Surgery OSCE Notes
COMMON SURGERIES
1. MODIFIED RADICLE MASTECTOMY
Always ask which side is tumor first – don’t start examining on the obvious side or mark in front of you.
MRM is complete removal of breast tissue and lymph nodes, leaving the underlying chest muscles.
Alternatives:
1. Radiation therapy
2. Chemotherapy
3. Or both
Surgery is best option.
Procedure:
1. General anesthesia
2. Eliptical incision
3. Skin is lifted from the sides
4. Breast tissue is removed completely exposing pec.major muscle
5. Pull this pec.major aside, expose pec.minor
6. Pull pec.minor to reveal underlying fatty tissue
7. Lymph nodes and surrounding fat are removed
8. Blood vessels are tied
9. Drainage tube is placed to side
10. Close incision
11. Dressing done
What type of clearance is done in MRM?
-Level 2 clearance of axilla is done, upto the axillary vein.
Complications of MRM?
- Pain around the scar
- Accidental damage to nerves in the chest cavity
2. LAPAROSCOPIC CHOLECUSTECTOMY
Steps
1.
2.
3.
4.
General anaesthesia
Small incision above or below the umbilicus of 10mm
Inflated with CO2 gas
3 more incisions are given
a. 10 mm at epigastrium
b. 5mm in mid clavicular line subcostally
c. 5 mm a little below and lateral to the above
5. Clamp duct and artery of the calot’s triangle
6. Remove Gallbladder
3. OPEN CHOLECYSTECTOMY
- Prophylactic 2nd gen cephalosporins are given – e.g cefotaxime
- Incision : right paramedian or right subcostal (kocher’s incison)
Layers:
Skin
Two layers of sup. Fascia
Ext oblique
Internal oblique
Etc.
.
4. APPENDICECTOMY
Types of incisions:
- Right paramedian incision (given if appendix is perforated)
- McBurney’s grid incision 6-8cm at right angle to spino-unbilical line, 1/3 distance from ASIS
(anterior-superior iliac spine) and 2/3 distance from umbilicus.
- Lanz incision – curved transverse incision planced at McBurney’s point. It is cosmetically better.
Layers cut during surgery:
1. Skin
2. Two layers of subcutaneous tissue – superficial fatty (camper’s) and deep membraneous
(scarpa’s). There is no deep fascia in the abdomen.
3. External oblique apponeurosis – downward and medially – incised in direction of fibres of
muscle.
4. Internal and transverse abdominal muscles are split (grid iron-right angle to each other)
5. Peritoneium is incised.
Trace the taenia coli, it leads to appendix is unable to find it.
Once appendix is freed at the base, a purse string suture is applied all around the appendix, using silk
sutures.
Look for mekel’s diverticulum
Closure:
1. Peritoneum is closed with chromic catgut (absorbable suture – retained for 15-25 days –
monofilament type)
2. Split muscles are sutures interrupted fashion with chromic catgut (biological type)
3. External oblique – chromic catgut (biological)
4. Subcutaneous fascia tissue – plain catgut – 7-10 days retention (biological)
5. Skin with interrupted fashion silk suture (non-absorbable)
5. HERNIORRHAPY
-
Indication: For direct for indirect hernia (inguinal)
Contraindicated in severe cardiopulmonary insufficiency
Done under regional or general aneasthesia
Precedure:
6-8 cm incision parallel to the inguinal ligament at he level of deep ring in the middle two thirds of
the inguinal ligament.
Layers:
1. Skin
2. Two layers of superficial fasia
3. External oblique is incised in the line of direction of fibres
4. Thin cremasteric box is opened
5. Identify sac:
a. Isolate the cord from the sac
b. Mobilize the sac
c. Open and see for contents
d. Reduce the contents
e. Transfixation ligature
f. Excise sac
Till here it is called herniotomy.
Repair (herniorrhaphy)
- 3 methods
o Basini’s repair
o Shouldice repair
o Tension free free mesh repair
Basini’s Repair:
1. Conjoined tendon is retracted upwards, approximated to inguinal ligament
2. Interrupted silk sutures are used to approximate the aponeurosis of transverse abdominus
muscle and the iliopubic triad .
3. Second interrupted silk sutures to join conjoined tendon to inguinal ligament
4. Suture line extends from pubic tubercle to medial border of internal ring.
Shouldice Repair:
4 layers of sutures in continuous fashion
Tension free mesh repair:
AKA: Lichenstien repair. Prolene mesh is used.
Precautions:
1. Ilioinguinal nerve care.
2. There should be no tension on sutures.
Complications:
Immediate: Hematoma due to injury to pampniform plexus of veins.
Other: Infection, Nerve entrapment
6. SURGERY FOR HYDROCELE
-
Indication: Vaginal hydrocele
Contraindication: Secondary hydrocele due to tumors – it contains haemorrhagic fluid
Procedure:
- Savlon and spirit are sued instead of iodine
- 5-6cm incision over the most prominent part parallel to median raphe of the scrotum
Layers:
1.
2.
3.
4.
5.
Skin
Dartos muscel
Ext. Spermatic fascia
Cremasteric fascia
Internal Spermatic fascia
At this stage, hydrocele is delivered. Draine the fluid via a trocar and cannula instrument.
Post-OP complications:
1. Hematoma
2. Infection
3. Injury to spermatic cord
7. THYROIDECTOMY
Incision: Horizontal neck incision is most common. Atleast 6-8 cm long, 2 cm above the sternal
notch.
SUTURES
Absorbable:
1. Plain catgut – biological type – 7-10 days retention – not to be used for infected areas.
2. Chromic catgut – biological type – 15-25 days retention – not to be used for infected areas.
3. Vicryl – synthetic toye – more strength – can be used for infected areas.
Non- Absorbale:
1. Prolene – synthetic
2. Mersilk - synthetic
3. Black silk – biological
4. Cotton – biological
FRACTURES
1. FEMUR NECK FRACTURE (INTRACAPSULAR)
Garden’s classification
a. Grade 1  Incomplete fracture of neck (medial tuberculae intact and vascularity preserved)
b. Grade 2  Complete fracture of neck without displacement (trabaculae aligned and
vascularity preserved)
c. Grade 3  Moderate displacement of less than half the diameter of femoral neck (trabeculae
and vascularity disturbed)
d. Grade 4  Complete off-ended femoral head (fully disrupted trabeculae and vessels)
Case e.g : Elderly, post-monopausal, osteoporosis present , there is leg shortening  displaced fractures.
Complication :
1. Non-Union
2. Avascular necrosis of femoral head
3. Thrombo embolism
4. Arthritis
Treatment:
1. <65 yrs old
i. Closed/ open reduction followed by internal fixation with screws and plates (DHS)
ii. Total hip replacement (THR) if irreversible damage.
2. > 65 yrs old
i. Fracture reduction and sliding hip screws (DHS)  for Grade 1 and 2
ii. Bipolar-arthroplasty – if patient less fit for surgery and much younger age.
iii. Hemi-arthroplasty – if patient less fit for surgery and near 65 age.
iv. THR  for Grade 3 and 4.
If acetabulum involved at any grade  THR
2. EXTRACAPSULAR (INTER TROCHANTERIC FRACTURE)
There is external rotation and shortening of leg. Road traffic accident case.
Complications: Thromboembolism, Malunion.
Treatment:
1. ABCDE of primary survey.
2. Internal fixation with DHS (dynamic hip screws)
a. Analgesia
b. IV antibiotics
c. On bed for 3 months with abducted and internally rotated leg.
3. FRACTURE TIBIA – FIBULA SHAFT (Open Fractures)
Treatment:
1. Wound excision (removal of all dead/ composed tissue)
2. Stabilize fracture by external fixation and leave wound open
3. Second look at 24 hrs-48hrs to ensure all necrotic tissue has been removed.
4. Plastic surgical or vascular reconstruction may be required.
Complications:
- Fat embolish
- DVT
- Pul. Emb in immobilized
- Non-union and mal-union.
4. PELVIC FRACTURE
Complications:
1. Massive internal bleeding
2. DVT
3. PE
4. Infection
5. Lumbar nerve damage
6. Gluteal nerve damage
7. Obturator nerve damage
8. Sciatic nerve damage
9. Cauda equine syndrome
10. Non/ Mal union
Treatment:
1. ABCDE
2. Immediately tie external hip tourniquet belt to stop bleeding.
5. HIP DISPLACEMENT
-
Posterior displacement  most common
RTA  front seat passenger hitting knees hard on dash board.
Complication:
1. Sciatic nerve injury
2. Avascular necrosis of femoral head
3. Associated
i. Fracture of femoral neck
ii. Fracture of posterior acetabulum
Treatment:
Reduction – closed manipulation and maintenance of reduction by skin traction
6. SUPRA-CONDYLAR FRACTURE
Fall on outstretched hand, inability to move elbow
Complication:
1. Damage to medial / ulnar / radial nerve
2. Vascular injury
3. Acute compartment syndrome
4. Malunion
Treatment:
ER  1. Undisplaced : Posterior plaster slab and collar and cuff with elbow flexed for 3
Weeks
2. Slight displaced : Closed manipulation under GA
3. Displaced: Closed manipulation under GA + skin traction with elbow in extension
+ Open reduction and Internal fixation with K-wiring.
7. CERVICAL VERTEBRAE FRACTURE:
1.
2.
3.
4.
Apply ATLS survey.
ABCDE (write full)
Stable spine manually, by sand bags or cervical collar
Asses patient. After stabilizing patient, do:
a. X ray Cervical spine (both AP and Lat. View), chest and pelvis
b. CT or MRI for detailed view.
8. C6 FRACTURE
Communited fracture (compression of vertebral column) / Single fracture
Treatment:
- Evaluation under anesthesia
- Removal of segments
- Stabilize with screws and plates
- Decompression of vertebral cord
PICTURES:
1. PILONIDAL SINUS
Hairs travel down the intergluteal furrow to penetrate skin or open mouth of sudoriferous gland, also
collect in cleft of nate and or postanal dimple.
Treatment:
Conservative:
Clean, remove all hairs, frequent wash, avoid long sitting.
Abscess (acute)
1. Rest baths, local antiseptic dressings and broad spec. antibiotics
2. Open abscess, remove all hair and granulation tissue, destroy tract with pure
phenol solution.
Long term surgical Rx – Techniques:
1. Lay open track, clean, secondary healing.
2. Excise all track, suture very accurately and suction and drain.
3. Excise all tracks, pack wound
4. Kary dakis operation
5. Bascom technique
2. PERIANAL FISTULA
Do MRI with contrast
Treatment:
Fistulotomy, then fistulectomy, then siton placement.
3. PERIANAL ABCESS
Treatment: Through drainage by cruciate incision, excising the skin edges.
4. DIABETIC FOOT ULCER/ PATIENT
Treatment: Control DM. Debridgement and antibiotics according to sensitivity with daily dressing. If
not improving  below knee amputation.
Tests: 1. X ray of foot to rule out osteomilitis.
2. Arterial Doppler ultrasound
3. Aspirate pus for culture and sensitivity.
5. DRY / WET GANGRENE
1. Counselling
2. Conservative: treatment for co-morbids, diet, DM, analgesis, jeep it dry, avoid pressure.
3. Surgical :
a. Surgical toilet
i. If no improvement  amputation
b. Limb saving  amputate until active bleeding & contraction is seen. Send tissue for
culture and sensitivity. Antibiotics. Daily dressing. Leave wound open.
c. Life saving  whole limb removed.
CT SCANS:
1. EXTRADURAL HEMATOMA
Middle meningeal artery involved. Patient will experience lucid interval.
Treatment:
1. Do ATLS survey
2. CT scan of head
3. Elevate head 30 degree
4. 0.25-1g/kg manitol
5. keep hypercapnia
Definitive tx: craniotomy with evacuation of haemorrhae and dithermy / clipping of bleeding vessel.
2. SUBDURAL HEMATOMA
-
Communicating veins bleed – elderly patient.
2 weeks old injury – subacute
More or equal 3 weeks old injury – chronic
Treatment:
- ABCDE
- Elevate head
- Craniotomy
3. SUBARACHNOID BLEEDING
Due to an aneurysm / AV malformation
Treatment:
- ABCDE
- Control BP
- Decrease ICP
- Hyperventilate patient
- Control fever
- Give Calcium Channel Blockers
When stable, do craniotomy + clipping of aneurysm / AV malformation.
Urgent embolization of feeding vessel..
UROLOGY
1. IVU will be given showing dilatation of calyses.
a. Treatment:
i. Reconstruction of hydronephrosis (Anderson – hynes operation)
ii. Intubated ureterostomy
iii. Endoscopic pyelolysis in obstruction
b. Diagnosis:
i. Cupping of calyceal system
ii. Hydronephrosis
iii. Chronic pyelonephritis
2. IVU image of stone at the pelvic ureteric junction.
a. Treatment of stricture
i. Endoscopic endopylotomy
ii. Or Endoscopic dilatation of stricture
iii. Or Open pyelotomy
b. Treatment of strone
i. Ureteroscopy
ii. Dilatation of stricture followed by stenting.
3. Stones in Kidney Pelvis
a. Above PUJ : ESW lithotripsy + DJ stenting
b. Below PUJ:
i. Endoscopic stone removal
ii. Lithotripsy
iii. Open surgery – ureterolithotomy
XRAY / CT SCAN – BLADDER CA.
Tests: Cystoscopy with bipsy
3 morning sample cytologies
Intravenous urography
CT scan
Lateral wall of bladder : 35% of all cancers
Transitional cell ca. : 90% of all cancers
Treatment:
Endoscopic resection
Or Intravesical chemotherapy (thiotepa and mitomycin)
Or Radiotherapy
Or Partial cystectomy
Or Radical cystectomy
TUMOR IN KIDNEY + WHITE LINE IN VEIN OF KIDNEY (THROMBOSIS)
Most common type: adenocarcinoma
Most common region: Upper pole
Staging:
1. T1 (4-7cm), T2 (>7cm)  Limited to kidney  Rx: Partial nephrectomy or radical
nephrectomy
2. T3  Extends into major veins within gerota’s fascia Rx: Venovenous
cardiopulmonary bypass
3. T4  Invades beyond the gerota’s fascia  Rx: Radical surgical excision
N0: No regional lymph nodes
N1: Mets to single regional lymph nodes
N2 : Mets to >1 regional lymph nodes
M0: No mets
M1 : Mets present
Investigations
1. Cystoscopy – one sided hematuria
2. IVU – function of contraletal kidney
3. USG – Difference between cyst and solid tumor
4. CT – staging
5. CXR – if it is secondary in lungs
6. Bone scan – mets
BARIUM STUDIES
1. Achalasia
a. Investigation:
i. Esophagoscopy
ii. Mamometry
b. Treatment
i. Heller’s operation (esophago cardiomyotomy
ii. Dilatation
2. Cancer esophagus
a. Investigation
i. Esophagoscopy – biopsy
ii. Bronchoscopy
iii. USG
iv. CT
Lower 1/3 esophagus cancer  laparotomy + lower esophagectomy + distal anostomosis
Upper 2/3 ca.  esophagectomy and reconstruction via:
i. Ivor Lewis approach  right thoracotomy (mid)
ii. McKeown operation (upper)
iii. Thoracoabdominal approach
Non-surgical  endoscopic stenting
Ca stomach : endoscopic biopsy, CT abd and pelvis.