[Year]

[Type the company

name]

Dr. Shariful Halim

MBBS,MD (P1), USMLE
(Step 1 & Step2 ck)

[SURGERY P-1 OSPE

PERSONAL NOTES]
[Type the abstract of the document here. The abstract is typically a
short summary of the contents of the document. Type the abstract of
the document here. The abstract is typically a short summary of the
contents of the document.]
Dr. Shariful Halim

Outline of OSPE: 10*6= 60 marks.

 X-rays: 2-3.
 Instruments:2-4.
 Appliances: 1.
 Suture materials: 1.
 Specimens: 1-2.
 Clinical cases: 1-2.

X-RAYS

1. Pneumoperitoneum:

a. Description:
This is a plain X-ray abdomen with both domes of
diaphragm, lower chest and upper pelvis in erect posture
A/P view.
b. Findings:
Cresentic free gas shadow under right/both domes of
diaphragm.
c. Radiological diagnosis:
Pneumoperitoneum.
d. Probable causes:
 Perforation of gas containing hollow viscus
(Perforated peptic ulcer- Most commonly anterior
wall of the first part of duodenum)
 After laparoscopy.
 After laparotomy.

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 After penetrating injury involving peritoneal cavity.

e. Cardinalclinical features:
 Symptoms: Sudden severe generalized abdominal
pain (May first start at epigastric region) + vomiting
+ shock.
 Signs: Abdomen doesn’t move with respiration,
board like rigidity, obliteration of liver dullness,
reduced/absent bowel sound.
f. Treatment:
 Resuscitation: NPO, NG suction, IV fluid and
electrolytes, Broad spectrum antibiotics, Urinary
catheterization.
 Surgery: Laparotomy followed by thorough
peritoneal toileting, repair of perforation and
reinforcement with omental patch.
g. Other points of perforation: See Sharif’s personal notes
Page- 71.

2. Small intestinal obstruction:

a. Description: Same as previous one.

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b. Findings
 Multiple distended loops of bowel with air fluid
levels in the central abdomen.
 Volvulae conniventes (indicate jejunum).
c. Diagnosis: Small intestinal obstruction.
d. Clinical features:
 Symptoms:Intermittent colicky abdominal pain,
vomiting, abdominal distention, constipation +
Shock features.
 Signs:Shock + Abdomen distended+/- Visible
peristalsis, Hyperactive bowel sounds (High pitched
tinkles and peristaltic rushes; may disappear later
ifobstruction is prolonged or strangulation occurs).
e. Investigations:
 S. electrolytes.
 BUN.
 S. creatinine.
 ECG.
 USG/CT scan (If mass suspected as a cause).
f. Treatment:
 Resuscitation:NPO, NG suction, IV fluid and
electrolytes (Commonly Hartmann’s solution),
Broad spectrum antibiotics, Urinary catheterization.
 Surgery: If no improvement within 24 hours or
patient deteriorates. Done according to cause: if
adhesion- Adhesiolysis, obstructed hernia- relieving
obstruction and herniotomy with herniorrhaphy or
hernioplasty).
g. Commonest cause:
 Adult: Bands and adhesion, obstructed hernia.
 Older: Volvulus, CA colon.
 Children: Roundwarm.
h. Source of fluid inside intestine: Intake, secretion from
stomach, pancreas, bile and intestine itself.
i. Source of gas: Swallowed air, products of digestion and
bacterial proliferation/ in obstruction- produce mainly
nitrogen (90%).
j. Sites of normal fluid level in X-ray: Duodenal cap, terminal
ileum.
k. Conditions predisposing to strangulation:
External/extramural causes.

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l. Electrolyte imbalance: Due to vomiting- Hyponatremia,

hypokalemia, Hypochloremia.
m. Other points to be studied: See Sharif’s personal notes P
80.

3. Volvulus:

a. Description: Std.
b. Findings:
 Tire/Tyre like distension of large gut
with convexity upwards (Like inverted
U).
 Haustrations are seen inside the lumen.
c. Radiological diagnosis:
Volvulus of sigmoid colon/Large gut obstruction.
d. Treatment:
 Immediate resuscitation: Std.
 Passage of flatus tube.
 Surgery:
 Manual untwisting with or without
resection of redundant segment and end
to end anastomosis.

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 If gangrenous bowel/non-viable:
Resection and end to end anastomosis.
e. Volvulus Occurs at:
 Common: Sigmoid colon, transverse colon, ileum
and jejunum.
 Never occurs: Ascending and descending colon,
duodenum, rectum.
f. Dangerous obstruction: Closed loop obstruction;
due to chance of strangulation.
g. Other points of volvulus: See Personal notes Page-
83.

4. GOO due to PS:

a. Description: This a barium meal X-ray of the stomach. (With

Duodenal cap series)
b. Findings:
 Huge dilatation of stomach.
 Multiple negative shadows in the stomach
(Retained food particles).
 Narrowing of pyloric region.
 Barium didn’t pass beyond the pylorus.
c. Diagnosis:GOO due to PS due chronic duodenal ulcer.
d. Effects of repeated vomiting: Dehydration, anemia, weight
loss.
e. Other points: See personal notes p- 68.

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5. GOO due to antral carcinoma:

a. Description: As previous one. + Duodenum.

b. Findings:
 Irregular filling defect at the pyloric antrum.
 Dilated stomach.
c. Diagnosis:GOO due to antral carcinoma of stomach.
d. DDx: GOO due to PS, Gastric lymphoma, CA head of
pancreas.
e. Oblique view preferred than A/P: As avoid interference by
vertebral column and better visualizes the pyloric region.
f. Other contrast X-ray of the GIT:
 Barium swallow: For esophagus.
 Barium follow through: For small intestine.
 Barium enema: For large intestine.
g. Other points to study: See personal notes P- (71- 79).

6. T-tube cholangiography: Unique- front.

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a. Description: T-tube cholangiogram showing well

visualization of intra-hepatic and extra-hepatic biliary
system with a filling defect in the distal end of common bile
ductand dye has partly entered into the duodenum.
b. Diagnosis: Retained stone in CBD.
c. Treatment:
 Endoscopic sphincterotomy and extraction of stone
with Dormia basket.
 Another option/If ERCP not available: Re-
exploration and removal.
d. What are the drugs used to dissolve gallstones?
Ans:
 Cheno-deoxy-cholic acid.
 U-r-so-deoxy-cholic acid.
e. Why T-tube cholangiogram is done?
 Detect any retained stone or stricture in the bile
duct.
f. Causes of radiolucent shadow in T-tube cholangiography:
 Retained stone.
 Clot.
 Air bubble.
 Worm.

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g. Causes of missed/retained stone:

 Inadequate exposure/exploration.
h. Signs of a missed stone:
 Clinical: Abdominal pain, fever, jaundice after
clamping the T-tube.
 Radiological: Persistent filling defect in the duct.
i. Other points to study: HBS part of personal notes.

7. Normal IVU/Intravenous urography:

a. Description: IVU.
b. Findings:
 Well visualization of
 Both kidneys which are normal in size and
no filling defect.
 Both pelvis and ureter are normal in
outline, no filling defect, no dilation.
 Bladder is properly outlined, no filling
defect.
c. Diagnosis: Normal study.

8. Hydronephrosis in IVU:

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a. Description: IVU.
b. Findings:
 Normal outline of left kidney, pelvis, ureter.
 Dilation of pelvicalyceal system of right side.
 Calyces are club shaped in right side.
c. How an IVU is done:
 Renal function must be normal.
 Overnight fasting for 8 hours and laxatives given to
reduce bowel shadow.
 First a plain X-Ray KUB is taken.
 Then 1 ml test does of urograffin (Sodium
diatriazoate) is injected IV and waited for 5-10
minutes for any reaction.
 If no reaction, full dose is given.
 X-ray taken in 1-5 minutes which shows
nephrographic and secretory function of the
kidneys.
 Later 15 minutes and then 20-30 minutes films are
taken.
 Further films are taken depending on the need.

d. Common findings in IVU/Common indications:

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 Hydronephrosis: Dilation of pelvicalyceal system,

clubbing of calyces.
 PCKD: Spider leg appearance.
 Ureterocele: Cobra head appearance.
 Renal cell carcinoma: Irregular filling defect, spider
leg appearance.
 Horseshoe kidney: Flower vase appearance.
e. How a retrograde urography/pyelography is done?
 Passage of cystoscope.
 IDying ureteric opeing with passage of ureteric
catheter.
 Passage of dye and X-Ray film is taken.
f. Study hydronephrosis from personal notes: Page- 114.

ORTHOPAEDIC X-RAYS:

1. Fracture clavicle:

a. Positive findings:
It is an X-ray of shoulder girdleA/P viewincluding upper
part of chest and upper arm showing displacedfracture of
left clavicle.
b. Clinical features:
 Pain.
 Swelling.
 Restriction of movement.
 Deformity:Dropping of affected shoulder.

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c. Structures many be injured:

 Vessels: SC vein and artery.
 Nerves: Brachial plexus.
 Other: Apex of lung/pleura.
d. Treatment:
 Un-displaced fracture:Triangular sling with elbow
bag for 6 weeks in adult and 3 weeks in child.
 Displaced fracture: Reduction followed by
immobilization.

2. Fracture Shaft of humerous:

a. X-ray arm A/P and (lateral view) showing fracture of the

shaft of the humerus of right side.
b. Nerve may be injured: Radial nerve.
c. Plaster: U-cast.
d. Duration: Adult 6 weeks, children 3 weeks.

3. Supra-condylar fracture of humerous:

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a. Positive findings:
It is an X-ray of elbow joint including lower part of the
humerous and upper part of radius and ulna of right side
both A/P and lateral view:
 Fracture of the supra-condylar region of
humerous.
 Lateral view shows:
 Posterior displacement of fracture
fragment distal fragment.
 Distal fragment is drawn up.
 A/P View shows:
 Lateral displacement of the distal fragment.
b. Common characteristics:
 In children with falling in outstretched hand.
 Deformity:Posterior concavity with undue
prominence of olecranon.
c. Immediate first aid: Immobilization of limb.
d. Treatment:
 Undisplaced fracture: Long arm back slab for 3
weeks in children.
 Displaced fracture: Reductionby traction and
counter traction under G/A followed by long arm
back slab with elbow at <90 degree for 3 weeks in
children.
e. Role of physiotherapy:

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 Preserve range of movement.

 Prevent stiffness.
 Prevention of disuse atrophy.
 Prevention of deformity.
f. Complications:
 Immediate:
 Hemorrhage.
 Injury to the brachial artery, radial nerve,
median nerve.
 Compartment syndrome.
 Delayed:
 Mal-union.
 Non-union.
 Joint stiffness.
 Deformity: Cubitas varus, Cubitus valgus.
 Volkmann’s ischemic contracture.

4. Colles’ fracture:

a. Positive findings:
 X-Ray wrist A/P and lateral viewsincluding distal
parts of radius and ulna and proximal part of hand
showing:
 Fracture in the lower part of radius.
 Postero-lateral displacement of distal
fragment.
 Upward pulling of distal fragment.

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b. Definition: Fracture of the lower end of the

radiusabout one inch above the lower articular
surface.
c. Clinical features:Std. features+ Deformity-Dinner fork
deformity.
d. Treatment:
 Undisplaced fracture:
 First 24 hours- Immobilization by short arm
back slab.
 Next 6 weeks:Colle’s full plaster- extends
from just below elbow to knuckles of hand.
 Displaced fracture:
 Closed reduction under G/A.
 Colle’s plaster for 6 weeks.
e. Complications:
 Early: Injury to radial nerve/artery, Carpal
tunnel syndrome.
 Late:
 Mal-union.
 Non-union.
 Stiffness of wrist and fingers.
 Sudeck’s atrophy/osteodystrophy.
f. Common age group: Post-menopausal women.

5. Fracture neck of the femur: unique-

a. Positive findings:
This is an X-ray of pelvis including both hip joints
showing fracture neck of the femur of right side.
b. Diagnosis:Incomplete/complete,
Undisplaced/partially displaced/totally displaced
fracture of neck of right femur.

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c. Common age-sex: Female in 5th-7th decade.

d. Clinical features: Std. fracture + deformity: Limb is
abducted, externally rotated and shortened.
e. Why union is difficult?
 Peculiarity of blood supply.
 Difficulty in immobilization.
 Intra-articular fracture.
f. Treatment:
 Undisplaced: Hip screw.
 Displaced:
 ORIF: Open reduction and internal
fixation.
 Hemiarthroplasty.
 Total hip replacement.
d. Complications:
 Internal hemorrhage.
 Shock.
 Avascular necrosis of head of femur.
 Stiffness of hip joint.
 Limb shortening.
 Deformity.
 DVT and PE.
 Bed sore.

6. Fracture of the shaft of femur:

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g. Positive findings:
This is an X-ray of thighincluding hip joint A/P view
showing:
 Fracture of shaft of right femur.
 Fracture fragment is laterally displaced.
h. Diagnosis: Displaced
transverse/oblique/spiral/comminuted fracture of
shaft of right femur.
i. Blood loss: Hip: 2-3L, Femur: 1.5-2L, Tibia: 1-1.5L,
Humerous- 500-750ml, Radius: 250-500ml.
j. Treatment:
 Undisplaced fracture:
 Tt. Shock
 Adult: Skeletal traction for 4
weeksfollowed by long leg full plaster for
8 weeks. (Total of 12 weeks)
 Children: Surface traction followed by hip
spika.
 Displaced fracture: Tt shock + ORIF with
intramedullarynail.
k. Advice to patient:
 Quadriceps exercise: Like Hasanfaruq.
 Regular movement of the toes.
l. Complications:
 Immediate:Shock, Renal failure, injury to soft
tissue and surrounding nerves.
 Delayed: Non-union, mal-union, deformity, joint
stiffness, disuse atrophy of muscles.
m. When callous forms:
 No pain or tenderness on the fracture site.
 No free movement of the fracture fragments.
 Callous felt as a hard mass.

7. Fracture shaft of the tibia:

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a. Positive findings:
 This an X-ray leg A/P view with knee and
ankle joints showing:
 Fracture at the lower third of shaft of
right tibia.
 If A/P: Lateral displacement of distal
fragment.
b. Difficulties with fracture of lower third of the tibia:
 Superficial bone- more commonly open fractures
occurs.
 Few attachments of muscles and tendons.
 Difficulty in immobilization.
 Distant from nutrient artery.
c. Immobilization: By skeletal traction (Steinman pin).
d. Treatment:
 Closed fracture:
 Stable Undisplaced fracture: Long leg full
plaster for 6 weeks followed by PTB plaster
till union (Commonly another 6 weeks).
 Displaced: Reduction under G/A followed
by immobilization.
 Open/compound fracture:
 ORIF/External fixation.
e. Complications:
 Immediate: Injury adjacent blood vessels and
nerves.
 Late: Mal-union, non-union, joint stiffness,
deformity, Volkmann’s ischemic contracture.

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8. Sequestrum:

a. Positive findings:
This is an X-ray of the leg showing:
 Translucent area in the cortex containing a
central radio-opaque shadow with
surrounding periosteal reaction.
 Obscured outline of cortex and medulla.
b. Radiological diagnosis:
 Chronic pyogenic osteomyelitis with sequestrum
formation.
c. Why acute osteomyelitis occur more in children?
 Less immunity.
 Rapidly growing bone.
 More elastic periosteum.
d. Why metaphysis is affected?
 Hair pin like orientation of blood vessels in
metaphysis.
e. Joint is not involved because: Growth plate prevents
penetration of blood vessels in joint.
f. Other points to be studied: See personal notes p- 175.

9. Other X-rays to be studied:

a. Ewing’s sarcoma: Page- 178.
b. Osteosarcoma: Page- 178.
c. Giant cell tumor:
 Soap bubble appearance.
 Eccentric lesion (Involves only one side, not the full
circumference).

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10. Images:

Simple bone cyst:Fills the medullary cavity but doesn’t expand

the bone.

Giant cell tumor:In mature bone, always extends up to sub-

articular margin.Soap bubble appearance.

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Aneurysmal bone cyst:Expansile cyst in the metaphysis.

Osteosarcoma:

 Mixed osteolytic and osteoblastic lesion at the metaphysis.

 Periosteal reaction: Codman’s triangle.
 Sunray spicule/appearance (2, 3 images esp.)

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Ewing’s sarcoma: At diaphysis, widening of shaft, onion peel

appearance.

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Acute osteomyelitis:

X-ray findings:

 Localized soft-tissue swelling adjacent to metaphysis with

obliteration of usual fat planes (after 3-10 days)
 Area of bone destruction- metaphysical mottling and
periosteal changes (lags 7-14 days behind pathologic
changes)

SUTURE MATERIALS:

Q. What is it?

Ans: Suture in sterile pack.

Q. Classify suture materials?

Ans:

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 Absorbable:
 Natural: Chromic catgut.
 Synthetic: Vicryl (Polyglactic acid/Polyglactin).
 Non-absorbable:
 Natural: Silk.
 Synthetic: Prolene, Dexon (Polyglycolic acid), PDS
(Poly Dioxanone Suture material).

 Relationship with needle:

 Atraumatic: Thread is attached with the needle.
 Traumatic: Thread is not set with needle.
 Catgut:
 Two types: Plain or Chromic catgut-Catgut with
chromic acid salt.
 Not from gut of the cat, but of sheep’s; esp. from the
submucosa of sheep jejunum.
 Brown/khakiin color.
 Absorption time: 21 days (1 month).
 Used for: Suturing pedicles,fascia,Peritoneum, SC
tissue,circumcision (3-0 chromic catgut).
 Advantage: Can be used in presence of infection(As it is
absorbable), Minimum tissue irritation.
 Disadvantage:
o Expensive.
o Early absorption.
o Doesn’t knot well.

 Vicryl (Polyglactic acid):

 Violetin color.
 Absorption time: 2-3month.
 Used for: Bowel anastomosis,
Cholecystojejunostomy,ligating pedicles.
 Silk:
 Black/sky in color.
 Strong.
 Best handling material.
 Knots well.
 Prolene: Blue.
 Use of non-absorbable suture material:
 Suturing the skin.
 Herniorrhaphy.

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 Suturing tough structures: Tendon, Aponeurosis, nerve,

vessels.
 Tension suturing in the abdomen.

 Numbering of suturing material:

 2- : Thick, for pedicle ligation.
 1-
 0-0.
 1-0.
 2-0: For bowel suturing.
 3-0: Circumcision.
 4-0: Face.
 5-0: For vascular anastomosis.
 6-0.
 7-0
 8-0
 9-0: For ophthalmic surgery. Requires operating
microscope.
 Types of suturing:
 Continuous: Bowel anastomosis.
 Interrupted: Skin closure, Lord’s operation.
 Tension suturing: Horizontal, vertical.
 Sub-cuticular.
 Types of knot: Reef knot, Granny knot, Surgeon’s knot.
 Suture materials used for upper midline closure in adults:
 Peritoneum: Vicryl/catgut.
 Rectus sheath: Prolene.
 Skin: Silk/prolene.
 Suture material for small gut anastomosis: Vicryl, Dexon,
catgut.
 Advantages of synthetic suture material:
 Non-absorbable/delayed absorbable.
 Adequate tensile strength.
 Minimum tissue reaction.
 Non-allergic.
 Can be easily sterilized. (By ethylene oxide).

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Instruments:

1. Autoclaving:
 Principle:
 At atmosphere boiling point of water is 100
deg cel.
 With rise of pressure the boiling point also
rises- so Increased heat content under
pressure in autoclave
 Steam under pressure has more
penetrating power.
 Upon contact with materials steam
condenses and liberates huge amount of
latent heat.
 Features:
 Temperature: 121 Deg cel.
 Pressure: 15lb./Sq. inch.
 Duration: 15 minutes.

2. Swab holding forceps: U-168.

a. ID points:
 Long shaft with handles.
 Blades are rounded,cicularly fenestrated and with
serrations.
 Catches near the handle.
b. Uses:
 Hold swab for painting.
 Clean operative field.
 Facilitate dissection at depth.
 Hold fundus of GB during cholecystectomy.
c. 5 operations it is used:
 Any major operation:
 Appendicectomy.
 Cholecystectomy.
 Cystolithotomy.
 Transvesical prostetectomy.
 C/S.

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d. Sterilization: Autoclaving (As it is a blunt metallic

instrument).

3. Mosquito/small artery/hemostatic forceps: 169.

a. ID:
 Small size.
 Pointed end may be curved.
 Catch near the handle.
 No transverse serrations.
b. Uses:
 Hold/clamp small blood vessels.
 Hold cut end of peritoneum, fascia, and
aponeurosis.
 Hold stay suture.
 Clamping catheter.
c. Sterilized: Autoclave (Blunt).

4. Medium curved hemostatic forceps: 170.

a. ID:
 Medium sized with slightly curved end.
 Transverse serrations in the inner aspect of blade.
 Catch near the handle.
b. Uses:
 Hold/clamp blood vessels.
 Hold cut end of peritoneum, aponeurosis, and
fascia.
 Holds stay sutures.
 Progressive clamping of catheter.
 Helps in diathermy, ligation.
 Crush the base of appendix during
appendicectomy.
 Pedicular clamp of GB, thyroid.
 Hold hard swab/Lahey’s swab.
c. Processes of surgical/intra-operative hemostasis:
 Artery forceps: Repeated crushing/clamping.
 Ligation.
 Cauterization: Electro-cauterization/diathermy,
Cold/cryo-cauterization.

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5. Large sized hemostatic forceps: 171

a. ID points:
 Large sized.
 Transverse serration on inner aspect blades.
 Catch near the handle.
b. Uses:
 Hold/clamp large vessels.
 Hold Lahey’s swab: To mop deep seated vessels.
 Remove large pedunculated tumor in nephrectomy
and splenectomy.

6. Towel clip: U-172.

a. ID:
 Single pair of curved tooth.
 Catch near the handle.
b. Uses:
 Fixed towelin draping.
 Fix sucker tube or diathermy wire with draping
sheet.
 Fixing or giving traction in tongue during tongue
surgery.
c. Advantage as a tongue holding forceps:
 Tongue never slips.
 Less injury, quick healing.

7. Bard Parker handle with BP blade:

a. BP knife: When BP handle is fixed with BP blade.

b. Uses:
 Incision.
 Excision.
 Stabbing: For drainage of any abscesses.
 Section:
 Cystic duct.
 Pedicle of kidney.

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8. Deaver’s retractor/Deaver’s abdominal retractor: U -173.

a. ID:
 Broad gently curved blade.
 Another end is flat-handle.
 Looks like an S.
b. Uses:
 Retraction of liver: During cholecystectomy,
choledocolithotomy, gastrectomy and vagotomy.
 Retraction of loops of intestineduring
hemicolectomy.
 Retraction of spleen.
 Retraction of abdominal wall.
c. Advantages:
 Less trauma and adequate exposure of the surgical
field.
d. Probable complication: Liver injury.
e. How to avoid: Gentle manipulation/traction, covering
retractor with mop.
f. Sterilization: Autoclaving.

9. Langenbeck’s/right angle retractor: U-174.

a. ID:
 Long handle.
 Small blade which is acutely curved.
 Circular openingin the middle of handle.
b. Uses:
 Retract skin, fascia and aponeurosisduringsmaller
operations:
 Hernia surgeries.
 Appendicectomy.
 Retract abdominal wall in children.
c. Sterilize: Autoclaving (Blunt).

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10. Richardson Eastman retractor: (IF Morris- Only one blade). U-

174.

a. ID:
 2 strong blades, right angled with the handle.
 Central holding area in the handle.
b. Uses:
 Retract abdominal wall/skin, fascia, aponeurosis,
muscles in larger operations:
 Gastrojejunostomy.
 Cholecystectomy.
 Choledocolithotomy.
 Other anastomosis operations.
 Hemicolectomy.

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11. Czerny’s retractor/Hernia retractor: See SRB Page 1249.

12. Other retractors: See SRB page 1249-50.

13. Sinus forceps (Lister’s): U-175.

a. ID:
 NO catch in handle.
 Long narrow blades with broad and blunt tip.
 Transverse serrations near tip.
b. Uses:
 Sinus:
 Explore.
 Drain.
 Remove FB.
 Drainage of abscess by Hilton’s method:
 For abscesses in: Axilla, breast, groin, neck,
face.
c. Other points about sinus and abscesses: See personal notes
p4, 21.

14. Lane’s twin gastro-jejunostomy clamps:U -176.

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a. ID:
 Two parts:
 Gastric part: Has screw. (Hold stomach)
 Jejunal part: Has metallic loop at the end.
(Hold jejunum).
 Inner surface is serrated longitudinally: To prevent
slippage.
b. Functions or purposes/action:
 Fixation, occlusion, hemostasis, apposition.
c. Indications of gastro-jejunostomy:
 GOO due to PS due to chronic duodenal ulcer.
 Along with curative resection of small antral
carcinoma of stomach.
 As a palliative procedure in irresectable CA stomach.
d. Hazards of using clamp: Crushing of gut, post-operative
bleeding.

15. Moynihan’s cholecystectomy forceps: U-177.

a. ID:
 Blades are acutely curved(Difference with
hemostatic forceps).
 Serrations in the inner aspects of the blades.
 Catches near the handle.
b. Uses:
 Catch the cystic duct b4 applying ligature in
cholecystectomy operation.
 Hold vagus in Truncal vagotomy.
 Hold sympathetic trunk in lumbar sympathectomy.
c. Advantages: Curved blades facilitate easy application of
suture and better visualization.

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16. Desjardin’s choledocolithotomy forceps: SRB- 1251.

a. ID:
 Long curved distal blades.
 Smooth serrations and fenestra in the tip.
 No catch near the handle.
b. Use: Removal of CBD stones.

17. Plane dissecting forceps: U-178.

a. ID:
 2 blades joined in one end and open in another
end.
 Serrations in inner aspect of the blades, near the
end.
 Coarse serrations in the outer aspectof blades.
b. Uses:
 Hold soft structure:
 Intestine.
 Peritoneum.
 Bladder.
 Biliary tree.
 Contact media for diathermy.
 For fine dissection.

18. Toothed dissecting forceps: U-177.

a. ID:
 Toothed end.
 No serrations in the inner aspect of blades.
b. Use:

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 Hold tough structures: Skin, fascia, aponeurosis,

rectus sheath, muscles and tendons.
 Contact media for diathermy.
c. Advantage:
 Less effort to hold tough structures.
 No slippage.
d. Sterilized: Autoclaving.

19. Kocher’s forceps: U-180.

a. ID:
 Tooth and socket at the tip.
 Transverse serrations in the inner aspects of blades.
 Catches near the handle.
b. Uses:
 Retracting cut end of vesselsin tough structures
like:
 Scalp.
 Palm.
 Sole.
 Periosteum.
 Hold tough structures, cut ends of muscles, ribs,
tendon, aponeurosis.
 Hold superficial thyroid vessels.
 Hold meniscus during menisectomy of knee.

20. Alli’s tissue forceps: U-181.

a. ID:
 Multiple teethin the end of blades.
 Catch near the handle.
b. Uses:
 Hold tough structures:
 Skin.
 Fascia.
 Rectus sheath.
 Aponeurosis.
 Hold intestineduring resection anastomosis
procedure.
 Hold mesoappendixduring appendicectomy.
 Advantages:
 No crushing.
 No vascular compromise.

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21. Babcock’s tissue forceps: U-182.

a. ID:
 Curved distal end of bladeswith triangular
opening/fenestra.(Allow soft tissue to bulge out).
 Catch near the handle.
b. Uses: Hold tubular structure.
 Hold tip of appendix during appendicectomy.
 Hold fallopian tube, ureter, vas deference.
 Hold intestine.
c. In appendicectomy:
 Small/short appendix: One Babcock is enough.
 Large/longer appendix: 2 Babcock needed.

22. Fine/rough curved scissor’s: U-182. + SRB-1250.

a. ID:
 Fine Cutting edges in the blades.
 No catches in the handle.
b. Uses:
 Rough: Cut stitch, tough structure.
 Fine:
 Extension of incision after applying B.P
knife.
 Fine dissection of deeper tissue.
 Cutting soft structure: Peritoneum.
c. Sterilization: Chemical sterilization by Lysol. (Any sharp
instrument- Chemical sterilization).

23. Kidney tray: U- 183.

a. ID:
 Metallic kidney shaped tray.
b. Use:
 Carry gauze piece and instruments.
 Keeping dissected GB, appendix.

24. Gully pot.

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25. Intestinal clamp (Occlusion or crushing variety):U-184.

a. ID:
 Occlusion variety: Thin, long blades with
longitudinal serrations, catches near the handle.
 Crushing variety: Stout blades, transverse or
oblique serrations on the inner aspect.
b. Use:
 Occlusion variety: Clamping intestine during
anastomosis.
 Crushing variety: Crushing intestine during
resection before anastomosis.
c. Advantages of occlusion clamp:
 Minimum crushing effect.
 Hemostasis:Reduce the bleeding.
 Occlusion: Prevent escape of intestinal content
thereby prevents contamination of peritoneal cavity
and wound.
d. Disadvantage of occlusion clamp:
 Occlude blood vessels.
 Crushing of wall leading to anastomotic leakage or
disruption.
e. If gangrenous bowel is not resected:
 Development of fecal fistula.
 Anastomotic leakage and disruption- peritonitis.
f. Number of occlusion clamp:
 End to end anastomosis: 2.
 Side to side anastomosis: 4.
g. Preparation of cut margin for anastomosis:

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 Washing with normal saline.

 Ensuring viability.

26. Proctoscope: DU-11. U-185.

a. ID:
 Obturator.
 Funnel with handle/sheath.
b. Why called Proctoscope?
 Part of gut developing from anal proctoderm(lower
third of rectum and anal canal) can be seen by it.
c. Indications of Proctoscopy:
 Diagnostic:
 See pathology in lower third of rectum and
anal canal like:
 Hemorrhoids.
 Rectal polyp.
 Rectal carcinoma.
 Internal opening of Peri-anal fistula.
 Take biopsy.
 Therapeutic:
 Sclerotherapy in 2nd degree internal
hemorrhoids.
 Polypectomy.
d. Contraindications:
 Painful anal conditions like:
 Anal fissure.
 Peri-anal abscess.
e. Positions of the patient in Proctoscopy:
 Left lateral position (Common).
 Knee elbow position.
 Lithotomy position.
f. Instruments needed for proctoscopy:
 Proctoscope.
 Gloves.
 Light source.
 Lubricants.
 Kidney tray with gauze piece.
g. Pre-requisites for proctoscopy:
 Informed consent.
 Maintenance of privacy.

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 Proper positioning and exposure.

 Bright light.
 Patient is to be assured.
h. Causes of bleeding per rectum:
 Hemorrhoids.
 Rectal polyp.
 Rectal carcinoma.
 CA colon.
 Ulcerative colitis.
 Bleeding disorder.

27. Needle holder: U-191.

a. ID:
 Cross serrations and a groove in the blades.
 Blades are small and strong.
 Long shaft.
 Catch near the handle.
b. Use:
 Hold needle.
 Hold the free end of thread.

28. Miscellaneous:
a. Instruments during appendicectomy:
 Draping, fixing sucker and diathermy wire
with draping sheet: Towel clip.
 Painting: Sponge/swab holding forceps.
 Incision: BP Blade/knife.
 Hold aponeurosis, rectus sheath, muscle:
Alli’s tissue forceps/Toothed forceps.

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 Retract abdominal wall: Right angle

retractor.
 Hold tip of the appendix: Babcock’s forceps.
 Clamp appendicular artery: Hemostatic
forceps.
 Crushing base: Medium sized hemostatic
forceps.
 Ligation of base: Needle holder, suture
material (Chromic catgut/Vicryl).
b. Incisions of appendicectomy:
 Grid iron.
 Lanz.
 Rutherford Morrison.
c. Instruments for cholecystectomy:
 Draping, fixing sucker and diathermy wire
with draping sheet: Towel clip.
 Painting: Sponge/swab holding forceps.
 Incision: BP Blade/knife.
 Hold aponeurosis, rectus sheath, muscle: Alli’s
tissue forceps/Toothed forceps.
 Retract abdominal wall: Right angle retractor.
 Retract liver: Deaver’s retractor.
 Clamp/catch cystic duct: Moynihan’s
cholecystectomy forceps.
 Clamp cystic artery: Hemostatic forceps.
 Ligation: Suture materials, needle holder.

d. Incisions for cholecystectomy:

 UMLI.
 URPMI.
 Right subcostal.
 Cockers.
e. Instruments in circumcision:
 Draping: Towel clip.
 Painting: Sponge/swab holding forceps.
 Clamping frenulum/frenular artery:
Mosquito forceps.
 Incising prepucial skin: Fine scissor.
 Ligation: Needle holder, suture material.
f. Site from where reactionary hemorrhage occur after
circumcision:

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 Slipping of ligature from frenular artery or

dorsal vein.
g. Complications of circumcision:
 Hemorrhage.
 Injury: To glans, urethra.
 Infection.
 Urethral edema- AUR.
 Urethral stricture.

Appliances:

1. Ryle’s tube/ NG tube: U-191.

 ID:
 About 1 meter long.
 Made of rubber/plastic.
 Three lead shots/metal beads in the tip.
 Markings at different levels:
 1st: 40 cm- Gastro-esophageal
junction/cardia.
 2nd: 50cm- Body of stomach.
 3rd: 60cm- Pylorus.
 Several windows near lower end.
 Uses:
 Therapeutic:
 Evacuation of gastric contents:
 In acute abdominal condition:
Intestinal obstruction, acute
pancreatitis, acute appendicitis,
acute Cholecystitis, perforation
of GCHV, abdominal trauma.
 GOO.
 Gastric preparation before
gastric surgery.
 After major abdominal surgery.
 Feeding purpose:

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 Comatose patient, facio-

maxillary injury, major head
and neck surgeries.
 Supplying medications.
 Diagnostic:
 Collection of gastric juice and analysis
for:
 Detect achlorhydra.
 Poisoning.
 Confirmation of hematemesis.
 Post-operative assessment of
vagotomy operation.
 Tracheo-esophageal fistula.
 In successful insertion of tube:
 Aspiration: Gastric content comes out.
 Passage of air into the tube and
simultaneous auscultation- Production
of gurgling sound.
 Confirmation by X-ray: Shows lead
shots/metallic beads at the tip inside
stomach.
 In failed insertion/When the tube in respiratory tract:
 Patient coughs violently.
 In unconscious patient: After insertion of
external opening of the tube in water-
Bubbling comes out.
 Complications of use:
 False passage/Laryngealor tracheal
intubations.
 Injury to nasal mucosa.
 Injury to soft palate, epiglottis.
 Aspiration pneumonia.
 Contra-indications:
 Nose:
 Large, bilateral ethmoidal polyp.
 Bilateral choanal atresia.
 Esophageal conditions:
 Corrosive injury.
 Malignant or benign stricture.
 Sterilization: Gamma rays.

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2. Transfusion set: U-195.

i. Parts:
 Nozzle: sharp pointed with opening- connect with bag.
 Dribbling chamber: For counting.
 Filtering chamber: Removal of micro-thrombi/clot.
 Connecting tube: The main channel- Rubber.
 Adaptor and regular: To control rate of transfusion.
ii. Blood products that are commonly transfused:
 Whole blood.
 Packed RBC.
 FFP.
 Platelet concentrate.
 Human albumin 5%-25%.
iii. Anticoagulants used:

Anticoagulant Storage Viability of

temperature RBC
ACD: 4 deg cel 21 days.
Acid (citric),
Citrate (trisodium)
Dextrose
CPD: 4 deg cel 28 days.
Citrate (trisodium),
Phosphate (sodium
Dextrose
CPDA: 4 deg cel 42 days.
Citrate,
Phosphate
Dextrose
Adenine

iv. Other points about transfusion: Personal notes- P40.

3. Infusion set with IV cannula and side valve: U-196.

A. Parts:
 Nozzle.
 Dribbling chamber.
 Connecting tube.
 Adaptor and regular.
B. Uses:
 Infusion of fluids.
 Infusion of drugs.

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C. Other points about fluids and electrolytes: Refer to personal

notes P- 35.

4. Laryngoscope: U-197.

a) Parts:
 Handle.
 Blade.
 Light source.
b) Uses:
 Facilitation of endotracheal intubation: For G/A or
mechanical ventilation.
 Detection of causes of voice problem.
 Detection of causes of throat pain.
c) Complications of use:
 Injury to:
 Oral cavity, teeth, gum, palate, uvula.
 Larynx.
 Pharynx.

5. Endotracheal tube: U-198.

i. Parts:
 Wide main channel with Balloon at the distal end/tip.
 Side port/channel to inflate the balloon.
ii. Uses:
 Administration of inhaled general anaesthetics.
 Mechanical ventilation: e.g. ICU patient/ pt. with
respiratory depression.
 Protection of airway in trauma patient.
iii. Complications:
 Injury to:
 Oral cavity, teeth, gum, palate, uvula.
 Larynx.
 Pharynx.

7. Airway tube/Oropharyngeal tube: U-8.

a) Uses:
 Prevention of fallback of tongue in unconscious patient.
 Prevention of tongue bite.
 Maintenance of clear airway.
b) Complications:

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 Injury to:
 Oral cavity, teeth, gum, palate, uvula.
 Pharynx.
 Larynx.

6. T-tube: U-186.

I. ID:
 Looks like a T.
 2 parts:
 Horizontal part: Placed in CBD.
 Vertical part: For bile drainage.
II. Use:
 Drainage of bile after choledocolithotomy.
 Prevention of bile leakage and thereby prevent biliary
peritonitis.
 Performing post-operative T-tube cholangiography.
III. Sterilization: Gamma ray.
IV. Complications of T-tube:
 Blockade or kinking: Bile retention.
 Too long: Obstruction of main pancreatic duct-
pancreatitis.
 Too short: May fall-leakage of bile.
 Early removal: Leakage of bile.
 Delayed removal: May be difficulties in removal.
V. Causes of bile leakage after cholecystectomy:
 Trauma to bile canaliculi.
 Slipping of ligature from cystic duct.
 Cholangitis.
VI. Post-operative jaundice after cholecystectomy:
 Retained stone.
 Cholangitis.
 Biliary stricture.

7. Tri-channel self-retaining Foley catheter: (Foley- American

urologist). U-197

a. ID:
 3 channels
 Narrow Oblique channel: Inflation of balloon.

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 Middle/wide straight channel: Drainage of urine.

 Wide oblique channel: UB irrigation.
 Balloon near the tip.
 Opening/side port near the tip.
b. Balloon capacity: Max. 30ml, Diameter: 7.2 mm.
(Circumference: 7.2*3= 21.6mm)
c. Made of: Latex.
d. Uses:
 After prostetectomy: Prevent blood clot (Balloon),
bladder rest (Continuous drainage), provide irrigation
of bladder.
 Any hemorrhagic condition of UB.
 In suprapubic cystolithotomy.
e. Information from the packet:
 Balloon capacity
 Size/Diameter.
 Length of tube.
 MFG/Exp. Date.
f. Pre-requisites for catheterization:
 Counseling.
 Informed consent.
 Privacy.
 Adequate light.
 Keep attendant.
g. Other appliances needed for catheterization:
 Sterile gloves.
 Lignocaine jelly.
 Povidone iodine.
 Gauzes piece.
 Draping sheet.
 Haemostatic forceps.
 Distilled water.
 Syringe-10ml.
 Urobag.
h. Procedure of catheterization: Personal notes p-56.
i. Catheterization without any urine passing:
 Clot in tube.
 Kinking of tube.
 False passage/ mis-puncture.
j. Complications of catheterization:
 Infection.

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 Injury to urethra- stricture urethra.

 Mis-puncture.
 Hemorrhage.
 Retained catheter.
 Incontinence after removal.
k. Sterilization: Gamma rays.

9. Bi-channel self-retaining Foley catheter: U-198.

a. ID:
 2 channels
 Narrow Oblique channel: Inflation of balloon.
 Middle/wide straight channel: Drainage of urine.
 Balloon near the tip.
 Opening/side port near the tip.
b. Uses:
 Therapeutic:
 Acute urinary retention.
 Chronic urinary retention with renal failure.
 Bladder incontinence.
 Intra-vesical chemotherapy.
 VVF.
 Evacuation of retained clot.
 Diagnostic and monitoring:
 Measuring urine output: Any shock state, per
and post-operative.
 Assess PVR.
 Urodynamic study.
 Contraindications:
 Ruptured urethra.
 Sterilized by: Gamma rays.
 Size: Adult: 16F/Fr, Child 8-10 F/Fr; 16F means
circumference is
16mm and diameter is 16/3mm= 5.33mm. (F= French
unit).
 Types of catheter:
 Non self-retaining catheter/intermittent
catheterization: Simple rubber catheter.
 Self-retaining catheter/indwelling
catheterization: Foley (Bi/Tri channel),
Malecot’s catheter, Gibbon’s catheter (SRB-
1074).

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 To keep for longer period: Silicon coated Foley is used.

 Malecot’s catheter: SRB-1072.
 Umbrella or flower at the tip.
 Never introduced per urethrally.
 Uses:
 SPC: Supra-pubic cystostomy.
 Perinephric abscess.
 Pyonephrosis.
 Can be kept for a longer duration (3 months).
 Less infection.

10. Plain rubber catheter: U-189.

i. ID:
 Single rubber tube
 Rounded tip.
 Only opening in side wall near the tip.
ii. Use:
 Drain urine from bladder temporarily.
 Find out residual urine (>50ml PVR is
significant, >100ml is indication of TURP).
 Other uses:
 In children asNG tube.
 As tourniquet for venesection.
iii. Non-self-retaining.

11. Surgical drains: SRB- 1252.

 A drain is a created channel which allows any fluid
collected, to come out after closure of the main wound.
 Types of drain:
 Corrugated rubber drain:Drains by capillary
action and gravity- but soak dressing and
uncomfortable for patient.
 Tube drains:Most common drain system.
 Penrose soft latex rubber tube.
 Multiple perforated tubes.
 Advantage:
o Quantity of fluid can be
measured.
o Can be kept for a longer time.
o Less infection.

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o Easy removal.
 Closed Suction tube drain system: Drain under
negative pressure. Used for thyroidectomy.
 Sump drain:
 Parallel air vent prevents the adjacent
soft tissues from being sucked into the
tube when negative pressure is applied.
 Used in:
o Entero-cutaneous, pancreatic
fistula.
 Glove drain.
 Wick drain: Gauze drain to drain pus, discharge.
 Classification of drain systems:
 Open/static drain: Corrugated/Penrose drain-
high infection rate.
 Closed siphon drain: Drain is connected with a
sterile bag with or without one way valve- low
infection rate.
 Closed suction drain: Vacuum is created with a
negative pressure to drain the secretion. E.g.
Closed suction tube drain after thyroidectomy,
mastectomy.
 Sump suction drain:Vacuum with negative
pressure + air vent.
 Under water seal drains: To drain pleural space.
 Indications of drains:
 Drainage of abscess.
 Drainage of pleural cavity.
 Aftermajor abdominal surgery: Biliary,
pancreatic and gastric surgery.
 Peritonitis, hemoperitoneum.
 Thyroidectomy, mastectomy, hydrocele
surgery.
 Problems of drains:
 Infection.
 Displacement.
 Interference with healing process.

ORTHOPAEDIC APPLIANCE:

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1. Plaster of Paris: U- 229.

 Component:Calcium sulfate hemihydrate

(CaSO4.1/2H20).
 Indications:Immobilization in Closed, Undisplaced,
simple fractures+ Correction of dislocation.
 Used as: Full plaster/cast, partial plaster/slab.
 Other things needed during its application:
 Gauze Bandage.
 Cotton.
 Water with pot.
 Assessment of usability: When air bubbling occurs in
water.
 Advantages:
 Takes exact shape of the limb- so no undue
pressure.
 Comfortable.
 Complications: P170 of personal notes.

2. Crepe bandage: New unique- p174.

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 Uses:
 Immobilization in joint strain/sprain: Esp. ankle
joint.
 Application of surface traction.
 Compression bandage.

3. Gauze bandage/Rolled bandage: U-230.

 Aims/purposes of bandage:
 Check bleeding by pressure.
 Giving restand support of fractured limb.
 Keep dressings and splints in position.

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 Prevent edema or swelling.

 Some uses of leucoplast/tape/micropore:

 Fix butterfly needle/IV cannula.
 Fix dressing over wound.
 Fix NG tube, catheter.
 Surface traction.
 Types of bandage: Rolled bandage, Crepe bandage.
 Types of Rolled bandage:
 Collar and calf sling: Fracture clavicle.

 Figure of eight bandage: Used in clavicular

fracture, knee/ankle fractures.

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 T-bandage: Used after drainage of ischiorectal

abscess.
 Cephalic bandage: In any operation of skull.
 Mastoid bandage: After mastoidectomy
operation.
 Coconut bandage/scrotal suspensory: After
hydrocele operation.
 Effects of tight bandage: Same is plaster of Paris.
 Sterilized by: Autoclaving.

4. Chisel: New unique- close to 175.

 ID:
 Only single side is beveled.

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 No graduation.
 USE:To remove chips of bone for grafting, to take
biopsy.
 Sterilized by: Autoclaving (?).
5. Hammer/Mallet:
 Use:
 During osteotomy, bone graft, bone biopsy.
 Method of sterilization: autoclave

6. Osteotome:

 ID:
 Both sides are beveled.
 Has graduation.
 Use:
 To make bone surface smooth, to cut extra growth of bone.
 Divide bones in various osteotomies.
 Correct deformities.
7. Amputation saw:

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 Use: Cut a bone during amputation operation.

 Bone nibbler:Nibble or chewing offof small piece of bone. To

make bone surface smooth, to cut extra growth of bone.

8. Bone cutter:

9. Periosteal elevator:

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PATHOLOGICAL SPECIMEN:

1. Acute appendicitis with gangrene: SRB color atlas Page-4.

a. Description:
 Jar containing a pathological specimen of appendix.
Coz:
 Worm like structure.
 Mesoappendix is attached with it.
 On end is blind and another is open and ligated.
b. Pathological findings:
 Appendix is red, swollen/congested.
 Tip is blackish. (IF gangrene).
c. Causes of acute appendicitis: Anything that obstructs
lumen.
 Luminal: Fecolith, intestinal parasites.
 Mural: Lymphoid hyperplasia, carcinoid.
 Extra-mural: Bands and adhesions.
d. Part of appendix liable to be gangrenous: Tip.
e. Fates, complications, DD, management- personal notes:
P89.
f. Formation of appendicular lump: Appendix and adjacent
structures.

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2. Mucocele of GB:See Makhan lal.

a. Description:
 Plastic/glass jar containing pathological specimen of
resected gallbladder which is pear shaped, has a
fundus, body, neck with:
 Huge distension.
 Translucent and thin wall.
b. Clinical features:
 May be asymptomatic.
 H/O of Pain in RUQ.
 NAV.
 Non-tender lump in RUQ.
c. Other points to be seen: Personal notes: Page- 98.
d. Confirmation of diagnosis: USG of HBS with pancreas.
e. Tt: Resuscitation F/B cholecystectomy.
f. Cause of huge enlargement of GB:
 Mucocele.
 Empyema.
 Malignant stricture of CBD.
 Peri-ampullary CA.
g. Pathogenesis of Mucocele:
 Obstruction of cystic duct at Hartman’s pouch
(Stone/tumor).
 Absorption of water and water soluble contents of
bile.
 Hyper-secretion of mucus.
 Mucocele.
h. Functions of GB:
 Storage and concentration of bile.
 Mucus secretion.

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3. Empyema of GB: See Makhan Lal.

a. Description: This is plastic jar containing pathological

specimen of resected GB showing:
 Moderate distension of GB.
 Whitish discoloration of wall.
 Thickening of wall.
 Pus inside gall bladder.
b. Management: Page- 99 of personal notes.

4. Chronic Cholecystitis with cholelithiasis: Makhan Lal.

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a. Findings: Plastic/glass jar containing pathological specimen

of resected GB showing:
 Fibrosed/contracted/small GB.
 Thickening of wall.
 Multiple multifaceted stone.
b. Clinical features:
 Symptoms:
 Recurrent attack of RUQ pain, aggravated by
fatty food intake.
 NAV.
 Flatulence/dyspepsia.
 Jaundice: If associated choledocolithiasis.
 Signs:
 Jaundice: If choledocolithiasis.
 Murphy’s sign negative.
 GB not palpable.
c. Indications of cholecystectomy:
 Following conservative treatment of acute
cholecystitis/empyema.
 Chronic calculus cholecystitis.
 Mucocele.
d. Complications of operation: P105 of personal notes.

5. Vesical calculus: Potato calculus.

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a. Description: Dry jar.

This is a plastic/glass jar containing specimen of bladder
stone which is:
 Large.
 Single.
 Oval.
 Chalky white in color.
 Smooth.
b. Clinical features: LUTS.
c. Treatment: Urology- 129p.
d. What is primary and secondary stone:
 Primary stone: Develops in apparently healthy urinary
tract with sterile acidic urine. Eg. Oxalate stone.
 Secondary stone: Develops in infected urinary tract with
alkaline urine. Phosphate stone.

6. Staghorn stone/Phosphate stone:

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Phosphate/Struvite stone.

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a. ID:Glass jar containing Staghorn calculus. Dirty white, single,

irregular.
b. Composition: Ca, Mg, and ammonium phosphate.
c. Clinical Features: p123.
d. Causes: p124.
e. Investigations: Same page.
f. Treatment: Same page.
g. Complications: P125.

Oxalate stone:

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7. Benign enlargement of prostate: Makhan lal.

a. ID: Glass jar containing pathological specimen of resected

prostate showing:
 Large sized solid structure.
 Pyriform shape.
 Traversed by urethra.
 Surface smooth.
 Lobulated: 3 lobes are seen
b. Portions of prostate represented by it: Central glandular
portion, capsular portion is left in the body.
c. Lobes in prostate:
 5: A/P, median, 2 lateral lobes.
d. Management: P130-134.

8. Carcinoma of breast: Makhan lal.

a. ID:
This is a plastic jar containing pathological specimen of
resected breast with nipple, areola and fibro-fatty tissue
showing:
 Retraction of nipple.
 Peau De Orange appearance of skin.
 Undersurface shows grayish white lump.
b. Diagnosis: CA breast.

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c. Cardinal signs:
 Stony hard irregular lump.
 Fixity.
 Palpable axillary LN.
d. Surgery done in the case: MRM.
e. Other surgery: Simple, radical.
f. Other points: Personal notes P152.

9. Carcinoma caecum: Makhan Lal- Color atlas.

a. Ulcero-proliferative growth in the caecum.

b. Diagnosis: CA cecum.
c. Clinical features and management: Personal notes p- 85-
89.
d. Operation done in this case: Right hemicolectomy.
e. Incision: Midline incision.

10. Sequestrum:

a. Dead piece of bone showing:

 Dirty white in color.
 Concavo-convex surface.
 Concave surface: Smooth.
 Convex surface: Irregular, moth eaten appearance.
b. Sequestrum:
Dead piece of bone within but separated from living bone.
Most commonly occur in chronic pyogenic osteomyelitis.
c. Sequestrum in X-ray:

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 More radio-opaque than surrounding bones.

 Lies inside a translucent cavity.
d. DDx of chronic pyogenic osteomyelitis:
 Tubercular/syphilitic/actinomycotic osteomyelitis.
e. Treatment:
 Sequestrectomy and saucerization (Filling of bone by
soft tissue graft).
 Antibiotics.
 Splintage (Immobilization).

11. Basal cell carcinoma: unique 223.

a. ID:
 Picture showing an ulcer:
 Site: Upper part of the face.
 Circular.
 Rolled edge.
 Floor covered by slough and exudates.
 DDx: SCC, malignant melanoma, Merkel cell carcinoma.
 Confirmation: Biopsy for histopathology.
 Treatment:
 Surgical excision with .5cm free margin.
 Radiotherapy.
 Prognosis: Poor.

12. Neck swelling: unique 224.

 Findings: Lateral neck swelling.
 DDx:
 Enlarged cervical LN: Due to TB, lymphoma,
secondaries, Throat infection.
 Tumor of Parotid/SM gland.
 Branchial cleft cyst.
 Dermoid cyst.
 Lipoma.
 Cystic hygroma.

PROBLEM BASED QUESTIONS:

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1) Appendicular lump:
A young married man of 28 years old is admitted in the surgery
word with pain in the RIF for 4 days. On examination a tender
lump on RIF is found with overlying muscle rigidity. CBC shows
raised PMNs.
 Probable diagnosis: Appendicular lump.
 Features: P-89-90.
 Management:
Ochsner-Sherren regimen:
 Complete bed rest.
 Propped up position.
 NPO.
 NGS.
 IV fluid.
 Broad spectrum antibiotics.
 Analgesics: Tramadol/morphine/pethidine.
 Antispasmodics: Hyoscine-N-butyl bromide.
 Continuous monitoring of the patient.
 Maintenance of I/O chart.
 ON complete recovery: Interval appendicectomy
6 weeks later.
 Other points: Personal notes P-89-90.

2) Obstructive jaundice:
A 30 Y/O female is admitted in surgery ward with complaints of
jaundice for 10 days, generalized itching with anorexia for 7
days. She gave history of taking OCP for 5 years. On
investigation S. bilirubin is 6.8mg/dl, ALP is raised.
 Diagnosis: Obstructive jaundice.
 Other features: Start from page 98 of personal notes.
 DDx:
 Causes of bile duct obstruction.
 Probable USG findings:
 Dilated CBD.
 Coz of obstruction: Stone, Cholangiocarcinoma,
peri-ampullary carcinoma.
 GB:
 IF stone: Fibrosed and thickened wall, GB
is contracted.
 Other than stone: Dilated GB.
 Tumor markers to be seen:

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 CEA.
 CA 19-9.

3) Electrolyte imbalance:
 A pt. came with complaints of severe vomiting and
diarrhea for last 24 hours. Patient is now drowsy,
lethargic, dehydrated with spasm of foot and hand. His
serum electrolyte shows:
 Sodium: 110 mmol/l.
 Potassium: 2.9 mmol/l.
 Chloride: 85 mmol/l.
 Calcium: 1.8 mmol/l.
 Diagnosis: Hyponatremia, hypokalemia, Hypochloremia
with hypocalcemia.
 Correction:
 Sodium and chloride by 3% NS.
 Potassium: Increased intake of potassium
containing food (Green coconut water, banana),
potassium tablet and syrup.
 Cause of spasm:
Hypocalcemic alkalosis.
 Pre-operative preparation: Std. preparation.

4) Acute pancreatitis:
 A patient comes with H/O alcohol consumption with
severe pain in upper abdomen and patient is lethargic
and febrile, his serum amylase and lipase levels are
elevated.
 Diagnosis: Acute pancreatitis.
 Other points to be studied: Personal notes p- 107.
 Clinical scoring systems: Ranson’s criteria, Apache II
scoring system, Glasgow score.

5) Head injury:
 A 30 year old male came in Mitford hospital with H/O
of RTA. He opens eye to painful stimuli, Motor
response is abnormal flexion, he makes some
incomprehensible sound.
 GCS of this patient:
 Eye opening: 2.
 Verbal response: 2.

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 Best motor response: 3.

 Other points to be studied: Personal notes: p- 185-89.

6) GOO:
 Typical features.
 Personal notes- p68.
7) Intestinal obstruction: Personal notes: P- 80.
8) Acute osteomyelitis:
A 10 Y/O boy presented with painful swelling around right
knee joint. He complains of high fever for 3 days and he is
unable to walk. He gave H/O accidental trauma falling from
bicycle 4 days back.
 Provisional diagnosis: Acute osteomyelitis.
 Why metaphysis: Due to hair pin manner of blood
vessels.
 Other points to be studied: Personal notes P- 175- 77.

FLUIDS: See common fluids: guide + Unique- 141 (new)+ 13-17 (old).

1) Normal saline:
 Yellow color.
 Plastic bag containing .9% normal saline.
 Composition:
 Sodium: 3.54 g/L (154 mmol/L).
 Chloride: 5.46 g/L (154 mmol/L).
 Uses:
 Dehydration.
 Daily replacement in post-operative patients.
 Washing purpose: Injured area, burn, gastric
lavage, peritoneal wash.
 Continuous irrigation of UB after TURP.
 Complications:
 Metabolic: Hyperosmolar state, reactive
hypoglycemia.
 Local thrombophlebitis.
 Sepsis.
 Sterilization:

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 Bag: Gamma ray.

 Fluid: Ultrafiltration.
2) 5% DA:
 Blue in color.
 Plastic bag containing 5% Dextrose in aqua.
 Composition:
 Dextrose anhydrate- 50g/L (278 mmol/L).
 Uses:
 Shock.
 Daily replacement in early post-op period.
 Dilution of drugs: Dopamine, aminophylline,
quinine.
 Contraindications: Vomiting, Bleeding.
 Complications:
 Hyponatremia.
 Reactive hypoglycemia.
 Thrombophlebitis.
 Sepsis.
3) 5% DNS:
 Green color.
 Plastic bag containing 5% DNS.
 Composition:
 Sodium: 3.54 g/L.
 Chloride: 5.46g/L.
 Dextrose: 50 g/L.
 Conditions used:
 Hypovolemic shock.
 2nd and 3rd post-operative day.
 Complications:
 Hypernatremia.
 Hyperosmolar states.
 Reactive hypoglycemia.
 Local thrombophlebitis.
 Sepsis.
4) ORS:
 Plastic bag containing ORS/Oral rehydration salts.
 Compositions:
 Sodium chloride: 2.6 g/L.
 Potassium chloride: 1.5g/L.
 Tri sodium citrate: 2.9 g/L.
 Glucose: 13.5 g/L.

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 Indications: Acute watery diarrhea, dehydration.

 Preserved for: 12 hours.
5) Cholera saline:
 Plastic bag containing cholera saline.
 Composition:
 Sodium: 3g/L.
 Potassium: .5g/L.
 Chloride: 3.5g/L.
 Acetate: 2.8 g/L.

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