperitoneum will not occur in appen-
dicular perforation. Lumen of appendix is
narrow (1-3 mm) and so gets obstructed easily.
As there is no muscle layer in appendix
perforation is easier than other part of the
bowel. Children, old age, faecolith, laxative
C
abuse, diabetes mellitus, immunosuppression
and pelvic appendix are high risk factors for
perforation in appendicitis. Figs 3.1A to C: Specimen showing inflamed appendix
with mesoappendix. Appendix is distended and turgid.
Appendicular mass is initially treated with It is a cul de sac like structure with serosa and mesentery
Ochsner Sherren regime. After 6 weeks interval attached to it. In second picture perforated appendix is
appendicectomy is done. seen with areas of necrosis. Third picture shows mesentery
Commonest bacterium involved is Escherichia containing enlarged lymph nodes. After appendicectomy,
the specimen should always be sent for histology to find
coli. Others are anaerobic bacteria, enterococci, out the severity of inflammation and also to rule out carcinoid
bacteroides, etc. tumour.
Surgical Pathology 291
Faecolith, tumour (carcinoid, adenocarcinoma
SPECIMEN OF CARCINOMA
caecum), worms, fibrosis, are the aetiologies for
appendicitis. OF BREAST
Appendicitis may have different sequelae like
– resolution, fibrosis, gangrene, suppuration,
obstruction, perforation, peritonitis, mass
formation or abscess formation.
Alvardo scoring system is used using migrating
pain, anorexia, nausea and vomiting, tenderness
in right iliac fossa, rebound tenderness, elevated
temperature, leucocytosis, and shift to left with
neutrophilia.
SPECIMEN OF FIBROADENOMA
OF BREAST
A
A
B
Figs 3.3A and B: Specimen of breast showing nipple—
areolar complex with axillary dissected nodes. It is a
specimen of total mastectomy with axillary clearance.
Whitish un-encapsulated tumour is visible. It invades the
breast tissue all over. It is fibrous, whitish/grey in colour,
cut surface is concave and gritty in sensation. Axillary
nodes are seen in axillary dissection area.
SPECIMEN OF STOMACH
Benign Gastric Ulcer
• Johnson’s classification of gastric ulcer is Type
I – ulcer in the antrum; Type II—both gastric
B ulcer and duodenal ulcer; Type III – pre-
Figs 3.2A and B: Specimen of fibroadenoma of pyloric ulcer; Type IV – gastric ulcer in
breast—a benign tumour. proximal stomach or cardia.
Fig. 3.7: Specimen of stomach (identified by the mucosal

pattern and rugae) showing deep ulcer near lesser
curvature. Margin of the ulcer is clear, not everted with
gastric mucosal folds converging towards the base of
the ulcer. 95% of benign gastric ulcer occurs towards
lesser curve. Benign gastric ulcer is more common in
Fig. 3.4: Cut section of breast showing gritty whitish lesser curvature, as it takes more burden of passage
tumour area without any capsule surrounded by normal of food and so more of wear and tear. Benign gastric
breast tissue. It is scirrhous carcinoma of breast. ulcer is rare in greater curvature, fundus and cardia.
Histologically it shows spheroidal ductal malignant epithelial Histologically it shows destruction of epithelial lining;
cells with abundant fibrous stroma. Medullary carcinoma proliferation of margin; destruction of the part of the muscle
is soft, encephaloid, bulky showing malignant columnar layer; granulation tissue in the floor; infiltration with chronic
cells, with intense lymphocytic infiltration. inflammatory cells; endarteritis and fibrosis in the base.
Fig. 3.5: Resected mastectomy specimen showing carci-

noma involving nipple—areola complex with axillary
dissection.
Fig. 3.8: Specimen showing hour glass contracture

as a complication of benign gastric ulcer.
• Pain, periodicity, haematemesis, induction

of vomiting to relieve pain, normal appetite
but decreased weight are the features.
• Barium meal X-ray shows niche and notch
effect. Gastroscopy with biopsy is mandatory.
• Complications are—perforation; bleeding;
Fig. 3.6: Patey’s mastectomy specimen showing tumour
hour-glass contracture; tea-pot deformity;
with breast tissue, nipple-areolar complex, pectoralis minor malignant transformation and penetration
muscle and axillary dissected lymph nodes. into pancreas.
Benign gastric ulcer Malignant gastric ulcer

Mucosal folds Converging mucosal folds upto the margin Effacing mucosal folds
Site 95% lesser curve Greater curvature
Margin Regular margin Irregular margin
Floor Granulation tissue in floor Necrotic slough in floor
Edge Not everted; punched or sloping Everted edge
Surrounding area Normal surrounding area and rugae Surrounding area shows nodules,
Size and extent Small, deep up to part of muscle layer ulcers and irregularities
Large and deep
• Treatment is partial gastrectomy with

Billroth I gastroduodenostomy.
• Gastric ulcer > 3 cm is giant gastric ulcer.
It has got 6-23% chances of turning into
carcinoma.
Carcinoma Stomach
Fig. 3.10: Specimen of stomach showing thickening of

the wall of stomach at pylorus – might be causing
obstruction.
Fig. 3.11: Specimen of stomach showing large ulcero-

proliferative lesion in the stomach with raised and everted
edge.
wall of part of the stomach with loss of rugosity. Thickening Lauren’s classification:
is extending into serosa.
• Diffuse type—It has got poor prognosis. Linitis
plastica and ulcerative types are of diffuse
Pathology of Carcinoma of Stomach
variety. Common in blood group A individuals.
Classification: • Intestinal type—Has got favourable prognosis.
Gross types: Cauliflower type. Polypoid and superficial types are of intestinal
Ulcerative type. varieties. Common in H. pylori infection.
Leather-bottle (Linitis-plastica). • Others
Fig. 3.14: Ulcerative lesion with everted edge in the

gastrojejunostomy stoma. It usually occurs only after 15
years of gastrojejunostomy surgery.
pylorus—feature of carcinoma stomach. In Asian countries
pylorus is the commonest site. In western countries proximal
stomach is the commonest site.
Fig. 3.15: Carcinoma stomach ulcerative type.
Fig. 3.13: Specimen showing features of Linitis plastica It is being classified as (Japanese classification)
—a diffuse type of carcinoma stomach mainly involving
submucosa and deeper layer (mother of pearl appearance).
I. Protruded.
It carries poor prognosis. It is type IV gastric carcinoma. II. Superficial.
It may be generalized or localized. It is 7-10% common. III. Excavated.
It is also called as leather—bottle stomach.
b. Advanced gastric cancer is defined as
involvement of muscularis and or serosa with or
Depending on the depth of the lesion without any involvement of lymph nodes.
a. Early gastric cancer is defined as involvement Borrmann’s classification:
of mucosa and or submucosa only with or without I. Circumscribed, single, polypoid carcinoma
any involvement of lymph nodes. without ulceration.
• Mucinous.
• Signet ring type.
Histological types
Adenocarcinoma—commonest. It could be
intestinal (well differentiated), papillary, tubular/
glandular. It can be diffuse—poorly differentiated.
Mucinous or signet ring type can occur.
Aetiologies for gastric cancer
‘It is the captains of men of death’. It is more common
in Japan.
Risk factors:
• Familial—10%. Napolean and many members
of his family died of carcinoma stomach.
• Gastric mucosa of people with blood group‘
A’ is more susceptible for carcinogens.
• Gastric polyps.
Fig. 3.16: Japanese classification of early gastric cancer. • Pernicious anaemia—High-risk.
• Gastric remnant- 15 years after gastrectomy.
II. Ulcerated carcinoma, with elevated wall • Diet—High salt diet, food with more nitro-
and sharp border. samines increases the risk.
III. Carcinoma with partial ulceration, partial • Fruits and vegetables rich in Vit. C protect
diffuse spread with elevated margin. from carcinoma stomach.
IV. Diffuse carcinoma. • Chronic gastritis (Atrophic, Autoimmune).
• Gastric dysplasia.
• Smoking, Alcohol.
• Helicobacter pylori infection— Cag A strain—
high-risk.
• Agammaglobulinaemia—High-risk.
• Chronic benign gastric ulcer—risk is 0.1 to
1%. But it depends on size and chronicity
of the ulcer and based on that it may be as
high as 6-23%. Cancer developing in a
previous benign gastric ulcer is called as ulcer
cancer.
• Giant hyperplasia of gastric mucosal folds
Fig. 3.17: Borrmann’s classification of advanced
gastric cancer.
(Menetrier’s disease).
• Genetic factors—mutations of H ras oncogene
and over expression of c-erb B2 gene may
Ming's classification:
be involved in gastric cancers. APC gene
• Expanding.
involved in familial polyposis coli is also
• Infiltrative.
involved in 25 % of gastric cancers. Increased
WHO pathological classification incidence of gastric cancers are observed in
• Papillary. hereditary non polyposis colorectal cancer
• Tubular. (HNPCC).
TNM staging for gastric cancer (carcinoma

stomach)
T Tumour
T0 No primary tumour
Tis Carcinoma in situ
T1 Tumour involving mucosa and
submucosa
T2 Tumour invading muscularis propria
and subserosa
T3 Tumour invading the serosa but not
adjacent organs A
T4 Tumour invading the adjacent organs
N Nodes
N0 No regional nodes
N1 Spread up to 1-6 nodes
N2 Spread up to 7-15 nodes
N3 Spread more than 15 nodes
M Metastasis
M0 Metastasis not present
M1 Metastasis present
Intestinal metaplasia is of three types— B

Type I: Mature; goblet cells secret sialomucin. Figs 3.18A and B: Colectomy specimen showing
multiple polyps.
Type II: Cells in different levels of dedifferen-
tiation. Cells secrete sialomucin and an abnormal Peutz-Jegher’s Polyp
sialomucin (sulphomucin)—a small quantity. • It is common in small intestine (jejunum) but
can also occur in large intestine.
Type III: Marked dedifferentiation of cells,
• Features are multiple, familial, hamarto-
secreting mainly sulphomucin.
matous intestinal polyps.
• Associated with melanosis of the oral mucosa,
SPECIMEN OF COLON— lips and occasionally digits.
MULTIPLE POLYPOSIS OF COLON • Microscopically it contains tree like branching
filaments of mucosa with smooth muscle wall.
Classification of Intestinal Polyps • It rarely turns into malignancy.
a. Inflammatory. Complications: Bleeding or intussusception, when
b. Hyperplastic (Metaplastic). occurs requires surgery either resection—
c. Hamartomatous: Peutz-Jeghers‘ polyp, anastomosis or colonoscopic removal.
Juvenile polyp, Cronkhite Canada syndrome
d. Adenomatous: (Neoplastic). Adenoma of Colon
Tubular (Pedunculated), tubulovillous, • It can be tubular, villous, tubulo-villous.
villous (sessile), FAP. • It also can be solitary or multiple.
e. Others: Haemangioma. • They present with diarrhoea, mucus
Lipomas. discharge, hypokalaemia, bleeding.
• It is potentially a malignant condition. • Treatment—Total proctocolectomy with
Potentiality increase with– permanent colostomy or total proctocolectomy
– The size of the adenoma. with ileoanal anastomosis with ileal pouch is the
– Sessile nature. treatment of choice. Pouchitis is the common
– Villous architecture. problem in ileal pouch. Alternatively a
– Dysplasia. conservative total colectomy with ileo rectal
Any adenoma more than 5 mm should be anastomosis can be done, but with a regular
resected colonoscopically. Huge villous adenoma follow up with sigmoidoscopy for any rectal
may require open surgical removal. polyps. If polyps are present snaring of polyps
should be done. Sulindac (a NSAID) given
Familial Adenomatous Polyp (FAP) to these patients causes disappearance of
It is inherited as an autosomal dominant polyps in the rectum.
neoplastic condition. (Chromosome no.5- long
arm—APC gene). Gardner’s syndrome:
• Incidence is equal in both sex, commonly FAP association is 10%.
involving the large intestine but can also Presents with bone, skin, soft tissue and dental
occur in stomach, duodenum and small abnormalities. Jaw osteomas are very common.
intestine. Other features are epidermoid cysts (> 50%),
• It is familial with a high potential for malignant exostoses, fibromas, lipomas.
transformation. Associated with desmoid tumours seen in the
• It can be associated with duodenal or scar, abdomen, intra-abdominal region and
ampullary carcinomas, Gardner’s syndrome mesenteric fibromatosis.
(Desmoid tumour in the abdomen, osteomas Congenital hypertrophy of pigment layer of
(75%) and epidermoid cysts) and also Turcot’s retina (seen as pigment spots) – Commonly seen.
syndrome (FAP + brain tumour (medulloblas- Often associated with MEN II b syndrome.
toma or gliomas)—(autosomal recessive)). Turcot’s syndrome
• It presents in younger age group (15-20 years). • FAP
• Usually multiple (over 100). • Brain tumour—medulloblastoma/gliomas
• Presents with lower abdominal pain, loose • Autosomal recessive
stools with blood and mucus, weight loss.
• If there is no adenoma at the age of 30 years, Cronkhite-Canada syndrome
then it is not FAP of colon. Not genetically related
• If not treated chance of turning into Occurs in old age—60 years
malignancy is almost 100%. Mean age of Generalized GI polyposis—stomach and
cancer development is 40 years. colon
• Investigations are double contrast barium Nail dystrophy, alopecia
enema and colonoscopy guided biopsy. Skin hyperpigmentation
• Screening of all the members of the family is
a must. Looking for pigment spots in retina SPECIMEN OF COLON—
(CHIRPES) and DNA tests for F.A.P are good
screening methods, but cost and availability
ILEO CAECAL TUBERCULOSIS
limits its use. Screening by colonoscopy begins Abdominal tuberculosis is common in India and
at the age of 10 years and then yearly for developing countries. It is 6th most common type
up to the age of 20 years. If there are no polyps of extra pulmonary tuberculosis. Incidence of
at the age of 20, then colonoscopy is done abdominal tuberculosis and its severity is more
once in 5 years up to the age of 50 years. in patients infected with HIV.
4. Anorecto-sigmoidal: Present as fistula, fissure,

abscess, and mass.
5. Involvement of liver, spleen and other organs
as a part of miliary tuberculosis.
6. Tuberculosis of the omentum.
Note:
• Chronic peritoneal tuberculosis may be
associated with pleural effusion and
pericardial effusion.
• Tuberculosis is not common in stomach,
duodenum and jejunum.
• Diffuse tuberculous colitis is less commonly seen
and it mimics ulcerative colitis in every respect
even in colonoscopy. Patient recovers well
with antituberculous drugs.
• Intestinal tuberculosis is called as Koenig’s
syndrome (1892).
Ileocaecal Tuberculosis
Fig. 3.19: Specimen of ileum and caecum showing It is most common site of abdominal tuberculosis
multiple undermined ulcers—Tuberculous ulcers. due to presence of abundant Peyer’s patches and
stasis of luminal contents favored by ileo-caecal
Routes of infection in abdominal tuberculosis valve.
• Ingestion of infected sputum
• Blood spread Causative organism
• Direct spread Mycobacterium tuberculosis
• From lymph nodes through lymphatic Acid fast 20% H2SO4
channels Alcohol fast
• Through fallopian tubes Gram neutral
Types Histology
1. Intestinal Epithelioid cells—diagnostic
Ileo-caecal region; commonly observed— Langhans giant cells
Ulcerative (60%), hyperplastic, ulcero-hyper- Features of granuloma
plastic. Caseating necrosis
Ileal region; commonly observed—Stricture
type. It is presently due to Mycobacterium tuber-
2. Peritoneal tuberculosis— culosis, earlier used to be due to Mycobacterium
a. Acute. bovis. Mode of infection may be direct or blood
b. Chronic. spread, usually from lungs.
1. Ascitic type.
2. Encysted (loculated) type. Types of Ileocaecal Tuberculosis
3. Plastic (Fibrous/adhesive) type. • Ulcerative—commonest (60%). Circumferen-
4. Purulent type. tial, transverse, often multiple 'girdle' ulcers—
3. Tuberculosis of mesentery and its lymph nodes. with skip lesions.
• Hyperplastic (10%):Fibroblast reaction in Often ileocaecal TB can cause intestinal
submucosa and subserosa causing obstruction.
thickening of bowel wall and enlargement
Note: Abdominal pain (90%) is the most common
lymph node, leading to nodular mass
symptom—(dull colicky pain) colicky in
(tumour-like) formation. It is common in young
intestinal type; dull in mesenteric type.
individual; it is due to infection by less
virulent, less volume organism; in presence Investigations
of adequate host resistance. • Chest X-ray to find out primary focus.
• Ulcero-hyperplastic—30%—features of both • Mantoux test; ELISA; SAFA ( Soluble Antigen
Clinical features of ileocaecal tuberculosis Fluorescent Antibody) test; serum immuno-
• Anaemia, loss of weight and appetite. globulin assay.
• Diarrhoea—10-20%. • ESR is raised.
• Fever—50-70%. • Ultrasound abdomen to see ascites, caecal
• Mass in right iliac fossa, (35%) which is hard, thickening, nodal status and other organs.
nodular, non-mobile, nontender with • Plain X-ray abdomen, if presentation is of
impaired resonance, which may mimic intestinal obstruction. It often shows calcifi-
carcinoma caecum. Subacute obstruction can cation.
occur. • Anticord factor antibody analysis to
differentiate from Crohn’s disease.
Ileocaecal region is common site due to— Barium study X-ray (Enteroclysis followed
• Stasis of the content by barium enema or barium meal follow
• Abundant Peyer’s patches—organism gets through X-ray)
trapped easily 1. Increased transit time; flocculation of
• Contact time of bacteria with mucosa is barium—early sign
greater 2. Pulled up caecum and goose neck deformity
• M cells in Peyer’s patches phagocytose due to fibrosis, shortening and retraction
bacilli and transfer to host cells of the ascending colon and ileocaecal
• Liquid content in the region segment
• More absorption of fluid and electrolytes 3. Obtuse ileocaecal angle
here 4. Hurrying of barium due to rapid flow
(Stierlin’s sign) and lack of barium in
inflamed bowel
Differential diagnosis of ileocaecal 5. Narrow ileum with thickened ileocaecal
tuberculosis valve (Fleischner sign)(Inverted umbrella sign)
• Carcinoma caecum 6. Calcifications
• Amoeboma 7. Incompetent ileocaecal valve.
• Appendicular mass 8. Ulcers and strictures in the terminal ileum
• Ectopic kidney and caecum—Napkin lesions.
• Retroperitoneal tumour 9. String sign – persistent narrow stream with
• Lymph node mass proximal mega ileum
• Psoas abscess 10. Hypersegmentation of the intestine—
• Crohn’s disease chicken intestine
Ileocaecal tuberculosis can be associated with • Colonoscopy is of value to rule out carcinoma.
adeno carcinoma of caecum, or large bowel It is easiest and most direct method in
lymphoma or HIV. establishing the diagnosis.
• Laparoscopy is very useful method of • Hepatosplenomegaly

investigation. Biopsy can be taken from • Lymph nodal enlargement - matted
omentum, peritoneum, nodes and suspected • Pseudokidney sign
areas. Ascitic fluid can be collected for
analysis. CT findings in abdominal tuberculosis
• Abdominal CT scan is better and more • Performed after oral diluted barium – CT
reliable. Very useful. enteroclysis; intravenous water soluble dye
• PCR assay of endoscopically biopsied tissue also injected to get still better contrast
or of ascitic fluid. • Diagnostic yield is as equal as barium study
• Stool culture for AFB. • Thickening of bowel wall, its site, extent
• Blind percutaneous needle peritoneal biopsy and severity
using Cope’s/Abraham’s needle is also • Thickening of ileocaecal valve
practiced. • Mesenteric nodes; mesenteric thickening
• Capsule endoscopy to see small bowel. • Adhesions, ascites, obstruction
• Transabdominal peritoneoscopy using • Peritoneal nodules—multiple
regular endoscope (gastroscope) and biopsy. • Solid organ granulomas
• Ascitic tap fluid analysis. • CT guided FNAC is possible
Ascitic fluid in abdominal tuberculosis Treatment
• Exudative with protein level > 2.5 d g/dl; • Anti-tuberculous drugs—INH, Rifampicin,
specific gravity more than 1.016 Ethambutol, Pyrazinamide is started.
• Serum-ascitic fluid albumin gradient is • During the period of treatment, patient might
< 1.1 go in for intestinal obstruction due to fibrosis
• Lymphocyte predominant cells with count and stricture formation. So ideally after
as high as 4000/mm3 ( > 250 . cu mm) 3 weeks of starting of ATD, often limited ileo-
• Glucose < 30 mg% caecal resection with 5 cm normal adjacent gut
• AFB in ascitic fluid is seen in only < 3% or segmental resection is done; rarely hemicolec-
cases tomy is required.
• ADA (Adenosine De-aminase) activity in • Occasionally ileo-transverse anastomosis is
ascitic fluid (95% specificity and 98% done to bypass the caecal region. But this
sensitivity) is not a good surgery compared to resection,
as tuberculous focus is still retained.
Ultrasound features observed in abdominal • Stricturoplasty is also very useful procedure.
tuberculosis
• Thickened bowel wall, mesentery, omentum,
and peritoneum Complications of abdominal/ileocaecal
• Loculated ascites with fine septae within tuberculosis
• Interloop ascites with alternate echogenic • Obstruction
and echofree areas—Club-sandwich appea- • Malabsorption, blind loop syndrome.
rance • Dissemination of tuberculosis to other areas
• Bowel loop radiates from its mesenteric of abdomen as well as extra abdominal sites
root—Stellate sign • Faecal fistula
• Mesenteric thickness more than 15 mm • Cold abscess formation.
concentric and uniform thickening in tuber- • Haemorrhage, perforation (rare)
culosis whereas in Crohn’s mesentery is • Note: Perforation is rare in GIT tuberculosis
eccentric but can occur
Differences between ulcerative and hyperplastic types of ileocaecal tuberculosis
Ulcerative type Hyperplastic type
1. Secondary to pulmonary tuberculosis 1. Primary GIT tuberculosis, could be due to
bovine bacilli
2. Virulent organism 2. Less virulent organism
3. Poor body resistance, old people 3. Good body resistance, young individual
4. Multiple transverse ulcers commonly 4. Chronic granulomatous lesion in the ileo-
in the ileum, often in the caecum region caecal region
5. Clinically presents with diarrhoea, 5. Presents as a mass in right iliac fossa
bleeding P/R, loss of appetite and
reduced weight
6. Complications: Stricture, intestinal 6. Complication: Subacute intestinal
obstruction obstruction
7. Chest X-ray shows primary lesion 7. No primary lesion in chest X-ray
8. Barium study shows ileal strictures 8. Barium study—Pulled up caecum, obtuse
with hypermotility ileocaecal angle
Ileal tuberculosis looking like abdominal cocoon. It may precipi-

• It is usually stricture type tate intestinal obstruction.
• It may be multiple • Multiple dense adhesions between bowel
• It usually presents with intestinal obstruc- loops; between bowel and peritoneum and
tion omentum.
• Bowel adhesion, localization, fibrosis, • Thickening of bowel wall with adhesions
secondary infections are quiet common • Infection may be from blood, contiguous
• Perforation though rare culminates in spread or from fallopian tubes
peritonitis
• Plain X-ray shows multiple air fluid levels. Types of Peritoneal Tuberculosis
• Treatment is resection and anastomosis and to
Acute type—mimics acute abdomen.
continue anti TB drugs
Exploratory laparotomy reveals straw-colored
Often stricturoplasty is beneficial
fluid with tubercles in the peritoneum, greater
omentum and bowel wall. It is an on-table
Peritoneal Tuberculosis
diagnosis. Fluid is evacuated and collected for
• Post-primary.
AFB study and culture. Omental biopsy is taken.
• Becoming more common.
Abdomen is closed (without a drain) with
• Activation of long-standing latent focus.
tension sutures to prevent burst abdomen. ATD
• Blood spread.
is started.
• Can develop from diseased mesenteric lymph
node, intestine or fallopian tubes.
Acute peritoneal tuberculosis
Pathology in Peritoneal Tuberculosis • Rare
• Enormous thickening of the parietal perito- • On-table diagnosis
neum with multiple tiny yellowish tubercles. • Features of peritonitis
• Dense adhesions involving peritoneum and • Due to perforation, or rupture of mesenteric
omentum with small bowel as content inside tuberculous lymph nodes
Chronic type: Tuberculous peritonitis. • They get recurrent colicky abdominal pain,
Present as abdominal pain, fever, ascites, loss diarrhoea, wasting, and loss of weight, mass
of weight and appetite, abdominal mass, doughy abdomen, and doughy abdomen.
abdomen (10%). Peritoneum is thickened with • Differential diagnosis: Peritoneal carcinoma-
multiple tubercles. Omentum is thick, fibrosed, tosis. Open/laparoscopic peritoneal biopsy
rolled up. is very useful tool to diagnose.
Infection is usually from mesenteric lymph • They respond well for drug treatment. Surgery
nodes, ileocaecal tuberculosis, from fallopian is indicated if obstruction occurs.
tubes rarely blood born (from lungs). Purulent form
Diagnostic laparoscopy is very useful. • It is invariably due to tuberculous salpingitis,
Ascitic form presenting as a mass in the lower abdomen
• Ascitic form shows enormous distension of containing pus, omentum, and fallopian
abdomen with dilated veins. tubes, small and large bowel.
• It presents with congenital hydrocele in male • Cold abscess gets adherent to the abdominal
with patent processus vaginalis, umbilical wall, umbilicus and may form an umbilical
hernia, rolled up omentum, shifting dullness, fistula.
fluid thrill, and mass abdomen. • Patient commonly has got genitourinary
• Ascitic tap reveals straw colored fluid from tuberculosis.
• Ultrasound, discharge study, X-ray abdomen
which AFB can be isolated. Fluid is pale
and other investigations are useful.
yellow, clear, rich in lymphocytes, with high
• Treatment: ATD’s are started; exploration of
specific gravity.
umbilicus, exploration of fistula and bowel
• Chest X-ray, Mantoux tests are other required
by pass is done.
investigations to be done.
• Prognosis is poor in this type.
• ATD’s for one year is required. Repeat tapping
may be initially required as part of the
Tuberculous Mesenteric Lymphadenitis
treatment. • Infection is usually through the Peyer’s
Encysted (Loculated) Ascites patches of the intestine (i.e. through oral
• Ascites gets loculated because of the fibrinous cavity). Usually several lymph nodes are
deposition. involved often causing massive lymph node
• Dullness, which is not shifting, is the typical enlargement. Commonly right-sided lymph
feature. nodes are involved, but left sided nodes can
• They may present as intra abdominal mass, also get involved.
which may mimic ovarian cyst, retroperito- • It presents with general symptoms (fever,
neal cyst or mesenteric cyst. malaise, weight loss).
• Treatment is ultrasound guided aspiration • Pain in umbilical region and right iliac fossa,
along with ATD’s. mass in right iliac fossa, which is matted,
nonmobile.
Plastic type • It may present with features of acute
• Here there are wide spread adhesions between appendicitis.
the coils of the intestine (ileum commonly), • Often coils of intestine get adherent to the
abdominal wall, omentum, with distension caseated mesenteric lymph nodes leading to
of the small bowel, leading to blind loop, intestinal obstruction.
ileus, intestinal obstruction (subacute, acute), • Most often caseating material may collect
thickened parietal peritoneum. between the layers of the mesentery, forming
a cold abscess, mimicking a mesenteric cyst
(Pseudo-mesenteric cyst).
• Massive enlargement of mesenteric lymph
nodes due to tuberculosis is called as tabes
mesenterica.
Presentations of mesenteric tuberculous

lymphadenitis
• Mesenteric tuberculous adenitis—acute/
chronic in right iliac fossa
• Pseudomesenteric cyst
• Cold abscess within the mesentery
• Tabes mesenterica
Tuberculosis of the omentum

• It usually occurs as a part of the other types
of abdominal tuberculosis
• Rolled up omentum with thickening is
characteristic
• Often cold abscess can develop per se in
the omentum
If it is so it can be dealt with laparoscopy
safely under the cover of ATD’s.
SPECIMEN OF INTESTINE
SHOWING CROHN’S DISEASE
Fig. 3.20: Speimen showing features of Crohn’s
It is a granulomatous, noncaseating inflam- regional enteritis.
matory condition of the ileum commonly and
of the colon often. Mesentery is thickened, oedematous, with
enlarged lymph glands which will never break
Aetiology nor calcify.
Unknown, but a familial and infective nature Rarely jejunum, stomach and other parts of
is thought of. GIT are involved. In colon, it is commonly
observed in caecum and ascending colon.
Clinical Features
a. Acute presentations: (5%) of Crohn’s disease
mimics acute appendicitis with severe
diarrhoea. Often there will be localized or
diffuse peritonitis.
b. Chronic Crohn’s
• First stage - Mild diarrhoea, colicky pain, fever
and tender, firm, nonmobile mass in right
iliac fossa with recurrent perianal abscess.
• Second stage is either acute or chronic Complications of Crohn’s

intestinal obstruction due to cicatrisation • Intestinal obstruction
with narrowing. • Stricture
• Third stage - Fistula formation - enterocolic, • Bleeding
enteroenteric, enterovesical, entero- • Fistula formation
cutaneous, etc. • Carcinoma
• Perianal abscess
Crohn’s disease is independent of age, sex, • Peritonitis
social and economic status and geographic area. • Pericolic abscess
It is often familial.
It is pre-cancerous condition but not as much as Differential Diagnosis
ulcerative colitis. • Intestinal tuberculosis.
• Carcinoma ileum or caecum.
Investigations • Differential diagnosis for mass in the right
iliac fossa (carcinoma caecum, actinomycosis,
Barium meal follow through shows appendicular mass, ileocaecal TB, ectopic kidney,
• Straightening of valvulae conniventes mesenteric lymphadenitis, etc).
• Multiple defects (cobble-stone appearance)
• Cicatrisation of ileum (string sign of Kantor)
• Rose thorn appearance of the bowel wall SPECIMEN OF COLON—
Radiologically Crohn’s disease is classified ULCERATIVE COLITIS
as non-stenosing type or stenosing type
An inflammatory condition of rectum and colon
Treatment of unknown etiology perhaps related to stress,
westernized diet, autoimmune factor, familial
Medical tendency, allergic factor.
• Bed rest, high protein diet, vitamin supple-
ment.
• Antibiotics—Sulphathalidine; Salazopyrine
• Steroids, azathioprine.
Surgery
Indications
Failure of medical treatment.
Intestinal obstruction.
Fistula formation.
Surgeries:
• Right hemicolectomy (Common procedure
done because commonly ileocaecal region is
involved).
• Segmental resection.
• Total colectomy and ileo-rectal anastomosis.
• Stricturoplasty.
• Temporary ileostomy.
Per se appendicectomy should not be done Fig. 3.21: Specimen showing multiple pseudopolyps
in Crohn’s , as it may lead on to external fistula. in the colon—a typical featutre of ulcerative colitis.
Disease commonly starts in the rectum, b. Chronic type (95%) Lasts for months and years
spreads proximally to the colon and often into with diarrhoea, blood loss, anaemia, invali-
the ileum as back wash ileitis. dism, abdominal discomfort and pain.
Pathology Investigations
• Barium enema - shows loss of haustrations,
narrow contracted colon (hose pipe colon),
mucosal changes, and pseudo polyps. It is
avoided in fulminant cases.
• Sigmoidoscopy and biopsy.
• Colonoscopy also is required.
Due to very high incidence of malignant
transformation in ulcerative colitis (10-20%),
multiple biopsies should be taken from suspected
areas of the colon. Risk increases with age of the
patient and duration of the disease (20%).
Complications
1. Pseudopolyposis
2. Turning into malignancy
3. Stricture formation commonly in recto
sigmoid and anal canal
Clinical Features 4. Toxic megacolon in transverse colon
• More common in females, begins in 3rd 5. Massive haemorrhage
decade. 6. Fistula in ano, piles
• Watery diarrhoea, mucus or blood stained 7. Liver cirrhosis (50%)
discharge per rectum. 8. Skin lesions
• Colicky pain, spasms. 9. Arthritis; iritis, ankylosing spondylitis
• Decreased appetite and loss of weight. 10. Sclerosing cholangitis, carcinoma of gall
• Relapses and remissions at regular intervals. bladder.
Presentation Treatment
Two types of presentations: • General: Fluid and electrolyte supplimen-
a. Fulminant type 5% common. tation.
• It is a severe form, with continuous diarrhoea • Nutrition (high protein, carbohyhrate,
with passage of blood, mucus and pus. vitamin, but low fat).
• Patient is ill and dehydrated. • Sedatives and tranquillizers.
• Mimics fulminant amoebic colitis; severe • Drugs: Salazopyrine; Sulphathalazine;
typhoid and dysentery. Steroids (as retention enema and systemic
• Abdominal distension occurs. therapy).
• May go for acute toxic dilatation (1.5%) in • Mebeverine HCl (Colospa).
transverse colon where in the diameter of
transverse colon > 6 cm. It has high mortality Indications for Surgery
and requires emergency surgery i.e. either • Toxic dilatation.
colostomy or resection with ileostomy and • Perforation.
later ileo-anal anastomosis. • Haemorrhage.
• Risk of malignant transformation.

• Early age group onset.
• Chronic invalidism.
Surgeries
1. Total procto-colectomy with ileoanal anastomosis
with pouches as reservoir (‘J’, ’S’, or ‘W’
pouches).
2. Total proctocolectomy with ileostomy
(permanent).
3. Total colectomy with colorectal anastomosis.
Proper follow up at regular intervals by
regular sigmoidoscopy evaluation should be
Fig. 3.23: Specimen of
done as rectum is also diseased and caecum, ascending colon,
vulnerable for complications. ileum showing large
proliferative lesion with
narrowing feature of
SPECIMEN OF COLON carcinoma colon.
Carcinoma Colon
Adeno carcinoma—commonest type.
Sigmoid colon (21%) is the commonest site
of malignancy after rectum (38%).
In caecum it is 12% common.
Gross types: Annular; Tubular; Ulcerative;
Cauliflower like. Fig. 3.24: Specimen showing growth in the
transverse colon with narrowing.
Annular (Stenosing) Type

It is more common on left side. Here the growth
spreads round the internal wall and so it often
presents with intestinal obstruction.
Fig. 3.25: Specimen of descen-

ding colon showing small pro-
liferative tumor—carcinoma
Fig. 3.22: Specimen of ascending colon, caecum, ileum colon. Usually it is of constrictive
and appendix – right hemicolectomy specimen. It shows type with obstructive presen-
proliferative localized lesion in the caecum. tation.
Ulcerative Type cancer. Cholesterol increases the bile acid
It is common on right side. Anaemia, loss of concentration in the intestinal lumen which
appetite and mass in right iliac fossa are the acts as cocarcinogen. High fiber diet protects
presentations. the colon against cancer.
• Genetic: Carcinoma colon is more common
Histology in individuals with adenoma colon or with
It is commonly adenocarcinoma. Rarely adeno- familial adenomatous polyposis (FAP).
squamous, and squamous carcinoma can occur. • Long standing ulcerative colitis – risk is 1%
Aetiologies of Carcinoma Colon per year after 10 years of onset of the disease.
• Diet: Frequent intake of red meat and satu- • Alcohol and cigarette smoking increases the
rated fat increases the incidence of colonic risk.
Staging of carcinoma colon

DUKE’S Astler—Coller’s
A. Confined to bowel wall, mucosa and A. Intramucosal
submucosa B1 Involvement up to muscularis propria
B. Extends across the bowel wall to the B2 Spread through the wall in to peritoneum
muscularis propria with no lymph nodes C1 B1 + Involvement of lymph nodes
involved C2 B2 + Involvement of lymph nodes
C. Lymph nodes are involved D Distant spread
Modified Duke’s TNM staging
A Growth limited to rectal wall Tis Carcinoma in situ
B Growth extending in to extra-rectal T1 Submuosal invasion
tissues but no lymph node spread T2 Muscularis invasion
B1 Invading muscularis mucosa T3 Invasion into pericolic fat
B2 Invading in to or through the serosa T4 Extraserosal involvement/adjacent
C Lymph node secondaries organs
D Distant spread to liver, lungs, bone, and N0 No nodes
brain N1 Up to 3 nodes
N2 4 or more nodes
M0 No metastasis
M1 Metastasis present
LVR staging
L Lymphatic vessel invasion
L0 Lymphatic vessel not involved
L1 Lymphatic vessel involved
V—Venous invasion
V0 No venous invasion
V1 Venous invasion present
R—Residual tumor after surgery
R0 Residual tumour not present
R1 Resected tumour margin is positive or
residual tumour is present
Hereditary Nonpolyposis Colonic Cancer

(HNCC)
• Autosomal dominant.
• No polyps.
• Three members of the family have colonic
cancers.
• Two first degree relatives have the same
cancer.
• Two consecutive generations observed.
• One relative, less than 50 years age will have
colonic cancer.
• Lynch syndrome I is site specific; commonly
on right side colon; 40% are metachronous;
early age onset is common.
• Lynch syndrome II has associated other
malignancies in stomach, breast, ovary,
endometrium and urinary bladder. It is cancer
family syndrome. A B
Note: Aspirin and other NSAID’s protect against Figs 3.26A and B: Specimen showing rectum, anal canal
colonic cancer. and sigmoid – (after Abdominoperineal resection/APR)
with ulceroproliferative/proliferative growth in the rectum.
Types Note the lower part of anal skin. Patient needs permanent
• Patient can have denovo, multiple, primary end colostomy in left iliac fossa. Digital examination of
the rectum (P/R) is the important method of diagnosis
carcinomas in different parts of the colon at
(90%). Aetiology, clinical features are similar to carcinoma
same time, i.e. synchronous (5%). colon. Rectal carcinoma is more common in females.
• Patient can present with growth in different It commonly begins as adenoma rectum. Villous adenoma
parts of the colon in different periods i.e. and adenomas of size more than 4 cm is likely to turn
metachronous (2-5%). into malignancy. Growth spreads to pararectal tissues,
sacrum and sacral nerves, prostate and urinary bladder
in males, uterus and vagina in females. It spreads to
SPECIMEN OF CARCINOMA pararectal/midrectal nodes when growth is in lower rectum;
to colonic and mesenteric nodes when growth is in upper
RECTUM rectum above the peritoneal reflection; to inguinal nodes
See Figures 3.26A and B. if growth is extending into anal canal. Through blood it
can spread into liver, lungs, brain, bones and adrenals.
Colloid carcinoma with signet ring is common in rectum
SPECIMEN OF CARCINOMA (12%). It carries poor prognosis. Presentation of carcinoma
rectum are usually as bleeding per rectum; tenesmus;
OF PENIS altered bowel habits; pain; backache (sacrum/sacral nerves
are involved); urinary symptoms; features of bowel
• Premalignant conditions of carcinoma penis obstruction; features of secondaries. MRI of pelvis is
– leukoplakia, condyloma acuminata (by useful to see rectal wall, pararectal tissues and pelvis.
human papilloma virus), erythroplasia of Nodal status is better assessed by contrast CT scan.
Querat, balanitis xerotica obliterans, phimosis Transrectal ultrasound is very useful to find out local
spread. APR; sphincter saving operations (anterior
and balanoposthitis.
resection); total mesorectal excision (TME) are various
• Buschke Lowenstein locally invasive verrucous treatment strategies. Adjuvant radiotherapy and
carcinoma is a large exophytic tumour which chemotherapy are beneficial. Laparoscopic mobilization
does not spread through the lymph nodes of rectum is very useful.
Jackson’s staging of carcinoma penis

Stage I Tumour involving only glans/prepuce/both 90% five-year survival
Stage II Tumour extending into body of penis 70%
Stage III Tumour having mobile inguinal nodes 50%
Stage IV Tumour spreading to adjacent structures/fixed nodes 5%
TNM staging
T0 No primary tumour
Tis Carcinoma in situ
T1 Tumour < 2 cm without deep invasion
T2 Tumour between 2-5 cm with minimal deep invasion
T3 Tumour > 5 cm with deep invasion/urethral spread
T4 Tumour spread to adjacent tissues
N0 No nodal spread
N1 Mobile regional nodes—unilateral
N2 Mobile regional nodes—bilateral
N3 Fixed regional nodes
M0 No distant spread
M1 Distant spread present
• Edge biopsy of penile lesion; FNAC of

inguinal lymph node; ultrasound of abdomen
to see external iliac nodes; SLNB (Sentinel
Lymph Node Biopsy) of Cabanas node are
the investigations required.
• If growth involves the glans without
extending into the proximal part of the shaft
of the penis, then partial amputation of the
penis is done. A length of 2.5 cm stump is
Fig. 3.27: Specimen showing features of carcinoma penis. retained. Clearance of 2 cm from the proximal
Proliferative lesion in the corona is seen with involvement extended part of the tumour is needed.
of glans penis. Tumour involves almost circumferentially. Advantage is proper streaming of the urine
Everted edge is obvious. Commonly it is squamous cell
carcinoma. But adenocarcinoma from Tyson’s glands, basal
is possible.
cell carcinoma, melanoma and secondaries (from prostate • Partial amputation of penis with bilateral ilio-
and urinary bladder) can occur rarely. inguinal lymph node block dissection is
or through blood. Treatment is wide local called as Young’s operation.
excision or partial amputation. • If tumour involves the proximal part of the
• Carcinoma penis spreads through the body of penis or if it is anaplastic/poorly
horizontal inguinal nodes, to deep Cloquet differentiated tumour total amputation of
nodes, and eventually to external iliac nodes. penis is done with perineal urethrostomy.
Nodes may get fixed to cause lymphoedema, Problems with perineal urethrostomy are
erosion of femoral vessels. Fungation at the scrotal ammoniacal dermatitis and stricture
site of nodal spread also can occur. at urethrostomy site. Dermatitis is prevented
• Presents as painless indurated/ulcerative/ by asking the patient to urinate in sitting
proliferative lesion which is hard and often position with lifting the scrotum upwards.
infected. Altered urinary stream can occur. Stricture needs dilatation.
• Total scrotectomy with orchidectomy is done • Therapeutic inguinal block is done whenever
along with total amputation of the penis – FNAC of node shows positive tumour.
Sir Piersey Gold operation. It prevents frequent • Superficial lymph node block is dissection
dermatitis of the scrotal skin because of the superficial to fascia lata in N0 disease.
perineal urethrostomy and also reduces the • Standard inguinal lymphadenectomy/block is
sexual desire. classical block dissection.
• When lymph nodes are involved and are • Modified inguinal block dissection is—small
mobile, bilateral ilioinguinal nodal dissection incision, limited dissection, preservation of
is done. Primary inguinal block is doing block saphenous vein.
dissection within 4 weeks of surgery for
primary tumour. Secondary inguinal block is
doing block dissection after 4 weeks of surgery
HYDROCELE, HAEMATOCELE
for primary disease. Complications of ilio- AND PYOCELE
inguinal block dissection are flap necrosis, See Figures 3.28 to 3.33.
lymphoedema of lower limb, femoral blow
out, infection, lymphorrhoea and haemorr-
hage. If primary tumour is poorly
differentiated, and if tumour is T2 or above
chances of inguinal nodal spread is more
than 50% and so a prophylactic inguinal
nodal dissection is done.
• Half the time, involvement of inguinal nodes
may be due to infection. So often a trial of
antibiotic therapy is given for 4-6 weeks to
reduce the size of the inguinal node.
• In case of carcinoma in situ, T1 lesion of glans
penis or well differentiated tumour in young
individual, circumcision and curative
radiotherapy to the penis can be given using
radioactive tantalum wire implantation (6000
cGy in 7 days) or by wearing radium penile A
mould continuously or intermittently (6000
cGy in 7 days) or by linear accelerator external
beam radiotherapy (6000 cGy in 5 weeks).
Involvement of nodes in these patients is less
than 10%.
Dresslers quandrangle – upper border is line
joining anterior superior iliac spine and pubic
tubercle; laterally line joining anterior superior
iliac spine and a point 20 cm below it; medially B
pubic tubercle and a point 15 cm below it. Nodal Figs 3.28A and B: Picture showing hydrocele fluid which
block dissection for carcinoma penis should is amber coloed. It contains water, salt, albumin and
cover this area adequately. fibrinogen. It clots only if the fluid comes in contact with
blood because of the calcium in the blood. It often contains
• Elective prohylactic inguinal block is done in cholesterol and tyrosine crystals. Hydrocoele can be
high risk group – invasive carcinoma; T2 and vaginal, congenital, infantile, encysted, bilocular or hydrocele
T3 tumours; with vascular invasion. of hernial sac.
Fig. 3.29: Haematocele showing brownish coloured fluid

in the sac. It can be acute and recent or it can be chronic
and clotted. In acute, recent type exploration is done under
general anaesthesia followed by evacuation. In old
haematocoele testis may not be viable and so orchidectomy
is needed.
Fig. 3.32A: Large sebaceous cyst—excised

specimen with sebum inside.
Fig. 3.30: Chylocele fluid is whitish lymph rich in cholesterol.

It is non-transilluminant and gets infected very easily.
It is seen in filarial disease.
Fig. 3.32B: Specimen showing uterus and cut section

of ovary. Cut section of ovary shows sebum—a feature
of teratomatous ovary.
SPECIMEN OF PANCREAS
See Figure 3.33.
Fig. 3.31: Pyocele of the scrotum. It is pus collection

SPECIMEN OF PERIAMPULLARY
in the tunica vaginalis testis. Because of tension and CARCINOMA OF PANCREAS
infective thrombosis of the testicular artery, viability of
the testis is often lost. Patient presents with fever, toxicity Periampullary Carcinoma is Tumour
and tenderness in the scrotum. Early surgical exploration Arising at or Near the Ampulla
and drainage of pus is required. Scrotal sac is kept open
and later when infection comes under control secondary
It could be:
suturing is done. Often needs orchidectomy if testis is • Adenocarcinoma from head of pancreas close
not viable. to the ampulla—50%.
tation and infiltration of pancreatic capsule.

It radiates to back and is also severe when
retropancreatic nerves (greater splanchnic
nerves) are involved.
• Loss of appetite and weight loss.
• Steatorrhoea/clay colored stool; silvery stool
is common in periampullary carcinoma as
blood bled from necrosed periampullary
tumour mixes with the clay stool.
• Palpable gall bladder—globular, smooth, soft,
nontender, moves with respiration, dull on
Fig. 3.33: Specimen of distal pancreatectomy with
percussion (palpable in 30% of carcinoma
splenectomy done for carcinoma of body of pancreas. head of pancreas, 50% of periampullary
Cystadenocarcinoma is common in the body of pancreas. carcinoma of pancreas).
Usually present as mass in epigastrium, which does not • Palpable liver—smooth and soft if it is due
move with respiration, non mobile, resonant on percussion
with palpable stomach in front. It may often present with
to hydrohepatosis (bile stasis); hard and
back pain. Jaundice is not common. CT scan is diagnostic. nodular if it is due to secondaries.
Treatment is distal pancreatectomy. It should be • Itching marks all over the body is present
differentiated from pseudocyst of pancreas, retroperitoneal due to increased bile salts; more prominent
tumor/cyst.
on the dorsal aspect of forearms , hands and
back.
• Dark coloured urine—tea colored urine; migra-
tory thrombophlebitis – 10% (Trousseau’s sign).
• If tumour is from head of pancreas,
occasionally primary tumour may be palpable
as deep, hard, nodular, non mobile, resonant
mass in upper abdomen adjacent to umbilicus.
• Splenomegaly due to splenic vein thrombosis
(10%) or secondary biliary cirrhosis can occur.
• Ascites, palpable supraclavicular lymph node
(Virchow’s), secondaries on rectal
examination (Blumer’s shelf), Sister Mary
Fig. 3.34: Specimen showing resected head of pancreas, Joseph nodule in the umbilicus are the
gall bladder, duodenal mucosa with periampullary growth. features of advanced tumour.
• Courvoisier law—in a patient with jaundice
if there is palpable gall bladder it is not due
• Tumour from ampulla of Vater—30%.
to stones. It is probably due to carcinoma
• Distal bile duct carcinoma—10%.
periampullary region/head of pancreas/
• Duodenal carcinoma adjacent to ampulla—
distal bile duct. Stones cause recurrent
10%.
cholecystitis, followed by fibrosis and so gall
Different presentations in periampullary carcinoma bladder is not capable to distend. Double
are: impacted stone is the exception to law.
• Obstructive jaundice – progressive, short • Rarely as upper gastrointestinal haemor-
duration, severe and initially painless. rhage either due to portal hypertension or
• Pain – is more in carcinoma head of pancreas; due to duodenal wall invasion by the tumour
in the epigastrium; and is due to duct dila- Major aetiologies are smoking, alcohol,
ERCP signs Important investigations

• Abrupt block pf pancreatic duct • Spiral CT/3D CT is ideal – to detect
• Pancreatic duct encasement operability, portal vein invasion, size, extent,
• Double duct sign nodal status
• Parenchymal filling • ERCP to take biopsy/brush cytology, sten-
• Scrambled egg appearance ting, to see the luminal extent of the tumour
Barium meal X-ray • MRCP is noninvasive—entire biliary tree is
• Is rarely done in periampullary carcinoma visualized properly
• Rose thorn appearance in hypotonic • Endosonography (EUS)—to assess size
duodenography properly; to take endosonographic FNAC
• Reverse 3 sign in periampullary carcinoma
Investigations to stage the disease
• Pad sign—widened C loop of duodenum
• 3D/spiral CT scan
in carcinoma head of pancreas
• EUS
• Gastric outlet obstruction features
• Laparoscopy
• ERCP
chronic pancreatitis, familial inherited

T1 Primary limited to pancreas –
susceptibility (5-10%), hereditary nonpolyposis
T1a < 2 cm; T1b - > 2 cm
colorectal cancer (HNPCC), Peutz-Jegher
T2 Primary tumour extension to duodenum,
syndrome, diabetes mellitus, mutations of
bile duct, peripancreatic tissue
different related genes. T3 Primary tumour extending into stomach,
Investigations are—liver function tests; spleen, colon, major vessels
prothrombin time; ultrasound abdomen (to see N0 No involvement of lymph nodes
gall bladder, CBD diameter, liver status, nodal N1 Lymph nodal spread present
findings, portal vein, splenomegaly, ascites); M0 No distant spread
spiral CT scan is better to see size/location/ M1 Distant blood spread present
extent of the tumour/portal vein infiltration/ Resection status
nodal status and operability; CT guided biopsy R0 No residual tumour found after resection
can also be done; endosonography with FNAC R1 Microscopic residual tumour after
(EUS with FNAC); barium meal X-ray – rose – resection
thorn appearance, reverse 3 sign; pad sign – widened R2 Macroscopic residual tumour after
‘C’ duodenal loop, gastric outlet obstruction; CA resection
19-9 (Carbohydrate Antigen) is the tumour R3 Inoperable
marker; periampullary tumour is diagnosed by
gastroduodenoscopy and biopsy; ERCP is Preoperative preparation in carcinoma
important in tissue diagnosis, extent of disease pancreas
and compression. • Adequate hydration and prevention of
dehydration postoperatively is important.
Dehydration is common in obstructive
TNM staging of pancreatic carcinoma (UICC jaundice
– Union International Center for Cancer) • Glycogen reserve in liver will be inadequate
Tx Primary cannot be assessed which should be replenished by giving
T0 Primary tumour - no evidence preoperative glucose orally or intravenously
• Patient is prone for hepatorenal syndrome pass and a second stage resection with closure
leading into renal failure postoperatively of pancreatic stump. In 1941, Trimble did one
due to sludging of the bile salts, due to toxins stage pancreaticojejunostomy.
and sepsis and so mannitol should be given • Traverso–Longmire pylorus preserving pancrea-
intravenously for 3 days prior to surgery ticoduodenectomy (1978)—Here 2 cm distal to
to flush the kidney (200 ml IV twice a day) the pylorus duodenum is cut and continuity
• ERCP stenting is done to drain bile if serum is maintained by anastomosing with jejunum.
bilirubin is high. Surgery is done after 2- • Fortner’s regional pancreatectomy (extended
3 weeks once bilirubin level drops down Whipple’s). Here in addition to Whipple’s
adequately. If ERCP is not possible then resection, segment of superior mesenteric vein
percutaneous transbiliary drainage (PTBD) is resected along with clearance of all regional
or cholecystostosmy using Foley’s or nodes; and continuity of portal vein is
Malecot’s catheter is done maintained by a synthetic vascular graft. Even
• Antibiotics one day prior to surgery – though technically it gives adequate clea-
cephalosporins/aminoglycosides rance, results are only equivocal.
• Often TPN may be required preoperatively • Total pancreatectomy is presently said to be
also which is continued postoperatively better. Reasons are – possibility of multicentric
• Pulmonary function study and respiratory nature of the disease, higher chance of recur-
physiotherapy to have adequate post rence after Whipple’s operation, malignant
operative pulmonary function cells may be present in pancreatic duct,
morbidity by pancreatic fistula or pancreatitis
Treatment of carcinoma pancreas after Whipple’s operation. Mortality in total
10-15% of pancreatic carcinomas (head) are pancreatectomy is higher (10-20%). Severe
operable. 40- 50% are locally advanced. Another resistant diabetes mellitus may be seen after
40-50% have distant spread to liver or lungs. total pancreatectomy.
In inoperable cases
Criteria for resection • Roux en Y choledochojejunostomy is an ideal
• Tumour size less than 3 cm palliative procedure along with gastrojejuno-
• Peri ampullary tumours stomy after doing cholecystectomy. 30% of
• Growth not adherent to portal system periampullary carcinoma/carcinoma of head
of pancreas develop eventual gastric
In operable cases (duodenal) outlet obstruction and so gastro-
• Whipple’s operation is done by removing jejunostomy is undertaken.
tumour with head and neck of pancreas, C • ERCP and stenting is done to drain bile.
loop of duodenum, 40% distal stomach, 10 Problem here are recurrent cholangitis, stent
cm proximal jejunum, lower end of the blockage and displacement, requirement of
common bile duct, gallbladder, peripancreatic, repeated stenting procedure.
pericholedochal, paraduodenal and • Adjuvant chemotherapy using gemcitabine
perihepatic nodes. Continuity is maintained – better but costly; dose is 1000 mg/m2 surface
by choledochojejunostomy, pancreaticojeju- area; 5 Fluorouracil; mitomycin; vincristine.
nostomy and gastrojejunostomy. Few do • Radioactive iodine seeds I125 to the field are
pancreaticogastrostomy into posterior wall on trial.
of the stomach. Mortality in Whipple’s • Immunotherapy—specific type to increase the
operation is 2-8%. Original Whipple’s effectiveness of chemotherapy and to improve
operation (1935) was two staged – initial by the cure rate.
Postoperative management in carcinoma • White bile on table carries poor prognosis

pancreas • Associated problems like pancreatitis,
• Maintenance of proper fluid and electrolyte diabetes mellitus
balance • Liver dysfunction
• Observation for bleeding and its control by
transfusion of blood, fresh frozen plasma
(FFP); prevention of DIC during initial period SPECIMEN OF GALLBLADDER
• Injection vitamin K intramuscular
• Respiratory care—ideally postoperative ICU
care is better. Often ventilator is needed for
24 hours
• Maintaining adequate urine output—
mannitol should be continued
• Injection octreotide infusion for 5 days to
suppress pancreatic secretion so as to
prevent the leak
• Antibiotics, nasogastric aspiration
Fig. 3.35: Specimen of gallbladder which is black
• Continuous monitoring the patient with and gangrenous.
pulse/blood pressure/oxygen saturation/
urine output hourly/drain site inspection/
abdomen distension/by doing HB%, LFT,
serum creatinine, bilirubin, arterial blood
gas analysis if needed, platelet count,
prothrombin time
Pain control in carcinoma pancreas

• CT guided 50% 20 ml ethanol injection in
to celiac ganglion.
• Epidural anaesthesia.
• Opioids administration.
• Transthoracic splanchnicectomy—greater
splanchnic nerve.
• Palliative radiotherapy—4000 cGy units.
Prognostic factors in carcinoma pancreas –

poor prognosis
• Mean survival rate 6-9 months
• Growth more than 3 cm
• Nodal involvement Fig. 3.36: Gallbladder showing cholecystitis with cholesterol
stone. Note the color of the stone—radiating crystalline
• Resection status—R0/R1/R2
appearance; usually single and radiolucent. Note also the
• Portal vein infiltration thickened, shrunken and pale gallbladder. Proliferation of
• Liver/lung secondaries mucus membrane causes deep clefts in the muscular
• Ascites/Trousseau’s sign/left supraclavi- coat called as Rokitansky—Aschoff’s sinuses. Fibrosis
and thickening of the muscular coat of the gallbladder
cular lymph nodal spread
with chronic inflammation are typical features.
A
F
Figs 3.37A to G: Gallbladder specimens with different types

of stones – pigmented/mixed/stone in Hartmann’s pouch/
single/multiple. Note the Hartmann’s pouch. It is always
pathological. In normal individual it is called as infundibulum
of the gallbladder. Note the faceting nature of the multiple stones.
D Faceting is due to equal pressure of the stones. Mixed stones
are the commonest type – 90%. They contain cholesterol;
calcium bilirubinate; calcium palmitate; calcium phosphate and
calcium carbonate. Pigment stones can be black or brown.
Black stones are usually calcium bilirubinate stones – they
are commonly seen in gall bladder in association with
haemolytic diseases; can also occur independently. Mucins
secreted by biliary lining glands (MUC A, MUC C5) are the
causes for development of pigment (black) stones. Brown
pigment stones are commonly observed in biliary tree - CBD,
hepatic ducts and ductules. These stones are commonly
associated with bacterial infection like E. coli as the nidus.
These bacteria release beta glucuronidase which transforms
E bilirubin to calcium bilirubinate. Other components may be
calcium palmitate and cholesterol.
Factors responsible for formation of gallstone: Modes of infection in cholecystitis are – haemato-
• Bile with altered cholesterol, lecithin and bile genous through cystic artery, through bile,
salts ratio is called as lithogenic bile (normal through portal vein.
ratio – bile salt + lecithin: cholesterol is 13:
Cholesteroses: It is chronic inflammatory condition
1). Within this ratio, micelle formation takes
of gallbladder where there is deposition of lipoid
place keeping cholesterol in solution. Above
content in the wall of the gall bladder as large
this ratio, super-saturation develops
‘foamy cells’ with phagocytosed cholesterol
(supramicellar zone) causing formation of
within it. It is due to defective transport of the
lithogenic bile and later to gallstone formation
absorbed cholesterol which gets accumulated in
– (Admiron’s triangular hypothesis).
mucosa. It is called as strawberry gallbladder.
Formation and aggregation of cholesterol
There is also increased absorption of cholesterol.
monohydrate crystals is called as nucleation
It is a premalignant condition. Cholecystectomy
which eventually forms stone.
should always be done in these patients.
• Other factors are obesity, oral contraceptives,
clofibrate, cholestyramine, ileal disease, ileal
resection, altered entero-hepatic circulation SPECIMEN OF CARCINOMA
• Bacterial infection (E. coli, Salmonella), GALLBLADDER
parasites like Clonorchis sinensis and Ascaris
lumbricoides.
• Hemolytic disorders like hereditary
spherocytosis, thalassaemia, etc.
Fig. 3.38: Mucocele of gallbladder. Note the mucus content

of the gallbladder. It is due obstruction at the cystic duct
leading to accumulation of mucus in the lumen of gallbladder
which is secreted by lining of the gallbladder. Bile will
not be present as there is obstruction of the cystic duct.
Mucocele should be treated with cholecystectomy B
otherwise it leads to empyema of gallbladder following
sepsis. Patient presents with soft, smooth, globular, Figs 3.39A and B: Gallbladder specimens showing
nontender mass in the abdomen, to the right of the upper proliferative lesion near the fundus in first picture and
part of the rectus abdominis muscle, in the right hypo- thickened scirrhous type of carcinoma in the second.
chondrium. It is dull on percussion, moves with respiration Note the gallstones in second specimen and also remaining
and horizontally mobile. mucosa shows features of choesteroses.
Aetiologies for carcinoma of gallbladder: Microscopically—commonly adenocarcinoma;

• 3% of gallstones with cholecystitis may occasionally squamous cell carcinoma, adeno-
develop carcinoma of gallbladder. squamous or carcinoid tumour can occur.
• 90% of carcinoma of gallbladder is associated
Spread of carcinoma gallbladder—direct spread to
with gallstones. Risk of developing carcinoma
liver (segment IV and V), bile duct, duodenum,
in gallstone disease is 7-10 times more than
general population. Relative risk is less if colon and kidney. Lymphatic spread to—lymph
stone size is less than 2 cm; it is 2.5 if stone node of Lund, periportal nodes, peripancreatic
size is 2-3 cm in size; it is 10 or more if stone and periduodenal nodes. Blood spread—to liver,
size is more than 3 cm. lungs and bones. It can also spread perineurally.
• Choledochal cyst, anomalous pancreatico Features of carcinoma of gallbladder
biliary duct junction (20%), cholesteroses of • It is common in places where there is more
gallbladder, gallbladder polyp more than 1 prevalence of gallstone disease—Patna—
cm in size or more than 3 in number or Bihar.
adenomatous polyp, porcelain gallbladder. • It is common in females.
• Chronic typhoid carriers, carcinogens, • Pain in right hypochondrium, mass in right
inflammatory bowel disease, hepatitis B and
upper abdomen which is hard and non tender.
hepatitis C virus infection.
• Jaundice.
Gross types of carcinoma gallbladder—polypoid, • Acute presentation of cholecystitis.
scirrhous and proliferative. • Palpable nodular liver secondaries, ascites.
Staging of carcinoma gallbladder

Nevin’s staging
Stage I Intramural
Stage II Spread to muscularis propria
Stage III Spread to serosa
Stage IV Spread to cystic lymph node of
Lund
Stage V Direct spread to adjacent organs/
metastases
TNM staging
Tumour Nodal spread
Tis Carcinoma in situ N0 No nodes
T1 Spread to mucosa or muscle layer N1 Cystic/nodes in porta/hepatoduodenal
T1a Only mucosal involvement ligament—spread
T1b Muscle layer spread N2 Peripancreatic/celiac/periduodenal/
T2 Spread to subserosa not beyond serosa superior mesenteric nodes—spread
T3 Spread beyond serosa or one adjacent Metastases
organ or < 2 cm to liver M0 No distant spread
T4 Spread > 2 cm to liver, 2 or more than M1 Presence of distant spread
2 adjacent organs—CBD, stomach,
duodenum, colon, omentum
• Incidental confirmation of carcinoma gall- Malignancies of the oral cavity
bladder histologically after cholecystectomy • Squamous cell carcinoma—commonest.
for chronic cholecystitis. Malignant cells with epithelial/keratin
Investigations for carcinoma gallbladder pearls are typical
• Ultrasound abdomen. • Minor salivary gland tumours
• CT abdomen. • Melanomas
• Liver function tests. • Adenocarcinomas—rare
• Sarcomas—rare
Treatment of carcinoma gallbladder
• Cholecystectomy along with resection of liver Sites of carcinoma in oral cavity in order
segments IV and V and perihepatic nodal occurance
clearance. In India In western countries
• Chemotherapy and radiotherapy as Cheek—commonest Tongue
adjuvant but poor success rate. Tongue Floor of the mouth
– Overall prognosis for carcinoma gall- Floor of the mouth Lips
bladder is poor. Palate Cheek
Lips
Features—
SPECIMEN OF • Carcinoma is common in posterior half of
HEMIMANDIBULECTOMY DONE cheek.
FOR CARCINOMA CHEEK • It can involve buccinator, pterygoids,
retromolar trigone, base of skull, pharynx.
Premalignant conditions of oral cavity— • It spreads through the cheek deeply into skin
leukoplakia; erythroplakia; submucosal fibrosis; causing fungation, ulceration, fistula
hyperplastic candidiasis. formation.
• Mandible can get involved by direct extension
Precipitating factors for oral carcinoma—smoking;
or through subperiosteal lymphatic spread.
spirit; sepsis; syphilis; sharp tooth; spices; betel
• Infection and halitosis can occur.
nut chewing (very important factor).
• Respiratory infection – bronchopneumonia
Gross types—ulcerative; proliferative; verrucous. are common.
• Pain, referred pain to ear can occur once
lingual nerve is involved.
• Everted edge and induration are observed.
• On bidigital palpation of mandible –
irregularity; thickening; tenderness; and site
of fracture can be made out.
• Trismus (if three fingers can not be passed
vertically into the mouth, then it suggests as
trismus) and dysphagia may be present.
• Submandibular and upper deep cervical
nodes are involved – when fixed can cause
Horner’s syndrome; hypoglossal nerve palsy
(tongue deviates to same side); spinal
Fig. 3.40: Hemimandibulectomy specimen showing ulcero- accessory nerve involvement (defective
proliferative lesion on the inner aspect of the cheek. shrugging of shoulder); and may cause
compression of external carotid artery leading • Problems of radiotherapy– osteoradionecrosis;

to absence of superficial temporal artery dryness and loss of taste sensation; mucositis;
pulsation. skin excoriation; trismus; laryngeal oedema;
• Features of advanced carcinoma – retromolar dysphagia due to pharyngeal oedema.
trigone involvement; extension into base of
skull and pharynx; fixed neck lymph nodes; Prognostic factors in oral carcinomas
and extension to opposite side. • Stage of the disease
• Problems with oral carcinoma – upper airway Stage I and II has got 80% 5 years survival
obstruction and bronchopneumonia; severe Stage III and IV has got less than 20%
feeding difficulties and malnutrition; immu- 5 years survival rate
nosuppression; sepsis and bleeding from • T3 and T4 lesions has got poor survival
tumour or from erosion of vessels; fungation; rate
fixity of secondary nodes and its problems. • Carcinoma lip has got best prognosis
• Investigations are edge biopsy; orthopantomo- • Carcinoma posterior 1/3rd tongue has got
gram of mandible; FNAC of lymph node; CT worst prognosis
neck and base of skull to assess spread. Open • Cheek, floor of the mouth and palate has
biopsy of lymph node is avoided as it may got intermediate prognosis
spread into further level of lymph nodes. If • Histologically positive nodes decrease the
ulceration or fungation has occurred open survival rate by 50%
biopsy of ulcer edge can be done. • Level III and IV, node > 3 cm, bilateral nodes
• Treatment is radiotherapy for early localised extracapsular nodal spread are poor
tumour; Patterson operation – wide excision prognostic factors
after raising a cheek flap; hemimandibulec- • Grading (differentiation) of the tumour
tomy/segmental resection/marginal mandi- • Tumour thickness > 6 mm has got poor
bulectomy. Radical neck dissection one side prognosis
and with modified neck dissection on • Exophytic tumour is better than infiltrating
opposite side with retaining of internal type
jugular vein; postoperative chemotherapy can
be given; chemotherapy can also be given
initially to downstage and later after surgery. TNM staging for all oral cancers
• Bony gap after hemimandibulectomy is • Tis—Carcinoma in situ
bridged using free rib graft/fibular bone • T0—No evidence of primary tumour
graft/stainless steel plate. • T1—Tumour < 2 cm
• Problems with surgery – bleeding; infection; • T2—Tumour 2-4 cm
flap necrosis; reconstruction problems; • T3—Tumour > 4 cm
morbidity. • T 4—Tumour involving adjacent soft
tissues/bone
Nodal prognostic factors • N0—No nodes
• Positive histology in node reduces the • N1—Node < 3 cm
survival • N2—Node size up to 6 cm; N2a – Same
• Level III and IV has poor prognosis side single node; N2b – Same side multiple
• Bilateral/contralateral nodes carry poor nodes less than 6 cm; N2c – Bilateral or
prognosis opposite nodes less than 6 cm
• Extracapsular spread/size > 3 cm carry • N3—Nodal spread more than 6 cm size
poor survival • M0—Distant spread not present
• Involvement of > 3 nodes is poor sign • M1—Presence of distant spread
Broder’s histological grading SPECIMEN OF KIDNEY SHOWING
Grade 1: Well differentiated > 75% keratin HYDRONEPHROSIS
pearls
Grade 2: Moderately differentiated 50-75% Definition of hydronephrosis (HN): It is an aseptic
keratin pearls dilatation of pelvicalyceal system due to partial
Grade 3: Poorly differentiated 25-50% or intermittent obstruction to the outflow of urine.
keratin pearls Congenital PUJ is the commonest cause of HN.
Grade 4: Very poorly differentiated < 25% Often it is bilateral and presentation on one side
keratin pearls is earlier than the other side.
B D
Figs 3.41A to D: Specimen of kidney showing dilated thin renal pelvis which is extrarenal; dilated calyces; and
thin renal parenchyma. In second picture ureter and PUJ (Pelvi Ureter Junction) are also seen. Here hydronephrosis
is due to congenital PUJ obstruction. Nephrectomy is done if the thickness of renal parenchyma is less than 2
cm, if DTPA scan shows less than 20% function, or hydronephrosis is infected. Nephrectomy is also done if kidney
function does not improve after pyeloplasty or surgical correction.
Aetiology
It can be unilateral or bilateral
Unilateral Bilateral
A. Extramural A. Congenital
1. Aberrant renal vessels (vein or artery) 1. Congenital stricture of external
2. Compression by growth (ca cervix, ca rectum) urethral meatus. Pinhole meatus.
3. Retroperitoneal fibrosis 2. Congenital posterior urethral valve.
4. Retrocaval ureter
B. Intramural
1. Congenital PUJ obstruction
2. Ureterocele
3. Neoplasm of ureter
4. Narrow ureteric orifice
5. Stricture ureter following removal of stone,
pelvic surgeries or tuberculosis of ureter.
C. Intraluminal
1. Stone in the renal pelvis or ureter.
2. Sloughed papilla in papillary necrosis.
• Aberrant renal artery or vein in the lower pole Classification I

of kidney can compress the PUJ causing HN. 1. Unilateral HN.
Renal angiogram confirms the diagnosis. 2. Bilateral HN without renal failure.
Treatment: If it is a vein it can be ligated 3. Bilateral HN with renal failure.
safely. But if it is an artery, it exclusively
supplies the lower pole of the kidney and Classification II
so cannot be ligated. So kidney is mobilised; 1. Intermittent HN: Obstruction occurs;
upper and lower poles are approximated swelling and pain appear in the loin. After
together so that artery is made to slip away sometime patient passes large amount of
from the site of compression - Hamilton Stewart urine following which swelling and pain
operation. disappear—Dietl’s crisis.
• In pregnancy dilatation of ureters and both 2. Persistent HN due to persistent partial
pelves occur due to atony of ureteric obstruction.
musculature by progesterone. It starts as early
as in the first few weeks of pregnancy and Classification III
lasts until few weeks after delivery. Involution 1. HN only.
occurs 2-12 weeks after delivery. 2. HN with hydroureter.
• Pathology: Initially pressure burden is taken
Classification IV
up by the pelvis; later calyces and renal
1. Extrarenal pelvic HN (80%).
parenchyma. Gradually, parenchyma thins
2. Intrarenal pelvic HN (20%) - Destruction
out due to destruction and it dilates causing
of kidney is earlier and severe in case of
eventually to compromised secretory function.
intrarenal pelvic HN as compared to
Parenchymal thickness of less than 2 mm
extrarenal pelvic HN.
is unlikely to function. In bilateral cases such
patients will go for renal failure. Initial stages Investigations
of obstruction, formation of urine continues • Blood urea and serum creatinine.
but it gets reabsorbed through the tubular • Urine for microscopy.
epithelium, venous channels and lymphatics. • Ultrasound abdomen: Investigation of choice.
Parenchymal thickness less than 2 cm is
Clinical Features critical. Cause of HN also can be identified.
A. In unilateral cases Type of pelvis, thickness of parenchyma, site
• Congenital PUJ obstruction and calculus are of obstruction and cause of obstruction (e.g.
the most common causes. stones) can be made out.
• M : F : : 2 : 1. • IVU: To find out the function of diseased as
• Right side kidney is more commonly affected. well as opposite kidney. Normal calyx is cup
• Loin pain which may be dull aching, with shaped. It gets flattened and later club shaped
dragging sensation or heaviness. which eventually becomes broadened in
• Mass in the loin which is smooth, mobile, hydronephrosis.
ballotable, moves with respiration, percussion • Whitaker test: Pass a fine needle into the renal
shows dull renal angle with a band of colonic pelvis through loin. Pelvis is perfused with
resonance in front. saline at a rate of 10ml/minute. Normally,
• Attacks of acute renal colic. initially the pressure increases and later it
• Often patient may be having Dietl’s crisis – will become constant. Persistent increase in
After an acute attack of renal colic, swelling pressure suggests HN.
is seen in the loin which disappears after Isotope renography (DTPA SCAN) is also useful
sometime following passage of large volume to study the function of the kidney before and
of urine. after the surgical treatment and also to see the
• If infected dysuria, haematuria, fever and efficacy of surgery as far as function is considered.
tenderness in renal angle. Treatment:
• Occasionally hypertension. Always conservative surgeries which are aimed
B. In bilateral cases at conserving the kidneys are done. Nephrectomy
is not done unless indicated.
From lower urinary tract obstruction
1. Treat the cause—Stone, congenital anomaly,
• Loin pain.
aberrant renal vessels.
• Features of bladder outlet obstruction -
2. Anderson—Hyne’s operation: (Dismembered
frequency, hesitancy, poor stream.
pyeloplasty):
• If renal failure develops early kidneys are
In congenital PUJ obstruction, the spasmodic
often not palpable.
segment and redundant pelvis is excised.
From bilateral upper urinary tract obstruction New pelvis is created and is anastomosed
• Loin pain, mass in the loin, attacks of renal to the cut end of the ureter in dependent
colic. position.
• In bilateral cases, when it is severe, features 3. Davis T-tube ureterostomy: By making
of renal failure like oliguria, oedema, and longitudinal incision T-tube is placed in the
hiccough may be present. ureter.
4. Non dismembered pyeloplasty: Here PUJ is
Complications not transected. Reconstruction is done
• Pyonephrosis. without PUJ transection by different methods.
• Perinephric abscess. For example Foley’s Y-V plasty.
• Renal failure in bilateral cases. 5. In bilateral cases, without renal failure, kidney
• Haematuria. with better function should be operated first.
• Stone formation. Otherside kidney is dealt after three months.
6. In HN with renal failure, initially bilateral Treatment

nephrostomy and haemodialysis support is After starting antibiotics, pus is immediately
required. After 3-6 weeks IVU is done and drained from the kidney through a loin incision
the functions of both kidneys are assessed. and nephrostomy tube (Cabot’s)/(Malecot
If their function is adequate, then treated catheter) is placed. If kidney is totally destroyed,
accordingly by Anderson Hyne’s operation. subcapsular nephrectomy is done. This also
If kidney function is inadequate (renal function prevents other kidney from getting infected
<20% on isotope study) then nephrectomy and through perirenal lymphatic connections. In
renal transplantation is the only option left. bilateral pyonephrosis, bilateral nephrostomy is
7. Laparoscopic or retroperitoneoscopic pyeloplasty the only choice. ‘J’ stenting is done often to keep
is becoming popular but is expensive and the ureters patent.
time consuming. It gives good result.
8. Endoscopic pyelolysis, though technically
easier results are not assured.
SPECIMEN OF RENAL
TUBERCULOSIS
Pyonephrosis Commonly it is secondary. Primary may be in
It is collection of pus in pelvicalyceal system, the lung. Through blood, bacteria reach the
which is converted into a multiloculated sac. glomeruli causing caseating granuloma with
Occurs due to:
a. Infection in preexisting hydronephrosis.
b. Following acute pyelonephritis, or
c. As a complication of renal calculus - either
pelvic stone or staghorn calculus.
Clinical Features
• Triad
A
– Anaemia
– Fever
– Loin swelling
• Tender mass in the loin which is smooth,

soft, not mobile, not moving with respiration.
• Patient may also have cystitis, pyuria,
burning micturition.
• Features of toxicity such as fever with chills
and rigors.
Investigations
• Plain X-ray KUB may show renal calculus.
• IVU shows HN.
B
• Cystoscopy reveals cystitis with efflux of
Figs 3.42A and B: Specimen of kidney showing dilatation
purulent pus through the ureteric orifice. and caseous material as content. It is tuberculous
• Ultrasound shows dilatation. pyonephrosis. Ureter is visualised in the specimen. Often
• DTPA scan , blood urea and serum creatinine. there may be ureteric stricture due to tuberculosis.
Langhan’s giant cells and epithelioid cells. These • Painful micturition with often haematuria;
granulomas coalesce to form a papillary ulcer haematuria may be overt or microscopic (50%).
and other consecutive different forms. • Renal pain and suprapubic pain.
• Tuberculous kidney is rarely palpable unless
Pathological Types there is hydronephrosis or perinephric
• Tuberculous papillary ulcer. abscess.
• Cavernous form. • Presentation like acute pyelonephritis.
• Hydronephrosis. • Features of urinary stones; recurrent urinary
• Pyonephrosis [due to (secondary) superadded tract infection; renal failure if both kidneys
infection by E. coli, Klebsiella]. are diseased; hypertension.
• Tuberculous perinephric abscess. • Enlarged prostate and seminal vesicle,
• Calcified tuberculous area (mimics calculi, thickened beaded vas, thickened epididymis,
hence called as pseudo calculi). impotence, infertility are other features.
• Caseous kidney - often called as putty kidney • Haemospermia; pelvic pain.
or cement kidney (it goes for autonephrec- • Dysparuenia; menstrual dysfunction; vaginal
tomy). discharge; infertility in females.
• Miliary tuberculosis. • Fever and weight loss.
• Tuberculous bacilluria occurs from an early • Often cough with expectoration and
stage of the disease which causes tuberculous haemoptysis may be present.
ureteritis and stricture ureter. Commonest site
for stricture is ureterovesical junction; second Investigations
common site is pelvi uretric junction. • Hb%; ESR; Chest X-ray; Mantoux skin test
Tuberculous cystitis eventually results in golf is usually positive.
hole ureter and thimble bladder (cystoscopic • Ultrasound abdomen to see kidney, bladder.
findings). This is due to fibrosis causing rigid • Three consecutive early morning samples of
withdrawn dilated ureteric orifice looking like urine (EMSU) are collected and sent for
a golf hole. Entire urinary bladder gets fibrosed, microscopy, (Ziehl-Neelsen staining), culture
stiff and is unable to dilate to accommodate urine in Lowenstein-Jensen culture media (L-J
causing thimble systolic bladder. media) or guinea pig inoculation.
Tuberculous prostatitis, seminal vesiculitis • Polymerase chain reaction (PCR) for
(P/R- palpable seminal vesicle), tuberculous tuberculosis.
epididymitis and funiculitis are other associa- • Plain X-ray KUB- may show calcification.
tions. Thickened epididymis with ulcer on the • IVU - Hydrocalyx, narrowing of calyx,
posterior aspect may be often found. stricture ureter which are multiple with
Tuberculous funiculitis with beaded, thickened dilatations in between.
vas deferens is seen. • Often RGP is very useful, as better definition
of ureter, pelvis, calyces and selective
Clinical Features sampling of urine are possible.
• It is common in males and common on right • Voiding cystourethrography (MCU) to see
side. ureteric stricture and reflux.
• Frequency—both day and night, polyuria. • Cystoscopy reveals multiple tubercles,
• Sterile pyuria—Urine is pale and opalescent bladder spasm, and oedema of ureteric orifice
with presence of pus cells without organisms eventually forming ‘golf hole ureter’, scarring,
in acid urine — abacterial aciduria. (Other ulceration, and bleeding, stone formation.
causes: Interstitial cystitis, Chlamydia). • CT scan of abdomen and pelvis.
Treatment
• Antitubercular therapy is started—INH,
rifampicin, ethambutol, and pyrazinamide.
Duration of treatment is one year.
• After 6-12 weeks of drug therapy, surgical
treatment is planned. Kidney is exposed.
Pyocalyx is drained. Cut edge of the capsule
is sutured—Hanley’s renal cavernostomy.
• Hydronephrosis—Anderson Hynes opera-
tion or nephrostomy or stenting (‘J’stent) of
ureter is done.
• Renal abscess not resolving for 2 weeks
Fig. 3.43: Cut section of specimen of kidney showing
should be drained. pus, necrotic area, and multiple infected abscesses–renal
• Ureteral stricture—Stenting/reimplantation carbuncle with multiple abscesses. Condition is common
of the ureter into the bladder/psoas hitch/ in diabetic.
Boari’s flap/ileal conduit (Koch’s ileal
conduit). • Staphylococci can be isolated from the urine
• Thimble bladder—Hydraulic dilatation/ • IVU shows obliteration of group of calyces,
ileocystoplasty/caecocystoplasty/sigmoid mimics renal cell carcinoma
colocystoplasty is done. • Treatment: Antibiotics, drainage of
• In unilateral lesion, with gross impairment carbuncle with Malecot catheter placement
of renal function-nephro ureterectomy. • Often, nephrectomy may be needed in severe
type
Indications for nephroureterectomy • Life threatening septicaemia can occur
• Nonfunctioning kidney which often needs not only nephrectomy
• Disease extensively involving the kidney but also higher antibiotics like mereponem,
• Disease causing hypertension and severe linezolid, and intensive critical care,
obstruction ventilator support
• Tuberculous pyonephrosis
• Coexisting renal cell carcinoma SPECIMEN OF KIDNEY WITH
RENAL CELL CARCINOMA (RCC)
• It is an adenocarcinoma arising from renal
SPECIMEN OF RENAL ABSCESS/
tubular cells- most common site is proximal
CARBUNCLE renal tubular cell. Common in upper pole
of kidney.
Renal abscess/renal carbuncle • More common in males; more common in
• A localised inflammatory necrotic mass of 5th-6th decade of life.
tissue involving renal parenchyma, caused
by Staphylococcus aureus and coliform Other names for renal cell carcinoma
organisms, source of which is cutaneous • Hypernephroma—misnomer. It is initially
infections like boil and carbuncle. Eventually thought that tumour is arising from above
infection may spread to entire kidney the kidney
causing multiple abscesses • Grawitz tumour
• It presents as ill defined tender swelling • Clear cell carcinoma
in the loin, with pyrexia and leucocytosis • Internist tumour
C D
Figs 3.44A to D: Renal cell carcinoma. Note the large sized tumour in one of the poles. It is common in upper
pole but can occur in lower pole. Occasionally it can be bilateral. Papillary tumours are eosinophilic papillary projections
which are less vascular and multicentric. It is an adenocarcinoma arising from renal tubules. Grossly it is large
vascular with a pseudocapsule infiltrating the renal capsule, and calyces. In first photo it is seen arising from lower
pole and in next two they are from upper poles. Cut section is yellowish due to lipoid content. Haemorrhagic areas
with necrosis are seen.
Aetiology
• It is associated with von-Hippel-Lindau disease (Cerebellar haemangioblastoma, retinal
angiomatosis, phaeochromocytoma, tumour or cysts of pancreas). Here RCC is commonly bilateral
• Diet rich in animal fat
• Environmental factors like asbestos, lead, cadmium and tobacco
• Cigarette smoking
• Chromosomal aberration, tuberous sclerosis
• Acquired cystic kidney disease after long-term dialysis
• Birt-Hogg-Dube syndrome with hereditary chromophobe RCC and oncocytoma
• Cortical renal adenoma? could be RCC by itself
Microscopy: Malignant cells which are cubical or Robson-Flocks and Kadesky staging of RCC
polyhedral containing lipid, cholesterol and glyco- Stage 1: Tumour confined to renal parenchyma.
gen. Histological types—clear (75%), granular, Stage 2: Tumour invasion to perinephric fat
spindle, sarcomatoid, and papillary (15%). but confined with in Gerota’s fascia
Spread Stage 3:
• Local: Into the perinephric pad of fat, calyces (a) Tumour invasion to renal vein or IVC
and renal pelvis. (b) Invasion to regional lymph nodes
• Blood spread: RCC enters the renal vein as (c) Both a+b
proliferating tumour thrombus which extends Stage 4:
into the IVC and later gets detached causing Invasion to adjacent organs other than adrenal
‘cannon ball secondaries’ in the lung which are Distant metastasis
often calcified. Once primary tumour is
removed, secondaries may regress due to Clinical features of RCC
tumour immunity. Occasionally secondaries • M: F: 2:1
occur in bone, liver and brain. Left testicular • Haematuria.
vein which drains into left renal vein may • Clot colic.
gets blocked by proliferating tumour thrombus • Dragging discomfort in the loin.
resulting in irreducible left sided varicocele. • Mass in the loin which moves with
• Lymphatic spread: To hilar lymph nodes, para respiration, mobile, nodular, hard, with dull
aortic lymph nodes. renal angle and resonant band in front.
• Left sided varicocele which is irreducible.
AJCC (American joint committee on cancer)
staging of RCC – TNM staging
Triad of RCC
Tx—Primary tumour cannot be assessed
1. Pain
T0—No primary tumour
2. Haematuria – 30%
T1—Tumour less than 7.0 cm size, limited
3. Palpable renal mass
to kidney. T1 a is tumour 4cm or less; T1b
is tumour 4-7 cm in size Note: 45% present as early disease; 25% as
T2—Tumour more than 7.0 cm size, limited locally advanced disease; 30% as metastatic
to kidney disease.
T3—Tumour extends into major veins,
adrenals, perinephric fat but not into the Atypical presentations:
Gerota’s fascia a. Due to secondaries
T3a—Into adrenal or perinephric tissue • Pathological fractures.
T3b—Into renal vein or IVC below diaphragm • Persistent cough and haemoptysis.
T3c—Tumour extends into IVC above the b. Persistent pyrexia with no evidence of infection.
diaphragm (Pyrexia of Unknown Origin) – 20%.
T4—Tumour invades Gerota’s fascia and c. Constitutional symptoms: Malaise, lethargy
extends beyond and severe anaemia.
N0—No lymph nodes d. Polycythemia: 4% - due to increased secretion
N1—Spread to single regional lymph nodes of erythropoietin.
N2—Spread to more than one regional lymph e. Hypercalcaemia due to PTH like hormone
nodes secretion, hypertension due to increased
M0—No blood spread secretion of renin from kidney tissue adjacent
M1—Distant spread present to lungs - 75%, to tumour.
soft tissues - 35%, bones - 20%, liver – 15%, Note: (Surgical renal conditions associated
CNS – 8%, skin – 8% with hypertension –PCKD (polycystic kidney
disease), renal cell carcinoma, and renal • Bone scan to see bone secondaries.
artery stenosis. • Peripheral smear, serum calcium, haematocrit
f. Nephrotic syndrome: Very rare. and ESR, RBC count are other supportive
g. Stauffer’s syndrome: Nonmetastatic reversible investigations.
liver dysfunction which gets corrected after
nephrectomy. It is 7% common. It caries poor Differential diagnosis
prognosis. • Polycystic kidney disease
h. Cushing’s syndrome. • Solitary cyst of kidney
i. Leukaemoid reaction due to bone marrow • Adrenal tumour
stimulation. • Retroperitoneal tumour
j. Secondary amyloidosis 5%. • Carcinoma colon
Investigations
Treatment of RCC
• Urine microscopy for RBCs.
Surgery is the treatment of choice.
• IVU - shows mass lesion and irregular filling
defect.
Structures removed in radical nephrectomy are
• Ultrasound abdomen - To know the size,
1. Entire kidney along with tumour
extension, lymph node involvement, spread
2. Perinephric tissue
to the liver, status of renal vein and IVC.
3. Ipsilateral adrenal gland
• CT scan: It is confirmatory and modality of
4. Proximal 2/3rd ureter/as low as possible
choice. Multidetector CT and CECT (contrast
5. Lymph nodes from crus of diaphragm to
enhancement CT) are very useful in detecting
aorta bifurcation with renal hilar nodes
early lesion/function/spread/venous status.
Lymph node status, tumour extension are 1. Radical nephrectomy:
well made out with CT. Contrast Approach is transperitoneal. Retroperitoneal/
enhancement CT scan helps to find out Nagamatsu (resection of 11th rib) approach/
function of opposite kidney and tumour thoraco abdominal approach/posterior vertical
thrombus in renal vein or IVC. are other approaches. Patient will be in lateral
• Renal angiogram through Seldinger techni- position. After laparotomy, colon is mobilized
que via transfemoral route, to see the medially. Vessels are identified and dissected
vascularity. Pharmaco-angiogram (Inject nor and ligated securely (transfixation and three
adrenaline along with dye while doing ligatures proximally using non absorbable silk/
angiogram). As tumour vessels are autono- polypropylene sutures).
mous they will not constrict whereas adjacent Preoperative renal artery embolisation can
normal vessels will constrict, so tumour blush be done to decrease vascularity and to facilitate
is visualised. Through angiogram, thera- the entire removal of tumour. Always ideally
peutic embolisation of tumour can be done renal vein is ligated first so as to prevent tumour
to reduce the vascularity of tumour. dislodgement, but it causes torrential haemor-
• MRI/MR angiogram is unique in identifying rhage from kidney and tumour due to congestion
the spread in to IVC especially in the thorax. and as such tumour is very vascular. So many
In such occasion oesophageal endosono- surgeons/urologists prefer to ligate renal artery
graphy is also useful to visualise thoracic first. In case of IVC extension, IVC is opened
extension of the tumour thrombus. after applying an oblique vascular clamp, tumour
• Chest X-ray shows cannon ball secondaries. thrombus is removed and IVC is sutured. In supra
Often it is calcified. CT chest is ideal and more diaphragmatic venacaval extension of thrombus,
reliable. cardio-pulmonary bypass is necessary.
2. Even in large fixed tumour, palliative nephrec- Prognosis in RCC

tomy or debulking is advised as it may cause Overall 5 year survival rate is 40%. In early
regression of secondaries. This spontaneous localised disease it is 70-90%. In advanced
regression is only transient and observed only and metastatic disease it is 10-15%
in few cases of RCC. Significance given earlier Prognostic factors are -
to this phenomenon is largely questioned at • Tumour size more than 4 cm carries poor
present. prognosis.
• Extension into the renal vein.
3. Nephron sparing surgeries in bilateral RCC
• Presence of secondaries.
(Bilateral partial nephrectomy)/or RCC in a
• Differentiation.
solitary kidney. Renal artery is temporarily
• Local extension.
occluded using vascular clamps and kidney is
• Hypercalcaemia and Stauffer’s syndrome
cooled to have proper control of bleeding and
carry poor prognosis.
adequate visualisation of the line of resection.
5 year survival is 65% for stage I and II; 40%
Partially resected specimen is assessed by frozen for stage III; 10% for stage IV
section biopsy. Retained partial capsule is
sutured after haemostasis. Renal arterial clamp
is released. SPECIMEN OF HYDATID CYST OF
LIVER
4. Pre-operative renal artery embolisation can
be done to decrease the tumour vascularity using Word meaning of Hydatid is ‘dew/watery drop’
gel foam/spheres/coils/muscle piece. in Latin and in Greek hydatid means watery
vesicle.
5. Chemotherapy: 5 FU, floxuridine, vinblastine
and progesterone can be tried. RCC is a
remarkably refractory solid tumour.
6. Interferons (IFN – alpha) and interleukins
(IL-2) have shown beneficial effects.
7. Antiangiogenic drugs are under trial like
endostatin and angiostatin. RCC is highly
vascular and there is highly angiogenic
environment to give possible benefit by
antiangiogenesis.
8. No role for radiotherapy.
9. Laparoscopic approach is becoming popular.
Here renal artery is ligated first. It is confirmed
to be safe and adequate.
10. Solitary lung metastasis patient may get

benefited by wide resection of the secondary. It takes few years to evolve into a complete
hydatid cyst. Most commonly involved segment
11. Humanised monoclonal antibodies like is segment VII – 27%. Commonly right lobe –
bevacizumab which neutralises VEFG are under 66%; both lobes in 16% and only left lobe in
trial. 17% is involved.
Pathology
It has got 3 layers
1. Adventitia (pseudocyst, pericyst): Is an
inseparable fibrous tissue due to reaction of
the liver to the parasite.
2. Laminated membrane (ectocyst): Formed of the
parasite itself, is whitish, elastic, contains
hydatid fluid, which can be peeled of readily
from the adventitia.
3. Germinal epithelium is the only living part,
lining the cyst (endocyst).
This layer secretes hydatid fluid, brood capsules
with scolices (heads of future worms).
Features of hydatid fluid

A
• Clear
• High specific gravity 1.005-1.009
• Shows hooklets and scolices
Note:
• Initial sexual cycle in the liver causes primary
echinococcosis. Once brood capsules disinte-
grate, it grows into daughter cysts.
• Few hydatid cysts develop from larval stage
– protoscolices/daughter cysts in an asexual
minor cycle in the same intermediate host
called as secondary echinococcosis.
• Dominant cyst means one cyst among multiple
B
cysts of a single patient which is either largest/
in most difficult position/communicating
with biliary tree/complicated.
Course of the Disease

• The parasite may die and cyst eventually may
get calcified.
• Commonly cyst enlarges and is palpable per
abdomen.
• It may cause complications like jaundice due
to pressure over biliary tree.
• Rupture into the peritoneal cavity causes life
threatening anaphylactic reaction and shock
requires proper management with steroids.
C • Rupture into biliary channels is commonest.
Figs 3.45A to C: Specimen of Hydatid cysts of liver Rupture into bowel, pleural cavity also can
during extraction from the liver and after extraction. occur.
• Secondary infection causing suppuration and • MRI when there is jaundice to visualise biliary
septicaemia. tree and its relation to hydatid cyst; to find
• Secondary cysts in the lung, spleen, mesentery, out cystobiliary communication; biliary
retroperitoneum and other organs can occur. hydatids in bile duct and hepatic ducts. ERCP
• Hepatic dysfunction. can also be done to find out the communi-
cations. Other method to find out the
Clinical Features cystobiliary communications is intraoperative
• Asymptomatic palpable liver with classical cholangiogram.
thrill (hydatid thrill) elicited by three-finger Aspiration of the cyst should not be done
test. due to risk of anaphylaxis but presently PAIR
• Jaundice and pain. (Puncture – Aspiration – Injection – Reaspiration)
• Features of anaphylaxis if ruptured. is done effectively.
• Discomfort in right upper quadrant area;
dyspepsia; hydatid cachexia in children;
Hassen Gharbi’s ultrasound based classification
weight loss; fatigue; vomiting.
of liver hydatid cysts (1981)
• Occasionally splenomegaly, pleural effusion,
Type 1: Pure fluid collection
cholangitis, allergic asthma, fever.
Type 2: Fluid collection with split wall
Type 3: Fluid collection with septa
Hepatoma; amoebic liver abscess; cystic disease Type 4: Heterogeneous appearance
of the liver Type 4: Reflecting thick walls
Investigations WHO classification of liver hydatid cyst

• Ultrasound is diagnostic. Reveals rosettes of Type CL: Active; unilocular; no cyst wall; early
daughter cysts, double contoured membrane stage; not fertile
of the cyst due to detachment of the cyst Type CE 1: Active; cyst wall present; hydatid
membranes, and calcification of cyst wall. sand present; fertile
Intraoperative ultrasound (IOUS) is very Type CE 2: Active; multivesicular rosette like
useful tool. cyst wall; fertile
• CT scan abdomen is more accurate in Type CE 3: Transitional; detaching laminated
identifying cyst characters—cart wheel look membrane; water-lily sign; beginning of
multivesicular rosette like. degeneration
• X-ray shows calcification. Type CE 4: Inactive; degenerative contents;
• Primary serological tests: ELISA; indirect no daughter cysts; not fertile
haemagglutination test; latex agglutination Type CE 5: Inactive; thick calcified wall; not
test; immunofluorescence antibody test; fertile
immunoelectrophoresis. 80-95% sensitivity
for liver hydatid.
• Secondary laboratory tests: Detection of Treatment
precipitation line—arc 5; immunoblotting;
polymerase chain reaction (PCR). More Drugs
specific, very useful in extrahepatic hydatid Praziquantel – 60 mg/kg along with albendazole
disease and calcified nonfertile liver hydatid for 2 weeks.
• Liver function tests. Albendazole 4 weeks cycles with 2 weeks drug
• Casoni’s test; complement fixation test— free interval.
historical interest. Mebendazole—600 mg daily for 4 weeks.
PAIR (Puncture–Aspiration–Injection– –alcohol is injected. If cyst wall is 6 cm or
Reaspiration)–percutaneously done (1980) more a drainage catheter is placed for 24 hours
for complete drainage and later alcohol
Indications for PAIR sclerosant is injected.
• Inoperable patients • Double – puncture aspiration and injection
• Patients who refuse surgery (D-PAI) or modified PAIR/PEVAC (Percuta-
• CL, CE 1, CE 2 and CE 3 types/Gharbi type neous evacuation of cyst) are other
1 and 2 procedures done.
• Relapse cysts • PAIR has gained wide acceptance as it is
• Infected cysts safe, less invasive, and easier to do, with low
• In pregnant women morbidity and mortality. Complications and
• Cysts more than 5 cm in different liver results are same as open surgery.
segments
Surgery
Results and problems of PAIR • Surgery is still the choice and gold standard
• Complication rate—10-40% therapy for hydatid disease. The abdomen
• Mortality rate—0.9-2.5% is opened, and the peritoneal cavity is packed
• Fever—35%-disappears in 72 hours with mops (black or coloured mops are used
• Anaphylaxis—0.1-0.2%-same as open to identify white scolices clearly so as to pick
surgery—but drugs should be kept ready up all and prevent any spillage). Fluid from
for anaphylaxis the cyst is aspirated and scolicidal agents
• Infection—10% well controlled by antibiotics (cetrimide, chlorohexidine, alcohol, hyper-
• Local recurrences—4% - repeat PAIR can tonic saline (15-20%), 10% povidone iodine
be done or H2O2) are injected into the cyst cavity
(formalin should not be used). Hypertonic
Contraindications for PAIR
saline should be left within the cavity for
• Inaccessible cysts
15-20 minutes to have effective scolicidal
• Cysts with multiple septae–honeycomb
effect.
cysts
• Detection of cystobiliary communications is
• Hyperechogenic cysts
very crucial as it may cause caustic sclerosing
• Communicating cysts to bile duct
cholangitis when scolicidal agent like
• Calcified cysts
formalin is used. Communicating openings
• Cysts in lung
may be single or multiple. Cyst more than
10 cm is likely to have cystobiliary communi-
Technique of PAIR cations. Often clinically features of communi-
• Done under US guidance. cations may not be present. Preoperatively
• Under local anaesthesia cyst is punctured there may be recurrent cholangitis; dilated
through thickest route/part of cyst wall using bile duct. Factors important are—its size;
a cholangiography 22 gauge needle. number; site; involvement of hepatic/bile
• Cyst is entered through nondependent wall ducts; liver dysfunction. Bile stained cyst on
and 50% of fluid is aspirated. All multiple/ table during aspiration is highly suggestive
daughter cysts are aspirated. Radiopaque dye of communication. White mops soaked with
is injected to see if any communications are hypertonic saline are kept in the cyst cavity
present. Scolicidal agents—15-20% hyper- and gallbladder is gently squeezed to see for
tonic saline is injected into the cyst. After the bile staining of the mop in the cavity which
20 minutes reaspiration is done. A sclerosant confirms communication.
• Laparoscopic pericystectomy is becoming more SPECIMEN OF MECKEL’S

popular. Contraindications are deeply situa-
ted cyst, densely adherent cyst, inaccessible DIVERTICULUM
cysts; more than 3 cysts; calcified cysts and • It is a congenital diverticulum arising from
cysts in other organs. Main problem with the terminal ileum and is part of the
laparoscopic pericystectomy is spillage and unobliterated proximal portion of the vitello
difficulty in preventing it. intestinal duct.
• Liver resection – only occasionally segmental — 2% common.
or hemihepatectomy is done. — 2 feet from the ileocaecal valve.
Procedures used to correct the cystobiliary — 2 inch in length.
communications and to obliterate the cavity are: • It is congenital, results from incomplete
• Suturing of the communication – simple closure of vitellointestinal duct. Its base is
suture using vicryl/PDS suture with T tube wide mouthed.
drain of bile duct. • Arises from the antimesenteric border of the
• Pericystectomy(Pericystectomy is done by ileum, containing all three layers of the bowel
peeling off the cyst wall and abdomen is with independent blood supply from terminal
closed with or without a drain); marsupiali- branch of superior mesenteric artery.
sation. • In 20% of cases mucosa contains heterotopic
• Tube drainage of the cavity; capitonage – spiral epithelium like gastric, colonic and or
suturing of the bottom of the cavity upward pancreatic tissues.
from base of cavity to the edge of the cyst • It may be connected to or communicates with
wall; introflexion – inverting the rim of the the umbilicus through a band or fistula.
cyst edge without apposition; omentoplasty. • It may be associated with oesophageal atresia,
• Internal drainage procedures like choledocho- exomphalos, anorectal malformations.
jejunostomy; transduodenal sphinctero-
plasty; Roux-en-Y cysto/intracystichepatico-
jejunostomy; Roux-en-Y hepaticojejunostomy.
• External drainage like cystobiliary discon-
nection anatomically between cyst and fistula
with multiperforated drain into the fistulas
through the cyst with multiperforated drain
into the cyst cavity with a T tube drain into
the bile duct (perdomo procedure); bipolar
drainage.
• Reconstructive procedure like pericysto-
jejunostomy; bile duct repair.
Malignant hydatid disease

• It is a misnomer as it is a benign condition
• It is caused by Echinococcus multilocularis Fig. 3.46: Meckel’s diverticulum
(Alveolaris). Multiple small cysts are seen
all over the both lobes of the liver Presentations of Meckel’s diverticulum
• It is difficult to treat and mimics malignancy • Asymptomatic—majority cases.
both clinically and prognosis wise, hence • Severe haemorrhage—most common
the name complication, seen in children aged 2 years
• They die of liver failure or younger – maroon coloured.
• Intestinal obstruction due to bands/
adhesions/intussusception.
• Perforation.
• Peptic ulceration.
• Diverticulitis-features mimics acute appen-
dicitis.
• Littre’s hernia.
• Silent Meckel’s diverticulum found during
laparotomy or laparoscopy or by radioisotope
study.
Diagnosis
• Tc99 radioisotope scan is very useful – shows
hotspot 95% accuracy.
• X-ray abdomen to see complications like
obstruction, perforation.
• Laparoscopy is very useful. Fig. 3.47: Jejunum showing multiple jejunal diverticula.
Jejunal diverticula are rare. Often it causes obstruction,
• Enteroclysis/small bowel enema may show haemorrhage or perforation. It needs resection.
the Meckel’s diverticulum.
Treatment
• Asymptomatic Meckel’s diverticulum can be
left alone when identified during laparotomy.
• Resection of a short segment of ileum
containing Meckel’s diverticulum and end
to end anastomosis is done.
• Meckelian diverticulectomy with closure of
enterotomy also can be done but chances of
retaining heterotopic tissues and stenosis are
higher.
SPECIMEN OF JEJUNAL
DIVERTICULA
See Figure 3.47.
SPECIMEN OF INTESTINAL
GANGRENE Fig. 3.48: Embolism is the common cause for superior
See Figure 3.48. mesenteric artery ischaemia. It may be from heart, aorta.
Often thrombosis also can cause ischaemia. Gangrene
is extensive involving most of the small intestine (jejunum,
ileum). After resection hardly any significant length of small
SPECIMEN OF INTESTINE WITH bowel is retained which eventually leads into shortgut
INTUSSUSCEPTION syndrome. Patient needs permanent home parenteral
nutrition. Even after surgical resection condition has got
See Figures 3.49A and B. high mortality and morbidity.
• Other causes in adolescents and adults are

submucus lipoma, leiomyoma, polyps in
jejunum (Peutz-Jegher syndrome), other
intestinal polyps, Meckel’s diverticulum and
carcinomas with papillary projections.
Pathology
Parts
• Apex is the one which advances.
• Intussuscipiens is the one which receives (outer
sheath);
• Intussusceptum are the tubes which advances
A B (middle and inner sheath).
Apex and inner tubes will have compromised
Figs 3.49A and B: It is the telescoping of one segment
of bowel into the adjacent segment. Ileocolic is the most blood supply leading in to gangrene.
common type. It occurs in children commonly during Because of ischaemia, apex sloughs off and
weaning period. Red currant jelly stool, sausage shaped bleeds, which mixes with the mucus to produce the
resonant mass, appearing and disappearing of mass,
classic red- currant jelly that is passed per anum.
empty right iliac fossa are the features. Barium enema
shows claw sign; Ultrasound shows target sign/ Due to constriction at the neck, there is impaired
pseudokidney sign. Therapeutic enema using barium or venous return causing congestion, oedema and
air is tried. If it fails, laparotomy, resection and anastomosis further arterial block leading into perforation at
is done.
this site. Gangrene which has set in, leads to
Definition of Intussusception perforation and peritonitis.
It is telescoping or invagination of one portion
(segment) of bowel into the adjacent segment. Clinical Features
• Sudden onset of pain in a male child, with
Types progressive distension of the abdomen,
1. Antegrade—commonest. vomitimg, with passage of ‘red-currant-
2. Retrograde—rare (jejunogastric in gastro- jelly’stool.
jejunostomy stoma). • Often ISS is recurrent, when it gets reduced,
• It can be single or multiple (rare). child automatically feels better and becomes
• It can be ileocolic (most common type, 75%), asymptomatic (Mother often complains that
colocolic, ileo-ileocolic, colocolic. ‘Bachha rotha he, Bachha sotha he’—It means
• It is common in weaning period of a child child cries during an episode and sleeps
(common in male), between the period of peacefully once it gets reduced).
3-6 months. • On examination, a mass is felt either on the
• Idiopathic intususception is common in left or right of the umbilicus which is sausage
children (90%), occurs in terminal 50 cm of shaped with concavity towards umbilicus,
ileum. smooth, firm, resonant, not moving with
• During weaning, change in diet causes inflam- respiration, mobile which contracts under the
mation and oedema of Peyer’s patches—may palpating fingers. Often mass appears and
stimulate disappears.
• Upper respiratory track viral infection which • Right iliac fossa is empty (Sign of Dance).
causes oedema of Peyer’s patches is also • After 24-48 hours, abdominal distension
thought as an etiology for intussusception appears and increases progressively with
in children. features of intestinal obstruction.
• Eventually gangrene and perforation occurs SPECIMENS OF SMALL BOWEL
with features of the peritonitis.
TUMOURS
Differential diagnosis
In children: • Tumours of small bowel, both benign and
Acute gastroenteritis. malignant are rare.
• Incidence is 3% of all GI malignancies. It is
Purpura with intestinal symptoms.
common in males 3:2. It is common in old
In adults:
people.
Carcinoma colon.
• Even though small bowel comprises 75% of
Mesenteric mass.
entire GI length and 90% of GI mucosal
Investigations surface, it is an uncommon tumour. This is
• Barium enema shows typical claw sign or coiled because of less luminal bacterial content;
spring sign. rapid transit time ( 2 hours); less exposure
• Ultrasound shows target sign or pseudokidney of mucosa to potential toxins; protective action
sign or bull’s eye sign which is diagnostic. of alkaline mucus rich succus entericus;
• Plain X-ray shows multiple air fluid levels. capacity of mucosal cells to detoxify
carcinogens like benzopyrones; high levels
Treatment of luminal IgA and more lymphoid tissue
• Reduction by hydrostatic pressure using either in the small bowel wall.
saline or microbarium sulphate solution or air
(popular in China). Barium or saline is infused
into the rectum through a catheter (Foley’s
catheter). Under fluoroscopy, reduction can
be observed. Child passes large quantity of
gas and faeces; distension of abdomen
disappears; pain is relieved; further X-ray
shows ileum, caecum and ascending colon.
Reduction is successful if done within 24 Fig. 3.50: Jejunum showing gross and cut section of
hours of presentation. It is done in children, the leiomyoma of jejunum. Cut section shows fleshy benign
where the success rate is 90%. tumour with smooth capsule.
• If reduction does not occur, laparotomy is done
under G/A. By gently milking out the
intussusception with warm packs, it is
reduced. After reduction viability of the bowel
is checked carefully. If manual reduction is not
possible, it is understood that the bowel is likely
to be gangrenous which requires resection and
anastomosis. In case of viable bowel, often
terminal ileum is anchored to the ascending
colon and Jackson veil band is cut. Patient also
requires nasogastric tube aspiration, IV fluids,
and broad spectrum antibiotics.
• If intussusception persists for more than
48 hours in infants and children or
intussusception in adult requires resection.
Fig. 3.51: Jejunum showing irregular thick constrictive
• Laparoscopic approach is also useful. type of tumour – feature of carcinoma jejunum. Note that
Note: Recurrent intussusception is 2% common. capsule is not present here.
• In duodenum it can present as obstruction/

jaundice
• Investigations – gastroscopy; small bowel
enteroscopy; dynamic enteroclysis; barium
meal follow through or video capsule
endoscopy
• Treatment is surgical resection
• Hamartomas can be left alone unless it
causes life threatening bleed
• Complications—haemorrhage; intestinal
obstruction and perforation; malignant
transformation
Fig. 3.52: Specimen showing ileum, appendix and caecum

and ascending colon. Tumour seen in the ileum which
Malignant Neoplasms of Small Bowel
is well localised and fungating and also large mesenteric • Adenocarcinoma is most common (35%). Other
nodes are clearly visible. types are gastrointestinal stromal tumours
• Aetiology— familial adenomatous polyposis (GIST); carcinoids; lymphoma; leiomyosar-
(FAP); Crohn’s disease; celiac disease coma; liposarcoma.
(commonly lymphoma); previous cholecys- • Metastatic small bowel tumour from
tectomy individuals; HIV and immunosup- melanoma can occur.
pressant therapies in transplant individuals • Presentations – vague abdominal discomfort;
(commonly lymphoma); Peutz-Jegher obstructive features; anorexia and weight loss;
syndrome (rarely turns into malignancy). anaemia; sudden severe bleeding per anum;
• Benign tumours are 50% of small bowel liver secondaries; ascites.
tumours. • When there is small bowel malignancy
additional separate primary malignancy can
Benign tumours of small bowel develop in colorectum/breast/pancreas/
• Brunner gland adenoma—in duodenum. It stomach. This is more common with small
does not turn into malignancy bowel carcinoid.
• Adenoma—common in duodenum. Size • Diagnosis is by – CT abdomen; video capsule
> 2 cm is potentially malignant. It can endoscopy; enteroscopes (push or Sonde pull
present as bleeding–melena/haematemesis; enteroscopes); enteroclysis; barium follow
obstructive jaundice if adenoma is near through X-ray; intraoperative enteroscopy;
ampulla; intestinal obstruction occult blood test in stool.
• Lipoma—common in ileum and jejunum CT abdomen, capsule endoscopy (26 × 11
• Leiomyoma—common in jejunum and mm) and laparoscopy are ideal tools for
ileum diagnosis. In CT, findings are – thickening of
• Hamartoma—Peutz-Jegher syndrome small bowel wall more than 1.5 cm, mesenteric
• Haemangioma nodes, bowel mass more than 1.5 cm; presence
Features of benign small bowel tumours of ileocolic/jejunoileal intussusception with
• Often they are asymptomatic concentric rings and doughnuts.
• GI bleeding is common presentation Most common type—adenocarcinoma is common in
• Intestinal obstruction; intussusception are duodenum and jejunum. Upper GI scopy and
other presentation CT are the investigations. Surgical resection/
• Palpable mass is rare pancreaticoduodenectomy are the procedures
done. It carries a poor prognosis. Patient with cells (Kulchitsky cells) found in the crypts of
Crohn’s disease have still worse outcome. Lieberkuhn. These cells are capable of amine
precursor uptake and decarboxylation (APUD
AJCC staging cells).
T1 – Mucosal; T2 – Muscularis spread;
T3 – Serosal; T4 – Extraserosal to adjacent Types of Small Bowel Carcinoids
tissues; N0 – No nodes; N1 – Presence of nodes; 1. Fore-gut carcinoids: bronchial/thymic/
M0 – No metastases; M1 – Presence of pancreatic/gastric. Produce low levels of
metastases serotonin. It is argyrophillic – cells can be
stained with metallic silver in the presence
GI lymphoma – GIT is most common site of extra
of reducing agent.
nodal lymphoma. It is commonly NHL type.
2. Mid-gut carcinoids: jejunal/ileal/appendi-
Incidence is 20 % of all NHL diseases. Stomach-
cular/right side colonic. Secretes high levels
60%; small bowel – 30% and colon are common
of serotonin. Argentaffin (stained with
sites. Primary small bowel lymphoma is NHL
metallic silver without a reducing agent) and
– B cell type, is common (80%). T cell lymphoma,
argyrophillic both.
when occurs has got worse prognosis than B
3. Hind-gut carcinoids: left-sided colon/rectum.
cell type. In 10-25% cases multiple lymphomas
Rarely produce serotonin, but produce
may be present.
somatostatin and peptide YY. Presentation
Usual presentations are malabsorption,
as submucosal nodules without ulcers. They
obstruction, palpable bowel mass (well-defined,
are hormonally inactive. It does not stain with
smooth and firm, mobile, with impaired reso-
silver.
nance, not moving with respiration,), perforation,
GI bleeding. Features of small bowel carcinoids
CT scan will show mass lesion; thickened • Primary tumour is usually small, < 1cm; when
bowel wall; mesenteric nodes; obstruction. size is < 1 cm nodal and hepatic spread is
CT guided biopsy may be beneficial in confirming. 20-25%. When size is 1-2 cm nodal spread
Treatment is surgical resection/chemo- increases to 80% but hepatic spread is
therapy. Overall prognosis is poor. 20 -25%. When tumour is more than 2 cm
nodal spread is more than 80% and hepatic
Diagnostic criteria for primary GI lymphoma spread is 50%.
are • Seen in 50-60 years of age group.
• Absence of clinically palpable lymph nodes • May be multicentric, when tumour is in
in neck/axilla organs other than appendix, like in small
• Absence of mediastinal nodes on chest bowel—40%. Appendicular carcinoid is
imaging like CT typically solitary.
• Absence of spleen/liver involvement • May coexist with synchronous adenocarci-
• Normal peripheral blood count noma of large bowel or breast.
• Mesenteric lymph nodes may be present • Most often they are asymptomatic—found
incidentally, and difficult to diagnose unless
Carcinoid Tumour there is hepatic spread.
It commonly occurs in appendix (65%), ileum • May present with abdominal pain, features
(25%), other parts of GIT and rarely bronchus, of intestinal obstruction.
testis, and ovary. In the small intestine, carcinoids • Once secondaries develop in the liver (which
are most often seen within the terminal 2 feet is yellowish) carcinoid syndrome develops
of the ileum. They arise from the enterochromaffin (10%), which is due to release of 5-HT, kinins,
prostaglandins, histamine and indoles • But it is the most common non-epithelial

causing flushing, diarrhoea, cyanosis, tumour of the small bowel. 25% of all GISTS
asthmatic attacks hepatomegaly, cardiac are from small bowel (Stomach is the
lesion on right side. Flushing and erythema commonest site of GIST – 50%; rectum – 15%;
of face and trunk is common – 80%. Tricuspid colon–10%).
and pulmonary valve fibrosis and stiffening • Equal in both sexes and common in 50-70
occurs due to persistent high 5 HIAA causing years age group.
right heart failure. Syndrome signifies hepatic • GIST arises from interstitial cell of Cajal
spread/bronchial carcinoid/retroperitoneal (pacemaker cell which intercalates between
carcinoid. Attacks can be induced by alcohol. smooth muscle cells and intramural neurons).
• Urine shows increased 5-hydroxy-indole- Mutation of tyrosine kinase and platelet
acetic acid (5HIAA) levels in 24 hours sample- derived growth factor alpha (PDGFα) are the
signifies carcinoid syndrome. newer pathogenetic theories.
• Indium 111 octreotide scintigraphy; I131 MIBG • GIST is classified as very low risk (2 cm);
scan and CT scan abdomen are very useful low risk (2-5 cm); intermediate risk (5-10 cm)
tools. and high risk (> 10 cm) based on tumour
size and mitotic activity of cells.
Treatment • 95% of GISTs express c-kit—CD117
• Surgery mutations a specific molecular marker.
If it is in the tip of the appendix (tip is common • Clinical features: Abdominal pain; weight loss;
site), appendicectomy and regular follow up GI bleed and large mass abdomen are typical.
is sufficient. If it is at the base of appendix Mass is extraluminal as it is submucosal
or terminal ileum right hemicolectomy is origin but expands and compresses the
required. In small bowel, if the primary mucosa. 50% of GIST can present as
tumour is < 1 cm, with no lymph nodes, then metastatic disease of liver and peritoneum
segmental intestinal resection and (ascites).
anastomosis is sufficient. Wide excision of GIST almost never metastasise to regional
bowel is necessary in case of large, multiple lymph nodes.
carcinoids, with involvement of lymph nodes. • Investigation: CT scan is the main
In liver secondaries, along with surgical investigation; others being tumour/molecular
debulking hepatic resection, hepatic artery marker to differentiate it from sarcomas.
ligation or embolisation is tried. Endosonography guided biopsy/guided
• Medical treatment FNAC are important to get histological
Mainly symptomatic when it is advanced or confirmation. 18 FDG PET scan is very useful
with spread; long acting somatostatin adjunct to CT but reserved for difficult/
analogue – octreotide can be given. 90% equivocal cases.
symptom palliation is achieved. Serotonin • Treatment: Surgical excision, commonly with
antagonists, antihistamines, alphamethyl bowel resection.
dopa, 5-Fluro-uracil, interferon—alpha, Imatinib mesylate—a specific oral drug (year
doxorubicin, dacarbazine, radiolabeled 2000) that inactivates tyrosine kinase kit and
somatostatin analogue and Indium111 labelled so prevents phosphorylation of the receptor
pentetreotide are tried with variable benefits. and proliferation of tumour is very much
beneficial in advanced cases. Now it is also
Gastrointestinal Stromal Tumours (GIST) used if the tumour size is more than 10 cm;
• It is rare tumour of GI tract – 0.2 % of all intraperitoneal rupture/spillage; haemor-
GI tumours. rhage in GIST; multifocal tumour. Duration
of Imatinib is usually one year. Newer drug pneumonia/spluttering during swallowing;
– SU11248 inhibits tyrosine kinase receptor stridor/regurgitation. Leiomyoma is smooth,
as well as blocks PDGFRA. Another newer sessile, lobulated, firm, with grey white whorled
derivative – sunitinib is used in imatinib appearance. Only when leiomyoma reaches
refractory cases. 5 cm in size it causes obstruction. Multiple diffuse
• Prognostic factors for GIST: Size of GIST more leiomyomas can occur occasionally in females,
than 5 cm; higher mitotic activity (> 10 mitoses often as part of the Alport’s syndrome which
per high power field); liver spread; KIT exon needs total oesophagectomy with gastric pull
9 mutation is more aggressive than KIT exon up, even though benign. Benign leiomyoma of
11 mutations. oesophagus rarely turns into leiomyosarcoma.
90% of oesophageal leiomyomas occur in lower
third of the oesophagus.
SPECIMEN OF CARCINOMA
• Investigations: are barium swallow X-ray/
OESOPHAGUS Oesophagoscopy/endosonography/CT
Benign tumours of the oesophagus are rare (1%). scan.
It grows slowly like a balloon by expansion with • Treatment: If tumour is more than 5 cm/
compression of surrounding structures. It never symptomatic tumour/intraluminal tumour/
infiltrates or spreads. It can cause obstruction/ when diagnosis is doubtful surgical
regurgitation/aspiration/mediastinal compres- enucleation is indicated. Enucleation is the
sion. It can be squamous papilloma/polyp/ choice therapy. Ideally through right-sided
inflammatory pseudo tumour/leiomyoma (com- thoracotomy it should be done. Occasionally
monest benign tumour of oesophagus–65%)/ oesophageal resection is needed if tumour
neurofibroma/rhabdomyoma/lipoma. True is very large/tumour with mucosal
adenoma in oesophagus is very rare. ulceration/if tumour is near OG junction.
— Features may be asymptomatic (85% Thoracoscopic resection can be done. Leak,
identified incidentally during contrast X-ray/ empyema, sepsis and stricture are the
endoscopy); dysphagia/air way obstruction/ occasional complications.
A B C
Figs 3.53A to C: Specimen showing gross as well as cut section of oesophagus
with proliferative lesion in the oesophagus. It is oesophagectomy specimen.
Note: Unlike in the stomach and intestine (gastric • Lipoma should be differentiated from
leiomyoma more than 6 cm/intestinal leiomyoma neurofibroma, sebaceous cyst.
more than 4 cm are potentially malignant), • Complications of lipoma are saponification,
increased size of the oesophageal leiomyoma calcification, infection, myxomatous
does not predispose the malignant transfor- degeneration and sarcomatous changes.
mation. • Lipoma in the retroperitoneum, thigh and
shoulder region commonly undergoes
SPECIMEN OF LIPOMA sarcomatous changes. Features of sarcomatous
• Lipoma is commonest benign tumour – changes are – rapid increase in size, increased
universal/ubiquitous tumour. It is benign vascularity with dilated veins, and fixity to
neoplasm which is usually capsulated arising deeper structures. Liposarcoma is the
from yellow fat. Tumour arising from brown commonest sarcoma. It may cause blood
fat is called as hibernoma – rare. spread to lungs and so CT chest should be
• It can be subcutaneous; subfacial; intramus- done along with incision biopsy of the primary
cular; subserosal; submucous; subsynovial; lesion.
intraarticular; intraglandular; extradural or • Treatment of lipoma is excision. It is done
retroperitoneal. using local anaesthesia if lipoma is small;
• Fibrolipoma is lipoma with fibrous tissue. under general anaesthesia if lipoma is large.
• Neurolipoma is lipoma with neural comp- • Liposarcoma is treated by wide excision/
onents which is often multiple and painful. compartment excision/amputation with
• Naevolipoma contains lipoma with haeman- adjuvant chemotherapy and regular follow
giomatous tissue with bluish discolouration up.
over the skin.
• Multiple lipomatosis are common in buttocks, SPECIMEN OF PAPILLOMA
thigh and neck.
Papilloma is warty swelling from the skin or
• Diffuse lipoma occurs commonly in plantar
often from the mucous membrane. It has got a
aspect, and retroperitoneum.
central axis of connective tissue, blood vessels
• Dercum’s disease/adipose dolorosa is
and lymphatics.
commonly seen in females; common in trunk,
buttocks and thigh. It is painful, tender,
usually diffuse deposition of fat without any True Papilloma
capsule. • It is a benign tumour with localised
• Lipoma is clinically smooth, soft, nontender, overgrowth of the epidermis. It is commonly
freely mobile, semifluctuant, usually non- pedunculated but rarely can be sessile.
transilluminant and slips between fingers.
Edge of the swelling when pressed with
fingers causes displacement of the swelling.
Fig. 3.54: Specimen of lipoma. Note the colour and Fig. 3.55: Pedunculated papilloma of skin. Note the
gross look. variegated surface and its root.
Pedunculated papilloma is villous with a
central axis of connective tissues, blood
vessels and lymphatics.
• Infective papilloma is a warty lesion due to
infection. For example, condyloma acuminata.
• Papilloma may be single or multiple. Papilloma
may be pigmented or nonpigmented.
• True papilloma may turn occasionally into
squamous cell carcinoma. There will be sudden
increase in size, bleeding or ulceration.
• Differential diagnosis: Amelanotic melanoma,
pedunculated lipoma or carcinoma.
• Papilloma can occur in the breast called as
duct papilloma which is the commonest cause
of bloody discharge from the nipple.
A
• Papilloma can occur in mucus membrane like
in oral cavity, urinary bladder (transitional
papilloma), in the rectum (columnar), in the
larynx, in the gallbladder (cuboidal).
• Treatment: True papilloma is excised with its
base along with surrounding 1 cm skin
margin. Infective warts can be treated by
excision or CO 2 snow or diathermy
coagulation.
Complications of papilloma
• Bleeding
• Malignant transformation
• Ulceration
• Mechanical disability like voice change B
when it occurs in vocal cord
SPECIMEN OF MELANOMA
Melanoma is common in females. In females, leg
is the commonest site. In males, trunk is the
commonest site. In Bantu tribe sole is the
commonest site. Eyes, mucocutaneous junction,
head and neck, meninges, oral cavity and
paranasal sinuses are other sites.
It is most common in Queensland Australia.
It is also common in Western countries and in
whites. C
Figs 3.56A to C: Black pigmented lesion in the skin
Risk factors are
of heel. Note the cut section to see the depth. Also note
• Exposure to UV light. the specimen of ilioinguinal block dissection showing multiple
• Albinism, xeroderma pigmentosa. lymph nodes which are pigmented.
• Junctional naevus, familial dysplastic M 1c—Other viscera or distant spread and

syndrome, sporadic dysplastic naevi. increase in LDH.
• Congenital naevus, size more than 20 cm.
• Familial (10% - through chromosomes 1p, 6q, Staging of malignant melanoma (older
7 and 9). system)
• Earlier skin cancers other than melanoma. IA: Thickness less than 0. 75 mm
• Patients who are on immunosuppressive IB: Thickness between 0.76 to 1.5 mm
drugs like after renal transplantation or NHL. IIA: Thickness between 1.51 to 4.0 mm
IIB: Thickness more than 4.0 mm
Differential diagnosis for melanoma (other pigmented
IIIA: Any of the above+ nodes less than
lesions of the skin)
3 cm
• Seborrheic keratosis, dermatofibroma.
III B: “ +nodes more than 3 cm
• Pigmented BCC, pigmented SCC.
IV: “ + any node + M1(distant spread).
• Naevus, sebaceous epidermal naevus.
• Kaposi’s sarcoma, mycosis fungoides.
Types
• Cutaneous haemangioma.
• Cutaneous melanoma
• Certain skin adnexal tumours.
• Extracutaneous (ocular is common site)
• Solar keratosis.
• Occult (Unknown primary).
• Pyogenic granuloma.
• Cutaneous angiosarcoma. Breslow’s classification:
Based on thickness of invasion measured by
Newer TNM staging (2002) for melanoma
optical micrometer.
T—Tumour. • I: Less than 0.75 mm.
T0—No tumour. • II: Between 0.76 to 1.5 mm.
Tis In situ tumour. • III: 1.51 mm to 4 mm.
T1a < 1 mm, level II, level III no ulceration. • IV: more than 4 mm.
T 1b < 1 mm, level IV with ulceration. Clark’s levels
T 2a 1—2 mm no ulceration. • Level 1: Only in epidermis.
T 2b 1—2 mm with ulceration. • Level 2: Extension into papillary dermis.
T 3a 2—4 mm no ulceration. • Level 3: Filling of papillary dermis
T 3b 2—4 mm with ulceration. completely.
T 4a > 4 mm no ulceration. • Level 4: Extension into reticular dermis.
T 4b > 4 mm with ulceration. • Level 5: Extension into subcutaneous
N—Node tissue.
N0 No nodes. Important features of melanoma
N1a one node micrometastasis. • Asymmetry
N1b—one node macrometastasis. • Border irregularity
N2a—2 or 3 nodes micrometastasis. • Colour variation
N2b—2 or 3 nodes macrometastasis. • Diameter > 6 mm
N2c—no nodes but satellite or in transit lesions. • Elevation
N3— 4 or more nodes; nodes with satellite or
in transits. Clinical Types
M—Metastasis • Superficial spreading melanoma: Most common
M 0—No blood spread. – 65%. It has got variegated irregular look;
M 1a—Skin, subcutaneous tissue, distant node. can occur in any part of the body; it has got
M 1b—Lung spread. radial growth and better prognosis.
• Nodular melanoma: 12-25%. Common in Features
younger age group; more aggressive; common • It can start in a pre-existing naevus (commonly
in mucosa and mucocutaneous junction; junctional naevus)-90% or as denovo in a
uniform, nodular; more vertical growth; nodal normal skin.-10%.
spread is common; has got poor prognosis. • Melanoma is unknown before puberty.
• Lentigo maligna melanoma: 7-15%. Less • Pigmentation with irregular surface and
common; least malignant; commonly involves margin with rapid growth.
head, neck, face and upper limbs; common • Ulceration, bleeding, itching, changes in the
in old age; also called as Hutchinson’s colour.
melanotic freckle. • No induration in melanoma.
• Acral lentiginous melanoma: 5%. Least common;
occurs in palms, soles and subungual region; Note: When a mole turns malignant, following
usually attains large size; nodular type with changes should be observed.
more vertical growth phase; has got poor • Major signs: Change in size, shape and colour.
prognosis. It is common in Japan. • Minor changes: Inflammation, crusting,
• Amelanotic melanoma: This is the worst type. bleeding, itching, diameter more than 5 mm,
Because of the undifferentiation, tumour cells halo around a mole.
loose their capacity to synthesise melanin.
It presents as rapidly progressive, pinkish Spread
fleshy tumour. It may mimic soft tissue • Through lymphatics it spread to regional lymph
sarcoma. It needs markers like S100, HMB45 nodes either by permeation or by emboli-
for diagnosis. sation. In-transit nodules or satellite nodules
in the skin between primary and regional
lymph node area is often seen due to
Melanoma retrograde spread to dermal lymphatics.
• 5 % of all skin cancers—Incidence • Through Blood: To lungs, liver (huge liver),
• 20 times more common in whites than blacks brain, skin, bones. Secondaries are typically
• Mucosal melanoma has got poor prognosis black. Extensive visceral involvement causes
• Can spread from mother to foetus melanuria. Melanoma in retina has got better
• Multiple melanomas are 1% common. prognosis, because there are no lymphatics,
• Melanoma in choroid will not cause lymph spread is delayed.
node involvement, as it has no lymphatic • Sometimes primary is very small and so
drainage. But late massive liver secondaries unnoticed (in anus, subungual region). They
are known to occur even after 10–20 years. present with features of secondaries only.
• 10% of melanomas are familial.
• Satellite nodules are secondary skin nodules Blood Spread in Melanoma
within 2 cm of primary. • Brain: Convulsions, localising features and
• ‘In-transit’ nodules are secondary skin raised intracranial pressure.
nodules beyond 2 cm of primary anywhere • Lung: Cannon ball secondaries, pleural
up to lymph node region. effusion, haemoptysis, chest pain and cough.
• Melanoma may present as occult secondary • Liver (massive liver), ascites.
(in liver, lungs, bone, brain) with unknown • Skin: cutaneous nodules often pigmented.
primary when primary is in anus, genitalia, • Bones: bone pain, pathological fracture.
eye, external auditory canal, adrenal gland, Paraplegia/neurological deficits in spine
nail bed and scalp metastasis.
Investigations • Isolated limb perfusion is done for melanomas

• No incision biopsy. It can cause early blood in limbs using melphalan. Femoral artery and
spread. vein are separately cannulated with a
• Excision biopsy of primary is ideal and proximal tourniquet. Melphalan is injected
commonly used method. at temperature 41ºC with oxygenator so that
• FNAC of lymph node. tumour tissues/cells become more sensitised
• Ultrasound abdomen to see liver secondaries for chemotherapy. Good control of local
(usually huge hepatomegaly occurs). disease is achieved with preservation of the
• Chest X-ray to see secondaries – cannon ball limb. DVT, bleeding, sepsis and gangrene of
type. HRCT of chest is ideal. the limb are the occasional complications.
• Relevant other methods depending on site There are less systemic toxicities.
and spread. • Chemotherapy using DTIC, melphalan,
• Urine for melanuria. carboplatin, vindesine is given especially
when there are secondaries in lungs, liver
Treatment for Melanoma or bones.
• Wide excision of 3-5 cm clearance. Skin graft • Immunotherapy/biological therapy using BCG,
or flaps are used to cover the defect. levamisole, Corynebacterium parvum, alpha
• Amputation, if small melanoma is in distal interferon is also used with some success rate
phalanx/subungual region. up to 40% in advanced melanomas.
• Disarticulation is done if it is in proximal
phalanx or large melanoma in fingers or Tumour Markers for Melanoma
melanoma in toes. • Melan–A.
• Melanoma between toes (web) needs forefoot • S 100.
amputation or disarticulation of adjacent two • HMB 45 (hydroxyl methyl bromide).
toes with adequate clearance. • LDH.
• Melanoma anal canal needs abdomino perineal
resection. Relation of tumour thickness to nodal spread–
• Enucleation of eye when primary is in eye. based on AJCC classification
• When FNAC of lymph nodes shows positive Lesion Tumour thickness Nodal spread
for tumour cells, then therapeutic lymph node Thin < 1 mm < 10%
block dissection is done. When FNAC of lymph Intermediate 1-4 mm 20-25%
node is negative, then elective lymph node Thick > 4 mm 60%
dissection (ELND/prophylactic lymph node
dissection) is done if tumour is undifferen-
tiated/thickness is 1-4 mm to prevent possible Prognostic factors
eventual nodal spread. ELND in FNAC • Tumour thickness—very important factor
negative patients is said to reduce the • Nodal spread
progression of the disease. • Ulceration
• Sentinel Lymph Node Biopsy (SLNB) is done • In-transit nodules
by injecting radio-labelled Tc 99 colloid • Vertical growth—poor prognosis
sulphur around primary tumour (or by • Metastatic disease
injecting isosulphan blue) and first node is • Staging
identified using gamma camera. It is dissected • Mitotic activity
and frozen section biopsy is done to confirm • Clinical types
the involvement. • Amelanotic—poor prognosis
Staging as prognostic factor

Stage I — > 90% prognosis
Stage II — 70%
Stage III — 35%
Stage IV — < 2%
SPECIMEN OF THYROID
B
Figs 3.58A and B: Gross and cut section of hemithyroidec-
B tomy. Entire lateral lobe and isthmus are removed. It is
done in solitary nodule thyroid/non toxic or toxic adenoma
of thyroid.
Figs 3.57A and B: Specimen of subtotal thyroidectomy
showing multiple nodules in both lobes. Specimen includes
both lateral lobes including isthmus (except only tissue
equivalent to pulp of the finger is retained in lower posterior
aspect of the gland). Procedure is done for nontoxic/
toxic multinodular goitre. Cut section shows multiple nodules
with few haemorrhagic spots. Nodules are usually non-
functioning but internodular tissues are active.
Hemithyroidectomy is removal of entire one lateral lobe
and entire isthmus. It is done when disease is limited
only to one side of the gland. Partial thyroidectomy is
removal of both lateral lobes of the gland which is in
front of the tracheo-oesophageal groove with isthmus.
It is done in nontoxic nodular goitre (but subtotal
thyroidectomy is better option). Near total thyroidectomy
is removal of most of the glands except small tissue
adjacent to parathyroids and recurrent laryngeal nerve.
It is done in papillary carcinoma of thyroid. Total Fig. 3.59: Specimen of thyroid after total thyroidectomy
thyroidectomy is removal of entire lateral lobes with isthmus. done for follicular carcinoma of thyroid. Note the both
It is done in case of follicular carcinoma of thyroid and lateral lobes and isthmus. Total thyroidectomy is done
medullary carcinoma of thyroid. for follicular and medullary carcinoma of thyroid.
SPECIMEN OF URINARY SPECIMEN OF PILONIDAL SINUS

BLADDER STONE
Urinary bladder stone can be primary or
secondary (occurs in bladder itself secondary
to infection). It is usually radio-opaque unless
it is uric acid stone. Presentations are –
suprapubic pain; haematuria; retention of urine Fig. 3.61: Pilonidal sinus. It is tuft of hairs entering into
the deeper plane causing inflammation, reaction and sinus
and recurrent cystitis. formation. It is common in intergluteal region in the midline
Treatment: Cystoscopic removal of stone after cleft. It can occur in webs of the hand or axilla occasionally.
fragmentation; laser fragmentation and removal; It is common in jeep drivers hence called as jeep bottom.
It is also common among barbers. Sinus in the midline
suprapubic percutaneous cystoscopic extraction is called as primary sinus. It eventually spreads laterally
or open suprapubic extraperitoneal cysto and forms additional sinuses in paramedian area called
lithotomy. as secondary sinus. It causes recurrent infection, abscess
formation which bursts open forming recurrent sinus with
pain, discharge and discomfort. Chronic pilonidal sinus
can cause sacral osteomyelitis, necrotising fasciitis.
Treatment : Excision and primary closure in prone position
under general anaesthesia; excision with Z plasty; excision
with multiple Z plasty; Karydakis excision and lateralised
suturing of the wound away from the midline; Limberg
buttock flap; Bascom technique of excision through lateral
approach is a good method. Through small lateral incision
or multiple small lateral incisions 2-4 mm sized sinus is
approached and pus is drained; hairs are removed with
only minimal excision of sinus is done. Cavity walls are
not excised. Lateral small wounds are either sutured or
left open for spontaneous healing. Condition has got high
recurrence rate (20%). It is due to improper removal,
overlooking of existing diverticulum, entry of new tuft of
hairs, breakage of scar.
SPECIMEN OF ROUNDWORMS
Fig. 3.60: Photo of oxalate and phosphate stones in
Ascaris lumbricoides is the causative worm. It
two different patients. Oxalate stone is brown/brownish
black in colour, hard with spikes (projections) on the causes worm colic; toxicity; acute intestinal
surface. Its colour is due to blood from the bladder
mucosa due to injury from spikes of the stone which Treatment of roundworm obstruction
gets coated over the surface. Oxalate stone is primary • Drugs: Piperazine citrate, mebendazole,
bladder stone which initially descends from the kidney albendazole.
above and then gets enlarged in the bladder. Phosphate • Most often by conservative treatment, worms
stone is white in colour, smooth, often softer with a
nidus in the centre and concentric laminations. Phosphate
get dispersed and passes per anally. But
stone is a secondary stone which is secondary to patient requires nasogastric aspiration, IV
infection—( E. coli, Proteus ), triple phosphate stone fluids, antibiotics, and observation.
(calcium magnesium ammonium phosphate stone). In • If patient is not responding, then laparotomy
this patient this stone has occurred in an existing ureteric is done. Worm bolus in the distal ileum is
stent site. milked in to the caecum. Often enterotomy
and removal of worms is required.
• Perforation due to worm requires immediate Note: Perforation usually occurs at the site of
laparotomy, removal of worms and closure pre-existing disease like nonspecific ileal ulcer,
of perforation. amoebic ulcer, typhoid ulcer, and suture line.
• Only rarely, resection and exteriorisation Vomiting of the roundworms does not signify
is required. obstruction by roundworms. It only signifies there
is intestinal obstruction (due to any cause) and
so worms proximally gets irritated and dispersed
moving proximally to get expelled per mouth.
SPECIMEN OF TESTICULAR
TUMOUR
99% of testicular tumours are malignant.
Figs 3.62A and B: Bolus of roundworms removed through

enterotomy as it was causing complete intestinal obstruction
at ileum. Enterotomy is closed afterwards horizontally.
Specimen 2nd shows roundworm bolus in the intestine.
obstruction with palpable worm bolus per abdo- B

men; recurrent subacute obstruction; perforation
at ileum leading to peritonitis; malabsorption; Figs 3.63A and B: Gross and cut-section of testicular
tumor. Note the cystic spaces with solid tissues and
iron deficiency anaemia; intraperitoneal abscess cartilages which signify the feature of teratoma of testis.
formation. Teratoma arises from totipotent cells in rete testis.
testis. If the testis is abdominal (abdominal

cryptorchid) and not hormonally adequately
active, then it is 20 times more prone to
develop testicular tumour and so
orchidectomy should be done. Patient with
inguinal cryptorchid who has not underwent
orchidopexy before puberty is more prone for
testicular tumour. 10% of testicular tumours
are associated with undescended testis. 5%
of patients with undescended testis develop
testicular tumour on the opposite side with
normally descended testis. Late orchidopexy
does not prevent testis from turning into
carcinoma but allows early diagnosis because
A
of the easily palpable position.
• Testicular atrophy.
• Klinefelter’s syndrome: Eunuch features;
testicular atrophy; gynaecomastia with
47 XXY karyotype.
• Hormonal fluctuation.
Classification
• Seminoma—40%.
• Teratoma—32%
• Seminoma + teratoma—14%.
• Choriocarcinoma, yolk sac tumour, embryo-
nal carcinoma
• Interstitial tumours—1.5% (Leydig cell
tumour, Sertoli cell tumour)
• Gonadoblastoma
• Lymphomas—7%; has got poor survival
rate. CNS/bone marrow disease is common
• Others—carcinoids, secondaries, meso-
thelial tumours, sarcomas
B
Figs 3.64A and B: Specimens showing seminomas with Seminoma Testis
smooth fleshy tumour and teratomas with solid and cystic
areas.
• It starts in the mediastinum of the testis.
It arises from germinal epithelium of the
Predisposing Factors secretary tubules of the testis.
• Undescended testis: There are abnormal germ • Grossly, it is lobulated, fleshy, homogeneous,
cells; altered blood supply and temperature; and creamy or pinkish in colour and it
gonadal dysgenesis. If testis is inguinal compresses adjacent testicular tissue.
(inguinal cryptorchid), then orchidopexy if • Histologically, malignant cells resemble
done before puberty, the incidence of testicular spermatocytes which are clear cells, with
tumour is equal to that of normally descended lymphocytic infiltration.
• It spreads through testicular lymphatics into Clinical Features
the para-aortic lymph nodes and then to left • Enlargement of testis.
supraclavicular lymph node. Through blood, • Fullness and heaviness in the scrotum.
it spreads to lungs, liver, brain and bone. • Pain in the testis (30%).
Types of seminoma • Testis will be enlarged, firm, and heavy, with
• Typical/classic form: It is commonest type; loss of testicular sensation.
occurs in middle age; syncytiotrophoblastic • Secondary hydrocele is common.
type (15%) occurs and produces high levels • Cremaster is hypertrophied and thickened.
of beta HCG. • Vas, prostate and seminal vesicles are normal.
• Spermatocytic seminoma: Occurs in older • Often para-aortic lymph nodes may be
people with different phases of spermato- palpable in epigastric region as hard,
gonia. Spread in this type is very rare. nodular, nontender, nonmobile, vertically
• Anaplastic type has got high mitotic index/ placed, resonant mass (not moving with
nuclear pleomorphism/anaplasia with high respiration).
potentiality to spread. • Haemoptysis, altered breathe sounds and
pleural effusion due to lung secondaries.
Teratoma • Bone pain and tenderness due to secondaries
• It arises from totipotent cells, i.e. ecto, meso, in bone.
endoderms. • Nodular secondaries in the liver.
• Grossly tumour surface is irregular, cut • Occasionally it may mimic acute epididymo-
section shows solid and cystic spaces with orchitis or acute haematocele.
areas of haemorrhages. It often contains • Gynaecomastia may be present in few
gelatinous fluid and cartilaginous nodules. teratomas.
Histologically there are four types—
Hurricane type is very aggressive, highly
1. Teratoma differentiated: (1%)
malignant testicular tumour which is more often
2. Teratoma intermediate: 30% common. Two
fatal in few weeks.
subtypes are A and B. Matured cells are found
Rarely, if tumour comes out of the tunica
in A type but in B type proper differentiated
tissues are not found and is more malignant. albuginea (tunica albuginea is resistant for
3. Teratoma anaplastic: (15%). Secretes alpha feto malignant cell infiltration), then scrotum gets
protein (AFP). infiltrated and spread can occur to inguinal
4. Teratoma trophoblastic: (1%). It shows high lymph nodes.
levels of βHCG. (Normal level is 100 IU).
Differential diagnosis
Interstitial Cell Tumour • Acute and chronic haematocele
• Leydig cell tumour (2%) musculinises. • Acute epididymoorchitis
Prepubertal tumour shows excessive output • Syphilitic orchitis
of androgens causing sexual precocity, • Lepra orchitis
extreme muscular development and may
mimic infant hercules.
• Sertoli cell tumour (1%) feminises. Postpubertal Sign of vas: To differentiate tumour from infection
tumour commonly arising from Sertoli cells - in testicular tumours vas is normal, cord
causes feminising effect with gynaecomastia, structures may become bulky because of
loss of libido and aspermia. It may be classic/ cremasteric hypertrophy where as in infection
large cell calcifying/sclerosing. vas is thickened, beaded, and tender.
Staging of testicular tumours Raised AFP always indicate teratomatous

I. Lesion confined to testis. feature of the tumour. AFP level is not increased
II. Nodes involved below the diaphragm in pure seminomas. HCG may be elevated in
III. Nodes involved above the diaphragm. advanced cases of seminomas. LDH level
IV. Distant (blood) spread. depends on growth rate/cellular prolifera-
tion/tumour burden. LDH is increased in
TNM staging 80% of advanced seminomas and 60% of
T0 No evidence of tumour nonseminomatous germ cell tumour.
Tis Carcinoma in situ • Chest X-ray to see lung secondaries. HRCT
T1 Tumour limited to testis and epididymis. scan is ideal.
Vascular/lymphatic invasion not • Ultrasound abdomen to see nodal status like
present. Tumour may invade tunica paraaortic nodes and liver secondaries. CT
albuginea but not tunica vaginalis abdomen is better.
T2 Tumour limited to testis and epididymis • Ultrasound scrotum to see echogenicity of
with vascular/lymphatic invasion. Or testis and tumour within.
tumour extends through the tunica
albuginea with involvement of tunica Treatment
vaginalis • Seminomas are radiosensitive. So after high
T3 Tumour invades spermatic cord with or orchidectomy, radiotherapy is given to
without vascular/lymphatic invasion. increase the cure rate and also to reduce
T4 Tumour invades scrotum with or without relapse. It is the treatment of choice in stage
vascular/lymphatic invasion I seminomas. Opposite testis should be
N0 Regional lodes not involved shielded during radiotherapy.
N1 Single/multiple nodes—not more than • Seminomas with high tumour marker level
2 cm in size are treated as nonseminomatous tumours.
N2 Regional nodes – between 2-5 cm • Chemotherapy is also effective. Cisplatin is
N3 Regional nodes > 5 cm very useful drug in seminoma.
M0 Distant spread not present • In teratoma after high orchidectomy,
M1 Distant spread present Retroperitoneal radical lymph node dissection
M1a Distant spread to nonregional nodes or (RPLND) is beneficial. Even in stage I disease,
to lungs chances of existing retroperitoneal spread is
M1b Distant spread to other than nonregional 30%. So RPLND (infra hilar) has a major role
nodes or lungs especially in teratomas which are relatively
radioresistant. It is removal of precaval,
Investigations retrocaval, paracaval, interaortocaval,
• No FNAC; No scrotal approach; No incision biopsy. retroaortic, para-aortic, common iliac nodes
Through inguinal approach, cord and testis along with removal of gonadal vein with
are exposed. A soft clamp is applied to the adjacent fibrofatty tissues from internal ring
cord at or above the level of the deep ring level to its insertion in to renal vein on left
so as to prevent dissemination through blood. side and inferior vena cava on right side.
Frozen section biopsy is done from the Commonly bilateral RPLND is done as
suspected area. If tumour is positive high contralateral nodes also can be involved.
orchidectomy is done (Chevassou manouvre). RPLND mortality is only 1%. Complications
• Measurement of tumour markers (βHCG, AFP, are haemorrhage; injury to structures like
LDH). AFP and HCG are elevated in nonsemi- major vessels/ureter/bowel; chylous ascites;
nomatous germ cell tumours (teratomas). lymphocele; retrograde ejaculation.
• Radiotherapy is not beneficial in teratoma. SPECIMEN OF TUBERCULOUS
• Chemotherapeutic drugs for teratoma are
Cisplatin, bleomycin, vinblastine, etoposide,
LYMPHADENITIS
ifsofamide, mesna, paclitaxel.
Follow-up
• Measurement of tumour markers at regular
intervals for 5 years and yearly after 5 years.
• CT abdomen and chest once a year.
Factors Affecting the Prognosis

• Histological appearance of tumour.
• Staging of the tumour.
• Age of the patient, younger the age poorer
the prognosis.
• Seminoma has got better prognosis than
teratomas.
• Hurricane type has got worst prognosis.
Fig. 3.66: Specimen of tuberculous lymphadenitis showing
yellowish caseating material with matting due to periadenitis.
SPECIMEN OF STAGHORN It is common in neck. Caseating type is more common
than hyperplastic type. Histologically epithelioid cells are
CALCULUS OF KIDNEY most important other than giant cells of Langhan’s,
macrophages.
Stages of Tuberculous Lymphadenitis

1. Stage of infection. and lymphadenitis.
2. Stage of periadenitis with matting.
3. Stage of caseating necrosis and cold abscess
formation.
4. Stage of formation of collar stud abscess.
5. Stage of formation of sinus which discharges
yellowish caseating material.
(For detail please refer chapter surgical procedures)
SPECIMEN OF SECONDARIES
IN NECK LYMPH NODES
See Figure 3.67.
(Please refer for detail chapter short cases)
Fig. 3.65: Staghorn calculus occupies the major and minor
calyces. It presents as recurrent pyelonephritis,
pyonephrosis and if bilateral renal failure. If kidney function
SPECIMEN OF TRANSITIONAL
is adequate which is confirmed by DTPA radioisotope CELL CARCINOMA OF BLADDER
scan then nephropyelolithotomy is done. Often initial
nephrostomy is needed. See Figure 3.68.
3. Squamous cell carcinoma originates from

bilharzial infection (5%) or calculus.
b. Connective tissue tumour:
1. Myoma, angioma, fibromas, sarcomas
2. Extra adrenal phaeochromocytoma.
2. Secondary: from adjacent organs like sigmoid
colon, rectum, uterus, and ovary, prostate.
Transitional Cell Carcinoma (TCC)

It is the commonest type of bladder tumour.
Aetiology
3C’s - Chemical carcinogens.
- Cigarette smoking.
Fig. 3.67: Secondaries in neck is hard, solid adherent - Cyclophosphamide.
tumour with often central necrosis and haemorrhages.
It may get fixed or eroded into major structures in the
Chemical carcinogens are the main factor.
region causing life threatening bleeding. Site for primary 2-Naphthylamine, aminobiphenyl, benzidine,
should be evaluated. Secondaries are treated by surgical chloro-O-toluidine, chloro aniline, other dyes.
block dissection if mobile and operable. If mobile surgery Occupation-wise it is common in textile, dye,
is not possible, then palliative chemotherapy is given.
cable, tyre, petrol, leather workers, painters,
chemical workers, sewage workers.
Tumour Groups
1. Nonmuscle invasive tumour without involving
lamina propria: Has got excellent prognosis.
(70%).
2. Nonmuscle invasive tumour with involvement
of lamina propria.
3. Muscle invasive type: (25%). Carries poor
prognosis.
4. Carcinoma in situ (flat noninvasive). Contains
irregularly arranged cells with large nuclei,
with high mitotic index, replacing normal
urothelium.
This may occur alone—Primary carcinoma in
Fig. 3.68: Specimen of urinary bladder showing multiple situ.
papillary/polypoid transitional cell carcinoma. It may occur in association with a new tumour
—Concomitant carcinoma in situ.
Bladder Tumours It can occur in a patient who had a previous
1. Primary: tumour—Secondary carcinoma in situ.
a. Epithelial It has got high malignant potential with 50%
1. Transitional cell carcinoma (90%). mortality rate.
2. Adenocarcinoma, arising from urachal It was called earlier as malignant cystitis as
remnant or in exstrophy bladder or it causes severe dysuria, suprapubic pain and
from glandular metaplasia (2%). frequency (terminology not used presently).
Types of Bladder Tumours Investigations
a. Superficial bladder tumour: It may be papillary, 1. Urine microscopy: for RBC’s and malignant
pedunculated with narrow stalk, which is cells.
often multiple. 2. Blood: Hb%, blood urea, serum creatinine.
It may be sessile with a wide base, which 3. IVU: shows filling defect with distortion and
can be single or multiple, which has got often hydronephrosis.
tendency to invade the muscle earlier. 4. Cystoscopy.
Mucosa in and around the tumour is 5. Bimanual examination under G/A - to stage the
oedematous, red, with dilated vessels, often tumour.
with encrustations. 6. U/S abdomen to see bladder wall, pelvis,
b. Muscle invasive TCC: Almost always they liver, lymph nodes.
are solid, sessile, with a broad base and with 7. CT scan to evaluate the extension.
irregular ulcerated surface.
It may spread through lymphatics to Treatment
pelvic lymph nodes or through blood to the a. Noninvasive tumour
lung, liver and bones. 1. Endoscopic resection of tumour.
It has got poor prognosis. 2. Intravesical chemotherapy using BCG
c. Carcinoma in situ. (weekly for six weeks), Mitomycin C,
Epirubacin, Adriamycin can be given
Sites especially for carcinoma in situ.
Lateral wall—commonest (35%). BCG is very useful. Very rarely BCG
Trigone—next common (32%). provocation can occur.
3. Systemic chemotherapy: Using cisplatin, 5
Staging FU, adriamycin, mitomycin.
4. Helmstein balloon degeneration for large
papillary tumour. Balloon is passed into
Jewitt-Strong-Marshall staging
the bladder and inflated so as to cause
I Subepithelial connective tissue.
pressure necrosis of the summit of the
II Muscle infiltration superficially.
tumour. So later remaining part of the
III Full thickness muscle and perivesical
tumour can be resected easily through
tissue infiltrated, but mobile.
cystoscopy.
IV Fixed to adjacent organs. b. Invasive bladder tumour:
IVa Prostate. 1. Curative interstitial radiotherapy using
IVb Pelvic wall. implantation of radioactive gold grains
TNM staging is used now (American joint (half life is two and half days), or radio-
committee for cancer 2002). active tantalum wires (half life is 4 months).
2. Radical deep external beam radiotherapy
Staging is done by Bimanual Palpation using cobalt 60 is useful as bladder is
under G/A retained and so normal act of micturition
Clinical Features and potency can be maintained.
1. Painless haematuria. Complication is that it may eventually
2. Features of cystitis, with suprapubic pain, lead to form a thimble bladder.
frequency, dysuria. 3. Surgery:
3. Hydronephrosis can occur when tumour A. Partial cystectomy when tumour is
obstructs the ureteric orifice. confined to fundus of the bladder and
4. Pain in groin, back, perineum, when tumour is single, with a margin of clearance
invades the pelvic wall. of 2.5 cm.
B. Radical cystectomy: CT scan is a must Indications for surgery

before doing radical cystectomy to see 1. Multiple bladder tumours
the pelvis and lymph node status. Here 2. Sessile tumours
urinary bladder, urethra, paravesical 3. Recurrent tumours
tissues, lymph nodes (pelvic) are 4. Poorly differentiated tumours
removed. In females, hystrectomy with 5. In situ carcinomas
removal of part of the vagina is done. 6. Squamous cell carcinoma
After surgery urinary diversion is done 7. Adenocarcinomas
either by doing continent ileal conduit
or uretero-sigmoidostomy or cysto- 5. Systemic chemotherapy by cisplatin,
sigmoido plasty using sigmoid colon adriamycin, mitomycin.
or by creating rectal urinary pouch. Prognosis: Depends on type, differentiation,
4. Intravesical chemotherapy by BCG, location, stage, invasion, number, lymph node
interferon along with BCG, mitomycin C, status, pelvis involvement and response to
thiotepa, adriamycin. treatment.
X-rays are usually a part of the examination for Gas Under Diaphragm
undergraduates as well as post-graduates in It is due to–
surgery. Students should have fair idea about • Perforated anterior duodenal ulcer (anterior
common X-rays, their findings and significances. DU perforates; posterior DU bleeds). It is the
However CT and MRI have taken over X-rays commonest cause of perforation. Acute ulcer
in places of diagnosis, X-rays are still commonly or chronic ulcer with acute exacerbation
used and in certain occasions it is the compulsory perforates commonly. Perforation may be
method of investigation. precipitated by NSAID, alcohol. Stage of
X-rays may be plain or contrast. Plain X-rays chemical peritonitis, stage of reaction/illusion
of abdomen/chest/bone or skull are being used and stage of bacterial peritonitis are typical.
for diagnosis. Contrast X-rays are barium • Gastric ulcer perforation—both benign and
malignant ulcer can perforate. But large gas
studies/angiograms/urograms/cholangio-
leak is more likely to be due to malignant
grams, etc.
ulcer perforation. Gas leak can occur
posteriorly into lesser sac causing abscess
PLAIN X-RAY ABDOMEN in lesser sac.
• Jejunal perforation—rare.
Plain X-ray abdomen is often taken in acute
• Ileum is another common site of perforation.
abdomen/to see stones in pancreas/gallstones
It causes faecal peritonitis and is more dan-
or any calcifications. It is also used to see viscus
gerous. It could be typhoid ulcer perforation/
perforation/multiple air—fluid levels/ground Crohn’s disease perforation/roundworm
glass appearance and so on. perforation/amoebic ulcer perforation (in
Plain X-ray abdomen is usually taken in terminal ileum)/tuberculous ulcer perforation
standing position. Often X-ray is taken in lateral (commonly it causes stricture—intestinal
decubitus position. obstruction – necrosis – perforation)/small
bowel malignancy like lymphoma or adeno-
Proper Plain X-ray Abdomen carcinoma or carcinoid perforation. In
• Is taken with low penetration X-ray exposing typhoid ulcer perforation there will be relative
diaphragm, upper part of the pelvis, bowel bradycardia, soft abdomen without guarding
shadows, liver shadow and peritoneal and rigidity due to Zenker’s degeneration,
outline. diarrhoea due to enteritis, increased bowel
• Calcifications due to pancreatitis (parenchy- sounds.
mal/ductal stone), radiopaque gallstones • Colonic perforation is due to amebic ulcer/
(10%), calcifications in liver/spleen/kidney/ toxic megacolon/carcinoma/ischaemic
meconium ileus/ovarian teratodermoids/ colitis.
gallstone ileus/phleboliths/vascular calcifi- • Traumatic perforation may be due to either
cations of aorta, renal or splenic arteries/ stab injury causing direct penetrating injury
of bowel or due to blunt injury abdomen. In
calcified fibroid/calcified amebic liver
blunt injury abdomen sudden shearing force
abscess/calcified hydatid cyst/calcified
causes traction of either duodeno-jejunal
lymph node may be seen.
junction or ileo-caecal region causing
• Gas under diaphragm is diagnostic of bowel perforation or transection of the bowel.
perforation. • Perforation can occur following surgical/
• Multiple air-fluid levels are features of diagnostic procedures like laparoscopic/
intestinal obstruction. open laparotomy/tubal insufflation.
X-rays 359
Fig. 4.2: Plain X-ray abdomen showing ground glass

appearance—feature of peritonitis. It may be primary/
secondary/tertiary. Secondary type is common—due to
perforation. Primary type is due to primary infection due
to E coli, gonococci, pneumococci, etc. It is common
in females. It progresses very fast with rapid deterioration.
It needs early laparotomy and peritoneal wash and
B drainage. Tertiary peritonitis is seen in post-laparotomy
patients—biliary/faecal. It is often difficult to diagnose.
Remember
• Appendicular perforation rarely causes
pneumoperitoneum because there is hardly
any gas in obstructive perforated appendix.
Pneumoperitoneum can occur in rare
instances, when the perforation is at the base
extending to the caecal wall.
• Minimum gas required to show gas under
diaphragm is 1 ml.
• Gas under diaphragm is seen in only 70%
of duodenal ulcer perforation. In 30% of cases
it may not be seen due to gas leak less than
1 ml as a result of sealing of perforation; and
adhesion between liver and diaphragm
(because of previous surgery leading into
adhesions or in alcoholic patients liver is
adherent to diaphragm due to perihepatitis)
C may not show this picture.
Figs 4.1A to C: Plain X-ray abdomen in erect • Large quantity of gas may be seen in case
posture showing gas under the diaphragm. of malignant perforation of stomach or colon.
• Patient should stand (erect posture) for 5-10 leading to stricture formation and obstruction.
minutes to allow gas to come under the Continuous suture is not used as it may cause
diaphragm. Lower chest should include in tearing of the edges and also compromises
X-ray exposure. the blood supply of the oedematous perfo-
• Gas is seen as a crescent of radiolucency below rated edges leading to poor healing and
the radiological white diaphragmatic line on eventual leak causing fistula or peritonitis.
the right side. Left side fundic gas shadow In gastric or duodenal perforations omental
may mimic the perforated gas. But very often pedicled patch can be placed to enhance the
a darker radiolucency gas can also be seen healing (as omentum is vascular, it improves
above the fundic gas shadow in X-rays of the blood supply of the closure site; its
perforated patients. adhesive property seals the perforation well,
• Interposition of colon between liver and and as it is rich in lymphatics it promotes
diaphragm can occur mimicking the gas the healing) – Roscoe-Graham operation. In
under diaphragm radiologically but it does infracolic (small or large bowel) leak, omental
not require any surgical intervention – patch is not advisable as it can cause omental
Chilladiti syndrome. banding and subsequent intestinal obstruc-
• Left lateral decubitus X-ray may be taken in tion. 10 liters of normal saline is used to give
patients who are critically ill and cannot be peritoneal wash. Drain is placed and
made to stand to get erect X-ray film. Patient abdomen is often closed with tension sutures.
is turned towards left with right side up and • In severe faecal peritonitis following ileal/
allowed to wait for 5 minutes. Gas will come colonic perforation, ileostomy or colostomy may
under diaphragm and above the liver. Lateral be a better option as closure of perforation
X-ray is taken from side to side. may not take up leading into re-leak or
• Gastric and duodenal ulcer perforations are peritonitis.
• DU perforation rarely can be treated conser-
less severe and less contaminated in initial
vatively (Harman-Taylor regime) – can be done
phases compared to ileal and colonic
only in early duodenal ulcer perforation if
perforations. Ileal and colonic perforations
thought of sealed and in patients totally unfit
are severe due to faecal peritonitis and
(critical cardiac patients) for surgery.
patients develop septicaemia/ARDS/DIC/
• In chronic duodenal ulcer perforation if
renal failure/MODS.
patient is opened within 6 hours and if there
• Emergency laparotomy after initial resus-
is not much contamination then definitive proce-
citation (nasogastric aspiration, IV fluids,
dures like vagotomy and gastrojejunostomy
catheterisation, and antibiotics) is the
or highly selective vagotomy (HSV) can be
mandatory treatment. After opening the
done. Good general condition of the patient
abdomen through adequate midline incision, and surgeon’s experience are a must.
infected fluid is collected for culture. Fluid • Perforated gastric ulcer may be of malignant
is sucked out. Omentum is followed to see nature and so edge biopsy should be taken.
the site of perforation. Once the perforation Few consider partial gastrectomy as the
site is identified, it is held carefully as it will treatment as perforated malignant gastric
be oedematous and friable. It is closed ulcer is always advanced (serosa is involved)
horizontally using interrupted sutures using silk/ and partial gastrectomy is sufficient as a
vicryl/thread. Initially 2 or 3 outer sutures palliation.
are placed; later centre suture is placed to • Ileal typhoid ulcer perforations may be
prevent tearing of the friable perforated edges. multiple and so carefully should be searched
Perforation is never closed longitudinally as for so as not to miss any additional
it may cause narrowing during healing period perforations. Often resection and anastomosis
X-rays 361
may be required in multiple perforations.
Biopsy from the edge is a must before closure
of ileal perforation.
• Typhoid ulcers are longitudinal and antimesen-
teric. Amebic ulcers are transverse and flask
shaped and can occur both in mesenteric as
well as antimesenteric areas.
• Post-laparotomy pneumoperitoneum takes
7-14 days to disappear. In children gas in
the peritoneum gets absorbed faster than in
adults.
• Penetrating injury (stab injury) can cause
pneumoperitoneum without any bowel injury
as air from the atmosphere can get into the
peritoneal cavity to show gas under the A
diaphragm.
Different signs in X-ray in perforation

• Cupola sign: Crescent shaped radiolucency
under the diaphragm
• Riglers sign: Visualisation of both aspects
of the bowel wall being outlined by gas on
either side
• Inverted V sign: Gas on either sides of the
falciform ligament
• Football sign: Collection of gas in the centre
of the abdomen like a foot ball
• Triangle sign: Gas between bowel loops
Conditions which mimic pneumoperito-

neum-pseudopneumoperitoneum
• Subpulmonary pneumothorax B
• Chilladiti syndrome Figs 4.3A and B: Plain X-ray abdomen showing
• Subphrenic abscess due to infections by gas multiple air-fluid levels due to intestinal obstruction.
forming organism like Clostridium welchii adhesions and bands either congenital or
• Subdiaphragmatic fat or omental fat under postoperative are the common causes. In
the diaphragm may rarely mimic gas under Asian countries hernia is the common cause
the diaphragm of intestinal obstruction.
Multiple Air-fluid Levels • Roundworm bolus obstruction.
It is due to intestinal obstruction. • Stricture ileum—either tuberculosis or
Crohn’s disease.
Causes of Intestinal Obstruction • Carcinoma small bowel/carcinoma colon
• Hernia (commonly inguinal hernias but can when it is stricture type (left sided colonic
be any hernias) and adhesions are the growth).
commonest causes. In Western countries, • Volvulus of colon/small bowel.
Intestinal obstruction may be dynamic or adynamic:
Dynamic obstruction Adynamic obstruction

Outside the wall In the wall In the lumen Cessation of peristalsis
• Hernia • Tuberculous stricture • Gallstones • Postoperative period
• Adhesions • Crohn’s disease • Roundworm • Electrolyte imbalance
• Volvulus • Malignancy • Inspissated faeces • Spinal injuries
• Intussusception • Radiation stricture • Meconium ileus • Uraemia
• Extrinsic compression • Benign tumours • Diabetes mellitus
• Retroperitoneal
haematomas and
surgeries
• Renal surgeries
Causes of intestinal obstruction:
Proximal small bowel Distal small bowel Large bowel

Site of Duodenum and Ileum Any where in large
obstruction jejunum intestine
Causes: Congenital TB strictures Malignancy
Lipomas Malignancy TB stricture
Leiomyomas Crohn’s Anorectal malformation
Malignancy Gallstones Volvulus
Bands and adhesions Hernias-common cause Congenital megacolon
Round Worm Bands
Congenital
Clinical features: Severe vomiting, Distention, vomiting, Constipation,
dehydration, no or less dehydration distention,
distension, colicky pain vomiting. Less pain
Special features: Dilatation and
Plain X-ray. Valvulae conniventes Characterless haustration
Intestinal obstruction may be due to either congenital or acquired causes:
Congenital causes Acquired causes
• Anorectal malformations • Hernia (commonest)
• Congenital megacolon • Postoperative
• Adhesions • Intussusception
• Duodenal atresia • Roundworm
• Intestinal atresia (ileal) • Gallstones
• Bands and adhesions • Tuberculosis
• Malrotation • Malignancy
• Volvulus neonatorum • Internal henias
X-rays 363
Intestinal obstruction may be: Pathology in Intestinal Obstruction
1. Acute: Common in small bowel. Changes proximal to the bowel obstruction:
2. Chronic.
3. Acute on chronic: Common in large bowel.
4. Closed loop obstruction.
Fluid collects just proximal to the obstruction

which is derived from saliva, stomach, pancreas
and intestine. Because of oedema and inflam-
mation absorption decreases, sequestration of
fluid from the circulation into the lumen occurs
and bacteria (E coli, Klebsiella, anaerobes,
bacteroides and other organisms) multiply, toxins
are released –toxaemia occurs. Vomiting, defective
mucosal absorption due to oedema and toxaemia,
Fig. 4.4: X-ray showing multiple air fluid levels–
sequestration of fluid into the gut lumen leads
feature of intestinal obstruction to severe dehydration, and electrolyte imbalance.
Normal GI secretions Gas in intestinal obstruction

Saliva – 1-1.5 litres Swallowed air—90%, diffusion from blood
Bile – 1 litre – 20% and bacterial action – 10%
Stomach – 1.5-2.5 litres 90% gas is nitrogen, remaining are H2S and
Pancreas – 1. 5-2 litres others
Intestine – 2.5-3 litres Gas initially located in proximal part of the
bowel later gets churned into distal fluid due
to peristalsis
Fluid in intestinal obstruction Bacteria in intestinal obstruction

Sequestration of the fluid into the lumen E. coli
Poor absorption through the mucosa Anaerobes – bacteroides
Contains toxins and multiplying bacteria Klebsiella
Can cause toxaemia and aspiration
Proximal to the collected fluid, air accumu- Bowel distal to the obstruction is inactive and
lates (derived from swallowed air (70%), diffusion collapsed.
from blood into the lumen (20%), from digested
product and bacterial action (10%). Main gaseous Clinical Features
component is nitrogen (90%) and also hydrogen • Abdominal pain: Initially colicky and
sulphide. Oxygen and carbon dioxide gets intermittent; later continuous and severe.
absorbed. During vigorous peristalsis air enters • Vomiting: In jejunal obstruction it is early and
the distal fluid, results in churning, and is the persistent. In ileal obstruction, it is recurrent
reason to cause multiple air-fluid levels in plain occurring at an interval; initially bilious later
X-ray abdomen. feculent. In large bowel obstruction, vomiting
is a late feature.
Changes at the site of the obstruction
• Distension: It is absent or minimal in case of
jejunal obstruction. Obvious with visible
intestinal peristalsis (VIP) and borborygmi
sounds in case of ileal obstruction. It is
enormous in case of large bowel obstruction.
• Constipation: It is absolute, i.e. neither faeces
nor flatus is passed.
Exceptions (obstruction without constipation)

• Richter’s hernia obstruction
• Gallstone obstruction
• Mesenteric vascular occlusion
• Intestinal obstruction with a pelvic abscess
• Other features
Dehydration—Oliguria → Renal failure.
Features of toxaemia and septicaemia:
Tachycardia, tachypnoea, fever, sunken eyes,
Closed Loop Obstruction
cold periphery.
When there is obstruction in the large bowel,
with ileo-caecal valve competence, pressure
increases in the caecum.
A B
Figs 4.5A and B: Plain X-ray showing multiple air-fluid
Perforation also can occur at the site of levels – feature of small bowel obstruction – ileal obstruction
obstruction due to the malignant growth. in a child and in an adult.
X-rays 365
Features of strangulation: Shock, tenderness,
rebound tenderness; guarding and rigidity,
absence of bowel sounds. In case of
strangulated hernia, a swelling which is tense,
tender, rigid, irreducible, no expansile
impulse on coughing and H/O recent
increase in size is seen.
Per-rectal examination: Shows empty, dilated
rectum, often with tenderness. If rectal growth
is the cause for obstruction, it may be
palpable.
Investigations
• Plain X-ray abdomen: Multiple air-fluid levels
– Proximal the obstruction → Lesser the air
fluid level.
– Distal the obstruction →More the air fluid
level. Fig. 4.7: Plain X-ray abdomen showing air-fluid levels
with dilated colon. Probable site of obstruction is distal
colon. It could be due to growth in the colon.
transverse colon is 5.5 cm. Dilatation of transverse

colon more than 6 cm is called as megacolon.
Caecum can dilate up to the diameter of 15 cm.
Caecal dilatation more than 15 cm diameter is
Fig. 4.6: Plain X-ray abdomen showing early intestinal

obstruction. X-ray shows dilated bowel loops with valvulae
conniventes. It takes 6-12 hours to develop multiple air-
fluid levels.
Normally, three fluid levels can be seen in

plain X-ray film—at fundus of stomach, at
duodenum and often at caecum.
Maximum caliber of jejunum is 3.5 cm; of Fig. 4.8: Plain X-ray abdomen showing valvulae
ileum is 2.5 cm; of caecum is 9 cm and of conniventes of jejunum.
a sign of impending perforation. Competent ileo- • Barium enema and meal is contraindicated in
caecal valve aggravates the chances of colonic acute intestinal obstruction.
dilatation and perforation because of the closed • Hb%, Blood urea and serum creatinine, serum
loop obstruction which increases the intra- electrolytes.
colonic pressure significantly. • CT scan abdomen is very reliable type of
investigation.
• Jejunum shows concertina effect due to valvulae
conniventes Treatment
• Ileum is smooth and characterless— • Naso-gastric aspiration: To reduce toxic effects
(Wangensteen) and to reduce possibility of aspiration pneu-
• Large bowel shows haustration monia.
• Replacement of fluid and electrolytes.
• Antibiotics: Ampicillin, gentamycin, metroni-
dazole, cephalosporins.
• Surgery: Immediate laparotomy is done and the
site (by finding the junction of dilated
proximal and collapsed distal bowel) and
cause of the obstruction is identified. The
obstruction is relieved.
The viability of the bowel is checked (by
colour (black or pink), peristalsis, pulsations,
bleeding, friability, serosal shining,). If bowel is
not viable resection and anastomosis is done. Proper
peritoneal wash is given and the abdominal
cavity is drained. Abdomen is closed in layers
using nonabsorbable sutures (polyethylene, poly-
propylene, nylon). Often tension sutures are
required. Small bowel can be decompressed using
Savage’s decompressor.
In case of right sided colonic obstruction right
hemicolectomy with ileo-colic anastomosis is done.
In case of left sided colonic obstruction left
hemicolectomy (resection) and colo-colic anasto-
mosis is done with a de-functioning colostomy (right
Fig. 4.9: X-ray abdomen in newborn showing features
of intestinal obstruction. It may be due to anorectal side transverse) which is closed after 6 weeks.
malformation, congenital megacolon, volvulus neonatorum.
Complications of intestinal obstruction Post-surgery complications

• Peritonitis • Pelvic abscess
• Hypovolaemic and septic shock • Subphrenic abscess
• Renal failure • Septicaemia
• ARDS • Biliary or faecal fistulas
• Intra-abdominal abscess • Burst abdomen
• Moribund status • Bands and adhesions
• Incisional hernias
X-rays 367
Obstruction due to recto-sigmoid growth with
patient being severely ill—Hartmann’s operation
can be done to save the life of the patient wherein
distal stump with the growth is closed, proximal
colon is brought out as end colostomy.
Causes for strangulation in intestinal

obstruction
• Distension causing reduced venous return
and so later decreased arterial supply
• Mesenteric twist
• Mesenteric ischaemia
• External compression like in hernia
In strangulation of bowel patient develops

• Pain which becomes continuous, with
tenderness, and rebound tenderness
• Toxic features due to absorption of toxins
and translocation of bacteria across the
mucosa into the blood
• Guarding and rigidity
• Systemic features like tachycardia,
tachypnoea, oliguria and drowsiness Fig. 4.10: Double-bubble sign in plain X-ray abdomen
seen in newborn. It is a feature of duodenal atresia. It
• Leucocytosis and altered blood urea, serum may also be seen in annular pancreas.
creatinine and electrolytes
Checking the viability of the bowel prior to Sigmoid Volvulus

resection
• Peristalsis, pulsation Plain X-ray abdomen:
• Colour of the bowel—pink or black; bleeding • Typically shows three lines in sigmoid
• Friability, serosal shining volvulus. Two outer lines signify outer
• Using 100% oxygen look for change in colour margins of the dilated sigmoid colon. One
as red/pink thick intervening line signifies the inner walls
• On table colour Doppler to see mesenteric of the sigmoid – Dahl Froment’s sign.
vessel • Omega sign/coffee-bean sign/bent inner tube
• IV fluorescent dye injection will make viable sign.
bowel purple (fluorescence) Dilute barium or water soluble contrast study
shows tapering of the upper end into a spirally
Note twisted sigmoid colon – bird-beak sign/ace of spades
Single bubble sign: Congenital hypertrophic appearance.
pyloric stenosis CT scan shows typical whirl pattern:
Double bubble sign: Duodenal atresia, annular Volvulus is twist/abnormal rotation of the
pancreas loop of the bowel on its own mesenteric axis.
Soap-bubble sign: Meconium ileus It occurs in sigmoid colon commonly (65%); in
Triple-bubble sign: Intestinal atresia caecum (30%), small bowel (midgut), stomach
occasionally.
Sigmoid volvulus is common in Asia;

common in India; common in south India
because of more fibre diet. Transverse colon
usually does not undergo volvulus because of
its broad and wide based short mesentery.
Note
Sigmoid volvulus is anticlockwise – 65% -
common in males
Caecal volvulus is clockwise (‘C’ for Caecum-
Clockwise) – 30% common in females
It requires one and half turn of rotation to cause

vascular obstruction and gangrene which
eventually leads into perforation either at the
root or at the summit of the sigmoid loop.
Enormous distension of the colon occurs.
Fig. 4.11: Plain X-ray abdomen showing sigmoid Sometimes ileum comes to the root of the sigmoid
volvulus – dilated sigmoid colon. volvulus and encircles it causing compound
Predisposing factors for sigmoid volvulus Sigmoid volvulus is common in

• Adhesions • Ogilvie’s syndrome
• Peridiverticulitis • Mentally retarded individuals
• Overloaded redundant pelvic colon • Chaga’s disease
• Long pelvic mesocolon • Hypothyroidism
• Narrow attachment of sigmoid mesocolon • Patients on anticholinergic drugs
Types • Multiple sclerosis
Acute Recurrent • Scleroderma
• Parkinson’s disease
Clinical features
• Pain abdomen Differential diagnosis
• Enormous abdominal distension • Ogilvie’s syndrome—colonic pseudoobs-
• Tympanic abdomen truction
• Features of obstruction – obstipation, • Faecal impaction in old age
vomiting (late), distension • Carcinoma rectosigmoid
• Tyre like feeling of sigmoid colon • Paralytic ileus
• Dehydration
• Later features of peritonitis once perforation Treatment
occurs • Flatus tube insertion gently in OT
• Sigmoidoscopy insertion gently in OT
• Sigmoidopexy
• Resection and exteriorisation – colostomy
and distal mucus fistula (Paul-Mikulicz
operation) and later closure of colostomy
after 6-12 weeks
X-rays 369
volvulus in which case knotted small bowel also
becomes gangrenous–ileo-sigmoid knotting.
Plain X-ray Abdomen Showing Pancreatic

Stones
• Pancreatic stones are commonly radiopaque
and multiple.
• It can be pancreatic parenchymal calcification
or ductal stones.
• In ductal stones ductal dilatation is common
(more than 3 mm). Often it will be 10–20 mm
diameter. Ductal stones are reasonably better
than parenchymal calcification. Treatment Fig. 4.13: Pancreatic parenchymal calcification in chronic
here is pancreaticojejunostomy with sple- pancreatitis. It is more difficult to manage than ductal
nectomy (Puestow’s); pancreaticojejunostomy stones.
without splenectomy (Partigton-Rochelle
operation); Frey’s decoring of the head and duodenectomy (Whipple’s operation); distal
jejunal anastomosis; duodenal preserving pancreatectomy or occasionally total
resection of head of pancreas in front of the pancreatectomy.
portal vein (Beger). • Ideal treatment for chronic pancreatitis is
• If there is parenchymal calcification – severity resection. But commonly done are drainage
of the disease is much more than ductal stones. procedures. Endoscopic stenting; stone
Patient is also more prone for malignant extraction are mainly for temporary remedy
transformation. Here resection of the pancreas or for initial control.
is better treatment. It may be pancreatico- • Essential investigations are HRCT scan,
ERCP (chain of lake appearance) and often
MRCP.
• Other investigations are blood sugar, serum
amylase (for relapsing cases) and LFT.
• It is common in males, common in Kerala
(diet, Tapioca induced – Kerala diabetes).
A
X-ray features in acute pancreatitis
• Gasless abdomen
• Sentinel loop
• Colon cut-off sign
• Duodenal ileus
• Mottled lucencies
• Renal halo sign
Treatment Strategy for Chronic Pancreatitis

• Resection procedures.
• Drainage procedures.
B • Management of biliary stenosis.
Figs 4.12A and B: Plain X-ray showing multiple pancreatic • Pain relief by drainage/resection/abdominal
ductal stones. Also note the photo picture of the removed
splanchnicectomy and celiac ganglionectomy.
stones of same patient.
Drainage Resection
• Technically easier – commonly done • Ideal procedure
procedure • Technically demanding
• Less mortality < 2-5% • Mortality 8-21% (Gall 1977)
• Adequate pain relief • Used when carcinoma is suspected or
• Recurrence of pain localised disease
• Diseased tissue is left behind • Head is the pacemaker of the disease – so
• Disease progression resection of head will control the disease
• Fear of occult carcinoma existing or later well
onset • Whipple’s resection is preferred
• Subtotal 95% pancreatectomy is also used
• Total pancreatectomy is last resort
About pancreatitis – ‘Pancreas is abdominal tiger’- • Endocrine dysfunction: Diabetes mellitus.

Moynihan • Mild jaundice is due to narrowing of
‘I do not know if this operations extended life retropancreatic bile duct and cholangitis.
of the patient, but they definitely shortened • Mass per abdomen, just above the umbilicus,
mine….’ which is tender, nodular, hard, felt on deep
— Unknown surgeon palpation, not moving with respiration, not
mobile, resonant on percussion.
Theodor Kocher called the pancreas “the mischief • Mallet-Guys sign : In right knee chest position,
maker of the abdomen.” Some surgeons have when left hypochondrium is palpated tender-
stronger language to describe this organ, but ness can be elicited in chronic pancreatitis
decorum demands that such a language be as bowel loops are shifted towards right
excluded from such a syllabus.” allowing direct palpation of the pancreas.
– JP Patrick O’Larey MD
‘Chronic pancreatitis remains an enigmatic Causes of Pain in Chronic Pancreatitis
process of uncertain pathogenesis, unpredictable • Disruption of perineural sheath of splanchnic
clinical course, and unclear treatment’ nerves due to toxins – of celiac ganglions
and greater splanchnic nerves (right and left).
‘Chronic pancreatitis is NOT primarily a surgical • Raised pancreatic ductal pressure.
disease. No surgery can reverse/get back the lost • Raised interstitial pressure.
exo/endocrine functions’. Surgery is an ultimate • Biliary obstruction.
inevitability for chronic pancreatitis. • Pseudocyst formation.
• Pancreatic chronic inflammation.
Clinical Features of Chronic Pancreatitis
• Pain in epigastric region, persistent and severe, Complications of Chronic Pancreatitis
that radiates to back. This pain is due to • Pseudocyst of pancreas.
irritation of retro-pancreatic nerves or due • Pancreatic ascites/pancreatic pleural effusion.
to ductal dilatation and stasis or due to • CBD stricture.
chronic inflammation itself. • Duodenal stenosis.
• Exocrine dysfunction: Diarrhoea, asthenia, loss • Portal or splenic vein thrombosis.
of weight and appetite, steatorrhoea (signifies • Peptic ulcer.
severe pancreatic insufficiency), malabsorp- • Carcinoma pancreas.
tion. • Pancreatic fistula.
X-rays 371
Indications for surgery in chronic Direct surgeries
pancreatitis
Drainages
• Intractable pain • Lateral pancreatico-jejunostomy – commonly
• Severe malabsorption, multiple relapses done – Partigton Rochelle operation
• Suspicious of carcinomas • Duval retrograde pancreatico-jejunostomy
• To deal complications like pseudocyst/ • Frey and Smith operation
ascites/effusion/portal hypertension/ • Beger’s procedure
biliary obstruction • Cystogastrostomy
• Pancreatic duct stenosis/obstruction • Cystogastrostomy with external drainage –
• Pancreatic duct > 7 mm in diameter Smith operation
• Roux-en-Y cystojejunostomy
Resections
Distal/subtotal/Whipple’s/rarely total –
pancreatectomies
Indirect procedures in chronic pancreatitis Biliary duct stenosis in chronic pancreatitis

Only as supportive method Indications for surgical intervention
• Sphincteroplasty • Persistent jaundice for 1 month
• Biliary - enteric anastomosis ( Choledocho • Cholangitis
jejunal/duodenal anastomosis) • Evidence of developing cirrhosis on biopsy
• Triple anastomosis – choledocho - jejunal, • Inability to exclude pancreatic cancer
pancreatico – jejunal and gastrojejunostomy • Progressive strictures of biliary ducts
• Splanchnicectomy/celiac ganglionectomy to • Persistent elevation of alkaline phosphatase
relieve pain Procedures
• ERCP stenting – usually temporary as • Choledochojejunostomy – Roux-en-Y
recurrence rate and problems of stent • Choledochoduodenostomy
(blockage, displacement, sepsis) • Resection if carcinoma is suspected
• ERCP stenting – temporary
Aetiology of chronic Classification of chronic Pathology

pancreatitis pancreatitis
• Focal necrosis
• Alcohol • Chronic relapsing • Segmental/diffuse fibrosis
• Stones in biliary tree • Chronic persistent • Parenchymal calcifications
• Malnutrition, diet i Chronic non-calcifying • Or ductal stones
• Hyperparathyroidism ii Chronic calcifying • Stricture or dilatation
• Hereditary (Familial – Ductal stones
hereditary pancreatitis) – Parenchymal
• Idiopathic
• Trauma
• Congenital anomaly
(Pancreatic divisum)
Fig. 4.14: Diagram showing choledochojejunostomy and

jejunojejunostomy for biliary stricture (Roux-en-Y)
Plain X-ray Abdomen Showing Gallstones

• Gallstones are commonly radiolucent (90%).
• Multiple stones are usually faceted because
of equal pressure in a compact gallbladder.
• Plain X-ray shows radiopaque lesion to the
right side of the vertebra below rib cage. It
should be differentiated from kidney stones.
In lateral view X-ray, gallstone will be in front
of the vertebra whereas kidney stone overlaps
the vertebra. Often gallstone has got central
radiolucent area – sea gull sign/Mercedes Benz
sign.
• Silent/asymptomatic gallstone is one which B
is identified on routine investigation where
Figs 4.15A and B: Cystogastrostomy and cystoje-

Silent gallstone need not be treated unless junostomy pictures done for pseudocyst of the pancreas.
• Patient is diabetic/immunosuppressed
• Chances of developing gallbladder carci- there are no specific relevant symptoms
noma related to gallstones. Chances of developing
• Stone more than 2.5 cm/multiple stones symptoms in a silent gallstone are 5% in
• If gallbladder wall is thickened 5 years and 20% in 15 years.
X-rays 373
Fig. 4.16: Duval procedure for chronic pancreatitis. It

is a type of pancreaticojejunostomy which is not commonly
used because of the high failure rate.
Fig. 4.18: Partington Rochelle operation (pancreatico-

jejunostomy) for chronic pancreatitis. Here spleen is
retained (in original Puestow’s spleen is removed).
Fig. 4.17: Frey and Smith operation. Here decoring of Fig. 4.19: Puestow’s pancreaticojejunostomy operation
head is done prior to pancreaticojejunostomy. for chronic pancreatitis. Here spleen is removed.
Fig. 4.21: Lateral X-ray of spine showing radio-opaque

shadow in front of the vertebrae – could be radio-opaque
gallstone. Note also the fused intervertebral disc spaces.
• Porcelain gallbladder is one where gallbladder

wall is calcified because of chronic cholecys-
titis. It is potentially malignant.
• Cholesterol stone occurs when there is
B
alteration in levels of cholesterol, lecithin and
bile salts. This altered bile has got more
Figs 4.20A and B: Multiple gallstones in a plain X-ray.
cholesterol than adequate micelle and is
Only 10% gallstones are radio-opaque. Often they are
faceted each other because of compact and equal pressure. called as lithogenic bile. Here bile is in
Center of the gallstone is often found radiolucent and supramicellar zone.
is called as Mercedes Benz sign/Seagull sign. • Mixed stones are commonest – 90%.
• ‘Gall stone is a tomb stone erected to the memory
Remember of the organism within it’ – Moynihan’s
• Presently ultrasound is ideal investigation aphorism.
for gallstones. • Saint’s triad: gallstones – colonic diverticulosis
• To see gallbladder function or confirm – hiatus hernia.
cholecystitis radioisotope HIDA/PIPIDA • Complications of gallstones: Acute cholecys-
scan is ideal. titis, chronic cholecystitis, empyema gall-
• Cholecystitis can cause jaundice due to bladder, mucocele of gallbladder, perforation
cholangitis. and peritonitis, secondary CBD stones,
• Other causes of jaundice should be ruled out cholangitis, pancreatitis, Mirizzi syndrome,
– CBD stones/Mirizzi syndrome. gallstone ileus, pericholecystitic abscess and
• Limey gallbladder is gallbladder filled with carcinoma of gallbladder.
toothpaste like mixture of calcium carbonate • Black pigment stones are more common in
and calcium phosphate. Plain X-ray shows gallbladder; brown pigment stones are
dense radio-opaque gallbladder shadow. common in CBD.
X-rays 375
Dissolution therapy
Indications Contraindications Methods
• Functioning gallbladder • Non-functioning GB • Ursode-oxycholic acid
with cholesterol stone • Stone more than 1.5 cm • Chenodeoxycholic acid
• Single stone less than • Radio-opaque stone • Citrates, monoterpenes
1.5 cm • Multiple stones • Percutaneous infusion of
• Radiolucent stone methyl tertbutyl ether
• Old age and patient who (MTBE) infusion into the GB
are not fit for surgery • Shock waves
Charcot’s triad of ascending cholangitis Reynold’s pentad of suppurative cholangitis

• Intermittent pain • Persistent pain
• Intermittent fever • Persistent fever
• Intermittent jaundice • Persistent jaundice
• Toxicity and shock
• Altered mental status
• Cholesterol stones are common in Western

countries; pigment/mixed stones are common
in Asian countries.
• Acute acalculous cholecystitis is 5% common
occurs after stress, major surgeries or in
cholecystoses.
Differential diagnosis of radio-opaque shadow

• Kidney stone
• Gallstone
• Calcified 12th rib tip
• Phlebolith
• Pancreatic stone
• Radio-opaque foreign body
• Faecolith
• Calcified lymph node
• Renal tuberculosis calcified Fig. 4.22: ARDS—Adult/Acute respiratory distress
• Renal cell carcinoma—calcifications syndrome. It occurs in respiratory failure, septicaemia,
• Adrenal tumour—calcification in toxic conditions and pulmonary oedema. It needs critical
care and ventilatory support. It has got poor prognosis.
• Teratomatous dermoid
• Calcification of atheroma in aorta
• Calcified lesion in liver – amoebic liver X-RAY BONES
abscess/calcified hydatid cyst See Figures 4.36 to 4.58.
CHEST X-RAYS OTHER PLAIN X-RAYS

See Figures 22 to 35. See Figures 4.59 to 4.75.
A
Fig. 4.23: Chest X-ray showing pulmonary infarct—
peripheral wedge-shaped lesion is typical. It may be due
to small/medium embolus.
Fig. 4.24: Chest X-ray showing hydropneumothorax with Figs 4.25A and B: Chest X-ray PA view and lateral
collapsed lung margin and fluid level. It could be due showing subcutaneous emphysema as dark multiple
to trauma, ruptured bullae or tuberculosis. streaks/lines.
X-rays 377
Fig. 4.27: Chest X-ray showing cannon ball secondaries.

Often there may be pleural effusion/consolidation also.
Early secondaries may be missed by chest X-ray as
only 60 - 70 % of the lung can be seen in chest
X-ray. So contrast (HRCT) is ideal to pick up lung
A secondaries. Secondaries in the lung are usually multiple,
smooth and rounded. It is because secondaries arise
from the single primary spread into different places of
the lung that occurs at same time with similar cellular
mitotic activity. It is smooth because of the lung resistance.
Common primaries causing secondaries in lungs are—
all sarcomas, carcinomas from breast, thyroid, kidney,
testis and prostate. Secondaries from kidney may be
calcified and it may disappear after palliative nephrectomy
because of the increased tumour immunity. Secondaries
in lung are usually treated by chemotherapy. Drugs are
specific of primary type. Solitary secondary or secondaries
limited to one segment may be considered for lobectomy.
But results are poor.
B
Fig. 4.28: Chest X-ray showing large soft tissue sarcoma.
Figs 4.26A and B: Chest X-ray PA view showing It was synovial sarcoma from shoulder extending into
carcinoma bronchus – left sided. chest wall. Patient underwent forequarter amputation.
Fig. 4.29: Thoracic aortic aneurysm

(descending thoracic aorta)
Fig. 4.31: Chest X-ray showing superior mediastinal mass

– tumour. It can cause compression over superior vena
cava causing dilated veins over the chest.
B
Fig. 4.32: Chest X-ray showing localized area with fluid
Figs 4.30A and B: Chest X-ray PA (6 feet {180 cm} level in the right lung – feature of lung abscess. HRCT
from patient) and lateral view showing mediastinal tumour– and bronchoscopy are essential investigations.
probably lymph nodal mass. It may be lymphoma/ Tuberculosis should be ruled out. Antibiotics, chest
secondaries. Ideal investigation is contrast CT chest. physiotherapy and often surgery are the therapeutic
Mediastinoscopy for diagnostic biopsy also may be useful. modalities.
X-rays 379
A B
Figs 4.33A and B: Chest X-ray showing localised lesion right lobe–lung
Hydatid cyst. After rupture it shows water-lily appearance.
A B
Figs 4.34A and B: Massive effusion on right side in one X-ray and left side in another. It may be due to malignancy
either primary or secondary or mesothelioma of pleura or due to tuberculosis. Malignant effusion is haemorrhagic.
It is treated by slow tapping (maximum 1000 ml at a time) or slow continuous decompression. Rapid tapping can
lead into sudden severe pulmonary oedema with respiratory distress often which may be life-threatening.
Fig. 4.35: Chest X-ray showing mediastinal mass – PA

view and lateral view. It is posterior mediastinal mass–
neurofibroma which was removed through thoracotomy.
Fig. 4.37: X-ray humerus showing osteochondroma

(exostoses). It is the commonest benign tumour of the
bone. It has got base, pedicle and a cartilaginous cap
often with a bursa near the cap. It may turn into
chondrosarcoma (not osteosarcoma).
Fig. 4.38: X-ray lower end of the radius and ulna showing
osteochondroma (exostoses) of the lower end of radius
Fig. 4.36: Achondroplasia. with scalloping of the lower end of the ulna.
X-rays 381
B
B
Figs 4.40A and B: X-ray showing osteolytic
secondaries in the ischium and pubic bone.
C
Figs 4.39A to C: X-ray pelvis showing osteoblastic
secondaries in ilium, ischium and sacrum (pelvic bones)- Fig. 4.41: X-ray humerus showing pathological fracture
primary is from prostate. in humerus due to secondaries from carcinoma breast.
Fig. 4.42: X-ray pelvis with both upper ends of femur.

It shows osteolytic lesion in right upper end of the femur.
Fig. 4.44: X-ray skull showing punched out lesions –

could be secondaries/primary hyperparathyroidism/multiple
myeloma/histiocytosis.
Fig. 4.43: X-ray skull showing secondaries in the skull-

soft tissue shadow with destruction. It is seen in secondaries Fig. 4.45: Skull X-ray showing salt and pepper lesion/
from follicular carcinoma of thyroid. It is usually vascular, multiple punched out lesions – primary hyperparathyroidism
pulsatile and well localised secondaries. – von Recklinghausen lesion – Osteitis fibrosa cystica.
X-rays 383
Figs 4.47A and B: X-ray neck with upper chest showing

cervical rib on left side. It is of complete type. It could
be of fibrous, bony, combined type; unilateral/bilateral;
asymptomatic/symptomatic. Commonest presentation is
neurological – tingling and numbness along the C8 and
T1 root distribution. When compression of subclavian artery
occurs it causes post stenotic dilatation due to Eddie’s
current. Thrombosis can occur in it which may throw
an embolus causing digital ischaemia/gangrene. X-ray
neck, angiogram, arterial Doppler, nerve conduction studies
Fig. 4.46: X-ray humerus showing widening with cystic are the needed investigations. Treatment is extraperiosteal
spaces – brown tumour of humerus due to primary excision of cervical rib with scalenotomy and often with
hyperparathyroidism. Differential diagnosis is secondaries. excision of first rib.
Fig. 4.48: X-ray skull, lateral view showing depressed

fracture. Depressed fracture skull often needs elevation.
CT head is a must to see intracranial injuries. If it is
in the midline it should not be elevated as it overlies the
Fig. 4.50: X-ray tibia showing Brodie’s abscess. Brodie’s
superior sagittal sinus.
abscess is subacute osteomyelitis with pus formation.
It can cause pathological fracture. It should be differentiated
from Ewing’s sarcoma.
Fig. 4.49: Plain X-ray pelvis showing ectopia Fig. 4.51: X-ray tibia showing osteomyelitis of the tibia–
vesicae. Note the separation of pubic bones widely. sclerosing osteomyelitis with pathological fracture.
X-rays 385
Fig. 4.52: X-ray femur showing osteomyelitis of the femur.

Dense bone in the centre – sequestrum can be seen.
Surrounding radiolucent area is area of granulation tissue.
It signifies separation of the sequestrum. Radiologically
sequestrum is denser than normal bone because of lack
of normal decalcification (dead bone is dense bone).
Sequestrum comes out through an opening, sinus (cloaca).
Surrounding bone is having new bone formation due to
periosteal reaction (involucrum). Sequestrum can be ivory
(syphilis); feathery (tuberculosis); granular (salmonella);
ring (amputation stump); black (fungal, stump). In
tuberculous osteomyelitis there is less or no new bone
formation.
B
Figs 4.53A and B: Orthopantomogram – OPG. It is taken
in oral carcinomas to look for mandibular secondaries,
in trauma (fracture mandible), osteomyelitis of the mandible
and jaw tumours. Patient keeps his/her chin over the
chinrest of the machine. Machine rotates around the jaw Fig. 4.54: Osteoclastoma of upper end of the fibula. Note
closely to get the film. First film (OPG) shows dentigerous the soap bubble appearance. It arises from epiphysis.
cyst. It should be differentiated from osteoclastoma. It also occurs in flat bones.
Fig. 4.55: X-ray lower end of the femur showing features

of osteosarcoma. Codman’s triangle; sun ray appearance;
new bone formation with destruction of bone with
pathological fracture.
Fig. 4.56: X-ray upper ends of tibia and fibula showing chondrosarcoma arising from fibula. Confirmation
is done by open biopsy. Treatment is wide excision with removal of the upper end of fibula.
Amputation is not required in every patient and depends on the extent of the tumour.
X-rays 387
Fig. 4.59: Anorectal malformation (ARM). Blind anal dimple

is marked with a radiopaque marker. X-ray is taken to
find out the level of rectal pouch and distance is measured
and assessed as whether it is above/below the
pubococcygeal line. It is used to find out whether ARM
is high or low.
Fig. 4.57: X-ray showing sacrococcygeal teratoma

in an infant.
Fig. 4.60: X-ray neck, lateral view showing thyroid swelling

Fig. 4.58: Skull X-ray showing soft tissue shadow with calcification. Fine calcification signifies papillary
which is radiopaque – could be meningioma or soft tissue carcinoma of thyroid. Ring calcification signifies multinodular
swelling. goitre.
Fig. 4.61: X-ray neck showing thyroid enlargement due Fig. 4.62: X-ray showing retrosternal goitre – extension
to multinodular goitre with ring calcification (coarse). from neck. Percussion over the sternum will be dull.
Pemberton’s sign will be positive (by raising arms above
the shoulder will cause dilatation of veins over face and
chest wall with dyspnoea due to compression of SVC
and trachea).
Fig. 4.63: X-ray showing large stone (radiopaque) in

submandibular salivary gland. Stone formation is common
in submandibular salivary gland; not in parotid gland.
(Secretion from parotid is serous with less calcium and
has dependent drainage; whereas secretion of
submandibular salivary gland is mucus, contains more
calcium; with nondependent drainage). Stone causes
sialadenitis. It is commonly radio-opaque. It is treated
by excision of the gland.
X-rays 389
A B
Figs 4.64A and B: X-ray neck AP and lateral view showing radiolucent air filled
area – feature of laryngocele. It is a unilateral narrow necked, air- containing diverticulum
resulting from herniation of laryngeal mucosa through thyrohyoid membrane where
it is pierced by superior laryngeal nerve. It can be external or internal. It presents
as a smooth, soft and resonant swelling in the neck adjacent to larynx which is
more prominent while blowing, coughing and Valsalva manoeuvre. Cough and
hoarseness are common. X-ray is diagnostic. Treatment is excision.
A B
Figs 4.65A and B: Mammography. It is plain X-ray of breast. Cranio-caudal and
medio-lateral films are taken. Microcalcification; smooth/irregular soft tissue shadow;
speculations are the findings to be looked for.
Fig. 4.66: Foreign body in trachearadio-opaque-coin. It needs

bronchoscopic removal under anaesthesia. It can cause collapse
of the lung, infection or erosion.
Fig. 4.67: Foreign body (COIN) in the lower oesophagus. Usually

it can be removed by an endoscope. Common foreign bodies are-
Coins, dentures, pins, fish or meat bones. Fish or meat bones
are more dangerous because of their ragged sharp edges which
often perforate the oesophagus causing mediastinitis, empyema
and septicaemia. Often it may be life-threatening. Sites of impaction
in oesophagus are cervical constriction—C 6; broncho aortic
constriction—T4; diaphragmatic constriction—T10; site of pre-existing
malignancy or inflammatory stricture. Features are— sudden
dysphagia with chest pain and breathlessness. Later presents with
features of shock, sepsis, mediastinitis and empyema.
Management— X-ray shows site and level of the foreign body;
Endoscopic removal can be tried; Impacted large foreign body
should be removed by thoracotomy; Antibiotics, jejunostomy, TPN,
ICT are also required.
X-rays 391
Fig. 4.68: X-ray showing calcified areas in the right side

of the pelvis. It could be teratomatous dermoid of ovary,
calcified nodes, bladder calculi, diverticula or bolus of
gallstones in ileum.
B
Figs 4.70A and B: X-ray showing diaphragmatic eventration
on right side (localised). It differs from diaphragmatic hernia
by not having sac and lungs are normal. Muscular
component of diaphragm is not well developed and so
Fig. 4.69: X-ray showing diaphragmatic hernia with bowel eventration occurs. It is treated by plication of diaphragm
shadow on the left side of the chest and heart shadow using nonabsorbable sutures. Left sided diaphragmatic
on right side. eventration in another X-ray is obvious and significant.
A B
Fig. 4.71: Plain X-ray showing

copper T in place.
C
Figs 4.73A to C: Plain X-ray showing calcified aorta
and femoral arteries in an atherosclerotic patient.
Fig. 4.74: Plain X-ray showing stents in CBD and pancreatic

ducts. It is placed in a patient who presented with recurrent
Fig. 4.72: Plain X-ray abdomen showing calcification in pancreatitis with block/stricture in both terminal CBD and
liver. It could be calcified amoebic liver abscess/calcified pancreatic duct. Later patient underwent choledocho-
hydatid cyst. jejunostomy and pancreaticojejunostomy.
X-rays 393
Fig. 4.75: X-ray skull showing haziness in maxillary region

on right side – feature of carcinoma of maxillary antrum.
PLAIN X-RAY KUB/KUBU (KIDNEY, Fig. 4.76: Plain X-ray KUB/KUBU (Kidney; Ureter:
URETER, BLADDER, URETHRA) Bladder: Urethra). Note the psoas shadow.
Preparation of the Patient for KUB

Enema/laxative are given on previous day and Psoas Shadow
the patient is asked to fast in order to reduce It is visualised well in normal kidney. It is
the shadows of bowel gas in X-ray. obliterated in enlarged kidney, scoliosis,
High penetration X-ray is taken in supine retroperitoneal tumours, cold abscess/psoas
position which covers pubic symphysis and abscess due to spinal tuberculosis, splenic injury,
lower two ribs. and retroperitoneal haematoma.
Interpreting the Films Ureteric Line

First bony parts are looked— hip, pelvis, lumbar Ureteric line in plain X-ray KUB is a conventional
vertebrae for fractures, scoliosis, spina bifida and line which runs along the tips of the transverse
secondaries in the spine. Lumbar spine should processes of the vertebrae, crosses the sacroiliac
be counted from below upwards (L5 to L1 ),not joints and reaches up to the point medial to the
from above downwards (as 12th rib may be absent ischial spine. Line is observed for any radiopaque
causing misinterpretation of 12th vertebra as L1 shadow which signifies ureteric stone. If it is
vertebra). present, its location and size should be observed.
Bladder, prostate and urethral areas should
Kidney Shadow be looked for any lesion.
Kidney shadows are visualized in plain X-ray
KUB due to difference in the density between BARIUM SWALLOW X-RAY
kidney and perinephric fat. Its size, location,
calcification and stones should be looked for.
(REFER PAGE 397)
In children perinephric fat is absent and so kidney Thick solution/paste of barium sulphate is given
shadows are not visualized. to the patient to swallow. Under fluoroscopy
Fig. 4.78: Plain X-ray KUB showing large stone IN renal

pelvis. It can be removed by PCNL;or open pyelolithotomy.
Figs 4.77A and B: Plain X-ray KUB showing bilateral

staghorn calculi. Patient may be presenting with renal
failure. Renal function tests, IVU, DTPA radioisotope scan,
ultrasound abdomen and urine culture are essential
investigations. Kidney with better function should be
operated first and later on other side. If there is renal
failure, initial haemodialysis and bilateral nephrostomy is
done. Later once kidney function is better than specific
nephropyelolithotomy is done. Stone is usually triple
phosphate stone (calcium, magnesium and ammonium Fig. 4.79: Renal stone on right side
phosphate stone). with a J stent on left ureter.
X-rays 395
Fig. 4.80: Plain X-ray showing stone in the renal pelvis

on right side (phosphate stone) and stone in the bladder,
(oxalate stone with spikes).
Fig. 4.81: Stone in the left ureter in middle 1/3. It should Figs 4.82A to C: X-ray showing large bladder
be removed by URS/PCNL/Laparoscopic/open ureterolitho- stone.
tomy.
Fig. 4.85: X-ray pelvis showing radiopaque Malecot’s

catheter in situ.
(dynamic study) while barium is descending

along the oesophagus slowly, oesophagus is
observed for any mucosal changes, alteration in
motility and block/narrowing. Once suspected
Fig. 4.83: Plain X-ray showing stones in horse shoe area is identified required films are taken as
kidney. IVU will show flower vas appearance. needed. Usually oblique films are taken.
What are the indications?
Any patient with dysphagia/odynophagia
(painful swallowing) for more than 3 weeks is
an indication for barium swallow/oesophago-
scopy.
• Achalasia cardia
• Carcinoma oesophagus
• Oesophageal strictures – corrosive
• Extrinsic compression – mediastinal mass
• Tracheo-oesophageal fistula
• Pharyngeal pouch and oesophageal diver-
ticula
• Oesophageal varices
• Hiatus hernia
• Oesophageal webs
• Leaking oesophageal anastomosis
Barium is radiopaque and so it is used. Barium
sulphate is inert and in sulphate media, it will
not get absorbed into circulation. Barium
phosphate (barium in phosphate media) gets
absorbed and barium is neurotoxic. Barium
Fig. 4.84: Large vesical calculus. It is radiopaque;
phosphate is commercially used rat poison.
phosphate/triple phosphate stone with laminations. It is Water soluble contrast like gastrograffin is used
secondary bladder stone (which is secondary to infection). for identifying leak, perforation or fistula.
X-rays 397
Barium Swallow X-ray of Pharyngeal Pouch pressure in the pharynx, mainly during
It is a protrusion of mucosa through Killian’s swallowing which leads to protrusion of mucosa
dehiscence, a weak area of the posterior pharyngeal through the Killian’s dehiscence causing
wall between thyropharyngeus (oblique fibres) and pharyngeal pouch.
cricopharyngeus (transverse fibres) of the inferior
The protrusion is usually towards the left.
constrictor muscle of the pharynx. Imperfect
relaxation of the cricopharyngeus increases the Stages:
1. Small diverticulum.
2. Large, globular diverticulum causing
regurgitation, cough, dysphagia, respiratory
infection.
3. Large pouch which is visible in the neck as
a globular swelling often tender, smooth and
soft. They present with dysphagia, features
of respiratory infection like pneumonia and
lung abscess, weight loss and cachexia. Pouch
may itself get infected and form an abscess.
Often the pouch may descend downwards
and enter the superior mediastinum.
Clinical features: Pain, dysphagia, recurrent
respiratory infection, swelling in the neck on the
left side which is smooth, soft and tender.
Gurgling in the swelling on pressing is common.
Swelling is usually resonant.
Fig. 4.86: Barium swallow showing pharyngeal pouch. Oesophagoscopy may cause perforation of
Patient is prone for aspiration and pneumonia which can pouch and mediastinitis. So it can be avoided
be seen in chest X-ray. or it should be done gently.
Treatment: Antibiotics has to be started.
Pharyngeal pouch is excised by an oblique neck
incision (approach from neck). As there is
cricopharyngeal spasm, cricopharyngeal myotomy
(i.e. cutting of cricopharyngeal circular muscle
fibres without opening the mucosa.) is done to
prevent the recurrence. Under general anaes-
thesia with nasogastric tube in the oesophagus,
oesophagoscope is gently passed into the
pharyngeal pouch and pouch is soaked with
acriflavine solution using ribbon gauze.
Complications:
1. Infection either mediastinitis or lung infection.
(Pneumonia or lung abscess).
Fig. 4.87: Pharyngeal pouch (Zenker’s diverticulum) 2. Pharyngeal fistula.
– anatomy and relations 3. Abscess in the neck.
Aetiology:
• Stress.
• Vit B1 deficiency.
• Chaga’s disease, varicella zoster infection
There is pencil shaped narrowing of cardia
(O-G junction) with enormous dilatation of
proximal oesophagus, which contains foul
smelling fluid and is more prone for aspiration
pneumonia.
Achalasia cardia is a precancerous condition.
Clinical Features
Common in females between 20 and 40 years
age group present with progressive dysphagia,
which is more for liquid than to solid food.
Regurgitation and recurrent pneumonia/lung
abscess are common. Also presents with
malnutrition, general ill health, chest pain and,
odynophagia.
Fig. 4.88: Barium swallow X-ray in Achalasia cardia showing
pencil narrowing of distal oesophagus near O – G junction
with proximal dilatation. Treatment
1. Modified Heller’s operation: Oesophagocardio-
Barium Swallow X-ray Achalasia Cardia myotomy.
It is failure of relaxation of cardia (Oesophago Either through thoracic or abdominal
gastric junction) due to disorganised oesophageal approach, thickened circular muscle fibres
peristalsis, as a result of failure of integration are cut longitudinally for about 8-10 cm, at
of parasympathetic impulses causing functional 2 cm proximal to the thickened muscle to 1 cm
obstruction. distal to O—G junction. Care should be taken
Barium swallow X-ray in Achalasia cardia Chest X-ray in Achalasia cardia

• Pencil shaped narrowing of the oesophagus • Features of aspiration pneumonia
at its lower end—bird beak appearance • Soft tissue shadow with air fluid level, right
• Proximal dilatation of the oesophagus— to right atrium
mega/sigmoid oesophagus
• Absence of fundic gas shadow
• No mucosal irregularity
Oesophagoscopy Oesophageal manometry is ideal

• Dilated proximal oesophagus • Unrelaxed lower oesophagus
• Smooth pencil shaped narrowing at lower • Resting high pressure
end of the oesophagus • Persistent high pressure in lower
• Only oesophagitis in the mucosa oesophageal sphincter (LOS).
• Biopsy is a must as it is potentially
malignant
• Normal stomach
X-rays 399
not to open the mucosa. Procedure is done
through thoracic/open laparotomy/laparo-
scopic approaches.
2. Nissen’s fundoplication is done along with the
above procedure to prevent reflux.
3. Negus hydrostatic dilatation is done to dilate
O—G junction. It is not very well accepted
method as chances of perforation are high.
Symptom control is around 75%. But chances
of recurrence and perforation are high.
4. Calcium channel blockers like nifedipine can
relieve the symptoms. Endoscopic injection
of botulinum toxin into the LOS is also tried.
What is presbyoesophagus?
It is diffuse oesophageal spasm with marked
hypertrophy of circular oesophageal muscle.
Intra oesophageal pressure is very high, often
400-500 mm Hg with uncoordinated oesophageal
contraction.
Dysphagia, odynophagia, persistent chest
pain and malnutrition are the presentations.
Cork screw oesophagus is typical in barium A B
swallow X-ray. Figs 4.89A and B: Barium swallow X-ray showing irregular
filling defect and shouldering sign of carcinoma oesophagus.
Treatment: Repeated oesophageal dilatation,
extensive lengthy oesophageal myotomy from
aortic arch to cardia using thoracoscopy. • Mycotoxin.
Total oesophagectomy with gastric/colonic/ • Alcohol and tobacco.
jejunal pull through. • Achalasia cardia.
• Oesophageal webs.
Barium Swallow X-ray in Carcinoma • Barrett’s oesophagus.
Oesophagus • Oesophagitis.
Features • Tylosis.
• Irregular filling defect. • Corrosive strictures.
• Shouldering sign at the beginning of the • 5% common.
tumour. • Common after 45 years.
• Narrowing. • Common in men.
• Rat tail lesion in fluoroscopy—normal • Common in China-Henan province.
oesophagus shows horizontal movements/ • In India: common in Orissa and Karnataka.
oscillations in fluoroscopy. This is absent in
What is tylosis?
carcinoma and so it looks like stiff area like
• Autosomal dominant condition seen from
rat tail.
childhood
What are the etiologies of carcinoma oesophagus? • Soles and palms are involved called as
• Diet: salted dry fish, high nitrosamines. palmoplantar keratoderma.
• Deficiencies: vitamin C, riboflavin • Waxy, yellow lesions, which does not itch.
• 60% of members of families develop • Hoarseness of voice due to recurrent laryngeal

carcinoma oesophagus after the age of 60. nerve palsy.
• Systemic retinoids are the drugs used for • Anorexia and loss of weight. (severe).
tylosis. (Cachexia).
• Pain—substernal or in the abdomen.
Pathology • Liver secondaries.
Common in Middle third— 50%. • Bronchopneumonia.
Lower third—33%. • Features of bronchooesophageal fistula in
Upper third—17%. carcinoma of upper third oesophagus.
In India squamous cell carcinoma is more • Supraclavicular lymph nodes may be
common—90%. palpable.
Lower 3 cms of oesophagus is lined by
columnar epithelium, and so adenocarcinoma Investigations
is common here. Barrett’s columnar metaplasia • Barium swallow: Shouldering sign and irre-
which occurs in lower third oesophagus is also gular filling defect.
more prone for adenocarcinoma. In western • Oesophagoscopy to see the lesion, its extent
countries adenocarcinoma is more common. and type.
Gross: Annular—15%. • Biopsy for histological type and confirmation.
Ulcerative—20%. • Chest X-ray to see pulmonary infection.
Fungating-cauliflower like—60%. • Bronchoscopy, to see invasion in upper third
growth.
Spread • Oesophageal endosonography to look for the
• Direct: In upper third it spreads through involvement of layers of oesophagus.
muscular layer and gets adherent to left main
bronchus, trachea, and left recurrent laryngeal
nerve (causing hoarseness), aorta or its
branches (causing fatal haemorrhage, but
rare). It may perforate and cause mediasti-
nitis. It may get adherent to pleura also.
• Lymphatic spread: It spreads both by lymphatic
permeation and lymphatic embolisation. It
can cause satellite nodules elsewhere in the
oesophagus away from the main tumour.
Above in the neck it spreads to left supracla-
vicular lymph nodes. In the thorax it spreads
to paraoesophageal, tracheo- bronchial lymph
nodes and to sub diaphragmatic lymph
nodes. In the abdomen it spreads to coeliac
lymph nodes.
• Blood spread occurs to liver.
Clinical Features
• Recent onset of dysphagia is the commonest
feature. For dysphagia to develop two third of
the lumen should be occluded. Fig. 4.90: Barium study showing shouldering sign, irregular
• Regurgitation and cough. filling defect and narrowing – carcinoma lower oesophagus.
X-rays 401
• CT scan to look for local extension and status
of tracheo bronchial tree in case of upper
third growth.
• Ultrasound abdomen to look for liver and
lymph nodes status in abdomen.
• Endoscopic oesophageal staining with
labeled iodine results in normal mucosa being
stained brown, but remains pale in carcinoma.
(As mucosa involved with carcinoma will
not take up iodine).
Fig. 4.92: Barium swallow X-ray showing rat tail lesion

Fig. 4.91: Contrast X-ray showing bronchooesophageal in the lower oesophagus near O-G junction with narrowing
fistula in a case of carcinoma oesophagus. Note the dye and irregularity – feature of carcinoma oesophagus.
entering into the oesophagus. In broncho/tracheo
oesophageal fistula water soluble nonionic agent (Dianosil)
is used. growths (depending on locations) can be
done.
Treatment
Gastrostomy should not be done as a palliative Upper third growth:
procedure. • Treated mainly by radiotherapy.
• Commonly it is advanced with left recurrent
Curative treatment: nerve palsy and bronchial invasion.
Indications: If it is early and operable, Mc Keown three
1. Early growth, when patient is fit. staged oesophagectomy and anastomosis is done
2. When there is no involvement of lymph nodes, in the neck. Initially laparotomy is done to
bronchus and liver. mobilize the stomach. Then thoracotomy through
• Post-cricoid tumour is treated mainly by right 5th space is done and oesophagus is
radiotherapy. mobilized. Through right side neck approach,
• Often pharyngo-laryngectomy is done along oesophagus with growth is removed. Anasto-
with gastric or colonic transposition. But mosis between pharynx and stomach is done
complications are more in this procedure. in the neck.
• Ivor-Lewis operation or Mc Keown operation Malignant bronchooesophageal fistula is
for lower third or middle third or upper third common in upper third growths.
Middle third growth: • Prevent bleeding.

Ivor Lewis operation: After laparotomy stomach • Prevent aspiration.
is mobilised. Pyloroplasty is done.
Palliative procedures
Through right 5th space thoracotomy is done
• External or intra luminal radiotherapy.
and growth with tumour is mobilised. Partial
• Traction tubes like Celestin or MB tubes through
oesophagectomy and oesophago-gastric anasto-
open surgery.
mosis is done in the thorax. Intercostal tube
• Pulsion tubes like self-expandable metal stents
drainage is placed during closure.
through endoscopes using C arm.
If growth is inoperable, Palliative radio-
• Endoscopic Laser.
therapy or chemotherapy is given.
• Chemotherapy – Cis platin, bleomycin,
Lower third growth: methotrexate, mitonycin and 5 fluoro uracil.
Here through left thoraco-abdominal approach, • Transhiatal oesophagectomy.
partial oesophago-gastrectomy is done with Intubation:
oesophago gastric anastomosis. Often jejunal Atkinson tube.
Roux-en-Y loop anastomosis is done. Celestin tube.
Orrhinger and Orrhinger approach, i.e. Trans Souttar tube.
hiatal blind total oesophagectomy with anastomosis Mousseau—Barbin tube—cheaper, but
in the left side of the neck. Through laparotomy, requires laparotomy to pass.
stomach and lower part of the oesophagus are Expanding metal stents are passed through
mobilised. Through left sided neck approach, endoscope under C-arm guidance.
upper part of the oesophagus is mobilised using Endoscopic laser is used to core a channel
finger. Blind dissection is completed by meeting through the tumour to improve dysphagia.
both fingers above and below in the thorax. Later
Complications of oesophagectomy
oesophagus is pulled up out above through the
• 5-10% mortality.
neck wound and removed. Continuity is
• Haemorrhage.
maintained in the neck. It is a palliative surgery.
• Respiratory infection, often severe.
Thoracoscopic— Laparoscopic oesophagectomy is
• Septicaemia.
practised in a few centers. It is popular and better.
• Chylothorax, injury to thoracic duct.
Total oesophagectomy with three field nodal
• Anastomotic leak—thoracic leak is most
dissection (celiac/thoracic/neck nodes) is also
dangerous.
done as a radical procedure. When interposition
• Hoarseness due to recurrent laryngeal nerve
is required, mobilised stomach or jejunum or colon
palsy.
(left) are used. Commonly it is placed in the
• Stricture formation.
thorax. Often it can be placed in substernal space
or in front of the sternum in subcutaneous plane
Terminal events in carcinoma oesophagus
(especially colon). Stomach is commonly used
• Cancer cachexia
to pull up as it has got good vascularity; and
• Sepsis
it is technically easier to mobilise and pull up
• Immunosuppression
for adequate length.
• Malignant tracheo-oesophageal fistula
(causes severe respiratory infection and
Palliative Treatment
death. Here expansile endoluminal stents are
Indications for palliative therapy
used at the site of fistula to have temporary
• Relieve pain.
benefit).
• Relieve dyspahgia.
X-rays 403
What is TNM staging for carcinoma oesophagus? patient to delay the gastric emptying. Glucagon
T0: no primary tumour. also can be used. Effervescent tablet (calcium
Tis: Carcinomas in situ. carbonate and antifoaming agent) is given to the
T1: Tumour involving submucosa. patient. 200 ml of barium sulphate solution is
T2: Tumour involving muscularis propria. given to drink. X-rays are taken to get double
T3: Tumour with peri-oesophageal spread. contrast barium meal X-rays.
T4: Involvement of recurrent laryngeal nerve,
Indications for barium meal X-ray
phrenic nerve, sympathetic chain, azygos
• Duodenal ulcer: Shows absent/deformed
vein and adjacent structures.
duodenal cap.
N0: No lymph nodes.
• Benign gastric ulcer: Shows niche (due to ulcer)
N1: Mobile regional nodes.
and notch (due to spasm).
M0: No distant spread.
• Gastric outlet obstruction.
M1: Distant spread or positive celiac nodes.
• Carcinoma stomach.
• Carcinoma pancreas: Pad sign.
BARIUM MEAL X-RAY • Periampullary carcinoma: Frostberg reverse ‘3‘
Barium meal X-ray is done using barium sulphate sign.
(95% w/v) solution of which 400-600 ml is givor • Chronic duodenal ileus.
orally. It is done on empty stomach. Microcrys- • Stomal ulcer.
talised barium sulphate solution is better. • Duodenal diverticula: trifoliate duodenum.
Procedure should be done under fluoroscopic • Trichobezoars.
guidance. Buscopan injection is given to the • Gastric fistulas.
• Pseudocyst of pancreas: Widened vertebro –
gastric angle.
Barium Meal X-ray Features of Benign

Gastric Ulcer
• Niche on the lesser curve with notch on the
greater curvature.
• Ulcer crater projects beyond the lumen of the
• Regular/round margin of the ulcer crater –
stomach spoke wheel pattern.
• Overhanging mucosa at the margins of a
benign gastric ulcer – projects inwards
towards the ulcer – Hamptom’s line.
• Converging mucosal folds towards the base
of the ulcer.
• Symmetrical normal gastric mucosal folds.
Features of chronic benign gastric ulcer
• It may be due to atrophic gastritis, smoking,
alcohol.
• Typical pain which is more after taking food
and is relieved by inducing vomiting.
• Periodicity, haematemesis are other features.
Fig. 4.93: Barium meal X-ray showing extrinsic compression
of stomach by gastric teratoma in a newborn child. Inset • Complications are – hour glass contracture,
shows CT picture of the tumour of the same child. tea-pot deformity, erosion into left gastric/
partially and retains its potentiality to

transform into carcinoma stomach.
• Giant gastric ulcer is benign gastric ulcer more
than 3 cm in size.
• Benign ulcer occurs usually in the lesser curve
whereas ulcer in greater curve is commonly
malignant.
Treatment for chronic benign gastric ulcer
is partial gastrectomy with Billroth I gastro-
duodenal anastomosis.
Barium Meal X-ray in Duodenal Ulcer

Absence of duodenal cap or deformed first part of
the duodenum is the classical feature of chronic
duodenal ulcer. It is due to spasm of the 1st
part of the duodenum causing its deformity.
Chronic duodenal ulcer can lead into secondary
diverticulum leading into trifoliate duodenum.
A
Fig. 4.95: Barium meal X-ray showing absence of duodenal

B cap without any obstruction. In chronic duodenal ulcer
duodenal cap may be deformed or absent. Duodenal cap,
Figs 4.94A and B: Barium meal X-ray showing niche
in normal barium meal X-ray is formed by pouching effect
and notch in gastric ulcer. Benign gastric ulcer is usually
of the normal first part of the duodenum. It is lost due
in lesser curve where there will be niche. Notch occurs
to spasm in chronic duodenal ulcer.
on the diagonally opposite side of the ulcer due to spasm
of circular muscle fibre.
Features of duodenal ulcer
splenic arteries, perforation and malignant • ‘Hurry, worry, curry’: stress, anxiety are the
transformation. Risk of carcinoma is 6-23%. basic aetiological factors.
• Patients with gastric ulcer treated with anti • Common in blood group O positive.
ulcer drugs like proton pump inhibitor will • Helicobacter pylori infection is seen in more
become symptomatically better but ulcer heals than 90% of duodenal ulcer. Other causes
Types of gastric ulcer (Johnson)

Type I: In the antrum near the lesser curve 55% Normal acid level
Type II: Proximal gastric ulcer with duodenal ulcer 25% High acid level
Type III: Pre-pyloric ulcer 15% High acid level
Type IV: Gastric ulcer in the proximal stomach or cardia 05% Normal acid level
X-rays 405
are NSAID’s, steroids, alcohol, smoking, Barium Meal X-ray of Gastric Outlet
hyperparathyroidism. Obstruction
• Anterior ulcer perforates; posterior ulcer • Absent duodenal cap, if it is due to cicatrised
bleeds. chronic duodenal ulcer.
• Hunger pain, early morning pain, periodicity, • Greater curvature is below the level of iliac
water brash, malaena are other features. crest.
• Complications are pyloric stenosis, bleeding, • Mottled stomach due to retained food
perforation and penetration into pancreas. particles which giv.es coated/mosaic
• Chronic duodenal ulcer will never turn into appearance.
malignancy. • Barium will not pass into the duodenum.
• Gastroscopy, biopsy for Helicobacter pylori • Dilated stomach.
is needed.
• Proton pump inhibitors, anti H pylori drugs Features of gastric outlet obstruction
are the treatment. • Pyloric stenosis is due to congenital/chronic
• Surgery is indicated when there is intractable duodenal ulcer/carcinoma pylorus
bleeding from the duodenal ulcer or when • Hypochloremic, hyponatraemic, hypokalae-
repeated recurrences or complication sets in. mic, hypocalcaemic, hypomagnesemic
Highly selective vagotomy is done for metabolic alkalosis with paradoxical aciduria
intractable or repeated recurrent duodenal is typical.
ulcers without pyloric stenosis. If there is • Persistent pain, vomiting, visible gastric
pyloric stenosis then only truncal vagotomy peristalsis, positive succussion splash,
with gastrojejunostomy (posterior, vertical, short positive ausculto-percussion test are the
loop, retrocolic and isoperistaltic) is done. special features.
Pyloroplasty cannot be done in chronically • Treatment: Correction of electrolytes, stomach
scarred duodenum because of the chances wash using Eswald’s stomach tube, TPN and
of duodenal leak. truncal vagotomy with posterior gastrojejuno-
stomy. Pyloroplasty, HSV or gastrectomy are
not done for pyloric stenosis due to chronic
duodenal ulcer.
Barium Meal X-ray of Carcinoma Stomach

• Irregular filling defect.
• Margin of the lesion projects outward from
the ulcer/lesion into the gastric lumen—
Carmanns meniscus sign.
• Distorted and altered gastric folds with
asymmetry.
• Kirklin complex.
• If growth is in the stomach, features of gastric
outlet obstruction due to narrowing may be
observed.
• In linitis plastica, there is small shrunken
stomach with diffuse mucosal changes –
Fig. 4.96: Barium meal X-ray showing secondary diverticula leather bottle stomach.
– trifoliate duodenum due to chronic duodenal ulcer. Primary
duodenal diverticula are congenital with involvement of • Carcinoma stomach is common in greater
all layers of duodenum. curvature.
Fig. 4.98: Barium meal X-ray with irregular filling

defect in the body of the stomach.
Figs 4.97A to C: Barium meal X-ray showing gastric

outlet obstruction. It is due to scarred chronic duodenal Fig. 4.99: Barium meal X-ray showing polypoid
ulcer (commonly)/or due to growth in the pylorus. carcinoma in the body of the stomach.
X-rays 407
Fig. 4.100: Barium meal X-ray showing carcinoma

pylorus with narrowing and irregular filling defect.
Barium Meal X-ray Showing Extrinsic

Compression
There will be smooth inward indentation over
the wall/curvature of the stomach with a visible Fig. 4.101: Barium meal showing extrinsic compression
into the stomach. It could be leiomyoma, GIST or lymph
extrinsic mass lesion. Mucosal pattern of the nodes.
stomach looks normal. It could be lymph nodal
mass/retroperitoneal mass/pancreatic mass/
gastric wall mass. CT will give the definitive X-rays are taken as required. Features such as
idea about the lesion. narrowing, smooth/irregular filling defect,
localised dilatation, obstruction or features of
specific conditions are looked for. In conditions
SMALL BOWEL ENEMA – like ileocaecal tuberculosis enteroclysis and
ENTEROCLYSIS barium enema X-rays are combined. Problems
with enteroclysis are poor patient acceptance,
It is visualisation of entire length of small and technical difficulty. Capsule endoscopy or
intestine –to assess anatomical problems. enteroscopes are better options to visualise the
Indications are small bowel/ileocaecal small bowel.
tuberculosis, stricture, small bowel tumours, When nasojejunal tube is not able to pass
partial obstruction and Crohn’s disease. barium meal follow through X-ray is done by taking
Technique: Patient is prepared overnight with late films of barium meal.
empty stomach and laxatives. Nasojejunal tube
is passed. Prokinetic drug like metoclopramide Barium Enema X-ray
is given. Micro barium sulphate solution Indications for barium enema are:
(50% w/v) or gastrograffin or water soluble • Carcinoma colon.
iodine dye solution is (500-800 ml) passed • Ileocaecal tuberculosis—combined with
through the tube. Under fluoroscopic guidance enteroclysis.
Fig. 4.103: Plain and contrast X-ray showing congenital

diaphragmatic hernia right side with colon as content.
Note the barium enema X-ray showing contrast entering
the right chest up to the apex.
per anally into the colorectum using a enema

tube from a enema can. Patient will be initially
in left lateral position and later in prone position.
In children a Foley’s catheter with inflation is
used to maintain the retention of enema.
Fig. 4.102: Enteroclysis/small bowel enema X-ray. Procedure often is observed under fluoroscopy.
Nasojejunal tube should be seen in proper enteroclysis. Injection buscopan is injected (20 mg IV) to relax
Here tube is removed prior to taking X-ray film. Microbar the colon. X-ray film is taken after complete filling.
solution or water soluble dye or gastrograffin is passed
through a nasojejunal tube which is negotiated under C
Patient is asked to evacuate the barium and later
arm guidance. Prokinetic drugs are given. X-rays are post evacuation film is taken. Air is insufflated
taken. It is done in small bowel tumours/small bowel into the colon to get air contrast film. Additional
tuberculosis/stricture/partial obstruction/ileocaecal different view films are taken to see the suspected
tuberculosis.
area properly.
• Ulcerative colitis. Different Findings

• Crohn’s disease. a. Hirschsprung’s disease
• Ischaemic colitis. Barium enema is done to look for the extent of
• Colonic polyps. disease and three zones. Foley’s catheter should
• Intussusception. not be used while doing barium enema in case
• Congenital megacolon. of Hirschsprung’s disease. Here barium in dilute
• Gastrojejunocolic fistula. saline is used – not in water.
• Congenital diaphragmatic hernia (Bochdalek). I. Distal immobile spastic segment i.e. agang-
lionic zone.
Technique of barium enema X-ray II. A proximal, middle transitional zone of about
24 hours liquid diet, laxatives for two nights 1-5 cm length with less, sparse number of
and enema on previous night are the required ganglions. (Cone).
preparations for barium enema X-ray. III. A still more proximal, hypertrophied dilated
About one liter of barium sulphate/micro segment is actually the normal ganglionic
barium sulphate solution (25% w/v) is infused area.
X-rays 409
A B C
Figs 4.104A to C: Barium enema X-rays taken after complete filling and evacuation of barium sulphate enema
solution. Air is insufflated per anum into the colo-rectum which delineates the mucosa better to visualise small ulcers/
small polyps.
B C
Figs 4.105A and B: Barium enema X-ray showing features Fig. 4.105C: Barium enema X-ray in new born
of congenital megacolon (Hirschsprung’s disease). It taken for congenital megacolon.
shows distal narrow segment, middle cone and proximal
dilated segment.
b.Carcinoma colon
• Irregular filling defect.
• Apple core lesion especially on left side.
• Metachronous growths (growths in different
parts of the colon) should be looked for –
5% common.
• Narrowing: left sided lesion.
Fig. 4.106: Barium enema X-ray showing growth

with stricture in the ascending colon.
Figs 4.108A and B: Barium enema X-ray showing irregular

filling defect in hepatic flexure with intussusception in one
X-ray and in splenic flexure in other X-ray (carcinoma
colon). Note growth in splenic flexure is narrow – stricture/
Fig. 4.107: Air contrast barium enema X-ray howing obstructive type (apple – core lesion). X-ray of hepatic
irregular filling defect in the ascending colon. flexure growth presented as intussusception.
X-rays 411
c. Ulcerative colitis
• Loss of haustrations.
• Contracted smooth colon.
• Presence of pseudopolyps.
• Collar button ulcers – contiguous mucosal
involvement.
• Hose pipe/pipe stem lesions.
• Increased presacral space more than normal
(normal is < 1 cm).
• Reflux ileitis.
• Rectum is almost always involved.
d. Ileo caecal tuberculosis
• Pulled up caecum due to fibrosis and
contraction.
• Obtuse ileo caecal angle (normal angle is acute)
• Hurrying of barium due to rapid flow – Stierlin
sign.
• Narrow ileum with thickened ileocaecal valve,
Fleischner – inverted umbrella sign.
• Incompetent ileocaecal valve.
• Ulcers and strictures in terminal ileum– napkin
lesions.
• Gooseneck appearance – ileum hanging from Fig. 4.109: Barium enema X-ray showing stricture colon.
fibrosed, pulled up caecum. Causes for stricture colon are tuberculosis, carcinoma
and post surgery.
A B C
Figs 4.110A to C: Barium enema X-ray showing features of ileocaecal tuberculosis in different patients. Note
the obtuse ileo caecal angle; pulled up caecum; incompetent ileo caecal valve.
Fig. 4.111: Barium enema X-ray showing stricture in ileo Fig. 4.112: Barium enema X-ray showing sigmoid
caecal junction probably due to tuberculosis. Colonoscopy diverticula.
and biopsy must be done.
e. Crohn’s disease
• Aphthoid ulceration.
• Skip lesions.
• Rectum is not commonly involved.
• String sign of Kantor.
• Cobble stone appearance: Pseudosacculations.
• Raspberry/rose thorn appearance.
• Fistula or strictures.
f. Sigmoid diverticula
• Saw teeth appearance of sigmoid colon –
concertina like: Serrated appearance.
• Champagne glass sign: partial filling of barium
with stercolith inside the diverticula.
• Fistula to adjacent structures.
g. Intussusception
• Claw sign: Coiled spring sign – pincer end.
• Empty right iliac fossa: Mainly in plain
X-ray abdomen with multiple air fluid levels
Fig. 4.113: Barium enema X-ray showing typical claw
(on ultrasound: Target sign/pseudo kidney sign/ sign/coiled spring sign – in transverse colon – ileocolic
bull’s eye sign). type – commonest type.
X-rays 413
Intravenous Urogram (IVU) (Intravenous pyelogram—IVP—older terminology)
Indications Findings
1. Hydronephrosis Clubbing of calyces
2. Congenital anomalies
a. Horse-shoe kidney Flower vase appearance
b. Duplex kidney and double ureter
c. Ureterocele Adder (cobra) head appearance
d. Polycystic kidney disease Spider leg appearance
e. Retrocaval ureter Reverse ‘J’ sign with hydronephrosis
3. Renal cell carcinoma Irregular filling defect
4. To see the function of the kidneys Bilateral stones, obstructive uropathy
in bilateral diseases
5. After surgery for urinary diseases To see the function of kidneys and outcome of
the surgery
6. Renal injury To see the function of other kidney (A very specific
investigation
Contraindications for IVU
1. Iodine sensitivity- may go for anaphylaxis. Hence, all precautions must be taken and essential
drugs should be available while doing IVU
2. Multiple myeloma and hypergammaglobulinaemias (Acute renal failure may be precipitated
due to dehydration)
3. Toxic thyroid
h. Ischaemic colitis 3. Then 1 ml test dose of sodium diatrizoate

• Thumb print sign in splenic flexure. (urograffin) or Meglumine iothalamate IV
Other signs in barium enema X-ray is injected and waited for 5-10 minutes.
• Stacked coin appearance due to submucosal If no adverse reaction occurs, then full dose
haemorrhages in Henoch Schonlein purpura. - 1 ml/Kg body weight IV of (300 mg of
• Scalloped edges in colon in pneumatosis iodine per Kg of body weight) urograffin
intestinalis. is given. (about 40-50 ml).
4. X-ray is taken in 1—5minutes which shows
the nephrographic and secretory function
INTRAVENOUS UROGRAM (IVU) of the kidneys.
Procedure: 5. Later, at 15 minute and then at 20-30 minute
Renal function must be normal. films are taken.
1. Overnight fasting for 8 hours is advised. 6. Further films are taken depending on the
Laxatives are given to reduce bowel need.
shadow and get a good quality film. 7. Film can be taken as late as 72 hours. Late
2. First a plain X-ray KUB is taken ( IVU films show bladder pathology as well as
should not be read without doing KUB). residual urine.
A B
Figs 4.114A and B: Bilateral hydronephrosis with hydroureter. It

could be due to BPH, stricture urethra, bladder tumour, extrinsic
compression of both ureters and bilateral congenital PUJ obstruction.
A
X-rays 415
Figs 4.115A and B: Extrarenal pelvis presenting with hydronephrosis. 80% of renal
pelvis is extra-renal. In this type of pelvis hydronephrosis causes less renal parenchymal
damage. It is easier to operate in such patient than with intra-renal pelvis hydro-
nephrosis(20%).
Fig. 4.116: IVU showing flower vase appearance in case

of horse shoe kidney. Fusion of one of the poles of the
both kidneys causes horse shoe kidney. Usually fusion
occurs in lower pole. Fusion at the upper pole is rare.
Fused isthmus is in front of the vertebra and aorta; and
often derives its blood supply from aorta. It is more prone
for infection, hydronephrosis and stone formation. Fig. 4.117: IVU showing right sided hydronephrosis and
Angiogram and IVU are diagnostic. proximal hydroureter. Note the clubbing of calyces.
A B
Figs 4.118A and B: IVU showing right-sided hydronephrosis. Note the

clubbing of the calyces. In second X-ray there is hydroureter also. Secretion
is normal on left side (cup shaped calyces are normal).
Fig. 4.120: IVU showing stricture distal ureter with proximal

hydroureter. Common cause is tuberculosis. It is confirmed
by cystoscopy ; selective urine sample for specific culture
Fig. 4.119: IVU—late film with bladder phase showing (for tuberculosis) (Dr Navinchandra Shetty, HOD,
enlarged median lobe in the urinary bladder (BPH). Radiology, KMC Mangalore).
X-rays 417
8. In case of renal failure with high blood urea,
dose of dye is increased to 2ml/Kg (600
mg/Kg) body weight to get a better film
-Infusion IVU. Often diuretics are used in
these patients to have better secretion.
9. Compression over lower abdomen for 10
minutes can be done to have better definition
of calyces; but not done in children and
patients with abdominal aortic aneurysm.
10. Minute IVU- In case of renal artery stenosis,
within first minute many films are taken
to see nephrographic (proximal convoluted
tubules are seen) shadow—where a small,
concentrated kidney is seen.
11. Upper part of ureter is visualised in supine
films whereas lower part in prone films.
12. Nonvisualisation of kidney: Here no
contrast is seen in the film even after
12 hours.
Retrograde Pyelography (RGP)

Indications
1. Failure of showing any secretions in an IVU
as late as in 72 hours film.
Fig. 4.122: Note the ureteric catheter
with injection of dye into the ureter
2. Urinary tuberculosis.
3. Urothelial tumours from the renal pelvis.
Procedure
Under G/A cystoscope is passed. Ureteric orifice
is visualised. Ureteric catheter is passed. Dye,
sodium diatrizoate is injected. Patient is put in
15° head down position to allow the dye to reach
upper urinary system. X-ray is taken.
Advantages
a. Prior to dye injection selective urine sample
can be taken from each ureter.
b. Brush biopsy from suspected urothelial
tumours of upper urinary tract can be taken.
c. Better-delineation of anatomy ( due to more
Fig. 4.121: Left-sided RGP-normal study. concentration of dye).
Disadvantages Vesicoureteric reflux is graded depending on the

Anaesthesia is required and is laborious. severity of the reflux as—
I. Ureters seen.
II. Ureters and pelvis are seen.
RENAL ANGIOGRAM
Procedure:
Retrograde Seldinger technique: Through femoral
artery, selective angiogram is done to visualize
tumour vascularity, narrowing or anomalies.
Therapeutic embolisation, transluminal
balloon angioplasty for renal artery stenosis can
also be done. Translumbar approach can also
used for angiogram (through aortogram).
Renal angiogram
Indications
1. Renal artery stenosis
2. Renal artery atheroma
3. Renal artery aneurysm
4. Occasionally renal cell carcinoma
5. Arterial anomalies
Complications
a. Paraplegia A
b. Embolism
c. Dissecting aneurysm
d. Bleeding
e. Renal tubular necrosis
Renal pharmacoangiogram: Noradrenalin is

injected along with the dye. Normal vessels will
constrict in response to noradrenalin. Since
tumour is autonomous, vessels in renal cell
carcinoma do not respond to noradrenalin and
so tumour blush is seen.
Micturating Cystourethrography (MCU)

Indications
a. Vesico ureteric reflux.
b. Posterior urethral valve.
Procedure: Catheter is passed into the bladder.
B
Dilute iodine dye is infused. X-ray is taken during
Figs 4.123A and B: Micturating cysto-urethrogram
micturition. Free reflux is looked for. X-ray is
showing concomitant existence of posterior urethral valve
taken following applying pressure over the (causing dilatation of proximal urethra) and vesico-ureteric
suprapubic region. Pressure reflux is studied. reflux (left side) (By Dr NC Shetty, Radiologist, Mangalore).
X-rays 419
Fig. 4.123C: MCU showing large bladder diverticulum.

Bladder diverticula may be congenital which is full thickness
diverticulum with muscle layer or may be acquired (common)
which is only mucosal and occurs due to chronic
obstruction. Diverticula may be traction or pulsion type.
Surgery is required for large diverticula.
III. Ureters, pelvis, cayces are seen.

IV. Calyces grossly distended. B
V. Tortuous elongated serpentine ureters. Figs 4.124A and B: First X-ray is ascending urethrogram
It can be unilateral or bilateral. Often it is showing failure of dye to pass into the bladder due to
associated with posterior urethral valve. It is often stricture near the bulbar urethra with a radiopaque Malecot’s
catheter inserted through suprapubic cystostomy (SPC).
complicated by infection, pyonephrosis and renal
In second picture, urethrogram shows multiple strictures
failure. but dye has reached above to the bladder.
Investigations: MCU, IVU, ultrasound, blood urea
and serum creatinine.
a. Post-gonococcal is commonest 70%.
Treatment: Tailoring of ureter with reimplantation. – Common in the bulb of urethra
especially in the roof.
Ascending Urethrogram – Here multiple strictures are common.
It is the investigation of choice for stricture urethra. Proximal stricture is the narrowest.
Red rubber catheter is passed through the external b. Tuberculous.
meatus. Water soluble iodine dye is injected c Other infection (Urethritis).
through the catheter. Oblique X-ray films are 3. Traumatic: Bulbous, Membranous.
taken to visualise the urethra. Site, size, extent 4. Post-instrumentation: Catheter, dilator,
of stricture and extravasation can be seen. cystoscope.
5. Postoperative: Prostate surgery,
Stricture Urethra Urethrostomy.
Classification I:
Classification II: According to portion involved
Aetiological— 1. Proximal: Common in bulbous urethra. (70%).
1. Congenital. 2. Distal: Congenital (in the external meatus).
2. Inflammatory: Often following trauma, in children.
Classification III: Dilatation is done ‘once a week for one month,

1. Permeable: Permits urine to pass. once a month for one year, and later once a year
2. Impermeable. on his birthday.’
Classification IV: Dilators used:
1. Passable: Allows catheter to pass. • Lister’s dilator (has got olive tip (blister)).
2. Impassable. • Clutton’s dilator.
Classification V: • Filiform bougies.
It can be single or multiple. Complications of dilatation:
Classification VI: According to part involved. • Infection and bleeding due to trauma.
In the roof (commonest) or in the floor. • False passage.
• Fistula formation.
Clinical Features 2. Visual internal cystoscopic urethrotomy or
• Poor urinary stream.
stricturotomy: Here using cystoscope, stricture is
• Forking and spraying of the stream.
visualised and is cut at 12 O‘ clock position,
• Incomplete emptying.
• Frequency, dysuria. until it bleeds (fibrous tissue is cut completely).
• Retention and often with overflow. After that Foley’s catheter is passed and kept
• Pain, burning micturition, suprapubic tender- in position for 48 hours.
ness. 3. External urethrotomy by open method. Not
• Thickening and button like feeling in bulbar commonly done presently as cystoscopic
urethra. (Clinically bulbous urethra is felt in urethrotomy is more popular. It is presently done
midline in the perineum by lifting the as an initial stage surgery for urethroplasty
scrotum). (Wheelhouse’s operation).
Investigations 4. Urethroplasty: Stricture is excised and urethra
• Urine microscopy and culture. is reconstructed using prepuceal skin or scrotal
• Blood urea and serum creatinine. skin. (Johanson’s urethroplasty).
• IVU to see hydronephrosis and function of
kidney. Problems in urethroplasty—
• Ultrasound abdomen. • Staged procedure and so prolonged
• X-ray of pelvis to see old fracture with history hospitalisation.
of trauma. • Infection.
• Ascending urethrogram is an essential inves- • Necrosis of skin flap.
tigation: To see the site, type, extent and false • Leak and fistula formation.
passage. Dye is injected the into the bladder • Re-stenosis.
through suprapubic needle puncture and Complications of stricture urethra
visualisation is done using C-ARM image
• Retention of urine
intensifier.
• Urodynamic studies. • Urethral fistula.
• Urethroscopy. • Infection—urethritis, cystitis,
pyelonephritis.
Treatment • Urethral diverticula.
• Periurethral abscess.
1. Intermittent dilatation: • Bilateral hydronephrosis.
Gradual dilatation is done initially with thin
• Stone formation.
dilators, later with thicker dilators of increasing
size. Dilatation should be done in OT under • Renal failure.
aseptic precaution. One should avoid forcible • Due to straining—hernia, haemorrhoids,
dilatation or over dilatation. rectal prolapse.
X-rays 421
Treatment:
• Ureteric meatotomy is done if there is
narrowing of the orifice.
• Co-existing complications are treated.
• Often heminephrectomy, including removal
of corresponding ureter may be essential as
treatment.
Retrocaval Ureter
• It is due to developmental defect of IVC, as
a result of which ureter passes behind the
IVC, causing right sided hydronephrosis with
upper third hydroureter.
• IVU shows hydronephrosis with ‘reverse J
sign.'
• Treatment: Anderson Hynes‘ operation.
Fig. 4.125: IVU X-ray showing bilateral

complete duplex kidney.
Duplication of Renal Pelvis

• Most common congenital anomaly of the
upper urinary tract (4%).
• Usually unilateral. Common on the left side.
In 3% of cases it is associated with duplication
of ureter. Upper renal pelvis is small, drains
the upper calyces. Lower renal pelvis is larger,
drains from middle and lower calyces.
• When associated with double ureter, it may
be partial where two ureters join in lower
third or complete where upper ureter opens
into the bladder at a lower level and lower
ureter opens into the bladder at the upper
normal ureteric orifice. This is called as
‘Weigert-Meyer Law.’ Fig. 4.126: IVU showing reverse ‘J’ sign—
• In partial duplex, there is reno-renal reflux feature of retrocaval ureter.
resulting in infection, stone formation and Ureterocele
hydronephrosis. • It is a cystic enlargement of the intra mural portion
Investigation: IVU is diagnostic. Ultrasound is of ureter due to congenital atresia of the ureteric
done to look for complications. Cystoscopy shows orifice. Its wall contains mucous membrane
double ureteric orifices on the same side. only.
Fig. 4.127: IVU reveals left sided ureterocele with duplex kidney. Note the characteristic
Cobra (Adder) head pattern of left ureterocele. One can observe left sided double
ureter-complete type.
• It is common in females, and often it is bilateral

(10%).
• It causes hydronephrosis, infection, and
calculi formation.
• Stephen classification: Stenotic, sphincteric,
sphinctero-stenotic.
• Investigations: IVU-shows Adder-head
appearance or cobra head appearance and
cystoscopy - shows translucent cyst which
is thin walled surrounding the ureteric orifice.
• Treatment: Cystoscopic ureteric meatotomy with
the removal of cyst wall. In addition, co-
existing complications like stone, obstruction,
infection should be treated.
ORAL CHOLECYSTOGRAM (OCG;

GRAHAM-COLE TEST)
Patient is advised to have fat free diet for 3 days.
Previous night 6 tablets of iopanoic acid
(Telepaque) is given orally. Next morning plain
X-ray abdomen is taken to visualise the gall
bladder.
Later fatty meal is given and X-rays at 10,
Fig. 4.128: Radioisotope bone scan showing skeletal 15, 30 and 60 minutes are taken to see the change
metastases-primary is from prostate. in the size of the gall bladder (which should
X-rays 423
IV Cholangiograms
It is done to visualise bile ducts and biliary tree,
by injecting IV Meglumine ioglycamate (Biligram)
and taking X-Ray abdomen. It can be combined
with OCG.
Problems with this method are poor visuali-
sation, drug reaction. It is not very useful if serum
bilirubin is >3mg%.
ERCP (Endoscopic Retrograde Cholangio

Pancreatography)
Through a side viewing gastro duodenoscope,
sphincter of Oddi is cannulated, dye is injected
and biliary and pancreatic tree is visualised. It
is done under C-ARM guidance. It is done under
sedation like midazolam or using propofol
Fig. 4.129: Oral cholecystogram with smooth filling anaesthesia. Patient is placed in prone position
defect (Cystic duct stone).
with the head turned towards right. After passing
gastroduodenoscope, sphincter is identified and
cannulated. Under visualisation 3 ml of water
soluble iodine contrast, is injected into the bile
duct and pancreatic duct. When cannula goes
upwards beside vertebra, it is in bile duct; and
if cannula goes across the vertebra it is in
pancreatic duct.
Indications
• Malignancy: irregular filling defect.
• Chronic pancreatitis - chain-of-lakes
appearance.
• Congenital anomalies, stones.
• Stricture of biliary tree.
• Choledochal cyst.
• For sampling of biliary and pancreatic juices
Fig. 4.130: OCG done to see the function of the for analysis and cytology.
gallbladder. • Brush biopsy from tumour site.
be less in size compared to the earlier film, as
Therapeutic uses
the gall bladder contracts on stimulation if it
• Extraction of biliary duct stone.
is functioning normally). Smooth filling defect
• Nasobiliary drainage.
signifies non-opaque stone.
• Stenting of tumour in the CBD or in the
Contraindications: Patients with serum bilirubin pancreas.
> 3 mg%, acute cholecystitis. • Dilatation of the biliary stricture.
OCG is not done now. • Endoscopic papillotomy.
A B C
Figs 4.131A to C: ERCP being done. Note the gastroduodenoscope with injection of dye. Finding in ERCP 1 is
filling defect in the CBD. In ERCP 2 there is dilatation of biliary radicles. In ERCP 3 there is radiolucent stone
(smooth filling defect) in distal CBD which can be removed through ERCP. Antibiotics should be given to prevent
cholangitis.
Complications Relative contraindications

• Pancreatitis. • Acute pancreatitis.
• Duodenal injury. • Previous gastrectomy.
• Cholangitis • Altered prothrombin time ( corrected by
• Bleeding injection Vitamin K, FFP).
• Bleeding disorders.
Percutaneous-Transhepatic
Cholangiography (PTC)
It is done in case of severe obstructive jaundice
under coverage of appropriate antibiotics and
after control of any bleeding tendency.
With the help of fluoroscopy, Chiba or Okuda
needle which is long, flexible, thin, blunt, without
beveled end, is passed into the liver through
right 8th intercostal space in mid axillary line.
Once needle is in the dilated biliary radicle, bile
is aspirated (sent for culture, cytology, analysis);
and then water soluble iodine dye is injected
into the same so as to visualise the dilated biliary
radicles, also the site and extent of any
obstruction.(I.e. tumour, stricture).
Procedure can be used for therapeutic stenting
Fig. 4.132: ERCP picture showing CBD stents. across the biliary tree through any obstruction
X-rays 425
either in the hepatic ducts or in the CBD into T-tube is flushed with 20 ml of normal saline
the duodenum (PTBD). to flush out any air bubble. Air bubble, when
present will be dense black area which shifts
Complications with change in position. 3 ml of urograffin is
Bleeding, biliary leak, biliary peritonitis and injected into the T-tube. Under guidance, X-ray
septicaemia. film is taken. Complete free flow of dye into the
duodenum indicates that there is no blockage.
Magnetic Resonance Cholangio T-tube can then be removed safely. Usually
Pancreatography (MRCP) T-tube is removed by gentle traction without any
Magnetic Resonance Cholangio Pancreato- anaesthesia. Block indicates residual CBD stones.
graphy (MRCP) is a non-contrast imaging
method, better than ERCP as diagnostic tool in Residual CBD stones can be removed by
biliary and pancreatic diseases. T2 T1 images • Burhenne technique: After 6 weeks once T tube
are used. track is matured, stone is removed through
the existing track after dilatation under
Per-operative Cholangiograms guidance ( C-ARM) using—
It is done during CBD exploration for - stricture, • Dormia basket
residual CBD stones, atresia, choledochal cyst, • Fogarty catheter
and cholangitis. • Choledochoscope
Fine polythene catheter is passed into the • ERCP and stone removal with CBD stenting
CBD through cystic duct and dye is injected. • Heparinised saline (250 ml of saline with
Under C-ARM image-intensifier, any block, 25,000 units of heparin daily for 5 days)
stricture can be identified and completion of the or bile acid flushing through the T-tube.
procedure can be confirmed. • ESWL to retained stone along with
endoscopic sphincterotomy to flush down
Postoperative T-tube Cholangiogram the residual stone
After choledochotomy, Kehr’s T- tube is placed • Resurgery – choledochojejunostomy/
in CBD. After 10-14 days water soluble dye is transduodenal sphincteroplasty
injected into the tube and x-ray is taken. Initially
A B C
Figs 4.133A to C: Plain X-ray showing T tube in place in postoperative period. Once dye is injected T tube cholangiogram
is taken which shows free flow of dye in duodenum without any shadows (in second film). In third film radiolucent
residual stone is present in distal CBD.
Fig. 4.135: Angiogram showing plenty of collaterals
Fig. 4.134: Cholecystocholangiogram. It shows dilatation

of CBD and proximal biliary tree. There is block in distal
CBD, most probably due to growth. CT scan and ERCP
are useful investigations. ERCP facilitates the stenting
of CBD as well as biopsy of the lesion.
ANGIOGRAMS
Angiograms are X-rays or imaging modalities
used to visualize the arterial system. First carotid
angiogram was done by Moniz (got Nobel Prize).
It is used to find out the site of block, collaterals, Fig. 4.136: Angiogram showing common iliac artery
distal run off and severity of the disease. In TAO block on right side
block is segmental with adequate collaterals
initially. It usually affects medium sized vessels.
In atherosclerosis block is diffuse. Angiogram
is also used to visualize aneurysms, A-V
malformations and A-V fistulas in limbs, cranium,
lungs and in other organs. Angiogram is useful
in arterial injuries and renal hypertension. Four
vessel angiogram of cranium (2 internal carotids
and one vertebral artery – another vertebral artery
fills by reflux) is useful tool in detecting and
planning the therapy for various intracranial
diseases. Coronary angiogram is done to find
out the type and extent of the block in ischaemic
heart disease. Celiac angiogram is useful in Fig. 4.137: Angiogram showing atherosclerosis of
detecting upper GI bleed. Superior and inferior both iliac vessels.
X-rays 427
Fig. 4.140: Fistulogram of a track in the neck. Fistula

can be congenital/acquired. Sinus is a blind track which
comes to an epithelial surface. Fistula is an abnormal
communication between lumen of one viscus to another
or between one viscus to surface. Congenital causes
may be branchial, tracheo-oesophageal, A-V fistula, or
umbilical. Acquired causes may be trauma, post surgery,
osteomyelitis, specific infections like Actinomycosis/
tuberculosis or malignancy. It also may be due to lack
of rest, epithelialisation, fibrosis, distal obstruction, presence
B of foreign body like sutures/sequestrum or irradiated
surface. Features are–discharging sinus which is nonmobile
Figs 4.138A and B: Seldinger technique showing Seldinger
with raised indurated edge and without floor. Opening
catheter in femoral artery. In other film block in superficial
of sinus/fistula may be evident with sprouting granulation
femoral is seen but deep femoral shows adequate flow.
tissue. Fistulogram is done to find out the extent/type
(straight or curved)/number (single or multiple tracks)
and communicating organ. Study of discharge (culture,
AFB, cytology), edge biopsy, CT sinusogram are other
investigations to be done. Probing of fistula, if needed
should be done carefully with gentleness.
mesenteric angiograms are useful in finding out

cause for lower GI bleed.
Angiograms can be continued as therapeutic
procedure in bleeding conditions by intra-arterial
embolisation using coils, clot, spheres etc.
Types of Angiograms
• Conventional angiogramm – dye (non ionic is
better) is injected into the artery and under
fluoroscopy/C-ARM image intensifier or
Fig. 4.139: Angiogram showing tibial artery block with computer monitoring, flow in the arteries is
formation of collaterals and adequate distal run off. visualized to find out the block. Translumbar
is not commonly done now. It can cause

bleeding, thrombosis or spinal cord
ischaemia.
• Seldinger retrograde angiogram through femoral
artery of one side – femoral artery is
cannulated using arterial needle. Guide wire
is passed. Through that arterial catheter is
passed. Dye is injected. Films are taken or
recorded in computer/C arm. Complications
are – infection, spasm of artery, bleeding,
thrombosis and dissection of the artery. It
is a commonly done procedure.
• CT angiogram – It is more reliable and better.
• MR angiogram – It is also very useful type
of angiogram.
• DSA (Digital Subtraction Angiogram) – Here
Fig. 4.141: X-ray Sialogram showing cannulation of the
duct and dye in the parotid duct. Fine cannula is passed dye is injected to artery or vein and bone
into the parotid duct opposite second molar tooth. 1 ml is subtracted using computer so that bone
water soluble dye is injected into it and X-ray is taken. image will not be there in the film and vessel
If more than one ml is injected, extravasation and chemical
is visualized better.
sialadenitis can occur. It is done in fistulas, sialectasis
(grape–cluster appearance), congenital anomaly and • Pharmacoangiogram – dilute solution of
strictures. It is not done in acute inflammatory conditions noradrenaline is injected along with the dye,
and neoplasms. constricts the normal vessels but not tumour
vessels as they are autonomous. It delineates
aortogram is conventional method. Aorta is tumour better with a tumour blush and also
punctured from behind adjacent to vertebra shows tumour vascularity. It is often used in
and dye is injected using arterial pump. It renal cell carcinoma in renal angiogram.
ULTRASOUND • Painless.
• Low cost
Ultrasound contains waves with a frequency of • Availability even as portable machines.
more than 20,000 cycles/second which the For superficial USG high frequency 7-10 MHz
human ears cannot hear. is used. Routine abdominal USG 3-5 MHz is
In medical sonography frequencies used are used.
commonly 2-10 MHz. The transducer or the probe
works as both transmitter of sound waves and
Disadvantages
receiver of echoes. The Piezo electric crystal (PZT
• Interpretation can be inadequate.
lead zirconate titanate) is the producer of
• Bowel shadow may prevent proper visuali-
ultrasound waves. Received signals from the
zation.
patient are fed into the computer which forms
• In obese patient image will be inadequate.
the image. Sound speed in body is 1540 m/s.
• Acoustic cavitation may occur in small
There are three types of ultrasound image
organs.
display.
Interpretation is based on echogenicity either
1. A-mode: Only one dimensional static display
hyperechogenic or hypoechogenic.
as spikes obtained. It is used only in eye scan.
Stones are well visualized with posterior
It is Amplitude mode.
acoustic shadow.
2. B-mode: Two dimensional real time images
in the form of grains. It is most widely used
Advanced Ultrasound Techniques
type. Using this mode Transverse, Longitudinal
1. Endosonography (EUS) used in visualization
or Oblique sections can be taken (Grey scale
of walls of oesophagus or stomach through
U/S).
gastroscopy.
3. M-mode: Here images are recorded as dots.
2. Transvaginal US.
It is mainly used in moving parts like
3. Transrectal US to see prostate.
Echocardiography. M-mode is also called as
4. Doppler US to study arterial and venous
TM Mode, i.e. Time Motion Mode.
diseases.
Uses
1. All abdominal and pelvic conditions, often Ultrasound as Therapeutic Use
in thoracic conditions. 1. To guide aspiration of amoebic liver abscess,
2. Ultrasound of thyroid is very useful method pericardial tap.
to differentiate between solid and cystic
lesions.
3. U/S is used in testicular tumours, epididymo-
orchitis, trauma to testis, erectile dysfunction.
4. U/S breast to differentiate solid from cystic
tumours.
5. Soft tissue and musculoskeletal system U/S.
6. Ocular U/S is ideal method to image eye and
intraocular structures - A mode.
Advantages
• No radiation.
• Non-invasive.
• Effective with efficiency. Fig. 5.1: Ultrasound showing abdominal aortic aneurysm.
Newer Imaging Modalities 431
Fig. 5.2: Ultrasound showing choledochal cyst. It is saccular Fig. 5.5: Ultrasound showing thyroid enlargement.
type. Todani classification type I–fusiforn type is commonest.
Type II–saccular; Type III is choledochocele; Type IV
is CBD and intrahepatic biliary dilatation; Type V is
intrahepatic dilatations with cysts. Incidence of carcinoma
in choledochal cyst is 30%.
Fig. 5.6: Ultrasound showing features of ureterocele –

Fig. 5.3: Ultrasound showing roundworm in gallbladder. Adder Head appearance of ureteric orifice. (By Dr
Raghavendra Bhat, Radiologist; Balmatta Scan Center)
2. On table US to assess the operability of

tumour. (During laparotomy to assess the
extent of tumour, lymph node status, etc.).
DOPPLER (CHRISTIAN JOHANN

DOPPLER)
Doppler effect is a change in the perceived
frequency of sound emitted by a moving source.
Frequency shift of moving object is recorded. So
it measures blood flow. Spectral Doppler wave-
form and ultrasound image are combined in
Fig. 5.4: Ultrasound showing liver, kidney and
ascites probably due to tuberculosis. duplex scanning.
Types • Air - Minus 1000 HN.

1. Continuous waves. • Water - Zero HN.
2. Pulsed waves – gives exact velocity waveform. • Fat-minus 100 HN.
Doppler will provide both audio and video • Bone - Plus 1000 HN.
signals. Other tissues come in between air and bone
Colour Doppler imaging displays flowing with different HNs.
blood as red when direction of flow is towards Both Plain and Contrast CTs are done
the transducer. Image will be blue if flow is away whenever required.
from transducer.
Advanced CT Methods
Uses • Spiral CT scan has become popular. They are
• To study cardiovascular system. faster and in a single breath holding time,
• To study vascularity of tumours. whole CT scan can be taken. It is based on
• To study blood flow and velocity in arterial principle of volumetric acquisition.
diseases so as to assess stenosis (its extent, • Multislice CT: It is mainly used in coronary
cause, etc.) like in atherosclerosis, TAO, angiography.
cervical rib, aneurysm, A-V fistulas. • Electron beam CT.
• To find out deep venous thrombosis (DVT), • High resolution CT (HRCT): Mainly for lung
varicose veins, perforator incompetence. diseases. Thin collimation; small field of view;
• To study grade of varicocele in males. high resolution bone algorithm are the
• In portal hypertension, renovascular hyper- principles. Contrast enhanced CT (CECT).
tension, IUGR, etc. • CT angiography.
Advantages Contrast Agents

1. It has replaced Venogram and Angiogram • Ionic: Water soluble iodide dyes like Sodium
in many places as a diagnostic tool. diatrizoate, Meglumine iothalamate (Conray,
2. It is reliable and non-invasive. Urograffin, Angiograffin). They are cheaper
but often toxic and cause anaphylaxis. Ionic
CT SCAN agents are hyperosmolar. Iodine component
decides the radio opacity and it depends on
Computerized tomography scan was invented iodine atoms and particle ratio. In ionic it
by Godfrey Hounsfield in 1963. He was a is 3:2 and in non-ionic it is 6:1. Adverse
Physicist. He received Nobel Prize (1979) for reactions are idiosyncrasy (anaphylactoid
the same. The first CAT scan is in the London reaction – not a true anaphylaxis; adrenaline
museum (By EMI, electron musical instrument 1in 1000 of 0.3 to 1.0 ml S/C or IM may be
Middlesex England). given to relieve angioneurotic oedema/
Narrow X-ray beams are passed from rotating bronchospasm) and problems of hyperos-
X-ray generator through the gantry where patient molar contrast media like hypervolaemia,
is placed. When X-rays pass through the tissues, blood-brain barrier damage, cardiac depres-
some of the X-rays get absorbed and some pass sion and damage to red cells and endothelium.
through, depending on the tissue density. The • Non-ionic are safer but expensive, like mono-
different grades of absorption in different tissues mers—Iohexol (Omnipaque), IOVERSOR
are detected through sensitive detectors which (optiray) or dimmers like Iodixanol. Nonionic
are translated to a Grey scale image by a computer. agents are low osmolar.
Density of tissues is numbered as Hounsfield • In abdominal CT, contrast agents can be given
Number (H.N.) (Hounsfield units) orally to delineate bowel properly.
Indications
• Trauma like head injury, chest injury, abdomen
trauma. In trauma only plain CT scan is taken.
• Neoplasms: To see the exact location, size,
vascularity, extent and operability.
E.g. Brain, abdominal, retroperitoneal,
thoracic and spinal tumours.
• Inflammatory conditions in various places also.
E.g. Psoas abscess, pseudocyst of pancreas.
Advantages of CT Scan
• One to two mm sized sections are possible.
• Amount of X-ray exposure is less.
• More accurate, sensitive, and specific.
• Small lesions are also detected. Fig. 5.7: CT scan showing parotid tumour right sided.
Depth, deep lobe involvement and nodal status should
• CT guided biopsies are done at present safely. be assessed.
Disadvantages
• Interpretation by an experienced radiologist
is important.
• Artifacts can be present.
• Cost factor and availability.
Findings
• Extradural haematoma—Biconvex lesion.
• Subdural haematoma—Concavo Convex lesion.
• Smooth margin in benign condition.
• Irregular margin in malignant condition.
Advantages of Spiral CT Scan

• Reduced scan time. Useful in children and
critically ill patients.
• Imaging in both arterial and venous phases
is possible.
• Improved lesion detection. Missing a lesion
Fig. 5.8: CT picture showing carcinoma maxilla right sided.
is uncommon.
• Multiplanar and 3-Dimensional analysis like
CT Angiography, Complex joint imaging,
Facial bone imaging is possible. MAGNETIC RESONANCE
IMAGING (MRI)
High Resolution CT
High resolution CT (HRCT) is a CT technique Earlier named as Nuclear magnetic imaging, the
used in chest scan where thin sections are taken term is not used now. Invented by Laterbuer and
to have better quality images. Mansfield – got Nobel Prize.
Fig. 5.9: CT scan showing mediastinal lymph node mass Fig. 5.12: CT abdomen showing cyst in the liver. It
– could be lymphoma or secondaries. Mediastinoscopy could be simple cyst or hydatid cyst.
and biopsy is needed. Later radiotherapy or chemotherapy
is the treatment.
Fig. 5.10: HRCT chest. Invert film. Fig. 5.13: CT scan showing gallbladder stone in
Hartmann’s pouch causing obstruction.
Fig. 5.11: CT scan chest showing Fig. 5.14: Pancreatic ductal stones – multiple
lung abscess right side. calcified stones. It needs pancreatico-jejunostomy.
Fig. 5.15: CT showing extrinsic compression of

stomach from a gastric teratoma in a newborn.
A B
C D
Figs 5.16A to D: CT scan showing secondaries in liver. Secondaries are usually multiple. Primary may be abdominal
or extra-abdominal. One has to evaluate for primary by upper/lower endoscopy; chest CT; clinical methods for
primary in breast/thyroid/melanoma. Treatment is palliative. Solitary secondary can be resected if primary is from
colon or well differentiated. Segmentectomy is done. Often one large secondaries with small remaining secondaries
can occur.
Fig. 5.20: CT picture showing features of hepatocellular

Fig. 5.17: CT picture showing primary carcinoma in stomach carcinoma right lobe. Hepatoma is usually large, solitary
with secondaries in liver. Note the thickening of the wall mass in one of the lobes. AFP, liver biopsies are other
of the stomach with mucosal irregularity. investigations. Early growth is treated by hemihepatectomy.
If there is cirrhosis, hemihepatectomy is technically difficult.
A
Fig. 5.18: Carcinoma pancreas with dilated common bile
duct (CBD). Whipple’s pancreaticoduodenectomy is needed
to this patient.
B
Fig. 5.19: CT picture showing features of cystadenocar-
cinoma of pancreas. It often attains large size; presents Figs 5.21A and B: CT scan showing carcinoma ascending
as mass abdomen without jaundice. colon. Note the narrowed lumen with irregularity.
Fig. 5.22: CT scan showing narrowing and irregularity Fig. 5.23: CT scan showing pelvic tumour
in the rectal mucosa – a feature of carcinoma rectum.
A B
Figs 5.24A and B: CT scan showing renal cell carcinoma (RCC) right side.
Fig. 5.25: CT scan showing retroperitoneal Fig. 5.26: CT scan showing retroperitoneal tumour encasing
tumour left sided the aorta with hydronephrosis of right kidney due to ureteral
obstruction.
Fig. 5.29: CT scan showing hydronephrosis of left kidney
Fig. 5.27: CT picture showing ascites.
B
Figs 5.30A and B: CT scan of head showing extradural
haematoma. EDH is biconvex in CT. It needs immediate burr-
hole surgery to decompress. Same side weakness, same
side ocular constriction with altered reflex (Kernohan’s notch
B effect), features of intracranial hypertension like hypertension,
vomiting and headache and often with ‘lucid interval’ are the
Figs 5.28A and B: CT scan showing pseudocyst of features. In ‘lucid interval’ patient after trauma becomes alright
pancreas. It needs cystogastrostomy/cystojejunostomy. and in 12-24 hours again develops features of compression
and deteriorates. It is due to slow bleeding causing late
compression features. It is dangerous as while symptom
develops patient may be away from hospital.
Fig. 5.31: CT scan of head showing concavo-canvex Fig. 5.33: CT picture showing astrocytoma—
lesions on both sides – feature of bilateral subdural common primary malignant tumour of brain.
haematoma.
Fig. 5.32: CT head showing hydrocephalous.
Fig. 5.34: CT scan showing features of meningioma.

• Magnetic field strength is measured in Tesla

(T).
• T1 relaxation time is the time taken to return
to original axis. T1 images are used to find
out normal anatomical detail. It has got high
soft tissue discrimination. Here fluid (CSF)
looks black. Fat is white in T1 images. It is
spin lattice relaxation time.
• T2 relaxation time is the time taken by the
proton to diphase. It is used to assess
pathological processes. In T2 images fluid/
water looks white. It is spin-spin relaxation
time.
Fig. 5.35: CT showing secondaries in brain. Note the • In Proton density images fluid looks in
multiple lesions in brain. Secondaries are the commonest between black and white.
malignant tumour in brain. Primary may be from breast,
lungs, thyroid or sarcomas. Treatment is external
• The magnet is kept under intense cold condi-
radiotherapy, chemotherapy, anticonvulsants. It has got tions to maintain a state of super conductivity.
poor prognosis. Coiled wires rest inside a double walled
apparatus that is bathed in liquid helium.
The apparatus is kept in a vacuum which
is left inside a liquid nitrogen filled tank. MR
scanner is enclosed in a stainless shield or
copper shield called as Faraday cage which
blocks the radiofrequency signals from local
radio/TV stations. Gradient coils are used as
magnetic devices. This coils because of
immense magnetic forces bang against
mooring causing loud rhythmic noise.
Radiofrequency coils transmit and receive
radiofrequency signals.
• It can be Plain MRI or Contrast MRI. Contrast
agent is Gadolinium given Intravenously.
Fig. 5.36: CT head showing secondaries in skull. It may
be from follicular carcinoma of thyroid or from adrenal Uses of MRI
neuroblastoma. Secondary in skull with thyroid primary
• It is very useful in Intracranial, Spinal and
is well localised, warm, vascular and pulsatile. Secondaries
in bone from other primaries are diffuse, hard and tender. Musculoskeletal lesions including joint
pathologies.
Principle • It gives direct anatomical sections of the area
When patient is placed in an external high magnetic with lesions at a high resolution.
field, protons of hydrogen atoms rotate in phase • MR angiogram is done without injecting IV
with each other and gradually return to their contrast agents.
original position releasing small amounts of • Cardiac MRI is very useful.
energy which is detected by sensitive coils. Proton • Breast MRI is used in multifocal recurrent
density and Relaxation time are assessed by cancers.
Radiofrequency pulse and the computer generates • Magnetic resonance cholangiopancreatography
a Grey scale image from this data. (MRCP) is a very useful noncontrast diagnostic
B
Figs 5.37A and B: CT angiogram renal trauma – some are reconstructed images. Note absence
of secretion right side. Probably right renal artery is injured or has undergone for spasm
A B
Figs 5.38A and B: MRI showing compression of T12 spine – tuberculosis
of spine. MRI is ideal investigation for spinal pathology.
A B
Figs 5.39A and B: MRI showing destruction of L4, L5 spine secondaries in spine. Patient presented with
neurological deficit in lower limbs. Patient needs immediate radiotherapy and surgical decompression of spine.
Fig. 5.40: MRI showing A–V Malformation right side.

Fig. 5.42: MRI showing features of spinal
tumour–ependymoma
tool which may replace diagnostic ERCP. Here

heavily T2 weighted images are used.
• MR Spectroscopy is chemical analysis of
elements in a tissue to differentiate between
tumour, inflammation, and degeneration.
Advantages
• Artefacts are not common.
• More sensitive and specific than CT scan.
• High soft tissue contrast; multiplanar
imaging.
• No ionizing radiation-so safer in pregnancy.
• Better for bone marrow, spinal diseases and
posterior fossa lesions.
Contraindications
Patients with Prosthesis in the body, metallic
foreign bodies, pacemakers, Cochlear implants,
cranial aneurysm clips should never undergo
MRI.
Precaution
Before entering the MRI room, the patient and
other personnel should remove all magnetically
Fig. 5.41: MRI spine showing extradural schwannoma. attractive materials.
A
Fig. 5.44: MRI showing glioma brain
Disadvantages
• Availability and cost factor.
• It is time consuming.
• Patient compliance is poor.
• In is not feasible in patients suffering from
Claustrophobia.
• It is not ideal in emergencies and critically
ill patients.
• It is not useful in lung pathology and
subarachnoid haemorrhage.
RADIOISOTOPE IMAGING
• It is discovered by Henri Becquerel – 1896
B
• Technetium 99 m is most commonly used
radioisotope. It has got half-life of 6 hours.
It has got less radiation effect to patient but
adequate dose to show metabolic activity. It
emits mainly gamma rays and low energy
electrons with less beta emission (high
energy). So there is no high energy radiation
to patient. Gamma rays easily get escaped
from body to get detected by gamma camera.
Technetium can form tracers for different
tissues or organs to get high level bioactivity.
Technetium 99 is derived from molybdenum
99 (half-life 66 hours) which decays
progressively into technetium 99.
C • Radioisotope can be used individually or can
Figs 5.43A to C: CT scan and MRI pictures of be combined with organ specific molecule
craniopharyngioma like DTPA.
• Radioactivity can be detected by gamma • Tc 99 sulfur colloid scan is used for reticulo-
camera which contains scintillating detector endothelial system in liver by making Kupffer
– sodium iodide. cells to take up the isotope. It is sensitive
in follicular nodular hyperplasia of liver.
Different isotopes are: • Radioisotope Tc 99 labeled RBC can detect
• DTPA Tc 99 scan – functional aspect of kidney. bleeding as low as 0.1 ml/minute from GI
• MAG3 has got better functioning capacity bleed. It is more sensitive than angiography
but costly. (detects 0. 5 ml bled/minute).
• DMSA Tc 99 scan – anatomical static images • Meckel’s diverticulum can be detected by
of kidney. technetium 99 pertechnate scanning:
• Captopril DTPA scan is used for renovascular • MIBG (Meta Iodo Benzyl Guanidine) scanning
hypertension. is useful in adrenal tumours.
• HIDA scan/PIPIDA scan for cholecystitis
• Gallium scan (Ga 67) for inflammatory POSITRON EMISSION
conditions–half-life 78 hours. TOMOGRAPHY (PET)
• Indium131 for leucocyte tagging.
• It is a functional imaging method using 18
• Thallium201 scan for cardiac imaging–73
Fluorodeoxy glucose (18 FDG) for metabolic
hours half-life.
agent localizes tumour. Perfusion agents are
• I131 for thyroid scan in borderline toxicity/ labeled NH3, Rb-81. It is useful to distinguish
ectopic thyroid/follicular carcinoma thyroid between high grade tumours from low grade
secondaries/retrosternal goitre–half-life tumours and also from benign tumours.
8 days. • SPECT is Single Photon Emission Computed
• Thallium – Tc99 subtraction scanning is used Tomography which gives three dimensional
to detect parathyroids. Sestamibi scanning image as opposed to a planar image by routine
is also used for parathyroid imaging. radionuclide imaging.
• MDP Tc99 (Methylene DiPhosphonate) scan Note: Most of the figures in this chapter are from
is used for bone. It is best for early detection Dr Raghavendra Bhat and Dr Ravichandra,
of acute osteomyelitis. Radiologists, Balmatta Scan Center, Mangalore.
Surgical instruments are essential for any surgery,

whether minor or major. All instruments should
be sterilised prior to use to prevent infection.
Parts of an instrument –
• Two finger bows for holding.
• A ratchet or lock.
• A pair of shaft or body.
• Joint either box type (with a slot) or pivot
(attached by a screw).
• Pair of blades at terminal part.
Fig. 6.1: Parts of an instrument. Fig. 6.3: Sponge holding forceps—(Rampley’s) both
curved and straight.
CHEATLE’S FORCEPS
It is used to pick sterilized articles like of the length, the surgeon’s hand will not get
instruments and drapes so to avoid touching contaminated while cleaning the patient. It is
of the instruments while transferring them from also used to swab the cavities, to mop the oozing
one tray/table to other. It is kept dipped in area, to hold gallbladder or cervix or tongue or
antiseptic solutions like savlon/cidex. It does bowel or stomach during surgeries, for blunt
not have lock. It is heavy metallic forceps with dissections or as ovum forceps. It can also be
curved blades with serrations. One blade of used to dry the operative field using a gauze.
proximal handle has got rounded ring for finger
and other blade has got free hook to have proper MAYO’S TOWEL CLIP
grip.
• It is used to fix drapes in operative field. It
is light but strong with small curved blades.
Curvature helps to hold entire thickness of
drapes firmly and easily. Two sharp teeth
one on each blade cross each other but do
not approximate (cross action tip).
• It is used to fix suction tubes, diathermy wires,
and laparoscopic cables in operative table.
Fig. 6.2: Cheatle’s forceps. • It is used to fix ribs in flail chest.
• It can be used to hold cord in hernia or to
hold tongue if specific instruments are not
SPONGE HOLDING FORCEPS available.
(RAMPLEY’S) • It can be used to hold dental wiring; patella
It has got fenestrated, serrated flat distal end. during patellectomy; in faciomaxillary
It is used to clean the operative field. Because fractures.
Instruments 449
each other (Approximating tip, but no cross action
in tip).
MOYNIHAN’S TETRA TOWEL

CLIP/FORCEPS
• It is used to hold the cut skin edges of the
incision to the four corners of the draped tetra
towels so as to isolate the operative field.
• Isolation also can be achieved by suturing
the drape margins to the subcutaneous tissue
at different points or using adhesive plastic
drape to skin and through the drape skin
incision is made.
Fig. 6.4: Mayo’s towel clip.
BACKHAUS’ TOWEL CLIP

It has got a ratchet catch, curved sharp ends Fig. 6.6: Moynihan’s tetra towel clip – it is with long blades
which approximate each other, but do not cross with a curvature with two teeth in each blade (total four).
DOYEN’S TOWEL CLIP

It is a short instrument with curved ends with
sharp points. Handles join at proximal ends.
When handles are pressed tips open and when
handles are released tips close and firmly grip
the towels.
Towel clips –
Mayo’s – cross action tip; no approximation
Backhaus’ – approximating tip; no cross action
Doyen’s – tension blades open when pressed
and vice versa
Fig. 6.5: Backhau's towel clip. Fig. 6.7: Doyen’s towel clip.
Moynihan’s tetra forceps/towel clip – to isolate Uses

cut edge of the skin incision for isolation; has • To catch bleeding points.
got two teeth on each blades • To open the facial planes in different
Bull dog towel clip – has got cross section surgeries.
action with tapering points • To pass a ligature and to hold it.
Gray’s towel clips – not used now • To hold fascia, peritoneum, aponeurosis.
• To hold sutures.
• To drain an abscess like a sinus forceps.
ARTERY FORCEPS (HAEMOSTAT) • To hold gauze as pea-nut.
• To crush the base of the appendix.
Types
• To clamp a catheter in between the hinge
Based on Size and ratchet of the haemostat.
• Small or mosquito artery forceps – Mosquito • To catch prepuceal skin in circumcision.
forceps is so called because of its fine tip which • Mosquito forceps is used in paediatric
even can catch the proboscis of a mosquito. surgery/micro surgery/cleft surgery/plastic
• Medium sized artery forceps. surgery.
• Large artery forceps. Instrument can also be used to catch arteries/
veins/capillaries and so ideally should be called
Based on Shape as haemostat. But common word used is artery
• Straight artery forceps. forceps. Haemostat has got serrations on the distal
• Curved artery forceps. half of the each blade. (In pedicle clamp entire
blade has got serrations).
Features of Artery Forceps Medium sized, curved half serrated haemostat
• Distal blades are having transverse serrations is called as Kelly’s artery forceps.
which are well apposed.
• Lock in the proximal part.
A Fig. 6.9: Kelly’s artery forceps – commonly used

haemostat.
NEGUS ARTERY FORCEPS

It is stout long jawed instrument (forceps) with
distal part of the jaws are bent like a hook with
B transverse serrations. It is used to catch bleeding
Figs 6.8A to C: Artery Forceps: (A) Straight

(B) Curved (C) Mosquito Fig. 6.10: Negus artery forceps.
Instruments 451
part of the tissues prior to ligation. Initially
bleeding area is clamped with haemostat and
later Negus artery forceps is clamped underneath
and artery is released. It facilitates easier passage
of the ligature across the bleeding vessels or
tissues.
RIGHT ANGLE FORCEPS— Fig. 6.12: Well’s arterial clamp.

MEIGSTER’S/LAHEY’S
clamp pedicles like in nephrectomy or
It has got 900 curves in terminal 1 cm part of
splenectomy.
the blades. Blades are longitudinally serrated. It
has got a ratchet. Tip is blunt. It is used to dissect
pedicles and to pass ligatures, to dissect the vagus BULLDOG CLAMP
and ligate in vagotomy, to hold bleeding vessels Light bulldog clamp has got pinch cock action
in depth, to dissect major vessels, to dissect and to open and close. Blades have got fine transverse
pass ligatures to cystic duct and cystic artery serrations. Pott’s bulldog clamp is paper clip
in cholecystectomy and in thyroid, biliary, like instrument with strong jaws (with serrations)
splenic, gastric, renal and pelvic surgeries. with spring loaded handle which permits a
Fig. 6.11: Meigster's right angle forceps.
WELL’S ARTERIAL CLAMP

It has got doubly right angled distal blades with
Fig. 6.13: Bulldog clamp.
longitudinal serrations in the jaw. It is used to
within. It has got a ratchet. It can be applied

to part of the circumference of the vessel in portal
vein, iliac veins, inferior vena cava while remo-
ving tumor thrombus in renal cell carcinoma,
in pancreatetectomy, major vessel surgeries.
Vascular anastomosis can be done using it.
DE BAKEY’S VASCULAR CLAMP

Its blades are long and well angulated so that
it can be used to clamp vessels/bleeders in the
depth with good grip without damaging the
vessel wall.
Fig. 6.16: De Bakey’s vascular clamp.
Fig. 6.14: Pott’s bulldog clamp.

PEDICLE CLAMPS
secure grip of the vessel. Bulldog clamp is used
A pedicle clamp is a stout haemostat with straight
to clamp vessels during vascular anastomosis
or curved blades with a ratchet. Entire blades
like for creating AV fistula in patient with renal
are serrated here. It can be with or without teeth.
failure; major vessel surgeries as for aorta, inferior
vena cave, portal vein, etc. With a firm grip it
blocks the vessel without injuring the vessel wall
and without any chance for slippage. Pott’s
bulldog clamp is used for large vessels like aorta,
vena cava.
SATINSKY VASCULAR CLAMP

It is light atraumatic long instrument with C
shaped distal blades which has got fine teeth
Fig. 6.15: Satinsky vascular clamp. Fig. 6.17: Spencer-Wells’ clamp/artery forceps.
Instruments 453
Fig. 6.18: Robert’s pedicle clamp.
Fig. 6.20: Kocher’s forceps.
pedicle well and prevents slippage of the

tissues and retraction of the vessels/bleeders.
• It is used to hold pedicles, tough structures,
cut ends of the muscles like-in
Fig. 6.19: Maingot’s pedicle clamp.
thyroidectomy/haemorrhoidectomy/
mastectomy/polypectomy/hysterectomy.
• Spencer-Wells’ pedicle clamp/artery forceps has • It is used to hold tough/fibrous structures
blunt tip without teeth. It can be straight or like in palms/soles/scalp to prevent
curved. Its blades are entirely serrated. It can retraction of vessels during surgery.
be small/straight/large. • It is used to hold peanuts (gauze pellets of
• Robert’s pedicle clamp It is stout curved 3-4 mm sized used in blunt dissection).
instrument with transverse serrations in the • It is used to hold gauze for blunt dissection,
distal blades on entire length with a ratchet. to hold resected bowel, to hold ribs during
Tip is without teeth. It is used to clamp major rib resection.
pedicles during surgeries like nephrectomy/
splenectomy. ALLIS’ TISSUE HOLDING FORCEPS
• Maingot’s pedicle clamp has got longitudinal
ridge on one of the distal blades and a groove • Here distal blades are not apposing each other
to receive in the other blade. Tip has got one • Tip has got teeth in each blade which are
– in – two teeth. It has got ratchet. It is a apposing.
crushing clamp. It is stronger than Kocher’s • It has got lock.
forceps/clamp. • It is used to hold skin flaps, fascias, fibrous
• Kocher’s forceps/clamp It has got transverse tissue, aponeurosis, galea (in craniotomy) and
serrations with one- in-two teeth at the tip.
It has got a ratchet. It can be curved/straight.
• Mayo’s pedicle clamp is stout and large with
curved long blades with serrations. It is useful
in clamping major pedicles.
KOCHER’S FORCEPS
• It has got serrations in the distal blades and
apposing tooth in the tip. It holds the tissues/
Fig. 6.21: Allis’ tissue holding forceps.
bladder wall. It is essential instrument in any nodes, to hold tumour tissue. It is also used as
surgery whether major or minor. It can be towel clip, as sponge holding forceps.
small/medium/large. Large Allis is used in
hysterectomy to hold vaginal wall and tough
structures.
MORRANT-BAKER’S APPENDIX
HOLDING FORCEPS
BABCOCK’S FORCEPS It is like Lane’s forceps but with apposing
serrations proximal to the tooth. These serrations
Their distal parts of distal blades are curved give a good grip on mesoappendix while holding
with triangular fenestra in it which allows soft appendix in appendicectomy. Its use is replaced
tissues to bulge out. Tip is non-traumatic with by Babcock’s forceps.
transverse serrations/ridges on it. It has got a
lock.
It is used to hold any part of the bowel,
fallopian tubes, appendix, urinary bladder,
ureter, cord, lymph node.
Fig. 6.24: Morrant-Baker’s tissue holding forceps.
MOYNIHAN’S TISSUE FORCEPS

It is the tissue holding forceps with thinner and
Fig. 6.22: Babcock’s forceps. curved blades. Its uses are like Allis’ forceps.
LANE’S TISSUE HOLDING

FORCEPS
It has got thick, stout distal blades with oval
fenestra in each blade with a curvature at the
end. It has got apposing tooth in the tip. It has Fig. 6.25: Moynihan's tissue forceps.
got lock.
It is used to hold bulky and tough structures KOCHER’S GLAND HOLDING
(like to hold breast during mastectomy; to hold FORCEPS
salivary glands while excising), to hold lymph
It has got terminal curved rings on each blade
with two spikes on each with inward direction.
Fig. 6.23: Lane’s tissue holding forceps. Fig. 6.26: Kocher’s gland holding forceps.
Instruments 455
These spikes create a secure grip of lymph nodes
while holding.
A
YOUNG’S GLAND FORCEPS

It has got long blades with each blade having
B
rounded flat end with a fenestra without any
serrations on its inner aspect. It is atraumatic.
It has got ratchet. It is used to hold lymph nodes, C
cyst wall during surgical excision.
Figs 6.28A to F: Dissecting forceps: (A) Non-toothed

Adson’s fine forceps, (B) Non-toothed forceps, (C) Toothed
Adson’s fine forceps, (D) Toothed forceps two in three
type, (E) Toothed forceps-one in two type, (F) Toothed
forceps heavy Victor-Bonney’s type.
Toothed-dissecting Forceps
It is used to hold skin and tough structures like
fascia, aponeurosis. It is not used to hold delicate
structures like bowel/vessel/nerve. It can have
one in two teeth or two in three teeth. Small,
fine forceps used for fine works is called as
Adson’s forceps. Adson’s forceps can be toothed
Fig. 6.27: Young’s gland holding forceps. or non - toothed. Victor-Bonney’s forceps is heavy
toothed dissecting forceps.
DISSECTING FORCEPS
KOCHER’S THYROID DISSECTOR
Plain Non-toothed Dissecting Forceps
It is used to hold delicate soft, friable structures It has got a curved blade with vertical grooves
like peritoneum, vessels, bowel, nerves, and on it. There is an eye on its tip. It is used to
tendons. It can not be used to hold skin or tough
structures. During surgical dissection it is used
to hold/fix/steady/stretch the structures as
needed. It is also used to hold bleeding points,
to cauterize small vessels. Fig. 6.29: Kocher’s thyroid dissector.
dissect the upper pole of thyroid in thyroidectomy

and to place as a surface while cutting the
superior pedicle. Through eye ligature can be
passed.
SINUS FORCEPS (LISTER’S)

It has got straight, long blades with serrations
in the tip. It does not have lock. Tip is broad.
It is used to drain pus from abscess cavity
(Hilton’s method). It is called as sinus forceps
because it is initially originated to pack the sinus
cavities. It is also used to pack nasal cavity and
ear. It is less traumatic.
Fig. 6.32: Self-retaining retractor.
field properly, to carry out surgery precisely and

also to prevent damage to adjacent structures
while conducting operation. It also prevents the
unnecessary handling of the adjacent tissues.
Fig. 6.30: Lister’s sinus forceps.
Types of Retractors
RUSSIAN FORCEPS • Light retractor is used to retract vessels, nerves,
tendons or any delicate structures.
This forceps has got clubbed tip in the blades
• Heavy, stout retractors are used to retract
with serrated inner surface. It is used to hold
abdominal wall, ribs, sternum, etc.
skin while skin suturing. It gives a very good
• Broad, flat retractors are used to retract at
grip over the skin while suturing without injuring
curved different angles like for liver, spleen,
it.
kidney, bowels, etc.
• Hook retractors are used to retract soft tissues.
Retractor may be plain/non – self retaining/
manual (which is held by an assistant and its
position is adjustable time to time) or self-retaining
(fixed retraction and continuous non - altered).
Retractor can be self-illuminating also with a
power lamp at the corner of the blade. Assistant
Fig. 6.31: Russian forceps used to hold skin is getting fatigue by continuous retraction is draw
while suturing. back of the manual retraction. Adjustments and
release of retractions whenever needed are
possible in manual retraction. Over retraction
RETRACTORS
and injury is possible here. Self retaining retractor
A retractor is an instrument used to retract tissues will not allow regular relaxation of tissues and
away from the operating field, to expose surgical non-adjustable. It is also bulky. But it maintains
Instruments 457
fixed position and assistant hands are free for
additional work.
Uses of retractors
• Retraction of cut edges of the incision
• To hold important structures like liver/
spleen, etc. away from surgical field
• To steady the tissues
• To control bleeding
• To avoid inadvertent trauma to adjacent
structures
Remember – retraction should be gentle and

adequate. Over retraction can cause injury to the
retracted organ/tissues and often bleeding.
SINGLE HOOK RETRACTOR

It is used to retract the skin. It is used in excision
of swellings like cyst, lipoma, and neurofibroma. Fig. 6.34: Volkmann’s retractor.
It is used to hold skin flaps while raising the
flaps.
Fig. 6.35: Fisch nerve hook.
LANGENBECK’S RETRACTOR
It has got a long handle and a small solid blade.
Fig. 6.33: Single hook retractor. It is used in hernia surgery or any superficial
surgeries to retract skin, fascia and aponeurosis
etc. It can be single bladed or double bladed.
VOLKMANN’S RETRACTOR/
CAT’S PAW
It is used to retract fascias in soles and palms.
There are multiple hooks with pointed edges.
Uses are same as single hook retractor.
FISCH NERVE HOOK Fig. 6.36: Langenbeck’s retractor.
It is a fine delicate blunt nerve hook used to

retract nerves during surgery. Examples—spinal CZERNEY’S RETRACTOR
accessory nerve, hypoglossal nerve retraction in (HERNIA RETRACTOR)
block dissection; ilio-inguinal nerve in hernia
surgery, lingual and hypoglossal nerves in This retractor has got thick, small blade on one
submandibular surgeries, facial nerve in side and biflanged hook on the other side in
parotidectomy. opposite directions. It is used in surgeries like
It is used to retract abdominal wall incisions/

loin incisions/subcostal wounds/any wounds
in depth.
‘C’ SHAPED RETRACTOR—ROUX

It is C shaped with curve at both ends. It is used
to retract wounds like in hernia, appendicectomy,
Fig. 6.37: Czerney’s retractor.
wide excisions, etc. C shape gives a proper grip.
hernia, laparotomy especially during closure.
Bleeders in the edge can be identified and
cauterised easily.
RIGHT ANGLE RETRACTOR

Here handle and blade are at right angle to each
other.
Fig. 6.38: Right angle retractor.
MORRIS’ RETRACTOR
It may be single blade type or double blade type. Fig. 6.40: ‘C’ shaped retractor.
It has flat transversely curved blade. There is
a blunt projecting ridge with backward projection ‘S’ SHAPED RETRACTOR
to have a better hold.
Here blunt curves on each end are in opposite
directions. Uses are like C shaped retractor.
Fig. 6.39: Morris’ retractors—single blade (one-

Fig. 6.41: ‘S’ shaped retractor.
sided) and double blade (both-sided).
Instruments 459
DEAVER’S RETRACTOR DOYEN’S RETRACTOR
It is a instrument like a question mark (?). It is It is used in pelvic surgeries and in laparotomies.
stout but atraumatic. Its action is levering of the It has a curved blade with convex edge with
tissues not by push or pull or traction. Moist a long handle.
mops should be kept underneath prior to placing
this retractor. It is a retractor with a broad, gently
curved blade.
Fig. 6.44: Doyen’s retractor.
Fig. 6.42: Deaver’s retractor (manual). BALFOUR’S SELF-RETAINING

RETRACTOR
It is used to retract the abdominal wall. It
It has got different adjustable blades so as to
is used to retract liver, spleen and other abdo-
retract abdominal wall and tissues during
minal viscera. It is atraumatic and gives adequate
surgery. It has got quadrangular metal frame.
exposure of the surgical field. All major
Two side heavy blades are hook shaped to fit
abdominal surgeries like vagotomy, cholecys-
into the wound sides. There is a detachable third
tectomy, gastrectomy, pancreatic surgeries,
colonic surgeries, kidney surgeries, anterior
resection/abdomino perineal resection, bladder
surgeries need this instrument.
KEYLAND’S RETRACTOR
It has got flat wide blade with a right angle handle.
It is manual retractor. It is used like Deaver’s
retractor.
Fig. 6.43: Keyland’s retractor (manual). Fig. 6.45: Balfour’s self-retaining retractor.
blade to retract the viscera. One of the side blades

has got screw to adjust the width of the retraction
by side blades. Detachable blade is also fixed
through an adjustable screw with a slot. Closed
instrument is inserted into the wound and
adequately widened as required to have its use.
Tissues/bowel/organs should not be trapped
while widening and adjusting.
MILLIN’S SELF-RETAINING
RETRACTOR
Fig. 6.47: Joll’s thyroid retractor.
It has got three-sided triangular metal frame with
two flat side blades and one long 'S' shaped circular retractor with two blades attached with
adjustable blade which has got two curves to a handle. End of the blades are sharp like a towel
retract urinary bladder or lower abdominal wall clip with a catch/ratchet on it. Handle has got
by each as needed. It is used in Millin’s open a screw by which instrument can be opened or
prostatectomy and other pelvic surgeries. closed. Upper and lower skin flaps in thyroid
surgery is retracted well using this instrument.
KOCHER’S THYROID RETRACTOR

This instrument has got two side adjustable
multihooked terminals (adjustable with screws)
over two side flanges which are connected with
a lockable joint. It is used in thyroidectomy.
Fig. 6.46: Millin’s self retaining retractor.
JOLL’S THYROID RETRACTOR

It is a self retaining retractor specifically used
for thyroid/parathyroid surgeries. It is a semi- Fig. 6.48: Kocher’s thyroid retractor.
Instruments 461
MOLLISON’S MASTOID
RETRACTOR
It is stout instrument with curved long blades
which has got sharp outward curved teeth to
retract tissues. Proximal shaft has got ratchet
with finger bows. It is self retaining, haemostatic
and gives wide exposure of the field. It is used
in mastoid surgery, laminectomy, to retract scalp
in neurosurgery, limb surgeries, etc. When shafts
are approximated blades will open.
Fig. 6.50: Bladder neck retractor.
Fig. 6.49: Mastoid’s retractor.
BLADDER NECK RETRACTOR

It is thin, long instrument with two thin long
distal blades. Proximal thin shafts have got a
ratchet. When ratchet closes, the blades will open.
It is used in retracting bladder neck in bladder
surgeries.
CHEEK RETRACTOR
It is single piece instrument with acutely-angled
blade with inward curled round margin. It is Fig. 6.51: Cheek retractor.
used to retract cheek to inspect the oral cavity

as well as to take biopsy of a lesion for diagnosis;
dental extractions; interdental wiring; excision
of lesions in jaw, gums and oral cavity (epulis,
papillomas, mucus cysts, etc).
SCAPULA RETRACTOR
It has got a long stout handle with broad right
angled blade with serrations. It is used to retract
scapula during thoracotomy.
Fig. 6.53: Kidney hilum retractor
Fig. 6.54: Morris kidney retractor.
inwards. It is used in renal surgeries like

nephrolithotomy, pyelolithotomy, pyeloplasty,
Fig. 6.52: Scapula retractor. nephrectomy.
KIDNEY HILUM RETRACTOR ALLISON’S LUNG RETRACTOR

It has got curved ‘C’ shaped small blade with It has got long handle with light blade. Blade
a long malleable shaft which is slightly curved. is made up of wires. Blade is right angle to the
It is used in extended pyelolithotomy (Gilvernet’s) handle. It is used to retract lungs. Lung can
to retract renal hilar tissues so as to reach the expand between wires of the blade. It is
pelvis. Intrarenal pelvis is approached by this atraumatic.
manner to remove the stone.
MORRIS KIDNEY RETRACTOR

It has got blade of 6.5 × 5 cm in size with a
curve. There is a blunt projecting ridge directed Fig. 6.55: Allison’s lung retractor.
Instruments 463
RIB RETRACTOR (TUFFIER’S) periosteum of the rib. Using periosteal elevator
periosteum is elevated and rasparatory is passed
There is a strong short shaft with blades attached under the periosteum from upper margin of the
to it at right angles. One blade is fixed whereas rib to prevent injury to intercostal vessels. There
other one is adjustable which can be fixed with are separate instruments for right side and left
a screw at required width. Blades are deep with side. Handle is held with blade facing forward
outer flanges so as to hold with a proper grip. and upward to determine the side.
It is used in thoracotomy in lung/oesophageal
and cardiac surgeries (trauma, tumours, mitral
valvotomy, mediastinal tumours, diaphragmatic FARABOEUF’S RASPARATORY
hernia, oesophagectomy, etc). It is a self retaining It is a periosteal elevator with a corrugated thumb
retractor. Other rib retractor used is Quervain’s rest, flat grooved handle and a broad rectangular
rib retractor which is stronger with wing like blade (beveled edge). It is used in elevating the
blades, fixed with a screw. periosteum in cervical rib resection, rib resection
for empyema, rib resection in chondromas, in
kidney exposure, in osteomyelitis of ribs.
Periosteum is retained so that regeneration and
remodeling can occur; intercostal vessels and
nerves are protected. It is not used to elevate
the inner surface of the ribs where Doyen’s
rasparatory is used.
Fig. 6.58: Faraboeuf’s rasparatory with thumb rest.
RIB SHEAR
It has got large rough handles. One blade has
got groove with serrations and is blunt. It is
passed underneath the rib as a protector to the
adjacent tissues. Other blade is cutting one which
apposes over the groove of first blade. It cuts
Fig. 6.56: Self-retaining rib retractor. the rib from front. Instrument is used for rib
resection.
DOYEN’S RIB RASPARATORY
It has got a stout handle with a curved semi-
circular distal blade to pass under the rib surface
for separating the periosteum after incising the
Fig. 6.57: Doyen’s rib rasparatory. Fig. 6.59: Rib shear used to cut the ribs.
RIB APPROXIMATOR
It has two strong curved blades with teeth;
proximal blade is mobile but can be fixed by
a screw whereas distal blade is fixed. It is used
to approximate the ribs during closure of
thoracotomy. Two blades are placed adjacent to
ribs and proximal blade is apposed adequately
and fixed with screw. Thoracotomy wound is
closed in layers. Screw is loosened to remove Fig. 6.62: Friedrich’s lung holding forceps.
the rib approximator.
BICKFORD’S BRONCHIAL CLAMP
It has got long distal blade which has got two
bends with longitudinal serrations and spikes
on the inner surface. It is used to clamp the
bronchus as it holds the cartilaginous part firmly.
Fig. 6.60: Rib approximator.
DUVAL’S LUNG HOLDING

FORCEPS
Fig. 6.63: Bickford’s bronchial clamp.
Its distal blades have triangular aperture with
its inner surface being finely serrated to have
firm grip on the lungs without any trauma. Blades SURGICAL NEEDLES
are gently curved which imparts a smooth action.
Types
It is used to hold the lung during lobectomy/
pneumonectomy. Based on the Edge
• Round body needle: It is round and smooth
on cross section. It is used to suture muscles/
intestines/soft tissues/vessels/nerves/
tendons/peritoneum.
• Conventional cutting needle: Here needle is
triangular on cross section with apex facing
inward. It is used to suture skin/aponeuro-
sis/tough structures.
Fig. 6.61: Duval’s lung holding forceps. • Reverse cutting needle: Here needle is triangular
(reverse) on cross section with apex facing
FRIEDRICH’S LUNG HOLDING outward. It increases the strength and is less
FORCEPS likely to bend while suturing.
• Taper cut needle: Here tip of the needle is reverse
It has got four pronged blades. Each prong is cut in section but eventually tapers into the
having sigmoid curve with a ball at the tip. It body as round in section. It improves the
is atraumatic because of smooth ball. It is used penetration of needle but minimises the
to hold wider area of lung tissue. trauma.
Instruments 465
• Blunt pointed needles are used to suture
friable organs like liver/spleen/kidneys.
• Spatulated side cutting needle (saber lock)—is
like a spatula with two lateral side cutting
edges.
• Micropoint needles, either round bodied or
reverse cutting or spatulated are used in
ophthalmic and micro surgery. It has got an
extra honing process.
• Trocar point needle is stout strong cutting end
with a robust round body. It is used in
obstetrics and gynaecology.
• Tru taper needle is one with tip angle of needle
is 22 degrees (unlike conventional angle is
32 degrees). It is used in vascular surgery.
• Visiblack needles: Needles coated with black
so that they are visible better in red back-
ground. It also prevents the glare from the
focus lights by the needles.
• Dolphin nose needle is specially designed
needle used for surgeries in patients with
hepatitis and AIDS which minimises the risk
of puncturing the gloves and fingers of the
surgeon.
• JB needle ( Juergen-Breunner needle): Oval
round bodied needle with a steep curve at
the distal half to have easy passage of the
needle through bowel in gastrointestinal Fig. 6.64: Different types of needles.
surgeries.
• Port closure needle in laparoscopic surgeries
• Ski needle with a ski-shaped curvature in the disposed. (Not reusable). It is available as
distal part so as to have easy passage through sterilised pack. These needles can be round
the port for laparoscopic intracorporeal body or cutting.
suturing. • Traumatic needle: It is eyed needle. Needle in
the eye area is wider than the body of the
Based on Curvature needle and so tissue trauma is more. These
• Straight needle. needles are re-usable.
• Curved needle. Half circle; 5/8 circle, etc.
Parts of a surgical needle
Based on Existence of the Eye • Eye or suture end
• Atraumatic needle is eyeless. Here suture • Body—straight/curved
material is attached to the needle by swaging • Needle point is tip
(Mr Merson of England). Size of the suture • Circumferential length of the needle
material and that of needle is same and so • Needle chord length—distance between the
tissue trauma is less. Needle once used is tip and eye
• Atraumatic needles are available as sterilized

packs. They are sterilised by ethylene oxide
or gamma sterilisation along with the sutures
which they coexist.
• Gallie’s needle is large eyed needle which was
earlier used in hernias to suture the defect
using fascia lata strips.
• Lane’s needle is half circle cutting needle with
a large eye.
• Mayo needle is obstetric needle with a large
square eye and is strong.
• Hagedorn reverse flattened point fish hook needle
used for suturing inaccessible sites.
• Symonds round bodied fish hook needles.
• Bonney Reverdin needle is a special needle with
an eye which is open to one side with small
slender shutter which can slid and closed
after passing the suture material.
• Kous Netzoff aluminium needle is used to suture
the liver tear.
NEEDLE HOLDER
Smaller distal blades with criss-cross serrations
often with a groove in the middle are the features
of a needle holder. Often there is a longitudinal
groove in the middle of the distal blade between
Fig. 6.65: Different types of needles. Diagram also shows serrations. Ratio of length of handle to blades
the eyeless/eyed needles and gives the meanings of 1/
is 4:1.
4th, 1/2, 3/8th and 5/8th circle needles.
It may be straight or curved. It may be
available in different sizes. While holding a
Note – needle in a needle holder one should get a good
• Weakest part of the needle is part near the control and good grip. This is achieved by placing
eye. the needle at junction of proximal 2/3 and distal
• Needle is sterilised in cidex/Lysol. It should
not be autoclaved as tip gets blunt.
• The needle is held at its center by placing
it at the junction of the proximal 2/3rd and
distal 1/3rd to have optimal grip, control
and precision.
• Needles can be 1/4 circle, 1/2 circle, 3/8
circle or 5/8 circle at their curvatures. Refer
diagram for the same. Different curvature
needles are used at different places
depending on the depth of the suturing.
• Needles are made up of stainless steel. Fig. 6.66: Needle holder.
Instruments 467
1/3 of the blade. Needle holder should be held one, used for tonsillectomy. Here cutting edge
between thumb and ring finger. Curved needle faces surgeon. Number 15 is used in plastic
holders are available to hold the needles and surgery, head and neck surgery, face surgeries.
work at the depth like in pelvis/thoracic cavity Numbers 20, 22 and 24 used in skin incisions
for better maneuverability and visualisation. of major surgeries like laparotomy, thoracotomy,
Needle holder is sterilised by autoclave. Tungsten craniotomy, incisions in limb. Blades are sterilised
– carbide inner surface coated needle holder is by gamma radiation with aluminum foil packing.
available which has got longer duration of life Commonly blades are used only once and then
due to reduced wear and tear of the instrument disposed. If sterilisation is needed it is done using
because of tungsten coating. cetrimide/Lysol immersion (not autoclave or
boiling).
BARD PARKER’S HANDLE Different ways of placing incisions—
(BP HANDLE) • Dinner knife position is used while making
lengthy incision.
Bard parker’s handle is a flat stainless steel • Pen holding/writing position is used to make
instrument with a slot on narrower side on both incision over the vessels/nerves/tumours.
surfaces to attach scalpel blade. 3, 4, 5 and 7 • Fiddle-bow position is used to make incisions
numbered blades are available. Number 4 handle with less pressure on delicate tissues.
is wider. Scalpel blades 10, 11, 12, and 15 fit • Grasping position is used to make long
in to Bard Parker handle numbers 3, 5 and 7. sweeping cuts.
Scalpel blades 18, 19, 20, 21, 22, 23 and 24 fit
in to slot of Bard Parker’s blade number 4. New
blade is used in to the slot of the handle for
each patient and so sharpness of the blade is
maintained. B P handle is sterilised by autoclave.
Fig. 6.68: Surgical blades of different numbers.

Blades are detachable and used only once.
Fig. 6.67: Bard Parker’s handles—3, 4, 5 and 7
SURGICAL BLADES
They are detachable blades. Number 11 blade
is stab knife blade which is used in incision Fig. 6.69: Different positions/methods used to hold knife
and drainage of an abscess and in making small while making incisions or doing dissections in different
incision like for drains. Number 12 blade is curved surgeries.
congenital torticollis to cut sternomastoid muscle,

Principles in making incision
congenital talipes equino varus, adductor
• Incision should be planned well prior to
tenotomy and lateral sphincterotomy for fissure
surgery for adequacy, for possible need for
in ano.
extension during course of the surgery, and
indeed be cosmetically acceptable. Ideally
incision site should be marked using sterile ANEURYSM NEEDLE
marker or methylene blue. Aneurysm needle is stout instrument with a deep
• Clean single stroke firm incision should be hook in one end with an eye opening in the
made with required depth. Repeated strokes blunt tip. Eye proceeds as a deep groove in the
and movements should be avoided. needle proximally which allows the ligature to
• Knife should be perpendicular to skin to stay firmly. This facilitates the passage of the
begin with, with blade pointing perpendi- ligatures across the deeper plane around the
cular to skin. But later blade should be blood vessels; to ligate the vessel in continuity;
parallel with curvature/belly of the blade in venesection; to pass the ligature around any
on the site of the incision. tubular structures. Earlier it was used to ligate
• While making lengthy incision like in the artery while treating the aneurysm. It is
abdomen, incision area should be stretched sterilized in glutaraldehye or Lysol but never
between thumb and index fingers of other by boiling or autoclave.
hand of the surgeon.
• Care should be taken to avoid injuries to
deeper structures like muscle/nerves/
vessels/bowel while making incisions
TENOTOMY KNIFE Fig. 6.71: Aneurysm needle.

Tenotomy knife straight/curved with a short
cutting edge with a fixed handle is used in SCISSORS
Scissors has got various purposes in surgical
field like dissection, cutting tissues, cutting suture
materials, opening tissue planes, venesection,
cutting bandages, corrugated/tube drains and
dressing, ophthalmic or microsurgeries, etc. It
can be straight, curved, small, medium or long
scissors.
Different scissors are
Mayo’s scissors are long and stout scissors. It can
be blunt tipped/pointed tip/straight or curved.
Mc Indoe scissor is having fine small blade. It
is used mainly for dissection and in cutting
delicate structures.
Metzenbaum scissor has got long blades in comparison
to shaft. It is used in depth dissection like vagotomy,
Fig. 6.70: Tenotomy knife. cholecystectomy, pelvic surgeries, etc.
Instruments 469
BOWEL OCCLUSION CLAMPS
Moynihan’s Occlusion Clamp (Gastric)
• It has got long distal blades with transverse
serrations with a longitudinal fenestration
one on each blade.
• It may be straight or curved.
• It is nontraumatic, noncrushing type.
• It occludes lumen of the bowel/stomach and
so prevents spillage of the content of the
bowel.
• It also occludes the vessels in the wall of
the bowel and so prevents bleeding during
surgery.
• It is used during anastomosis of the stomach
and other parts of the bowel.
Kocher’s occlusion clamp (gastric): Blades have
longitudinal serrations without fenestration.
Doyen’s intestinal occlusion clamps (straight or
curved): Have longitudinal serrations with
apposing blades.
Lane’s paired gastrojejunostomy clamps (straight or
curved): It is used in gastrojejunostomy. It steadies
the anastomising parts well. It has got a hook
at the tip and a screw on the blade to fix each
other.
Fig. 6.72: Different scissors used in surgical

practice.
Heath suture cutting scissor—has got long shaft,

small curves angled blades with tip is having
fine serrations which ensures the proper grip
Fig. 6.73: Moynihan’s occlusion clamp.
of the suture material to be cut. Suture is held
with dissecting forceps and is cut using Heath’s
scissor between knot and skin where suture
enters.
Steele’s scissor is like Metzenbaum scissor with
similar use.
Lister’s bandage/dressing cutting scissor has got flat
lower blade to avoid damage to skin. Lower blade
has got a knob at the terminal. Fig. 6.74: Doyen’s occlusion clamp.
Fig. 6.77: Payr’s gastric occlusion clamp
Fig. 6.78: Moynihan’s gastrojejunostomy clamp.

Fig. 6.75: Lane’s paired gastrojejunostomy clamps with
hook and screws used for gastrojejunostomy. Carwardine’s twin intestinal occlusion clamps: It has
got a slot on one part shaft and a corresponding
screw on the other part shaft. These slot and
screw fits into each other to facilitate proper
intestinal anastomosis.
Payr’s gastric occlusion clamp: It has got
longitudinal serrations on the inner surface of
the blades with several ball like projections along
the sides which interlock each other of the
opposite blade to have a firm grip on the stomach/
bowel while using.
Moynihan’s gastrojejunostomy clamp: It has got long
fenestrated blades with oblique serrations.
Central and one lateral blade are straight where
jejunum is placed while doing gastrojejunostomy
and third lateral blade is ‘L’ shaped within which
stomach occupies while using. Serrations and
L shape prevents slippage of the bowel while
anastomosing.
CRUSHING CLAMPS
Fig. 6.76: Carwardine’s twin intestinal occlusion clamp
with screw and slot to fix. It is used to have easier intestinal
Payr’s crushing clamp gastric/intestinal/
anastomosis. appendix crushing.
Instruments 471
Fig. 6.80B: Desjardin’s choledocholithotomy forceps.
Fig. 6.79: Payr’s crushing clamp.

It is used for choledocholithotomy (removal
of CBD stones). Length and curve facilitate the
• It is stout and heavy instrument with double stone extraction better. In laparoscopic cholecys-
lever in the handle with longitudinal tectomy, to make easier delivering of the gall
serrations. bladder it can be used to remove stones from
• Once applied it crushes the bowel. So before gall bladder by passing through the 10 mm port.
applying it, line of resection of stomach/bowel Disadvantage is the instrument may dilate the
should be assessed properly. It is applied CBD significantly while manipulating.
to the part which has to be removed. Viability Lawson-Tait Choledocholithotomy Forceps/Alligator
of the bowel is lost once it is applied. Forceps is used which has got alligator jaws that
• It is used in gastrectomy, resection and facilitate passage through a narrow duct with
anastomosis of the bowel. lesser chances of dilating the duct.
• It can be gastric crushing or intestinal
crushing or appendix crushing clamp. All
are similar; only size of the blades is smaller BAKE’S DILATOR
in intestinal and appendix crushing clamps. It is long malleable metallic instrument with club
Parker Kerr’s crushing clamp is a stout, heavy at the terminal end. It is available in different
crushing clamp with longitudinal serrations. sizes.
It is used to assess the CBD, duodenal papilla
for patency or block. Dilator is passed through
the choledochotomy opening downwards to
reach the metal tip (olive blunt tip) to duodenum.
It signifies the patency. It is called as steel sign.
Gradually from lesser diameter to higher diameter
sized dilators are passed.
Fig. 6.80A: Parker Kerr crushing clamp.

Fig. 6.81: Bake’s dilator.
DESJARDIN’S CHOLEDOCHO-
CHEATLE’S GALLSTONE SCOOP
LITHOTOMY FORCEPS
WITH OR WITHOUT HOOK
It has got long distal blades with smooth
serrations and fenestra in the tip. It does not It is flexible long instrument with a blunt scoop on
have lock and so accidental damage to CBD one side with a handle. Few instruments often contain
mucosa or crushing of the CBD stone are avoided. a hook on other side. Scoop is to remove the debris
Henry Gray’s cholecystectomy forceps is similar but

A has right-angled blades with transverse
serrations.
GALLSTONE PROBE
B
It is a long malleable instrument with an olive
on one or both ends with a handle. Its diameter
is 6 mm. It is used to explore the common bile
Figs 6.82A and B: Picture showing Cheatle’s
gallstone scoop and also scoop with a hook.
duct and hepatic ducts for patency, and presence
of stones. Small stones in common bile duct can
from the gallbladder or common bile duct; and also be pushed into the duodenum. If stone is
to support or push the stone while removing. Hook impacted, its exact location can be found by
is used to dislodge the impacted stone. passing it.
CHOLECYSTECTOMY FORCEPS
These instruments are used to hold the fundus
and Hartmann’s pouch of the gall bladder during
cholecystectomy. It is also used to dissect the
cystic duct and artery and to pass ligature around
the cystic duct and artery.
Fig. 6.84: Gallstone probe is available as one side or

both sides olive tip which is flexible, long and thin.
MAYO ROBSON’S CHOLECYSTO-

Fig. 6.83: Cholecystectomy forceps – two types – Henry
Gray’s right-angled; Moynihan’s parrot beak curved. ENTEROSTOMY CLAMP
It has got long curved semicircle like blades. It
Types is used while bypassing the biliary tree–
Moynihan’s cholecystectomy forceps has long shafts cholecystoenterostomy done as a palliative
with slight curve at the short distal blades like procedure in obstructive jaundice (in carcinoma
a parrot beak with oblique serrations inside. head of the pancreas or periampullary or
Instruments 473
Before removal of ‘ T’ tube, patency of CBD
should be confirmed.
It is done by following methods:
• The vertical limb (done in 10-14 days) is
clamped and observed for development of
pain, fever and jaundice in 24 hours. If normal
then one can presume that there is no
obstruction in the CBD.
Fig. 6.85: Mayo Robson’s cholecysto • Water soluble iodine dye is injected through
enterostomy clamp. the tube to visualise biliary tree and free flow
of dye into the duodenum. (Postoperative ‘T’
tube cholangiogram). It is done in 14 days
carcinoma distal common bile duct). This clamp
which is the time required to develop fibrous
is used to clamp the gallbladder to keep in
track. Once there is free flow tube is removed
position while doing cholecysto jejunosostomy.
and track gets closed on its own.
But choledocho jejunostomy Roux-en-Y is a better
palliative bypass procedure because narrow Complications/problems of T tube
cystic duct may get blocked later causing re- • Kinking/block/break in T tube.
obstruction of the biliary tree. Cystic duct may • Displacement/slipping of T tube out of
end into the common bile duct lower down and common bile duct may cause biliary
its junction may get involved by the tumour peritonitis.
invasion causing re-block and so failure of the • Improper pancreatic duct drainage due to
palliative procedure. tube.
• Impaired enterohepatic circulation.
KEHR’S ‘T’ TUBE • Biliary infection, secondary haemorrhage, bile
leak and peritonitis, foreign body reaction
• It is used after opening of CBD (choledo- • Difficulty in removal even after adequate
chotomy). CBD is closed with ‘T’ tube in situ pressure is managed by gradual continuous
• It is made up of latex or red rubber. ‘T’ tube pressure and occasionally exploration may
has got horizontal part which is kept in the be needed.
CBD and vertical part which is allowed to
come out to drain bile. Amount of bile draining
is measured daily.
SUCTION INSTRUMENTS
These are essential instruments needed in all
surgical practice to suck out blood from the
surgical field, pus, infected fluid, fluid in
peritoneal/thoracic/cranial cavities. It has got
a suction tip of varying type, suction tube which
connects tip to the suction apparatus and suction
creating system, either central suction system or
power suction system with two suction glass
bottles connected to each other or manual suction
apparatus (now not used). Suction tip has got
a long bent tube with openings at one end to
suck the fluid, with a stout handle which has
Fig. 6.86: Kehr’s ‘T’ tube. got a proximal ridged part at the other end to
which suction tube (rubber or plastic) is attached,

which is in turn is connected to suction
apparatus. Suction tip and suction tubes should
be sterile. They are sterilised by autoclave.
Types of Suction Tips

• Adson’s fine suction tip: It is angled with a
vent/thumb rest to control the suction as
needed. It is a fine suction tip which is used
in meticulous surgeries like plastic, vascular
and reconstructive surgeries. It can not be
used when large quantity of blood/pus/
fluid/clot needs to be sucked out.
Fig. 6.89: Poole’s multi-perforated suction tip.
will be inside the outer tube attached with

Fig. 6.87: Adson's suction tip. a screw on proximal aspect. Outer tube has
got a thumb rest hole/vent which when
• Yankauer’s suction tip—It is large suction tip closed with thumb, only then the suction tube
used mainly in peritoneal cavity after lavage, will function. With thumb placed on the vent
in haemoperitoneum, in peritonitis, in pelvis, suctioning is done in the peritoneum or other
in thoracotomy, etc. It has got central hole cavities, while removing the suction tube
with outer small multiple holes. It creates thumb is released so that sucking effect on
strong suction and so may suck omentum; the bowel or omentum or vessels or over the
bowel wall, etc. and so with one hand bowel stoma is prevented while withdrawing the
and omentum should be pushed aside while suction tip. It acts by sump action principle.
sucking the fluid. Often its tip is supported It can also be used for decompressing the
by a rubber tube. When it is present, care distended bowel.
is taken to see that it is not left inside the
peritoneal cavity by inadvertent slippage. TRACHEOSTOMY TUBE
Types
1. Fuller’s bivalved tracheostomy tube: It has got
outer tube and inner tube. Outer tube is
Fig. 6.88: Yankauer’s suction tip. biflanged and so insertion is easier. Inner
tube is longer with an opening on its posterior
• Poole’s multi-perforated suction tip: It has got aspect. Inner tube can be removed and re-
outer and inner tubes – one inside the other. inserted easily whenever required.
Outer tube has got multiple holes with blunt 2. Jackson’s tracheostomy tube: It has got outer
closed tip so that bowel/tissues will not be tube, inner tube and an obturator.
sucked inside. Inner tube has got one terminal 3. Red-rubber tracheostomy tube.
and another proximal side holes. Inner tube 4. PVC tracheostomy tube.
Instruments 475
TRACHEAL DILATOR
(TROUSSEAU’S)
Here blades open up while approximating the
handle. Blades have got club-shaped blunt tip.
It is used to dilate the tracheal opening during
A tracheostomy and to keep it open while
introducing the tracheostomy tube.
Fig. 6.91: Tracheal dilator.
TRACHEAL HOOK
It is single blunt hook/sharp hook with a handle
which is used to stabilise the trachea and retract
strap muscles and isthmus during tracheostomy
by placing under the cricoid to pull it upwards.
Sharp hook is used to stabilise the trachea. Blunt
B
hook is used to retract strap muscles.
Figs 6.90A and B: Tracheostomy tube (A) Fuller’s

(B) Jackson’s tracheostomy tube.
Fig. 6.92: Tracheal hook.

Modern tracheostomy tubes are made of
plastic. They are soft, least irritant and dis-
posable. They have inflatable cuff which makes CRICOID HOOK
it easier to give assisted ventilation. Cuff should It has got thin shaft and two curved prongs at
be deflated at regular intervals to prevent tracheal the end of the blade with a handle. It is used
pressure necrosis. (For assisted ventilation to retract the isthmus during tracheostomy.
endotracheal tube can be kept for 7 days. Beyond
that period patient needs tracheostomy for further
ventilation).
Indications for Tracheostomy Fig. 6.93: Cricoid hook.

• In head, neck and facial injuries.
• Tetanus.
• Tracheomalacia after thyroidectomy.
ENDOTRACHEAL TUBE
• Laryngeal oedema/spasm. It is a gently curved tube used to pass in to the
• Major head and neck surgeries like trachea via the nasal/oral route. It is made up
Commando’s operation, block dissection, etc. of India rubber or portex. It may be cuffed or
• Rae preformed tracheal tube: There is bending

in the part of the tube that remains outside.
It can be oral or nasal bends.
• Spiral embedded/armored/reinforced: Middle
segment of the tube is spirally embedded with
nylon/metal filaments to make it resistant
for kinking and tolerable in high pressure.
• Endotrol tube has got cable like mechanism
to have a control over the tip.
• Hi-low jet three: Lumen tracheal tube with main
lumen for ventilation, another for jet
ventilation, suctioning, oxygenation and
Fig. 6.94: Endotracheal tube.
bronchoscopy and third one for irrigation
and sampling from trachea.
noncuffed (plain). Cuff is present on the distal • Laser shield endotracheal tube which is made
part of the tube which is inflated using air through up of silicon with impregnation of metal
a fine tube present on the body of the endotracheal particles.
tube. Small pilot balloon on the proximal part • Oxford endotracheal tube: Here 2 cm of nasal
is present to check the tension of the cuff. Cuff end of the tube is bent at 90 degrees and
prevents aspiration and air leak. Capacity of the is used in cleft lip and cleft palate surgeries.
cuff is 4 ml. and often tip is radio-opaque. When
noncuffed tube is used, ribbon gauze should be Complications of Endotracheal Tube
packed around it to protect air way from • Oesophageal intubation—most dangerous
aspiration. Its distal end is beveled – 38 degrees should be identified by ventilation,
towards left as tube is passed from the right auscultation, absence of vapour in the
angle of the mouth of the patient. It has got a proximal part of the tube. It should be
thick black mark which should pass just beyond removed and reintroduced immediately.
the vocal cords. Cuff should be 3 cm beyond • Trauma to oral/nasal/pharynx/larynx.
vocal cords in adult and 1 cm beyond vocal cords • Right sided intubation as right bronchus is
in infants. Different sized tubes are available shorter, wider than left and it is in line with
depending on age of the patient. Number 6.5 tracheal lumen. Left side will not get ventilated
to 8.0 in females and 8.0 to 9.5 in males are used.
in this situation.
Styllet is often used while passing the
• Bronchial obstruction/aspiration.
endotracheal tube for easy intubation.
• Infection—bronchopneumonia, septicaemia.
It is used in general anaesthesia, to maintain
• Kinking, blocking of the tube.
airway in emergency in patients with trauma,
• Tracheal dilatation/erosion.
in patients with respiratory distress, in cardiac
• Inadvertent extubation/difficult extubation.
arrest. It is a life saving tube used during
• Laryngeal/pharyngeal oedema, laryngitis.
resuscitation. It is usually kept for 7 days. If patient
needs further continuation of artificial ventilation • Vocal cord dysfunction/laryngeal or tracheal
then tracheostomy is done. narrowing.
Types
MAGILL’S FORCEPS
• Cole tube: Here distal part is narrow and is It is long, sidewise angulated with fenestrated
used in pediatric anaesthesia. blades with rings in the handle without ratchets.
• Lindholm tube: It has 90º curve at oropharynx. Angulation helps while using in proper vision
Instruments 477
• Penrose soft latex rubber tube.
• Multiple perforated tubes.
3. Closed suction tube drain system.
4 Glove drain.
5. Wick drain is a gauze drain to drain pus,
discharge, etc.
Fig. 6.95: Magill’s forceps.

Advantages of tube drains
• Quantity of fluid like bile, pus can be
measured
of oropharynx. It is used to assist in endotracheal • It can be kept for longer time
intubation, removal of dentures, teeth, foreign • Skin excoriation will not occur
body from the oropharynx in anaesthetised • Patient will be more comfortable
patient. It is used to pass nasogastric tube under • Infection rate is less
vision in anaesthetised patient. • Removal is easier
• Dye can be injected and cavity or communi-
DRAINS cation can be assessed using ‘C-ARM’
A drain is a created channel which allows any
Classification of Drain System
collected fluid to come out after closure of the
1. Open (static) drains: e.g. corrugated drain,
main wound.
Penrose drain (soft latex rubber tubing).
Infection rate is higher.
2. Closed siphon drains: Here drain is connected
to a sterile bag with or without one-way valve.
It reduces the infection.
3. Closed suction drains: Here negative pressure
A of –100 to –500 mmHg is used to create
vacuum to drain the secretions.
Figs 6.96A to C: Drains (A) Corrugated rubber drains

(B) Multiple perforated drains (C) Tube drain.
Types
1. Corrugated rubber drain: It drains by capillary
action and gravity. It is cheaper and techni- Fig. 6.97: Romovac suction drain. Here suction is created
by pressing the suction corrugation. There is a sharp
cally easier. But it allows soakage of dressings
metallic introducer to pass the tube into the required area
and causes discomfort to the patient. after puncturing the skin. It is used for thyroidectomy,
2. Tube drains mastectomy, radical dissection, wide excisions, flap
• Malecot catheter can be used as tube drain. surgeries, etc.
4. Sump suction drain: Here negative suction with

a parallel air-vent is used to prevent the
adjacent soft tissues being sucked into the
lumen of the drain.
5. Under water seal drain to drain pleural space.
Indications for Drains

• In drainage of an abscess.
• In bleeding surgical conditions like trauma,
peroperative bleed.
• In haemo, pyo or pneumothorax.
• In acute abdominal conditions like peritonitis,
haemoperitoneum.
• In major abdominal surgeries like of pancreas,
biliary tree, stomach, etc.
• In thyroid surgery. Fig. 6.98: Intercostal drainage tube with
• In hydrocoele surgery. underwater seal bottle.
This tube end should be dipped in the water

Problems in Drains
column properly. Smaller glass tube often bent
• Infection through the drain.
in between is not dipped inside the water column
• Displacement.
which allows the air to go out. It is used in haemo-
• It may not drain adequately and can give
thorax/pneumothorax/empyema/after thora-
a false information.
cic/oesophageal surgeries. In haemothorax/
• It may interfere with healing process inside.
empyema, chest tube is inserted in the mid
Presently keeping a drain itself is a questioned
axillary line in 6th intercostal space. It is easier
debate and controversy all over. Older dictum
to pass the tube in this line as muscles are thin
was ‘ when in doubt keep a drain and the surgeon
and patient will be comfortable if tube is in this
can sleep happily’—is questioned at present.
position.
Drains if not used properly may be counter-
productive.
PAUL’S DRAINAGE TUBE
Note:
A drain should be placed always in most It is a bent glass tube with two ends. Edge with
dependent position and should be brought out two collars is passed through the enterotomy
through shortest straight route with a separate
stab incision. It should be anchored to skin
securely. Corrugated drain should be kept with
adequate length otherwise it may get into the
abdominal cavity during phases of respiration.
INTERCOSTAL DRAINAGE TUBE

It is made up of portex with proximal end having
multiple holes which is inserted in to the pleural
space. Other end is connected to a glass tube
the tip of which is dipped inside the under water
bottle which allows the expulsion of air outside. Fig. 6.99: Paul’s drainage tube.
Instruments 479
in to the intestine and fixed with a purse string It is achieved by
suture. End with a single collar is attached to – Balloon tip of catheter -Foley’s catheter.
a rubber tube to remove the bowel contents from – Flower tip of catheter - Malecot’s catheter,
distended bowel. It is not used now. De-Pezzers.
– Strapping catheter externally - Gibbon’s
CATHETERS catheter.
b. Intermittent catheterisation: A sterile catheter
They are hollow tubes used to relieve urinary is introduced intermittently by the patient or
retention, obtain urine for analysis, irrigate by others.
bladder and to instill drugs into bladder.
India Rubber Catheter FOLEY’S CATHETER (FREDRICK
• Red in colour contains high sulfur.
EUGENE BASIL FOLEY
• Heat resistant.
• Causes more irritation. AMERICAN UROLOGIST)
Latex Rubber It is a self retaining urinary catheter made up
• Softer, smooth, less irritant. of latex. It has got a balloon near the tip into
• Can be kept for long time. which distilled water is infused to make it self-
• Sterilised by boiling, autoclave or gamma retainable. Usually Foley’s catheter is kept for 7
radiation. days. It is sterilised by γ-radiation.
Metal Catheters Size: Adults -16 F

• Female and male catheters are different. Children- 8 F or 10 F
• Used in difficult catheterisation. (F- French unit, Charriere unit, where each unit
• To empty bladder prior to vaginal equals 0.33 mm). 16 F means circumference of
hysterectomy. the catheter is 16 mm. Diameter is one third of
Polyethylene Catheters circumference).
Transparent and stiffer.
Gum Elastic Catheters
• From gum resins with cotton/silk impreg-
nated.
• Formalin vapour sterilisation.
• Boiling or autoclave cannot be done.
• Not used now.
Types
• Non self-retaining catheter: Simple red rubber
catheter.
• Self-retaining catheter: Foley’s catheter,
Malecot’s catheter, Gibbon’s catheter,
De-Pezzer catheter.
Types of Catheterization
a. Indwelling catheterisation: When a catheter is
left behind in bladder and remains so it is
called an indwelling catheter. Fig. 6.100: Foley’s catheter.
Uses Complications
• To pass per urethrally in retention of urine • Infection.
of any cause (BPH, stricture, trauma) • Encrustation.
• To measure the urine output in renal failure, • Bleeding.
postoperative patients, and terminally ill • Stone formation.
patients, and patients under critical care • Blockage, false passage.
• After prostatectomy or TURP – three way • Stricture.
catheter is used for irrigation also. Here it • Difficulty in removal of the catheter due to
is also used as haemostatic by inflating more blockage of the balloon channel. Here bulb
distilled water in to the balloon and giving of Foley’s can be punctured from above under
traction causing tamponade effect ultrasound guidance or injection of ether into
• Paraplegia/neurogenic bladder—initially the balloon so as to burst it but it may cause
Foley’s catheter is used later condom chemical cystitis or passing a stilette into the
drainage is better channel.
• To give bladder wash in haematuria,
infection, etc. MALECOT’S CATHETER
• Percutaneous suprapubic cystostomy
It is self-retaining urinary catheter with an
• Cholecystostomy
umbrella or flower at the tip. It is made of red
• To drain fistulas
rubber, contains sulphur and so it is radio-
• To control bleeding from nostrils/post
opaque.
haemorrhoidectomy secondary haemor-
It is never introduced per urethrally.
rhage
It is sterilised by boiling.
• In children to give enema or to do barium/
contrast enema X-rays.
Types
1. Two-way Foley’s.
2. Three way Foley’s- To give bladder irrigation
e.g. Following TURP.
3. Silicon coated Foley’s: To reduce reaction and
so as to keep for longer period (3 months).
Procedure
Fig. 6.101: Malecot’s catheter.
After cleaning under strict asepsis, lignocaine
gel is lubricated into the urethral meatus. Catheter Advantages
is passed into the urethra. Sometimes Maryfield • Malecot’s catheter can be kept for a long
introducer is used to pass Foley’s catheter. Once period of time (3 months)
catheter is in the bladder, urine will flow out. • It drains fluid adequately.
It is now connected to an urosac bag. Balloon • Less infection rate.
is inflated with 20-30 ml (amount is written on • Removal is easier.
the catheter) of distilled water to make it self
retainable. During removal of the catheter same Disadvantage
amount of water should be removed from the Surgery (Open method) is required to insert the
balloon before pulling out the catheter. catheter.
Instruments 481
Uses Complications
• Suprapubic cystostomy (SPC). • Injury to bowel, peritoneum.
• In case of urinary retention when Foley’s • Infection.
catheterisation fails (after two trials)
• For diversion of urine following bladder, SIMPLE RED RUBBER CATHETER
prostate or urethral surgeries
• To continuous drainaige of abscess cavities– It is a nonself-retaining urinary catheter. It is
• Perinephric abscess stiffer than Foley’s catheter. Its tip is rounded
• Pyonephrosis and blunt. Opening is only on the side wall (In
• Subphrenic abscess flatus tube opening is present on both sides and
• Amoebic liver abscess also at the tip). Here English unit is used to
• Cabot’s nephrostomy number – diameter is 1 + catheter number/2.
• Cholecystostomy
• Infected pseudocyst of the pancreas
• Gastrostomy, caecostomy (tube type)
SUPRAPUBIC CYSTOSTOMY (SPC)

It is placing of Malecot catheter into the bladder
above the pubis by open method, or percuta-
neously under guidance using Foley’s catheter.
It is a temporary opening through the abdomen
into the bladder.
Prerequsite: Bladder must be full and is confirmed
by dullness below the umbilicus or by ultrasound.
Indication: Retention of urine when urethral
catheterisation fails.
Procedure: Under local anaesthesia (Xylocaine
2% above the pubis, in the midline) or G/A, a
Fig. 6.102: Red rubber catheter.
vertical midline incision of 3 cm in length is
placed through linea alba. Skin, fascia, anterior
rectus sheath are incised. Recti are retracted. In Uses
extraperitoneal space, peritoneum with pad of • Used to drain urine from the bladder tempo-
fat is reflected upward. Bladder is identified by rarily in retention of urine.
detrusor muscle pattern and vesical venous • To find out residual urine. After passing urine,
plexus and is confirmed by aspirating urine catheter is introduced into the bladder. The
through a syringe. The bladder is opened near amount of retained urine is measured. If it
the fundus. Urine is aspirated. Bladder wall is is more than 30-50 ml it signifies obstruction.
inspected for any pathology. Malecot’s catheter It often increases more than 200 ml in
is straightened using artery forceps and placed conditions like BPH and indicates significant
in the bladder. Sutures are placed around the obstruction that needs surgical intervention
Malecot’s catheter. Wound is closed in layers. like TURP.
In percutaneous SPC, Foley’s catheter is passed • While doing cystography to infuse dilute
into the bladder using trocar and cannula. iodine dye in to the bladder.
• Single gentle passage of the red rubber catheter

is tried as a diagnostic method to identify
the urethral/bladder/renal injuries. Haema- A
turia signifies urinary tract injury. Measured
normal saline is infused in to the bladder
and return volume is collected; if it is less,
then it indicates injury to bladder.
• For administration of intravesical chemo-
therapy or therapeutic BCG infusion in to
the bladder per urethrally in bladder
carcinoma
• To collect urine from the bladder for culture B
and sensitivity.
• To identify the urethrally in perineal surgery/ Figs 6.104A and B: (A) Rounded catheter
urethral surgery/penectomy. introducer, (B) Maryfield introducer.
• To dislodge and push back the calculus
impacted in the urinary meatus or in the Two types—
urethra. • Long slender metallic type with rounded tip
• To administer nasal oxygen. • Maryfield introducer: It is long curved flat
• For suction of throat/endotracheal tube/ metallic introducer with a longitudinal groove
tracheostomy tube. over its convex surface over its entire length
• As a tourniquet for venesection and surgeries which ends at the tip as a blunt projection.
of fingers and toes. This projection helps in hooking the catheter
• Used as a sling in many places like to hold tip (Foley’s catheter) and the groove
cord, to hold vagus, to hold pedicles, to hold accommodates the body of the catheter and
oesophagus/bowel/ureter. prevents it from slipping away.
• To irrigate and clear the pus after opening
the abscess cavity/or any other cavities in
depth. GIBBON’S CATHETER
• To irrigate common bile duct after chole- It is a self-retaining catheter made up of plastic
dochotomy; to irrigate ureter/renal pelvis after with a stillete in it which makes its passage easier
stone removal. through urethra. There are different sizes for
males and females because of the difference in
DEPEZZER’S CATHETER length of the urethra in male and female. Catheter
It is a self-retaining catheter with a bulb at the has two ribbons attached which can be used
end which makes it self-retaining. Its uses are to fix to the genitalia by adhesive plaster.
like Malecot’s catheter. It can not be passed per Gibbon’s catheter is least irritant to urethra.
urethrally. Usually 24 French size is used.
Fig. 6.103: Depezzer’s catheter.
CATHETER INTRODUCER
It is used to negotiate the catheter in to the urethra
Fig. 6.105: Gibbon’s catheter. Note the look and
or in other places wherever it is used. method of fixing in male and female.
Instruments 483
TIEMANN CATHETER b. Female metal catheter: It is short metallic catheter.
Tip is rounded with multiple side holes. It
It is made up of PVC with beaked, stiff tip. has got one flat curved handle. It is used to
Different colour codes are used on the beaked empty the bladder in pelvic surgeries like
tip for different numbers of the catheter. Side vaginal hysterectomy.
holes are located proximal to the colour codes.
No. 12—White
No. 14—Green URETERIC CATHETER
No. 16—Vermilon It is thin slender flexible radio-opaque tube of
No. 18—Red 70 cm length with a black mark at every 5 cm
No. 20—Yellow junction. French unit is used. 3-8 French (F) are
No. 22—Maroon available. Initially cystoscope is passed and
No. 24—Blue under visualisation ureteric catheter is passed
through ureteric orifice with a stillete. Stillete
METAL CATHETERS maintains the stiffness and patency of the
catheter. It can be olive-tipped; whistle; coude’;
They are metal catheters which are stiff and can or open-ended. It is used while doing retrograde
be passed in to the urethra even if other catheters pyelography (RGP); to collect selective urine
fail. sampling in tuberculosis; to assess and relieve
the ureteric obstruction; as an ureteric stent.
Types: These are of two types.
a. Male metal catheter: It is long tube with a curve
at the tip. Tip is rounded and blunt with side
holes. Two rings near the base help in holding
the catheter. It is used to empty the bladder
in retention of urine when other types of
catheter fail. With prior lubrication of urethra
using adequate quantity of lignocaine jelly,
it is passed like a dilator with all aseptic
precautions. Catheter is passed through the
external meatus into the urethra. Once it
reaches the bulbar urethra a resistance is felt,
then handle is rotated across the inguinal
ligament, groin towards the midline over to
the abdomen. Sudden release of resistance of
catheter entering in to the bladder is felt. Urine
will come out of the catheter easily. Catheter
will stay there firmly only if entered properly.
Fig. 6.107: Ureteric catheter.
URETHRAL DILATORS
• Lister’s dilator.
Fig. 6.106: Male and female metal catheters. • Clutton’s dilator.
• Filiform bougies. CLUTTON’S DILATOR

• Gum elastic bougies.
• Olivary tip bougies. It is a long metallic instrument with a curve and
• Whip bougies. blunt tip at the end. Handle is violin shaped.
It is numbered in English units. Denominator
of the part signifies the circumference in the base
LISTER’S URETHRAL DILATOR and numerator suggests the circumference in the
It has got olive tip with a rounded handle. Handle tip. Difference between denominator and nume-
is rounded with numbers marked. Denominator rator is 4. Numbers are like 6/10; 8/12; 10/14
is circumference in mm at the base of the Lister’s — so on. Set 12 of dilators are available.
dilator. Numerator signifies circumference just
proximal to the olive tip (narrowest point).
Difference between denominator and numerator
is 3 mm. So each dilator is narrowed for 3 mm
from base to proximal end of olive tip.
Circumference of olive tip is equal to circum-
ference in the base. Numbering is based on
English scale (diameter in mm = Number/2 +
1. It is used dilate stricture urethra; to pass catheter
by open rail road technique in rupture urethra.
With all aseptic precautions urethral
dilatation is done (proper cleaning and draping).
It is done under local lignocaine jelly application
or under general anaesthesia. Dilator is passed
up to the bulb when a resistance is felt. Then
handle is gently curved over the inguinal
ligament, groin and over the abdomen towards
midline. A feel of entry in to the bladder is felt
while entering the bladder. Once left like that
dilator stays there firmly with free side-to-side
Fig. 6.109: Clutton’s dilator.
movement otherwise it will fall back.
Persistent pain; severe resistance and
bleeding per urethra are the features to consider FILIFORM BOUGIES
failure of the dilator entering in to the bladder. It is a small cylindrical hygroscopic instrument
False passage; bleeding; infection and fistula used in tight strictures to negotiate one of the
formation are the complications of urethral bougies. Bougies are passed in bunches in to
dilatation. the urethra. One of the bougies will be negotiated
across the stricture by trial and error maneuver.
That particular bougie is left in place which
absorbs the urethral fluid and secretions; and
gets swollen causing required dilatation. Later
metallic dilators like Lister’s or Clutton’s dilators
are passed to achieve adequate dilatation. Many
types of filiform bougies are furnished with
Fig. 6.108: Lister’s urethral dilator. threaded hollow mounts at the proximal ends.
Instruments 485
Fig. 6.111: Bladder sound.
It is not used now. It can be used as urethral

dilator.
THOMPSON-WALKER’S
SUPRAPUBIC CYSTOLITHOTOMY
FORCEPS
It has got a spoon shaped elongated concave
blades with spikes on the inner surface which
gives secure grip of the stone from the bladder.
A
It has no ratchet. Shaft has got a ring for placement
of thumb and another is curved open to place
four fingers. It is used to hold and remove stones
from the urinary bladder in suprapubic
cystolithotomy.
Fig. 6.112: Thompson-Walker’s suprapubic

cystolithotomy forceps.
BOOMERANG NEEDLE
It is sharply curved needle attached to a special
holder with a spring within it. Needle has got
B sharp point and a slot. Suture material is passed
through the slot to pass deep in to the tissues.
Figs 6.110A and B: Filiform bougie with followers. One When handle is compressed through spring,
of the bougie can be negotiated through the tight strictures needle rotates inwards passing through the
and which helps in further dilatation through metallic dilators.
tissues in front. It is used in suturing prostatic
Larger sized screw ended gum elastic bougie capsule in open prostatectomy.
can be attached to the filiform follower thread
to do the subsequent dilatation.
BLADDER SOUND
Bladder sound used to explore the bladder for Fig. 6.113: Boomerang needle used to suture
the presence of stones by sound – hence the name. prostatic capsule in open prostatectomy.
NASOGASTRIC TUBE/RYLE’S TUBE requirement. In postoperative period, it is

removed once patient passes flatus; adequate
It is one meter long which is made up of red bowel sounds are heard; content in the tube is
rubber or plastic. Original Ryle’s tube was made reduced to less than 50 ml.
up of moulded red rubber. Presently used
nasogastric tubes are made up of polyethylene It has got markings at different levels:
or portex. Tip is blunt without opening. • At 40 cm distance, indicates the level of gastro-
Subterminal multiple openings are present on oesophageal junction.
all the sides. It is sterilised by gamma rays. • At 50 cm distance, indicates the level of body
of the stomach.
• At 60 cm distance, indicates the level of the
pylorus.
• At 65 cm distance, indicates the level of the
duodenum.
Indications
Diagnostic:
• For gastric function tests. To assess free acid
and total acid – in gastric/duodenal ulcers;
pyloric obstruction/carcinoma stomach
(exfoliative cytology); achylia; Zollinger –
Ellison syndrome; pernicious anaemia; saline
load test to confirm gastric motility and outlet
obstruction; small bowel enema.
• Hollander’s test for completion of vagotomy.
• To diagnose tracheo-oesophageal fistula.
• Baid test for pseudocyst of the pancreas.
Therapeutic:
Fig. 6.114: Ryle’s tube.
• In acute abdominal conditions like
It has got three lead shots in the tip which peritonitis/obstruction, etc.
makes it radio-opaque. It also facilitates easy • In abdominal trauma.
passage of the tube through the oesophagus. Once • After abdominal surgeries.
tube is inside the stomach, bile/gastric juice will • In pyloric stenosis.
come out of the proximal end, often confirmed • In upper GIT bleeding.
by aspiration. Stethoscope is placed over the • In paralytic ileus, gastric dilatation to
stomach; syringe with air is pushed in to the decompress the bowel.
tube; if tip of the tube is in the stomach air entering • For feeding purpose in comatose patients,
in to the stomach can be heard through the faciomaxillary injuries, major head and neck
stethoscope. surgeries, head injuries, pharyngolaryngeal
It is passed through one of the nostrils using surgeries; cleft palate;
xylocaine 2% jelly. Under anaesthesia it is passed Ryle’s tube is British type, made up of red
using Magill’s forceps. It should be fixed securely rubber, usually 75 cm in length, with lead shot
to the nostrils otherwise it may get displaced in the tip. It is available as different sizes from
or come out. It should be replaced with new tube 8 French to 18 French units.
in 2 weeks. Intermittent suction or continuous Levin’s tube is American tube made up of portex,
open drainage can be done depending on 125 cm in length. Now it is commonly used tube.
Instruments 487
Complications
• Injury to nostrils and bleeding.
• Pharyngitis/rhinitis.
• Discomfort/unacceptancy.
• Ulceration in the pharynx/oesophagus.
• Aspiration pneumonia as lower sphincter is
kept open—dangerous complication—may
cause death also.
• Perforation of oesophagus.
Nasogastric tube is contraindicated in
corrosive oesophageal burns in initial phases
for 2 weeks.
Fig. 6.116: Flatus tube.
INFANT FEEDING TUBE
It does not have lead shots and no markings. rectosigmoid area. Proximal end is connected
It is used in children and infants similar to Ryle’s to water container to observe the quantity of air
tube. bubble which signifies the amount of gas getting
deflated.
HERNIA BISTOURY
It has got a handle and a flat blade with a small
cutting edge on one side near the tip. Tip is blunt.
Instrument is used to divide constriction band
Fig. 6.115: Infant feeding tube.
FLATUS TUBE
It is made up of India rubber, 45 cm in length.
There is one opening in the tip and another on
the side proximal to the tip. (Urinary catheter
like red rubber catheter has no opening on the
tip, only side opening is present). It is used in
sigmoid volvulus to decompress and derotate;
in paralytic ileus; in subacute intestinal
obstruction. It is passed per anal in to the Fig. 6.117: Hernia bistoury.
in strangulated hernia, to cut lacunar ligament of different sizes and snugly fits in to proximal
in femoral hernia. It helps to protect adjacent end of cannula. Trocar with sheath is punctured
structures while cutting the band. in to the needed place and trocar is removed.
Through sheath fluid is evacuated. Through the
sheath Foley’s catheter can also be passed to
CORD HOLDING FORCEPS/RING keep in place. It is used in per cutaneous
FORCEPS cystostomy, draining hydrocele fluid, draining
It has got semicircular tips which when pus from gallbladder, pleural cavity, maxillary
approximated forms as ring. It has got a ratchet antrum, etc.
to have a proper grip. It is used to hold cord
structures during inguinal hernia surgery so that HERNIA DIRECTOR
hernioplasty/herniorrhaphy can be done
effectively. Hernia director is used to protect the bowel in
strangulated/obstructed hernia while releasing
the narrow constricting band. Key’s hernia
director has got grooved gently curved long blade
with ridged stout handle. Childe’s hernia director
has two wings on sides of the blades as a guard
with a handle. Constriction ring is cut using
hernia bistoury.
Fig. 6.118: Cord holding forceps/ring forceps used

to hold cord structures in inguinal hernia surgery.
TROCAR AND CANNULA

Trocar has got stout handle with a sharp pointed
distal end. Trocar passes through the cannula
Fig. 6.120: Key’s and Childe’s hernia directors.
PROCTOSCOPE (KELLY’S)
Indications
• Diagnostic: Piles, fissure in ano, polyps,
stricture, to see internal opening in fistula,
carcinoma or any rectal bleeding.
• Therapeutic: Injection therapy for partial
prolapse or piles, cryotherapy for piles,
banding for piles, polypectomy, biopsy for
carcinoma rectum or anorectum.
Types
• Illuminating with a bulb at the distal part
Fig. 6.119: Trocar and cannula. • Nonilluminating.
Instruments 489
SAINT MARK’S ANAL DILATOR
It is hollow conical instrument with both ends
are closed. Distal end is tapered, smooth and
rounded. It is available in three different sizes.
It is used for anal dilatation in post anorectal
surgeries and in anal stenosis. Xylocaine jelly
is applied to the blunt tip and is gently passed
through the anal canal to achieve dilatation.
Fig. 6.121: Proctoscope. Fig. 6.122: Saint Mark’s anal dilator.
Parts FISTULA BISTOURY

Proctoscope is conical shape, with proximal
It is a long blade with solid knife with a cutting
diameter more than the distal, so as to illuminate
edge. It is used to lay open the fistula in ano
the light at the required site properly. Obturator
along with Brodie’s fistula probe.
is the inner part which allows the easy insertion
of the proctoscope. Usual medium sized
proctoscope is 10 cm in length with proximal
diameter of 3.5 cm and distal diameter of
2.5 cm – tapering. This tapering allows light to
reflect and pass distally. Proximal funnel shaped
flange is 5 cm in diameter.
Positions for Proctoscopy

• Left lateral position (common).
• Right lateral.
• Lithotomy.
• Knee-elbow position.
Technique of Proctoscopy
After doing digital examination, proctoscope with
the obturator is introduced inside, through the
anal canal in the direction towards the umbilicus.
The obturator is removed. Proctoscope is
withdrawn and during the course of withdrawal,
any pathology has to be looked for.
Acute anal fissure is contraindication for
Fig. 6.123: Fistula bistoury.
proctoscopy.
BRODIE’S FISTULA DIRECTOR

It is a long instrument with a winged-flat handle.
Shaft is curved, gradually tapering to form a
pointed tip with a groove along the curvature
longitudinally which allows the knife to pass
to do fistulotomy. It is used in probing and treating
fistula in ano; to release tongue tie as a guide
and protector and in external urethrotomy.
Fig. 6.124: Brodie’s fistula director.
PILE HOLDING FORCEPS

It has got long distal blades ending as a ring.
Each has got fenestra with a groove on its inner
surface. It is used to hold pile mass during Fig. 6.126: Yeoman’s punch biopsy forceps.
haemorrhoidectomy. It differs from sponge
holding forceps which has got serrations on the MOYNIHAN’S GLASS TUBE
inner aspect of the ring. Tongue holding forceps
is also similar but without groove or serrations This glass tube of 20 cm in length with a bevelled
on the inner aspect of the ring. one end and other end connected to a rubber
tube with a two circular ridges to facilitate the
holding of the purse string suture around the
tube. It is used to decompress the proximal bowel
in intestinal, obstruction without contaminating
the peritoneal cavity.
Fig. 6.125: Pile holding forceps has got groove on

the inner aspect of the rings in the distal blades.
YEOMAN’S PUNCH BIOPSY Fig. 6.127: Moynihan’s glass tube to decompress

bowel in intestinal obstruction.
FORCEPS
It has got two short stout jaws on the tip. Upper jaw
DUPUYTREN’S ENTEROTOME
is rectangular, mobile and cutting. Lower jaw is
fixed and is having a cup. Through a handle It has a stout distal blade with longitudinal
(without ratchet) jaws can be closed and opened. serrations. It has got butterfly nut and screw on
Mobile jaw takes punch biopsy from the rectal the proximal end which when tightened causes
lesion whereas fixed jaw accommodates the biopsy crushing effect on the structure between the
tissue in the cup. It is used to take biopsy from rectal blades. It is specifically used in colostomy closure
lesions like carcinoma, ulcers, polyps, etc. extraperitoneally by placing this instrument over
Instruments 491
the spur of the colostomy. It is kept in place for reach and open the inner table. Perforator should
5-7 days and if needed further tightening can be carefully used to avoid injury to deeper
be done using screw. Spur gets necrosed and structures. Later burr is used to widen the hole
colostomy closes gradually on its own or by made by perforator.
placing few sutures in front. Presently colostomy
closure is done intraperitoneally by formally SUTURE MATERIALS
suturing bowel wall either single layer or two
layers. Features of Ideal Suture Material
• Adequate tensile strength.
• Good knot holding property.
• Should be least reactive.
• Easy handling property.
• Should have less memory. Recoiling tendency
of the suture material after removal from the
Fig. 6.128: Dupuytren’s enterotome used for extraperitoneal
closure of the colostomy by crushing the spur.
packet is called as memory of suture material.
Suture material should have poor memory.
More memory causes recoiling, difficulty in
SPIGOT handling and knotting.
It is a glass rod of 10 cm length, with one end • Should be easily available and cost effective.
narrow and blunt. In colostomy, once a loop of
the colon is delivered through the abdominal Classification I
wound it is used to pass through the mesocolon. Absorbable
It stabilises the loop of colon in position and • Catgut (Natural absorbable monofilament suture
prevents it from slipping in to the peritoneal material). It is 99% collagen derived from the
cavity. It is rarely used now. submucosa of jejunum of the sheep or serosa
of beef (Kit means sheep). After washing,
intestine is slit longitudinally into four
strands; muscle and fat are removed using
Fig. 6.129: Spigot used in as colostomy glass rod to
prevent the slipping of the colon into the peritoneal cavity. water spry-sliming. Chemical bath
saponification is also used to remove fat.
Strands are spun together, dried with tension
HUDSON’S BRACE WITH and electronically polished. It is absorbed by
PERFORATOR AND BURR inflammatory reaction and phagocytosis.
Hudson’s brace is used to do burr holes in skull Plain catgut is yellowish white in colour.
bone. Using brace initially perforator is used to Absorption time is 7 days. It is used for
subcutaneous tissue, muscle, circumcision in
children.
Chromic catgut is catgut with chromic acid
salt. Twenty percent chromium salt in water
with 5 parts of glycerine is used to treat the
catgut. It is brown in colour. Its absorption
time is 21 days. It is used in suturing muscle,
fascia, external oblique aponeurosis, ligating
pedicles, etc. Atraumatic sutures are
Fig. 6.130: Hudson’s brace, perforator and burr. manufactured either by swaging or by
entangling the suture material into the grooved • Polyglecaprone 25/Monocryl is monofila-
proximal part of the needle by mechanical ment containing 75% glycolide and 25%
pressure. Wound suture material in a support caprolactone. It has got smooth surface,
card is packed in a foil envelope with isopropyl excellent handling property, good knot
alcohol. It is sterilised by gamma radiation. security and adequate tissue compatibility.
• Polyglactic acid/polyglactin 910/vicryl - • Glycomer/Biosyn monofilament
Synthetic braided multifilament absorbable.
It is synthetic absorbable suture material Uses of Absorbable Suture Materials
– copolymer of glycolide and lactide. It has • In bowel anastomosis like gastrojejunostomy,
got excellent tensile strength, long tensile half resection and anastomosis vicryl (2 zero) is
life, low reactivity, less memory, easy used.
handling and knotting. • In cholecystojejunostomy (CCJ), choledocho-
It gets absorbed in 90 days. Absorption jejunostomy ( CDJ), pancreatico-jejunostomy-
is by hydrolysis. It is violet in colour. Coating vicryl is used.
consists of 50% calcium stearate which acts • In suturing muscle, fascia, peritoneum,
as a lubricant. It is multifilament and braided. subcutaneous tissue, mucosa.
It is very good suture material for bowel • In ligating pedicles, e.g. Ligation of pedicles
anastomosis, suturing muscles, closure of during hysterectomy. 1 –zero chromic catgut
peritoneum. It is sterilised by ethylene oxide. or vicryl are used.
Vicryl plus is vicryl coated with • In circumcision usually 3-zero plain or
antibacterial material (triclosan). Vicryl chromic catgut or vicryl rapid are used.
rapide is low molecular weight vicryl with Absorbable suture materials should not be
rapid absorption of suture material. It is used used in suturing tendon, nerves, vessels (vascular
in circumcision and in subcuticular suturing anastomosis) or in hernia surgery where tissue
• Polyglycolic acid/Dexon/Synthetic polymer approximation under stress is needed.
of glycolic acid is multifilament absorbable
suture material (braided) like vicryl. Usually Nonabsorbable Suture Materials
it is coloured green/natural beige. It is • Silk is natural multifilament braided nonab-
sterilised by two stage ethylene oxide process. sorbable suture material derived from cocoon
It is not affected by infection. Its knot security of silkworm larva. It is black in colour, a
is poor and so at least 5 knots should be coating got from a vegetable dye. It is coated
placed for security. suture material to reduce capillary action.
• Polyglyconate/Maxon is a monofilament Serum proofing of the suture material is also
absorbable copolymer of glycolic acid and done to reduce the capillary attraction. It has
trimethylene carbonate. It has got good knot got less memory; good knot holding property;
holding/security; suppleness and flexibility. easy handling ability.
It is used in soft tissues and skin. It can not • Cotton is twisted multifilament natural non-
be used in cardiac/vascular/neural/ absorbable suture material. It is white in colour.
opththalmic surgeries. It can be colourless • Linen is derived from bark of cotton tree
or green coloured. (natural nonabsorbable twisted multifilament
• Polydioxanone suture material/PDS is suture material). It is made from flax and
synthetic monofilament absorbable suture cellulose in nature. It has got excellent
material. It is cream/blue/violet/in colour knotting property and is commonly used as
or colourless with properties like vicryl. It ligatures.
is costly but better suture material than vicryl. • Polyamide is monofilament synthetic
It is relatively inert. non absorbable polymer. Nylon (New York
Instruments 493
and London) is a polyamide. Multiple pre use, may cause injury to surgeons but they
cut nylons are available for skin suturing/ are very high tensile strength and low
ligatures. It has got less tissue reaction, easy reactivity. Kinking is another problem.
handling ability, inertness, adequate elasticity
Uses of nonabsorbable suture materials
and can be used in presence of infection.
• In herniorrhaphy for repair.
Ethilon/surgidek/dermalon/sutupak pre cut
sutures are different polyamides. Memory is • For closure of abdomen after laparotomy.
high like that of polypropylene and so causes • For vascular anastomosis (6—zero ), nerve
problem. Polyethylene (Ethylene) is synthetic suturing, tendon suturing.
monofilament nonabsorbable suture material. • For tension suturing in the abdomen.
It is black in colour. • For suturing the skin.
• Polyester is synthetic multifilament braided
polymer— non absorbable suture material. Classification II
Polyester has got high tensile strength and a.Natural
good knot holding property. But it is stiff • Catgut.
with difficulty in handling and may cause • Silk.
sawing effect to tissues. Dacron is made up • Cotton.
of untreated polymers. It is white in colour. • Linen.
Ethibond is polyester coated with poly- • Collagen sutures are derived from collagen
butylate— polytetramethylene adipate. It is fibrils of flexor tendon sheaths/tendo-Achilles
green in colour. Polydek/tevdek are coated of beef. It can be plain or chromic.
with polytetrafluoroethylene (PTFE). They are • Homologous sutures derived from the
green in colour. Black sutulene is impregnated patient’s fascia like strips of fascia lata used
with wax. Silicon treated ticron is white/ for hernioplasty or blepharoplasty.
blue in colour. • Cargile membrane is derived from the
• Polypropylene (prolene) is synthetic mono- submucosa of caecum of ox. It is used to cover
filament suture material. It is blue in colour. peritoneum/pleura and to prevent adhesions.
It has got high memory. (Prolene mesh used
It is not used now.
for hernioplasty is white in colour). It is inert,
• Kangaroo tail tendon has got high tensile
flexible, strong and least reactive. It can be
strength— not used now.
re-sterilised by autoclave once or twice.
• Polybutester— Novafil is monofilament, blue b. Synthetic
coloured, synthetic suture material which has • Vicryl, dexon, PDS, maxon.
got adequate flexibility, suppleness and • Polypropylene, polyethylene, polyester,
strength. polyamide.
• Stainless steel metallic non toxic suture/wire
(steel, tantalum, silver) are useful in approxi- Classification III
mating bones and tough structures, in a. Braided: Polyester, polyamide, vicryl, dexon,
orthopaedic and thoracic surgeries (sternotomy and silk.
or thoracotomy), in reconstructive surgeries, b. Twisted: Cotton, linen.
surgeries of skull base or head and neck, sinus
surgeries, in dental surgeries. Monofilament Classification IV
is called as steel suture/metallic suture. a. Monofilament: Polypropylene, polyethylene,
Multifilament is called as metallic/steel wire PDS, catgut, steel.
which can be twisted or braided. Metallic b. Multifilament: Polyester, polyamide, vicryl,
sutures/wires are difficult to handle and to dexon, silk, cotton.
Classification V 5. Horizontal tension suturing

a. Coated. 6. Vertical tension suturing
b. Uncoated.
Numbering of suture material
2—Thick. For pedicle ligation.
1—
1—zero.
2—zero. For bowel suturing.
3—zero.
4—zero.
5—zero. For vascular anastomosis.
6—zero.
7—zero.
8—zero.
9—zero. For ophthalmic surgery. Requires
microscopy. Fig. 6.132: Types of suturing.
Types of knots
1. Reef knot.
2. Granny knot.
3. Surgeon’s knot.
Fig. 6.131: Photo-showing different types of

suture materials (with pack).
• Length of the suture material is written on

the packs. It can be 45 cm; 76 cm; 90 cm or
152 cm so on.
• Company code for a particular suture
material is important to identify it in detail.
• Lot number, batch number, needle descrip- Fig. 6.133: Types of knots.
tion, needle curvature, needle size are
mentioned on the packs. MITCHEL’S CLIP DEVICE
• Name of manufacturing company, license
• Mitchel’s metal clip: It has got two sharp points
number, manufacture date and expiry dates
on their teeth to grip the edges of the skin
are mentioned on the pack.
wound when applied.
• Mitchel’s clip applicator: It has got a groove
Types of Suturing
on the inner surface of each blade with a
1. Continuous suturing.
tooth on the ends of the blades to apply the
2. Interrupted simple suturing.
clips to the edges of skin wound.
3. Interrupted mattress suturing.
• Mitchel’s clip extractor: It has got short distal
4. Subcuticular suturing.
blades, one blade has a hood which comes
Instruments 495
Types
Bectin Dickenson syringe (BD syringe): It is a glass
syringe with a glass piston and barrel having
a nozzle at the end to fit in to the BD needle.
Proximal end of the barrel has got a rim with
one side being flat that prevents from rolling
and breakage. It is sterilised by boiling.
Disposable plastic BD syringes are commonly
used now which is sterilised by gamma radiation.
BD injection syringes are available as 2 ml,
3 ml, 5 ml, 10 ml, 20 ml, 50 ml and 100 ml capacity.
1 ml tuberculin/insulin syringes, Luer-lock BD
syringes (needle can be locked near the nozzle
to prevent slipping of the needle) are other
modifications.
Record syringes: It is like BD syringe with a metallic
screw at the proximal end of the barrel which
can fix the barrel of the syringe so that piston
will not come out.
Gabriel syringe: It is used for injection
sclerotherapy for internal piles using 5% phenol
in almond/olive oil (almond/vegetable oil acts
as a vehicle which holds phenol for long period
of action). It is a stainless steel syringe with two
metallic finger brims near the proximal end. One
more metallic finger brim is present on the
proximal end of the piston to place thumb while
injecting. Special needle which may be straight
Fig. 6.134: Mitchel’s clip devices with clip, applicator, or curved and sharply pointed is used for
extractor and clip magazine. injection of haemorrhoids. Patient is placed in
left lateral position. Using proctoscope pedicle/
in front of the clip while another blade is upper part of the piles is identified. Sclerosant
flat which comes under the clip, with pressure is injected in to the submucosal plane only which
on the finger rings clip is extracted. It does is confirmed by pale bleb with thin vessels over
not have ratchet. it. If it turns as white patch it means it is more
• Mitchel’s clip magazine: Here clips are superficial and needle is withdrawn and
arranged in a row and other end with teeth replaced in submucosal plane. 4 ml at each site
is used to hold the skin margins together like with two piles in one sitting is done and further
a toothed forceps. injections are given if needed with a 3 weeks
gap until complete sclerosis and obliteration of
SYRINGES piles occurs.
It is basic instrument in medical practice used Indications for sclerotherapy in piles
to give injections through any route, aspirate • 1st and early 2nd degree piles.
fluids, to give wash over surface or deeper places. • Piles in pregnancy and old individuals.
Contraindications for sclerotherapy enamel. It is used in oral cavity biopsies, dental

• Infection at the site. extraction, tonsillectomy, excisions of small oral
• Secondary piles. cavity lesions.
• Association of fissure in ano or fistula in ano.
ASEPTO SYRINGE/DAKIN’S
SYRINGE
It is made up of glass with broad flanged proximal
end to which a rubber bulb can be fitted in to
it. It has got a tapered tip through which tubes/
catheters can be fit to give wash, to suck the
contents. It is used to give bladder wash in
infection, in postprostatectomy period, to give
wash in different cavities and in depth, to instill
Fig. 6.137: Doyen’s mouth gag.
methylene blue in to the bladder to find out any
fistula, to remove clots from prostate or other
cavities during surgery. JENING’S MOUTH GAG
It is a self-retaining mouth gag with a thin rim
and ratchet. Blades fit in to the alveolar margins
not on the teeth. So it is useful in oedentulous
patients. It has got a gap to pass endotracheal
tube.
Fig. 6.135: Asepto syringe used for bladder wash.
TOOMY SYRINGE
It is used to give bladder wash through cystoscope
while doing transurethral resection of prostate
(TURP). It has got a metallic nozzle which fits
well in to the cystoscopic sheath. It creates a
strong suction force to suck the irrigated fluid. Fig. 6.138: Jening’s mouth gag.
TONGUE DEPRESSOR
It is a flat steel atraumatic plate with a 90º angle
at the centre. Ends are rounded with smooth
edge. It is used to inspect posterior third of tongue,
Fig. 6.136: Toomy syringe. oral cavity, tonsils, to take biopsy, etc. Anterior
two thirds of the tongue is depressed gently with
tongue depressor (Refer page 497).
DOYEN’S MOUTH GAG
It has got flat, broad, strong, curved distal blades AIRWAY
which has got serrations on the outer aspect so
as to have proper grip over teeth. Blades are It is curved metal/plastic hollow instrument
covered with rubber tubes to prevent injury to with broad proximal end and curved tapered
Instruments 497
Fig. 6.141: Humby’s knife to harvest skin graft.
between the rods in to the flat leave which has

got three knobs which fits exactly in to the
openings of the blade. Front leaf has got slots
which when pushed gets fixed over the blade.
Using firm constant pressure with sawing action
split skin is harvested from the thigh. Punctuate
bleeding over the donor area confirms the proper
skin harvesting. Donor graft is placed over the
sterile wooden board. Multiple small window
cuts are made to prevent formation of seroma.
Fig. 6.139: Tongue depressor.
Skin is placed over the recipient bed and fixed
using polypropylene sutures or skin staples.
Dressing is placed and part is immobilized. Graft
is inspected on 5th day for take up. Donor area
is inspected after 10 days and kept open without
dressing. Stages of graft intake are—stage of
plasmatic imbibition, stage of revascularisation
and stage of circulation.
Other knives used for harvesting skin graft
are
Fig. 6.140: Airway.
• Braithwaite’s skin grafting knife: Disposable
blade.
distal end. It helps breathing to patient during • Watson’s skin grafting knife: Disposable
postoperative period, patient in intensive care. blade.
It also promotes the suction of secretions through • Thiersch’s skin grafting knife: It has got knife
the hollow. It prevents tongue to fall back in with permanent blade.
unconscious patient, patient with head injury • Electrical dermatome.
and during induction of general anaesthesia. In
a patient with epilepsy it is used to prevent MYER’S VEIN STRIPPER
tongue fall during convulsion period. It is used strip off varicose vein usually long
saphenous vein. It is passed from above just below
HUMBY’S KNIFE the sapheno-femoral junction. Usually stripping
is done up to the middle of the leg. Saphenous
It is used to take split skin graft from donor site.
neuralgia is a rare complication (Refer page 498).
Usually it is taken from thigh. Often it can also
be taken from arm, leg, and forearm. Humby’s
knife has got stout handle, two flat leaves in
BONE CUTTING FORCEPS
blade, one of which is fixed and other can be It has got short blades with sharp firm cutting
rotated. Disposable skin grafting blade is passed edges to cut bones; with a stout handle
BONE NIBBLER
It has got sharp edges in the tip with blades
being concave. It may be having single action/
double action joint. It is used to nibble the bone
in pieces like in craniectomy, rib resection,
amputations of small bones, etc.
Fig. 6.142: Myer’s vein stripper.
Fig. 6.143: Bone cutting forceps. Fig. 6.145: Bone nibbling forceps/bone nibbler.
SEQUESTRECTOMY FORCEPS/
with ridges. It gives optimum mechanical force SEQUESTRUM HOLDING FORCEPS
to cut bones/bone spurs. Some instruments are
supported with leverage system. It has a stout blade with thick transverse
serrations with a groove in the middle without
a ratchet. It is used to remove sequestrum in
BONE ELEVATOR/BONE LEVER osteomyelitis. Sequestrum should be formed
It has got curved blade with blunt edge and before removal. X-ray should show clear
serrations on concave surface. Proximal long shaft radiolucency around dense dead bone—a sign
has got ring for grip. Some bone lever has got of complete separation of the sequestrum.
proximal knife like handle instead of ring. It is
used in manipulating the fracture segments in
open reduction and so to isolate fracture ends
from surrounding soft tissues. It is also used
to elevate the fracture segments/bone from the
depth for placement of nails/fixation. Fig. 6.146: Sequestrectomy forceps/sequestrum
holding forceps.
FERGUSSON’S BONE HOLDING

FORCEPS/LION FORCEPS
It has got curved blade with stout blunt teeth,
Fig. 6.144: Bone elevator/bone lever. looks like jaw of a lion. Bone is held in the gap
Instruments 499
Fig. 6.147: Fergusson’s bone holding forceps/lion forceps.
between the jaws. It is used to hold bones in

open reduction of fractures, maxilla in maxillec-
tomy, and mandible in mandibular fixation.
CHISEL
Chisel has got proximal rounded flat head which
receives the blows of a mallet. Handle is stout,
10 cm in llength. Shaft is of equal size of handle
which ends as one side beveled only (abrupt
bevelling). It is used to chip the bone using mallet
blow. It is also used in bone grafting,
sequestrectomy, etc.
Fig. 6.149: Osteotome.
to find out the length of the osteotome inside

the wound. It is used for all ostetomies in different
congenital and acquired conditions.
MALLET
Mallet is a hammer made up of stainless steel
or lead. It is lighter than conventional hammer.
It is used to give repeated blows on the flat surface
over the head of chisel or osteotome. Blow should
be flat without rebound.
Fig. 6.148: Chisel. Fig. 6.150: Mallet.
OSTEOTOME GIGLI’S SAW

It is similar to chisel but both sides it is bevelled It is 14 inches long with four flexible metal wires
and beveling is gradual. Shaft has got the marks braided together with rough sharp surface.
It has got loops on either ends to hook the handles

on it which is essential while cutting the bone.
It is used to cut the bones like mandible, maxilla,
amputation of femur/tibia, skull bones between
the trephine holes. It is originally used to cut
Fig. 6.151: Gigli’s saw/Gigli’s wire saw. the pubic bone in narrow pelvis.
PREOPERATIVE PREPARATIONS
Operations may be elective wherein patient is 2. Any previous diseases like hypertension,
properly prepared with all investigations and diabetes mellitus, epilepsy, bronchial asthma
precautions or emergency wherein immediate tuberculosis, hepatitis, cardiac diseases.
surgery is required to save the life of the patient 3. Drug therapy: Steroids, antihypertensives,
like perforation of bowel, haemorrhage, and sedatives, antibiotics, antiepileptics.
trauma.
Patient is admitted 2-3 days prior to date of Examination
the elective major surgery. Patient is evaluated General: Posture, teeth, mouth opening, dilated
with essential investigations like haemogram, veins, neck movements, tremor, air-way.
urine analysis, ECG, blood electrolytes, chest X- Anaemia, oedema, jaundice, cyanosis.
ray, echocardiography, physician and
Respiratory system: To look for asthma, tuber-
cardiologist’s opinion and treatment. If patient
culosis, emphysema, COPD.
is anaemic prior to surgery, blood transfusion
is required. Asthma, respiratory diseases, Air-way: Mouth opening, Malampatti scoring,
diabetes has to be managed properly. Electrolyte tyromental distance, temperomandibular joint
supplement prior to surgery is required. assessment.
Prior to shifting the patient to operation
Cardiovascular system: Hypertension, ischaemic
theatre following rules should be followed:
heart disease, arrhythmias, cardiac failure,
• Correct identification of the patient.
valvular diseases.
• Consent for the surgery should be taken.
• Preparation of the patient according to the Spine: Curvature, intervertebral space, skin over
requirement. the back for any infection.
• Nothing should be given orally 6-8 hours
Other systems: Abdomen, skeletal system.
before surgery.
• Bladder should be empty before sending
Preoperative Investigations
patient to the theatre. If required the patient
Haematocrit, blood sugar, blood urea, serum
is catheterised.
creatinine, electrolytes, chest-X-ray, ECG,
• Enema, as by instruction should be given.
blood grouping, blood-gas analysis, cardiac
• Ornaments, dentures, nail polish, hearing
assessment.
aids, contact lenses should be removed before
Prothrombin time, bleeding time, clotting time,
shifting the patient.
liver function tests, pulmonary function tests,
• Head cover, feet covers, theatre dress to the
arterial blood gas assessment-in specific surgical
patient is must.
diseases.
• Premedication, as per instruction should be
given.
• Ward nurse should accompany the patient Preoperative Care and Treatment
to theatre and should hand over the patient • Control of respiratory and cardiac diseases
to theatre nurse. special care with cardiologists, chest
therapists, respiratory physiotherapy. To stop
smoking (15 days prior to surgery);
PREOPERATIVE ASSESSMENT
prophylactic antibiotics; bronchodilators;
History steroid inhalers; possible need of ventilator
1. Chronic cough, smoking, alcohol, drug intake, after surgery.
drug allergy.
Surgical Principles and Procedures 503
• Improvement of Hb% status, if anaemia is calcium gluconate) and alkalosis is
present. essential in these patients. Gastric lavage
• Preoperative antibiotics are given as per is given for 5 days prior to surgery by
instructions of the surgeon. passing stomach (Ewald’s) tube using
• Blood should be kept ready for major normal saline to remove residual food,
surgeries. to decrease mucosal oedema, to maintain
• Correction of diabetes mellitus, malnutrition gastric tone.
• Purgatives/enema. • In obstructive jaundice: Specific problems
• Skin preparation by shaving the area, or are altered prothrombin time (bleeding
depilation using creams. Patient should take tendency), hyopoalbuminaemia and
proper bath prior to surgery. malnutrition, sepsis, anaemia, dehydra-
• Patient should be kept nil per orally for tion and diminished carbohydrate reserve.
8 hours. Hepatorenal syndrome is specific problem
• Special preparations for gastric/colonic or postoperatively—due to endotoxaemia,
biliary surgeries should be done. acute tubular necrosis due to toxins,
• Colonic preparation: Low residue diet for sludging of bile salts in the renal tubules,
72 hours; bowel wash with saline; gut hypovolaemia. Management is by – fresh
irrigation using oral polyethylene glycol frozen plasma; mannitol infusion;
with electrolytes taken in two litres of water antibiotics; human albumin infusion;
in 2 hours to clear the entire bowel. It injection vitamin K 10 mg for 5 days;
acts also by osmotic hygroscopic action. intravenous dextrose to improve the
It is also achieved by oral intake of carbohydrate reserve.
mannitol for 2-3 days. Bowel antiseptics
Note: Informed consent is absolute need.
like neomycin 1 gram three times/day
prior to surgery. Total gut irrigation by
Premedication
passing nasogastric tube through which
It is given one hour before surgery:
infusion of normal saline was done. It • For sedation and relief of anxiety: Pethidine 50
is infused (8 litres of saline) until clear mg/morphine 10 mg/diazepam 10 mg/
saline is passed from anum. ( On-table Midazolam 1-2.5 mg.
colonic lavage by passing a tube through • To suppress vagal activity: Atropine 0.6 mg
performed appendicectomy opening IM.
(purse string suture is placed) and another • To reduce vomiting: Promethazine (phenergan)
opening in distal colon just proximal to 12.5 mg.
obstruction and saline is irrigated from
first to second tube continuously to ASA (American Association of Anesthesio-
achieve proper cleaning of the colon). logists) grading of the patient for surgery
• Gastric preparation in gastric outlet obstruc- 1. Normal individual
tion: Patient is having hypokalaemia, 2. Mild— moderate systemic disease—
hyponatraemia, hypomagnesaemia, Diabetes and hypertension under control
hypochloraemia, hypocalcaemia with 3. Severe systemic disease—uncontrolled
metabolic alkalosis and paradoxical diabetes and hypertension
aciduria. Correction of dehydration, 4. Incpacitating systemic disease
electrolytes, anaemia (blood), hypopro- 5. Moribund status
teinaemia (amino acids, total parenteral Class E—Emergency surgery
nutrition), hypocalcaemia (intravenous
OPERATION THEATRE thermophillus spores are used to assess the

completeness of the sterilisation in mass scale.
Asepsis Double autoclaving is done for instruments
Asepsis means organisms are prevented to access of orthopaedic or ophthalmic surgeries.
the patient or individual. Modern rapid autoclaves can sterilise in
3 minutes with 143° temperature or in 10
Sterilisation minutes with 121° temperature.
It is freeing an article from pathogens by removing
or killing all bacteria, spores, fungi and viruses.
Disinfection
It is killing of all bacteria, fungi and viruses but
not spores.
Antisepsis
Antisepsis is inhibition of growth of micro-
organisms.
DIFFERENT METHODS OF
DISINFECTION
Physical Agents Fig. 7.1: Autoclave machine for sterilisation.
• Burning or incineration is used to disinfect
contaminated articles like dressings.
• Hot-air oven: Here temperature used is 160 • Radiation:
to 180° for one hour. – Ionising type of radiation: Atomic gamma
• Boiling: It kills bacteria but not spores and radiation is used for commercial purpose
viruses. Temperature is between 90 to 99°. to sterilise suture materials, disposable
It is used to disinfect syringes, utensils. It materials in packets. It is viable, safe and
is not useful for gloves, rubber materials. cheaper. All disposable materials like
• Autoclave: It is steam under pressure. gloves, tubes are sterilised by this method.
Temperature attained is between 120 and – Nonionizing radiation, either infra-red
135°. It is sterilised for 20 minutes with radiation or ultraviolet radiation is used
15 pounds/sq inch (2 kg per square cm) to reduce the bacteria in air, water. Bacteria
pressure. It kills all organisms including and virus are vulnerable to ultraviolet rays
spores. Completeness of sterilisation is below 3000Å. Exposure to eyes and skin
confirmed by using specific gelatin protein can cause burn injury.
which precipitates only in steam under
pressure for 20 minutes. Green coloured strip Chemical Agents
turns black if autoclave is complete (The Bowie- • Phenol: It is used as standard to compare
Dick test) (signaloc). Surgical gloves, linen, the efficacy of other agents.
cotton, paper, bottles, plastics, dressings, • Cresol is more powerful and nontoxic. 5%
surgical instruments are sterilised by this solution is used.
method. Sharp and plastic instruments cannot • Lysol is emulsified cresol with soap. 2%
be sterilised by this method. Bacillus solution is effective.
• Chlorhexidine (hibitane) is useful antiseptic. Eusol bath is dipping the ulcer bearing
• Hexachlorophane: It is not used in infants part in dilute eusol solution for 30 minutes
and children because it can get absorbed 2-3 times a day.
through intact skin in this age group causing – Iodine.
severe neurotoxicity. – Iodophors: These are antiseptics and
• Dettol (chloroxylenol) 5% solution is used. also sporicidals. They are non-irritant
• Cetrimide is cationic surfactant (cetavlon) 2% and do not stain skin. Povidone-iodine is
solution is used. a good example, which is commonly
• Savlon is combination of cetrimide and used.
hibitane. It is very commonly used antiseptic • Alcohols: Ethyl or isopropyl alcohols are used.
in operation theatres and wards. • Formaldehyde: It is useful to disinfect the
• Halogens: rooms like operation theatre. It is effective
– Bleaching powder. at a high temperature and humidity of
– Sodium hypochlorite. 80-90%. It is commonly used to fumigate the
– EUSOL: Edinburg University solution room. 500 ml of formalin with one litre of
contains sodium hypochlorite, boric acid water is boiled to get formaldehyde vapour.
and calcium hydroxide. Adding potassium permanganate to the same
Materials Method of sterilisation
All theatre appliances Autoclave
Sharp instruments (scissors, needles, blades) Glutaraldehyde 2%, Lysol
plastic materials
Endoscopes Glutaraldehyde
Rubber equipments Glutaraldehyde
Syringes Autoclave, hot air oven, gamma radiation
Heart-lung machine Ethylene oxide
Disposable articles Gamma radiation
Operation theatre and rooms Ideally by UV radiation or by formaldehyde
Sera and biological materials Filtration
Lab glassware Hot-air oven
Ward, sick room, furniture Formaldehyde, iodophor spray, glutaraldehyde
Clothes, bed sheets especially for burns patients Autoclaving
Soiled dressings, materials, animal carcasses Incineration, Lysol, iodophors
Excreta Lysol, iodophors
Cleaning of skin before surgery Iodophors 2%, savlon, spirit
For cleaning infected wounds Iodophors, acriflavine, savlon, H2O2
To remove slough from the wounds EUSOL, H2O2
Before injection Spirit is used to clean the skin
Cleaning the ward Phenol, cresol, lysol
Hand wash Chloroxylenol, savlon, spirit, iodophors
Bladder wash 0.1% potassium permanganate solution (Condy’s
-lotion), solution of acetic acid and silver nitrate
Water Chlorination, potassium permanganate
Fruits, vegetables Potassium permanganate
solution can create formaldehde vapour. • Pathology room with facilities for frozen
Room is kept closed for 12 hours. section and relaxing room for pathologists.
• Glutaraldehyde (cidex 2% ): It is used to
sterilise sharp instruments. Instruments Principles of an Operation Theatre
should be dipped for 10 hours to achieve • An airconditioning is a must to have a filtered
complete sterilisation. It is potent bactericide, continuous flow of air.
sporicide, fungicide and viricide. • Doors and windows should be kept closed
• Hydrogen peroxide (H2O2) : It is used as topical as much as possible.
oxygen therapy. Because of its effervescence • Ward nurse should handover the patient to
and release of nascent oxygen it removes the theatre nurse with all details, case sheets,
tissue debris. It is used to clean wounds, tag, side of surgery, blood to be transfused,
cavities, ulcers and as mouth wash, as ear premedication details. While shifting the
drops to clear ear wax. patient, ward nurse must take care of the air
• Acriflavine and proflavine are orange-red way and IV line of the patient, must keep
coloured dyes used as antiseptics. It is effective tongue depressor, swabs, air-way in the trolley.
against gram-positive and few gram-negative • Patient should be shifted to theatre always
organisms. It retains its activity in pus and in a trolley. Patient should remove all
body fluids. jewelleries and wear theatre gowns, cap, feet
covers.
OPERATION THEATRE ROOM • Patient must be transferred from ward trolley
to theatre trolley, which should have modern
Operation theatre is like a temple to all surgeons. accessories like oxygen, side guards, drip
stand, oxygen masks, pulse oximetre placing
Theatre Plan area, tiltable couch.
• Every operation theatre should have a waiting • Patient’s trolley and ward blankets should
area, entrance, surgeon’s changing and not be taken inside the operation theatre.
relaxing room, changing room and relaxing • Initially patient should be kept in pre-
room for nurses, autoclave and sterilisation operative room and later should be shifted
room, OT scrub area, all sets of instruments, to theatre. Anesthetist and surgeon and also
instruments for anaesthesia, adequate number theatre nurse should accompany the patient.
of racks, toilets, air – conditioned ventilator, • Theatre nurse should confirm the consent
OT tables, trolleys to shift patients, OT form, case sheets, site and side of the surgery,
laundry, good light, C-ARM image intensifier. etc.
• Operation theatre should have an adjoining • Separate theatre shoes should be worn by
postoperative ward. This ward should be surgeons, anaesthetists, theatre nurses and
close to the OT, easily accessible (as surgeon assistants.
and anaesthetist should able to rush to the • Unnecessary movements, talking loudly,
postoperative ward in short period without laughing, commenting should be avoided as
changing their OT dress). patient may be awake especially when spinal
• In many theatres light music are played to anaesthesia is given.
calm the patient just before inducing. • All persons entering the theatre should wear
• Easy to clean floor, roof and walls must be theatre dress (pant and shirt), cap, mask,
present. footwear or shoes (shoes are ideal). Material
• Instrument cleaning, washing, and arranging for dress should be smooth, non-woven fabric,
unit is present which keeps the instruments which is easily boilable. Cap should cover
ready, packed and autoclaved as directed. and conceal hair fully.
• Clothes, dresses should be washed, cleaned, • Theatre nurse and OT assistant should
ironed and kept ready every day. Fresh, clean accompany the patient while handing over
cotton blanket should be used to the patient to postoperative nurse from OT.
in theatre. • Patient should be shifted outside the OT once
• Ideally all mobile phones should be switched anaesthetist confirms the fitness for shift. It
off inside the theatre. is the anaesthetist who decides when to shift,
• Any public person or relative of the patient how to shift and how long the patient should
should not be allowed inside the theatre. be in postoperative ward.
Selected people may be allowed only by prior
permission from medical director of the Modes of infection and sepsis in OT
hospital and from operating surgeon. • Patient’s skin
• One senior nurse is made in charge of all • Surgeon, nurses and OT technicians, by
activities in the theatre like shifting patients, unclean hands, nostrils, throat, skin
arranging theatre tables, autoclave and other • Contamination of OT floor and wall
sterilisation methods, cleaning the instru- • Improper sterilisation
ments, packing the instruments for autoclave. • Poor handling of instruments
She decides the duties of her junior nurses • Poor packing and poor storage of instru-
and makes a list of nurses for that day surgical ments
scrubbing. Operation theatre assistant and • Theatre clothes, footwear and shoes
technicians are also under her supervision • Not disinfecting the OT properly and
and should follow her instructions strictly. adequately after using the OT for infected
She should be answerable for any default cases
and problems in the theatre occurred or
created by her fellow nurses and theatre boys. Scrubbing and Wearing OT Gown
• Scrub nurse is the one, who washes to assist and Glove
the surgeon, arranges the instrument table • Both hands, forearms up to elbow joints
and gives instruments to surgeon during should be rinsed with running water and
procedure. She should be well aware of the soap. Any ring, jewellery, wristwatch should
steps of surgery, and instruments required. be removed prior to the scrub.
She should be alert, quick, and understan- • Using brush and soap, finger nails, hands
dable. on both sides are cleaned. Then forearm is
• One nurse in each theatre works as a brushed and washed. Procedure is repeated
circulating nurse who provides additional three times (presently whether need to brush the
instruments required during surgical hands are controversial).
procedure. She also takes care of the counting • After thorough rinsing the hands by running
of the surgical mops and swabs used. Used water, hands are washed with antiseptic
mops or swabs should be kept hanging in solution and then with warm water.
mop rack or swab rack which should be • Once fully scrubbed, she/he should not touch
visible to the operating team. Name, procedure with hands any objects or his/her own face
and number of mops collected and used or parts of body. She should keep her hands
should be written on a blackboard. Scrub and fingers tucked with each other with
nurse and circulating nurse are fully in forearm and hands outstretched.
charge and responsible for swab counts. She • Using a sterile towel, forearm and hands are
also will be legally questioned and penalised along dried up. Both hands are inserted into the
with the surgeon if there is negligence in mop armholes of the sterile gown. The gown is
counts. not touched or pulled but both arms kept
outstretched. Circulating nurse will pull the

back tapes of the gown and ties it over the
back.
• A back wrap gown, has got two tapes to tie
on the front aspect.After wearing gloves, one
tape is given to the scrubbed scrub nurse/
surgeon who has already with gown and
gloves. She/he will encircle the gown round
and bring it in front and give to the surgeon
to tie it with other tape.
Theatre technique of wearing gloves

A. After using glove powder, with the bare
Fig. 7.2: Correct method of wearing gloves.
hand inner aspect of the cuff of the glove
is held. It is pulled over the hand. It should
not be wrapped over the wrist cuff of the bundles of five, ten and so on. So counting
gown at this stage is easier.
B. Fingers of this gloved hand should hold • Taking care of swab rack and collecting the
the cuff of the other glove from outside used mops from scrub nurse and hanging
and it is slided over the fingers and hand the mops in groups of five. Mops presently
C. Now cuff of the glove is pulled proximally used in many theatres are having radio-
over the wrist of the gown using other opaque threads so to identify when needed
gloved fingers by taking X-ray or through a C-ARM.
• Collection of specimens, pus, fluids and
Circulating Nurse labelling with name, unit, number. It may
One who supplies all additional instruments be for culture, cytology or for histopathology.
and mops. She also keeps the mop counts. • Keeping account of the disposable
instruments and suture materials, drugs and
Duties of Circulating Nurse fluids used in each procedure.
• Keeping counts of instruments, mops given • Noting the duration of the surgery, quantity
to scrub nurse. Instruments are kept in of blood transfused, type of anesthesia
Fig. 7.3: Method of wearing glove.

Prevention of infection
• Cleaning of the patient’s skin where incision
is placed by povidone iodine, cetrimide,
spirit
• Isolation of surgical area by proper draping
with green towels
• Transparent sheeting of the skin through
which skin incision is placed
• Adhesive films to the skin
• Use of on table parenteral antibiotic in major
cases
• Always clean cases are done first and then
infected cases
• Proper sterilisation
• Double autoclaving for orthopaedic and
ophthalmology cases Fig. 7.4: OT mop rack to keep used mops during
surgery.
D B
Figs 7.5A to D: Different materials required to give anaesthesia – air way; Boyle’s apparatus; direct
laryngoscope; Laryngeal Mask Airway – a special device tube to give anaesthesia.
• Documenting in record-book or theatre • Main danger exists in some anaesthetic

computer. agents, which may cause life-threatening
Theatre nurse should not discuss or reveal explosions. It may cause burns, loss of vision,
about the procedure or technique done outside hearing loss, damage to OT, may also
theatre with anybody. It is surgeon’s duty to sometimes cause death. Ether is one, which
explain about the patient’s condition, procedure can be explosive.
done and problems. She will never comment • An OT has got high power electric supply
about anything in theatre. for its basic needs like aircondition, lights,
machines, cautery, suction apparatus, other
Septic Operation Theatre modern instruments like laparoscope,
• All infected cases like abscess drainage, C- ARM, etc. Because of the presence of too
amputation for gangrene, slough excision, many electric circuits and possibility of
dressing of large ulcers should be done in dangers of static electricity, theatre staff should
a separate OT. Otherwise clean surgeries may take enough precautions to prevent any
get infected. It is especially important when electric injury to patients and theatre
orthopaedic surgeries are going on. personnel.
• Entrance to septic OT must be separate from • Good earthing is essential.
that of main OT. • It is ideal to use theatre dresses made of cotton
• Staffs working in septic OT should not enter
(cotton clothes) to patient, surgeon and
main OT.
nurses. Drapes and other materials should
• Instruments should be kept separate for septic
also be made of cotton.
OT.
• Rubber should be used wherever required
• Drapes, towels, mops should be placed in
like in wheel of trolley, Boyle’s apparatus,
a plastic bag after use and sent to laundry
mattresses, floor, wall of the theatre.
immediately. It should be labelled as infected.
• Circulating nurse should wear gloves while • When cautery is used, electric shock is
working in a septic OT. common and so enough precautions has to
• Disinfection of shoes is essential once it is be taken. Often cautery burns can occur to
used in septic OT. the patient.
• Daily disinfection of OT is essential. • An electrician should be immediately
• Swab culture of the OT materials at regular available whenever there is problem like
intervals is needed. power failure, short circuit, default in any
• Separate Boyle’s apparatus is used in septic of the electrical instruments.
OT. Beware of possible anaesthetic explosions and
• Dress is changed when one comes out of electrical injuries in OT.
septic OT and enters the main OT.
Most important people in OT
Precautions in an Operation Theatre • First and foremost is the patient
• In the absence of proper safety measures and • Next are surgeon and anesthetist
precautions, OT is a place where one is prone • Essential are theatre nurses and theatre
for accidental trauma and injuries, which may assistant
be danger to patient as well as theatre • Surgery is a team work. All are important
personnel.
SURGICAL PROCEDURES
URINARY CATHETERISATION Foley’s catheter is commonly used. Urosac

bag, gloves, sterile towel, 2% xylocaine gelly and
Catheters used—simple non-self retaining red distilled water are needed.
rubber catheter, Foley’s self retaining catheter,
Gibbon’s catheter, metal catheter. Procedure
• Explain the patient about the procedure. Sterile
Indications gloves are worn after hand wash. Patient will
• Retention of urine due to BPH, stricture be in supine position with legs apart. Genitalia
urethra, trauma (with all care and precaution are cleaned with povidone iodine solution.
gently one trial is done). Draping is done using sterile towel.
• In major surgery postoperative period. • Prepuce is retracted and glans is cleaned
• In acute conditions and in shock patients again. 20 ml of 2% xylocaine jelly is taken
to measure the hourly urine output. in a syringe and pushed into the urethra
through the external meatus.
Causes of Retention of Urine • After 5 minutes, penis is held vertically (so
• Bladder outlet obstruction. that urethra gets straightened to make easier
• BPH, carcinoma prostate. passage of the catheter) and Foley’s catheter
• Prostatitis, prostatic abscess. tip is lubricated with jelly and is gently passed
• Bladder carcinoma close to bladder neck. into the urinary bladder. Urine flow through
• Bladder stone obstructing bladder neck. the catheter confirms that it is inside the
• Hypertrophy of bladder neck muscle. bladder.
• Stricture at bladder neck. • It is advanced further more and balloon near
• Causes at urethral level. the tip is inflated using distilled water. Air
• Urethral stricture- may be due to trauma or is not used for this purpose. Normal saline
inflammatory (gonococcal/nonspecific) or may get crystallised and so ideal is distilled
neoplastic or after catheterisation/cystoscopy water (Note: in endotracheal tube only air
or after surgery (TURP/urethral surgery/ is used inflate the balloon. Water should never
perineal urethrostomy). be used as if balloon bursts aspiration can
• Urethral stone. occur). Quantity inflated should be noted in
the case sheet. Usually 20 ml is used. It is
• Tumours.
actually written in the Foley’s catheter. After
• Posterior urethral valve.
inflation catheter is pulled out to confirm that
• Urethral trauma.
balloon is inflated properly.
• Meatal stenosis.
• Catheter is connected to urosac bag. Prepuce
• Pinhole meatus/phimosis.
is placed in normal position otherwise
• Other causes— paraphimosis can develop.
– Postoperative period. • In adult 16 F catheter is used. F-French unit- 16
– Postsurgery—of haemorrhoidectomy/ mm circumference (Charriere unit). Usual
fissurectomy/fistulectomy. Foley’s catheter is kept for 7-10 days. If there is
– Spinal injury/spinal surgery/spinal a need to keep catheter for more than 10 days
anaesthesia. then silicon coated Foley’s catheter is used as
– Drugs like anticholinergics, antidepres- it is least reactive. Foley’s catheter is made up
sants or antihypertensives. of latex. In children 10 F or 8 F is used.
• Three-way Foley’s catheter is used to irrigate • For gastric function tests.

the bladder with normal saline/glycine • In gastric outlet obstruction to decompress
solution continuously in post-TURP (Trans- the stomach and also to give stomach wash.
urethral Resection of Prostate) or after bladder Stomach tube is better (Ewald’s tube) for this.
surgery or after bladder trauma. • For feeding purpose.
• Foley’s catheter often is reinforced with • Baid test: Passed Ryle’s tube will be palpable
tension wires to prevent block and is called per abdomen in pseudocyst of pancreas as
as haematuric Foley’s catheter. stomach is stretched forward.
• Maryfield introducer is used often to pass • Ryle’s tube will not enter the stomach in
the Foley’s catheter into the bladder. It has Boerhaave’s syndrome.
got a curve with a groove over the convex
part to accommodate the catheter. Procedure
• Balloon should be deflated completely before • Procedure is explained to the patient. Usually
removal of the catheter otherwise urethral no. 16 tube is used in adult. It is one meter
injury and haematuria can occur. long usually of plastic (earlier red rubber)
• In females labia majora are retracted apart to with three lead shots in the tip. Lead shots
identify the urethral orifice to pass the catheter. in the tip make it easier to pass. (Infant feeding
tube does not have lead shots). It has got
Complications of Catheterisation
different marking ring/rings (2, 3, and 4).
• Infection.
First ring signifies O-G junction (40 cm). Two
• False passage.
rings for body of stomach (50 cm), three for
• Bleeding.
the pylorus (60 cm) and four for duodenum
• Inability to deflate the balloon while removing
(70 cm).
the catheter. In such occasions, following
• Xylocaine jelly 2 % is lubricated to the tube.
methods are used—
It is passed one of the nostril (wider one)
– Inflating the balloon further with ether/
horizontally until it reaches the posterior
air/water and bursting the balloon.
pharyngeal wall. Patient is asked to swallow
– Passing guide wire of the ureteric catheter
if needed with the help of cup of water. Tube
via the inflating channel.
passes through the relaxed cricopharyngeus
– After giving traction to catheter so as to
and then into oesophagus. Afterwards it is
make balloon nonmobile and fix, long,
easier to pass into the oesophagus. Once it
fine needle is passed per-abdomen in
suprapubic place so as to puncture the is in the oesophagus adequately tube is fixed
balloon. to nostril.
Confirmation of the tube in the stomach is
Causes for Inability to Pass the Catheter done by aspirating the bile and also by injecting
• Urethral stricture, BPH. 30 ml of air into the stomach through the tube
• Non-cooperation by the patient. which can be heard in the epigastrium with a
• Meatal stenosis. stethoscope as a gurgling sound.
Tube can be used for continuous drainage
INSERTION OF A NASOGASTRIC or drainage hourly or at regular intervals.
TUBE Problems with Ryle’s Tube
Indications • Discomfort to the patient.
• For decompressing stomach in intestinal • Blockage.
obstruction, after abdominal surgery. It pre- • Coiling in the mouth.
vents aspiration and distension of intestines. • Displacement.
ABSCESS DRAINAGE pus is aspirated and confirmed. Adequate

incision is made over the skin in longitudinal
Abscess is a localised collection of pus lined to neurovascular bundle. Pyogenic membrane
by granulation tissue covered by pyogenic is opened using sinus forceps. Pus is collected
membrane. It contains pus in loculi. for culture and sensitivity. All loculi should be
broken. Wound is washed with saline. Gauze
drain or corrugated drain is placed in the wound.
Antibiotics are continued. Wound is allowed to
granulate and heal.
Local anaesthesia may not act as pus is acidic
in nature and xylocaine will not be effective in
this acidic media.
Complications
• Improper drainage and residual abscess.
• Septicaemia.
Fig. 7.6: Pyogenic abscess—Parts.
• If abscess is near the major vessels, sloughing
of the wall of the vessel and torrential
Bacteria Causing Abscess haemorrhage can occur occasionally.
• Staphylococcus aureus. – Sarcoma and aneurysms may mimic
• Streptococcus pyogenes. pyogenic abscess especially when it is
• Gram-negative bacteria (E. coli, Pseudomonas, deep seated and so necessary investi-
Klebsiella). gations like CT scam and aspiration of
• Anaerobes. the content should be done before incision
and drainage.
Factors Precipitating Abscess Formation
• General condition of the patient: Nutrition, Abscess in Special Locations
anaemia, age of the patient. Abscess in special locations may not show
• Associated diseases: Diabetes, HIV, immuno- features of formed abscess. In those locations
suppression. abscess should be drained without waiting for
• Type and virulence of the organisms. features of formed abscess- pointing, fluctuation.
• Trauma, haematoma, road traffic accidents. They are–
Abscess should be drained only once it is formed – Parotid abscess.
under the cover of antibiotics. – Breast abscess.
– Ludwig’s angina—It is actually a cellulitis
Features of formed abscess are not an abscess but needs exploration and
• Pointing tenderness decompression.
• Visible pus – Thigh abscess.
• Excruciating pain – Ischiorectal abscess.
• Localized swelling
• Induration (browny induration) Parotid Abscess
Parotid abscess presents as severe pain and
Abscess is Drained by Hilton’s Method tender swelling in the parotid region in front
Under general or regional anaesthesia, after of the tragus. Often patient will be toxic, dehy-
cleaning and draping, using needle with syringe drated with trismus. Parotid abscess is drained
under general anaesthesia with endotracheal position and a sand bag under the shoulder.
tube in place. Blair’s vertical incision is placed A 5 cm incision is made under the anterior
in front of the tragus. Abscess cavity is opened axillary fold longitudinally. Skin and superficial
using sinus forceps with multiple horizontal fascia is incised. Using sinus forceps deep fascia
incisions in deeper plane. Care should be taken is opened in parallel to the line of the axillary
not to traumatize the facial nerve. After draining vessels. Care is taken not to injure axillary vessels
pus and proper saline wash drain is placed into (vein). After draining pus and saline wash,
the wound. Loose sutures in the skin may be gauze/corrugated drain is placed. Antibiotics
placed. Facial nerve injury, septicaemia, laryngeal are continued.
oedema and local spread of sepsis are the – Complications are sinus formation, bleeding,
complications. Infection when spreads to shoulder stiffness.
pharynx/larynx/parapharyngeal space needs
tracheostomy. Ischiorectal Abscess
It is drained under general/spinal anaesthesia.
Breast Abscess Procedure is done in lithotomy position. After
Breast abscess is commonly due to Staphylococcus cleaning and draping, cruciate incision is placed
aureus. It is common in lactating women. It should over more indurated/more prominent area of the
always be drained under general anaesthesia. ischiorectal fossa. Incision is deepened. Parts of
There will not be any localization. Diffuse the angles of the flaps are excised so as to prevent
swelling and tenderness all over the breast is it to close to form recurrent abscess formation.
common. Occasionally tender axillary lymph Sinus forceps is inserted to enter the fossa and
nodes may be palpable. After cleaning and to drain the pus. Using finger all loculi are broken.
draping, pus is aspirated and confirmed initially. Rectal examination is done to find out the
Either circumareolar or submammary incision possibility of existing fistula. Cavity is packed
is made. After draining pus and braking loculi, with gauze and dressing is done using ‘T’
a counter-incision is made on the upper part. bandage. Antibiotics and regular dressings are
After proper saline wash of the wound, drain required.
is placed across the incision and counter- – Digital examination of the rectum should be
incision. If patient is lactating, suppression of done to see for fistula. If fistula is present,
lactation is done using Bromocryptine 2.5 mg. fistulectomy is done at same or later period.
Regular expression of milk either manually or
using breast pump should be done. Otherwise Ludwig’s Angina
recurrent infection or fistula can occur. • It is an inflammatory oedema of sub-
– Acute breast abscess may mimic mastitis mandibular region and floor of the mouth,
carcinomatosis/inflammatory carcinoma of commonly due to streptococcal infection.
breast. There is bilateral browny cellulitis of
– Breast abscess which is not drained but sublingual and submandibular region.
treated with antibiotics may form organized, • It is common in severely ill and in advanced
hard, non-tender swelling in the breast called malignancy, causing trismus, laryngeal oedema.
as Antibioma which will mimic carcinoma Extension of infection into parapharyngeal
breast. Antibioma contains thick walled space may lead to dreaded internal jugular
fibrous tissue with sterile pus as flaques vein thrombosis.
inside. It needs excision. • As the infection is deep to the deep fascia
in a closed fascial plane, it spreads very fast
Axillary Abscess causing dangerous complications.
Axillary abscess is drained under general • Clinical features: Fever, toxicity, diffuse
anaesthesia with axilla in hyper extended swelling, dysphagia, dyspnoea, and trismus.
• Treatment Cold Abscess
– Antibiotics—penicillns (high dose 20 It is due to caseation necrosis and localisation
lacs 4th-6th hourly), cefaperazone, due to tuberculous infection. There will not be
sulbactum, metronidazole—antimicro- any signs of inflammation. It is well localised,
bial. soft, cystic, nontender swelling without any
– IV fluids for adequate hydration. warmness. It is commonly due to tuberculous
lymphadenitis, but can occur in tuberculosis of
spine, kidney or other areas. FNAC shows
caseation necrosis, macrophages and typical
epithelioid cells. Cold abscess is drained using
nondependent incision. After drainage wound is
sutured without placing a drain.
Tuberculous Lymphadenitis
Causative organism: Mycobacterium tuberculosis
(Not M. bovis).
Site: Common in neck lymph nodes.
Common in upper deep cervical (jugulo-
digastric—54%) lymph nodes.
Fig. 7.7: Incision for draining of Ludwig’s angina.
Next common is posterior triangle lymph
nodes (22%).
– Decompression of the submandibular region Mode of infection: Usually through the tonsils,
is done, by making a deep incision occasionally through blood from lungs.
extending into the deep fascia and also It may be associated with pulmonary
cutting both the mylohyoid muscles. Either tuberculosis or renal tuberculosis.
it is left open or delayed suturing is done,
(better option) or it is loosely sutured with Stages of tuberculous lymphadenitis
a drain in situ. 1. Stage of infection and lymphadenitis
2. Stage of periadenitis with matting
• Complications
3. Stage of caseating necrosis and cold abscess
1. Laryngeal oedema and respiratory distress
may require tracheostomy. formation
2. Septicaemia. 4. Stage of formation of collar stud abscess
3. Extension of infection into parapharyngeal 5. Stage of formation of sinus which discharges
space. yellowish caseating material
Types
Hyperplastic Caseating
• 20% common • 80% common
• Discrete, firm or hard • Matted due to periadenitis
• Occurs in the cortex of lymph node • Involves medulla
• Host immunity is good • Body resistance is not adequate
• Drugs act better • Drugs do not reach in proper concentration
• Drug resistance is uncommon and may not be effective
• No cold abscess or sinus formation • Drug resistance is common
• Blood spread • Cold abscess or sinus are common
• From tonsils
Clinical Features
• Swelling in the neck which is firm, matted.
• Cold abscess is soft, smooth, nontender,
fluctuant, without involvement of the skin.
• As a result of increased pressure , cold abscess
ruptures out of the deep fascia to form collar
stud abscess which is adherent to the overlying
skin.
• Once collar stud abscess bursts open,
discharging sinus is formed.
• Tonsils may be studded with tubercles and so
clinically should always be examined.
• Associated pulmonary tuberculosis should
also be looked for.
• Nonspecific lymphadenitis.
• Lymphomas.
• Secondaries in the neck.
• Branchial cyst mimics cold abscess.
• Lymph cyst mimics cold abscess.
• HIV with lymph node involvement.
• When there is discharging sinus—actinomy-
cosis.
Investigations
1. Haematocrit, ESR
2. FNAC of lymph node.
3. HIV test.
4. Open biopsy when FNAC is inconclusive.
5. Chest X-ray to look for pulmonary tuberculosis.
Fig. 7.8: Stages of tuberculous lymphadenitis.
Treatment
• Often fibrosis and calcification can occur with Antituberculous drugs have to be started:
or without treatment. • Rifampicin 450 mg OD on empty stomach.
• Gross pathology: Firm, matted, lymph node, It is bactericidal. It discolours urine red.
with cut section showing yellowish caseating It is also hepatotoxic.
material. • INH. 300 mg OD. It is bactericidal. It causes
• Microscopic: Epithelioid cells with caseating intolerance, neuritis, hepatitis (INH).
material are seen along with Langhan’s type • Ethambutol 800 mg OD It is bacteriostatic.
of giant cells It causes GIT intolerance.
• Disease can also occur in other lymph nodes • Retrobulbar neuritis (green colour blindness).
like, axillary lymph nodes, para-aortic lymph • Pyrazinamide 1500 mg OD (or 750 mg BD).
nodes, mesenteric lymph nodes, inguinal It is bactericidal. It is hepatotoxic, also causes
lymph nodes. Disease may be associated with hyperuricaemia and increases psychosis.
HIV infection, lymphomas. Duration of treatment is usually 6-9 months.
Differences between pyogenic abscess and cold abscess
Pyogenic abscess Cold abscess
• Red, warm, tender, with signs of acute • No signs of acute inflammation
inflammation • Tuberculous bacteria
• Pyogenic bacteria are nonspecific organisms • Nondependent incision is used
(Streptococci, staphylococci) • Wound is curetted and sutured
• For drainage, dependent incision is used • Drain is not placed – if placed sinus may
• Suturing of the wound is not done form which is difficult to treat
• Drain is placed
• Heals well and rapidly once drainage is
adequate
Treatment of Cold Abscess Midtracheostomy: Ideal and commonly used.

• When there is cold abscess, initially it has
It through 2nd and 3rd rings behind isthmus.
to be aspirated. (Needle is introduced into
It is approached by dividing thyroid isthmus.
the cold abscess in a nondependent site along
a ‘Z’ track (in zigzag pathway) so as to prevent Lowtracheostomy: Below the isthmus level.
sinus formation). It is deep and impinges the suprasternal notch.
• But if it recurs, then it should be drained. It can cause torrectial bleed which is difficult
Drainage is done through a nondependent to control.
incision. After draining the caseating material,
wound is closed without placing a drain.
• Surgical removal of tuberculous lymph
nodes— It is done by raising skin flaps and
removing all caseating material and lymph
nodes. Care should be taken not to injure
major structures.
Indications for surgical removal of tubercular
lymph nodes
• There is no local response to chemotherapy
• When sinus persists
TRACHEOSTOMY
Tracheostomy is making an opening in the Fig. 7.9: Tracheostomy tube with inflation part and
syringe (Inflated with air).
anterior wall of trachea and converting it into
a stoma on the skin surface.
Tracheostomy Tubes
Types 1. Fuller’s bivalved tracheostomy tube: It has
• Emergency tracheostomy. got a outer tube and a inner tube. Outer tube
• Elective tracheostomy. is biflanged and so insertion is easier. Inner
• Permanent tracheostomy. tube is longer with an opening on its posterior
aspect. Inner tube can be removed and re-
High tracheostomy: Above the level of isthmus. inserted easily whenever required.
It can cause tracheal stenosis. It is above second 2. Jackson’s tracheostomy tube: It has got outer
ring. tube, inner tube and an obturator.
3. Red-rubber tracheostomy tube. Indications for tracheostomy

4. PVC tracheostomy tube. respiratory obstruction due to
• Acute infections causing oedema laryx
• Trauma
• Neoplasms—benign/malignant
• Foreign body
• Bilateral abductor palsy
• Congenital causes
Respiratory secretions due to
• Inability to cough—tetanus, head injury,
neurological causes, strychnine poison
• Painful cough in chest injuries, pneumonia
• Aspiration of secretions
Respiratory insufficiency due to chronic lung
diseases like emphysema, chronic bronchitis,
bronchiectasis
Technique of Tracheostomy
Fig. 7.10: Figure showing the position of
tracheostomy tube. Neck of the patient is hyper extended by placing
sand bags under the shoulder. Vertical (midline)
or horizontal incision is made. Deep fascia is
Modern tracheostomy tubes are made of opened. Strap muscles are retracted laterally.
plastic. They are soft, least irritant and Isthmus is divided or retracted upwards. A few
disposable. They have inflatable cuff which drops of lignocaine are instilled into the trachea
makes it easier to give assisted ventilation. Cuff to suppress the cough reflex. Trachea is fixed
should be deflated at regular intervals to prevent with tracheal hook. Second and 3rd or 3rd and
tracheal pressure necrosis (For assisted 4th tracheal rings are opened and circular
ventilation, endotracheal tube can be kept for opening is made. Tracheostomy tube is placed.
7 days. Beyond that period patient needs It is tied around the neck.
tracheostomy for further ventilation).
Note
• First tracheal ring should never be used to do
Indications for Tracheostomy tracheostomy as perichondritis of cricoid cartilage
• In head, neck and facial injuries. with stenosis can occur.
• Tetanus. • Skin should not be sutured or loosely sutured
• Tracheomalacia after thyroidectomy or to prevent development of subcutaneous
bilateral recurrent laryngeal nerve palsy. emphysema.
• Laryngeal oedema/spasm. • Cautery should be used during tracheostomy as
• Major head and neck surgeries like much as possible to prevent oozing/bleeding from
Commando’s operation, block dissection. places like muscles, tracheal cut edge. Often
• Acute laryngitis as in diphtheria. torrential haemorrhage known to occur which may
• Carcinoma larynx, foreign body larynx, burns need a re-exploration to control bleeding.
mouth, pharynx, larynx.
• Respiratory paralysis like bulbar palsy. Tracheostomy Care
• Respiratory failure due to asthma, ARDS. • Regular suctioning of the tube.
Functions of the tracheostomy

• Alternate pathway for respiration bypassing
the upper air-way
• It decreases the dead space by 50% and
reduces the resistance to airflow so as to
improve the ventilation
• It prevents aspiration in bulbar palsy, coma,
haemorrhage from larynx/pharynx
• In injuries of head, chest, abdomen, in
respiratory paralysis lower airway is kept
clean and patent by doing suction of the
secretions through the tracheostomy tube
• Tracheostomy is better and ideal for
intermittent positive pressure ventilation
(IPPR)
• To give general anaesthesia when endo-
Fig. 7.11: Vertical midline or transverse incisions are
tracheal intubation is not possible
used for tracheostomy. Vertical midline extends from
corcoid cartilage to sternal notch. It is used in emergency Complications of Tracheostomy
and often in elective tracheostomy. It gives rapid access • Bleeding.
with less dissection but leads into poor scar. Transverse
incision can be used in elective tracheostomy. It is placed
• Aspiration, sudden apnoea.
two finger breadths above the sternal notch with a length • Pneumothorax.
of about 5 cm transversely. It has got a better cosmetic • Surgical emphysema in the neck.
scar.
• Cleaning of tracheostomy tube.

• Humidification of the inspired air using
normal saline/ringer lactate/acetylcystine
mucolytic agent to liquefy secretions or crusts
so that to prevent blockage.
• Constant observation of the patient for block,
bleeding.
• Periodic deflation of the cuff of the tube for
short period to prevent pressure necrosis of
tracheal mucosa.
• Prevention of infection.
• Decannulation of tracheostomy should be
done with care especially in children as
sudden respiratory distress can occur and
in such occasion emergency reinsertion of
the tube should be done.
• Flexible brochoscopy may be needed to clear
the lower air-way through the tracheostomy Fig. 7.12: Advanced secondaries in neck with
tube. tracheostomy tube to control respiratory stridor.
Nursing care
• Consent should be taken.
• Materials like tracheostomy tubes, ( 8.5 size),
sterile gown, drapes, gloves, cap, mask,
tracheostomy sterile set, gauze, local
anaesthetic agent, suction apparatus and
tubes, connecting tubes to ventilator, sterile
syringes should be kept ready.
• During procedure the patient is monitored
for vital signs.
• Proper nursing care of the tracheostomy tube
is done like, humidifying, cleaning, suction,
care of the wound, checking of cuff pressure.
• Tracheal dilator and additional tracheo-
stomy tube should be kept ready at bedside
in case of blockage of existing tube/balloon
not getting inflated to replace with a new
one.
• Absolute asepsis like scrubbing hands,
using sterile equipments are essential.
• Sterile suction tubes should be used.
• Care of inner tube is essential in case of
Fig. 7.13: Permanent tracheostomy is done in a patient metal tracheostomy tube.
who underwent total laryngopharyngectomy for carcinoma • Regular dressing of the wound is needed.
larynx. Patent is on nasogastric tube for feeding purpose. Antibiotics are required to prevent
pulmonary sepsis.
• Mediastinal emphysema.
• Injury to adjacent structures like oesophagus,
CIRCUMCISION
recurrent laryngeal nerve, thyroid gland.
• Tracheal stenosis. Procedure
• Laryngeal stenosis due to perichondritis of In children it is done under G/A. In adults it
cricoid cartilage. is done under local anaesthesia.
• Tracheitis/tracheo-bronchitis. After cleaning and draping, LA (1% ligno-
• Displacement/blockage of the tube or erosion caine (plain) injected circumferentially near the
of the tube into major vessels. root of the penis) is given (ring block). Dorsal
• Tracheo-oesophageal, tracheoarterial fistula. skin is cut up to the corona and later circum-
Fig. 7.14: Circumcision technique.

Indications
• Religious.
• Phimosis.
• Paraphimosis after doing initial dorsal slit.
• Balanitis and balanoposthitis (common in
diabetics).
• Early carcinoma of prepuce or glans penis
— both diagnostic as well as therapeutic
purpose.
• Certain sexually transmitted diseases, e.g.
herpes infection.
ferentially and ventrally. The skin is cut with

A
inner layer. Care is taken to see that optimum
(less) skin is cut ventrally to prevent the
occurrence of chordee. Frenular artery is transfixed
and ligated ventrally using chromic catgut ( 2—
0 or 3—0). Small bleeders are also ligated. Skin
is apposed to the cut edge of corona using
interrupted chromic catgut sutures. Post-
operatively, antibiotics and analgesics are given.
Plastic cap: Hollister Bell cap technique: This cap
is fitted over the glans penis and prepuce is rolled
over it. A tight ligature is tied over it near base
of the prepuce. In 7 days, skin and prepuce
sloughs off and is shed with the cap. Bleeding
will not occur due to thrombosis of prepuceal B
vessels. Technique can be used for religious Figs 7.15A and B: Phimosis.
circumcision/balanoposthitis without phimosis.
It is contraindicated in phimosis and Causes
paraphimosis. 1. Congenital in which case the child will have
pinhole meatus and ballooning of prepuce
Complications occurs when child urinates.
• Reactionary haemorrhage due to slipping of 2. Balanitis (inflammation of glans) and balano-
ligature from frenular artery dorsal vein. posthitis (inflammation of glans, prepuce and
• Infection. sac). Common in diabetics. Patients with
• Stricture urethra near the external meatus in phimosis are more prone for recurrent infec-
children. tion, smegma collection and more prone for
• Chordee due to removal of excess skin on carcinoma penis.
the ventral aspect. Treatment: Circumcision.
• Rarely priapism can occur.
PARAPHIMOSIS
PHIMOSIS • Inability to cover (place back) the glans with
It is inability to retract the prepuce over the glans. retracted prepucial skin.
chromic catgut. Dressing is placed over the wound.

Patient needs formal circumcision at a later period
(after 3 weeks) once oedema subsides.
EXCISION OF THE SWELLING

• Swellings like sebaceous cyst, lipoma,
pyogenic granuloma, Papilloma are excised
usually under local anaesthesia. Dermoid cyst
which is extending into the deeper plane
should be excised under general anaesthesia.
• After cleaning and draping, xylocaine 1%
injection is infiltrated around the swelling
Fig. 7.16: Paraphimosis. and underneath the swelling by lifting the
swelling.
• After passing urinary catheter if prepuceal
skin is not placed back over the glans Incision
paraphimosis can occur. • In sebaceous cyst elliptical incision is placed
• It causes ring like constriction proximal to encroaching the punctum.
the corona and prepuceal skin. As a result • In swellings like lipoma/ganglion lineal
the glans will be swollen, oedematous with incision is placed.
severe pain and tenderness. • In swelling like papilloma/pyogenic
• Often glans will undergo necrosis or becomes granuloma elliptical incision covering the
gangrenous. entire lesion is placed.
Treatment Procedure
• Manual reduction of prepuceal skin is to be • Skin flaps on either side are raised adequately
tried. until edge of the swelling is clearly seen. Using
• If not possible, initial dorsal slit is made to scissor sharp dissection is done to remove
relieve the oedema and compression. Antibio- the entire swelling. Bleeding points are
cauterised/ligated. Skin is closed using non-
tics and analgesics are given. Circumcision
absorbable monofilament polypropylene/
is done after 3 weeks.
polyethylene 3-zero sutures.
• In a sebaceous cyst, capsule should be
DORSAL SLIT OF PREPUCE removed completely otherwise recurrence can
occur. Often avulsion of the capsule also done
Indications
to complete the procedure.
• Paraphimosis. • In a large swelling like of large lipoma
• To do biopsy from a growth underneath the drainage tube may be kept for 48 hours.
prepuce either in the glans or in prepuce itself. • Dressing is placed. Antibiotics and analgesics
After cleaning and draping, xylocaine plain are given.
(1%) is injected into the root of the penis • Suture removed in 5-8 days.
circumferentially. Using two mosquito forceps
oedematous prepuceal skin is held. Dorsally skin LYMPH NODE BIOPSY
in midline is cut. Fibrous ring/constriction ring
proximally is identified and is cut. Once released Indications
properly skin will move freely properly. ‘V’ shaped • Lymphoma to find out the grade, type of
cut edge is sutured with continuous plain/ lymphoma.
• In secondaries in lymph node only when Complications and Difficulties
FNAC is inconclusive but clinically node is • Bleeding.
significant. Significant node is one which is • Injury to major structures like nerves and
based on size (variable in different locations vessels.
and type of primary but hard node > 1 cm • Infection.
is significant) and texture (hard) probably
harboring tumour spread. FNAC is the first
choice in secondaries as biopsy of node may PLEURAL TAP
block the lymphatics and may allow spread (THORACOCENTESIS)
of tumour to next level of nodes.
Indications
• Tuberculosis of lymph node.
• Pleural effusion both diagnostic as well as
• Rare lymphatic diseases.
therapeutic. The fluid is sent for culture,
cytology, microscopy, specific gravity,
Site of Node Selection for Biopsy
biochemical analysis like proteins for
• Neck nodes—superficial/deep.
diagnosis of tuberculosis, malignancy.
• Axillary node.
• In empyema thoracis, for diagnostic purpose
• Groin node: These nodes can often be non-
before placing an ICT.
specific because of repeated recurrent
• Intrapleural administration of drugs.
inflammation. Hard, large sized node can be
considered as significant.
Position
In sitting position, leaning forward over a
Procedure
wooden support.
Lymph node biopsy ideally should be done under
general anaesthesia. Superficial nodes/nodes
upper posterior triangle may be removed under
local anaesthesia-xylocaine 1%.
After cleaning and draping, incision is placed
parallel to neurovascular bundle. Adequate
incision is a must otherwise technique will be
difficult. After skin incision, fascia is incised.
Lymph node is identified based on shape, colour
and texture. Node is separated from adjacent
structures. Node is held using Lane’s tissue
holding forceps. After removal haemostasis is
maintained. Node is cut to see the interior texture.
It is fleshy in Hodgkin’s lymphoma. It is yellowish
caseating in tuberculosis and dark, haemor-
rhagic in secondaries. Skin is closed with
interrupted sutures using monofilament
non-absorbable sutures. Sutures removed in
7 days.
Ideally entire one node with its intact capsule
should be removed specially in lymphomas.
Many times it may be difficult because of fibrosis Fig. 7.17: Pleural tap. Note the position of the
and adherent lymph nodes. patient and placement of the needle.
Site
Tip of scapula at 7th intercostal space (poste-
riorly).
Procedure is done in sitting and leaning
forward over a support. Tapping is done from
behind. After giving local anaesthesia wide bore
needle (Abraham needle) is used to tap the fluid.
Needle with stopcock (3-way) is used. 50 ml
syringe is connected to the stopcock. Fluid is
aspirated to syringe from pleura with stopcock
in straight position. Then knob is turned right
angle to empty the syringe to reservoir. Procedure
is repeated to clear the fluid.
For diagnostic tap, 50 ml of fluid is aspirated
to send for biochemical/cytological analysis and
culture.
For therapeutic aspiration— 750-1000 ml per
day is aspirated. If more quantity is aspirated
rapidly, pulmonary oedema may develop leading
to often ARDS which may be life-threatening.
Fig. 7.18: Intercostal tube drainage under water seal.

Complications
• Infection. (5 ml of 1% xylocaine injection), an ICT is
• Dry tap or bloody tap. placed in 6th or 8th intercostal space in case
• Sudden vagal shock. of haemothorax and pyothorax and in
• Pain and respiratory distress. pneumothorax ICT is placed in 2nd or 3rd
space.
INTERCOSTAL TUBE DRAINAGE • A small incision is made in midaxillary line
(as the muscle bulk is less here and so passage
(ICT DRAINAGE) of ICT is easier), parallel to intercostal space
It is the method of draining collections in the (above the rib, i.e. lower part of intercostal
pleural cavity safely so as to make the lung to space to avoid injury to neurovascular bundle
expand. which are located in the groove in the lower
part of rib). Tube with side openings is pushed
Indications into the pleural cavity.
• Haemothorax. • Other end is connected to under water seal (200
• Pneumothorax. ml of sterile water). Air-water column moving
• Haemopneumothorax. with respiration can be observed. Tube is fixed
• Empyema thoracis. with skin sutures.
• Traumatic lung contusion. • Usually for pneumothorax ICT is kept for
• After thoracotomy to drain pleural cavity. 2-3 days (Till lung expands—Confirmed by
check chest X-ray). For haemothorax and
Procedure pyothorax it is kept for 4-6 days or until it
• Patient is in 45° partial lying positions with stops draining and lung expansion is
backrest support. Under local anaesthesia confirmed by repeat chest X-ray.
• To have a proper expansion of lungs patient
is asked to blow foot ball bladder (balloon)
(Breathing exercise). If there is broncho-pleural
fistula, ICT should be placed for longer time
until fistula heals.
Fig. 7.20: Bronchoscope.
Types
• Rigid bronchoscopy: It is used for removal of
foreign body, bronchial wash, etc. It reaches
up to the third generation bronchioles. It is
useful to take biopsy from carcinoma of
proximal divisions but not from carcinoma
of peripheral lung. Rigid scope has got multiple
holes to allow ventilation during procedure
( Oesophagoscope does not have side holes).
It is done under general anaesthesia.
• Flexible bronchoscopy: It reaches up to 5th
generation bronchioles. It can be done under
local anaesthesia. It is mainly used for
diagnosis and biopsy.
Complications
• Bleeding.
Fig. 7.19: Intercostal tube drainage in a • Infection.
patient with haemothorax. • Perforation.
• Bronchospasm.
Complications and Problems
1. Infection.
2. Displacement and inadequate functioning. PERICARDIAL TAP
3. Injury to intercostal vessels and bleeding. (PERICARDIOCENTESIS)
4. Injury to intercostal nerves, lung and
Indications
mediastinum.
• Pericardial effusion due to any cause—viral,
5. Pain at the site of ICT placement.
tubercular.
• Haemopericardium.
BRONCHOSCOPY • Purulent pericardium.
Indications
Procedure
Diagnostic: To take biopsy in carcinoma lung,
A 16 or 18-gauge needle is passed into the
lung abscess, pulmonary tuberculosis.
pericardium just below the xiphoid process
Therapeutic: To remove foreign body, to suck out directing upwards and backwards towards left
the bronchial secretions. side with an angle of 45° to the surface.
This site is used because it is— PERITONEAL TAP

• Most dependent aspiration.
• Unlikely to traumatize heart. Indications
• Pleura is not punctured. • For diagnosis—abdominal tuberculosis,
• Coronary vessels are not injured. peritoneal secondaries, ascitic fluid study.
Presently U/S guided aspiration is commonly • For therapy—in massive Ascites to relieve
done. Procedure should be done under ECG distress by removing fluid—in malignancy,
monitor. portal hypertension.
Complications Site
• Injury to heart causing bleeding/ventricular
fibrillation. In the spinoumbilical line lateral to rectus
• Infection. abdominis muscle.
Procedure
CARDIAC TAMPONADE
Patient is asked to empty the urinary bladder.
Accumulation of fluid or blood in the pericardial Abdomen is percussed to confirm the dullness
space causing increase in the intrapericardial in the flank. Site of tapping is marked. Site is
pressure is called as cardiac tamponade. below the umbilical level away from the lateral
margin of the rectus muscle. Xylocaine 1%
Causes injection local anaesthetic is infiltrated.
• Trauma. 20 gauge needle is inserted into the peritoneal
• Progressive pericardial effusion due to cavity. Ascitic fluid comes into the syringe.
tuberculosis, viral, bacterial infections. Syringe is connected to the 3 way stopcock to
• Often uraemia can cause significant pericar- have controlled tapping.
dial effusion. For diagnostic purpose 50 ml of fluid is
aspirated. Fluid is sent for culture/cytology/
Clinical Features AFB/biochemical analysis.
• Widened cardiac dullness and hypotension. To relieve distress 1500 ml/day is aspirated.
• Muffled or decreased heart sounds. If more quantity is a aspirated sudden hypo-
• Increased venous pressure with raised jugular tension and cardiac arrest can occur. It is always
veins. safer to do procedure with an intravenous line
• Pulsus paradoxus. (pulse becomes weaker with IV fluids flowing.
on inspiration than expiration).
• In severe cases, heart is unable to expand Complications and Difficulties
causing shock and often sudden death. • Infection and peritonitis.
• Bleeding—haemoperitoneum.
Investigation • Bowel injury.
Chest X-ray and U/S confirms the diagnosis. • Negative tapping—In loculated ascites due
ECG—altered QRS complex. to (commonly) abdominal tuberculosis, fluid
may not get and so ultrasound guidance is
Treatment needed to get fluid.
• Pericardial tap as early as possible to allow • In females tense Ascites should be differen-
heart to expand adequately. tiated from large ovarian cyst before
• Occasionally open pericardiotomy is required. tapping.
VASECTOMY cord like vas which is held with ring clamp is

dissected- clamped- a small piece of 5 mm is cut.
Indications Cut ends are ligated using silk. Opposite vas is also
• For family planning purpose. Consent both similarly brought into the same wound by
partners is needed. Look for any hernia/ manipulation and clamped and ligated after
hydrocele—if present vasectomy should be cutting. Skin is not closed. It gets apposed
done along with specific surgeries for these automatically and heals on its own. Often two
conditions. separate approaches can be used for each side.
• Previously while doing prostatectomy Postoperatively antibiotics and analgesics are
vasectomy is done to prevent retrograde given.
infection of testes.
• In specific diseases like tuberculosis of vas, Advice: Contraception should be used to have
vasectomy may be done for biopsy purpose. protected intercourse for a minimum 6 weeks/
• There are no specific contraindications for 15 ejaculations.
vasectomy but if patient is having hernia or
hydrocele, it is better to do vasectomy along Complications of Vasectomy
with surgery for hernia or hydrocele. • Infection, pyocele.
• Bleeding, haematoma, haematocele.
Types • Sperm granuloma.
• Classical method—Scalpel technique • Recanalisation and failure.
• No scalpel technique (Shunqiang Li- China)
Classical method— After cleaning and draping, VASO-VASOSTOMY
2-5 ml of xylocaine plain 1% is injected into root (RECANALISATION PROCEDURE)
of the scrotum lateral aspect. Skin, dartos are
Indications
incised (2-3 cm vertical incision). Once spermatic
Patient who has underwent vasectomy earlier
fascia is incised cord structures are identified.
if needs fertility (one more child) again.
Vas deferens is felt as thickened whitish cord
like structure. It is dissected using mosquito artery
Technique
forceps. It is held using Babcock’s forceps as
Under general/spinal anaesthesia incision over
loop outside the wound. Vas is clamped in two
the front of the scrotum is made. Cord is dissected.
different places with a gap in between using
Cut ends of the vas are identified. Both ends
two artery forceps. A piece of the vas (5 mm)
are carefully mobilized. Cut ends are trimmed
is excised. Cut ends are ligated using non-
to see the clear lumen. Fine 3 zero polypropylene
absorbable sutures like silk. Skin is closed with
suture material is passed through the lumen to
sutures. Procedure is repeated on the other side.
act as a stent. Cut ends are sutured using
Dressing is placed. Sutures removed after 7 days.
polypropylene continuous sutures. Stent is
No scalpel technique— Two special instruments are brought out through vas and through scrotal
used here. An extracutaneous ring clamp and skin away from main wound. Skin is closed with
Chongquing’s sharpened curved mosquito clamp. sutures. Procedure is commonly done on both
After cleaning and draping, xylocaine 2 % of 2-3 sides. stent is kept for 3 weeks and removed.
ml is injected under the skin of midline raphe Success rate of vaso-vasostomy is 30%.
proximal aspect. Vas deferens of one side is felt and
pushed under the raphe. It is carefully held with Complications
extracutaneous ring clamp. Skin is incised using • Infection.
sharp tip of the curved mosquito clamp. Whitish • Failure.
STOMA CARE patient, as it is nonphysiological, distressing

and socially not acceptable.
Definition of Stoma • Patient should be explained about the
Stoma is an artificial opening or ‘mouth like’ procedure and should be convinced and
to the exterior, the abdominal wall so as to drain consoled about the stoma.
the content from the tubular structures inside, • Detailed meaning, explanation and after care
like bowel or ureter. It is done for diversion of of the stoma should be discussed.
urine or faecal matter in case of malignancy, • Indication for the stoma and consent for the
trauma, and sepsis or after surgery. same should be taken.
• Reassurance about the stoma, its care, and
Types its position should be diagrammatically
Ileostomy:Terminal 5 cm ileum is projected out, explained to the patient and his close relative.
on to the skin of abdominal wall to drain semi- • In case of obstructive disease, stoma is done
liquid, faecal matter. as an inevitable procedure to relieve the
obstruction often it may be temporary.
Colostomy: Colon at different levels, as required • Proper bowel preparation by bowel wash,
can be brought out to the skin as colostomy, to gut irrigation is required before surgery.
divert faecal matter. • The surgeon selects the site of the stoma.
Cutaneous ureterostomy: Cut ends of one or both Nurse should be there with surgeon. Stoma
ureters are apposed to the skin of abdominal is usually sited midway between anterior
wall. superior iliac spine and umbilicus.
– It should be away from the belt line.
Ileal urinary conduit: Segment of isolated ileum – It should be away from the scar, creases,
can be used to drain urine from the ureter as urinary and bony points.
ileal conduit. Ureters are anastomosed to a closed – Patient should be assessed for proper size,
ileal conduit. Ileal stoma is brought out as stoma. adequacy for stoma in lying down, sitting,
Different types of continent ileostomies are in use and standing positions.
to prevent leak, soakage and discomfort. – Proper stoma appliances should be
decided after thorough check up and
Vesicostomy: It is done in children. Here anterior
discussion with patient and patient’s
bladder wall is brought out and bladder mucosa relative.
is sutured to the skin of abdominal wall. – Stoma site should be marked properly
Stoma created may be round (commonly) or before surgery.
square in shape. – Ileostomy is usually sited on the right iliac
fossa, colostomy on left iliac fossa.
– Allergy for the particular appliances
should be checked for.
– The patient should consult stoma
therapist.
Postoperative Care for the Stoma

• Stitches are removed in 6-10 days.
Fig. 7.21: Different types of stoma. • Dressing should be done first over the stoma
and after placement of appliance, laparotomy
Preparation and Counselling of the wound is dressed otherwise stoma appliance
Patient for Stoma will not sit properly.
• Stoma of any type causes to certain extent • Patient should be observed for any compli-
of psychological and physical trauma to the cations.
• Once wound has healed patient can take bath • Change of the type of appliance.
by removing the appliances. After bath skin • Refashioning of the stoma.
is dried up and stoma appliances can be fit
again. Stoma Appliances
• Patient should be taught about the stoma care Stoma appliances are devices, which are used
and its appliances. to collect and dispose the effluent materials which
• Care and prevention of skin excoriation due come out of the stoma.
to leak is also looked into.
Ideal Stoma Appliance
• Psychotherapy is given for the patient.
It is:
• Skin should be absolutely dry prior to placing • Leak proof.
the stoma appliances. • Should not damage the stoma and sur-
rounding skin.
Complications of Stoma • Should prevent odor.
• Skin excoriation. • Should be available.
• Mucosal prolapse • Easier to use.
• Stenosis and block.
Types of Appliances
• Infection either bacterial or candidial.
It can be—
• Diarrhoea due to irritation.
• Closed type is discarded when full and is
• Leak due to improper fitting of the appliances,
used in patients with well formed stool.
scar, irregularity of stoma, prolapse.
• Drainable type is used in patients with loose
• Bleeding from the stoma edge. liquid stool. It can be emptied and retained
• Herniation of the abdominal contents and re used. Immediately after colostomy,
adjascent to stoma. drainable appliance is used. Later it can be
changed over to closed type.
Skin Excoriation It can also be—
It is a major problem in stoma patients. It is • One-piece stoma appliance with a bag and
basically due to leak adjascent to appliances. adhesive attached system, which adheres to
Causes for excoriation: skin around the stoma.
• Leak due to improper appliances. • Two-piece stoma appliance has got a flange
• Wet skin before placing the appliance. with adhesive system and a bag over it, which
can be removed and replaced with a new
• Inadequate stoma hole.
one without disturbing the flange underneath.
• Improper and inadequate adhesive sheet
usage. Bag can be—
• Allergy • Transparent, in which fluid can be visualized.
• Infection like of bacteria and Candida. It is used in initial period of the stoma.
• Altered weight of the patient. • Opaque, in which fluid cannot be visualized.
• Stoma bag is overfilled or kinked or air in It is used eventually later.
the stoma bag.
General Care and Advice to
Treatment of excoriation Patients with Stoma
• Control of infection by antibiotics or control • Patient can have normal diet. Diet, which
of moniliasis. regulates the bowel action, is better. Plenty
• Allergy has to be confirmed, and if it is the of water is advisable.
cause the agent is found out and treated as • Patient can go for normal work, exercise like
required. sports, swimming, tennis. Stoma appliances
• Zinc oxide cream application. suitable for these works are available.
• Antidepressants, anticholinergics might • It is indicated when permanent urinary

cause constipation. So these drugs should diversion is required like carcinoma urinary
be taken carefully. bladder, pelvic malignancies where both
• Using irritant solutions near stoma should ureters are involved.
be avoided. It may lead to dangerous • Initially after procedure, a Foley’s catheter
complications. is passed into the stoma for seven days and
• Patient can have normal sexual activity. later a nonreturn valved stoma appliance is
• Patient should have additional stoma bags used.
in hand so as to use if required urgently.
• Patient should be aware of different applian- Specific Complications
ces available and should be well versed with • Stomal obstruction and urine block.
its use. He can take the help of the stoma • Phosphate deposition and encrustation
societies. causing stomal infection and block.
• Urinary tract infection often can be severe
ILEOSTOMY leading to septicaemia.
It is indicated when large bowel is entirely
diseased or removed with an unprepared bowel
where anastomosis cannot be undertaken like
Crohn’s disease, malignancy, large bowel
fistulas, gangrene or perforation of colon.
Ileostomy is sited at right iliac fossa in the
middle of the spinoumbilical line.Ileum carries
unformed liquid stool and so leak, skin changes
and requirement of more bags is common.
Fig. 7.23: Ileal urinary conduit as urinary diversion.
CAECOSTOMY
• Caecostomy is placing a tube in to the caecum
Fig. 7.22: Picture of ileostomy stoma site. for temporary drainage of the contents.
• It is done in acute conditions of the colon
(as colon is not prepared) like perforation,
ILEAL URINARY CONDUIT obstruction, and gangrene.
• Isolated ileal loop is used as stoma. Ureters • It is usually of valvular type and drainage
are implanted to this ileal loop. Through this is dependent. Wash with an irrigating fluid
ileal stoma in right iliac fossa in the middle can be given. Once tube is removed closure
of spino-umbilical line, urine is drained as is spontaneous. As the tube is not wide,
diversion. Often continent ileal conduits are blockage and inefficient drainage is the
used. problem.
• It is technically easier and better accepted
by the patient.
• Permanent caecostomy is not done.
• Other management is like in other stoma care.
COLOSTOMY
It is an artificial opening made in the colon to
the exterior (skin) to divert faeces and flatus.
Types
• Temporary: Is done in conditions wherein
diversion is required to facilitate healing
distally in the rectum or distal colon. And
this is closed once the purpose is over.
– Site of temporary colostomy is usually right
hypochondrium and left iliac fossa.
– It can be loop colostomy or Devine’s double-
barrel colostomy (wherein there is a gap
between the two openings of colostomy
which prevents spillage into the distal
loop).
• Permanent colostomy is always end colostomy Fig. 7.24: Caecostomy placement with
placed in left iliac fossa—6 cm above and caecostomy tube in situ.
medial to the anterior superior iliac spine.
A B
C D
Figs 7.25A to D: Types of Colostomy (A) Temporary colostomy site, (B) Loop colostomy—appearance,
(C) Devine’s double barrel colostomy, (D) Permanent end colostomy.
Indications • In defunctioning colostomy, loop is brought

out and proximal and distal ends are
Temporary Permanent separated completely so as to give complete
Congenital megacolon AP-Resection rest to the distal part.
Anorectal malformations Carcinoma anal canal • Terminal colostomy is an end colostomy and
Sigmoid volvulus Hartmann’s operation is always a permanent one. End of the
Perforation of left-sided colon
Left sided colonic growth remained colon is sutured to the skin usually
High anal fistula in left iliac fossa.
Trauma to left sided growth
Colostomy Care
• Similar to stoma care.
• Initially stoma bag should be transparent as
content is liquid stool but later it can be
opaque.
• Regular consultation with stoma therapist.
• Care of the skin.
• Training for managing colostomy, its care to
prevent leak, odor, and discomfort.
Closure of Colostomy
– When temporary colostomy is done, it is
closed usually after 3 months. Closure of
colostomy is done after proper bowel
preparation, under general anaesthesia.
– Proper postoperative care is important. Enema
should not be given postoperatively. Patient
Fig. 7.26: Colostomy bag fixed at colostomy site. should perform anal sphincter exercises to
prevent sphincter atrophy and to maintain
Complications of colostomy sphincter tone.
1. Prolapse of mucosa
2. Retraction THYROIDECTOMY
3. Necrosis
4. Stenosis Types
5. Herniation 1. Hemithyroidectomy: Along with removal of one
6. Bleeding lobe, entire isthmus is removed. It is done
7. Diarrhoea in benign diseases of only one lobe.
8. Enteritis 2. Subtotal thyroidectomy commonly done in toxic
9. Skin excoriation thyroid either primary or secondary and also
often for nontoxic multinodular goitre. Here
Educating the patient regarding the proper about 8 grams, or a tissue, size of pulp of
usage of colostomy bags and proper care of the finger is retained on lower pole, on both sides
colostomy is very essential. and rest of the thyroid gland is removed.
• In Loop colostomy, a loop of colon is brought 3. Partial thyroidectomy is removal of the gland
to the surface of the skin (abdominal wall) in front of trachea after mobilization. It was
with a thin glass rod or tube passed through earlier done in nontoxic multinodular goitre.
the mesocolon. Now subtotal thyroidectomy is preferred.
4. Near total thyroidectomy: Here both lobes except immediate release of sutures including that
the lower pole which is very close to recurrent of deep fascia has to be done and pressure
laryngeal nerve and parathyroid is removed. over the trachea is released. Then patient is
It is done in case of papillary carcinoma of shifted to operation theatre, and under general
thyroid. anaesthesia exploration is done and bleeders
5. Total thyroidectomy: Entire gland is removed. are ligated. Blood transfusion may be required.
It is done in case of follicular carcinoma of thyroid, 2. Respiratory obstruction: It may be due to
medullary carcinoma of thyroid. haematoma (if it is so, the haematoma has
to be evacuated), or due to laryngeal oedema.
Procedure For laryngeal oedema, immediate emergency
Position: Under general anaesthesia patient is endotracheal intubation is done along with
put in supine position with neck extended by steroid injections. Often emergency tracheo-
placing a sand bag under shoulder—with stomy may be required as a life saving
table tilt of 15º head up to reduce venous procedure.
congestion. 3. Recurrent laryngeal nerve palsy: It can be
transient or permanent. Transient is 3%
Incision: Horizontal crease incision is done, two common. They usually recover in 3 weeks
finger breadth above the sternal notch, from one to 3 months. Often they require steroid
sternomastoid to the other. supplement and speech therapy. Permanent
Skin and platysma are incised—upper flap raised paralysis is rare.
upto thyroid cartilage, lower flap up to sterno- 4. Hypoparathyroidism is rare 0.5% common.
clavicular joint. Deep fascia is opened vertically Mostly it is temporary due to vascular spasm
in the midline. Strap muscles are retracted or of parathyroid glands, occurs in 2-5th
cut in between two Kocher’s forceps. Pretracheal postoperative day. Present with weakness,
fascia is opened to mobilise the thyroid. First, +ve Chvostek’s sign, carpopedal spasm,
short stout middle thyroid vein is ligated, and convulsions. Serum calcium estimation has
then superior thyroid pedicle is ligated close to to done and then 10 ml of 10% Calcium
the gland so as to avoid injury to external gluconate is given IV eighth hourly, and later
laryngeal nerve. Inferior thyroid artery is ligated supplemented by oral calcium 500 mg 8th
away from the gland so as to avoid injury to hourly. After 3-6 weeks, patient is admitted,
recurrent laryngeal nerve. Mobilised gland is drug is stopped and serum calcium level is
removed. Bed is sutured with catgut so as to repeated.
prevent bleeding. Drain is placed. The wound 5. Thyrotoxic crisis (Thyroid storm): occurs in
is close in layers. a thyrotoxic patient inadequately prepared
for thyroidectomy and rarely a thyrotoxic
Thyroid steal: Patient is taken to operation theatre patient presents in a crisis following an
for few days before doing surgery so as to reduce unrelated operation or stress. They present
the anxiety of the patient. in 12-24 hours with severe dehydration due
to circulatory collapse, hypotension,
Complications of Thyroidectomy hyperpyrexia, and often cardiac failure.
1. Haemorrhage: May be due to slipping of Treatment is injection hydrocortisone, oral
ligatures either superior thyroid artery or antithyroid drugs, tepid sponging of whole
other pedicles. It will cause tachycardia, body, beta blocker injection, oral iodides, large
hypotension, breathlessness, and compres- amount of IV fluids for rehydration, digitoxin,
sion over the trachea may cause severe stridor, cardiac monitor, often ventilator support, and
respiratory obstruction. As a first aid, observation. It has got high mortality rate
with critical period of 72 hours. Fluid and Disadvantages

electrolyte management, cardiac management • Infection.
are important aspects to be monitored and • Discharge from the site.
treated.
6. Injury to external laryngeal nerve causes LASERS IN SURGERY
weakness of cricothyroid muscle leading to
alteration in pitch of voice. (Light Amplification Stimulated Emission of
7. Hypothyroidism. Revealed clinically after 6 Radiation)
months. Molecules are placed in a compact area and
8. Wound infection, stitch granuloma power is passed through this so as to activate
formation. the molecules. Molecules get activated at different
9. Keloid formation. periods and move in different directions , which
they hit to each other releasing energy. This
energy is allowed to act through optical system
to the area wherever required.
CRYOSURGERY – Depending on the molecules used it is named.
• It is the destruction of tissues by controlled – Argon Laser.
cooling. – Yttrium-Aluminium Garnet Laser (YAG
• System contains an automatic defrosting Laser).
device with a cryoprobe. – CO2 Laser.
– Neon Laser.
Gases used are
– Holmium laser.
1. Nitrous oxide – minus 98 degree temperature. – Erbium laser.
2. CO2—minus 60°.
3. Liquid N2—minus 180°. Uses of Laser
4. Freon—minus 190°. • In cranial surgery in children.
• Commonly used is nitrous oxide as it is easily • In ENT to treat vocal cord lesions, Laryngeal
available, cheaper and achieves optimum lesions.
temperature required for different procedures. • In ophthalmology it is very useful in retinal
surgery like for detachment,
Mode of Action – Iridotomy,
1. It produces intracellular crystallization, – Dacrocystitis,
dehydration and denaturation of proteins and – Capsulotomy,
cell death. – To liquefy human lens,
2. It causes the obliteration of microcirculation – In glaucomas, etc.
and so cell death. • In General surgery:
– In bleeding duodenal ulcer.
Indications – For palliative decoring of tumors in
• To remove warts and lesions in the skin. carcinoma oesophagus.
• Cryotherapy for piles. – In carcinoma rectum.
• For chronic cervicitis. – In haemorrhoidal treatment (1st and 2nd
degree).
Advantages – In bladder tumour resection.
• Relatively bloodless and painless. – In cervical cancer.
• Adequate control of extent and depth in – To achieve bloodless field.
freezing. – In varicose veins – Endo Venous Laser
• Equally effective. Ablation (EVLA)
• Often in making incisions in abdomen and
other places.
Advantages of Laser
• Blood less field.
• Faster.
• Small lesions can be removed easily and
completely.
Precautions
• All reflecting instruments should be avoided
otherwise laser will reflect and can injure
normal tissues or the working team in the Fig. 7.27: Circular stapler for colorectal anastomosis.
OT itself.
• All should wear protective spectacles to
protect their eyes. 5. Stapler for lung apposition.
6. Endostaplers: Staplers used during Laparo-
Disadvantage scopic surgeries. For bowel anastomosis it
Availability and cost factors. is commonly used. Endovascular staplers are
used to ligate vascular pedicles like renal
pedicles during Laparoscopic nephrectomy.
STAPLERS IN SURGERY
Staplers are used for apposition of tissues. Used Disposable Staplers
in skin, bowel, lungs, etc. Disposable staplers are available but are costly.
Advantages
Types
Technically easier and faster.
1. Cutaneous staplers give clean apposition. It
is faster and technically easier. Problem is Disadvantages
removal requires specific instrument and Cost factor, availability.
costlier than sutures.
2. Linear staplers are used to close the bowel Problems with Staplers
either completely or partially. • It is not completely haemostatic and so
3. Circular staplers also called as EEA Stapler— bleeding can occur.
End to End Anastomosis. It is commonly used • Leak from anastomosis, improper apposition.
for colorectal anastomosis in Anterior • Intestinal obstruction.
resection for carcinoma rectum, oesophago-
gastric anastomosis after oesophagogastric
resection in case of carcinoma at O-G Junction.
DIATHERMY (ELECTROCAUTERY)
Parts are stapler gun, and cartridge with It is the method to control bleeding or to cut
two rows of stapler pins for apposition. the tissues during surgery.
Loaded cartridge is detachable. Cut ends of
bowel are placed over gun and cartridge. Once Types
gun is shot, cartridge moves to the gun and Based on type of current.
creates anastomosis. 1. Unipolar cautery.
4. GIA stapler (Gastrointestinal anastomosis 2. Bipolar cautery. It is safer because its effect
stapler) for side to side anastomosis like small is seen only in between electrode points.
bowel or ileo-colic anastomosis. Adjacent tissues will never get damaged.
Based on type of action: • Semm changed 75% open gynaecological

1. Coagulation cautery which causes haemosta- surgeries into laparoscopic surgeries.
sis by tissue coagulation. Here temperature • Prof. TE Udwadia, Mumbai did first laparo-
is 100 degrees. scopic cholecystectomy in India.
2. Cutting cautery: Here temperature is 1000
degrees which disintegrate the tissues. It is Advantages of Laparoscopic Surgery
not haemostatic. • Relatively less painful compared to open
3. Blended current is combination of both surgery. Trauma of assess is very less.
coagulation and cutting. • Shorter hospital stay and early return to work.
• Faster postoperative recovery.
Uses • Better visualization of the anatomy ie. better
• For coagulation of bleeders during surgery approach for dissection and visualization of
to achieve haemostasis. other parts of abdomen for any other pathology
• To cut muscles, fascia, etc. • Instrumental assess to different abdominal
• It is essential for laparoscopic surgical locations is better many times compared to
procedures. Bipolar is commonly used. open method.
• It is used to remove small cutaneous lesions, • Minimal scar in the abdomen.
to control bleeding duodenal ulcer.
Instruments Used
Disadvantages • Zero degree laparoscope is commonly used.
• Infection. Side viewing scopes are also used to have
• Cauterization of normal tissues. better visualization.
• Explosive problems. • Cold light source either Halogen lamp or
• Diathermy burn to the patient where Xenon lamp is used. Halogen lamp is used
diathermy plate is kept. commonly and is cheaper. Xenon lamp gives
• Burn injury or electrical shock to surgeon high visualization.
and assisting personnel. • Camera: 3 chip camera is commonly used
with high resolution.
Precautions • Video-monitor to display images.
• Proper earthing. • CO2 insufflator.
• Avoid loose contact of electrodes. • Long fine dissectors like in open surgical
• It should be kept off when not in use during techniques.
procedure. • Hooks and spatulas are used along with cau
tery for dissection.
LAPAROSCOPIC SURGERY • Clip applicators.
• Needle holder.
History • Endostapler.
• First laparoscopic cholecystecomy is done by • Veress needle.
Muhe of Germany in 1985 and by Mouret • Suction-irrigation apparatus.
in Lyon in 1987. • Trocars of different sizes—10 mm, 5 mm.
• McKeran and Saye performed first laparo- • Reducers to negotiate smaller instruments
scopic cholecystectomy in USA in 1988. through larger ports.
• First laparoscopic appendicectomy was done
by Semm as prophylaxis. Preparation
• First laparoscopic appendicectomy for acute Always general anaesthesia. Other preparations
appendicitis was done by Schreiber 1987. are same as for open method.
Technique • It increases the arterial pressure also.
• Pressure bandages are applied to both legs • It compromises the respiratory function by
to improve the venous return and to decrease compressing over the diaphragm impairing
the stasis. the pulmonary compliance.
• Head end of the table is lowered to have easier
insertion of veress needle and scope. Complications
• Ryle‘ tube and Foley’s catheter are must before • CO2 Narcosis and Hypoxia.
insertion of the trocars. • Sepsis – Subphrenic abscess, Pelvic abscess,
• Pneumoperitoneum is created using veress septicemia.
needle through umbilical incision. Assess can
• IVC compression.
be achieved by open method through an
• Bleeding.
umbilical incision.
• Leak from the site, e.g. bile leak.
• Organ injury during insertion of ports, e.g
CO2 is used to create pneumoperitoneum
major vessels, bowel, mesentery, liver.
commonly.
• Subcutaneous emphysema and pneumo-
• It is readily available.
mediastinum formation.
• It is cheaper.
• Gas emboli though are rare but fatal.
• It suppresses the combustion.
• Postoperative shoulder pain due to
• It is easily absorbed by tissues.
diaphragmatic irritation.
• It has a high diffusion coefficient.
• Cardiac dysfunction due to decreased venous
• It is quickly released via respiration.
return.
Other gases used are: Air, Nitrous oxide, Helium, • Injury to the abdominal wall vessels and
Argon. nerves.
Pneumoperitoneum is created up to 15 mm Hg • Cautery burn to abdominal structures.
which distends the abdominal cavity adequately • Abdominal wall hernias.
to have proper visualization of the abdominal • Wound infection.
contents. • Mortality — 0.5 %.
• Laparoscope is inserted through the umbilical
port (10 mm). Abdomen is evaluated for Relative Contraindications
pathology. Liver, gallbladder, pelvic organs • Cardiac compromised patient.
are visualized. • Peritonitis patients.
• Additional ports (3-4) through trocars depen- • Previous abdominal surgeries.
ding on the procedure to be done are placed. • Bleeding disorders.
It may be either 5 mm port or 10 mm port. • Morbid obesity.
These ports are placed in such a way to have • Pregnancy in third trimester.
a proper triangulation of instruments for • Portal hypertension.
dissection.
• To use clip applicator 10 mm port is required. Basic Laparoscopic Surgeries
Physiologic Changes due to Laparoscopic cholecystectomy.
Pneumoperitoneum Laparoscopic appendicectomy.
• CO 2 causes hypercarbia, acidosis and
hypoxia. LAPAROSCOPIC
• Pneumoperitoneum due to pressure on the
CHOLECYSTECTOMY
IVC decreases the venous return and so the
cardiac output. Is fast becoming popular method of treatment.
injure or clip the CBD or hepatic ducts. Gall

bladder is separated from its bed using cautery
and spatula and removed through the epigastric
port. Abdomen may be drained. Patient is
discharged after 48-72 hours.
Complications
• CBD injury.
• Bile leak.
• Haemorrhage.
• Postoperative jaundice.
• Subphrenic and other intraabdominal
Fig. 7.28: Ports for laparoscopic cholecystectomy abscess.
• Septicaemia.
Indications • When problem arises one should be ready to convert
into open cholecystectomy. Conversion rate to open
Gallstones—symptomatic.
cholecystectomy is 2-10%. It is indicated when
Cholecystitis.
there is uncontrolled bleeding, dense
Biliary colic.
adhesions, suspect CBD injury, when
anatomy is indistinct.
Relative Contraindications
• When required one should not be hesitant
• End-stage cirrhosis, ascites or portal hyper-
to do conversion.
tension.
• Cholangitis: Cholecystectomy should be done LAPAROSCOPIC
after control of cholangitis.
APPENDICECTOMY
• CBD stones: Here initially ERCP and stone
extraction is done from CBD then Indications
laparoscopic cholecystectomy is done. Acute appendicitis. Here main advantage is
confirmation of the diagnosis. Other parts of the
Technique abdomen are also visualized.
After pneumoperitoneum, patient is placed in
Relative Contraindications
head up and slight left tilt position so as to make
Appendicular mass and abscess.
bowels to fall below and towards the left side.
one 10 mm trocar is placed at umbilicus and
Technique
through this umbilical port, laparoscope is passed.
Laparoscope is passed through the umbilical
One 10 mm port in the epigastric region and port. Two additional ports are placed one in
two 5 mm ports in the right subcostal line are lower midline (5 mm), another at right lumbar
placed for grasping the gallbladder and for region. Mesoappendix is clipped or cauterized
dissection. Initially, through the working channel using bipolar cautery. Appendix base is clipped
gall bladder is held and Calot’s triangle is dissected. or ligated using Roeder knot and ligature.
Cystic duct and cystic artery are clipped.
An intraoperative cholangiogram, done with Complications
C-Arm, will help. Through the epigastric port, • Appendicular stump leak.
clips or ligatures are applied to the cystic duct • Pelvic abscess.
and cystic artery, close to the gall bladder. Care • Bleeding.
should be taken to avoid bleeding and not to • Injury to caecum, ileum.
• Ovarian diseases.
• Infertility.
• Staging of the malignancy.
• Biopsy from the tumours.
• Chronic pain abdomen where U/S, endo-
scopies, barium studies are negative then
diagnostic laparoscopy is useful.
Advantages
• Laparotomy is avoided.
• Once diagnosis is made, therapeutic
procedure can be carried out also in the same
sitting.
RETROPERITONEOSCOPY
Fig. 7.29: Ports for laparoscopic appendicectomy
It is becoming popular in urology to assess
kidney, ureter, adrenals for various urologic
ADVANCED LAPAROSCOPIC procedures.
SURGERIES Through a small loin approach, retroperito-
neum is expanded by inflating balloon in the
• Presently most of the abdominal surgeries
space. Once space is created different ports are
can be done through laparoscopy.
placed to do dissections.
• It requires advanced technology, skill.
Surgeon should be expert in doing
Procedures
intracorporeal and extracorporeal knotting.
Procedures done through retroperitoneoscopy
• Procedures done are: are:
– Laparoscopic hernia repair. • Nephrectomy.
Laparoscopic splenectomy. • Pyeloplasty.
– Laparoscopic fundoplication. • Adrenalectomy.
– Laparoscopic vagotomy and • Pyelolithotomy.
gastrojejunostomy. • Uretero-lithotomy.
– Laparoscopic Nissen’s fundoplication. • Retroperitoneal lymph node dissection.
– Laparoscopic colectomy. (RPLND).
– Laparoscopic hysterectomy. It is becoming
very popular. Complications
– Laparoscopic urologic surgeries. • Injury to vessels.
– Laparoscopic paediatric surgeries. • Paralytic ileus.
• Bowel (colon) injury.
DIAGNOSTIC LAPAROSCOPY
Advantage
Indications Complications of pneumoperitoneum is not
• Acute pelvic conditions. present and so respiratory reserve is well
• Tubal pregnancy. maintained.
7. Upper horizontal.
8. Thoracoabdominal.
9. Subumbilical.
10. Incision for lumbar sympathectomy.
11. Lower midline.
12. Lower right or left paramedian.
13. Incisions for appendicectomy—Mac
burney’s, Rutherfold Morrison’s, Lanz,
Laparoscopic.
14. Pfannensteil incision.
15. Lower horizontal.
16. Mayo Robson incision.
17. Mercedes Benz extension incision.
18. Groin incision.
19. Battle’s incision – lateral paramedian
A
incision – not used now – causes rectus
muscle denervation.
Factors Affecting the Incisions

• Type of surgery—emergency or elective.
• Sepsis.
• General condition of the patient.
• Age of the patient.
• Nutrition.
• Type of closure.
• Suture materials used.
• Postoperative management.
• Chronic diseases like cough, vomiting.
Upper incisions are always better. Horizontal incisions
are better.
• Abdominal incisions should be of adequate
length to expose and perform the surgery
B
effectively. Skin, subcutaneous tissue, two
layers of superficial fascia, anterior rectus
sheath, posterior rectus sheath and perito-
Figs 7.30A and B: Different incisions in the abdomen.
neum should be opened in the line of incision.
While opening the peritoneum, care must be
ABDOMINAL INCISIONS taken not to injure the bowel content and
so it should be lifted properly using artery
Different Abdominal Incisions
forceps and felt for any content and then
1. Upper midline.
opened. Rectus muscle in vertical paramedian
2. Upper right paramedian.
incisions is separated from its medial aspect
3. Upper left paramedian.
to reach the posterior rectus sheath.
4. Kocher’s incision (right subcostal).
• Lateral side of rectus muscle if approached
5. Left subcostal.
is called as Battle’s incision which should
6. Bucket handle—Roof top.
not be practiced as it denervates the rectus
muscle. Retraction of the abdominal wound
GASTROSTOMY
is done using proper instruments of different
types. It is done if feeding is required more than one
• While closing the abdomen it closed in layers– month.
peritoneum using vicryl; anterior and Indications
posterior rectus sheath using nonabsorbable • Severe mal nutrition
monofilament sutures. • Major surgeries
• In case of peritonitis/acute abdomen, • Severe sepsis
abdomen is closed with single layer through • Trauma
and through interrupted sutures with tension • Head and neck surgeries
support (tension sutures).
• Drain when required should be kept away
from the main wound. In emergency laparo-
tomy, lengthy midline incision with left sided
curve adjacent to umbilicus.
• In trauma and ruptured aneurysms, incision
should be made from xiphisternum to pubic
symphysis to expose widely for rapid
intervervention.
A B
Complications of Abdominal Incisions
• Wound infection.
Figs 7.32A and B: Types of gastrostomy: (A)
• Haematoma in the wound. Temporary gastrostomy (B) Permanent gastrostomy.
• Burst abdomen – serosanguinous discharge
with feeling of given way is typical.
• Fistula through main wound Types
• Incisional hernia Based on duration of use:
Temporary
Permanent.
Based on lining:
Mucus lined (permanent).
Serosal lined (Temporary).
Based on technique:
1. Stamm’s Temporary Gastrostomy done after
opening the abdomen, anterior wall of the
stomach is opened . Feeding tube (Malecot’s
catheter) is placed in position. Two layers
of purse string sutures are put around the
tube. Wound is closed.
2. Kader-senn temporary gastrostomy.
3. Percutaneous endoscopic gastrostomy.
4. Janeway’s mucus lined permanent gastro-
Fig. 7.31: Tension sutures placed to prevent burst stomy by creating tunnel in stomach
abdomen. wall.
Problems in gastrostomy GASTRECTOMY

• Leak
• Infection Types
• Aspiration and pneumonia 1. Billroth I is done for benign condition. Here
along with partial gastrectomy, gastroduo-
Contraindications denostomy is done.
2. Billroth II is done for carcinoma stomach.
• Previous gastric surgeries.
After partial gastrectomy, gastrojejunostomy
• Intestinal obstruction.
is done and duodenal stump is closed.
• Gastric outlet obstruction.
3. Lower radical gastrectomy is done in early
carcinoma pylorus. Here along with the
JEJUNOSTOMY growth and proximal 5 cm of stomach,
omentum, lymph nodes, spleen with tail of
Jejunostomy for enteral nutrition becoming more
pancreas is removed and Billroth II
popular because of—
anastomosis is done.
– its comfort,
4. In growth of upper part or O-G junction, upper
– easy to do,
radical gastrectomy is done along with
– can be kept for long time,
oesophago-gastric anastomosis.
– lesser complication than gastrostomy. 5. In some cases like linitis plastica, total
– Indications are same as gastrostomy. gastrectomy along with oesophago jejunal
anastomosis is done.
Fig. 7.33: Needle jejunostomy Figs 7.34A and B: Types of anastomosis after gastrectomy:
(a) Billroth I anastomosis (b) Billroth II anastomosis.
Types Indications
• Witzel jejunostomy: Site of placing • Chronic benign gastric ulcer.
jejunostomy is 30 cm from duodenojejunal • Benign tumors of stomach (Leiomyoma).
junction. • Carcinoma stomach.
• Needle jejunostomy using catheter of small • Stomal ulcer.
gauge. • Bleeding ulcer.
Procedure Complications
Abdomen is opened through upper midline • Bleeding.
incision. Tumour is felt and explored. Liver, • Bile leak.
omentum, tumor fixity, rectovesical pouch, nodes • Duodenal blow out.
in mesocolon are looked for. Omentum is mobi- • Gastric fistula.
lised and detached from colon. Kocherisation • Dumping syndrome.
is done by mobilising second part of the • Anaemia.
duodenum. Right gastric artery is ligated. Left
gastroepiploic artery is also ligated. Care should CHOLECYSTECTOMY (OPEN)
be taken not to injure middle colic artery. Stomach
is divided using linear cutter stapler at duodenal Indications are similar to laparoscopic cholecys-
stump. Alternatively it can be divided using tectomy.
crushing clamp at gastric side and occlusion Preparation is similar like for obstructive
clamp at duodenal side and duodenal stump jaundice or any other laparotomy. Incision is
is closed using 2 zero vicryl sewing machine right subcostal Kocher’s incision. Nasogastric
sutures. Stomach is lifted upwards and tube should be passed. After opening the
descending branch of left gastric artery is ligated abdomen, contents are explored. One mop is kept
securely. Large occlusion clamp is applied and over the stomach and retracted medially; another
stomach is divided after applying crushing clamp over the colon and retracted below. One more
on the tumor side. New lesser curve is created under surface of the liver margin and retracted
often with a valve using vicryl single layer sutures. above using Deaver’s retractor. Gallbladder is
Billroth II or any of its modification type of held using gallbladder holding or sponge holding
gastrojejunostomy anastomosis is done. Often forceps and retracted outwards towards the
a jejunojejunostomy is added to prevent possible wound. Hartmann’s pouch is held with
duodenal leak. Corrugated or tube drain is kept Babcock’s forceps (Hartmann’s is pathological
on right subhepatic pouch for 5 days. infundibulum of the gallbladder). Calot’s triangle
dissected carefully using peanut, scissor and long
artery forceps. Cystic duct is identified and
dissected carefully. Cystic artery is also identified
above that and dissected. Anomalies and
A
variations of cystic duct like low insertion,
insertion into right hepatic duct etc are common
and should be remembered. Cystic duct is doubly
ligated using silk or vicryl suture material. Cystic
artery is ligated using silk. Gallbladder is
mobilized from liver bed using cautery and
suction. Small bleeders in gallbladder bed of the
B liver are cauterized. Ligated cystic duct is
cannulated along with a syringe. Air bubble
should not be there in the cannula/needle or
syringe (if present it will be mistaken for a
radiolucent stone in C ARM or X-ray). Water
C soluble iodine dye is injected into the CBD
through this cannula. Any stone if present in
Figs 7.35A to C: Gastrectomies for carcinoma stomach CBD appears as radiolucent area. It indicates
at different locations (A) Lower radical gastrectomy (B) that choledochotomy should be done. Other
Upper radical gastrectomy (C) Total radical gastrectomy indications are – palpable stone in CBD; dilated
CBD more than 10 mm; recent jaundice; US Complications

shows CBD stone or when in doubt. • Injury to common bile duct, common hepatic
artery, duodenum.
In difficult gallbladder – fundus first method is used.
• Biliary fistula.
Fundus is separated from liver bed and dissected
• Abscess formation–subphrenic/local/pelvic.
towards the Calot’s triangle. Carefully cystic duct
• Waltermann Waltmann syndrome–collection
is dissected and ligated. In difficult situations,
of fluid in the subhepatioc pouch/gallbladder
mass ligature of cystic duct and cystic artery
bed which is compressing on IVC causing
is also done. Subtotal cholecystectomy is done when
cardiac symptoms.
it is not possible to dissect the gallbladder near
• Obstructive jaundice.
Hartmann’s pouch.
• Sepsis, septicaemia and its problems.
Drain is placed in subhepatic pouch (tube/
corrugated). Wound closed in layers.
Definitions of Common Terminologies in Surgery
Abscess—localized collection of pus in a cavity lined by granulation tissue covered by pyogenic

membrane.
Achalasia cardia—a neuromuscular disorder where there is dilatation of oesophagus without stenosis.
Acute rejection—occurs during the first 3 months of transplantation characterised by mononuclear
cell infiltration of the graft.
Agraphia—loss of power of writing without paralysis of muscles of writing.
Amoeboma—extensive reaction leading to granuloma formation in response to amoebic mucosal
invasion.
Anchovy sauce—chocolate-coloured pus in amoebic liver abscess.
Aneurysm—dilatation of localized segments of arterial system.
Angular stomatitis—moist, infected reddish brown fissure at the angle of the mouth.
Anhidrosis—lack of sweating.
Ankylosing spondylitis—chronic inflammatory condition involving mainly sacroiliac joints and
spine, where the intervertebral disc is replaced by vascular connective tissue that undergoes
ossification.
Annular pancreas—developmental anomaly where there is a ring of pancreatic tissue surrounding
the 2nd or 3rd part of duodenum due to failure of complete rotation of ventral pancreatic duct.
Anorexia—lack or loss of appetite for food.
Aphagia—complete oesophageal obstruction, which is usually due to bolus impaction and represents
a medical emergency.
Appendicitis—inflammation of appendix, may be acute or chronic.
Appetite—physical desire for food.
Ascites—collection of excess serous fluid in peritoneal cavity.
Atelectasis of lung—collapse of one or more segments of lung following blockage of some part
of bronchial tree commonly with inspissated mucus plug.
Atheroma—subendothelial plaques seen in arteries near bifurcation or at the origin of major branches
in atherosclerosis.
Atherosclerosis—degenerative disease of the arteries, mainly large and medium sized, characterised
by accumulation of lipids and fibrous tissue in intima along with smooth muscle proliferation.
Auriculotemporal syndrome—flushing, sweating and pain over the parotid area due to injury
to the auriculotemporal nerve with subsequent regeneration.
Bacteraemia—presence of bacteria in blood with no clinical manifestation.
Miscellaneous 547
Barrett’s oesophagus—metaplasia of mucosal lining of oesophagus in response to chronic
gastroesophageal reflux.
Belanoposthitis—infection of the glans penis and prepucial sac.
Branchial cyst—cystic swelling seen in the upper part of the neck, develops from the persistent
embryonic cervical sinus.
Brodie’s abscess—chronic abscess in the metaphysial region of the bone surrounded by dense
sclerotic bone.
Burn—coagulative destruction of surface layers of the body.
Bursae—endothelial-lined, containing little fluid present between tissues that slide past each other
and help to decrease the frictional force.
Cachexia—a profound, marked state of constitutional disorder, general ill health and mal-nutrition
(cancerous, cardiac, fluorosis, hypophysial).
Callosity—localised, superficial, circumscribed, thickened part of skin seen over region of friction.
Cancer-en-cuirasse—skin over the chest is infiltrated with multiple cancerous nodules resembling
like a coat of armour.
Caput medussae—veins seen radiating from the umbilicus in the anterior abdominal wall, indicates
obstruction in porto-systemic circulation.
Carbuncle—infective gangrene of the subcutaneous tissue caused by infection from a hair follicle.
Caroli’s disease—congenital dilatation of the intrahepatic biliary ducts.
Cellulitis—nonsuppurative, superficial spreading inflammation of skin and subcutaneous tissue.
Chemodectoma—tumour arising from chemoreceptor cells on medial side of the carotid bulb.
Chemosis—oedema of conjunctiva.
Cholecystitis—inflammation of gallbladder, may be acute or chronic.
Chronic rejection—occurs very slowly, over months after the grafted organ has started functioning
normally, mediated by antibodies and T cells.
Chylocele—presence of chyle in the sac of Tunica vaginalis.
Chylothorax—accumulation of chyle in the pleural space.
Chylous ascites—accumulation of chyle in abdominal cavity often seen in lymphomas,
adenocarcinoma that causes lymphatic obstruction.
Chyluria—passage of chyle in urine, probably due to development of fistulous connection between
lymphatics and urinary tract.
Claudication distance—distance the person can walk before the onset of claudication pain.
Claw foot—there is increased concavity of the arch of foot.
Cleft lip—occurs due to failure of fusion of median nasal process and maxillary process.
Cleft palate—occurs due to incomplete fusion of premaxilla and palatine processes.

Clubbing—bulbous enlargement of soft parts of terminal phalanges, with both transverse and
longitudinal curving of the nail.
Colostomy—artificial opening made into the large bowel in order to divert its content into exterior,
may be permanent or temporary.
Commensals—non-pathogenic organisms that invade body surfaces like skin, mucus epithelial
lining of nose, pharynx, larynx, GIT, anterior urethra, vagina, and conjunctival sac.
Condyloma acuminata—warts or papilloma caused by HPV.
Condyloma lata—raised, flat, white, hypertrophied epithelium seen in secondary stage of syphilis
at muco-cutaneous junction.
Constipation—persistent, difficult, infrequent or seemingly incomplete defaecation. Stool frequency
is not the sole criteria for diagnosis of constipation.
Corn—circumscribed, horny thickening, with central core being pushed into the skin, formed over
areas under extreme pressure, often painful.
Cretinism—hypothyroidism in infants.
Cyanosis—bluish discolouration of the nail due to increased amount of reduced Hb in capillary
blood.
Cystic hygroma—swelling in the neck, due to sequestration of jugular lymph sac from lymphatic
system.
Dactylitis—infection of phalanges and metacarpals.
Dental cyst—painless, cystic swelling with eggshell crackling occurring in relation to normal erupted
pulpless, dead tooth.
Dentigerous cyst—circumscribed painless smooth swelling occurring at the site of unerupted tooth.
Diarrhoea—passage of abnormally liquid or unformed stools at an increased frequency; acute if
<2 weeks, persistant if 2-4 weeks, chronic if >4 weeks.
Diverticulosis—acquired herniation of mucosa through the circular muscle at the points of penetration
of blood vessel.
Dysorexia—impaired or deranged appetite.
Dysphagia lusoria—dysphagia caused by compression of oesophagus by congenital vascular
anomalies.
Dysphagia—sensation of ’sticking’ or obstruction of the passage of food through mouth, pharynx
or oesophagus.
Ectopia vesicae—congenital defect or failure in formation of anterior wall of allantois and lower
anterior abdominal wall exposing the posterior wall of bladder.
Ectopic testis—one which has deviated from its usual path of descent.
Miscellaneous 549
Elephantiasis neuromatosa—severe form of plexiform neurofibromatosis involving the subcutaneous
nerves of the limbs.
Emesis (vomiting)—oral expulsion of gastrointestinal contents resulting from contraction of gut
and thoraco-abdominal wall musculature.
Empyema necessitatis—pus of empyema burrows throws chest wall and becomes superficial
presenting on either anterior or lateral aspect.
Empyema thoracis—collection of purulent fluid between parietal and visceral layers of pleura.
Encephalocele—protrusion of brain.
Endemic goitre—increased goitre prevalence in children in 6-12 years, greater than 10%.
Epididymo-orchitis—inflammation of epididymis and testis.
Epispadias—external urinary meatus opens on the dorsal surface of the penis.
Epulis—tumour arising from mucoperiosteum of gums.
Erysipelas—diffuse cuticular infection associated with inflammation of the superficial lymphatics.
Erythroplakia—when red area is predominant in leucoplakia.
Ewing’s tumour—primary malignant tumour of bone arising from the metaphysis, commonly seen
in childhood.
Exophthalmos—forward protrusion of eyeball as a result of cellular infiltration of retro-orbital
space leading to retraction of eyelid, lower first followed by upper, seen in thyrotoxicosis.
Fissure-in-ano—ulcer in the skin lined part of anal canal.
Fistula—a track that is lined by granulation tissue may be epithelialised, communicating two hollow
viscera or a hollow viscus to surface.
Fistula-in-ano—a track that is lined by granulation tissue connecting an external opening on the
perianal skin to an area in the depth of the anal canal or rectum.
Flatulent dyspepsia—feeling of fullness after food with belching and heart burn often seen in
gallbladder disease.
Galactocele—cystic lesion of the breast, as a result of blockage of one of the main lactiferous duct,
containing milk that has inspissated.
Ganglion—localised, painless subcutaneous cystic swelling commonly over the dorsum of the hand.
Gangrene—death of body part with putrefaction and loss of function.
Gastroparesis—delay in emptying of food from stomach.
Globus pharyngeus—sensation of lump lodged in the throat, however, no difficulty is encountered
while swallowing.
Goitre—diffuse or nodular enlargement of thyroid usually resulting from a benign process or a
process of unknown origin.
Guarding—involuntary muscle rigidity or stiffness indicating underlying parietal peritonitis.

Gynaecomastia—here male breast resembles a female breast.
Haematemesis—vomiting of blood, caused by bleeding in upper GI tract, may be bright red or
dark coloured taking the typical coffee ground colour.
Haematocele—haemorrhage into the tunica vaginalis testis.
Haematochezia—bright red blood from rectum that may or may not mix with stools.
Haemorrhoids—varicosities of the veins of the anal canal.
Haemothorax—blood in pleural space.
Haitus hernia—prolapse of part of stomach into the thoracic cavity through oesophageal haitus.
Hallux rigidus—painful, rigid great toe due to osteoarthritis of 1st metatarsophalangeal joint.
Hallux valgus—valgus displacement of great toe.
Hard chancre—occurs in primary syphilis, over external genitalia nipple, lips, which has characteristic
indurated base, with regional lymph nodes enlarged and discrete showing no signs of suppuration.
Heart burn—burning sensation behind the lower part of sternum radiating up to the neck.
Heberden’s nodes—small pea-like swelling seen in the terminal interphalangeal joints of fingers
due to osteoarthrosis.
Hemianopia—blindness in one half of each visual field.
Hepatomegaly—enlargement of liver.
Hernia—protrusion of whole or part of viscus through the wall that contains it.
Hiccup—brought by spasmodic contraction of diaphragm.
Horseshoe kidney—lower poles of kidneys are joined by fibrous band or renal tissue.
Hour-glass stomach—occurs due to cicatricial contracture around a saddle-shaped lesser curve
ulcer.
Hunger pain—pain seen in chronic duodenal ulcer, below xiphisternum about 1½ to 4 hr after
meal, relieved by taking food.
Hydrocele—is abnormal collection of serous fluid within the sac of tunica vaginalis testis.
Hydrocephalus—increased amount of CSF under tension in the cerebral ventricles.
Hydrohepatosis—gross dilatation of intrahepatic biliary canaculi filled with white fluid.
Hydronephrosis—aseptic dilatation of pelvis and calyses of the kidney due to obstruction to the
flow of urine.
Hyper-acute rejection—occurs within minutes of transplantation and is due to destruction of the
transplanted organ by pre-existing antibodies in the recipient.
Hypersplenism—enlargement of spleen with depletion of one or more blood cells that can be
corrected by splenectomy.
Miscellaneous 551
Hypospadias—external urinary meatus opens on the undersurface of the penis.
Impotence—inability to achieve and maintain an erection, sufficient for intercourse.
Incidentalomas—adrenal tumours incidentally found either by ultrasonography or by CT scan
performed for other disorders of abdomen.
Infection—invasion of tissues by pathogenic organism (bacteria/virus/fungi).
Intermittent claudication—cramp-like pain that develops on exercise in muscles of calf (commonly),
thighs, buttocks due to accumulation of metabolites and, relieved by rest.
Intestinal obstruction—interference in the normal forward progression of intestinal contents.
Intestinal pneumatosis—gas-filled cysts are formed under the mucosa and submucosa of intestine.
Intussusception—invagination of one part of bowel into the next part, often occurs in forward
direction.
Involucrum—new bone formation from periosteum in osteomyelitis.
Jaundice—yellowish discolouration of skin, tissues and body fluids due to increased bile pigments
(normal serum bilirubin—1 mg%, direct—0.25 mg%, indirect—0.75 mg%).
Keloid—overgrowth of scar tissue extending beyond the original wound site.
Latent stone—stone in post-prostatic pouch or diverticula does not produce typical feature of stone
but revealed only X-ray or cystoscopy.
Leiomyoma—benign tumour of smooth muscle.
Leucoplakia—white hyperkeratotic patch in the mouth or penis which may be small, well
circumscribed or wide extensive lesion.
Lid lag—eyelid cannot keep pace with eyeball when it looks down following the instruction of
the examiner.
Lid retraction—upper eyelid is higher than the normal.
Ligaments—tissues that provide stability to joints, and transmit tensile force across the joints.
Lipoma—benign tumour of mature fat cell.
Lumbar spondylosis—degenerative condition involving both disc space and intervertebral joints.
Lung abscess—localized area of suppuration and cavitation within the lung substance.
Lymph scrotum—dilatation and tortuosity of cutaneous lymphatics of scrotum.
Lymph varix—dilatation of lymph vessels of spermatic cord.
Lymphangioma—localised cluster of dilated lymph sac seen in the skin and subcutaneous tissue,
of congenital origin, does not communicate with normal lymph system.
Lymphoedema—interstitial oedema of lymphatic origin.
Lymphomas—neoplastic alteration in lymphoreticular tissues.
Macrocheilia—hypertrophy of lip.
Macrostoma—abnormally large oral orifice due to imperfect fusion of mandibular and maxillary
processes.
Major histocompatibility antigens—important antigens, which are glycoprotein molecules present
on all somatic cells, responsible for graft rejection.
Mallet finger—persistent flexion of terminal phalanx due to rupture of extensor tendons.
Mallory-Weiss syndrome—disruption of mucosa and submucosa of the upper end of the stomach
after a bout of forceful retching.
March fracture—stress fracture affecting 2nd metatarsophalyngeal joint.
Mechanical dysphagia—dysphagia caused due to obstruction by a large bolus.
Meconium ileus—small bowel obstruction seen in infants due to inspissated meconium resulting
from inadequate secretion of pancreatic and intestinal enzymes.
Melanoma—malignant tumour of melanocyte of neural crest in origin.
Meningioma—benign tumour arising from arachnoid villi.
Meningitis—inflammatory reaction in the meninges following growth of bacteria in CSF.
Meningoencephalocele—protrusion of meninges and brain.
Meningocele—protrusion of meninges.
Metatarsus adductus—forefoot is adducted with normal hindfoot.
Micrognathism—congenital deformity where mandible is very small.
Microstoma—abnormally small oral orifice due to excessive fusion of mandibular and maxillary
processes.
Motor aphasia—loss of power of speech without paralysis of muscles of speech.
Multiple myeloma—malignant tumour of bone marrow.
Nausea—subjective feeling of need to vomit.
Necrosis—microscopic cell death.
Neurilemmoma—benign tumour arising from Schwann cell of neurilemma.
Neuroblastoma—tumour arising from immature nerve cells of the sympathetic nervous system
of adrenal and extra adrenal sites.
Neurofibroma—benign tumour containing both neural and fibrous components.
Nystagmus—involuntary oscillation of eyeball.
Odonophagia—painful swallowing.
Odontomes—tumour arising from tooth germs.
Miscellaneous 553
Oedema—collection of fluid in the interstitial space and serous cavities, becomes evident only
when 5-6 litres of fluid has accumulated. Pitting on pressure is evident when the circumference
of limb increases by 10%.
Onychogryphosis—thickened crooked overgrowth of toe nail.
Onychomycosis—fungal infection of nail.
Osteosarcoma—primary malignant tumour of bone arising from the metaphysis, commonly seen
in adolescent age.
Osteomyelitis—acute inflammatory process in the bone commonly occurring in the metaphysis.
Pallor—paleness of skin and mucous membrane, due to diminished circulating RBCs or blood
supply.
Palmar erythema—bright red warm palms,which blanches on pressure.
Pancreatic pseudocyst—collection of fluid in lesser sac following acute pancreatitis or pancreatic
injury.
Pancreatitis—non-infectious inflammatory disease of pancreas caused by activation, interstitial
liberation and autodigestion by its own enzymes.
Papilloma—simple pedunculated overgrowth of all layers of skin.
Paralytic ileus—here there is neurogenic failure of peristalsis to propel the intestinal contents.
Paraphimosis—inability to reduce the previously retracted prepuce.
Paratendinitis—inflammation of tendon sheath.
Paratendon—sheath that encloses a tendon.
Peau d’orange—‘orange peel’ appearance of skin seen in carcinoma breast due to blockage of
subdermal lymphatics and cutaneous oedema.
Peritonitis—inflammatory response of peritoneal lining to various factors (micro-organism, foreign
body, extravasated secretions (bile, urine, blood, meconium).
Pes planus—the height of the arch of foot becomes low and medial border touches the ground.
Phaeochromocytoma—tumour arising from chromaffin cells of adrenal medulla.
Phagophagia—fear of swallowing.
Phimosis—difficulty to retract the prepuce fully and freely over the glans up to the coronal sulcus.
Phlebhitis—thrombosis of superficial vein accompanied by marked pain and inflammatory response
of the overlying tissues.
Pleural effusion—fluid collection between parietal and visceral layers of pleura.
Plexiform neurofibromatosis—fibromyxomatous degeneration of nerve sheath that occurs in the
terminal branches of cutaneous nerves.
Pneumothorax—air in pleural space.
Porcelain gallbladder—dystrophic calcification in gallbladder following acute or sometimes chronic

cholecystitis, causing hard radiopaque gallbladder.
Priapism—persistent painful erection of penis.
Prognathism—congenital deformity where mandible is larger than average, and protrudes.
Prostatism—symptom complex of frequency, urgency, difficulty in micturition.
Pseudodiarrhoea—frequent passage of small quantities of stool, often associated with rectal urgency,
associated with IBS and colitis.
Ptosis—drooping of upper eyelid due to paralysis of levator palpebrae superioris muscle.
Pyelocele—infected hydrocele.
Pyonephrosis—kidney becomes multilobular sac containing pus.
Quinsy—abscess in the peritonsillar region causing severe pain and trismus.
Ranula—retention cyst arising sublingual salivary gland.
Regurgitation—effortless passage of gastric contents into the mouth.
Residual urine—amount of urine collected by passing catheter after voiding urine.
Rest pain—continuous, burning pain seen in lower limbs over the distal foot in advanced stage
of ischaemia, aggravated on elevating the limb, caused by ischaemic neuritis and tissue necrosis.
Retention of urine—failure to pass urine in the presence of normal kidneys and its accumulation
in bladder.
Retractile testis—testis is pulled from the scrotum into the superficial inguinal pouch due to the
strong contraction of cremester muscle, often seen in younger age group.
Retroperitoneal fibrosis—deposition of fibrous tissue in the retroperitoneal space.
Rhabdomyoma—benign tumour of skeletal muscle.
Rigidity—stiffness of abdominal musculature brought by the patient himself due to fear of being
hurt.
Sebaceous cyst—swelling arising due to blockage of duct of sebaceous gland which often opens
into hair follicle.
Sarcoma—rapidly growing malignant tumour of connective tissue, may arise from any tissue of
mesoblastic origin, spread occurs by blood.
Satiety—state of feeling of being completely full of food.
Septicaemia—presence of organisms and their toxic products in blood.
Sequestrum—dead bone in situ.
Shock—profound widespread reduction in effective delivery of oxygen and other nutrients to tissues
leading to reversible, and if prolonged, to irreversible injury (Parillo, 1994).
Sinus—blind track, lined by granulation tissue may be epithelialised, leading from the surface
down into the tissues.
Miscellaneous 555
Sjögren’s syndrome—autoimmune disease causing progressive destruction of salivary and lacrimal
gland.
Slough—piece of dead tissue like skin, fascia, or muscle.
Soft chancre—caused by Haemophilus ducreyi; multiple painful ulcers over external genitalia with
enlarged painful regional lymph nodes which has tendency towards suppuration.
Spider naevi—is a central arteriole with numerous small vessels radiating from it, commonly seen
in liver disorders over the territory of superior vena cava—over face, neck, shoulder, and forearm;
ranges in diameter from 3-15 mm.
Splenomegaly—enlargement of spleen, has to enlarge to more than 2 and a half times to become
palpable.
Splenunculi—accessory splenic tissue.
Spondylolisthesis—gradual slipping forward of the lumbar spine on the sacrum following
degenerative changes in the facet joints and the discs.
Sterilisation—is the process of killing all microorganisms.
Stomatitis—inflammatory, erosive, ulcerative condition of oral mucous membrane.
Surgical emphysema—means air in subcutaneous tissue which was been forced through the chest
wall following an injury to lung.
Syrigomyelia—congenital defect due to mechanical dilatation of the central canal, secondary to
partial obstruction of drainage of CSF from 4th ventricle to the cisterna magna.
Talipes calcaneovalgus—foot is dorsiflexed and everted.
Talipes equinovarus (club foot)—hindfoot is held in varus and is plantar flexed; forefoot adducted
and supinated.
Tenderness—sign elicited by physician by exerting pressure over the diseased site where the patient
complains of pain.
Tendinosis—slow degenerative changes seen in tendons with advancing age.
Tendon—tissues that attach muscle to bone, thereby help in transmitting load from muscle to
bone.
Tenesmus—ineffectual straining at stools with passage of mucus and blood.
Thyroglossal cyst—cystic swelling developing from remnants of thyroglossal duct.
Thyrotoxic crisis—ultra acute form of thyrotoxicosis occurring in thyrotoxic patients inadequately
prepared for thyroidectomy.
Thyrotoxicosis—physiological condition resulting from action of excess of T4 and T3.
Torticollis—deformity in which the head is bent to one side while the chin points to other side.
Tracheomalacia—tendency of trachea to collapse following thyroidectomy for large goitre.
Trigeminal neuralgia—burning or shooting pain along the distribution of trigeminal nerve.
Trigger finger—difficult extension of the affected finger, which extends suddenly with a click.
Trismus—unable to open the mouth due to muscular spasm around temporo-mandibular joint.
Unascended kidney—failure of kidney to ascend from its embryonic position in pelvis and remains
as pelvic organ.
Undescended testis—failure of testis to descend into the scrotum from its embryonic position in
lumbar region along the inguinal canal.
Ureterocele—cystic dilatation of intramural portion of the ureter.
Varicocele—dilatation and tortuosity of veins of pampiniform plexus.
Varicose vein—vein that is dilated, tortuous and saccular, associated with valvular incompetence.
Virulence of organism—ability of organism to establish in the host, to multiply, and to cause
progressive disease.
Volvulus neonatorum—volvulus seen in neonates due to arrested rotation of gut.
Volvulus—twisting of a portion of bowel about its mesentiry.
Wart—elevated lesions with rough keratinised surface, seen over skin and mucus membrane any
where in the body, caused by HPV virus, often contagious.
Water brash—reflux of sour material up to the mouth occurring spontaneously or on bending.
Weight loss (significant)—unintentional loss of > 10% of body weight in 6 months or 5% in past
one month.
White bile—it is the content of the bile duct seen in complete obstruction of common bile duct,
which neither bile nor white.
Xerophthalmia—dryness of eyes due to lack of lacrimal secretion.
Xerostomia—dryness of mouth due to lack of salivary secretion.
a. Sensation—
• Paraesthesia—altered sensation felt in the form of pins and needle.
• Hyparaesthesia—the skin is hypersensitive to normal stimuli.
• Hypoaesthesia—decreased feeling of sensation.
• Anaesthesia—total loss of sensation in the affected part.
b. Deformities of fingers and digits—
• Syndactyly—fusion of two or more fingers.
• Polydactyly—presence of extra digit which may be rudimentary or fully developed.
• Ectrodactyly—absence of digit.
• Macrodactyly—overgrowth of finger.
c. Smell—
• Parosmia—perversion of sense of smell.
• Anosmia—loss of sense of smell.
Miscellaneous 557
d. Head injury—
• Cerebral concussion—head injury leading to temporary physiological paralysis of function without
any organic structural damage, where the patient’s recovery is complete and perfect after a
brief period of unconsciousness.
• Cerebral contusion—head injury leading to rupture of white fibres of the brain causing petechial
haemorrhages, with prolonged variable period of unconsciousness.
• Cerebral laceration—head injury leading to tear of brain surface with effusion of blood into
CSF leading to subarachnoid haemorrhage.
e. Bezoars—foreign bodies in stomach
• Trichobezoar—hair in stomach following abnormal habit of chewing hair.
• Phytobezoar—abnormal vegetable matter in stomach.
f. Some characteristic facies—
• Facies Hippocratica—an anxious look, bright eyes, pinched face and cold sweat are the features
seen in terminal stage of peritonitis.
• Facies of dehydration—features consists of sunken eyes, drawn cheeks, dry tongue.
• Adenoid facies—high-arched palate, narrow dental arch, protruding incisor teeth seen in patients
with enlarged adenoids.
• Carcinoid facies—typical facial flushing seen in patients with carcinoid tumour with metastasis
in liver.
• Facies of cretinism—pale, puffy, wrinkled face with dry cold skin and protruding tongue.
• Facies of Cushing’s—round-shaped face like a full moon with pursed lips.
g. Contour of chest—
• Pectus excavatum (Funnel chest)—congenital condition where there is depression of sternum and
xiphoid process along with inward curving of costal cartilages and adjacent ribs.
• Pectus carinatum (Pigeon chest)—deformity where sternum is unusually pushed forward and is
prominent due to excessive growth of costal cartilages.
• Barrel-shaped chest—antero-posterior diameter is greater than transverse diameter, seen in
emphysema.
• Flat chest—transverse diameter is greater than antero-posterior diameter, seen in emphysema.
• Rachitic chest—bead-like prominences at costo-chondral junction.
h. Anomalies in breast—
• Amazia—absence of breast.
• Polymazia—accessory breast, present along the milk line.
• Athelia—absence of nipple.
• Polythelia—accessory nipples may occur along the milk line (from anterior axillary fold to the
fold of groin).
i. Ulcer—break in continuity of the covering epithelial surface, skin or mucus membrane.
• Margin—junction between normal epithelium and ulcer.
• Edge—area between margin and floor.
• Floor—exposed surface of the ulcer.
• Base—on which the ulcer rests, better felt than seen.
j. Biopsy—
• Needle biopsy—a core of tissue is removed by introducing a hollow needle into the swelling
(Vim Silvermann needle for liver biopsy.
• Drill biopsy—a core of tissue is removed by introducing a sharp cannula attached to a high
speed compressor air drill.
• Punch biopsy—using a punch biopsy forceps, a piece of tissue is taken from the margin of the
tumour along with surrounding normal tissue.
• Open biopsy—done by surgery; incisional—only a slice of tumour is removed; excisional—whole
lesion with surrounding normal tissue is removed for malignant but only the lesion for benign.
• FNAC—tissue from the suspected lesion is aspirated using fine needle (22/23 gauge) and sent
for cytology.
• Exfoliative cytology—cells shed from tumour present in hollow viscus is collected and studied
under microscopy for any malignancy (e.g—respiratory tract tumours, bladder tumours).
k. Swelling—
• Impulse on coughing—impulse elicited on coughing over swelling which are in continuity with
pleural, abdominal, cranial, spinal cavities.
• Fluctuation—it is a feel over a swelling containing gas or liquid due to pressure transmitted
in perpendicular direction.
• Translucency of a swelling—means it contains clear fluid (water, serum, lymph, plasma) and can
transmit light through it.
• Reducibility of swelling—swelling reduces and disappears completely.
• Compressibility of swelling—swelling can be compressed but do not disappear completely.
l. Tongue—
• Ankyloglossia—inability to protrude the tongue out.
• Macroglossia—painless, large tongue.
• Black hairy tongue—due to fungal infection.
m. Nails—
• Koilonychia—spoon shaped, brittle nails.
• Terry’s nail—whitening of nailbed, a manifestation of hypoalbuminaemia.
n. Abnormal stools—
• Melaena—black, tarry (sticky) stools.
• Steatorrhoea—bulky, pale, sometimes frothy, porridge-like.
• Slimy stool—when there is excess mucus.
• Pipe stem stool—in carcinomatous stricture of rectum.
• Tooth paste stool—in Hirschsprung’s disease.
o. Haemorrhage under skin—
• Petechiae—tiny haemorrhage less than 1 mm diameter.
• Purpura—haemorrhage 2-5 mm in diameter.
• Ecchymosis—haemorrhage >5 mm in diameter.
• Haematoma—haemorrhage large enough to elevate the skin.
p. Vertebral column—
• Scoliosis—abnormal lateral curvature of spine.
• Kyphosis—abnormal antero-posterior curvature of the spine, with forward concavity.
• Lordosis—abnormal antero-posterior curvature of the spine, with forward convexity.
Miscellaneous 559
q. Skin eruptions
• Macule—not raised above the skin.
• Papule—raised tiny nodule.
• Pustule—papules containing pus.
• Nodule—large papule as a solitary projection from the skin.
• Vesicle—small blister.
• Wheal—elevated patches on the skin with centre pale than periphery.
• Café-Au-lait patches—coffee brown patches, significant when they are more than 5 in number.
r. Pain:
Types—
• Colic—It is a paroxysmal, intermittent pain, gripping in nature brought about by obstruction
of a muscular conducting tube. 4 types—ureteric, biliary, intestinal, appendicular.
• Vague aching—mild continuous pain.
• Burning pain—sensation felt as contact with a hot object, typically seen in acid peptic disease.
• Throbbing pain—typically felt in severe inflammatory condition as in abscess.
• Shooting pain—pain shoots along the course of a nerve as in sciatica.
• Stabbing pain—sudden, severe pain of short duration, e.g—duodenal ulcer perforation
• Constricting pain—reveals compressing nature of pain from all direction; e.g—typical anginal
pain.
Special types of pain—
• Renal pain—dull or severe ache over the renal angle (between outer border of erector spine
muscle and lower border of 12th rib), may spread towards umbilicus; brought about by distension
of renal capsule and pelvis.
• Prostatic pain—vague discomfort or fullness in perineum or rectal area, often associated with
difficulty in passing urine.
• Urethral pain—burning pain felt in the penis or vulva occurs at the end of micturition.
• Ureteric pain—starts in the loin, radiates along the course of ureter to the groin and inner aspect
of the upper part of thigh.
Radiation of pain—pain extends to another site while the original pain persists at the original site.
e.g—Ureteric colic radiating to the groin, pain of duodenal ulcer radiating to the back.
Referred pain—when pain is felt at distant site from the source, and there is no pain at the diseased
site; e.g—in diseases of hip joint there is referred pain over the knee joint.
Shifting or migration of pain—pain is felt at one site in the beginning and it later shifts to another
site with no pain in the original site; e.g—pain in acute appendicitis is initially felt around umbilicus,
which later shifts to right iliac fossa (Mc’Burney’s point).
s. Fever:
Normal body temperature—36.7°C-37.2°C
• Continuous fever—temperature remains above the normal throughout the day, not fluctuating
more than 1°C in 24 hr.
• Remittent fever—temperature remains above normal throughout the day, and fluctuates more
than 1°C in 24 hr.
• Intermittent fever—temperature remains high only for a few hours a day.
t. Micturition:
Normal act of micturition—5-6 times in 24 hr.
Incontinence—involuntary loss of urine.
• True incontinence—constant dribbling of urine from the bladder.
• False or overflow incontinence—urine overflows from distended bladder which has been totally
decompensated and acts as a fixed reservoir.
• Stress incontinence—few drops of urine flow out while straining due to distortion of the normal
anatomic relationship between bladder and the urethra, as a result of which any rise in intra-
abdominal pressure is unequally distributed to bladder and urethra.
• Automated—periodic contraction without the patient’s knowledge.
• Urge incontinence—precipitous loss of urine preceded by strong urge to void.
Irritative symptoms—
• Frequency—refers to increased number of times one feels the need to urinate.
• Nocturia—increased frequency in the night (normally not more than 2).
• Dysuria—painful or difficult urination, usually caused due to inflammation.
• Strangury—painful desire to micturate which starts in the bladder and extends to the tip of
urethra, which neither produces urine nor helps in relieving pain—“painful ineffective micturition”.
• Urgency—sudden severe urge to void that may or may not be controllable.
Obstructive symptoms—
• Hesitancy—prolonged interval necessary to voluntarily initiate the urinary stream.
• Intermitancy—involuntary start—stopping of urinary stream.
• Post-void dribbling—terminal release of drops of urine at end of micturition.
• Straining—is use of abdominal musculature to raise intra-abdominal pressure to urinate.
• Sense of residual urine—sensation of incomplete emptying of the bladder that the patient recognises
after voiding.
Haematuria—haemorrhage into the urinary tract gives red or brownish tinge to the urine; macroscopic—
if there is visible reddish discolouration of urine; microscopic—when bleeding is minimal it is
detected only on microscopy.
Anuria—complete absence of urine production.
Oliguria—24 hr urine output is less than 300 ml.
u. Nerve injury—
• Neurapraxia—transient physiological block of nerve following pressure effect of short duration
or stretching, where spontaneous and complete recovery is the rule.
• Axonotmesis—there is disruption of nerve fibres within an intact sheath, recovery is generally
satisfactory unless there is extensive intraneural fibrosis.
• Neurotmesis—complete or partial division of nerve.
Miscellaneous 561
Most Commons in Surgery
1. Most common anaemia in surgical patients—Iron deficiency anaemia
Age Cause
Males < 50 yr Duodenal ulcers
> 50 yr Secondary to carcinoma colon
Females < 50 yr Secondary to menorrhagia, pregnancy
> 50 yr Secondary to carcinoma colon.
Neonates, children Worm infestation
Bleeding Meckel’s diverticulum
2. Common surgery causing anaemia:
a. Billroth-II: Due to defective iron absorption (as the duodenum becomes a blind loop) and
B12 deficiency due to decreased acid and intrinsic factor production.
b. Terminal ileal resection - B12 deficiency as the ileum is the site of absorption
3. Most common cause of acute blood loss in surgical patient:
a. GI bleeding due to acid peptic disease
b. Accidents—spleen, liver, major vessels injuries
c. Gynaecological causes in females—ruptured ectopic, rupture uterus
4. Common cause of pneumonia/sepsis in ICU—Pseudomonas aeruginosa
5. Commonest hospital risk factor for sepsis—indwelling urinary catheter
6. Causes of generalised tender lymphadenopathy—
Infections—HIV, infectious mononucleosis, secondary syphilis
Drugs—phenytoin
Autoimmune—SLE, rheumatoid arthritis.
7. Causes of generalised non-tender lymphadenopathy:
a. Acute and chronic leukaemia
b. NHL
8. Lymph nodes and malignancy:
Site Commonest malignancy

1. Virchow’s node Secondaries from adenocarcinoma of stomach,
pancreas, colon; testicular neoplasms; cervical cancer.
2. Para-aortic nodes Primary malignant lymphoma, metastatic
testicular tumours.
3. Hilar lymph nodes Primary lung cancer.
4. Non-tender unilatera- NHL
epitrochlear lymph nodes
9. Commons in NHL
a. Extranodal site of primary malignant Stomach in MALT (mucosa associated

lymphomas lymphoid tissue)
b. Bacteria associated with NHL Helicobacter pylori in MALT lymphoma
c. Cause of increased incidence of
CNS NHL AIDS
10. Commonest malignancy of lymph nodes—secondaries
11. Commonest NHL in children—Burkitt’s lymphoma
12. Commonest site for Burkitt’s lymphoma—abdominal cavity:
a. Boys—Peyer’s patches of the small intestine
b. Girls—Pelvic organs.
13. Common complications of treatment of Hodgkin’s disease:
a. Second malignancies related to alkylating agents
b. Infertility
c. Hypothyroidism due to radiation
d. Sepsis in splenectomised patients
e. Congestive cardiomyopathy due to the effect of doxorubicin.
14. Commonest bone malignancy - secondaries.
15. Commons in spleen:
a. Hypersplenism Portal hypertension
b. Parasitic disease Echinococcus
c. Primary tumour Benign haemangiomas
d. Malignancy Metastatic NHL
e. Multifocal calcification Histoplasmosis.
16. Commonest symptom associated with vessel /platelet disorder - epistaxis followed by petechiae.
17. Common clinical finding in protein C deficiency—Recurrent DVT (65%)
18. Renal disease with increased risk of venous thrombosis—nephrotic syndrome (cause: loss of
Antithrombin III, protein C, protein S in urine)
19. Common sites of origin of embolism:
a. To the lungs—femoral veins following DVT.
b. To the arterial systems—clot/vegetations dislodged from left heart.
20. Common cause for paradoxical embolism—patent foramen ovale.
21. Commons in phlebothrombosis:
a. Cause—stasis of blood flow.
b. Location—deep veins of the calf.
22. Commonest cancer associated with superficial migratory thrombophlebitis (Trousseau’s sign)—
Pancreatic carcinoma.
23. Commonest cause of fat embolism — fracture of long bones and pelvis.
Miscellaneous 563
24. Association of blood group and GI pathology:
Pathology Blood group
Duodenal ulcer O
Gastric carcinoma A
25. Cause for post-transfusion hepatitis—Hepatitis C in 90% of cases.

26. Commonest preservative used in blood bank.
CPDA 1 (shelf life of CPDA1 blood is 35 days)
Citrate Calcium-binding anticoagulant
Phosphate Maintains 2,3 dPG level
Dextrose Nutrition for RBCs
Adenine Substrate for ATP.
27. Blood components with highest concentration of factor VIII –vWF multimers —cryoprecipitate.
28. Effect of acute blood loss on Hb% and haematocrit—no change.
29. Commonest cardio tonic agent used in treatment of shock—dopamine.
30. Types of surgery associated with greatest cardiac risk:
a. Emergency surgeries.
b. Right upper quadrant abdominal surgeries
c. Thoracic surgeries.
31. Commonest perioperative complication in diabetes mellitus;
Infections—wound sepsis, UTI, pneumonia.
32. Biochemical effects of surgical trauma/sepsis:
a. Increased catabolism of proteins
b. Increased glucagon secretion
c. Increased cortisol and catecholamine secretion.
33. Common contraindications of enteral feeding:
a. Short bowel syndrome.
b. Intestinal obstruction.
c. Severe vomiting/diarrhoea
d. Enterocolitis.
e. GI fistulas.
34. Nutritional problems in systemic diseases:
a. Renal failure—inability to handle urea load.
b. Hepatic failure—hepatic encephalopathy.
c. Cancer—anorexia, cachexia.
d. Diabetes mellitus—hyper/hypoglycaemia.
35. Commonest cause of death following surgery—pneumonia.
36. Organisms involved with intravascular catheter sepsis:

a. Staphylococcus aureus.
b. Staphylococcus epidermidis.
c. Candida.
37. Source of postoperative UTI—indwelling urinary catheter.
38. Commonest site in lungs for embolus—right lower lobe.
39. Commonest cause for poor wound healing—infection.
40. Environmental factor accelerating wound healing—UV light
41. Vitamin which reverses corticosteroid effects in a wound—retinoic acid.
42. Commonest causes for wound haematoma:
a. Inadequate wound haemostasis.
b. Anticoagulants.
c. NSAIDs.
43. Common cause of wound seroma—creation of large subcutaneous space.
44. Commonest initial sign of wound dehiscence—discharge of serosanguinous fluid from the wound.
45. Common cause of myonecrosis—Clostridium perfringence.
46. Commonest type of human bite—knuckle laceration from punching the mouth of another person.
47. Causes of foot ulcers in diabetes mellitus:
a. Peripheral neuropathy
b. Ischaemia
c. Soft tissue infection.
48. Sites of pressure ulcer:
a. Sacrum (commonest site)
b. Greater trochanter
c. Ischial tuberosity
d. Calcaneous.
e. Lateral malleolus.
49. Common complication in burns:
a. Wound infection (Pseudomonas aeruginosa, Staphylococcus aureus)
b. Sepsis.
50. GI abnormality associated with burns—Curling’s ulcer in stomach.
51. Sites of atherosclerosis in descending order:
a. Abdominal aorta.
b. Coronary artery.
c. Popliteal artery.
d. Descending thoracic aorta
e. Internal carotid artery.
Miscellaneous 565
52. Complication of atherosclerosis:
Artery Complications
a. Abdominal aorta Aneurysm, embolism
b. Peripheral artery Gangrene
c. Coronary artery Angina, MI
d. Internal carotid artery TIA, stroke
e. Renal artery Renovascular hypertension
53. Commonest peripheral artery aneurysm—poplitial artery.
54. Commenest cause of cystic aneurysm of the artery—polyarteritis nodosa.
55. Commonest site of pain in occlusive arterial diseases:
Artery Site
a. Aorta mid abdomen
b. Common iliac buttocks
c. Common femoral thigh
d. Superficial femoral knee
e. Poplitial calf
f. Tibial artery foot
56 Screening test for volar arch artery—Allen’s test.

57. Vasculitis associated with young male smokers—thromboangitis obliterans.
58. Commonest cause of axillary vein thrombosis—over exercising upper extremity hence called
effort vein thrombosis.
59. Commonnest cause for varicose veins in legs:
Primary-congenital absence of sentinal valve in the common femoral vein.
Secondary-vessel obstruction as in DVT.
60. Commonest cause for superior venacaval obstruction— obstruction of the SVC by small cell
carcinoma of the lung.
61. Commonest cause for inferior venacaval obstruction—extension of a pelvic/femoral vein
thrombosis into IVC.
62. Commonest cause for secondary hypertension in men—unilateral renovascular hypertension.
63. Commonest cause for renovascular hypertension in females—fibromuscular hyperplasia (renal
angiogram shows string of beads appearance)
64. Commonest surgically correctable cause of secondary hypertension in young-Coarctation of
aorta.
65. Tumours and secondary hypertension
1. Renal Renal adenocarcinoma
Wilms’ tumour.
2. Adrenal Primary aldosteronism

Pheochromocytoma.
3. Neurogenic Increase in intracranial pressure, e.g. brain tumours
4. Parathyroid Adenoma causing primary hyperplasia/hyperparathyroidism
66. Organisms producing infective endocarditis:
a. Streptococcus viridans 50-75%
b. Staphylococcus aureus 25%
c. Enterococci.
67. Organisms in infective endocarditis:
a. Secondary prosthetic valve—Staphylococcus epidermidis
b. Colon cancer, IBD—Streptococcus bovis.
68. Procedures and organisms producing infective endocarditis:
a. Dental/upper respiratory procedures—Streptococcus viridans.
b. GI/GU procedures Enterococcus.
69. Valve abnormalities in carcinoid heart diseases:
a. Tricuspid regurgitation
b. Pulmonary valve stenosis.
70. Commonest cardiac tumour—cardiac myxoma.
71. Commons in pericarditis;
Infective Viral, e.g Coxsackie B

Bacterial Streptococci
Metabolic Uremia
Collagen disease SLE
72. Commonest cause of spontaneous pneumothorax—rupture of an apical subplueral bulla.

73. Location of lung cancer:
a. Periphery—Adenocarcinoma
b. Central—Squamous cell carcinoma.
74. Lung cancer and smoking:
a. Greatest relationship to smoking—Squamous cell carcinoma.
b. No relation ship to smoking—Bronchio-alveolar carcinoma.
75. Sites of metastasis of primary lung cancer:
a. In chest cavity—Hilar and mediastinal lymph nodes.
b. Outside the lung—Adrenal gland (50%).
76. Commonest primary lung tumour in children-Bronchial carcinoid.
77. Commonest mediastinal tumour/lesion:
a. Anterior—Thymoma.
b. Posterior—Neurogenic tumour.
c. Middle—Pericardial cyst
Miscellaneous 567
78. Common organisms causing Ludwig’s angina:
a. Aerobic/anaerobic streptococci.
b. Eikenella corrodens.
79. Commonest oral manifestation of AIDS:
a. Candidiasis.
b. Aphthous ulcer
c. Hairy leukoplakia.
80. Diseases associated with mucosal pigmentation:
a. Polyp syndrome—Peutz Jegher’s syndrome.
b. Endocrine disorder—Addison’s disease.
81. Common location of leukoplakia:
a. Ventrolateral tongue.
b. Floor of the mouth.
c. Lower lip.
82. Common cancer in oral cavity—Squamous cell carcinoma.
84. Confirmatory tests in the workup of neck mass:
a. FNAC—when lymph node secondary is suspected.
b. Excision biopsy—When malignant lymphoma is suspected.
85. Common complication of vomiting—Electrolyte imbalance.
86. Common location for NSAIDs induced erosions/ulcers:
a. Prepyloric area.
b. Antrum.
87. Artery responsible for bleeding in gastric/duodenal ulcers:
a. Gastric ulcer—Left gastric artery.
b. Duodenal ulcer—Gastroduodenal artery.
88. Surgery leading to dumping syndrome—Billroth II gastrojejunostomy (incidence 5-10%).
89. Commonest cause of marginal ulcer in post gastrectomy—incomplete vagotomy.
90. Commonest gastric cause of protein loss—Ménètrier’s disease.
91. Nerve fibres responsible for abdominal pain:
a. Visceral pain—unmyelinated afferent C fibres.
b. Parietal pain—C fibres and myelinated
92. GI location of haematochezia—below the ligament of Treitz.
93. Megacolon causes:
a. Congenital—Hirschsprung’s disease.
b. Acquired—Chagas’ disease.
94. Common causes of gut obstruction:
a. Foregut—Obstructive peptic ulcer disease, Carcinoma stomach, Carcinoma of head of pancrease.
b. Hind gut—Annular obstructing cancer in carcinoma colon.
95. Commonest abdominal hernia in decreasing order:

a. Indirect inguinal hernia.
b. Direct inguinal hernia.
c. Femoral hernia.
96. Hernia with highest rate of incarceration—Femoral hernia.
97. Commonest hernia in adults with ascites/pregnancy—umbilical hernia.
98. Hernia with highest mortality—Obturator hernia due to difficult preoperative diagnosis.
99. Commonest site of volvulus:
a. Elderly patients—sigmoid colon
b. Young adults—Cecum
100. Common cause of nontoxic megacolon—Ogilvie’s syndrome
101. Sites of squamous cell carcinoma in oral cavity in descending order:
a. Floor of the mouth.
b. Lower lip .
c. Lateral border of tongue
d. Hard palate.
e. Tongue base.
102. Commonest location of verrucous carcinoma—mandibular sulcus.
103. Commonest site of salivary gland tumour—parotid gland.
104. Commonest salivary gland tumour—Pleomorphic adenoma.
105. Commonest malignant tumour of salivary gland—mucoepidermoid carcinoma.
106. Malignant salivary gland tumour is common in—submandibular salivary gland.
107. Commonest sites for Kaposi’s sarcoma in oral cavity in AIDS:
a. Hard palate.
b. Gingiva.
c. Buccal mucosa.
108. Commonest feature of oesophageal disease—heart burn.
109. Common causes of dysphagia:
a. For solids but not for liquids — Obstructive lesions, e.g. web, cancer.
b. For solids and liquids — Motility disorder.
c. For liquids but not for solids — Achalasia cardia.
d. Oropharyngeal dysphagia — Neuromuscular disorder.
e. Intermittent dysphagia for solids — Lower oesophageal rings.
f. Progressive dysphagia for — Peptic stricture secondary to Barrett’s
solids with heart burn
g. Intermittent dysphagia with — GORD
noncardiac chest pain
110. Commonest benign tumour of oesophagus—leiomyoma.
Miscellaneous 569
111. Common cause of Mallory-Weiss syndrome—severe retching in alcoholics.
112. Commonest complication of diverticular disease—diverticulitis.
113. Common cause of fistula in GI tract:
a. Diverticulitis.
b. Crohn’s disease.
114. Common GI site for acute ischaemia—small bowel
115. Common site for chronic ischaemic colitis—splenic flexure.
116. Commonest malignant tumour of small bowel—secondaries from colon, rectum, ovary.
117. Common GI site for polyps—sigmoid colon.
118. Common GI tract polyp—hyperplastic polyp.
119. Common cause of an appendiceal mucocele—non-neoplastic chronic proximal obstruction
of appendix.
120. Commonest tumour of appendix—carcinoid tumour.
121. Common cause of haematobilia—trauma to the liver.
122. Cause of segmental dilation of intrahepatic bile ducts—Caroli’s disease.
123. Common site for intra-abdominal abscess—sub-diaphragmatic space.
124. Commonest worldwide cause of hepatic abscess—Entamoeba histolytica.
125. Parasitic cause of cholangiocarcinoma—Clonorchis sinensis.
126. Common cause of Budd-Chiari syndrome:
a. Polycythemia rubra vera.
b. OCP.
c. Hypercoagulable state.
127. Commonest cause of portal vein thrombosis in adults—pyelephlebitis.
128. Common in liver:
a. Tumour like condition—focal nodular hyperplasia.
b. Benign tumour—cavernous haemangioma.
c. Malignant tumour—metastasis.
d. Primary tumour—hepatocellular carcinoma.
129. Common location of cholangiocarcinoma:
a. Ampulla/common bile duct.
b. Junction of right and left hepatic duct.
130. Common cause of acute peritonitis—ruptured viscus.
131. Common cause of air in biliary tree—gallstone ileus.
132. Common cystic disease in GIT—choledochal cyst.
133. Commonest cause of acute cholecystitis—impacted stone in cystic duct (90%)
134. Commonest cause of acalculous cholecystitis—ischaemic compromise of cystic artery.

135. Commonest cause of hydrops in gallbladder—chronic obstruction of cystic duct.
136. Commonest benign tumour in gallbladder—papilloma.
137. Commonest cause of gallbladder cancer—gallstones.
134. Complication of pancrease divisum—recurrent pancreatitis.
135. Common location of aberrant pancreatic tissue in decreasing order:
a. Wall of stomach, duodenum, jejunum.
b. Meckel’s diverticulum.
136. Common complication of annular pancreas—bowel obstruction.
137. Cause of persistent pain in a patient with acute pancreatitis—pseudocyst of pancreas.
138. Common site for pancreatic tumour—head of pancreas.
139. Commonest islet cell tumour—insulinoma.
140. Pancreatic cause of secretory diarrhoea—Vipoma.
141. Common cause of galactorrhoea after prolactinoma is primary hypothyroidism.
142. Common location of pyramidal lobe of thyroid—superior extension from the isthmus.
143. Common symptom of lingual thyroid—dysphagia.
144. Common cause of midline cystic neck mass—thyroglossal cyst.
145. Cause of endemic goitre—Iodine deficiency.
146. Common test to evaluate functional status of goitre—serum TSH.
147. Commonest thyroiditis—Hashimoto’s thyroiditis.
148. Thyroiditis occurring in the postpartum state—subacute painless lymphocytic thyroiditis.
149. Thyroiditis mimicking thyroid cancer—Reidel’s thyroiditis.
150. Commonest cause of hyperthyroidism—Grave’s disease.
151. Commonest cause of thyroid storm—inadequately treated Grave’s disease before surgery.
152. Commonest cause of benign thyroid tumour—follicular adenoma.
153. Commonest thyroid cancer—papillary adenocarcinoma.
154. Commonest extranodal site of papillary cancer metastasis—lungs, bone.
155. Thyroid cancer presenting as solitary cold nodule—follicular carcinoma.
156. Thyroid cancer with a familial history—medullary carcinoma.
157. Cause of primary malignant lymphoma of thyroid—pre-existing Hashimoto’s thyroiditis.
158. Commonest cause of primary hyperparathyroidism—benign parathyroid adenoma.
Miscellaneous 571
159. Anaemia leading to malignancy.
Plummer-Winson/Paterson-Kelly syndrome—post-cricoid carcinoma.
160. Commonest cause of secondary hyperparathyroidism—chronic renal failure
161. Commonest metabolic bone disease—osteoporosis.
162. Commonest childhood sarcoma—embryonal rhabdomyosarcoma.
163. Malignant tumour that do not matastasise—basal cell carcinoma.
164. Commonest carcinomas that invade blood vessels:
a. Renal cell carcinoma.
b. Follicular carcinoma of thyroid
c. Hepatocellular carcinoma.
165. Sarcoma that invades lymphatics—rhabdomyosarcoma.
166. Tissue resistant to tumour invasion:
a. Mature cartilage.
b. Elastic tissue in artery.
167. Common symptom in bone metastasis—bone pain.
168. Osteoblastic bone secondary is commonly produced by carcinoma prostate.
169. Pure osteolytic bone secondary is commonly produced by lung/kidney.
170. Most common malignancies in respect to various sites.
Site Common malignancy
1. Lymph nodes a. Metastasis, e.g. carcinoma breast, colon
b. Primary: NHL
2. Lung a. Metastasis, e.g. breast.
b. Primary: adenocarcinoma.
3. Brain a. Metastasis, e.g. Lung carcinoma.
b. Primary: Glioblastoma multiforme.
4. Liver a. Metastasis: Lung carcinoma
b. Primary: Hepatocellular carcinoma.
5. Bone a. Metastasis, e.g. Breast carcinoma
b. Primary: Adult—Multiple myeloma
Adolescent—osteosarcoma.
6. Adrenals a. Metastasis, e.g lung
171. Commonest primary site for metastasis to Virchow’s node in decreasing order:
a. Adenocarcinoma of stomach
b. Adenocarcinoma of pancreas
172. Metastatic sites in descending order:

Primary Metastatic sites
a. Breast Lung, bone, liver
b. Colorectum Liver, adrenals, bone
c. Renal Lung
d. Transitional cell Adrenals
carcinoma of bladder
e. Lung Liver, bone, brain, adrenal.
f. Melanoma Liver, lung, adrenal, brain, bone, skin
g. Ovary Liver, lung
h. Prostate Bone, lung, liver
173. Commonest cause of death in cancer patient—Infection (sepsis due to gram-ve organisms).
174. Commonest cause of hypercalcaemia in cancer:
a. Metastasis to bone.
b. Secretion of a PTH like peptides.
175. Commonest paraneoplastic syndrome is hypercalcaemia secondary to secretion of a PTH like
peptide.
176. Commonest cause of Eaten-Lambert syndrome is small cell carcinoma.
177. Cancer associated with pulmonary osteoarthropathy is primary lung cancer
178. Common tumour markers known:
Malignancy Tumour marker
Multiple myeloma Bence Jones proteins
Ovarian cancer CA 125
Small cell carcinoma CEA, bombesin
Prostate cancer Prostate specific Ag.
Breast cancer CEA, CA 15-3.
Medullary carcinoma of thyroid Calcitonin.
Colorectal cancer CEA
Pancreatic cancer CA19-9, CEA
179. Cancer frequency in decreasing order:

a. Children ALL, CNS tumours, Burkitt’s lymphoma, neuroblastoma,
Wilm’s tumour, Ewing’s sarcoma.
b. Men Prostate, lung, colon.
c. Women Cervix, breast, lung, colon.
180. Cancer mortalities in decreasing order:
a. Men Lung, prostate, colorectal.
b. Women Lung, breast, cervix, colorectal.
Miscellaneous 573
181. Cancer associated with parasitic disease—
Squamous cell carcinoma of bladder—Schistosoma hematobium
Cholangiocarcinoma—Clonorchis sinensis.
182. Common cancer in geographical area:
a. South-East China – Nasopharyngeal carcinoma
b. Japan – Adenocarcinoma of stomach
c. South-East Asia – Hepatocellular carcinoma
d. Africa – Burkitt’s lymphoma
183. Commonest complication associated with cyclophosphamide—Haemorrhagic cystitis.
184. Breast lump with respect to age:
Breast lump Age
Fibrocystic disease < 50 yr
Infiltrating ductal carcinoma > 50 yr
Fibroadenoma < 35 yr
185. Commonest cause of blood stained nipple discharge

< 50 yr - Intraductal papilloma.
> 50 yr - Infiltrating ductal carcinoma.
186. Commonest cause of acute mastitis—Staphylococcus aureus in lactating women.
187. Commonest cause of fat necrosis—Breast trauma.
188. Drug associated with development of fibroadenoma—cyclosporine.
189. Commonest disorder of male breast—Gynaecomastia.
190. Commonest breast disease with microcalcification:
a. Benign disease—Sclerosing adenosis.
b. Malignant disease—Ductal carcinoma in situ.
191. Cancer with eczematous changes of the nipple—Paget’s disease.
192. Cancer misdiagnosed as acute mastitis—Inflammatory carcinoma.
193. Cancer with increase incidence of bilaterality—Lobular carcinoma in situ.
194. Commonest subtype of breast cancer with high propensity for CNS, ovary, uterus, bone marrow
metastasis—Invasive lobular carcinoma.
195. Lymph nodes involved in cancer breast in decreasing order of frequency—
a. Axillary lymph nodes
b. Internal mammary nodes
c. Supraclavicular nodes.
196. Important nerve injury:
a. Claw hand – Ulnar nerve palsy.
b. Wrist drop – Radial nerve palsy
c. Waiter’s tip deformity – Brachial plexus lesion at Erb’s point
d. Klumpke’s paralysis – Injury to lower trunk of brachial plexus.
197. Cause of axillary nerve injury:

a. Fracture of surgical nack of humerus.
b. Dislocation of shoulder joint.
198. Commonest site of disc herniation – L5 - SI disc.
199. Commonest site of nerve entrapment.
Nerve Site
Median nerve Carpal tunnel
Sciatic nerve Sciatic notch in buttocks
Peroneal nerve Behind the knees.
Lateral femoral nerve Inguinal ligament
200. Commonest benign soft tissue tumour—lipoma.
201. Tumours arising from fat:
a. Yellow fat—Lipoma.
b. Brown fat—Hybernoma.
202. Sites of humerus fracture and nerve injury:
Site Nerve injured

a. Surgical neck of humerus Axillary nerve
b. Mid shaft/distal third Radial nerve
c. Supracondylar elbow fracture Median nerve
d. Medial epicondyle Ulnar nerve
203. Common causes of neuropathic joints:

a. Diabetes mellitus
b. Syringo myelia
c. Tabes dorsalis
204. Important sites of vascular necrosis:
a. Femoral head
b. Scaphoid
c. Body of talus
205. Common primary bone tumour with respect to age.
Age Tumor
a. 1st and 2nd decades Ewing’s sarcoma
b. 10- 25 yr Osteogenic sarcoma
c. >30 yr Chondrosarcoma
d. >50 yr Multiple myeloma
206. Common primary bone tumours in descending order of frequency:
a. Multiple myeloma
b. Osteogenic sarcoma
Miscellaneous 575
c. Chondrosarcoma.
d. Ewing’s sarcoma
e. Giant cell tumour.
207. Common benign bone tumour—osteochondroma.
208. Commonest site of osteosarcoma—distal femur/proximal tibia.
209. Common causes of pathologic fracture:
a. Metastasis from breast carcinoma
b. Osteoporosis
210. Common neurological symptom in patients with cancer:
a. Headache
b. Altered mental status—metabolic encephalopathy
211. Commonest neurological complication of systemic cancer—cerebral metastasis.
212. Cancer with most neurological complication—malignant melanoma.
213. Common CNS tumour with respect to location:
a. Cerebrum Metastasis
b. Cerebellum Astrocytoma.
c. Spinal cord Ependymoma.
214. Common cause of costovertebral angle pain:
a. Acute pyelonephritis
b. Renal adenocarcinoma
215. Commonest cause of microscopic haematuria in males—BPH.
216. Common congenital renal disorder associated with Tumer's syndrome—Horseshoe kidney.
217. Common cause of renal calcifications on radiograph:
a. Stones
b. Nephrocalcinosis
c. Calcified tumours/cyst
d. Medullary sponge kidney
218. Commonest cause of scrotal swelling—hydrocele.
219. Common bilateral testicular malignancy—metastatic malignant lymphoma.
220. Commonest cause of male impotence—psychogenic.
221. Commonest systemic fungal disease in AIDS—candidiasis.
222. Commonest CNS fungal infection in AIDS—Cryptococcus meningitis.
223. Commonest electrolyte abnormality in AIDS—hyponatremia, SIADH.
224. HIV related common CNS disease—HIV encephalopathy (60% of AIDS patient).
225. Malignancy associated with immunosuppressive treatment in transplant patients:
a. Squamous cell carcinoma of skin
b. Cervical cancer
c. Malignant lymphoma
d. Basal cell carcinoma
226. Test used to localize the cause of B12 deficiency—Schilling’s test.
227. Coagulation system tests:
a. Extrinsic coagulation system—Prothrombin time
b. Intrinsic coagulation system—Activated thromboplastin time
228. Cause of anaemia in renal disease—Erythropoietin deficiency (Site of production—peritubular
capillary endothelial cells in kidneys, liver).
229. Cause of persistent haemolytic anaemia post-splenectomy for congenital spherocytosis—failure
to identify and remove accessory spleens (splenenculi).
230. Plasmocytoma commonest locations:
a. Solitary plasmocytoma—vertebrae
b. Extra-medullary plasmocytoma—upper repiratory tract
231. Commonest vascular disorders:
Cause Name
a. Genetic Osler-Weber-Rendu syndrome
b. Age dependent senile purpura
c. Nutritional scurvy
d. Metabolic excess glucocorticoid
232. Common clinical cause of adult vitamin K deficiency.

postoperative patient on antibiotics who is nil per oral.
233. Commonest cause of coagulation deficieny in liver disease-multiple clotting foctor deficiency.
234. Commonest clinical features of micronutrient deficiency:
a. Zinc—perioral pustular rash
b. Copper—microcytic anaemia
c. Chromium—hyperglycaemia
d. Selenium—myopathy
e. Manganese—dermatitis
235. Malignant hyperthermia:
Triggers— a. Succinylcholine
b. Halothane
Treatment—Dantrolene
Index
A Antibioma 130 Barium swallow x-ray of

Anticoagulants 89 pharyngeal pouch 397
Abdomen examination 143 Antisepsis 504 Basal cell carcinoma 242
Abdominal aneurysms 66 Antithyroid drugs 159 Basic laparoscopic surgeries 537
Abdominal compartment Antithyroid drugs 160 Basic pattern of case sheet writing
syndrome 33 Aortic aneurysm 205 2
Abdominal incisions 540 Appendicectomy 538 Bassini’s herniorrhaphy 21
Abrahamson nylon darning 23 Appendicular abscess 207 Bassini’s repair 19
Abscess drainage 513 Appendicular mass 207 Bassini’s stitch 21
Abscess in special locations 513 Arm-foot venous pressure 79 Bazin’s disease 229
Absorbable 491 Arterial diseases 40 Bendavid classification 18
Acinic cell tumour 265 Arterial/venous grafts 58 Benign gastric ulcer 291
Acquired AVF 234 Arteriovenous fistula 233 Berliner modified shouldice repair
Acrocyanosis 69 Artery forceps 450 23
Acute arterial occlusion 62 Ascending urethrogram 419 Berry’s aneurysms 66
Additional problems in large Asepsis 504 Bickford’s bronchial clamp 464
incisional hernia 33 Assessment of voice change 134 Biological behaviour of carcinoma
Adenoid cystic carcinoma 265 Atherectomy 57 cheek 249
Adenolymphoma 265 Auchincloss operation 113 Bisgaard method 84
Adenoma of colon 297 Axillary abscess 514 Bladder mass 208
Adrenal mass 206 Bladder neck retractor 461
Axillary artery 46
Adson’s test 42 Bladder sound 485
Axillary dissection 111
Advanced CT methods 432 Bladder stone 348
Axillary dissection/axillary
Advanced laparoscopic 539 Bladder tumours 354
clearance 111
Advanced ultrasound techniques Blood pressure 6
Axillary nodes 111
430 Blood spread in melanoma 345
Axillary sampling 108
Ainhum 72 Bone cutting forceps 497
Air embolism 64 Bone elevator/bone lever 498
Airway 496 B Bone nibbler 498
Allen’s test 43 Bone secondaries in carcinoma
Allis’ tissue holding forceps 453 Babcock’s forceps 454 breast 122
Allison’s lung retractor 462 Backhaus’ towel clip 449 Boomerang needle 485
Ambulatory venous pressure 79 Bacteria causing abscess 513 Boston’s sign 146
Ameloblastoma 258 Bairnsdale ulcer 228 Bowel occlusion clamps 469
Amoeboma 208 Bake’s dilator 471 Branchial cyst 270
Anaemia 4 Ballet’s sign 146 Branchial fistula 270
Anaplastic carcinoma 168 Bard parker’s handle Branham’s/nicoladoni’s sign 43
Andrew’s operation 23 Barium enema x-ray 407 Breast 91
Aneurysm needle 468 Barium meal x-ray 403 Breast abscess 514
Aneurysms 65 Barium meal x-ray in duodenal Breast conservative surgery 109
Angiograms 426 ulcer 404 Breast implants 125
Angiography 51 Barium meal x-ray of carcinoma Breast reconstruction 123
Annular type 306 stomach 405 Breslow’s classification 244
Anterior tibial artery 44 Barium swallow x-ray achalasia Broder’s classification 241
Anthracycline regimes 112 cardia 398 Brodie’s fistula director 490
Brodie-trendelenburg test 74 Chisel 499 Cyst of the epididymis 284

Bronchoscopy 525 Choice therapies 161 Cystadenocarcinoma 203
Buerger’s disease 52 Cholangiography 424 Cystic hygroma 271
Buerger’s postural test 41 Cholecystectomy 537 Cystic swellings 100
Buerger’s postural test 43 Cholecystectomy forceps 472 Cysts 216
Bulldog clamp 451 Circle of death 30 Czerney’s retractor 457
Burkitt’s lymphoma 239 Circulating nurse 508
Bursae 221 Circumcision 520
Buschke-lowenstein tumour 287 Cirsoid aneurysm 232
D
Clamp 472 Dalrymple‘s sign 145
Clip/forceps 449 Darning 23
C De bakey’s vascular clamp 452
Closed loop obstruction 364
C shaped retractor 458 Closure of colostomy 532 Deaver’s retractor 459
Caecostomy 530 Clubbing 5 Deep vein thrombosis 87
Calculus of kidney 353 Clutton’s dilator 484 Dental cyst 259
Calf musculovenous pump 87 Cold abscess 273 Dentigerous cyst 258
Capillary filling time 42 Cold abscess 515 Depezzer’s catheter 482
Capillary haemangioma 231 Cold and warm water test 43 De-quervain’s subacute granulo-
Carbimazole 159 Colonic mass 205 matous thyroiditis 171
Carcinoid tumour 338 Colostomy 531 Dermal flares 86
Carcinoma breast 104 Colostomy care 532 Dermatofibroma 239
Carcinoma breast classified 122 Columbia classification (haagsen, Dermatofibrosarcoma
Carcinoma breast in pregnancy cooley and stout) 103 protuberans 240
123 Common carotid artery 46 Dermoids 217
Carcinoma breast in pregnant Compartment syndrome 62 Diabetic foot and diabetic gangrene
woman 123 Compound palmar ganglion 230 71
Carcinoma caecum 207 Compression 407 Diabetic ulcer 228
Carcinoma cheek 249 Condition age treatment 161 Diagnostic laparoscopy 539
Carcinoma colon 306 Confirmation of retrosternal Diathermy 535
Carcinoma lip 252 extension 140 Differences between dental cyst
Carcinoma of male breast 125 Congenital AVF 233 and dentigerous cyst 259
Carcinoma penis 285 Congenital epulis 257 Differences between paget’s
Carcinoma stomach 293 Conservative breast surgeries 115 disease and eczema of
Carcinoma thyroid 162 Conservative treatment 79 nipple 101
Cardiac tamponade 526 Contraindication for surgery 82 Different abdominal incisions 540
Cardiovascular system 142 Contrast agents 432 Difficulties and complications in tep
Carotid body tumour 272 Cooper’s ligament repair 24 repair 30
Carotid pulsation 141 Costoclavicular compression Diffuse hyperplastic goitre 153
Cat’s paw 457 manoeuvre 42 Diffuse toxic goiter 161
Catheter introducer 482 Coumarin derivatives 90 Digital subtraction angiography 52
Catheters 479 Course of the disease 331 Disappearing pulse syndrome 43
Cavernous haemangioma 231 Courvoisier’s law 199 Diseases of the arteries 52
Ceap classification 86 Cowen‘s sign 145 Disinfection 504
Cell carcinoma of bladder 353 Cricoid hook 475 Disinfection 504
Cervical rib 269 Crile’s method of palpation of gland Disposable staplers 535
Cervical sympathectomy 59 139 Dissecting aneurysm 68
Cheatle’s forceps 448 Critical limb ischaemia 50 Dissecting forceps 455
Cheatle’s gallstone scoop Crossed-leg test 43 Dorsal slit of prepuce 522
Cheek retractor 461 Crushing clamps 470 Dorsalis pedis artery 44
Chemical agents 504 Cryosurgery 534 Double hernia 36
Chemical sympathectomy 60 Cyanosis 5 Doyen’s mouth gag 496
Index 579
Doyen’s retractor 459 Fibrous epulis 257 Guttering of vein 44
Doyen’s rib rasparatory 463 Field block method 19 Gynaecomastia 131
Doyen’s towel clip 449 Filarial hydrocele and chylocele 282
Drains 477 Filiform bougies 484
Dry gangrene 50 Fisch nerve hook 457 H
Duct carcinoma in-situ 121 Fistula 229 Haemangioma 231
Duct ectasia 130 Fistula bistoury 489 Halsted radical mastectomy 114
Duct papilloma 130 Flatus tube 487 Halsted test 42
Ductal lavage 107 FNAC 106 Hamartomata 230
Ductography 109 Foam sclerotherapy 80 Harvey’s venous refilling test 42
Duplex scan 78 Fogarty catheter 63 Hashimoto’s thyroiditis 170
Duplication of renal pelvis 421 Follicular carcinoma 165 Heparin 89
Dupuytren’s enterotome 490 Fontaine classification of limb Heparin antagonist 89
Duties of circulating nurse 508 ischaemia 50 Herceptin 118
Dyshormonogenesis 179 Forceps 454 Hereditary nonpolyposis colonic
Forceps/lion forceps 498 cancer 308
Frey’s syndrome 268 Hernia 7
E Frostbite 72 Hernia bistoury 487
Echosclerotherapy 80 Frozen section biopsy 107 Hernia director 488
Ectopic thyroid 179 Fruchaud’s myopectineal orifice 17 Hernia retractor 457
Eczema 101 Fuchsig’s test 43 Hernioplasty 24
Edge biopsy 108 Further treatment 167 Herniotomy 20
Elevated arm stress test 42 Hesselbach’s triangle 16
Embolectomy 63 History taking 91
G
Embolism 62 Hodgkin’s lymphoma 236
Endarterectomy 57 Gaiter’s zone 84 Holding forceps 454
Endoscopic sympathectomy 59 Galactocoele 128 Homan’s test 77
Endotracheal tube 475 Galactorrhoea 131 Hook phlebectomy 82
Endo-venous laser ablation 82 Gallstone probe 472 Hormone therapy in carcinoma
Enlarged spleen 205 Ganglion 220 breast 118
Enroth sign 145 Gangrene 40 Humby’s knife 497
Enteroclysis 407 Gas under diaphragm 358 Hydrocele 280
Epulis 257 Gastrectomy 542 Hydronephrosis 205
Erythroplakia 248 Gastric ulcer 403 Hyperabduction manoeuvre 42
Estrogen receptor study 107 Gastrointestinal stromal tumours
Excision of the swelling 522 340
Exophthalmos 146
I
Gastrointestinal system 156
Eye signs only 147 Ian-Aird test 77
Gastrostomy 541
Ideal stoma appliance 529
Genitourinary system 156
F Ileal urinary conduit 530
Gibbon’s catheter 482
Ileocaecal tuberculosis 207
Facial artery 46 Gifford‘s sign 145
Ileocaecal tuberculosis 298
Familial adenomatous polyp 297 Gigli’s saw 499
Ileostomy 530
Faraboeuf’s rasparatory 463 Gilbert classification 18 Implantation dermoid 218
Fat embolism 64 Gilbert mesh repair 27 Incision 522
Fegan’s technique 79 Goldzieher’s sign 146 Incisional hernia 31
Fegan’s test 77 Granulation tissue 225 Incisional hernia surgery 33
Femoral artery 45 Grave signs 103 Indandione derivative: 90
Femoral hernia 38 Griffith’s sign 146 Infant feeding tube 487
Fibroadenoma 125 Groin hernia 17 Inguinal hernia 7
Fibrocystadenosis 126 Grove’s sign 146 Injection sclerotherapy 79
Inlay mesh repair 25 Left sided colonic mass 205 Mass, lumbar region 205
Insertion of a nasogastric Leriche’s syndrome 49 Mass, right hypochondrium 196
In-situ saphenous vein graft 57 Letrozole 117 Mass, right iliac fossa 207
Intercostal drainage tube 478 Leucoplakia 248 Mass, umbilical region 206
Intercostal tube drainage 524 Levels of the axillary nodes 100 Mastalgia 131
Intermittent claudication 49 Lid lag sign 144 Mastitis 100
Interpreting the films 393 Lid retraction 146 Maydl’s hernia 37
Interstitial cell tumour 351 Life saving procedures 71 Mayo’s operation 34
Intraarterial thrombolysis using Limb saving methods 70 Mayo’s towel clip 448
fibrinolysins 63 Line of demarcation 50 Mean’s sign 146
Intraluminal stent placement 57 Lingual thyroid 179 Medullary carcinoma of breast 121
Intramammary mastitis 129 Lipodermatosclerosis 86 Medullary carcinoma of thyroid
Intravenous urogram 413 Lipoma 213 169
Intussusception 206 Lister’s urethral dilator 484 Meggitt’s classification 71
Ischiorectal abscess 514 Loewi‘s sign 145 Meigster’s/lahey’s 451
Isotope lymphoscintigraphy 235 Lotheissen’s repair 38
Melanoma 244
Low molecular weight heparin 89
Meleney’s ulcer 228
Ludwig’s angina 514
J Menstrual history 133
Lugol‘s iodine 160
Mesenteric cyst 206
Jaundice 4 Lumbar sympathectomy 59
Mesh repair 27
Jaw tumours 256 Lupus vulgaris 228
Mesh repair for incisional hernia
Jejunostomy 542 Lymph node biopsy 522
Lymph nodes 5 33
Jellinek‘s sign 145
Lymphadenitis 353 Metal catheters 483
Jening’s mouth gag 496
Lymphangiographic classification Metastatic carcinoma of breast 118
Joffroy‘s sign 145
235 Methimazole 159
Joll’s thyroid retractor 460
Lymphangiography 235 Microsclerotherapy 80
Lymphoedema 235 Micturating cystourethrography
K Lymphomas 236 418
Lytle’s repair 21 Minor salivary gland tumours 267
Keel’s operation 33
Mitchel’s clip device 494
Kehr’s tube 473
Modified radical mastectomy 113
Keratoacanthoma 240 M Moebius sign 145
Keyland’s retractor 459
Macvay operation 24 Moebius sign 147
Kidney hilum retractor 462
Magill’s forceps 476 Mollison’s mastoid 460
Kidney shadow 393
Malecot’s catheter 480 Mondor’s disease 130
Knie‘s sign 145
Kocher‘s sign 146 Malignant lymphoma 170 Morris kidney retractor 462
Kocher’s forceps 453 Malignant neoplasms of small Morris’ retractor 458
Kocher’s test 139 bowel 338 Moynihan’s glass tube 490
Kocher’s thyroid dissector 455 Mallet 499 Moynihan’s occlusion clamp 469
Kuntz nerve 59 Mammography 105 Moynihan’s tissue forceps 454
Kuntz‘operation 23 Management of malignant 266 Mucoepidermoid tumour 265
Management of ruptured Multiple air-fluid levels 361
aneurysm 67 Mycotic aneurysm 65
L Manchester staging 103 Myelomatous epulis 258
Lahey’s method of examination Marjolin’s ulcer 241 Myer’s vein stripper 497
139 Martorelle’s ulcer 227
Laparoscopic surgery 536 Mass, epigastrium 201 N
Laryngocele 271 Mass, hypogastrium 208
Lasers in surgery 534 Mass, left hypochondrium 205 Naffziger’s sign 145
Left sided adrenal mass 205 Mass, left iliac fossa 208 Nasogastric tube 486
Index 581
Nasopharyngeal carcinoma 255 Paraumbilical hernia 33 Pseudocyst of the pancreas 203
Necrosis 50 Parotid abscess 513 Psoas abscess 208
Needle holder 466 Parotidectomy 268 Psoas shadow 393
Negus artery forceps 450 Patey’s modified radical Psychiatry 156
Neoplasm of lip 252 mastectomy 115 Pugh’s modification 201
Nerve block method 19 Patey’s operation 113 Pulse 6
Neurilemmoma 220 Paul’s drainage tube 478 Pyonephrosis 205
Neurofibroma 219 Pedicle clamps 452 Pyonephrosis 324
Neurogenic claudication 49 Perforator and burr 491
Neuromuscular system 156 Perforators 86
Nipple deviation 95 Peripheral aneurysms 68 Q
Nipple discharge 91 Peritoneal tap 526 Quadrants of breast 96
Nodular goitre 153 Peritoneal tuberculosis 301 Quart therapy 110
Nonabsorbable suture materials Per-operative cholangiograms 425
492 Perthes’ test 77
Non-hodgkin’s lymphoma 238 Peutz-jegher’s polyp 297 R
Nottingham prognostic index 121 Pfannensteil incision 27 Radioactive iodine 180
Nuttall’s operation 33 Pharyngeal pouch 271 Radiofrequency ablation method
Nyhus classification 18 Phimosis 521 82
Nyhus pre-peritoneal mesh repair Phlegmasia alba dolens 87 Radioiodine therapy 160
25 Phlegmasia caerulea dolens 88 Radioisotope bone scan 107
Phylloides tumour 127 Radioisotope imaging 444
Physical agents 504 Radiotherapy in carcinoma breast
O Physical examination 3 119
Oedema 5 Physiologic changes due to 537 Ranula 256
Omental cyst 206 Pigmentation 73 Raynaud’s disease 56
Omentoplasty 60 Pile holding forceps 490 Raynaud’s phenomenon 55
Onlay mesh repair 25 Pizzillo’s method of palpation 139 Raynaud’s syndrome 56
Operation theatre room 506 Plain non-toothed dissecting Reactive hyperaemia time test 44
Oral anticoagulants 90 forceps 455 Recanalisation procedure 527
Oral submucosal fibrosis 248 Plain x-ray abdomen showing Reconstruction after surgery 251
Order of appearance of signs 146 gallstones 372 Reisman’s sign 146
Oschner’s Mahoner’s test 76 Pleural effusion 122 Renal angiogram 418
Osteotome 499 Pleural tap 523 Renal cell carcinoma 205
Ovarian mass 208 Pneumoperitoneum 537 Repair 27
Point block 19 Respiration 6
Polycystic kidney 205 Respiratory system examination
P Popliteal aneurysm 68 143
Paget’s disease 101 Popliteal artery 45 Rest pain 50
Pain 40 Portal hypertension 201 Reticular varices 86
Palliative treatment 402 Posterior tibial artery 44 Retractor 459
Palpable gallbladder in right Pratt’s test 77 Retrocaval ureter 421
hypochondrium 197 Pregangrene 50 Retrograde pyelography 417
Palpable kidney mass 205 Pregnancy epulis 258 Retromolar trigone 249
Palpable left lobe of the liver 201 Premalignant conditions 249 Retroperitoneal cysts 206
Pancreatography 425 Premedication 503 Retroperitoneal tumours 206
Pantaloon hernia 27 Proctoscope 488 Retroperitoneoscopy 539
Papillary carcinoma 163 Profundaplasty 57 Reverse saphenous vein graft 57
Papilloma 215 Proper plain x-ray abdomen 358 Rib approximator 464
Para-aortic lymph node mass 205 Propranolol 159 Rib retractor 463
Paraphimosis 521 Propylthiouracil 159 Rib shear 463
Richter’s hernia 35 Slough 50 Submandibular salivary gland

Riedel’s thyroidis 171 Small bowel swellings 206 tumours 266
Right angle retractor 458 Snellen/donder’s sign 146 Subtotal thyroidectomy 155
Ring occlusion test 12 Solitary thyroid nodule 151 Suction instruments 473
Rive’s stoppa’s mesh placement 32 Specimen, carcinoma Suker’s sign 146
Rives preperitoneal mesh repair 25 oesophagus 341 Superficial temporal artery 46
Robbin’s modifications 18 Specimen, hydatid cyst of liver Superior border of the isthmus 141
Rochin’s sign 146 330 Suprapubic cystostomy 481
Romberg hernia 36 Specimen, intestinal gangrene 335 Surgical blades 467
Roos test 42 Specimen, intestine with Surgical jaundice 199
Rosenbach‘s sign 145 intussusception 335 Surgical needles 464
Routine investigations 79 Specimen, jejunal diverticula 335 Surgical principles and procedures
Russian forceps 456 Specimen, kidney with renal cell 535
carcinoma 326 Suture materials 491
Specimen, lipoma 342 Swelling 91
S Specimen, meckel’s diverticulum Syringes 495
S shaped retractor 458 334
Saddle embolus 63 Specimen, melanoma 343
T
Saddle hernia 36 Specimen, papilloma 342
Saint mark’s anal dilator 489 Specimen, pilonidal sinus 348 Tamoxifen 116
Sainton’s sign 146 Specimen, renal abscess/carbuncle Tanner’s slide operation 23
Salivary neoplasms 260 326 Taxanes 112
Salivary tumours 266 Specimen, renal tuberculosis 330 Taxis 16
Satinsky vascular clamp 452 Specimen, roundworms 348 Tenotomy knife 468
Scanlon’s operation 113 Specimen, thyroid 347 Teratoma 351
Scapula retractor 462 Specimens, small bowel tumours Teratomatous dermoid 218
Schwartz test 77 337 Theatre plan 506
Scissors 468 Spermatocele 284 Therapeutic embolisation 65
Sclerosants 79 Spigot 491 Therapeutic uses 180
Sebaceous cyst 218 Squamous cell carcinoma 240 Thermography 109
Secondary hydrocele 282 Stages of tuberculous Thoracocentesis 523
Selective estrogen antagonists 117 lymphadenitis 353 Thread veins 86
Seminoma testis 350 Staplers in surgery 535 Thrombectomy 57
Sentinel node biopsy 108 Stellwag‘s sign 145 Thromboangiitis obliterans 52
Septic operation theatre 510 Sterilisation 504 Thyrocardiac 161
Sequestration dermoid 217 Sternomastoid tumour 273 Thyroglossal cyst 176
Sequestrum holding forceps 498 Stoma appliances 529 Thyroglossal fistula 179
Severe exophthalmos 147 Stoma care 528 Thyroid cyst 155
Shianoya’s criteria 53 Stones 369 Thyroid disorders 132
Shouldice method 19 Stoppa’s giant prosthesis Thyroid function tests 159
Shouldice repair 21 reinforcement 26 Thyroid ophthalmopathy in
Sigmoid volvulus 367 Strangulated hernia 36 grave’s disease 147
Simple red rubber catheter 481 Stricture urethra 419 Thyroidectomy 171
Single hook retractor 457 Stripping of vein 81 Thyroidectomy 532
Sinus 229 Struma lymphomatosa 170 Thyrotoxicosis and
Sinus forceps 456 Subareolar mastitis 128 hyperthyroidism 155
Skeletal system 156 Subclavian artery 46 Tiemann catheter 483
Skin adnexal tumours 239 Subclavian steal syndrome 61 Toilet mastectomy 115
Skin excoriation 529 Subfascial endoscopic perforator Tomography 445
Skin sparing mastectomy 110 ligation surgery 82 Tongue depressor 496
Sliding hernia 36 Sublingual dermoids 256 Toomy syringe 496
Index 583
Toothed-dissecting forceps 455 Tubulodermoids 218 Venous doppler 78
Total mastectomy 111 Tumour 349 Venous refilling time 42
Tourniquet test 76 Tumour markers for melanoma Venous return 87
Toxic nodule 158 346 Venous ulcer 83
Toxic thyroid in children 161 Verrucous carcinoma 249
Toxic thyroid in pregnancy 161 Vigourox’s sign 146
Tracheal hook 475 U Virchow’s triad 87
Tracheostomy 517 Ulcer 222 Von Graefe‘s sign 144
Tracheostomy care 518 Ulcer due to chilblains 227
Tracheostomy tube 474 Ulcer due to frostbite 227
Transabdominal preperitoneal
W
Ulceration 40
mesh repair 28 Ulcerative type 307 Warfarin sodium 90
Transitional cell carcinoma 354 Ulnar artery 45 Wayne‘s diagnostic indices 157
Transtuzumab 118 Umbilical hernia 35 Well’s arterial clamp 451
Transurethral resection of prostate Ureteric catheter 483 Werner’ abridged classification 147
27 Ureteric line 393 Wet gangrene 50
Traumatic acute arterial occlusion Ureterocele 421 White cell trapping theory 86
62 Urethral dilators 483 Wilder sign 146
Traumatic fat necrosis 128 Urinary catheterisation 511 Wolf-chaikoff effect 156
Trendelenburg operation 80 Uterine mass 208
Trendelenburg test 74
Triangle of pain 30
X
Triple assessment 108 V Xeromammography 106
Trivex method 82 Van dyke’s modification 147 X-ray bones 375
Trocar and cannula 488 Van nuy’s prognostic index for dcis X-ray spine or mri spine/pelvis 107
Trophic ulcer 227 121
Trousseau’s/Payne’s sign 146 Varicocele 284 Y
Trucut biopsy 107 Varicose veins 73
True papilloma 342 Varients 241 Young’s gland forceps 455
Tube 512 Vascular diseases 40
Tuberculous lymphadenitis 515 Vasectomy 527 Z
Tuberculous mesenteric lympha- Vaso-vasostomy 527
denitis 301 Venography 78 Zieman’s test 13

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SRB’s

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

SRB’s Bedside Clinics in Surgery

First Edition : 2009

Thangam Verghese Joshua MS MCh

Index .............................................................................................................................................. 577

INTRODUCTION AND WRITING CASE SHEETS OF SURGICAL CASES

Respiratory System b. Urine routine.

Cardiovascular System IMPORTANT POINTS OF

Examination of Cranium and Spine

METHOD OF WRITING A CASE Pain

Personal History direct inguinal hernias are in inguinal region.

Fig. 1.3: All hernias should be

Fig. 1.9: Respiratory system should be examined to find

Digital Examination of the Rectum Diagnosis

ring occlusion test/invagination test/Zieman’s

How is finger invagination test done?

What is the prerequisite to do ring-

Fig. 1.14: Anatomy of the inguinal canal. IL—Inguinal

What is inguinal defence mechanism?

Can occur from childhood to adult. Common in elderly.

Fig. 1.15: Diagrammatic representations of direct and indirect sacs.

How clinically is enterocele and omentocele differentiated?

Fig. 1.16: Bilateral direct hernia. Note the medial location

Fig. 1.18: Direct sac on table during surgery.

Fig. 1.17: Large bilateral direct hernias. Note, on right

What is Hesselbach’s triangle?

Fig. 1.22: Anatomy of Hesselbach’s triangle. LUL—Lateral

How is tone of abdominal muscle checked

Fig. 1.23: Parts of hernia—neck, body and fundus. C

What is Fruchaud’s myopectineal orifice?

What are the newer classifications of groin

7 days. It takes 6 months to achieve more than

What are the steps in inguinal hernia

Fig. 1.33: Tanner's slide operation—relaxing incision placed

Darning (Abrahamson nylon darning)

Macvay operation (Cooper’s ligament repair)

What are the complications of the inguinal What is hernioplasty?

Figs 1.39A to G: Placement of prolene mesh in inguinal hernia repair.

• Stoppa’s giant prosthesis reinforcement of

If TURP facility is not available what other

What are the recent approaches for

Fig. 1.45: Diagrammatic representations of TEP and TAPP.

Indications for TEP Contraindications for TEP

Difficulties and complications in TEP repair

Advantages of TEP repair

Note: fistula formation but it is found to be safer.

How is paraumbilical hernia treated? is large. Additional lipectomy (panniculectomy)

Fig. 1.49: Paraumbilical hernia.

Fig. 1.50: Umbilical hernia Fig. 1.52: Richter’s hernia.

and its content is usually small bowel. Posterior

What is pantaloon hernia?

What are the problems of

Fig. 1.55: In strangulated hernia, if the content is stran-

What is Maydl’s hernia? reducible or irreducible hernia. Patient himself

cases. It is below and lateral to pubic tubercle

Fig. 1.59: Maydl’s ‘W’ hernia.

How is femoral hernia treated?

Fig. 1.64: Different approaches for femoral hernia.

significantly. Release and assess the time of