2. Review of Surgery
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
www.IMediSTAR.com
AND
Dr. Avantika Singh, MBBS
Alumna of Vardhman Mahavir Medical College and
Safdarjung Hospital, New Delhi, India
Founder, I-MediSTAR
Innovation in Medical Science, Technology and Research
www.IMediSTAR.com
PEEPEE
PUBLISHERS AND DISTRIBUTORS (P) LTD.
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4. FOREWORD
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.
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. 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 authors 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 the authors as also the students a resounding success.
Dr. Devi Prasad Shetty
Dr. Devi Prasad Shetty
Chairman and Founder
Narayana Health
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6. INTRODUCTION TO THE AUTHORS
Dr. Krishna Adit Agarwal
Krishna is a recent medical graduate
of Vardhman Mahavir Medical College
and Safdarjung Hospital, New Delhi.
He aspires to specialize in the field of
Renal Medicine and has been offered
a position at the prestigious Beth
Israel Deaconess Medical Center (a teaching affiliate of
Harvard Medical School) as a Research Fellow from
August 2014.
He has consistently performed well in his medical school
examinations and displayed the ability to approach
academic and practical problems in a logical, analytical
and systemic manner.
He has also undertaken several initiatives for the medical
students like envisioning and organizing the Medical
Students’InternationalConference(MEDSICON)atVMMC.
As the founder of the first MEDSICON conducted in 2011,
Krishna aimed at providing undergraduate (bio) medical
students an opportunity to showcase their research
potential and take their research ideas forward. It has
grown over the past three years and now receives a
handsome international and national participation.
Krishna has also been a co-founder of Innovation in Medical
Science, Technology and Research (I-MediSTAR) which
is an organization providing medical students and
graduates with various opportunities to hone their clinical
and research skills. He has also been instrumental in
setting up of the ‘Journal of Young Medical Researchers’
(JYMR), an open access journal providing an exclusive
avenue for young researchers to publish their work.
Krishna is a highly intellectual, dedicated and practical
thinking doctor who excels in thinking beyond the
boundaries of the fixed academic curriculum.
Dr. Avantika Singh
Avantika is a recent medical graduate
from Vardhman Mahavir Medical
College and Safdarjung Hospital, New
Delhi. She aspires to specialize in the
field of Neonatal Medicine and has
been offered a position at the
prestigious Boston Children’s Hospital (a teaching affiliate
of Harvard Medical School) as a Research Fellow from
August 2014.
Avantika has excelled in her medical school, winning
numerous accolades. She topped the University in the
third and final professional examinations. She was awarded
gold medals in Community Medicine and Obstetrics and
Gynecology, silver medals in Pediatrics, Surgery,
Ophthalmology and ENT, and bronze medal in Internal
Medicine besides a distinction in Pharmacology.
Besides excelling in academics, she has founded an
organization – Innovation in Medical Science,Technology
and Research (I-MediSTAR). The organization provides
mentorship to medical students and graduates seeking
to sharpen their clinical and research skills. It conducts
various skill-based hands-on workshops to help students
learn the science and art of medicine.
Avantika has also been the co-founder of Medical
Students’ International Conference (MEDSICON) and
organized it at VMMC for the past three years. The
conference provided the much-needed platform to young
researchers to share their research ideas with the medical
community. She is also the Student Editorial Board
Coordinator at the Journal of Young Medical Researchers
(JYMR).
Avantika is a brilliant doctor, who strives to excel in life.
She is compassionate and caring towards her patients
and has the ability to make the best possible medical
decisions.
Prof. Dr. Renuka Sharma
Professor, Dept. of Physiology
VMMC and SJH, New Delhi
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8. 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 the next edition
of this book.
“Let the young know they will never find a more interesting,
more instructive book than the patient himself”
- Giorgio Baglivi
Most importantly, attend your clinics and listen to the patient, for the patient teaches you far more than any book ever
can!
Dr. Krishna Adit Agarwal
Dr. Avantika Singh
New Delhi, India
PREFACE
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10. 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
and
The awesome team at Peepee Publishers and
Distributors Pvt. Ltd.
for their wonderful work with this book.
ACKNOWLEDGEMENTS
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12. 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
Fluid & Electrolyte Balance, SIRS and MODS
CREATIVE TEAM
Shashank Singh
Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
Vinay Kumar
Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
Kaveri Pandit
Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
Sachin Goel
Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
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13. xii Review of Surgery for Students
Dr. Rohan Khandelwal
MS, MRCS (Edin.), FIBD
Oncoplastic Breast Surgeon
Editor-in-Chief: Journal of Young Medical Researchers
Dr. Megha Tandon
MS, DNB, MRCS Ed.,FICS,FIAGES
Instructor forATLS (American College of Surgeons)
Dr. Mayank Mehrotra
MBBS, MD Anaesthesiology (Gold Medallist)
Senior Resident, Department of Anaesthesiology
VMMC and Safdarjung Hospital, New Delhi
REVIEWERS
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14. Section 1: Gastrointestinal Surgery
Chapter 1. Hernias 1
Chapter 2. Oesophagus 6
Chapter 3. Stomach and Duodenum 15
Chapter 4. Liver and The Biliary System 26
Chapter 5. Pancreas and Spleen 46
Chapter 6. Small and Large Intestines 57
Chapter 7. Intestinal Obstruction 73
Chapter 8. Rectum and Anal Canal 81
Chapter 9. Bariatric Surgery 90
Section 2
Chapter 10. The Breast 93
Section 3
Chapter 11. Thyroid and Parathyroid Glands 111
Section 4
Chapter 12. Adrenal Gland 129
Section 5
Chapter 13. Oral Cavity and Oropharynx 131
Section 6
Chapter 14. Salivary Glands 137
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
CONTENTS
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15. 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 222
Section 12
Chapter 29. Fluid and Electrolyte Balance, SIRS and MODS 242
Section 13
Chapter 30. Post-Operative Fever 247
Section 14
Chapter 31. Principles of Anaesthesiology 250
Section 15
Chapter 32. Miscellaneous Questions Asked in Exams 260
Section 16
Chapter 33. Surgical Instruments 268
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16. OESOPHAGUS
Chapter
2
ZENKER’S DIVERTICULUM
A.k.a. Pharyngoesophageal diverticulum, hypopharyngeal
diverticulum, pharyngeal pouch.
• A diverticulum arises by two mechanisms:
o Pulsion diverticulum: Push from inside the
lumen increases intraluminal pressure and results
in an outpouching, e.g., Upper and lower
oesophageal diverticuli.
o Traction diverticulum: Pull from outside results
in an outpouching, e.g., Middle oesophageal
diverticulum.
• Diverticuli can be of 2 types:
o Congenital diverticuli: Full thickness, mucosa to
serosa, e.g., Meckel’s diverticulum.
o Acquired diverticuli: Partial thickness, muscles
are not involved, e.g., Zenker’s diverticulum.
• Zenker’s diverticulum results from an uncoordinated
swallowing associated with cricopharyngeal muscle
spasm and delayed muscle relaxation which cause
increased intrapharyngeal pressure and outpouching
of the mucosa at the weakest point of the pharyngeal
wall – Killian’s dehiscence.
• Killian’s dehiscence is a weak area of the pharynx
lying below the inferior constrictor muscle and above
the cricopharyngeus muscle.
• Clinical Presentation:
o Dysphagia.
o Lumpiness.
o Regurgitation of swallowed food.
o Halitosis.
o Cough.
Fig. 2.1: Zenker’s diverticulum
SECTION 1 : GASTROINTESTINAL SURGERY
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17. Oesophagus 7
• Diagnosis:
o Barium swallow.
o Water soluble contrast and CT.
o Endoscopy is usually not performed for the risk of
perforation.
• Treatment:
o Diverticulectomy and cricopharyngomyotomy:
Excise the diverticulum and reduce the tone of
cricopharyngeus muscle to prevent recurrence.
o Diverticulopexy: Reverse the direction of
diverticulum and fix it so that it can drain and
gradually reduce in size.
o Botulinum toxin injection into the crico-
pharyngeus: Maximum relief of 6 months.
o Dohlman’s procedure: Double-lipped oesophago-
scope is used for cutting and stapling.
o Medical management in patients unfit for
surgery: Can use calcium channel blockers or
nitrates.
GASTRO-OESOPHAGEAL REFLUX DISEASE
(GERD)
GERD is a chronic condition characterized by reflux of
acidic stomach contents back into the oesophagus, causing
damage to the mucosal lining of the oesophagus.
• Pathophysiology: The most important factor causing
reflux is abnormal lower oesophageal sphincter.
Normally, this sphincter stays closed and relaxes only
during swallowing. In acid reflux disease, this
sphincter loses its tone and remains open, allowing
acidic contents of the stomach to go back into the
oesophagus and damage its mucosal lining.
• Other Important Factors:
1. Lower oesophageal sphincter.
2. Oesophageal motility.
3. Gastric emptying.
4. Angle between the stomach and oesophagus
(Angle of His).
• Causes:
1. Idiopathic.
2. Obesity.
3. Hiatal hernia.
4. Hypercalcemia.
5. Zollinger-Ellison syndrome.
6. Scleroderma or systemic sclerosis.
7. Visceroptosis a.k.a. Glenard syndrome.
8. Chronic steroid use.
• Clinical Presentation:
1. Heartburn (retrosternal burning pain).
2. Regurgitation.
3. Pain while swallowing (odynophagia).
4. Water brash.
5. Coughing (due to laryngeal irritation).
• Diagnosis:
1. 24-hour ambulatory monitoring of pH is the
investigation of choice.
o pH is measured 5 cm above and below the
gastro-oesophageal junction.
o Patient maintains a symptom diary also.
2. Manometry.
3. Upper GI endoscopy.
• Treatment:
1. Lifestyle modification
o Weight reduction.
o Sleep hygiene.
o Avoidance of heavy meals before lying down.
o Stopping smoking and alcohol.
o Moderate exercise.
2. Medications
o Proton Pump Inhibitors (PPI), e.g.,
Pantoprazole, Rabeprazole, Omeprazole.
o H2-Receptor blockers, e.g., Ranitidine,
Famotidine.
o Antacids, e.g., Sucralfate, Aluminium
hydroxide etc.
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18. 8 Review of Surgery for Students
3. Surgery
o Nissen’s fundoplication: The upper stomach is
wrapped around the oesophagus to strengthen the
lower oesophageal sphincter and prevent reflux.
It is a 360 degree wrap.
o Belsey’s fundoplication: Partial 270 degree wrap.
o Hill’s repair.
o Laparoscopic fundoplication.
• Complications:
1. Oesophageal stricture.
2. Oesophageal ulcer.
3. Barrett’s oesophagus: Metaplasia of the normal
stratified squamous epithelial lining of the lower
oesophagus to the intestinal simple columnar
epithelium with goblet cells. It is a pre-malignant
condition, strongly associated with the develop-
ment of adenocarcinoma of the oesophagus.
HIATUS HERNIA
It is an abnormal protrusion of the stomach into the thorax
through a weakness or defect in the diaphragm.
• Types of hiatal hernias:
1. Type I a.k.a. Sliding Hernia: Occurs due to a laxity
of the phrenico-oesophageal ligament resulting in
dislocation of the upper stomach into the posterior
mediastinum.
2. Type II a.k.a. Rolling or Paraoesophageal Hernia:
Occurs when the fundus of the stomach herniates
alongside a normal oesophagus.
3. Type III: Mixed variety.
(See Fig. 2.2)
• Associated Risk Factors:
1. Increased intra-abdominal pressure due to violent
coughing, chronic constipation, pregnancy,
obesity etc.
2. Congenital diaphragmatic weakness.
3. Smoking.
• Clinical Presentation:
1. Rolling hiatal hernia usually presents with
dysphagia or symptoms of obstruction.
2. Sliding hiatal hernia usually presents with
symptoms of heartburn and regurgitation.
• Diagnosis:
1. Upper GI endoscopy.
2. Barium swallow in erect position.
3. Plain X-rays – Might show an abnormal air fluid
level in the thorax.
Fig. 2.2: Hiatus hernia
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19. Oesophagus 9
• Treatment
1. Lifestyle modification.
2. PPIs, H2-blockers, antacids to reduce acid
production.
3. Nissen’s fundoplication.
4. Laparoscopic fundoplication.
5. Hill’s repair.
BOERHAVVE SYNDROME
It is a full-thickness tear in the left distal oesophagus (a
few centimetres away from the stomach) due to forceful
vomiting or retching against a closed glottis.
• Clinical Presentation:
o Usually patient has a history of severe retching or
vomiting followed by severe abdominal or chest
pain.
o Odynophagia, tachycardia, tachypnoea, cyanosis
and shock may develop.
o Mackler’s triad: Classical presentation seen in less
than 20% of cases comprises chest pain, vomiting
and subcutaneous emphysema.
o Subcutaneous emphysema may be audible as
Hamman’s crunch or Hamman’s sign.
• Investigations:
o Gastrograffin oesophagogram (water soluble
contrast).
o Plain X-ray.
o CT scan.
• Treatment:
o IV rehydration.
o Antibiotics to prevent mediastinitis.
o Surgery – Left thoracotomy with lavage and
primary repair within 48 hours.
o Controlled fistula may be otherwise used.
MALLORY-WEISS SYNDROME
A.k.a. Gastro-oesophageal laceration syndrome.
It is a partial thickness mucosal tear at the gastro-
oesophageal junction due to retching or vomiting. The
initial vomitus does not contain blood, but the subsequent
vomitings contain blood from the bleeding laceration.
• Clinical Presentation:
o Usually presents as hematemesis following a severe
episode of vomiting or retching.
o May also present as melena.
• Investigations:
o Upper GI endoscopy is the investigation of choice.
• Treatment:
o Bleeding usually stops within 2-3 days.
o Endoscopic cauterization may be used to stop the
bleeding if it persists.
TRACHEO-OESOPHAGEAL FISTULA
A fistula is defined as a tract open at both ends, connecting
two epithelial lined cavities. The trachea-oesophageal
fistula refers to an abnormal communication between the
trachea and oesophagus. It is generally a congenital
abnormality but it may also occur following laryngeal
surgeries.
• During the development of the trachea and
oesophagus, normally a septum divides them in a
cranio-caudal direction. But if the septum develops
in a cranio-dorsal direction then a trachea-oesophageal
fistula results.
• Pressure necrosis due to an indwelling tracheostomy
tube might also cause an abnormal communication
between the trachea and oesophagus.
• Types:
Table 2.1: Types of tracheo-oesophageal fistula
Type Remarks
Type A Second-most common type
Type B
Type C Most common type
Seen in 80-87% of the cases
Type D
Type H
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20. 10 Review of Surgery for Students
• TOF is commonly associated with Down’s syndrome.
• Other congenital anomalies often present in
association with TOF–VACTERL anomalies:
1. Vertebral anomalies.
2. Anorectal anomalies (Most common association).
3. Cardiac anomalies (PDA, VSD, Tetralogy of
Fallot).
4. Tracheo-oesophageal fistula.
5. Renal anomalies.
6. Limb anomalies (Radial hypoplasia being the most
common).
• Polyhydramnios is seen in 50% of the mothers with
a TOF-afflicted foetus.
• Clinical Presentation:
1. The newborn often has excessive drooling from
the mouth, followed by choking on his own
secretions and cyanosis.
2. A red-rubber tube cannot be passed beyond
8-10 cm in the oesophagus.
3. Child chokes with each feed because the milk goes
into the trachea and causes choking and cyanosis.
4. Other complications like pneumonitis and lung
abscess may occur.
• Investigations:
1. Inability to pass a nasogastric tube.
2. Plain X-ray shows coiling of the nasogastric tube
at the fistula site.
3. Water soluble contrast may be given, which does
not go beyond the fistula site.
• Treatment:
1. A right posterolateral thoracotomy is done from
the 4th intercostal space to repair the defect.
2. Waterston’s criteria takes into account the birth
weight (BW) and presence or absence of pneumonia
into account while deciding on surgery:
o BW>5.5 lbs and pneumonia absent – Surgery
can be performed immediately.
o BW<4 lbs and pneumonia severe –
Gastrostomy should be done to feed the child
and definitive surgery performed a few weeks
later.
OESOPHAGEAL WEB
Table 2.2: Types of oesophageal webs
Congenital Acquired
• Rare • More common than the
congenital variety
• Common in lower • Common at the upper end of
oesophagus oesophagus, at the level of
cricopharyngeus
• Common in post- or peri-
menopausal women
• An asymmetrical mucosal web
• Associated with iron deficiency
anaemia (Plummer-Vinson
Syndrome / Paterson-Brown-
Kelly Syndrome)
• Can cause dysphagia in some
cases, therefore a.k.a
Sideropenic dysphagia
Fig. 2.3: Tracheo-oesophageal fistula
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22. THE BREAST
Chapter
10
RELEVANT ANATOMY
Mammary glands are modified sweat glands. They are
located in the superficial fascia anterior to the pectoral
muscles and the anterior thoracic wall. Retromammary
space is a layer of loose connective tissue separates the
breast from the deep fascia.
The connective tissue stroma condenses in certain
regions forming well defined ligaments called ‘the
suspensory ligaments of Cooper’. These are continuous
with the dermis of the skin and support the breast.
Axillary tail of Spence perforates the deep fascia and
extends into the axilla through the foramen of Langer.
Physiology
Oestrogen is responsible for initiating ductal development.
Progesterone plays a role in differentiation of epithelium
and lobular development; it stimulates TDLU formation
and expansion during puberty and pregnancy. (Aid to
remember: DOPE-L:Ductal development–Oestrogen;
Progesterone: Epithelial differentiation, lobulardevelopment).
Prolactin is responsible for lactogenesis.
Oxytocin is released by suckling reflex, responsible
for expulsion of milk into ducts.
Arterial Supply
• Upper Part: Superior thoracic artery and
Acromiothoracic artery (Branches of axillary artery).
• Lateral Part: Lateral thoracic artery (branch of axillary
artery).
• Medial Part: Perforating branches of internal thoracic
artery.
Venous return is parallel to the arteries.
Innervation
• Anterior and lateral cutaneous branches of 2nd-6th
Intercostal nerves.
• Nipple is innervated by the 4th intercostal nerve.
LYMPHATIC DRAINAGE OF THE BREAST
Lymphatic vessels pass to the axillary, supraclavicular,
parasternal and abdominal lymph nodes as well as to the
opposite breast. Cutaneous lymphatics of one breast
communicate with the cutaneous lymphatics of the
opposite breast across midline.
Superficial Lymphatics
• Drain the nipple and areola.
SECTION 2
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23. 94 Review of Surgery for Students
• Form a ‘subareolar plexus of Sappey’.
• Communicate with deeper lymphatics within breast
parenchyma.
Deeper Lymphatics
• Located in the parenchyma of the breast.
• 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
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.
• 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.
(See Fig. 10.1 and Table 10.1)
TRIPLE ASSESSMENT
In any patient who presents with breast lump or other
symptoms suspicious of carcinoma, the diagnosis is made
using triple assessment. The PPV (positive predictive
value) exceeds 99%:
1. Clinical History and Examination.
2. Radiological Studies:
• Predominant component of breast in non-lactating
women is FAT and in lactating women is
GLANDULAR TISSUE. For younger patients
(denser breasts) ultrasound is a better investigation
Central group of Axillary LN
Anterior, Posterior, Lateral
group of axillary LN
Apical group of Axillary LN
Supraclavicular group (Lowest
group of Deep Cervical LN)
Right Lymphatic Duct or the
thoracic duct on the left side
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)
since in mammography both dense tissue and
tumours show up as solid white areas. Mammo-
graphy is more useful for older patients with less
dense tissue.
• Mammogram:
o Performed in all patients above 35: Involution of
breast has usually started by this age, breast
stroma is replaced by radiolucent fat making
sensitivity of mammogram greater.
o BI-RADS (Breast Imaging, Reporting and Data
System) scoring is used (Table 10.2).
Fig. 10.1
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24. The Breast 95
• Ultrasound:
o Useful in young women and in pregnant
women.
o Helps distinguish cysts from solid lesions. Helps
localise impalpable areas of breast pathology.
• MRI:
o Helps to distinguish scar from recurrence in
women who’ve had BCS.
o Useful for women with breast implants.
3. Pathological Studies:
• Current evidence suggests that 14-gauge (14G) core
biopsy, properly carried out, provides better
sensitivity and specificity than FNAC.
• Types of biopsy procedures:
o Fine needle aspiration cytology (FNAC): A very
thin needle (21G - 30G) attached to a syringe
to withdraw (aspirate) a small amount of tissue
from the suspicious area.
– Advantage: Least invasive for cell
diagnosis, rapid, very accurate.
– Disadvantage: False negatives (mainly due
to sampling error), invasive cancer cannot
be distinguished from in situ disease.
o Core Biopsy: It is now the standard of care. A
spring loaded core needle biopsy device (hollow
needle) is used (12G-18G).
– Advantages:
♦ Histology gives important oncological
information including tumour type and
grade.
♦ Tells receptor status (imp before
neoadjuvant therapy).
♦ Facilitates definitive diagnosis of
benign lesions.
♦ Differentiates between DCIS and
invasive disease.
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 appropriate
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25. 96 Review of Surgery for Students
♦ Microcalcifications, asymmetry and
architectural distortion can be studied
well.
Vacuum assisted core biopsy (VACB) is
done using systems like ‘Mammotome’.
Ultrasound guided biopsies or stereotactic
needle biopsies (mammogram from two
angles) are also done.
o Surgical (Open) Biopsy:
– Incisional biopsy: Only part of the
suspicious area, enough to make a diagnosis
is removed.
– Excisional biopsy: Entire abnormal area
with or without a rim of normal breast
tissue margins are removed.
BENIGN BREAST DISEASE
Benign breast diseases can be subdivided into three
categories:
1. Congenital.
2. ANDI (Aberrations of normal breast development
and involution).
3. Non-ANDI.
Congenital Causes
1. Accessory breast tissue and nipples (Polymazia and
supernumerary nipples). Incidence: 1% of women.
These can occur anywhere along the milk lines with
most common site being axilla (for accessory breast)
and below the breast (for accessory nipples). These
undergo cyclical and lactational changes. They are
also prone to any benign or malignant disease.
Treatment involves reassurance or excision.
2. Breast hypoplasia: It presents with breast asymmetry
if it is unilateral. Poland syndrome is a condition
which occurs commonly in males and is characterised
by amastia, absent/partial pectoralis muscle and
syndactyly.
3. Athelia: Absence of nipples.
4. Micromastia: Postpubertal underdevelopment of
breast tissue.
ANDI (Aberrations of Normal Development
and Involution)
It refers to the aberration of the physiological processes
which occur in the breast from menarche till menopause
(Table 10.3).
BREAST LESIONS (Fig. 10.2)
Fig. 10.2: Location of various breast lesions
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26. The Breast 97
Dupont and Page Classification of Breast
Changes (3 groups)
1. Non-Proliferative Changes:
a. 70% of all changes are non-proliferative.
b. Risk of cancer: Nil i.e. Relative risk is same as
general population (1:1).
c. These changes include:
i. Mild epithelial proliferation
ii. Cystic changes
iii. Apocrine changes
iv. Duct papilloma
2. Proliferative Changes Without Atypia:
a. 26% of all changes.
b. Risk of cancer: 1.5-2 : 1 as compared to general
population.
c. These changes include:
i. Florid epithelial hyperplasia.
ii. Sclerosing adenosis.
iii. Papillomatosis.
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 Nipple discharge,
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 Carcinomaifepithe-
liosis is present
Treatment Reassurance, Conservative: Surgical excision Aspiration, F/U Hadfield
Excision if rapid 1. Firm breast support to exclude toensureresolution. operation
growth, giant 2. Vit E malignancy 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
Diuretics (to reduce
congestion)
5. Danazol
6. Tamoxifen (used
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, the lobules are unable to involute properly and the epithelial acini remain. These may then form cysts.
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27. 98 Review of Surgery for Students
3. Proliferative Changes with Atypia:
a. 4% of all changes.
b. Risk of cancer: 4-5 : 1 as compared to general
population.
c. If these changes are detected on FNAC: Surgical
excision is always done.
d. These changes include:
i. Atypical Ductal Hyperplasia.
ii. Atypical Lobular Hyperplasia.
Fibroadenoma
• Epidemiology:
o Most common benign breast tumour in women
<40 years old, incidence declines with increasing
age.
o Develops in 50% women who receive cyclosporine
after renal transplant.
• Clinical Features:
o Painless (mostly) or painful swelling.
o May spontaneously disappear or involute during
menopause (partially hormone-dependent).
o Giant Fibroadenoma: >5 cm in size OR occupies
>1/3rd of the breast.
• On Examination:
o Discrete (well-defined), smooth, round bordered.
o Firm to hard in consistency non-tender/tender
lump.
o Highly mobile within the breast tissue (also called
breast mouse).
o Multiple lesions may be present (10-15%). They
may also be bilateral.
• Diagnosis: Triple assessment is needed for all breast
lumps:
o Clinical Examination (as mentioned above).
o Imaging: Ultrasonography is preferred in patients
who are younger than 30 years or pregnant. Both
mammography and ultrasound are useful in
patients older than 30 years (and not pregnant).
• Ultrasound:
o Circumscribed, homogeneous, hypoechoic masses
which may have gentle lobulations and a thin
pseudocapsule.
• Mammography:
o Circumscribed oval or round masses which
occasionally have coarse calcifications.
o Large lobulated “pop-corn” calcifications may be
present.
o Fibroadenoma does not contain adipose tissue,
hence appears DENSER than the surrounding
normal tissue.
• Pathology:
o Fine needle aspiration or core biopsy.
o Shows a benign tumour with two components:
Epithelial and mesenchymal (fibroblastic/
connective tissue). Duct epithelium is non-
neoplastic, fibroblastic component is neoplastic
(monoclonal). The connective tissue proliferation
envelops the acini (terminal duct) and compresses
them into clefts (now called ‘canaliculi’).
o Types: (Mixed forms are the rule!)
A. Intracanalicular fibroadenoma: If mesen-
chymal proliferation invades the canaliculi, it
compresses the ducts, which are irregular,
reduced to slits (Mesenchyme predominates).
B. Pericanalicular fibroadenoma: Mesenchyme
proliferates around the ductal spaces, so that
they remain round or oval, on cross section
(Glandular/epithelial tissue predominates).
• Malignant Potential:
o Risk of malignant transformation in fibroadenoma
is low. But risk of developing cancer in the breast
parenchyma is elevated among women with
fibroadenomas.
o Patients with fibroadenoma are 2.17 times more
likely than women in the general population to
develop invasive breast cancer.1
However, newer
studies do not support these findings.
o Risk is higher in case of complex fibroadenoma
(Relative risk is 3.10) and positive family history
of breast cancer.1
Reference: 1. Dupont WD, Page DL, Parl FF, et al. Long-term
risk of breast cancer in women with fibroadenoma. N Engl J Med
1994; 331:10-15.
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28. The Breast 99
Complex fibroadenomas are those with cysts >3
mm in diameter, sclerosing adenosis, epithelial
calcifications etc.
• Treatment:
o Observation: If triple assessment is negative for
cancer and consistent with a fibroadenoma then
conservative follow-up can be offered. Inform the
patient about the limitation of the tests and assess
promptly if there is symptomatic or clinical
change.
o If fibroadenoma is rapidly growing, giant (>5 cm),
causing physical deformity, discomfort or
emotional distress:
– Open excision (Enucleation).
– Ultrasound guided percutaneous excision (<4
cm in largest diameter).
– Cryoablation (<4 cm in largest diameter).
Phyllodes Tumour
(Also called Cystosarcoma Phyllodes/Serocystic
Disease of Brodie)
Phyllodes tumours are considered to be on a spectrum of
disease that consists of fibroadenoma on one end and
malignant form of phyllodes tumours on the other end.
• Epidemiology:
o Tumour of adult women: Most common between
40-50 years of age, i.e., prior to menopause (about
15 years after the typical age of presentation of
fibroadenoma).
o Account for less than 1% of all breast neoplasms.
• Clinical Features:
o Large fast growing painless breast lump which
increases in size within just a few weeks.
• On Examination:
o Firm, mobile, well-circumscribed, non-tender
breast mass (i.e., similar to fibroadenoma) with a
smooth and lobulated surface.
o Large tumour with an average size of 5 cm.
o Overlying skin may have a shiny appearance and
be translucent enough to reveal underlying breast
veins.
• Diagnosis: Triple Assessment is Needed for all Breast
Lumps:
o Clinical Examination (as mentioned above).
o Imaging: Unreliable since it cannot differentiate
benign cystosarcoma phyllodes from the malignant
form or from fibroadenomas.
o Pathology:
– Fine-needle aspiration is usually inadequate.
Core biopsy is more reliable.
– Definitive method for diagnosing phyllodes
tumours are:
♦ For smaller lesions: Open excisional breast
biopsy.
♦ For large lesions: Incisional biopsy.
– Shows a fibroepithelial tumour composed of
an epithelial and a cellular stromal component.
Cleft like spaces lined by epithelium with
stroma projecting into these in a leaf-like
fashion (phyllodes = leaf). Can be benign,
borderline, or malignant depending on
histologic features like stromal cellularity,
infiltration at the tumour’s edge, mitotic
activity etc.
• Malignant Potential:
o All forms of phyllodes tumours are regarded as
having malignant potential.
o 85-90% of phyllodes tumours are benign and 10-
15% are malignant.
o Although the benign tumours do not metastasize,
they have a tendency to grow aggressively and can
recur locally.
o The malignant forms metastasize hematogenously.
o Most common metastatic site: Lungs followed by
skeleton, heart, liver.
• Treatment:
o Best treatment: Complete excision (wide local
excision), with accurate histologic examination
and continued follow-up care.
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30. Chapter
22 GENERAL
PRINCIPLES
Assessment of a trauma patient should follow the ATLS
system (Advanced Trauma Life Support):
1. Airway and Cervical Spine Protection
• Ensure proper cervical spine immobilization in
all trauma patients. This can be achieved with in-
line immobilization techniques or with a
traditional neck collar, sandbag or tape.
• Next, check for the patient’s vocal response. If
the patient can speak, then his/her airway is not
immediately compromised.
• Clear the mouth and airway of any obvious
secretions and foreign bodies.
• Manoeuvres to open the airway include a jaw
thrust and/or chin lift.
• Consider nasopharyngeal airway if airway tends
to repetitively close after these manoeuvres.
• If the GCS</= 8, a definitive airway like an
endotracheal tube is warranted.
2. Breathing and Ventilation
• All trauma patients should receive 100% high flow
oxygen through a mask or ET tube if it is in place.
• Examine the chest for adequate ventilation by
inspection, percussion and auscultation on the
front and back of the chest by log-rolling
manoeuvres.
Primary
survey and
resuscitation
Secondary
survey
Definitive
management
Primary Survey and Resuscitation
• The rapid primary survey and resuscitation go hand
in hand with each other.
• ABCDE of primary survey and resuscitation
Table 22.1: ABCDE of primary survey and resuscitation
A Airway and cervical spine protection
B Breathing and ventilation
C Circulation and bleeding control
D Disability, i.e., neurological assessment
E Exposure – Assess for other injuries after undressing
the patient
SECTION 9 : TRAUMA CARE AND BURNS
Fig. 22.1: General ATLS trauma protocol
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31. 194 Review of Surgery for Students
• Evaluate for the “deadly dozen” of chest trauma,
specially the life-threatening ones.
• Decompress a tension pneumothorax by a needle
thoracostomy in the 2nd intercostal space midcla-
vicular line.
• Insert a chest tube for other conditions like
pneumothorax and haemothorax.
• Control active bleeding from any vessel.
3. Circulation and Control of Bleeding
• Check the patient’s conscious level, skin colour
and pulse for evidence of hypovolemia.
• Secure 2 large-bore IV cannulas, take samples and
start aggressive fluid resuscitation.
• Titrate fluids against the patient’s initial response
to a fluid challenge and his/her vital signs.
• Evaluate for internal bleeding and treat accordingly.
4. Disability
• This includes rapid assessment of the patient’s
neurological status.
• Monitor pupils for size and reaction.
• Calculate the Glasgow coma score.
• Evaluate periodically to observe any changes.
• Exclude causes of altered consciousness like head
injury, hypovolemia, hypoglycaemia, alcohol and
drug abuse.
5. Exposure
• Expose the patient completely and examine the
front and back by log-rolling manoeuvres.
6. Adjuncts to the ABCDE of Primary Survey
• Take blood samples for biochemical and
haematological tests.
• Blood grouping and cross-match should be done.
• ECG, BP monitoring and pulse oximetry.
• ABG sampling.
• Urinary catheter.
• Nasogastric tube.
• Trauma radiography series.
Secondary Survey
• Secondary survey is undertaken only after the
completion of primary survey and initial stabilization
of the patient.
• It consists of reviewing the patient history and
carrying out a thorough head-to-toe examination of
the patient.
• Review the history (AMPLE)
o A – Allergy history.
o M – Medication and vaccination (TT) history.
o P – Past medical history.
o L – Last meal timings and contents.
o E – Events of the accident.
• Examination
o Examine the front of the patient and then perform
a log-roll to examine the back.
o Head and face – Head injuries, fractures, ENT
bleeds, inspection of mouth, foreign bodies and
airway compromise.
o Neck – Cervical spine, subcutaneous emphysema.
o Chest – Complete chest examination.
o Neurological–Periodic GCS calculations, complete
neurological examination.
o Abdomen and pelvis – Complete abdominal
examination, signs of peritonism, pelvic fractures,
perineal injuries, rectal and vaginal examination.
o Extremities – Limb injuries are not immediately
life-threatening, therefore, focus on the ABCDE
first. Then later observe for limb injuries, align
the fractured bone and evaluate distal neurovascular
function before and after the intervention.
Definitive Management
• Should be reached to as soon as possible after the
primary and secondary surveys are complete.
• If the patient is to be transferred to another hospital,
he/she should be hemodynamically and cardio-
vascularly stable and accompanied by an experienced
trauma care doctor.
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33. Chapter
33
SURGICAL
INSTRUMENTS
Name 5 mm Trocar Sheath
Illustration
Features • Laparoscopic instrument.
• Placed in the patient's abdomen to serve as a port for
insertion of various other laparoscopic instruments.
5 mm trocar sheath
SECTION 16
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34. Surgical Instruments 269
Name Allis Tissue Holding Forceps
Illustration
Features • Has sharp teeth.
• Used to hold tough tissues like fascia of the breast.
• Grasping/Holding bowel tissues to be resected.
• Can cause trauma to the tissues.
Name Aneurysm Needle
Illustration
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.
Aneurysm needle
Allis tissue holding forceps
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