Surgery

SURGERY
QUESTIONS
B Y : D EEPANSHI MA L H OTRA
Q1. WHAT IS SHOCK?
WRITE
ETIOPATHOGENESIS AND
MANAGEMENT OF
SEPTIC SHOCK?
Shock is defined as a generalised state of low tissue perfusion which is
inadequate for normal cellular repiration, resulting in severe dysfunction of vital
organs.
TYPES OF SHOCK:
1. Hypovolemic Shock
2. Septic shock
3. Neurogenic shock
4.Cardiogenic shock
5.Anaphylactic Shock
SEPTIC SHOCK
• ETIOLOGY:
• Due to infection caused by bacteria, fungi or
protozoa.
• In most of cases it is due to gram negative
organisms including E.coli,
Kleibsella,Proteus.
• Clinically there are two types of shock;
1. Early warm shock- Toxin cause cutaneous
vasodilation and skin is warm and pink.
Diagnosis is easily made as there is associated
focus of infection in the body.
2. Late cold shock- If toxemia persists, it leads
to increased capillary permeability,
hypovolemia, decreased cardiac output,
tachycardia. Skin is cold and clammy. If toxemia
still perisists it can lead to Multiple Organ
dysfunction syndrome and multiple system
organ failure.
MANAGEMENT
• GENERAL MEASURES-
1. Establish clear airway and maintenance of adequate ventilation and oxygenation.
2. If patient is unconscious with breathing difficulty, endotracheal intubation may be required.
3. Maintenance of blood pressure-
A large bore cannula (16G) is inserted into forearm vein and Iv fluid bolus is given- 10-15ml/kg
bodyweight over 15-20mins and then reassess the patient if rcondition improved or not, may
require repeat bolus.
Maintenance fluid- 4ml/kg/hr for first 10kg
2ml/kg/hr for next kg
1ml/kg from 21kgs onwards
• Consider use of inotropes only after sufficient bolus
fluids.
• SPECIFIC TREATEMENT-
• Treat infection by-
• Broad spectrum antibiotics
• Wound debridement, Abscess drainage
• Treat shock by-
• IV fluid infusion
• Vasopressor drugs(noradrenaline)
• Steroids in high dose after 4 hours to improve
the cardiac, renal and pulmonary functions of body.
AXILLARY ABSCESS IN SEPTIC
SHOCK PATIENT
Q2.
MALIGNANT
MELANOMA
MALIGNANT MELANOMA
• It is a malignant tumout arising from melanocytes.
• Most commonly seen in young adults.
• It has high chances of metastasis and most likely to cause cancer related death.
• Origin - It may arise denovo in normal skin or malignant change may occur in pre
existing mole(most common- Junctional and Compound nevus)
• Common site- Back, Arms,Neck, Scalp
• Spread-
Local extension
Lymphatic spread- It occurs to regional lymph nodes by embolization.
MALIGNANT MELANOMA
3. genetic
Predisposing factors: 1. white race 2. ultraviolet rays 4. trauma
predisposition
1. Pigmented skin
2. Variable size and 3. Surface may be flat
Clinical features- lesion, usually black in 4. firm in consistency
margins are irregular or raised
color
5. mobility- tumour
arises from skin and
can be lifted from
deeper structures.
CLASSIFICATION
STAGING
• Clinical staging-
Stage1- Primary tumour only
Stage2- Enlargement of regional lymph nodes
Stage3- Distant metastasis
*Clark level of tumour invasion

It is based on histopathology of specimen after surgical excision.
CLARK LEVEL OF TUMOUR INVASION
Investigations-
1. Diagnosis is confirmed by excision biopsy.
2.FNAC of regional lymph nodes is very accurate in picking up metastasis.
3. Sentinal lymph node biopsy
•Treatement-
Surgical excision is the treatement of choice. It is resistent to both Rt and CT. 1-2cm of healthy
margin should be excised. Excision elliptical along Langer line to allow tension free closure.
If lymph nodes 1. aim of
are involved, Stage 3 treatement is
block dissection. palliative only
Q3. BASAL
CELL
CARCINOMA
BCC
• Most common malignant skin tumor.

• It arises from basal epidermis and hair follicles cells in pilosebaceous adnexa, hence occurs only in skin.
• It cannot occur in the mucosal surface having squamous epithelium (tongue, lips) due to lack of
pilosebaceous adnexa in these areas.
• It is a tumor of low-grade malignancy. Mortality is extremely rare but cosmetic disfigurement is the main
consideration with basal cell carcinoma.
• It commonly affects white skinned people of elderly age having high exposure to sunlight (in Australia, New
Zealand).
• Site: It is mostly seen on face above an arbitrary line joining ear lobule to the angle of mouth (sun exposed
area) . The most common site is inner canthus of eye. . It is also called "tear cancer" because it is commonly
seen in region of the face where tears roll down. -
• Types- Nodular: Solid, nonfluctuant swelling with central depression and pearly appearance.
• Cystic: Blue-gray, semitranslucent, cystic nodule with a network of fiery red blood vessels on the surface.
• Ulcerative- Non healing ulcer is the most common presentation. But the crust breaks
down with a discharge leading to recurrent ulceration. On examination, the margins of
ulcer are raised and rolled out. BCC
• Field fire type: It grows rapidly leading to destruction and disfigurement of facial
skin.
• Spread: The tumor is slow growing and locally invasive, hence called Rodent ulcer. It
gradually erodes deeper tissues like muscles, bone, cartilage, etc. and produces
severe disfigurement.
• Spread by lymphatics or bloodstream does not occur.
• Rarely basal cell carcinoma changes to squamous cell carcinoma in recurrent or
neglected cases. In such situation, margins of the ulcer become everted and it
spreads to regional lymph nodes.
TREATMENT
• Treatment: Surgery and radiotherapy are equally effective. The type of treatment is
decided by the patient's condition and extent of disease.
- In patients having extensive tumor eroding skull bones, radiotherapy is the treatment
of choice. Dosage of radiotherapy is 4,000-6,000 rads.
- In patients having localized lesion of the face, surgery is the treatment of choice .
Tumor is excised with healthy margin.
-Cryosurgery and C02 laser can be used for reating small lesions.
-Moh micrographic surgery: Used to minimise the tissue damage and decrease
disfigurement on areas like face. Tumor is excised in horizontal slices.
• Moh's micrographic surgery
Q4.
SQUAMOUS
CELL
CARCINOM
A
SQUAMOUS CELL CARCINOMA
(EPITHELIOMA, EPIDERMOID
CARCINOMA)
• It arises from surfaces covered with squamous epithelium (skin, upper aerodigestive
track, vagina). Sometimes surfaces not covered by squamous epithelium undergo a
change to squamous type due to factors causing chronic irritation (squamous
metaplasia), e.g. Transitional cell lining of urinary bladder undergoes squamous
metaplasia by stones.
• In case of skin, squamous cell carcinoma arises from prickle cell layer of epidermis. It
is more common in skin of the face of elderly people. It is more common in white
skinned people.
• It is more malignant and more rapidly growing than basal cell carcinoma
Leukoplakia: Small, circumscribed white plaque
PREMALIGNANT •
• Senile (solar) keratosis: Prolonged sun exposure
LESIONS THAT
• Paget's disease
CAN LEAD TO
• Bowen's disease
SCC • Radiodermatitis: Exposure to X-rays
• Lupus vulgaris: Cutaneous tuberculosis
• Chronic ulcers (Marjolin's ulcer)
• Xeroderma pigmentosa
• Conditions causing chronic skin irritation:
Countryman's lip is carcinoma lower lip in
farmers due to sun exposure. Chimney sweep
cancer is carcinoma scrotum in chimney
sweepers due to irritation by clothes soaked in
oil or pitch. ).
TYPES
• Ulcerative-most common presentation
• Proliferative-cauliflower like
• Ulceroproliferative.
CLINICAL FEATURES
. It commonly presents as nonhealing ulcer that is progressively increasing in size. . The
ulcer is irregular in shape with everted and indurated edges.The base is indurated,
attached to deeper structures and has a blood stained discharge
. The diagnosis is confirmed by wedge biopsy from the margin of the ulcer that shows
"epithelial pearls" or "cell nests".
Spread
Local spread to adjoining structures
Lymphatic spread to regional lymph nodes
DIFFERENTIAL
DIAGNOSIS Basal cell carcinoma
Tubercular ulcer
Syphilitic ulcer
Chronic nonspecific ulcer
Keratoacanthoma.
TREATMENT
• Treatment of primary lesion:
• Surgery and radiotherapy are equally effective. Principles of local treatment are same
as for basal cell carcinoma
• Tumor should be excised with a healthy margin. A4mm clearance margin should be
achieved <2cm and 1cm clearance if >2cm tumor.
• Treatment of metastatic lymph nodes:
• The regional lymph node enlargement can be due to secondary infection of the
ulcerated growth. In such case, the decision for surgery should be taken only if lymph
nodes do not regress with antibiotic treatment. Diagnosis of metastatic deposits in
lymph nodes is confirmed by fine needle aspiration biopsy (FNAB). . The treatment is
block dissection of regional lymph nodes.
Q5. ENUMERATE
SKIN
MALIGNANCIES
• Basal cell carcinoma
• Squamous cell carcinoma
• Malignant melanoma
• Merkel cell carcinoma
H
Q6. WAYS OF SPREAD OF
MALIGNANT DISEASE WITH AT
LEAST ONE EXAMLE OF EACH
SPREAD OF MALIGNANT DISEASES
• One of the cardinal features of malignant tumors is the ability to invade and destroy
adjoining structures (local invasion or direct spread) and disseminate to distant sites.
• Routes of Metastasis
• 1.Lymphatic spread
• 2. Haematogenous spread
3.Spread along body cavities and natural passages (Trans coelomic spread, along
epithelium-lined surfaces. spread via csf, implantation)
• 1. LYMPHATIC SPREAD
• In general, carcinomas metastasise by lymphatic route while
sarcomas favour haematogenous route. However, some sarcomas may also spread by
lymphatic pathway.
• The involvement of lymph nodes by malignant cells may be of two forms:
• i) Lymphatic permeation
• . ii) Lymphatic emboli
I
• Generally, regional lymph nodes draining the

tumor are invariably involved producing
regional nodal metastasis e.g. from carcinoma
breast to axillary lymph nodes, from cancer of
the thyroid to lateral cervical lymph nodes,
bronchogenic carcinoma to hilar and para-
tracheal lymph nodes etc.
• Eg:Virchow's lymph node metastasis
preferentially to left supraclavicular lymph node
from cancers of abdominal organs e.g. cancer
stomach, colon, and gallbladder.
HEMATOGENOUS
SPREAD
• This is common mode of spread by sarcomas
(also by carcinomas)
• Arteries have thicker wall than veins and
hence hematogenous spread occurs through
veins.
• The most common sources of hematogenous
metastases in the lungs are malignant
tumors of the ovary, osteosarcomas, and soft
tissue sarcomas.
• Cancer of the stomach and pancreas often
metastasize to the liver.
TRANSCOELOMIC SPREAD
• Uncommon route of spread.
• Eg: Carcinoma of stomach seeding to both ovaries (Krunkenberg tumor)
• Carcinoma of bronchus and breast seeding to pleura and pericardium.
IMPLANTATION
There are rare reports of spread by this type.
Eg: Prolonged contact of cancer of lower lip causing implantation to
opposing upper lip.

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SURGERY

*Clark level of tumour invasion

1. Diagnosis is confirmed by excision biopsy.

2.FNAC of regional lymph nodes is very accurate in picking up metastasis.

3. Sentinal lymph node biopsy

• Most common malignant skin tumor.

Chronic nonspecific ulcer

• Generally, regional lymph nodes draining the

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