Surgery Ospe

SURGERY OSPE
Breakdown ............................................................................................................................... 6
Plain X ray ................................................................................................................................ 7
Perforation of Gas containing hollow viscus ..................................................................... 7
Small intestinal obstruction ................................................................................................. 9
Large intestinal obstruction ...............................................................................................11
Renal stone in plain x ray KUB ...........................................................................................13
Pneumothorax .....................................................................................................................15
Contrast X ray .........................................................................................................................16
Gastric Outlet obstruction due to pyloric stenosis ...........................................................16
Gastric outlet obstruction due to carcinoma of stomach/antral carcinoma ....................18
Post operative T-tube cholangiogram (Normal) ................................................................19
Post operative T-tube cholangiogram (showing retained stone in CBD) ........................21
IVU showing hydronephrosis .............................................................................................22
Renal stone in X ray KUB and IVU .....................................................................................23
Orthopedic X Ray ....................................................................................................................24
Supracondylar fracture of humerus ...................................................................................24
Colles’ Fracture ...................................................................................................................26
Fracture neck of femur ........................................................................................................28
Fracture shaft of femur .......................................................................................................30
Fracture patella....................................................................................................................32
Fracture shaft of tibia ..........................................................................................................33
Giant cell tumor ...................................................................................................................35
Osteosarcoma .....................................................................................................................36
Specimen .................................................................................................................................37
General .................................................................................................................................37
Sebaceous cyst..................................................................................................................37
Burn ...................................................................................................................................38
GIT ........................................................................................................................................39
Acute appendicitis ..............................................................................................................39
Carcinoma Caecum ...........................................................................................................40
Sigmoid volvulus ...............................................................................................................41
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HBPS ....................................................................................................................................42
Chronic cholecystitis with cholelithiasis ..............................................................................42
Specimen of resected Gall baldder ....................................................................................44
Mucocele of Gall bladder ...................................................................................................45
Empyema of Gall bladder ...................................................................................................46
Ruptured Spleen ................................................................................................................46
Urology.................................................................................................................................48
Renal cell carcinoma ..........................................................................................................48
Staghorn Calculi / Renal stone ...........................................................................................49
Bladder stone.....................................................................................................................50
Torsion of testis..................................................................................................................51
Testicular tumor/Seminoma ...............................................................................................52
Breast ...................................................................................................................................53
Carcinoma of breast ...........................................................................................................53
Skin ......................................................................................................................................54
Squamous cell carcinoma ..................................................................................................54
Basal cell carcinoma ..........................................................................................................55
Malignant melanoma ..........................................................................................................56
Orthopedics .........................................................................................................................57
Sequestrum .......................................................................................................................57
Giant cell Tumor.................................................................................................................58
Instrument ...............................................................................................................................59
Hemostatic/artery forceps ..................................................................................................59
Mosquito/small hemostatic forceps ....................................................................................59
Medium sized hemostatic forceps ......................................................................................60
Large sized hemostatic forceps..........................................................................................60
Retractors ............................................................................................................................61
Deaver’s abdominal retractor .............................................................................................61
Right angle retractor ..........................................................................................................62
Morris abdominal retractor .................................................................................................62
Cat’s paw retractor .............................................................................................................63
Forceps ................................................................................................................................64
Swab holding forceps .........................................................................................................64
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Sinus forceps .....................................................................................................................65
Moynihan’s cholecystectomy forceps .................................................................................66
Plain dissecting forceps .....................................................................................................67
Toothed dissecting forceps ................................................................................................68
Kocher’s artery forceps ......................................................................................................69
Alli’s tissue forceps ............................................................................................................70
Babcock’s tissue forceps....................................................................................................71
Clamps .................................................................................................................................72
Intestinal clamp ..................................................................................................................72
Twin Gastro-jejunostomy clamp (Lane’s) ...........................................................................73
Miscellaneous ......................................................................................................................74
Proctoscope .......................................................................................................................74
Proctoscopy .......................................................................................................................75
Kidney tray .........................................................................................................................75
Gulli pot .............................................................................................................................76
Needle holder ....................................................................................................................77
Scalpel..................................................................................................................................78
Bard-parker handle with detachable blade .........................................................................78
Bard Parker Blade..............................................................................................................79
Laparoscopy ........................................................................................................................80
Laparoscopic instruments ..................................................................................................80
Laparoscopic trocar and cannula .......................................................................................83
Laparoscopic grasper ........................................................................................................84
Laparoscopic clip applicator ...............................................................................................85
Laparoscopic camera .........................................................................................................85
Maryland’s forceps .............................................................................................................85
Orthopedics .........................................................................................................................86
Bone nibbler.......................................................................................................................86
Bone cutter ........................................................................................................................87
Amputation saw .................................................................................................................88
Chisel.................................................................................................................................88
Osteotome .........................................................................................................................89
Periosteal elevator .............................................................................................................89
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Hammer .............................................................................................................................90
Appliance.................................................................................................................................90
Ostomy Pouch (stoma appliance) ......................................................................................90
Catheter................................................................................................................................91
Bi-channel self retaining Foley’s catheter ...........................................................................91
Tri-channel self retaining Foley’s catheter ..........................................................................93
GIT/HBS tubes .....................................................................................................................94
Nasogastric tube/Ryle’s tube..............................................................................................94
T tube ................................................................................................................................95
Airway management tubes .................................................................................................96
Airway tube (Guedel’s) .......................................................................................................96
Laryngeal Mask..................................................................................................................97
Endotracheal tube ..............................................................................................................98
Plastic tracheostomy tube ..................................................................................................99
Laryngoscope ..................................................................................................................100
Intra venous cannula.........................................................................................................100
Suture Material ..................................................................................................................101
Transfusion set..................................................................................................................103
Infusion set ........................................................................................................................104
Fluid and Blood .................................................................................................................105
Whole Blood ....................................................................................................................105
20% Mannitol ...................................................................................................................105
5% DNS ...........................................................................................................................105
Hartman’s solution ...........................................................................................................106
Splint/Bandage ......................................................................................................................106
Plaster of Paris ..................................................................................................................106
Rolled Bandage .................................................................................................................108
Crepe bandage ..................................................................................................................109
Others: elbow bag, collar and cuff, Splint, Gauze ...........................................................110
Data/Problem .........................................................................................................................110
General principles .............................................................................................................110
Burn .................................................................................................................................110
Electrolyte imbalance .......................................................................................................111
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Acid base imbalance ........................................................................................................112
Cellulitis + DM ..................................................................................................................112
GIT ......................................................................................................................................113
Gastric outlet obstruction .................................................................................................113
Appendicular lump ...........................................................................................................114
Intussusception ................................................................................................................115
HBPS ..................................................................................................................................115
Obstructive jaundice ........................................................................................................115
Acute pancreatitis ............................................................................................................117
Urology...............................................................................................................................118
UTI ...................................................................................................................................118
Renal stone......................................................................................................................119
Undescended testis .........................................................................................................119
Breast endocrine ...............................................................................................................120
Thyroid .............................................................................................................................120
Breast lump......................................................................................................................120
Head injury .........................................................................................................................121
Operative............................................................................................................................122
Circumcision ....................................................................................................................122
Appendicectomy ..............................................................................................................122
Laparoscopic appendicectomy .........................................................................................123
Cholecystectomy..............................................................................................................123
Sebaceous cyst................................................................................................................124
Drainage of abscess ........................................................................................................125
Procedure Station .................................................................................................................125
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Breakdown
● Plain X ray (1)
● Contrast X ray (1)
● Orthopedic X Ray (1)
● Specimen (1)
● Instrument (1)
● Appliance (1)
● Splint/Bandage (1)
● Data/Problem (1)
● Procedure Station (2)
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Plain X ray
Perforation of Gas containing hollow viscus
Positive findings ➢ Plain x ray of chest in

➢ P/A view in
➢ erect posture
➢ with both domes of diaphragm
➢ showing
➢ Crescentic gas shadow under right
dome of diaphragm
Radiological dx Pneumoperitoneum (most probably due to
perforation of gas containing hollow viscus)
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Causes of pneumoperitoneum 1. perforation of gas containing hollow
viscus
2. during laparotomy
3. during laparoscopy (co2 inflation)
4. penetrating injury
5. tubal insufflation test
Clinical feature/most common one Symptom: abd pain
Sign: general: shock
Abd:
➢ inspection: thoracic respiration
➢ palpation: board like rigidity
➢ percussion: loss of upper border of
liver dullness
➢ auscultation: absence of bowel sound
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Small intestinal obstruction
Positive findings Plain x ray of abdomen in erect posture A/P

view showing
1. distended loops of bowel
2. in central area of abdomen
3. with multiple air fluid level
4. with valvulae conniventis
5. in stepladder pattern
Radiological diagnosis Small intestinal/bowel obstruction
Important causes of such condition 1. dynamic
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➢ intraluminal: stone, impacted feces,
trichobezoar, phytobezoar (bezoar)
➢ intramural: stricture, tumor, volvulus,
intussusception
➢ extraluminal: bands and adhesion,
obstruction of herniated bowel loop
(obstructed hernia)
2. adynamic: paralytic ileus
Mention 3 causes in young adults 1. obstructed hernia
2. intussusception
3. intestinal TB
Cardinal features of this condition 1. abd pain
2. vomiting
3. distension
4. constipation
Examination findings General: dehydration, shock may be present,
toxic (if strangulation)
Abd:
➢ insp: distended, visible peristalsis
(only in dynamic)
➢ palpation: tenderness, rigidity
➢ perucssion: nothing specific
➢ auscultation: early bowel sound loud,
late absent / adynamic absent,
present in dynamic
Other investigations ➢ USG of W/A
➢ Serum lipase/amylase
➢ Serum electrolytes
➢ Serum urea, creatinine
➢ RBS, CBC, Hb, Chest x ray, ECG (GA
fitness)
Electrolyte imbalance 1. Hypovolemia/dehydration
2. Hyponatremia
3. Hypokalemia
4. Hypochloremia
Resuscitation steps 1. NPO
2. IV fluid
3. Analgesic
4. Antibiotic
5. Catheterization
6. NG suction (if near upper GIT)
7. Bowel preparation/Gut preparation (if
near lower GIT)
..after resusctiation:
➢ Laparotomy
➢ Reduction/relief of obstruction
➢ Check viability
➢ If viable: fixation
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➢ If not: resection + anastomosis
➢ If needed: stoma
Fluid used for resuscitation 1. Hartman’s solution
2. Ringer’s solution
3. If not available then cholera ➔ normal
saline
Never give: DA/DNS
Large intestinal obstruction
Identify this x ray film X ray abdomen erect posture A/P view with
both domes of diaphragm
Radiological findings 1. 2 parallel air fluid levels, diagonal,
running from LUQ to RIF (Omega
sign)
2. Tire like shadow
3. Haustration (if seen, write then only)
Diagnosis Large intestinal obstruction, due to sigmoid
volvulus
Predisposing factors for volvulus 1. Long pelvic mesocolon
2. Short attachment of pelvic mesocolon
3. Increased mobility of the sigmoid
colon around
4. High residual diet
5. Overloaded sigmoid colon
6. Chronic constipation
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(long mesocolon ➔ short attachment ➔ full
bowel ➔ chance of twisting)
Clinical features of volvulus Same…distension, constipation, pain,
vomiting
Abdomen (same as SBO) + tire like mass in

Left side of abdomen
Further investigation Same…..
1. Usg w/a
2. Serum amylase/lipase
3. Serum electrolyte
4. Creatinine/urea
5. GA fitness
Treatment Same as SBO (see from above)
**fixation: sigmoidopexy
(extra: before laparotomy: pass a flatus tube
to release gas + pressure, this may relieve
obstruction and volvulus spontaneously
5 options of treatment (options of definitive 1. Insertion of flatus tube (conservative)
treatment) 2. If viable: sigmoidopexy
3. If not: resection and anastomosis
4. Stoma placement
➢ Temporary (paul mikuliz)
➢ Permanent (hartmann’s procedure)
Life threatening complication if treatment is 1. Strangulation (ischemia of obstructed
delayed segment)
2. Gangrene
3. Perforation
4. Peritonitis
5. Septicemia ➔ septic shock ➔ death
12
Renal stone in plain x ray KUB
Describe the x ray Plain x ray KUB region in erect posture

Showing
Radio-opaque shadow in right lumbar
region/para-spinal region
Probable diagnosis Right sided renal stone
Further 3 investigations 1. IVU (intra-venous urogram)
2. USG of KUB region
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3. Serum creatinine, urea
One minimally invasive + 1 non surgical Non-surgical procedure: extra corporeal
shockwave lithotripsy (ECSWL)
Minimally invasive procedure: Per-cutaneous

Nephro-lithotomy (PCNL)
Open surgical procedure: Open nephro-

lithotomy (if in kidney), Open pyelo-lithotomy
(if in renal pelvis)
Complications of surgical procedure of its 1. Hemorrhage
removal 2. Injury to kidney
3. Injury to ureter
4. Injury to gut
5. Injury to vessel
6. Infection: pyelonephritis, septicemia,
septic shock
7. Failure of stone removal/failure of
complete removal/retained stone
Complication if left untreated 1. Hydronephrosis
2. Pyonephrosis
3. Damage to kidney: acute tubular
necrosis, acute renal failure
4. Infection ➔ septicemia ➔ septic
shock
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Pneumothorax
Radiological findings
Diagnosis
Immediate surgical treatment
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Contrast X ray
Gastric Outlet obstruction due to pyloric stenosis
What is this x ray Barium meal x ray of stoamch and duodenum

Identify this plate Barium meal x ray of stomach and duodenum
Showing
➢ Loss of duodenal cap
➢ Contrast didn’t pass to duodenum
➢ Symmetrical Narrowing of the distal
end of the stomach/pylorus
➢ Dilatation of proximal part
Diagnosis Gastric outlet obstruction most probably due
to pyloric stenosis
Other investigations ➢ USG of W/A
➢ Upper GIT endoscopy
➢ Serum electrolyte
Metabolic and electrolyte imbalance/effects ➢ Hyponatremia

of repeated vomiting ➢ Hypokalemia
➢ Hypochloremia
➢ Metabolic alkalosis
➢ Paradoxical aciduria
Treatment Resuscitation:
➢ Normal saline/Hartman’s solution:
hyponatremia + hypochloremia
➢ Give K: correct hypokalemia
➢ Rest will be corrected automatically
Preparation:
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➢ Correction of dehydration
➢ Correction of anemia
➢ NG suction
➢ Nutritional support
➢ Antibiotic
➢ Analgesic
Definitive:
➢ Stenting/balloon dilatation
➢ Vagotomy (to reduce further acid
secretion)
➢ Gastrectomy, followed by gastro-
jejunostomy
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Gastric outlet obstruction due to carcinoma of stomach/antral
carcinoma
What type of x ray is this Barium meal x ray of stomach

Types of contrast x ray in GIT 1. Barium swallow (esoph)
2. Barium meal (stomach, duodenum)
3. Barium follow through (small gut)
4. Barium enema (large gut)
One other imaging where dye is used IVU, T tube cholangiogram, Contrast
Enhanced CT scan
Findings ….showing
1. Irregular filling defect of the distal end
of the stomach
2. Dilatation of the proximal stomach
3. Constrast passed to duodenum
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Radiological diagnosis Gastric outlet obstruction due to carcinoma
stomach
How to confirm diagnosis Upper GIT endoscopy followed by biopsy and
histopathology
5 relevant symptoms Symp:
Anorexia, wt loss, anemia, vomiting, abd
lump (LUQ)
Late signs:
➢ Virchow’s node enlargement (left
supra clavicular LN)
➢ Sister mary joseph nodule
➢ Blummer-shelf
Post operative T-tube cholangiogram (Normal)
T tube given after: open cholecystectomy +

choledocholithotomy (to rest the distal CBD)
Progressive clamping done on: 8th, 9th, 10th
day
11th day: T tube cholangiogram
If normal: remove on 12th day
Name of this radiograph T-tube cholangiogram
Findings 1. T tube is in position
2. Extra and intrahepatic biliary
channels
➢ Well visualized
➢ Normal caliber
➢ No stone seen
➢ No filling defect (no osbtruction)
3. Dye passed to small gut
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4. Clamp is seen (if seen then say)
So this is a normal T tube T tube
cholangiogram
Clinical condition where this appliance is used Choledocholithiasis – after operation:
cholecystomy with choledocholithotomy with
T tube drainage
(don’t say cholecystitis/cholelithiasis:

because if no stone in CBD, we don’t touch
CBD ➔ then no need of T tube)
When is post op cholangiography done 11th post op day
What is your next step Since everything is normal
Remove T tube on 12th POD by gentle
traction
Causes of radiolucent shadow in biliary tree in 1. Radiolucent stone (cholesterol
post op t tube cholangiography stone) (retained stone)
2. Air bubble
3. Clot
4. Worm bolus
Complications of t tube 1. Tube itself may be blocked:
Obstructive jaundice, RUQ pain
2. Leakage of bile
3. Stricture
4. Infection (cholangitis)
5. Clot formation in CBD
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Post operative T-tube cholangiogram (showing retained stone in
CBD)
Name of the x ray T tube cholangiogram

Three radiological findings 1. T tube is in position
2. Extra and intrahepatic biliary channels
➢ Well visualized
➢ Dilated
➢ Radiolucent shadow/stone seen
➢ Filling defect present
3. Dye didn’t pass to small gut
Radiological diagnosis T tube cholangiogram showing retained stone
in CBD
Aim of using this tube 1. To rest CBD after surgery in CBD
2. To check bile flow
Causes of retained stone in CBD 1. Inadequate exposure
2. Inadequate exploration of CBD
3. Failure to remove
Do you want to remove the tube now No
How will you manage the case now 1. T tube ➔ dormia basket stone
removal…if not possible/removed,
2. ERCP/endoscopic sphincterotomy ➔
dormia basket stone remove….if not,
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3. Open choledocholithotomy (again)
IVU showing hydronephrosis
Name the x ray Contrast x ray of Kidney and urinary bladder

region (Intra venous urogram/IVU)
3 radiological finigns 1. Outline of right kidney is enlarged
2. Calyces of right side is dilated
(clubbing of the calyces)
3. Pelvis of the right kidney is dilated
Diagnosis My diagnosis is right sided hydronephrosis
5 important cause of bilateral Problem in bladder and urethra
hydronephrosis
Bladder cause/bladder outlet obstruction
➢ Bladder stone
➢ BPH
➢ Prostatic carcinoma
➢ Bladder carcinoma
Urethra
➢ Urethral stone
➢ Urethral stricture
➢ Urethral cancer
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Name of operation for hydronephrosis (HN) 1. According to the cause (if treatable)
2. Pyeloplasty (if PUJO)
3. Nephrectomy (if long standing HN ➔
kidney damage)
(most common cause of unilat HN is PUJO

(pelvi-ureteric junction obstruction ➔
treatment of this is ➔ reconstruction of pelvis
of kidney called pyeloplasty)
Treatment of most usual cause of B/L BPH mx
hydronephrosis in a 50-year-old male
Medical:
➢ Tamsoulin (alpha 1d blocker)
Surgical:
➢ Prostatectomy: TURP, TVP, RPP, PP
3 indications for surgical treatment of renal 1. Stone size large
stone 2. Recurrent attack of stone
3. Infection of kidney, pelvis
(pyelonephritis)
Renal stone in X ray KUB and IVU
Name the imaging Contrast x ray of Kidney and urinary bladder

region (Intra venous urogram/IVU)
Which investigation is mandatory before it Serum creatinine
(dye ➔ will pass through kidney ➔ so need
to see whether kidney is ok)
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Radiological diagnosis Left sided renal stone
3 clinical presentations of this condition 1. Loin pain
2. Hematuria
3. There may be fever
3 options of treatment of this condition Non surgical: Extra corporeal shockwave
lithotripsy
Minimal invasive: per cutaneous nephro-

lithotomy
Surgical: open nephrolithotomy (if in kidney),

pyelolithotomy (if in pelvis)
Orthopedic X Ray
Supracondylar fracture of humerus
What is your finding? Plain x ray of left elbow joint
in both A/P and lateral view
including proximal radius and ulna and distal

humerus showing
24
Fracture at the supracondylar region of
humerus
Posterior displacement in lateral view
Medial displacement in A/P view

Radiological dx Supra-condylar fracture of humerus
When does it commonly happen/mechanical Fall on outstretched hand (1)
injury RTA (2)
Fall from height (3)
Age group common Young (5-10 years)
Points to see during assessment/clinical Look: deformity, bruising, swelling
feature Feel: temperature (raised), tenderness
(tender), crepitation, feel pulse (may be
absent), sensory examination (there may be
sensory loss)
Move: do motor examination (there may be
muscle paralysis), see joint mobility, active
and passive movement
Complications of such injury Immediate

➢ Hemorrhage
➢ Injury to surr. Structures
➢ Infection
➢ Nerve injury: median, ulnar, radial
➢ Vessel injury: brachial artery
➢ Compartment syndrome
➢ Embolism: air, pulmonary
Delayed
➢ Delayed union
➢ Malunion
➢ Non union
➢ Joint stiffness
➢ Volkman’s ischemic contracture
What type of deformity may occur Due to nerve damage: claw hand
Due malunion: varus deformity, valgus
deformity
What are the radiological signs of healing 1. Callus formation
2. No gap in fracture site
What are the clinical signs of healing 1. Tenderness at the fracture site
2. Movement not possible
How will you manage/manage if 6 years If undisplaced: immoblization by long arm
backslab ➔ X ray ➔ long arm cast ➔ 6
weeks (no need to write if fracture is grossly
displaced)
If displaced:
Closed reduction ➔ external fixation by K
wire ➔ immobilization (same as above)
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Physiotherapy
Purpose of physiotherapy in this case 1. Prevent joint stiffness
2. Prevent deformity
3. Prevent muscle wasting
Colles’ Fracture
Finding Plain x ray of right hand, including wrist joint

and distal part of radius and ulna in both a/p
and lateral view showing
Fracture of the distal end of the radius just

proximal to the wrist joint
Lateral displacement and lateral angulation in

A/P view (left picture)
Dorsal displacement and dorsal angulation in

lateral view (right picture)
And impaction
Radiological diagnosis Colles’ fracture
Most common cause of this Fall on outstretched hand
fracture/mechanism of this fracture
Diagnostic points of colles fracture ➢ Hx of fall on OS hand
➢ Post menopausal lady
➢ Deformity
• Dorsal displacement
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• Dorsal angulaiton
• Radial/lateral displacement
• Lateral angulation
• Impaction
• Supination
• Dinner fork deformity
Treatment In undisplaced: immoblization ➔ colles
backslab ➔ 1 week ➔ x ray ➔ colles plaster
➔ 6 weeks
Displaced: open reduction ➔ internal fixation

(plate, screw, nail) ➔ immoblization (as
above)….
Physiotherapy
Treat underlying cause
Complications Immediate
➢ Hemorrhage
➢ Infection
➢ Nerve injury: median nerve
➢ Vessel injury: radial artery
Delayed
➢ Delayed union
➢ Malunion
➢ Non union
➢ Joint stiffness
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Fracture neck of femur
Name the imaging Plain x ray of pelvis in A/P view including both hip
joint and proximal part of femur
Showing
Radiological finding Disruption of the shenton’s line on the right side

And a fracture line is seen in the neck of the right
femur
The right femur is displaced laterally and upwards

Radiological diagnosis Fracture neck of right femur
Common victims Post-menopausal laddies
Clinical presentation/3 features 1. History: pain in hip, unable to walk
2. Sign: right sided lower limb: shortened +
externally rotated
Treatment Immediate mx:
If in shock: IV fluid, blood transfusion
Pt immoblized, in rest
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Analgesic
Anti ulcerant
Definitive:
Un-displaced: hip screw + immobilization
Displaced: Open reduction + internal fixation
By: age < 20: Knowles pin
Age >20: dynamic hip screw
Elderly patient: prosthesis (hemiarthroplasty, total
hip replacement)
Followed by immobilization
Physiotherapy
➢ Hemorrhage
➢ Infection
➢ Nerve injury: femoral nerve, sciatic nerve
➢ Vessel injury: femoral artery
Delayed
➢ Avascular necrosis of femoral head
➢ Delayed union
➢ Malunion
➢ Non union
➢ Joint stiffness
What will happen if left untreated Avascular necrosis of femoral head
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Fracture shaft of femur
Mention 3 findings Plain x ray of left thigh including hip joint in

both A/P and lateral view
Showing
(Oblique) Fracture in the shaft of the femur
Distal fragment is displaced laterally in
A/P view
And Posteriorly in lateral view
Distal fragemnt is displaced proximally
Radiological dx Fracture shaft of left femur
Mention clinical feature ➢ Shock
➢ Look: limb shortening, swelling,
hematoma
➢ Feel: tender
➢ Move: restricted movement
Treatment of this case/initial Initial treatment (resuscitation)
management/definitive treatment ➢ Shock: IV fluid, transfusion
➢ Definitive:
Reduction:
➢ Skeletal traction: adult
➢ Surface traction: children
Internal fixation:
➢ <6y: Hip spica
➢ >6y: Titanium elastic nail system
(TENS)
➢ Adult/elderly: plate, screw, nail
30
Then immobilization for 12 weeks in adult:
long leg cast (from hip to ankle)
➢ Massive Hemorrhage ➔ shock
➢ Infection
➢ Nerve injury: femoral nerve, sciatic
nerve
Delayed
➢ Delayed union
➢ Malunion
➢ Non union
➢ Joint stiffness
Immediate grave complication Hypovolemic shock
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Fracture patella
Findings Plain x ray of Knee joint including patella,

distal femur, proximal tibia fibula showing
Fracture of the patella

And proximal fragment is pulled upwards
Radiological diagnosis Fracture of patella
Mechanism of such injury Trauma
Sudden violent pull of the patellar tendon
Presentation Look: knee swelling, bruising
Feel: knee pain, crepitation
Move: restricted knee joint movement
32
Treatment Undisplaced: immobilization by plaster for 6
weeks
Displaced: open reduction + internal fixation
by plate/screw/nail + immobilization
Physiotherapy
Definitive surgical treatment Same as above (ORIF)
➢ Hemorrhage
➢ Infection
➢ Nerve injury: femoral nerve, sciatic
nerve
Delayed
➢ Delayed union
➢ Malunion
➢ Non union
➢ Joint stiffness
Fracture shaft of tibia
33
Findings Plain x ray of right leg including both knee
and ankle joint showing
Transverse Fracture in the shaft of the tibia
Distal fragment displaced laterally (a/p view)
and posteriorly (lateral view)
Diagnosis Facture shaft of right tibia
How will you immobilize the fracture Fixation: internal fixation: plate, screw, nail
Immobilization: long leg cast (mid thigh to

foot)
Treatment Open reduction:
In adult: skeletal traction
In children: surface traction
Fixation: internal fixation: plate, screw, nail
Immobilization: long leg cast (mid thigh to
foot)
How long will plaster be given Upper limp: adult: 6 weeks, children: 3 weeks
Lower limb: adult: 12 weeks, children: 6
weeks
So in this case: adult: 12 weeks, children: 6

weeks
Complications Same as above fractures
Clinical signs of healing 1. Tenderness
2. Unable to move the fragments
34
Giant cell tumor
Identify Plain x ray to wrist joint including distal

radius and ulna and also hand showing
➢ Multiple osteolytic lesion
➢ Soap bubble appearance of the
lesion
➢ Widening of the distal radius
➢ Thinning of the cortex of distal
radius
Diagnosis Giant cell tumor of radius
Name 3 probable diagnosis (GCT + any bone 1. GCT
tumor) 2. Osteoblastoma
3. Chondroblastoma
4. Simple bone cyst
5. Aneurysmal bone cyst
How will you confirm the diagnosis Biopsy and histopathology of the lesion
Outline the treatment plan for most probable 1. Surgery: wide local excision
diagnosis 2. Medical therapy: denosumab
3. Chemotherapy
4. Radiotherapy
35
Osteosarcoma
Name of the x ray plate ….as given

Read the x ray / name 3 radiological findings 1. Mixed osteolytic and osteosclerotic
lesion
2. Sun ray appearance
3. Codman’s triangle
4. Periosteal reaction
Of the distal end of the femur
Radiological Diagnosis Osteosarcoma
Name 2 common sites of this lesion Lower end of femur
Upper end of tibia
(around the knee)
Upper end of humerus

Lower end of radius
(away of elbow)
Clinical presentation ➢ Age: young
➢ Wt loss, cachexia, anemia
➢ Look: swelling, redness
➢ Feel: painful, hard mass
➢ Move: restricted movement
➢ There may be pathological fracture
Confirmation of diagnosis Biopsy and histopathology of the lesion
Modalities of treatment of this condition Surgery ➔ followed by prosthetic
Chemotherapy
Radiotherapy
36
Specimen
General
Sebaceous cyst
Descirbe the lesion Hemispherical/rounded swelling on the left

side of the upper back
Well defined margin
Surrounding skin normal
Overlying skin containing punctum
Most probably sebaceous cyst on the back

Common sites of type of lesion Face
Scalp
Back
Axilla
Groin
How will you treat this patient Excision of the cyst
If infected ➔ incision and drainage
Complications of such lesion Infection
Abscess formation
Ulceration of surface
(Sebaceous horn)
37
Treatment if lesion is infected Incision and drainage + antibiotic
Burn
50 kg, 30% burn

2 immediate life threatening complication 1. Shock
2. Lung: laryngeal edema/ARDS
3. Kidney: AKI
2 ways of airway management in this patient 1. Suction/clearance
2. Chin lift, jaw thrust
3. Airway tube
4. Laryngeal mask
5. Endotracheal tube
6. Surgical/needle prick
cricothyroidotomy
7. Tracheostomy
Fluid management in 1st 24 hours 4x50x30 = 6000 mL = 6 L fluid
3L fluid in 1st 8 hour
3L fluid in next 16 hours
Which operation in chest wall to prevent Eschartomy
inadequate respiration
38
GIT
Acute appendicitis
Identify the specimen Inflamed vermiform appendix

Write pathological findings Red swollen congested appendix
Engorged blood vessel on surface
Tip is gangrenous
Diagnosis Acute appendicitis
Clinical presentation Symptoms: pain around umb ➔ shifted to RIF,
anorexia, nausea, vomiting, fever
Sign: pointing sign, tenderness in RIF, rebound
tenderness, rovsing sign, psoas sign, obturator
sign
Causes of acute app (like intestinal Impacted feces, worm (intraluminal)
obstruction) Malingnancy, lymphoid hyperplasia, stricture
(intra-mural)
Bands, adhesion (extra luminal)
d/d in female Ruptured ectopic pregnancy
Torsion of ovarian tumor
Torsion of fibroid
PID
Endometriosis
4 complications Gangrenous appendicitis
Burst appendix
Peritonitis
Appendicular lump
39
Appendicular abscess
Septicemia, septic shock
Investigation CBC (neutrophilic leukocytosis)
ESR: raised
X ray erect posture abd A/P: to exclude
perforation
USG: (to exclude gyne/obs causes)
Urine RME: to exclude UTI
Serum amylase/lipase: to exclude acute
pancreatitis
Operation name Open appendicectomy
Laparoscopic appendicectomy
Carcinoma Caecum
Identify a b c d A=Cecum
B=Ascending colon
C=transverse colon
D=Descending colon
Diagnosis Carcinoma cecum (??)
Investigations done to confirm diagnosis Colonoscopy + biopsy and histopathology
Tumor marker
USG of W/A
CBC: anemia
Name the incision Midline incision
40
Pre-op preparation for such a surgery ➢ Correction of anemia, dehydration,
malnutrition
➢ Correction of fluid + electrolyte
imbalance
➢ IV fluid
➢ Prophylactic antibiotic
➢ Bowel preparation/3 days preparation
(low residual diet, liquid, NPO,
antibiotic neomycin, laxative, enema)
Sigmoid volvulus
3 radiological features See in x ray

Diagnosis Sigmoid volvulus
Three predisposing factors See in x ray
2 pre-operative findings distension, constipation, pain, vomiting
Abdomen (same as SBO) + tire like mass in

Left side of abdomen
2 surgical options Laparotomy ➔ Reduction of the volvulus
followed by:
41
1. If viable: sigmoidopexy
2. If not viable: resection and
anastomosis with
permanent/temporary colostomy
HBPS
Chronic cholecystitis with cholelithiasis
Identify specimen Resected gallbladder with stone

Write pathological findings 1. Shrunken gall bladder (chronic
cholecystitis)
2. Thickened wall
3. Multiple/numerous stones seen
Diagnosis Chronic cholecystitis with cholelithiasis
Clinical presentation Symptom
➢ Repeated episodes of RUQ pain
➢ After fatty meal (fatty food intolerance)
➢ Anorexia, nausea, vomiting
➢ Fever: mild
Sign:
➢ Murphy’s sign: absent
➢ Gall bladder: impalpable (shrunken)
Most important investigation to diagnose USG of whole abdomen with special attention
such a case to gall bladder and bile duct
Pre-op USG findings of this conditions 1. Hyperechoic structure casting
posterior acoustic shadow
2. Gall bladder shruken/contracted
42
What operation is done here Cholecystectomy
Indications of this operation/removal 1. Chronic cholecystitis
2. Cholelithiasis
3. Choledocholithiasis (a part)
4. Mucocele of GB
5. Empyema of GB
6. Carcinoma GB
Complications of operation 1. Hemorrhage
2. Injury to liver, bile duct, GIT, pancreas
3. Acute pancreatitis
4. Infection: cholangitis, hepatitis
5. Intestinal obstruction
6. Failure of removal
7. Septicemia, septic shock
Complications of gall stone 1. In the GB
➢ Biliary colic
➢ Acute cholecystitis
➢ Chronic cholecystitis
➢ Mucocele
➢ Empyema
➢ Erosion
➢ Perforation of GB
2. In the CBD
➢ Cholangitis
➢ Choledocholithiasis
➢ Obstructive jaundice
3. Gallstone ileus
Effect of gall stone impacted in neck of gall Mucocele
bladder Mucocele ➔ infected ➔ empyema
Effect of gallstone impacted in CBD Cholangitis
Obstructive jaundice (choledocholithiasis)
Type of stone seen within the lumen of this Cholesterol stone/yellow stone
picture
What are the other types 1. Black stone
2. Brown stone (due to organism)
Factors responsible for formation of gallstone 1. Fat
2. Estrogen: OCP, reproductive age,
pregnancy
3. Hemolytic anemia
4. Infection with Ascaris lumbricoides
43
Specimen of resected Gall baldder
Identify Specimen of resected gall bladder

Which operation Cholecystectomy
Name 4 indication Done….see previous
Write 4 complications during this operation Done…see previous
2 imaging modalities to identify pathology of Ultrasonography
this organ CT scna/MRI/MRCP
44
Mucocele of Gall bladder
Descirbe and identify it Pear shaped organ

Hugely distended
Normal color
No redness/pus seen
So, it is mucocele of GB
Write its pathogenesis Stone impacted in neck ➔ bile in GB ➔
absorption of bile ➔ secretion of mucus in
GB ➔ accumulation of mucus ➔ hugely
distended
Important clinical presentation of this Palpable gallbladder which is painless
condition
Causes of palpable gall bladder 1. Benign
➢ Mucocele
➢ Empyema
2. Malignant
➢ Ca head of pancreas
➢ Peri ampullary carcinoma
➢ Cholangiocarcinoma
➢ Ca-GB
Clinical condition where this organ becomes Same
palpable
What investigation will you do to confirm USG of W/A with attention to HBS, GB and
diagnosis bile duct
Treatment Cholecystectomy
What complication if not treated in time Empyema
Gangrene
Perforation
Fistula
45
Empyema of Gall bladder
Identify Distended, red, swollen, purulent gall bladder

So it is likely to be empyema gall bladder
Treatment Supportive mx: antibiotic, analgesic…. ➔
after infection subsided ➔ cholecystectomy
Ruptured Spleen
46
Describe the pathology in the given picture There are multiple tears in the spleen
Diagnosis Splenic rupture
Ways of clinical presentation of this condition Shock
Abdominal pain
3 important clinical sign 1. Tachycardia, hypotension, cool
periphery: shock
2. Balance sign: Fixed dullness over left
upper quadrant (clotted blood around
spleen)
3. Kehr sign: referred pain to tip of left
shoulder
Investigations to be done FAST (focused abdominal sonar for trauma)
USG of abdomen
X ray of Abdomen
Hb%, ABO and Rh typing
Mention treatment Splenectomy
In few cases: splenorrhaphy, mesh repair

Indication of splenectomy 1. Splenic rupture
2. Splenomegaly: thalassemia
3. Part of other operation
➢ Ca stomach
➢ Ca pancreas
➢ Ca left colon
Pre-op preparation 1. Correct anemia, dehydration,
nutrition, coagulopathy
2. Antibiotic prophylaxis
3. Vaccination (organism which thrive
in absence of spleen)
➢ Hemophilus influenzae
➢ Neisseria meningitidis
➢ Streptococcus pneumoniae
4. Avoid travel to malaria/kala azar
zones
Important post op measures Long term prophylactic antibiotic
Regular vaccination
Avoid travel to malaria/kala azar zones
47
Urology
Renal cell carcinoma
Identify the specimen Mass lesion seen in kideny

Areas of hemorrhage and necrosis seen
Diagnosis Renal cell carcinoma
Clinical feature Painless hematuria
Loin mass
Polycythemia (due to more Erythropoietin)
Hypercalcemia (due to more vitamin D)
Hypertension (due to more Renin)
Investigation to confirm diagnosis USG of whole abdomen + doppler study
(tumor thrombus in IVC)
CECT (contrast enhanced CT scan)
Treatment modalities of renal cell carcinoma Surgery
Radiotherapy
48
Staghorn Calculi / Renal stone
Identify the given specimen Hemisection of kidney showing stone in the pelvis
and calyces of kidney with a stag-horn appearance
Diagnosis Staghorn calculus/stone of kidney
Composition of this stone Phosphate stone
Triple phosphate stone: Ca+Mg+NH4 Phosphate
(also called struvite)
Types of renal stone C=calcium stone
O=oxalate stone
X=xanthine stone
U=urate stone
P=phosphate stone (staghorn calculus)
Causes of this type of stone 1. Infection with proteus
2. Decreased water intake
Clinical presentation of renal stone See in x ray
Investigations to do for diagnosis See in x ray
Treatment options See in x ray
How to prevent recurrence 1. Plent fluid intake
2. Limit tea, coffee
3. Maintain hygiene
Complications if untreated 1. Hydronephrosis
2. Infection (pyonephrosis, pyelonephritis,
perinephric abcess, paranephric abscess)
3. Renal failure (if longstanding)
49
Bladder stone
Identify given specimen Urinary bladder stone

What are the symptoms they produce 1. Lower abdominal pain radiates to tip
of glans penis
2. Pain during micturition
3. Hematuria
4. LUTS (if stone in bladder
outlet…BOO)
Investigation 1. X ray KUB region
2. IVU/RGU (retrograde urogram)
3. USG KUB
4. Urine RME
5. Serum urea, creatinine
Composition COXUP….
Treatment General treatment: antibiotic, analgesic, fluid
intake
Specific:
1. Litholaplaxy (crush stone, take pieces
out thru small opening, such as per
urethra)
2. Open cystolithotomy (take stone out
as a whole)
50
Torsion of testis
3 features form the picture 1. Right testis is swollen

2. Right testis is shiny and engorged
3. Prominent veins
Diagnosis Torsion of the right sided testis
Cause of the condition 1. Anatomical abnormality (bell clapper
deformity)
2. Abnormally high up testis
3. Straining for micturition
4. Trauma
5. Running/exercise
3 clinical features 1. Sudden severe pain in the scrotum
2. Testis high up
3. Elevation of testes: increases pain
4. Testis swollen + tender (but not as
much as epididymo orchitis)
2 steps of surgery 1. De torsion of the testis
2. Check viability ➔ if not ➔
orchidectomy ➔ if viable ➔
orchidopexy
3. Fix the opposite testis as well
51
Testicular tumor/Seminoma
Identify+findings Bulky mass occupying whole of testis

Cut margin: white, homogenous
Dx: seminoma
Probable diagnosis Seminoma
What is the type of this tumor Germ cell tumor of testis
What investigations can be done to confirm USG of scrotum
your diagnosis Tumor marker: LDH, AFP, beta HCG
Biopsy and histopathology
What are the treatment options Surgery (orchidectomY)
Chemotherapy
Radiotherapy
52
Breast
Carcinoma of breast
Identify the given specimen and describe the 1. Nipple retraction

lesion 2. Peau d’ orange appearance
3. (if seen: lump present in upper + outer
quadrant)
Diagnosis Carcinoma of breast
Cardinal signs of this diagnosis Lump ➔ hard, fixed
Axillary lymph node ➔ palpable, not tender,
hard
Risk factors of this disease 1. Family history
2. Early menarche
3. Late menopause
4. Nullipara
5. Obesity
6. Radiation
What is triple assessment 1. Clinical assessment (age, lump)
2. Imaging (mammography, USG)
3. Pathology (FNAC, biopsy)
Modern investigation for diagnosis of ca Imaging + pathology from above
breast
How can you confirm diagnosis Biopsy and histopathology
Treatment modalities of breast carcinoma 1. Local: surgery, radio
2. Systemic: hormone, chemo
Surgery: Radical Mastectomy, Modified RM,

Breast Conservative Surgery, Simple
mastectomy
53
Hormone: tamoxifen
Operation needed to be done in this case Radical mastectomy/MRM (depends on exact
extent of spread)
Absolute indication of this operation early + locally advanced Breast cancer
(in distant metastasis, surgery not possible)
Other surgery than can be performed Done….
Skin
Squamous cell carcinoma
Describe the lesion Ulcerative lesion

Shape: irregular
Site: according to picture provided
Magin: irregular
Edge: raised + everted
Floor: pus + slough + blood
Temp, tenderness: absent
Base: indurated
LN: hard, non tender
Diagnosis and d/d Squamous cell carcinoma
d/d:
54
basal cell carcinoma
ulcer due to TB, syphilis, non specific cause
(any other cause of ulcer)
Points of clinical examination Examination of ulcer: see from above
Treatment of this patient Small: wide local excision with 1 cm tumor
free margin + graft/flap
LN if present: LN dissection
Large: amputation of affected limb
Basal cell carcinoma
Describe picture with findings Nodular (early)/ulcerative (late =rodent ulcer)

Site : above the line connecting ear lobule and
angle of mouth
Shape: irregular
Margin: irregular
Edge: rolled and everted
Base: indurated
Draining LN: hard, non tender
Diagnosis Basal cell carcinoma
If ulcer present: may write rodent ulcer
d/d Squamous cell carcinoma
Other ulcerative lesion
Confirmatory investigation Biopsy and histopathology
Treatment modalities of this condition Surgery: wide local excision with tumor free
margin + followed by graft/flap
Radiotherapy
Prognosis of this disease good prognosis if detected early
55
Malignant melanoma
Describe the lesion Pigmented macular lesion /pigmented

nodular lesion
Shape: irregular
Margin: irregular
Skin: surrounding skin normal
Color: un-uniform
Most probable diagnosis Malignant melanoma
2 d/d 1. Benign nevus
2. Basal cell carcinoma
3. Squamous cell carcinoma
Name three differential diagnosis of this Same
condition
How to confirm your diagnosis Biopsy + histopathology
Management plan Surgery: wide local excision with tumor
free margin + followed by graft/flap
Radiotherapy
Chemotherapy (can spread by blood)
Which operation to do if lesion is malignant wide local excision with tumor free margin
+ followed by graft/flap
Three ways of skin covering after excision of the 1. Primary closure
lesion 2. Grafting
3. Flap replacement
**SqCC: spread by lymph; no role of chemo: only surgery

**BCC: locally malignant, no role of chemo, only surgery + radio
**Melanoma: spread by blood: surgery, radio (while local), chemo (while distant)
56
Orthopedics
Sequestrum
Identify + 2 identifying points This is a plastic jar containing pathological

specimen of sequestrum
➢ Chalky white in appearance

➢ One side is smooth
➢ Another side appears moth eaten
Diagnosis Sequestrum
Pathological condition where it is produced Chronic osteomyelitis
Commonest organism responsible for this Staphylococcus aureus
Typical radiological findings Radio-opaque lesion surrounded by radio-
lucent margin
Specific treatment of the disease condition Antibiotic, followed by
1. Deroofing
2. Sequestrectomy
3. Curettage
4. Saucerization
Followed by, splintage
If needed: graft/flap
2 complications Pathological fracture
Growth disturbance
Deformity
Limb length discrepancy
57
Giant cell Tumor
Identify the specimen This is a plastic jar containing pathological

specimen of Giant cell tumor, which is an -
o Epiphyseal
o Eccentric
o Expansile tumor
Treatment See x ray
58
Instrument
Hemostatic/artery forceps
Mosquito/small hemostatic forceps
Identify Mosquito/small hemostatic forceps

Uses (2) 1. Ligate appendicular artery during
appendicectomy
2. Hold small bleeding vessels
3. Hold cut edges of peritoneum
4. Retract cut edges of peritoneum
5. Clamping of t tube, catheter
Sterilization Autoclaving
59
Medium sized hemostatic forceps
Identify Medium sized hemostatic forceps

Identifying points 1. Transverse serration on inner aspect of
blade
2. Anterior end slightly curved
3. Handle with catch
Uses (2) 1. To crush the base of appendix during
appendicectomy
2. Hold medium sized bleeding
points/vessels
3. Hold cut edges of peritoneum, fascia,
aponeurosis
4. As a tool for blunt dissection
Large sized hemostatic forceps
Identify Large sized hemostatic forceps

Uses 1. Remove large tumor in case of
nephrectomy
2. Ligate/clamp large vessels
60
Retractors
Deaver’s abdominal retractor
Identify
Operations where it is used (2-3) 1. Cholecystectomy
2. Cholecystolithotomy
(Operations where liver is open and needs to be 3. Gastrectomy
retracted) 4. Truncal vagotomy
5. Repair of perforated duodenal ulcer
6. Pancreatico-jejunostomy
7. Right hemicolectomy
8. Nephrectomy
Complications of its use Liver injury
Liver hemorrhage
How to avoid liver injury 1. Hold liver carefully
61
Right angle retractor
Identify Right angle retractor
Identifying points 1. end curved at 90 degree

2. Circular opening in the middle of the body
Uses/operations where it can be used (any 2) 1. Herniotomy/ herniorrhaphy/ hernioplasty
2. Appendicectomy
3. Thyroid surgery
Why do you prefer this method of sterilization All microorganism + including their spores killed
What will you do in case it falls off the operative Autoclave it/replace it with an autoclaved one
field
Morris abdominal retractor
Identify Morris abdominal retractor

Points 1. 2 ends curved 90 degree
2. No opening in the middle of the body
Operations where it is Used 1. Appendicectomy
2. Thyroidectomy
62
Cat’s paw retractor
Uses
Sterilization autoclaving
63
Forceps
Swab holding forceps
Identify Sponge holding/swab holding forceps

Identification points (3) 1. Long shaft
2. Oval blades
3. Blades are serrated on their inner aspect
Uses (2) 1. Hold swab during antiseptic washing
2. Hold fundus of GB during
cholecystectomy
3. Hold caecum during appendicectomy
4. Hold vesical calculus during
cystolithotomy
Name 2/3 operations where it is used 1. Appendicectomy
2. Cholecystectomy
3. Cystolithotomy
4. Any operation:
➢ Hernia operation
➢ Laparotomy
Mention the structured held by this instrument 1. Fundus of GB
2. Caecum
3. Vesical calculus
4. Coils of intestine
Can it be reused after boiling? Give reasons No. It must be autoclaved to kill the spores
64
Sinus forceps
Identify Sinus forceps

Uses/most important 2 uses Incision and drainage of an abscess in a site
where there are important vital structures
(Hilton’s procedure)
Name the important regions where it is used to Where there is chance of injury to underlying
drain abscess/Where is hilton’s method applied major vessels and nerves/vital structures
1. Face
2. Neck
3. Axilla
4. Breast
5. Groin
Principle of abscess drainage/hilton’s method of • give incision to skin
abscess drainage • cavity opened by thrusting a pair of sinus
forceps
• blunt incision done by separating the
blades
• introduce a gloved finger
• break all loculi gently
• introduce a pack soaked with Eusol
• Send pus for c/s
• Insert a drain for dependent drainage
65
• Keep wound open and allow secondary
healing
Moynihan’s cholecystectomy forceps
Identify Moynihan’s cholecystectomy forceps

Identifying points 1. Smaller blades in comparison to handles
2. Blades are serrated
3. Curved in front (more acutely than artery
forceps)
4. Tip is pointed (more than artery…)
Uses 1. Catch cystic duct + cystic artery in
cholecystectomy
2. Catch pedicle of testis/thyroid during
operation
3. Vagotomy: catch trunk of vagus
4. Lumbar sympathectomy: catch
sympathetic trunk
Advantages 1. Curved tip: better visualization when held
deep inside body
2. Visualization helps in providing ligature
during cholecystectomy
66
Plain dissecting forceps
Identify 2 blades attached at one end

Transverse serration in inner aspect
No tooth at tip
For gripping, serration at outer aspect
Why is there serration on the inner aspect To grasp structures
Uses 1. Hold delicate structure: peritoneum, gut
wall etc
2. Needle picking up in between sutures
3. Contact point for diathermy
4. Blunt dissection
67
Toothed dissecting forceps
Identify
Uses Hold tough structures
1. Skin
2. Linea alba
3. Scalp
4. Fascia
5. Tendon
Purpose/advantage of the tooth To grip tough tissue + prevent from slipping
Disadvantage Cannot be used on delicate structure
Can cause injury
68
Kocher’s artery forceps
Identify
Identifying points 1. At the tip: tooth and groove
2. Inner aspect of the baldes: transverse
serration
3. Catches at handle
Uses 1. Hold vessels during operations
➢ Appendicectomy
➢ Mastectomy
➢ Thyroidectomy
➢ Craniotomy
2. Crush base of appendix during
appendicectomy
3. Obs: Artifical rupture of membrane (ARM)
69
Alli’s tissue forceps
Identify
Identifying points 1. Tip has teeth + grooves
2. No serration at inner aspect
3. Gap between the blades
4. Catch at handle
Uses (4/2) Hold tough structures during operation
1. Margins of skin
2. Margins of fascia
3. Margins of linea alba
4. Neck of bladder
70
Babcock’s tissue forceps
Identify
Identifying points 1. Tips of blades: curved, fenestrated
2. No teeth at the end
3. There are serration at the tip
4. Catch
Uses/operations where it is used Hold gut during operation/delicate structure
1. Hold cut margin of stomach
(gastrectomy)
2. Cut margin of duodenum (whipple’s
operation)
3. Hold fallopian tube (tubectomy, BLSO)
4. Hold vas deferens (vasectomy
71
Clamps
Intestinal clamp
Identify Intestinal clamp (occlusion variety)

What are the types of intestinal clamp and how 1. Occlusion variety: longitudinal serration
can you identify them? at inner end
2. Crushing variety: transverse serration at
inner end
Uses Gut resection and anastomosis
Name some operations where it can be used Any cause of bowel Obstruction:
Intussusception
Volvulus
Malignancy of gut
Stricture
Any resection surgery:

Hemicolectomy
Transverse colectomy
Total proctocolectomy
72
Advantages of intestinal clamp 1. Occlusion of resected bowel segements
2. Occlusion causes reduced bleeding from
cut ends
3. Occlusion prevents leakage of contents
form the gut into the peritoneum
4. Prevents contamination of peritoneum
with bacteria
How many intestinal clamps required for side to 2
side anastomosis
How do you prepare cut margin for anastomosis Povidone iodine
Twin Gastro-jejunostomy clamp (Lane’s)
Identify
Identifying points/parts with functions of each 2 parts:
Gastric part : has screw, applied by surgeon, to
stomach
Jejunal part: no screw, applied by assistant, to
jejunum
Uses Gastro-jejunostomy operation
Whipple’s operation
Gastrectomy
Functions Occlusion, prevent bleeding, prevent
contamination of gut etc….
73
What are the indications of gastrojejunostomy? 1. PUD
2. Pyloric stenosis
3. Carcinoma stomach
4. Carcinoma head of pancreas
5. Part of whipple’s procedure
Miscellaneous
Proctoscope
Identify
Parts of the instrument 1. Funnel/outer sheath (proctoscope proper)
2. Obturator
Why is it called proctoscope Lower 2/3rd of rectum + whole anal canal develop
from proctodeum
So it is called proctoscope
Length of a proctoscope 15 cm
Uses Proctoscopy
Diagnostic
➢ Internal hemorrhoid
➢ Rectal polyp
➢ Carcinoma of anal canal
➢ Carcinoma of rectum
➢ To take biopsy material
Therapeutic
➢ Injection sclerotherapy
➢ Polypectomy
74
Sterilization No need of sterilization, because it touches
already contaminated area. Simple antiseptic
wash is adequate
Proctoscopy
Identify the procedure being performed

Indication of the procedure/2 diagnostic/1 Diagnostic
therapeutic ➢ Internal hemorrhoid
➢ Rectal polyp
➢ Carcinoma of anal canal
➢ Carcinoma of rectum
➢ To take biopsy material
Therapeutic
➢ Injection sclerotherapy
➢ Polypectomy
Contraindication Anal fissure
Peri-anal abscess
Pre-requisites for proctoscopy 1. Counselling
2. Consent
3. Privacy
4. Attendant
5. Proper exposure
6. Proper light source
7. Bladder empty needed
Positions of proctoscopy 1. Left lateral
2. Dorsal
3. Lithotomy
Name the clinical exams routinely performed Inspection of anal verge
before doing this procedure Digital rectal examination
Kidney tray
Identify
75
Identifying points 1. Metallic tray
2. Kidney shaped
Uses 1. Carry materials for dressing, stitch cutting
etc
2. Keep dissected GB, appendix
Gulli pot
Identify
Uses 1. Carry antiseptic solution
2. Carry dressing solution
3. Keep resected segment for pathological
analysis
76
Needle holder
Identify
Uses 1. Hold needle during suturing
2. Holding ends of the threads
77
Scalpel
Bard-parker handle with detachable blade
Identify
Uses Incision
Sterilization Blade: Gamma radiation (sharp instrument)
BP handle: autoclaving
Can it be reused? Blade no, handle yes after sterilization
78
Bard Parker Blade
Identify
Mention 1 use for each numbered instrument 11: Lap chole, abscess drainage
15: excision of sebaceous cyst, fibroadenoma
20: laparotomy, lim amputation
Mention the handle number for each instrument Handle 4: blade no 20
Handle 3: blade no 15
Can it be reused? Give reasons Never
Sterilization Gamma radiation
79
Laparoscopy
Laparoscopic instruments
Identify them
Scissor
Atraumatic forceps
Grasping forceps
80
Laparoscopic Trocar and
cannula
Maryland forceps
81
Clip applicator
Laparoscopic telescopes
82
Hook scissors
Mention 3 operations where they are used Lap. Cholecystectomy

Lap. Appendicectomy
Lap. Hernioplasty
Sterilization Chemical sterilization
What will you do if one of these instruments accidentally fall on the floor Replacement/immersion
during operation? in glutaraldehyde solution
for 35-40 mins
Laparoscopic trocar and cannula
Identify
Name some common operations where it is used Lap. Cholecystectomy
Lap. Appendicectomy
Lap. Hernioplasty
Purposes of use Inflate abdomen with co2
Introduction of camera
Insertion of other instruments
Retrieval of cut GB, appendix
Sites of introduction 1st port: 10 mm: below umbilius
83
2nd port: 10 mm: below xiphoid process
3rd port: 5 mm: below right costal margin @ mid
clavicular line
3 advantages of operation done by this Small incision
instrument Less injury
Early return to normal action
Less post operative complication
Quick healing
Sterilization Chemical sterilization
Complication of this operation Hemorrhage
Injury to bowel, liver, pertioneum
Port site infection
Port site herniation
Surgical emphysema
Laparoscopic grasper
Identify
Uses 1. Grasp neck of GB to retract it towards
RIF
2. Better identification of callot’s triangle
Sterilization + time required Chemical – glutaraldehyde: 35-40 mins
84
Laparoscopic clip applicator
Identify
Uses Apply clip to cystic duct and cystic artery prior to
their resection
Sterilization + time required Chemical – glutaraldehyde: 35-40 mins
Laparoscopic camera
Visualization of the structures
Maryland’s forceps
Laparoscopic: to grasp, to blunt dissect, also used as needle holder
85
Orthopedics
Bone nibbler
Identify
Purpose Cut small fragments from raw surface of bone
Uses 1. Freshen irregular fracture site
2. Smoothen rough surface after amputation
3. Remove sequestrum
4. Remove pathological tissue from bone
86
Bone cutter
Identify
Uses To cut/remove bone
87
Amputation saw
Identify
Uses Cut bone during amputation
Sterilization Sharp: chemical glutaraldehyde
Chisel
Identify
Point Tip bevelled on one side only
Uses Cut bony projection
Make hole in bone
Saucerization
Sterilization Autocalve
88
Osteotome
Identify
Point Tip bevelled on both sides
Uses/operations where it is used Cut projection of bone
Make bone surface smooth
Periosteal elevator
Identify
Uses Elevate periosteum during orthopedic operations
89
Hammer
Identify
Uses
Sterilization
Appliance
**Catheter, tubes, infusion sets, bags**
Ostomy Pouch (stoma appliance)
Name the parts A=ostomy pouch/bag
90
B=Flange//wafer
C=splint
2 indications Temporary (to rest resected and
anastomosed bowel after operation)
Permanent (to divert feces to the outside)
3 complications Skin irritation
Skin excoriation
Parastomal herniation
Intestinal obstruction
1 function of each of the parts A = collection of feces/bowel content
B = connects pouch to gut + prevents direct
contact of skin with the content + prevent
excoriation
C = secure attachment + prevent detachment
How is it sterilized? Gamma radiation
Catheter
Bi-channel self retaining Foley’s catheter
Name it …
Identification point 2 channels
One for urine
One to introduce distilled water
Balloon situated near the tip
91
Parts Straight channel (A) for urine
Side channel (B) to inject distilled water
Inflatable balloon (C)
Why is it used in a shock patient To monitor urine output and assess response
to treatment
Indication of catheterization Therapeutic
➢ Relief of retention
➢ In case of urinary incontinence
➢ During surgery/anesthesia
Diagnostic
➢ Monitor urine output
➢ Sample collection
➢ Cystourethrogram
Contraindication Urethral rupture
Urethral stricture
Acute infection of urethra
Other materials required to use it 1. Disposable syringe
2. Distilled water
3. Local anesthetic agent/lubricant
4. Urobag
5. Antiseptic solution
What anesthesia needed to apply it Local anesthesia
2 similar appliance 1. Tri channel self retaining foley’s
catheter
2. Rubber catheter
Complication of catheterization 1. Urethral injury
2. Rupture
3. Stricture
4. Bleeding
5. Infection
6. Catheter blockage
7. Bladder atony
92
Tri-channel self retaining Foley’s catheter
Name it …
Identifying points Three channel:
One to inflate balloon by injecting distilled
water (side channel)
One to drain urine
One for continuous irrigation of bladder

Information from the packet Size
Length
Capacity
MFG, EXP
Which jelly used for catheterization lidocaine/xylocaine
Pre-requisite of catheterization ➢ Counselling
➢ Privacy
➢ Attendant
➢ Proper exposure
➢ Proper lighting
➢ Exclusion of stricture, rupture and
other contraindications
How will you inflate the balloon? Side channel ➔ 20 cc distilled water injected
by syringe
Use of this Any hemorrhagic condition of bladder ➔
chance of clot formation ➔ continuous
irrigation prevents clot formation
➢ After prostatectomy operation

➢ After TURP
➢ After TURBT
Advantage of this after prostatectomy ➢ Continous drainage of bladder
operation ➢ Rest to bladder
➢ Irrigate bladder continuously
93
Complications of prolonged catheterization ➢ Urethral infection
➢ Stricture of urethra
➢ Bladder atony
➢ Catheter blockage
How to sterilize it Gamma radiation
GIT/HBS tubes
Nasogastric tube/Ryle’s tube
Name it Nasogastric tube/ryle’s tube

Identifying points 1. 3 marking
➢ 40 cm: cardiac end of stomach
➢ 50 cm: body
➢ 60 cm: pylorus
2. Side openings near tip
3. Tip is blind and metallic
Use (2/4) Diagnostic
➢ Collect gastric juice for analysis of
PUD
➢ Diagnosis of GOO
Therapeutic
➢ NG suction
➢ Gastric lavage
➢ Nutrition
➢ Medication
How can you make sure tube has reached Syringe ➔ air injection ➔ auscultate the
the right position stomach ➔ harsh sound
Aspiration ➔ gastric contents seen
Complications of this Injury to nose, nasopharynx, larynx,
esophagus, soft palate
Bleeding: epistaxis
Infection
94
T tube
Name T-tube
Identify Horizontal part
Vertical part
Looks like a T
Use Drainage of bile
Give rest to CBD after choledocholithotomy
Prevent leakage of bile (biliary peritonitis)
Pass contrast ➔ do T tube cholangiography
In case of residual stone ➔ conduit for
dormia basket stone removal
When is post op t tube cholangiography done On 11th POD
When is it removed On 12th POD if no problems
95
Airway management tubes
Airway tube (Guedel’s)
Name it …
How can it help in recovery of patient Airway clearance
Prevents tongue fallback
Easy passage of air
Can it be reused? Yes, but shouldn’t be
96
Laryngeal Mask
Identify
Name its common purpose of use Keep airways of patient open during
anesthesia/coma
Manage airway in a trauma patient
Can it be resued? Yes, but shouldn’t be
97
Endotracheal tube
Identify
Name its common purpose of use Keep airways of patient open during
anesthesia/coma/mechanical ventilation
Manage airway in a trauma patient
2 other devices of similar purpose Airway tube
Laryngeal mask
Tracheostomy tube
Complications of its use Injury to larynx, trachea, palate, pharynx,
esophagus
Aspiration pneumonia
Blockage of the tube
What other instruments needed to assist its Muscle relaxant: suxamathonium/vecuronium
introduction Laryngoscope
Others:
Induciton of G/A: TPS (thio-pental sodium)
Maintenance: halothane/N2O
98
Plastic tracheostomy tube
Identify
Name its common purpose of use Bypass obstruction of upper airway
In case of laryngeal edema
99
Laryngoscope
Identify …
Parts Handle
Blade
Light source
Uses Helps in intubation during general anesthesia
(laryngeal mask, airways, ET tube
placement)
Laryngoscopy (to detect causes of
hoarseness, stridor, laryngeal edema)
Complications Injury to palate, pharynx, larynx, oral cavity
Intra venous cannula
Name it
Indication/use 1. Administration of Intra venous fluid
2. Blood transfusion
3. Intravenous medication
4. Parenteral nutrition
Size according to color Yellow: 24 gauge
100
Blue: 22 gauge
Pink: 20 gauge
Green: 18 gauge
Grey: 16 gauge
Brown: 14 gauge
Other materials required to use it 1. Micropore
2. Alcohol pad
3. Torniquet (to make vein prominent)
Suture Material
What points to be noted form a suture material ➢ Number (1-0, 2-0 etc)
packet ➢ Round bodied or cutting body
➢ Natural/synthetic
➢ Absorbable/non absorbable
➢ Monofilament/polyfilament
➢ Traumatic/atraumatic
➢ Length
➢ Name: prolene, vicryl, catgut,
silk etc
Criteria of an ideal suture material ➢ sterile
➢ easy to handle
➢ predictable behavior in tissue
➢ predictable tensile strength
➢ easily glides through tissue
101
➢ secure knot easily
➢ inexpensive
➢ non allergenic
➢ non capillary
➢ non carcinogenic
➢ non electrolytic
➢ non shrinkable
Group suture materials according to source Natural: catgut, silk

(natrual/synthetic) Synthetic: prolene, vicryl, PDS, nylon
(polydioxanone)
Group suture materials according to Non absorbable: silk, prolene, nylon
absorbability Absorbable: catgut, Vicryl, PDS, Dexon
Group suture materials according to thickness 1-0 thickest, then thinner
Types of suture materials From above
Name some synthetic suture materials From above
1 use of each appliance Non absorbable:
Silk: skin closure, tendon repair,

hernioplasty
Prolene: skin closure, tendon repair,
hernioplasty
Nylon: skin closure, tendon repair,
hernioplasty
Absorbable:
Catgut: gut anastomosis, closure of
peritoneum, small vessel anastomosis
Vicryl: gut anastomosis, closure of
Dexon: gut anastomosis, closure of
PDS: gut anastomosis, closure of
Which suture material used in small gut Absorbable: catgut, Vicryl, PDS, Dexon
anastomosis
Which suture material used midline closure Peritoneum closure: absorbable
Linea alba, skin: non absorbable
5 advantage of synthetic suture material Non allergenic
No/less FB reaction
Less irritation
More tensile strength
How are they sterlized Ethylene oxide
Types of suturing Interrupted
Continuous
Mattress
Sub-cuticular
Types of knots Reef knot
Granny knot
102
Surgeon’s knot
Catgut
Uses From Above
Advantage Absorbable
Mild tissue reaction
Prolene
2 advatage Non absorbable
High tensile strength
Glides through tissue easily
2 disadvantage Knot not secure
Discomfort to patient
Transfusion set
What is it
Parts ➢ Connector
➢ Adaptor
➢ Double chamber:
• Filter chamber
• Counting chamber
➢ PVC tube
➢ Roller clamp/regulator
Advantage of 2 chamber Counting chamber: helps count blood drop
and rate of transfusion
Filter chamber: filteration of micro-thrombi and
clot
Use Blood transfusion
IV infusion
103
Drain tube
3 steps of its use Identify + clean desired vein
Connect transfusion set to bag
Cannulate the vein
Conditions where it can be used in surgery Acute blood loss
ward Major surgery
Prophylactic prior to surgery
Pre operative preparation
Severe burn
Anemia
Name some blood products Whole blood
RCC
FFP
Platelet concentrate
Cryoprecipitate
Factor VIII concentrate
What anticoagulant is used in blood bag CPD (citrate phosphate dextrose) solution
ACD (acid citrate dextrose) solution
Complications of blood transfusion Mismatched transfusion
Infection
Allergic reaction
TRALI
TACO
Infection
DIC
How is it sterilized Gamma radiation

Can it be reused No
Infusion set
What is it
Identifying points 1. Single chamber/only counting
chamber
2. Roller clamp/regulator
3. PVC tube
104
4. Syringe
5. Connector
6. Adaptor
(no filter)
Parts Same as above
Uses IV infusion of fluid
IV infusion of drugs
Fluid and Blood
Whole Blood
Name 2 storage solutions used to store blood CPD (citrate phosphate dextrose) solution
in Bag ACD (acid citrate dextrose) solution
3 indication for its use Acute blood loss
Major surgery
Prophylactic prior to surgery
Pre operative preparation
Severe burn
Anemia
4 side effects of massive use of this Volume overload
Hyponatremia
Hypokalemia
Hyperkalemia
Metabolic acidosis
Hypothermia
20% Mannitol
Mechanism of action Osmotic diuretic: draws fluid into vessel from

outside
Indication Cerebral edema
Raised ICP
Head injury
5% DNS
Name of the fluid

Constituent 5% dextrose and 0.9% NaCl
Four indication of it Vomiting
105
Peri/pre/post operative fluid management
while NPO
Hyponatremia
IV medication
Maintenance fluid
Normal daily requirement of fluid and energy Fluid: 3 L

in an adult person with avg body built? Energy: 2200 Kcal
Complications Hyponatremia
Hypernatremia
Fluid overload
Thombophlebitis
Hartman’s solution
What ions Na, Cl, K, Ca, Lactate

Indication 1. Management of burn patient
2. Management of pt with intestinal
obstruction, GOO etc.
Splint/Bandage
Plaster of Paris
What is it Plaster of Paris

Chemical component Calcium sulphate hemihydrate
CaSO4.(1/2)H2O
106
Uses Fracture immobilization
Correction of deformity
Correction of dislocation
Rest to limb/tissue
4 clinical conditions where it is used Fracture
Dislocation
Developmental dysplasia of hip
CTEV (congenital talipes equinovarus)
What materials needed for application of Water

plaster Plaster of paris
Soft roll
Rolled bandage
Advantages of using it Exact shape of limb can be adapted
Comfortable
Helps in immoblization
How will you understand that its usable If bubbling appears, it is in usable condition
Complications of plaster of Paris Due to the material:
➢ Allergic reaction
➢ Ulceration
➢ Itching
Too tight casting
➢ Gangrene
Due to prolonged immobilization:
➢ Joint stiffness
➢ Muscle wasting
➢ Bone osteoporosis
Faulty technique
➢ Non union
➢ Malunion
➢ Delyaed union
107
Rolled Bandage
Identify this appliance Rolled bandage

Characteristics White
Fenestrated
Thin
Flexible
Aim/purpose Immobilization of limb
Rest of tissue
Correction of deformity
As a padding in tight cast/splint
Common use As bandage in fracture, dislocation, wound
closure (as gauze), deformity, sprain
Also in different region as:
➢ Pressure bandage
➢ T bandage (groin)
➢ Barrel bandage (head)
Advantage 2 Less costly
Easily available
Comfortable
Easy to apply
disadvantage 2 Threads may be impacted in wound and cause
infection
Need to be changed frequently
Stains easily with blood and pus
Effect of tight bandage Compartment syndrome
Ischemia
108
Gangrene
Volkman’s ischemic contracture
How is it sterilized Autoclaving
Name the above bandage Barrel bandage

T bandage
Crepe bandage
Identify
2 characteristics Pink color
Elastic
Self retaining clips
Re-usable
109
Pressure doesn’t hamper joint mobility and
muscle contraction
2 uses Ankle sprain
Varicose vein (pressure stocking)
DVT
Lymphedema
Others: elbow bag, collar and cuff, Splint, Gauze

Use of gauze + sterilization Gauze
➢ Nothing but small cut piece of
rolled bandage
Use:
➢ Fracture
➢ Dislocation
➢ Padding for splinting
➢ Wound coverage
➢ As pack for hemostasis
Sterilization:
➢ Autoclaving
Use of splint + sterilization Use:
➢ Fracture immobilization
➢ Deformity correction
Sterilization:
Antiseptic solution/gamma radiation
Use of soft roll + sterilization During application of plaster of paris
Wound closure, packing for hemostasis
Sterilization: gamma radiation
Elbow bag indication Clavicle fracture
Tennis elbow
Golfer’s elbow
Cervical collar indication PCID (prolapsed cervical IV disc)
Cervical spine injury
Data/Problem
General principles
Burn
25 year old female ….60 kg….30% of mixed burn…pulse 110/min, BP 80/60 mmg
2 methods of measuring of burn area 1. Patient’s palm + digit = 1% TBSA
110
2. Wallace chart (rule of 9)
3. Lund and bowder chart (most
accurate)
Differentiate superficial bleeding + deep Sup:pink, moist, sensation intact/painful,
bleeding blood vessel not seen, blanchable, fluid loss
less, better prognosis
Deep: hard, leathery, anesthesia, blood
vessel seen, not blanchable, fluid loss more,
worse prognosis
Calculate fluid req for 1st 24 hours 4x60x30 = 7200 mL = 7.2 L
3.6 L in 1st 8 hours
3.6 L in next 16 hours
Steps of management of burn wound Local mx of burn wound:
➢ Debridement of dead tissue
➢ Thorough washing
➢ Dressing: silver nitrate, silver
sulfadiazine, mafenide acetate
➢ After healing: primary/secondary
closure (flap/graft)
➢ If needed: escharotomy
Local complications of burn Eschar
Wound contracture
Hypertrophic scar
Keloid
Marjolin’s ulcer (malignant transformation)
40 year female….50 kg….front of chest, abdomen, front of both lower limbs affected. She
came to hospital 3 hours later.
Calculate % of burn Front of chest and abdomen = 18%
Front of both lower limb = 18%
Total = 36%
st
Fluid in 1 24 hour 4x36x50= 7200 mL = 7.2 L
3.6 L in 1st 8 hours
3.6 L in next 16 hours
Name the IV fluid used in burn/this pt Hartman’s solution/ringer’s (crystalloid) in 1st
24 h
Next 24 h: add colloid
Prophylaxis Against tetanus
Against gas gangrene
Type of Dressing to be done Silver sulfadiazine
Silver nitrate
Mafenide acetate
Cerium citrate
Electrolyte imbalance
Patient came with severe vomiting and diarrhoea for last 24 hours, drowsy
Na: 115……K: 2.5…..Cl: 86 mmol/L
Write the electrolyte imbalance of this patient Hyponatremia, hypokalemia, hypochloremia
111
How will you correct it Normal saline: correction of Na and Cl
For correction of K: treatment of cause ➔ if
not ➔ oral KCl ➔ if not ➔ IV KCl
Causes of this condition 1. Diarrhoea
2. Vomiting
3. Intestinal obstruction
4. Profuse sweating
5. Diuretic therapy
Cause of spasm of muscle in hands and feet Hypocalcemia ➔ tetany
Acid base imbalance

21 year old has undergone operation for splenic trauma/rupture….on 2nd POD
her ABG:
PH: 7.32; PaO2: 8.4 KPA; PaCO2: 7.4 KPa; Base excess: -2 mmol/L
{Range: PaO2: 75 mmHg – 100 mmHg (10.5-13.5 KPa)

PaCO2: 38-42 mm hg (5.1-5.6 KPa)
Base excess: from -2 to +2 mmol/L}
Electrolyte:
Na: 138 (135-145); K: 3; Cl: 100 (99-110); HCO3: 28 (22-32)
Serum creatinine: 9 micromol/L (normal is 50-100 micromol/L)

What is your diagnosis? Type II respiratory failure with hypokalemia
(hypoxia + hypercapnia)
What is the acid base imbalance Respiratory acidosis (raised PaCO2)
What may be the cause of this acid base Post operative complication:
imbalance Atelectasis/ARDS/Pulmonary embolism
3 positive findings in this condition Cyanosis, flapping tremor, Kussmaul
breathing
Breath sound: diminished
Percussion note: dull
3 measures to be taken for this case Low concentration o2 therapy
Continuous positive airway pressure (CPAP)
IV fluid to correct electrolyte abnormality
Correct underlying cause
Name 2 sequel of this condition if untreated Respiratory distress
Death
Cellulitis + DM
50 year, male, obese, smoker: red, edematous, painful swelling of left leg. High fever, state of
confusion. WBC count: 14500, 85% is neurtrophil. RBS 23 mmol/L
Other investigations to do Blood culture
Pus from leg culture/sensitivity
112
HBA1C
Urine for ketone body
Doppler USG
Duplex study of lower limb vessels
Why is patient so confused Possible causes:
Septicemia
DIC
Diabetic ketoacidosis
How will you monitor clinically Pulse, BP, temperature: signs of shock
Dehydration
Urine output
How will you prepare patient for surgery 1. Broad spectrum antibiotic
2. Peri-operative and intra-operative
insulin to control diabetes
3. Analgesic drugs
GIT
Gastric outlet obstruction

35-year-old man came to you with vomiting, abdominal pain, dyspepsia for 1 day. He gave
history of irregular peptic ulcer pain for last 2 years.
PH: 7.52 (7.35-7.45)
Na: 125 (135-145)
K: 2.75 (3.5-5.0)
Cl: 85 (99-110)
Ca: 1.8 mmol/L (>2.2)
38 year old man … repeated vomiting ….gen weakness….spasm of hands and feet.
Dehydrated and anemic. Lab:
pH: 7.47
sodium: 125
K: 2.4
Cl: 85
Calcium: 6.7 mg/dL (8.6-10.3)
What is your primary diagnosis Gastric outlet obstruction
Possible causes 1. Pyloric stenosis/chronic duodenal
ulceration
2. Carcinoma stomach/antral
carcinoma/malignant cause
Investigation 1. Barium meal x ray of stomach
2. Upper GIT endoscopy
3. Biopsy and histopathology from the
lesion
Biochemical abnormalities Hyponatremia
Hypokalemia
113
Hypochloremia
metabolic alkalosis
hypocalcemia
paradoxical aciduria
Basis of weakness/spasm of hands and feet Weakness: hypokalemia
Spasm: hypocalcemia ➔ tetany
Management of biochemical abnormalities Normal saline: will correct Na, K
If urine output is normal, it will automatically
correct K, Ca, Alkalosis
If not: administer oral/IV KCl
What should be used for correction of From above
biochemical abnormalities
Complications if surgery is done without Arrythmia
correction of this state Coma
Convulsion
Death
Definitive treatment If benign case: vagotomy, gastro-jejunostomy
If malignant: gastrectomy
Preparation of this patient for operation Correct dehydration, electrolyte
abnormalities, acid base imbalance, anemia,
nutritional status
NG suction and gastric lavage repeatedly
How to Prepare the stomach for operation NG tube insertion ➔ 200 mL normal saline in
stomach ➔ aspiration by 50 cc syringe until
clear fluid return ➔ repeat every 4 hourly
Appendicular lump
Young married man….28 years old….pain in RIF…for 4 days…O/E: tender lump in RIF,
overlying muscle rigidity
Blood count: polymorph leukocytosis, urine RME: no pus cells, USG lower abdomen: normal
finding
Diagnosis Appendicular lump
When is it formed 3-5 days after acute appendicitis attack
How is it formed Greater omentum
Appendix
Cecum
Terminal ileum
Peritoneum
All wrapped together

Differential diagnosis Abdominal tuberculosis/Ileocecal TB
Mesenteric lymphadenitis
Carcinoma caecum
Other investigations MT test
Genexpert test
Colonoscopy
Biopsy and histopathology
114
Signs and symptoms of this disease Hx of acute app 3-5 days back
Tender firm mass in RIF
Fever (low grade)
Name of the conservative regimen Ochsner-Sherren regimen
What are the complications Appendicular abscess
Burst appendix
Gangrenous appendix
Peritonitis
Septicemia
Septic shock
Intussusception
4 year old boy….bleeding during defecation/red currant jelly; sausage shaped mass around
umbilicus. Electolyte: metabolic acidosis
Most likely diagnosis Intussusception
Other clinical features (3) Dehydration
Distension
Visible peristalsis
Cecum is high up, RIF empty (sign of dance)
What investigation to confirm diagnosis USG, CT scan: target sign
Barium enema: claw sign
How to prepare the patient for definitive NG suction
treatment IV fluid
Correction of anemia, dehydration, nutrition
Analgesic
Antibiotic
HBPS
Obstructive jaundice
65 years old man…painless progressive jaundice, wt loss, generalized itching, GB palpable
but non tender
Bilirubin: 18 mmol/L (<1)
ALT: 35
AST: 40
ALP: 750 (<120)
PT: 20 sec (control: 12 sec)
Provisional diagnosis Obstructive jaundice due to malignant biliary
obstruction most probably due to carcinoma
head of the pancreas
Other possibilities Cholangiocarcinoma
Periampullary carcinoma
Choledocholithiasis
Symptoms of this disease Deep jaundice
Pale stool
115
Dark urine
Palpable gall bladder
Itching
Other investigations USG of whole abdomen
MRCP
ERCP
CT scan of whole abdomen
CECT
Biopsy and histopathology of lesion
4 imaging modalities USG, MRCP, CECT, plain x ray of the
abdomen
Imaging investigation I want to do 1st + why USG of W/A + HBS
Localize lesion + see the condition of all
structures
How will you confirm diagnosis Biopsy and histopathology
Tumor marker
3 dangers of operation of obs jaundice Chance of infection
patient Chance of bleeding
Chance of hepato-renal syndrome
Chance of hepatic failure
How will you prepare this pt for surgery Correction of
anemia,
dehydration,
fluid-electrolyte imbalance,
infection,
coagulopathy,
nutritional status,
prevention of hepatorenal syndrome
assess for G/A fitness
Dangers if operation done without Bleeding
preparation Infection
Hepato-renal syndrome (renal failure)
Arrythmia
Death
30 year old female is admitted in surgery war with complaint of jaundice for 10 days,
generalized itching and anorexia for 7 days. History of taking OCP for 5 years. On
investigation: blirubin 6.8 mmol/L, raised ALP
Most probable cause Obstructive jaundice due to
choledocholithiasis
59 year old man …6 weeks history of jaundice and pruritus. He had Cholecystectomy for
cholelithiasis 12 weeks ago.
Probable causes of jaundice of this patient ➢ Residual/retained stone in CBD
now ➢ Primary CBD stone
➢ Biliary stricture
➢ Clot in CBD
➢ Worm in CBD
116
➢ Carcinoma head of pancreas
➢ Cholangiocarcinoma
Investigation (3 biochemical, 2 imaging) Biochemical:
➢ Serum Bilirubin
➢ Serum ALT
➢ Serum ALP
➢ PT, INR
Imaging:
➢ USG of WA+HBS
➢ MRCP
➢ CT scan of abdomen
CECT
Upper abdominal pain, vomiting, fever with chills and rigors, mild yellow coloration of sclera
for 1 week. Lab:
WBC: 15000/mL
Hb: 9 gm/dL
Serum creatinine: 3 mg/dL
Glucose: 8 mmol/L
Biliruibn: 6 mg/dL
SGPT: 100 (ALT)
SGOT: 110 (AST)
ALP: 750
PT: 20 sec
Diagnosis Obstructive jaundice with cholangitis
Causes Form above
Further investigation From above + CBS with ESR
How will you prepare the patient Same ….
Post operative complications Hemorrhage
Injury to bile duct, liver, gut
Residual/retained stone
Wound infection
Septicemia
Septic shock
Death
Acute pancreatitis
30 year old…alcoholic…sudden severe upper abd pain, retching, mild fever, pain radiating
to back.
Examination: abdomen distended and tender
Plain x ray abdomen: paralytic ileus (colon cut off) but no perforation/free gas.
Lab: serum amylase: 1000 (30-110), lipase 150 (60-140), WBC: 15000/cubic mm
Most probable diagnosis Acute pancreatitis
3 causes of this Gallstone
Alcoholism
Abdominal trauma
After surgery
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Post ERCP
Viral infection
Autoimmune
Hypercalcemia, hyperparathyroidism
d/d Perforated peptic ulcer disease
Acute cholecystitis
Imaging technique to confirm USG of whole abdomen
MRCP
CECT (contrast enhanced CT scan)
Complications Hyperglycemia
Hypocalcemia
Intestinal obstruction
Septic shock
ARDS
AKI
Pancreatic necrosis
Pancreatic abscess
Pancreatic pseudocyst
Progression to chronic pancreatitis
Name 2 scoring systems to predict outcome Glasgow criteria
Ranson Criteria
Apache II criteria
Treatment outline Conservative ➔ correction of shock, fluid and
electrolyte imbalance ➔ broad spectrum
antibiotic + analgesic ➔ CECT ➔ if necrosis
➔ necrosectomy ➔ if no necrosis ➔ nothing
more is done
Urology
UTI
Newly married lady….complaints of frequency, micturition, dysuria, fever, loin pain for last 1
week
Probable diagnosis Urinary tract infection, most probably cystitis
Risk factors of this condition Females have short urethra
Anatomical defect in urethra
Frequent sexual intercourse
Incomplete bladder emptying
Foreign body in urethra
Poor genital hygiene
Investigation CBC with ESR
Urine RME
Urine for C/S
Serum urea, creatinine
Serum electrolyte
Treatment Antibiotic
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Ciprofloxacin 100 mg 1+0+1 for 3 days ➔ 5
days ➔ 7 days
Or Amoxicillin 500 mg 1+1+1 for 7 days
Plenty water, maintain genital hygiene,

urinate before and after intercourse
Renal stone
30 year old man…loin pain that increases during movement….fever + burning sensation
during micturition. Urine RME:
Epithelial cell: 1-2/HPF
RBC: plenty
Pus cell: 15-20/HPF
Most probable diagnosis Renal stone
Two imaging studies X ray Kidney and Urinary bladder region
Intra venous urogram (IVU)
Outline the role of contrast imaging in this Will show stone + filling defect in the affected
patient kidney
Site, size of the stone and state of the kidney,
ureter, bladder
Modalities of treatment if final diagnosis is ECSWL (non surgical)
same as the probable diagnosis PCNL (minimally invasive surgery)
Open nephrolithotomy
Undescended testis
6 month old boy presented with empty right hemiscrotum
Boy of 11 months…brought to OPD…complain: right sided inguinal swelling. O/E: right

hemiscrotum found empty and under developed
Possibilities 1. Undescended testis
2. Ectopic testes (don’t say in case of 2nd
scenario)
3. Retractile testis
4. Vanishing testis
What other things to look for during clinical 1. Any intra abdominal/inguinal lump
examination 2. Apparent sexual characteristics
3. Any other congenital anomaly
Investigations to perform in this pt USG of whole abdomen
CT scan of whole abdomen
Laparoscopy
Management of the most common possibility Undescended testis:
➢ Pull down/bring the testis +
orchidopexy
➢ If not viable: orchidectomy
➢ Hormonal treatment
When best to operate Before 1 year, must within 2 years
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Complications if not treated/operated timely 1. Infertility
(3) 2. Malignancy (seminoma)
3. Torsion of testis
4. Risk of hernia
Breast endocrine
Thyroid
32 year old lady….palpitation…redness of eyes…lost 3 kg over 3 months…despite good
appetite/swelling in the neck
TSH: 0.05 (0.5-5)
T3: 27 nmoL/L (1.3-2.7)
T4: 83.6
ESR: 10 mm
What is your diagnosis Thyrotoxicosis
(if swelling in neck: toxic goiter)
What are the causes of such scenario Grave’s disease
Toxic multinodular goiter
Toxic adenoma
Exogenous administration of excess
thyroxine
Treatment options for such case Drug: carbimazole, PTU
Srugery
Radio-iodine therapy
Preparation of patient for operation 3 drugs:
➢ Carbimazole
➢ Propranolol
➢ Lugol’s iodine
Investigation
➢ T3, t4, TSH
➢ Serum calcium
➢ Laryngoscopy: see vocal cord
➢ G/A fitness
What may happen if patient not adequately ➢ Thryoid storm (carbimazole)
prepared ➢ Cadiac arrest, arrhythmia
(propranolol)
➢ Increased hemorrhage/injury
(lugol’s iodine)
➢ Hypocalcemia ➔ tetany
Breast lump
48 year old woman….2 cm painless lump in right breast…..detected during self examination
At least 4 features on clinical examination 1. Hard
that will make you suspect that the lump was 2. Non tender
malignant 3. Fixed
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4. Skin tethering present
5. Nipple retraction
6. Blood stained nipple discharge
7. Peau d’ orange
Three points in history to indicate that she 1. Family history
was suffering from breast cancer 2. Early menarche
3. Late menopause
4. Nullipara
How to confirm diagnosis Biopsy and histopathology
Investigations Mammography (48 year)
FNAC
Core biopsy + histopathology
Investigations to detect metastasis Chest X Ray
Bone scan
CT scan of Chest
CT scan of abdomen
PET scan
Head injury
30 year old male…RTA….opens eyes to painful stimuli, motor response: flexion to pain, make
incomprehensive sounds
Calculate GCS of him Eye: painful stimuli: 2
Voice: incomprehensive sound: 2
Movement: flexion to pain: 3
Total: 7
Grade severity according to GCS Here: severe head injury
[15 w/o LOC: minor

14-15 + LOC: mild
9-13: moderate
8 or less: severe]
Investigation for him CT scan of brain
MRI of Brain
Ophthalmoscopy
Lumbar puncture and CSF study
Clinical feature of raised ICP Headache, nausea, vomiting, photophobia
Bradycardia, hypertension, papilledema
Types of intracranial hemorrhage Extra dural
Subdural
Sub arachnoid
Intra-cerebral
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Operative
Circumcision
Name instruments used in circumcision 1. BP handle with blade (scalpel)

2. Artery forceps
3. Fine scissor
4. Toothed forceps
5. Mosquito forceps
6. Needle holder
7. Suture material
Which artery is the source of bleeding during Frenular artery
circumcision
Complication of circumcision Hemorrhage
Injury: glans, urethra, penile shaft, vessel,
nerve
Infection
Urethral stricture
Appendicectomy
Which operation is being done Open appendicectomy

Possible incision for this operation (2/4) Grid iron incision
Rutherford Morrison incision
Lanz incision
Right paramedian incision
Two complication during this operation Hemorrhage
Injury to: cecum, ileum, colon, bladder, ureter
Infection
Delayed: bands, adhesion
What will happen if it was not operated in Same as complication of acute app
time/2 complications if operation is not done
122
Name some instruments used in this Kidney tray
operation Gulli pot
Scalpel (BP blade with handle)
Retractor: right angle
Tissue forceps
Allis tissue forceps
Mosquito forceps
Intestinal clamp
Fine scissor
Needle holder
Suture material
Laparoscopic appendicectomy
5 year old boy presented with RIF pain and fever for 2 days. O/E there was severe
tenderness in the mcburney’s point. WBC: 16.5 k. Laparoscopic picture given:
Diagnsois Acute appendicitis

Justify from the scenario ….
4 signs ….
2 morphological changes in picture ….
Which operation is being done Laparoscopic appendicectomy
2 complication in patient not treated properly Burst appendix
Appendicular lump
Peritonitis
Cholecystectomy
Name instruments used in cholecystectomy Kidney tray
Gulli pot
Scalpel (BP blade with handle)
Retractor: right angle, Deaver’s retractor
Tissue forceps
Allis tissue forceps
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Moynihan’s cholecystectomy forceps
Mosquito forceps
Intestinal clamp
Fine scissor
Needle holder
Suture material
Incisions for cholecystectomy operation 1. Right subcostal (kocher’s inicison)
2. Upper midline
3. Right upper para median
Sebaceous cyst
Diagnosis Resected speciment of sebaceous cyst

How will you make incision
Transverse elliptical incision with punctum

inside the ellipse
Complication if not treated Infection
Absess
Ulceration
Sebaceous horn
Most common site of this Scalp
Face
Back
Groin
Scrotum
axilla
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Drainage of abscess
Instruments required to drain an abscess 1. Scalpel (BP handle with blade)

2. Sinus forceps
3. Swab holding forceps
4. Kidney tray
5. Gullipot
6. Toothed dissecting forceps
Name 2 methods for draining abscess + 1. Open method: incision and drainage:
example e.g breast abscess
2. Hilton’s method: in areas with vital
structures: e.g abscess in axilla
Two complications if abscess is not treated 1. Burst spontaneously
2. Sinus
3. Fistula
4. Septicemia ➔ septic shock
Procedure Station
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SURGERY OSPE

Perforation of Gas containing hollow viscus

Positive findings ➢ Plain x ray of chest in

Positive findings Plain x ray of abdomen in erect posture A/P

Never give: DA/DNS

Large intestinal obstruction

Abdomen (same as SBO) + tire like mass in

Describe the x ray Plain x ray KUB region in erect posture

Minimally invasive procedure: Per-cutaneous

Open surgical procedure: Open nephro-

Gastric Outlet obstruction due to pyloric stenosis

What is this x ray Barium meal x ray of stoamch and duodenum

Metabolic and electrolyte imbalance/effects ➢ Hyponatremia

What type of x ray is this Barium meal x ray of stomach

Post operative T-tube cholangiogram (Normal)

T tube given after: open cholecystectomy +

(don’t say cholecystitis/cholelithiasis:

Name of the x ray T tube cholangiogram

IVU showing hydronephrosis

Name the x ray Contrast x ray of Kidney and urinary bladder

(most common cause of unilat HN is PUJO

Renal stone in X ray KUB and IVU

Name the imaging Contrast x ray of Kidney and urinary bladder

Minimal invasive: per cutaneous nephro-

Surgical: open nephrolithotomy (if in kidney),

Supracondylar fracture of humerus

What is your finding? Plain x ray of left elbow joint

in both A/P and lateral view

including proximal radius and ulna and distal

Posterior displacement in lateral view

Medial displacement in A/P view

Complications of such injury Immediate

Finding Plain x ray of right hand, including wrist joint

Fracture of the distal end of the radius just

Lateral displacement and lateral angulation in

Dorsal displacement and dorsal angulation in

Displaced: open reduction ➔ internal fixation

Radiological finding Disruption of the shenton’s line on the right side

The right femur is displaced laterally and upwards

Mention 3 findings Plain x ray of left thigh including hip joint in

Findings Plain x ray of Knee joint including patella,

Fracture of the patella

Fracture shaft of tibia

Immobilization: long leg cast (mid thigh to

So in this case: adult: 12 weeks, children: 6

Identify Plain x ray to wrist joint including distal

Name of the x ray plate ….as given

Upper end of humerus

Descirbe the lesion Hemispherical/rounded swelling on the left

Most probably sebaceous cyst on the back

50 kg, 30% burn

Identify the specimen Inflamed vermiform appendix

3 radiological features See in x ray

Abdomen (same as SBO) + tire like mass in

Chronic cholecystitis with cholelithiasis

Identify specimen Resected gallbladder with stone

Identify Specimen of resected gall bladder