Chaptersonly use Sample personal For Review of for Students

AUTHORS

Dr. Krishna Adit Agarwal, MBBS Alumnus of Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Founder, I-MediSTAR Innovation in Medical Science, Technology and Research only www.IMediSTChaptersAR.com AND use Dr. Avantika Singh, MBBS Alumna of Vardhman Mahavir Medical College and SampleSafdarjung Hospital, New Delhi, India Founder, I-MediSTAR Innovation in Medical Science, Technology and Research personalwww.IMediSTAR.com For

PEEPEE PUBLISHERS AND DISTRIBUTORS (P) LTD. Review of Surgery for Students

Published by Pawaninder P. Vij and Anupam Vij Peepee Publishers and Distributors (P) Ltd. Head Office: 160, Shakti Vihar, Pitam Pura Delhi-110034 (India)

Correspondence Address: 7/31, First Floor, Ansari Road Daryaganj, New Delhi-110002 (India) Ph: 65195868, 23246245, 9811156083 e-mail: [email protected] only e-mail: [email protected] Chapters e-mail: [email protected] www.peepeepub.com use

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First Edition : 2014

ISBN: 978-81-8445-167-2 FOREWORD

Dr. Devi Prasad Shetty Chairman and Founder Narayana Health

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

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

Due to the vast gap in demand and supply of post-graduate seats, entry into higher medical education has remained elusive to majority of MBBS graduates. In spite of large number of medical graduates, we are contending with only 2,030 post-graduate seats in General Surgery. only With the scenario tough and competitive, the aspirants for General Surgery course need well-organized material for preparation and better outcomes in the entrance tests.Chapters In this direction, the book ‘Review of Surgery for Students’ by Dr. Krishna Adit Agarwal and Dr. Avantika Singh should come handy.

With well classified and clearly laid out content, the effort of the young authorsuse in their maiden publication deserves admiration. I am sure they will be able to enrich subsequent editions with valuable feedback from students and faculty alike. I wish theSample authors as also the students a resounding success. Dr. Devi Prasad Shetty personal For Chaptersonly use Sample personal For INTRODUCTION TO THE AUTHORS

Dr. Krishna Adit Agarwal Dr. Avantika Singh Krishna is a recent medical graduate Avantika is a recent medical graduate of Vardhman Mahavir Medical College from Vardhman Mahavir Medical and Safdarjung Hospital, New Delhi. College and Safdarjung Hospital, New He aspires to specialize in the field of Delhi. She aspires to specialize in the Renal Medicine and has been offered field of Neonatal Medicine and has a position at the prestigious Beth been offered a position at the Israel Deaconess Medical Center (a teaching affiliate of prestigious Boston Children’s Hospital (a teaching affiliate Harvard Medical School) as a Research Fellow from of Harvard Medical School) as a Research Fellow from August 2014. August 2014. He has consistently performed well in his medical school Avantika has excelled in her medical school, winning examinations and displayed the ability to approach numerous accolades. She topped the University in the academic and practical problems in a logical, analytical third and final professional examinations. She was awarded and systemic manner. gold medals in Community Medicine and Obstetrics and Gynecology, silver medals in Pediatrics, Surgery, He has also undertaken several initiatives for the medical Ophthalmology and ENT, and bronze medal in Internal students like envisioning and organizing the Medical Medicine besides a distinction in Pharmacology. Students’ International Conference (MEDSICON) at VMMC. As the founder of the first MEDSICON conducted in 2011, Besides excelling in academics, she has founded an Krishna aimed at providing undergraduate (bio) medical organization – Innovation in Medical Science, Technology students an opportunity to showcase their research and Research (I-MediSTAR). The organization provides potential and take their research ideas forward. It has mentorship to medical students and graduatesonly seeking grown over the past three years and now receives Chaptersa to sharpen their clinical and research skills. It conducts handsome international and national participation. various skill-based hands-on workshops to help students learn the science and art of medicine. Krishna has also been a co-founder of Innovation in Medical use Science, Technology and Research (I-MediSTAR) which Avantika has also been the co-founder of Medical is an organization providing medical students and Students’ International Conference (MEDSICON) and graduates with various opportunities to hone their clinical organized it at VMMC for the past three years. The and research skills. He has also been instrumental in conference provided the much-needed platform to young setting upSample of the ‘Journal of Young Medical Researchers’ researchers to share their research ideas with the medical (JYMR), an open access journal providing an exclusive community. She is also the Student Editorial Board avenue for young researchers to publish their work. Coordinator at the Journal of Young Medical Researchers (JYMR). Krishna is a highly intellectual,personal dedicated and practical thinking doctor who excels in thinking beyond the Avantika is a brilliant doctor, who strives to excel in life. boundaries of the fixed academic curriculum. She is compassionate and caring towards her patients and has the ability to make the best possible medical For decisions.

Prof. Dr. Renuka Sharma Professor, Dept. of Physiology VMMC and SJH, New Delhi Chaptersonly use Sample personal For PREFACE

Review of Surgery for Students is aimed at providing the most concise and high-yielding information to undergraduate students preparing for their surgery final professional examination in India and abroad. There are a lot of surgery textbooks available in the market but no review book was so far available to help the students properly revise what they have learnt at their medical school. Our book is based on the Indian examination pattern and features a point-wise approach to topics. It is a book that has been written keeping in mind the last minute examination stress faced by students and it strives to help them retain the matter and answer well in the examinations. Only the must-know line diagrams have been included in the book. These diagrams are easy to remember as well as draw in the exam and will help achieve higher scores.

We have consulted the standard surgery textbooks, Bailey and Love’s Short Practice of Surgery (26th Ed.) and Manipal Manual of Surgery (3rd Ed.) alongwith various online resources in preparing this review book. Although, we have tried our best to include the latest guidelines and management protocols but these guidelines are continuously being updated and we encourage our readers to keep themselves up-to-date with the future advances in surgery.

Being the first edition, there might be some inadvertent errors in the book. We request our readers to kindly email us any corrections, suggestions and contributions in the form of latest protocols, line diagrams, newer topics asked in exams etc. to surgery@imedistar .com . We welcome your feedback and will surely incorporate it in theonly next edition of this book. Chapters “Let the young know they will never find a moreuse interesting, more instructive book than the patient himself” Sample - Giorgio Baglivi

Most importantly, attend yourpersonal clinics and listen to the patient, for the patient teaches you far more than any book ever can!For Dr. Krishna Adit Agarwal

Dr. Avantika Singh New Delhi, India Chaptersonly use Sample personal For ACKNOWLEDGEMENTS

We are thankful to…

Gods in Heaven

Gods on Earth, Our Parents

Our Gurus, Guides and Mentors

Dr. Jayashree Bhattacharjee

Dr. Chintamani, Dr. Harish Chellani

Dr. Renuka Sharma, Dr. Rajeev Tiwari

Dr. Sugandha Arya, Dr. Harpreet Singh

Our great friends, especially Manmohan

for igniting the spark to write this book Our Dear Readers only Chaptersand The awesome team at Peepee Publishers and Distributors Pvt. Ltd. use for their wonderful work with this book. Sample personal For Chaptersonly use Sample personal For CONTRIBUTING AUTHORS

Joyutpal Biswas Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi Arteries, Veins & Lymphatics and Burns

Akriti Sinha Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi Miscellaneous Questions asked in exams

Arushi Devgan Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi Paediatric Surgery

Aditya Ranot Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi Oral Cavity and Oropharynx and Salivary Glands

Nayan Agarwal University College of Medical Sciences and G.T.B. Hospital, New Delhi Trauma Care

Shivani Sharma Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi only Fluid & Electrolyte Balance,Chapters SIRS and MODS use CREATIVE TEAM

SampleShashank Singh Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi

personalVinay Kumar Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi

For Kaveri Pandit Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi

Sachin Goel Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi xii Review of Surgery for Students

REVIEWERS

Dr. Rohan Khandelwal MS, MRCS (Edin.), FIBD Oncoplastic Surgeon Editor-in-Chief: Journal of Young Medical Researchers

Dr. Megha Tandon MS, DNB, MRCS Ed.,FICS,FIAGES Instructor for ATLS (American College of Surgeons)

Dr. Mayank Mehrotra MBBS, MD Anaesthesiology (Gold Medallist) Senior Resident, Department of Anaesthesiology VMMC and Safdarjung Hospital, New Delhi

Chaptersonly use Sample personal For CONTENTS

Section 1: Gastrointestinal Surgery

Chapter 1. 1

Chapter 2. Oesophagus 6

Chapter 3. and Duodenum 15

Chapter 4. and The Biliary System 26

Chapter 5. and Spleen 46

Chapter 6. Small and Large Intestines 57

Chapter 7. Intestinal Obstruction 73

Chapter 8. and 81

Chapter 9. 90

Section 2 Chapter 10. The Breast Chaptersonly 93 Section 3 Chapter 11. Thyroid and Parathyroid Glands use 111 Section 4 Chapter Sample12. Adrenal Gland 129 Section 5 Chapter 13. Oral Cavitypersonal and Oropharynx 131 Section 6

Chapter 14. Salivary Glands 137

For Section 7: Urology

Chapter 15. Kidney and Ureter 142

Chapter 16. Urinary Bladder and Urethra 153

Chapter 17. The Prostate Gland 161

Chapter 18. Penis, Testis and Scrotal Sac 167 xiv Review of Surgery for Students

Section 8: Arteries, Veins and Lymphatics

Chapter 19. Arterial Disorders 177

Chapter 20. Venous Disorders 186

Chapter 21. Lymphatic Disorders 191

Section 9: Trauma Care and Burns

Chapter 22. General Principles 193

Chapter 23. Head Trauma 195

Chapter 24. Chest Trauma 201

Chapter 25. Abdominal Trauma 204

Chapter 26. Burns 208

Section 10

Chapter 27. Paediatric Surgery 213

Section 11 Chapter 28. General Surgery Chaptersonly 222 Section 12 Chapter 29. Fluid and Electrolyte Balance, SIRS and MODS use 242 Section 13

Chapter 30. Post-Operative Fever 247

Sample Section 14 Chapter 31. Principles of Anaesthesiology 250 personalSection 15 Chapter 32. Miscellaneous Questions Asked in Exams 260 For Section 16 Chapter 33. Surgical Instruments 268 Chapter SECTION 1 : GASTROINTESTINAL SURGERY 2

OESOPHAGUS

ZENKER’S DIVERTICULUM lying below the inferior constrictor muscle and above the cricopharyngeus muscle. only A.k.a. Pharyngoesophageal diverticulum, hypopharyngealChapters diverticulum, pharyngeal pouch. • A diverticulum arises by two mechanisms: use o Pulsion diverticulum: Push from inside the lumen increases intraluminal pressure and results in an outpouching, e.g., Upper and lower oesophagealSample diverticuli. o Traction diverticulum: Pull from outside results in an outpouching, e.g., Middle oesophageal diverticulum. • Diverticuli can be of 2personal types: o Congenital diverticuli: Full thickness, mucosa to Forserosa, e.g., Meckel’s diverticulum. o Acquired diverticuli: Partial thickness, muscles are not involved, e.g., Zenker’s diverticulum. Fig. 2.1: Zenker’s diverticulum • Zenker’s diverticulum results from an uncoordinated • Clinical Presentation: swallowing associated with cricopharyngeal muscle o Dysphagia. spasm and delayed muscle relaxation which cause o Lumpiness. increased intrapharyngeal pressure and outpouching of the mucosa at the weakest point of the pharyngeal o Regurgitation of swallowed food. wall – Killian’s dehiscence. o Halitosis. • Killian’s dehiscence is a weak area of the pharynx o Cough.

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• Diagnosis: • Causes: o Barium swallow. 1. Idiopathic. o Water soluble contrast and CT. 2. Obesity. o is usually not performed for the risk of 3. Hiatal . perforation. 4. Hypercalcemia. • Treatment: 5. Zollinger-Ellison syndrome. o Diverticulectomy and cricopharyngomyotomy: 6. Scleroderma or systemic sclerosis. Excise the diverticulum and reduce the tone of 7. Visceroptosis a.k.a. Glenard syndrome. cricopharyngeus muscle to prevent recurrence. 8. Chronic steroid use. o Diverticulopexy: Reverse the direction of diverticulum and fix it so that it can drain and • Clinical Presentation: gradually reduce in size. 1. Heartburn (retrosternal burning pain). o Botulinum toxin injection into the crico- 2. Regurgitation. pharyngeus: Maximum relief of 6 months. 3. Pain while swallowing (odynophagia). o Dohlman’s procedure: Double-lipped oesophago- 4. Water brash. scope is used for cutting and stapling. 5. Coughing (due to laryngeal irritation). o Medical management in patients unfit for • Diagnosis: surgery: Can use calcium channel blockers or nitrates. 1. 24-hour ambulatory monitoringonly of pH is the Chaptersinvestigation of choice. GASTRO-OESOPHAGEAL REFLUX DISEASE o pH is measured 5 cm above and below the (GERD) gastro-oesophagealuse junction. GERD is a chronic condition characterized by reflux of o Patient maintains a symptom diary also. acidic stomach contents back into the oesophagus, causing 2. Manometry. damage to the mucosal lining of the oesophagus. 3. Upper GI endoscopy. • Pathophysiology:Sample The most important factor causing • Treatment: reflux is abnormal lower oesophageal sphincter. 1. Lifestyle modification Normally, this sphincter stays closed and relaxes only o Weight reduction. during swallowing. personalIn acid reflux disease, this o Sleep hygiene. sphincter loses its tone and remains open, allowing o Avoidance of heavy meals before lying down. acidic contents of the stomach to go back into the For o Stopping smoking and alcohol. oesophagus and damage its mucosal lining. o Moderate exercise. • Other Important Factors: 2. Medications 1. Lower oesophageal sphincter. o Proton Pump Inhibitors (PPI), e.g., 2. Oesophageal motility. Pantoprazole, Rabeprazole, Omeprazole. o H2-Receptor blockers, e.g., Ranitidine, 3. Gastric emptying. Famotidine. 4. Angle between the stomach and oesophagus o Antacids, e.g., Sucralfate, Aluminium (Angle of His). hydroxide etc.

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3. Surgery dislocation of the upper stomach into the posterior o Nissen’s fundoplication: The upper stomach is mediastinum. wrapped around the oesophagus to strengthen the 2. Type II a.k.a. Rolling or Paraoesophageal Hernia: lower oesophageal sphincter and prevent reflux. Occurs when the fundus of the stomach herniates It is a 360 degree wrap. alongside a normal oesophagus. o Belsey’s fundoplication: Partial 270 degree wrap. 3. Type III: Mixed variety. o Hill’s repair. (See Fig. 2.2) o Laparoscopic fundoplication. • Associated Risk Factors: • Complications: 1. Increased intra-abdominal pressure due to violent 1. Oesophageal stricture. coughing, chronic constipation, pregnancy, obesity etc. 2. Oesophageal ulcer. 2. Congenital diaphragmatic weakness. 3. Barrett’s oesophagus: Metaplasia of the normal stratified squamous epithelial lining of the lower 3. Smoking. oesophagus to the intestinal simple columnar • Clinical Presentation: epithelium with goblet cells. It is a pre-malignant 1. Rolling hiatal hernia usually presents with condition, strongly associated with the develop- dysphagia or symptoms of obstruction. ment of adenocarcinoma of the oesophagus. 2. Sliding hiatal hernia usually presents with HIATUS HERNIA symptoms of heartburn and regurgitation.only Chapters• Diagnosis: It is an abnormal protrusion of the stomach into the thorax through a weakness or defect in the diaphragm. 1. Upper GI endoscopy.use • Types of hiatal hernias: 2. Barium swallow in erect position. 1. Type I a.k.a. Sliding Hernia: Occurs due to a laxity 3. Plain X-rays – Might show an abnormal air fluid ofSample the phrenico-oesophageal ligament resulting in level in the thorax. personal For

Fig. 2.2: Hiatus hernia

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• Treatment oesophageal junction due to retching or vomiting. The 1. Lifestyle modification. initial vomitus does not contain blood, but the subsequent vomitings contain blood from the bleeding laceration. 2. PPIs, H2-blockers, antacids to reduce acid production. • Clinical Presentation: 3. Nissen’s fundoplication. o Usually presents as hematemesis following a severe episode of vomiting or retching. 4. Laparoscopic fundoplication. o May also present as melena. 5. Hill’s repair. • Investigations: BOERHAVVE SYNDROME o Upper GI endoscopy is the investigation of choice. It is a full-thickness tear in the left distal oesophagus (a • Treatment: few centimetres away from the stomach) due to forceful o Bleeding usually stops within 2-3 days. vomiting or retching against a closed glottis. o Endoscopic cauterization may be used to stop the • Clinical Presentation: bleeding if it persists. o Usually patient has a history of severe retching or vomiting followed by severe abdominal or chest TRACHEO-OESOPHAGEAL FISTULA pain. A fistula is defined as a tract open at both ends, connecting o Odynophagia, tachycardia, tachypnoea, cyanosis two epithelial lined cavities. The trachea-oesophageal and shock may develop. fistula refers to an abnormal communication between the o Mackler’s triad: Classical presentation seen in less trachea and oesophagus. It is generallyonly a congenital than 20% of cases comprises chest pain, vomitingChaptersabnormality but it may also occur following laryngeal and subcutaneous emphysema. . o Subcutaneous emphysema may be audible as • During the usedevelopment of the trachea and Hamman’s crunch or Hamman’s sign. oesophagus, normally a septum divides them in a • Investigations: cranio-caudal direction. But if the septum develops in a cranio-dorsal direction then a trachea-oesophageal o Gastrograffin oesophagogram (water soluble fistula results. contrast).Sample o Plain X-ray. • Pressure necrosis due to an indwelling tracheostomy tube might also cause an abnormal communication o CT scan. personalbetween the trachea and oesophagus. • Treatment: • Types: o IV rehydration. For Table 2.1: Types of tracheo-oesophageal fistula o Antibiotics to prevent mediastinitis. Type Remarks o Surgery – Left thoracotomy with lavage and Type A Second-most common type primary repair within 48 hours. Type B o Controlled fistula may be otherwise used. Type C Most common type MALLORY-WEISS SYNDROME Seen in 80-87% of the cases Type D A.k.a. Gastro-oesophageal laceration syndrome. Type H It is a partial thickness mucosal tear at the gastro-

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Fig. 2.3: Tracheo-oesophageal fistula

• TOF is commonly associated with Down’s syndrome. • Treatment: • Other congenital anomalies often present in 1. A right posterolateral thoracotomy is done from association with TOF–VACTERL anomalies: the 4th intercostal space to repair the defect. 1. Vertebral anomalies. 2. Waterston’s criteria takes into account the birth 2. Anorectal anomalies (Most common association). weight (BW) and presence or absence of pneumonia into account while deciding on surgery: 3. Cardiac anomalies (PDA, VSD, Tetralogy of Fallot). o BW>5.5 lbs and pneumonia absent – Surgery can be performed immediately. 4. Tracheo-oesophageal fistula. o BW<4 lbs and pneumonia severe – 5. Renal anomalies. only ChaptersGastrostomy should be done to feed the child 6. Limb anomalies (Radial hypoplasia being the most and definitive surgery performed a few weeks common). later. use • Polyhydramnios is seen in 50% of the mothers with a TOF-afflicted foetus. OESOPHAGEAL WEB • Clinical Presentation: Table 2.2: Types of oesophageal webs 1. TheSample newborn often has excessive drooling from Congenital Acquired the mouth, followed by choking on his own • Rare • More common than the secretions and cyanosis. congenital variety 2. A red-rubber tubepersonal cannot be passed beyond • Common in lower • Common at the upper end of 8-10 cm in the oesophagus. oesophagus oesophagus, at the level of cricopharyngeus 3. Child chokes with each feed because the milk goes Forinto the trachea and causes choking and cyanosis. • Common in post- or peri- menopausal women 4. Other complications like pneumonitis and lung • An asymmetrical mucosal web abscess may occur. • Associated with iron deficiency • Investigations: anaemia (Plummer-Vinson 1. Inability to pass a nasogastric tube. Syndrome / Paterson-Brown- 2. Plain X-ray shows coiling of the nasogastric tube Kelly Syndrome) at the fistula site. • Can cause dysphagia in some cases, therefore a.k.a 3. Water soluble contrast may be given, which does Sideropenic dysphagia not go beyond the fistula site.

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THE BREAST

RELEVANT ANATOMY Arterial Supply only Mammary glands are modified sweat glands. They areChapters• Upper Part: Superior thoracic artery and located in the superficial fascia anterior to the pectoral Acromiothoracic artery (Branches of axillary artery). muscles and the anterior thoracic wall. Retromammary • Lateral Part: Lateral thoracic artery (branch of axillary space is a layer of loose connective tissue separates the artery). use breast from the deep fascia. • Medial Part: Perforating branches of internal thoracic The connective tissue stroma condenses in certain artery. regions forming well defined ligaments called ‘the Venous return is parallel to the arteries. suspensorySample ligaments of Cooper’. These are continuous with the dermis of the skin and support the breast. Innervation Axillary tail of Spence perforates the deep fascia and • Anterior and lateral cutaneous branches of 2nd-6th extends into the axilla throughpersonal the foramen of Langer. Intercostal nerves.

Physiology • is innervated by the 4th intercostal nerve. OestrogenFor is responsible for initiating ductal development. LYMPHATIC DRAINAGE OF THE BREAST Progesterone plays a role in differentiation of epithelium Lymphatic vessels pass to the axillary, supraclavicular, and lobular development; it stimulates TDLU formation parasternal and abdominal lymph nodes as well as to the and expansion during puberty and pregnancy. (Aid to opposite breast. Cutaneous lymphatics of one breast remember: DOPE-L:Ductal development–Oestrogen; communicate with the cutaneous lymphatics of the Progesterone: Epithelial differentiation, lobular development). opposite breast across midline. Prolactin is responsible for lactogenesis. Superficial Lymphatics Oxytocin is released by suckling reflex, responsible for expulsion of milk into ducts. • Drain the nipple and areola.

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• Form a ‘subareolar plexus of Sappey’. Anterior, Posterior, Lateral • Communicate with deeper lymphatics within breast group of axillary LN parenchyma.

Deeper Lymphatics

• Located in the parenchyma of the breast. Central group of Axillary LN • Drain predominantly into: 1. Internal Mammary LN/Para-sternal LN • Found in the first 3 intercostal spaces along the internal mammary vessels deep to the plane of Apical group of Axillary LN costal cartilages. 2. Axillary Lymph Nodes: (75% drainage) • Six groups: Out of which apical group of lymph nodes receive the efferents of all the other groups. Supraclavicular group (Lowest group of Deep Cervical LN) • These are in continuity with the supraclavicular LN felt in the posterior triangle above the clavicle. They drain into the subclavian trunk. This enters the great veins directly or via the thoracic duct or jugular vein. Right Lymphatic Duct or the thoracic duct on the left side (See Fig. 10.1 and Table 10.1) only TRIPLE ASSESSMENT ChaptersFig. 10.1 In any patient who presents with breast lump or other symptoms suspicious of carcinoma, the diagnosis is made since in mammography both dense tissue and tumours showuse up as solid white areas. Mammo- using triple assessment. The PPV (positive predictive value) exceeds 99%: graphy is more useful for older patients with less dense tissue. 1. Clinical History and Examination. • Mammogram: Sample o Performed in all patients above 35: Involution of 2. Radiological Studies: breast has usually started by this age, breast • Predominant component of breast in non-lactating stroma is replaced by radiolucent fat making women is FAT andpersonal in lactating women is sensitivity of mammogram greater. GLANDULAR TISSUE. For younger patients o BI-RADS (Breast Imaging, Reporting and Data (denser ) ultrasound is a better investigation System) scoring is used (Table 10.2).

For Table 10.1: Levels of axillary lymph nodes Level Position Lymph node groups I Lateral to pectoralis minor • Anterior (Pectoral): Located along lateral thoracic vessels • Posterior (Subscapular): Located along subscapular vessels • Lateral (Humeral): Located along the axillary vein II Along pectoralis minor • Central: Situated in the floor of axilla • Interpectoral (Rotter’s): Lie between P. major and P. minor muscles III Medial to pectoralis minor • Apical (Infraclavicular)

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Table 10.2: BI-RADS assessment categories

Category Assessment Remarks and likelihood of cancer Next step

0 Incomplete Cloudy X-ray/Difficult to read/Patient moved Need additional imaging evaluation when image was taken (Mammography/USG) or Prior mammograms for comparison

1 Negative No evident signs of cancer Continue routine screenings

2 Benign No apparent cancer, but other findings (such as cysts) Continue routine screenings are described in the report

3 Probably Benign > 0% but < 2% likelihood of malignancy Repeat mammogram in six months. If family/personal history of breast cancer, you may opt to do more tests now rather than wait

4 Suspicious > 2% but < 95% likelihood of malignancy Tissue diagnosis (e.g. Core biopsy) Category 4A: Low suspicion for malignancy (> 2% to < 10%)

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

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

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

6 Known Biopsy- N/A Surgical excision when clinically Proven Malignancy Chaptersappropriate only • Ultrasound: – Advantage: Least invasive for cell o Useful in young women and in pregnant diagnosis,use rapid, very accurate. women. – Disadvantage: False negatives (mainly due o Helps distinguish cysts from solid lesions. Helps to sampling error), invasive cancer cannot localise impalpable areas of breast pathology. be distinguished from in situ disease. • MRI:Sample o Core Biopsy: It is now the standard of care. A o Helps to distinguish scar from recurrence in spring loaded core needle biopsy device (hollow women who’vepersonal had BCS. needle) is used (12G-18G). o Useful for women with breast implants. – Advantages: 3. Pathological Studies: ♦ Histology gives important oncological •ForCurrent evidence suggests that 14-gauge (14G) core information including tumour type and biopsy, properly carried out, provides better grade. sensitivity and specificity than FNAC. ♦ Tells receptor status (imp before • Types of biopsy procedures: neoadjuvant therapy). o Fine needle aspiration cytology (FNAC): A very ♦ Facilitates definitive diagnosis of thin needle (21G - 30G) attached to a syringe benign lesions. to withdraw (aspirate) a small amount of tissue ♦ Differentiates between DCIS and from the suspicious area. invasive disease.

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♦ Microcalcifications, asymmetry and Congenital Causes architectural distortion can be studied 1. tissue and (Polymazia and well. supernumerary nipples). Incidence: 1% of women. Vacuum assisted core biopsy (VACB) is These can occur anywhere along the milk lines with done using systems like ‘Mammotome’. most common site being axilla (for accessory breast) and below the breast (for accessory nipples). These Ultrasound guided biopsies or stereotactic undergo cyclical and lactational changes. They are needle biopsies (mammogram from two also prone to any benign or malignant disease. angles) are also done. Treatment involves reassurance or excision. o Surgical (Open) Biopsy: 2. Breast hypoplasia: It presents with breast asymmetry – Incisional biopsy: Only part of the if it is unilateral. is a condition suspicious area, enough to make a diagnosis is removed. which occurs commonly in males and is characterised by , absent/partial pectoralis muscle and – Excisional biopsy: Entire abnormal area with or without a rim of normal breast syndactyly. tissue margins are removed. 3. : Absence of nipples. 4. : Postpubertal underdevelopment of BENIGN breast tissue. Benign breast diseases can be subdivided into three categories: ANDI (Aberrations of Normal Development 1. Congenital. and Involution) 2. ANDI (Aberrations of normal breast development only It refers to the aberration of the physiological processes and involution). Chapterswhich occur in the breast from menarche till menopause 3. Non-ANDI. (Table 10.3). use SampleBREAST LESIONS (Fig. 10.2) personal For

Fig. 10.2: Location of various breast lesions

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Table 10.3: Aberrations of normal development and involution Normal Breast development Cyclical changes Involution* physiologic process → Age Puberty- 25 years 25-40 years 35-55 years Site Stromal Lobular Stromal Lobular Ductal Aberration Juvenile Fibroadenoma Cyclical mastalgia, Sclerosing Macrocysts Duct ectasia hypertrophy cyclical nodularity lesions (Previously called Fibroadenosis) Clinical Excessive Discrete, highly Generalised or discrete May present Smooth, tense , features breast mobile lobulated lumps, diffuse, irregular with a mass or cysts which Bilateral or development mass lumpiness in breast. mimic a cancer on feel firm on central nipple Can be multiple/single/ mammogram palpation, may retraction (Note: unilateral/ bilateral cause pain, Unilateral nipple Premenstrual multifocal and retraction could be mastalgia bilateral cancer) Investigation USG (Guided biopsy Mammogram USG to ensure no may be done if >25 + biopsy solid component years) Malignancy Rarely–Sarcoma Carcinoma if epithe- liosis is present Treatment Reassurance, Conservative: Surgical excision Aspiration, F/U Hadfieldonly Excision if rapid 1. Firm breast support to exclude to ensure resolution. operation growth, giant 2. Vit E Chaptersmalignancy Excise if recurs (Cone excision fibroadenomas 3. Oil of Evening after 2 aspirations of the major (>5 cm) and if Primrose ducts) patient desires 4. Analgesics and use Diuretics (to reduce congestion) 5. Danazol 6. Tamoxifen (used Sample in UK) USG:Ultrasonography *Involution: For normal involution of the lobule, it is important that specialised stroma should be continually present around it. If the stroma disappears too early, thepersonal lobules are unable to involute properly and the epithelial acini remain. These may then form cysts. Dupont and Page Classification of Breast iii. Apocrine changes ChangesFor (3 groups) iv. Duct papilloma 1. Non-Proliferative Changes: 2. Proliferative Changes Without Atypia: a. 26% of all changes. a. 70% of all changes are non-proliferative. b. Risk of cancer: 1.5-2 : 1 as compared to general b. Risk of cancer: Nil i.e. Relative risk is same as population. general population (1:1). c. These changes include: c. These changes include: i. Florid epithelial hyperplasia. i. Mild epithelial proliferation ii. Sclerosing adenosis. ii. Cystic changes iii. Papillomatosis.

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3. Proliferative Changes with Atypia: which may have gentle lobulations and a thin a. 4% of all changes. pseudocapsule. b. Risk of cancer: 4-5 : 1 as compared to general • Mammography: population. o Circumscribed oval or round masses which c. If these changes are detected on FNAC: Surgical occasionally have coarse calcifications. excision is always done. o Large lobulated “pop-corn” calcifications may be d. These changes include: present. i. Atypical Ductal Hyperplasia. o Fibroadenoma does not contain adipose tissue, hence appears DENSER than the surrounding ii. Atypical Lobular Hyperplasia. normal tissue. Fibroadenoma • Pathology: o Fine needle aspiration or core biopsy. • Epidemiology: o Shows a benign tumour with two components: o Most common benign breast tumour in women Epithelial and mesenchymal (fibroblastic/ <40 years old, incidence declines with increasing connective tissue). Duct epithelium is non- age. neoplastic, fibroblastic component is neoplastic o Develops in 50% women who receive cyclosporine (monoclonal). The connective tissue proliferation after renal transplant. envelops the acini (terminal duct) and compresses • Clinical Features: them into clefts (now called ‘canaliculi’). o Painless (mostly) or painful swelling. o Types: (Mixed forms are the rule!)only o May spontaneously disappear or involute duringChaptersA. Intracanalicular fibroadenoma: If mesen- menopause (partially hormone-dependent). chymal proliferation invades the canaliculi, it compresses the ducts, which are irregular, o Giant Fibroadenoma: >5 cm in size OR occupies reduceduse to slits (Mesenchyme predominates). >1/3rd of the breast. B. Pericanalicular fibroadenoma: Mesenchyme • On Examination: proliferates around the ductal spaces, so that o Discrete (well-defined), smooth, round bordered. they remain round or oval, on cross section o FirmSample to hard in consistency non-tender/tender (Glandular/epithelial tissue predominates). lump. • Malignant Potential: o Highly mobile within the breast tissue (also called o Risk of malignant transformation in fibroadenoma breast mouse). personal is low. But risk of developing cancer in the breast o Multiple lesions may be present (10-15%). They parenchyma is elevated among women with Formay also be bilateral. fibroadenomas. • Diagnosis: Triple assessment is needed for all breast o Patients with fibroadenoma are 2.17 times more lumps: likely than women in the general population to develop invasive breast cancer.1 However, newer o Clinical Examination (as mentioned above). studies do not support these findings. o Imaging: Ultrasonography is preferred in patients o Risk is higher in case of complex fibroadenoma who are younger than 30 years or pregnant. Both (Relative risk is 3.10) and positive family history mammography and ultrasound are useful in of breast cancer.1 patients older than 30 years (and not pregnant). • Ultrasound: Reference: 1. Dupont WD, Page DL, Parl FF, et al. Long-term risk of breast cancer in women with fibroadenoma. N Engl J Med o Circumscribed, homogeneous, hypoechoic masses 1994; 331:10-15.

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Complex fibroadenomas are those with cysts >3 be translucent enough to reveal underlying breast mm in diameter, sclerosing adenosis, epithelial veins. calcifications etc. • Diagnosis: Triple Assessment is Needed for all Breast Lumps: • Treatment: o Clinical Examination (as mentioned above). o Observation: If triple assessment is negative for cancer and consistent with a fibroadenoma then o Imaging: Unreliable since it cannot differentiate conservative follow-up can be offered. Inform the benign cystosarcoma phyllodes from the malignant patient about the limitation of the tests and assess form or from fibroadenomas. promptly if there is symptomatic or clinical o Pathology: change. – Fine-needle aspiration is usually inadequate. o If fibroadenoma is rapidly growing, giant (>5 cm), Core biopsy is more reliable. causing physical deformity, discomfort or – Definitive method for diagnosing phyllodes emotional distress: tumours are: – Open excision (Enucleation). ♦ For smaller lesions: Open excisional breast – Ultrasound guided percutaneous excision (<4 biopsy. cm in largest diameter). ♦ For large lesions: Incisional biopsy. – Cryoablation (<4 cm in largest diameter). – Shows a fibroepithelial tumour composed of an epithelial and a cellular stromal component. Phyllodes Tumour Cleft like spaces lined by epitheliumonly with (Also called Cystosarcoma Phyllodes/Serocystic Chaptersstroma projecting into these in a leaf-like Disease of Brodie) fashion (phyllodes = leaf). Can be benign, borderline, or malignant depending on Phyllodes tumours are considered to be on a spectrum of histologicuse features like stromal cellularity, disease that consists of fibroadenoma on one end and infiltration at the tumour’s edge, mitotic malignant form of phyllodes tumours on the other end. activity etc. • Epidemiology: • Malignant Potential: o TumourSample of adult women: Most common between o All forms of phyllodes tumours are regarded as 40-50 years of age, i.e., prior to menopause (about having malignant potential. 15 years after the typical age of presentation of fibroadenoma). personalo 85-90% of phyllodes tumours are benign and 10- 15% are malignant. o Account for less than 1% of all breast neoplasms. o Although the benign tumours do not metastasize, • Clinical Features: For they have a tendency to grow aggressively and can o Large fast growing painless breast lump which recur locally. increases in size within just a few weeks. o The malignant forms metastasize hematogenously. • On Examination: o Most common metastatic site: Lungs followed by o Firm, mobile, well-circumscribed, non-tender skeleton, heart, liver. (i.e., similar to fibroadenoma) with a • Treatment: smooth and lobulated surface. o Best treatment: Complete excision (wide local o Large tumour with an average size of 5 cm. excision), with accurate histologic examination o Overlying skin may have a shiny appearance and and continued follow-up care.

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Assessment of a trauma patient should follow the ATLS 1. Airway and Cervical Spine Protection system (Advanced Trauma Life Support): • Ensure proper cervical spine immobilizationonly in Chaptersall trauma patients. This can be achieved with in- line immobilization techniques or with a Primary Secondary Definitive traditional useneck collar, sandbag or tape. survey and survey management resuscitation • Next, check for the patient’s vocal response. If the patient can speak, then his/her airway is not immediately compromised. Fig. 22.1: General ATLS trauma protocol Sample • Clear the mouth and airway of any obvious secretions and foreign bodies. Primary Survey and Resuscitation • Manoeuvres to open the airway include a jaw • The rapid primary surveypersonal and resuscitation go hand thrust and/or chin lift. in hand with each other. • Consider nasopharyngeal airway if airway tends • ABCDE of primary survey and resuscitation to repetitively close after these manoeuvres. For • If the GCS

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• Evaluate for the “deadly dozen” of chest trauma, Secondary Survey specially the life-threatening ones. • Secondary survey is undertaken only after the • Decompress a tension pneumothorax by a needle completion of primary survey and initial stabilization thoracostomy in the 2nd intercostal space midcla- of the patient. vicular line. • It consists of reviewing the patient history and • Insert a chest tube for other conditions like carrying out a thorough head-to-toe examination of pneumothorax and haemothorax. the patient. • Control active bleeding from any vessel. • Review the history (AMPLE) 3. Circulation and Control of Bleeding o A – Allergy history. • Check the patient’s conscious level, skin colour o M – Medication and vaccination (TT) history. and pulse for evidence of hypovolemia. o P – Past medical history. • Secure 2 large-bore IV cannulas, take samples and o L – Last meal timings and contents. start aggressive fluid resuscitation. o E – Events of the accident. • Titrate fluids against the patient’s initial response • Examination to a fluid challenge and his/her vital signs. o Examine the front of the patient and then perform • Evaluate for internal bleeding and treat accordingly. a log-roll to examine the back. 4. Disability o Head and face – Head injuries, fractures, ENT • This includes rapid assessment of the patient’s bleeds, inspection of mouth, foreign bodies and neurological status. only Chaptersairway compromise. • Monitor pupils for size and reaction. o Neck – Cervical spine, subcutaneous emphysema. • Calculate the Glasgow coma score. o Chest – Completeuse chest examination. • Evaluate periodically to observe any changes. o Neurological–Periodic GCS calculations, complete • Exclude causes of altered consciousness like head neurological examination. injury, hypovolemia, hypoglycaemia, alcohol and o Abdomen and pelvis – Complete abdominal drugSample abuse. examination, signs of peritonism, pelvic fractures, 5. Exposure perineal injuries, rectal and vaginal examination. • Expose the patient completely and examine the o Extremities – Limb injuries are not immediately front and back by log-rollingpersonal manoeuvres. life-threatening, therefore, focus on the ABCDE first. Then later observe for limb injuries, align 6. Adjuncts to the ABCDE of Primary Survey the fractured bone and evaluate distal neurovascular •ForTake blood samples for biochemical and function before and after the intervention. haematological tests. • Blood grouping and cross-match should be done. Definitive Management • ECG, BP monitoring and pulse oximetry. • Should be reached to as soon as possible after the • ABG sampling. primary and secondary surveys are complete. • If the patient is to be transferred to another hospital, • Urinary catheter. he/she should be hemodynamically and cardio- • Nasogastric tube. vascularly stable and accompanied by an experienced • Trauma radiography series. trauma care doctor.

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07/08/2014 These are only sample pages from multiple chapters. Not complete chapters. www.IMediSTAR.com FREE SAMPLE COPY NOT TO BE REPRODUCED OR SOLD. Chapter SECTION 16 33 SURGICAL INSTRUMENTS

Name 5 mm Trocar Sheath only Illustration Chapters use Sample personal For 5 mm trocar sheath

Features • Laparoscopic instrument.

• Placed in the patient's abdomen to serve as a port for insertion of various other laparoscopic instruments.

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Name Allis Tissue Holding Forceps

Illustration

Allis tissue holding forceps

Features • Has sharp teeth.

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

• Grasping/Holding bowel tissues to be resected. • Can causeChapters trauma to the tissues. only use Name Aneurysm Needle IllustrationSample personal For Aneurysm needle

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

• Used to hold a vessel.

• Used to place a ligature around the vessel.

• Can also be used for blunt dissection.

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