SURGERY

Presentation by :
Dr. Anisha Chhetri
Dr. Emima Chhetri
Dr. Shovana Ghimire
Parts of Practical Exam
Surgery Orthopaedics

Spotters including orthopaedics (10

marks)

Long Case (30)

Short Case ( 10 marks) Short Case (5)

Table VIVA Xray and Specimen ( 5 marks) Xray (5)

Table VIVA Procedure ( 5 marks)

Table VIVA Instruments (5 marks) Instruments (5)

 Table of Contents
01 02 03 04
Instruments X- Ray Specimen Surgical Procedures

05 06 07
Suturing Technique Short Cases FAQs
Instruments
 Intercostal Chest Drain
Uses: To drain fluid/air from :
-Pleural Effusion
-Empyema Thoracis
-Hemothorax ,
-Pneumothorax

Other Use: As abdominal Drain in Laparotomy

Precautions :
In hemothorax: chest tube tip should be pointed downwards
In pneumothorax : pointed upwards.
Insertion : Through Safety Triangle
Boundaries :

Anteriorly By lateral border of Pectoralis Major

Laterally by LateraL Border of latissimus Dorsi
Inferiorly by line of 5th ICS
Superiorly by base of axilla

https://www.ebmconsult.com/content/images/Procedures%20Images/Chest%20Tube%20Thoracostomy%200.png
 Three-Way Self Retaining Foley’s Catheter
Three surgeries where it is used:
1. TURP (Transurethral Resection of Prostate)
2. TURBT ( Transurethral Resection of Bladder Tumor)
3. Frank Hematuria

Precaution to take in male patient:

- Only inflate the balloon after you see urine in catheter;
- If there is no urinary drainage wait until you reach the
bifurcation of catheter to avoid urethral injury

Q. Show where the balloon is in the catheter

http://mederen.com/catalog/urology/foley-catheters/3-way-standart-foley-catheter.html
https://medical-dictionary.thefreedictionary.com
Length of Urethra
Female : 4cm long ;
6mm diameter
Male : 20cm long; 8-9
mm diameter

Parts of Urethra in male:

● Anterior urethra :
Penile Urethra ,
Bulbar Urethra

● Posterior urethra :
Membranous
Urethra, Prostatic
Urethra
 Two Way Self retaining Foley’s Catheter
Uses:
- To relieve acute urinary retention
- For input/output monitoring in sick patients following spinal
anesthesia and major surgeries, in sedated/comatose patients

https://www.urotoday.com/urinary-catheters-home/indwelling-catheters/description/types.html https://www.tradeindia.com/fp1918449/Two-Way-Foley-Catheter.html
 Corrugated Red Rubber Drain
● Passive and open drain- drains by capillary action and
gravity.

● Uses :
- Drainage of pus from abscesses like breast abscess,
- Used in hydrocele for drainage after eversion of sac
-After laparotomy (for peritonitis) to prevent residual
abscess in post operative period.

● Inserted into the most dependent part.

● Disadvantage: more risk of infection, allows soakage of

dressing, causes discomfort

● Sterilized by Glutaraldehyde solution (Cidex)

 Ryle’s Tube / Nasogastric Tube
Uses:
Diagnostic:
● Evaluation/Assessment of UGI bleeding
● Collecting gastric content for analysis
● Diagnose Tracheoesophageal fistula
● Baid test for pseudocyst of pancreas (Because stomach is
stretched towards the abdominal wall, Ryle's tube passed will be felt per
abdominally (Baid test))

Therapeutic:
● NG feeding in debilitated patients
I. Acute Severe Pancreatitis
Ii. Intestinal Obstruction
Iii. Following Laparotomy
Iv. In comatose patients.
- Gastric Lavage in Poisoning cases
Insertion:
● at least 50-60 cm (Central Incisor to GE Junction - 40 cm)
● Measure from tip of nose to ala of ear, then ala of ear to xiphisternum. Mark that
point and insert that length.
● Please follow this link for a video from Geeky Medics
https://www.youtube.com/watch?time_continue=10&v=WZvIw0SnYrE&feature=emb_l
ogo&ab_channel=GeekyMedics

Techniques to confirm its position

a. Push air from free end then auscultate with bell of stethoscope in epigastrium.
Gush of air heard correct position
b. Free content of stomach pour out from tube as soon as it reaches stomach
c. Put free end in bowl of water - bubbles come out
d. Chest X Ray : check the presence of radiopaque line of the NG tube

Contraindications
● Absolute : Mild Facial Trauma , recent nasal surgery
● Relative : Coagulation abnormalities , recent alkali ingestion (risk of esophageal
rupture) , esophageal stricture , varices

Complications
● Placement may cause tissue trauma , gagging , vomiting , rupture (rare)
● Incorrect placement may lead to respiratory tract intubation leading to aspiration
Length: 5 inches/ ~ 13 cm long
Proctoscope
Use: Diagnostic
• Diagnosis of piles: The pile mass protrudes into the lumen of the
proctoscope
• An anal or a rectal polyp may be seen protruding into the lumen of the
proctoscope
• Carcinoma of anal canal or rectum may appear as a proliferative mass or
an ulcerating lesion
• Diagnosis of ulcerative colitis: Associated proctitis may appear as red,
congested mucosa which bleeds to touch and in some cases
pseudopolyps may be seen
• The internal opening of a perianal fistula may be seen
• The apex of an intussusception may be seen in the anal canal through
the proctoscope.

Therapeutic
• Used during injection sclerotherapy of piles. The injection is made at the
base of the pile mass visualized through the proctoscope
• Used during polypectomy
• Used while taking a biopsy from a rectal or an anal growth.
https://dir.indiamart.com/impcat/kelly-proctoscope.html?biz=10
Technique :
● Consent
● Place patient in Sim’s Position
● Lubricate proctoscope with jelly
● Insert it slowly with pointing part pointing towards umbilicus
● Slowly remove the obturator
● Show light

C/I : Anal fissure

https://en.wikipedia.org/wiki/Sims%27_position#/media/File:Position_Sim's_Posterior.jpg
Blunt/ Non- Toothed forceps
● Tip has serrations for better grip
● Uses: To hold delicate structures like
- peritoneum,
- vessels,
- bowel,
- nerves,
- tendons
(To catch hold bleeding vessels, To catch hold bowel
during anastomosis)

Mayo’s Towel Clip

● Uses:
- To hold gauze pad in position
- To fix suction tubes, diathermy wires,
laparoscopic cables in OT
- To fix drapes https://www.medimove.co.uk
- To fix ribs in flail chest https://www.proprofs.com
 Cat’s paw Retractor
Use:
To retract skin flaps or fascia for
operation at the surface (eg. excision of
sebaceous cyst, lipoma, dermoid, etc.)

Langenbeck Right Angle Retractor

Use: To retract skin, fascia, aponeurosis in
superficial surgeries.
3 surgeries Used: Hernia (Mesh Repair) ,
Appendectomy , Open Cholecystectomy
 Allis Tissue Holding Forceps
- To hold soft tissues for long period while minimising tissue
damage (skin flaps, fasciae, muscle aponeurosis , bladder
wall )
- Using the ratchet, they can be locked on to tissue, and can
be used to provide a gentle traction.
- Usually during appendectomy , mesh repair

https://www.healthsoothe.com/allis-forceps-allis-clamp
 Babcock Forcep
Use :
● To hold appendix during appendectomy
● To catch hold bowel in resection and
anastomosis
● To hook ureter in ureterolithotomy

https://www.medikrebsusa.com/products/babcock-intestinal-and-tissue-grasping-forceps-20-cm
Curved artery forceps
- To catch hold bleeding vessels.
- For fine dissection.
- To hold gauze as peanut
- To hold fascia, peritoneum, aponeurosis
- To pass ligature

https://www.colmed.in/artery-forcep-curved.html
 Blade Holder aka Bard Parker Handle
To hold blade ; used in mesh repair,
appendectomy/laparotomy

https://www.greenfarmsupplies.com/our-products/surgical-equipme https://www.bbraun.com/en/products-and-therapies/wound-closure
nts/ /knotting-expert-club/surgical-instruments-best-practices.html#scal
pel
 Curved Intestinal Clamp/ Straight
Intestinal Clamp
3 surgeries it is used in:
1. Rt/ Lt Hemicolectomy
2. Segmental Resection and anastomosis of
intestine
3. Distal Gastrectomy
4. Clamped part is to be resected

2 Types :
● Crushing
● Non crushing ( sed in part which is to be
retained to maintain integrity of mucosa

https://www.capesmedical.co.nz
 Sponge Holding Forceps
● It is used to
- clean the operative field,
- to swab the cavities,
- to mop the oozing area,
- to hold gallbladder and cervix during
surgeries, https://austos.com/dressing-sponge-holding-organ-tissue-grasping-forceps/ae-bf118r
- for blunt dissections, /
- as ovum forceps.

Deaver’s Retractor
Surgeries used : Laparotomy , Open
Cholecystectomy (to retract liver),
Nephrectomy , Pyelolithotomy

https://dir.indiamart.com/impcat/kelly-proctoscope.html?biz=10
Bulldog Clamp
To catch hold small vessels
during surgery

Vascular Clamp
https://new-medinstruments.com

To hold small vessels in

cases of bleeding

https://www.wexlersurgical.com
Desjarden Stone holding
Forceps
Used to remove stones from common bile duct
(choledocholithotomy) , kidney , bladder.
Peculiarity : Grips absent ; if present then stone can get
crushed and left behind

https://www.b4medicalsupplies.com/shop/surgical-instruments/desjardins
-stone-forcep/
 Sinus Tissue Holding Forceps

Used in Hilton Method of Drainage of abscess

It is the technique used to drain abscess near
neurovascular bundles.
 Kocher’s Forceps
- Used to hold pedicles, tough structures, cut ends of the muscles.
- Used to hold gauze for blunt dissection, to hold resected bowel, to hold
rib during rib resection.
X RAY
Free gas under right side of diaphragm
Causes :
1. Perforation of hollow viscera containing gas
• Peptic ulcer perforation—gastric or duodenal
• Perforation of malignant gastric ulcer
• Small gut perforation due to typhoid ulcer, tubercular ulcer, crohn's disease.
• Large gut perforation due to tubular ulcer, crohn’s or ulcerative colitis.
− Blunt trauma abdomen causing perforation or transaction of small or large
gut.
2. Penetrating injury abdomen causing peritoneal penetration, with or without
underlying
visceral injury.
3. Bullet injury abdomen—with peritoneal penetration and with or without
underlying hollow
viscus injury.
4. Following laparoscopic procedure or following abdominal operation—due to
entrapment
of carbon dioxide gas or air.
Treatment
Perforated duodenal/ulcer : Graham’s Omentopexy
Enteric perforation : Repair of perforation/Ileostomy
Traumatic : repair
 Right renal stone
Radiopaque shadow measuring 3 x 3 cm in Rt
renal area
Investigation of choice - CT IVU
Treatment Percutaneous Nephrolithotomy
Complication of tx - Bleeding , retained stone,
injury to renal parenchyma , liver , colon
Types of stone ?
Different treatment modalities ?
 Conservative
Asymptomatic
Treatment

>2cm PCNL
Renal
stone
Symptomatic <2cm ESWL/RIRS

Nephrectomy
Staghorn (No function)

PCNL w or w/o
ESWL (functioning
kidney)
 Multiple Right Renal
stones
Multiple shadows in Right kidney
Complication :
● Obstruction (Hydronephrosis ,
Hydroureteronephrosis)
● Hematuria
● Cystitis
● Pyelonephritis
 Vesical Calculus
Radio opaque shadow measuring
1) 4 x 3 cm in urinary bladder.
2) 2 x 2 cm in urinary bladder

Complication : Hematuria , Repeated UTI

, Obstruction causing hydronephrosis

Treatment : Cystolitholapaxy
Open Cystolithotomy
Percutaneous Cystolithotomy
 Percutaneous
Large size /
Cystolithotripsy /
Urethral stricture
Open Surgery

Bladder stone

Transurethral
Small Litholapaxy
Lithotripsy
1 2
Right ureter stone
● Radiopaque shadow measuring
1 x 1.5 cm in right upper ureter
● Treatment : Right URSL
Right Ureterolithotomy
Right PCNL
 Upper ⅓ rd RIRS/
No
>10mm ESWL
Obstruction/
Infection Middle ⅓ rd
Ureteric Stone

5-10 mm
URS
Lower ⅓ rd

fail

Conservative Open surgery

<5mm Tx

Obstruction/ Emergency
Infection Decompression
Left Vesicoureteric
Junction Calculus
Radio opaque shadow measuring 1 x 0.5 cm left to
pubic symphysis
Diagnostic tool - USG
Treatment - URSL ( Ureteroscopic Lithotripsy)

Bladder Calculus VUJ calculus

Change of position of No change

stone in movement of
patient
Pneumothorax of Left
lung
Cause : Traumatic Injury to chest
Rupture of bullae
COPD , Pneumonia
Treatment : Intercostal Chest drain
Triangle of safety of Intercostal Chest tube
drain ?
Types of Pneumothorax?
Left Double J stent with radio
opaque shadow in upper coil
Procedures where DJ stent is placed in situ
● Post PCNL (Percutaneous Nephrolithotomy)
● Post URSL ( Ureteroscopic Lithotripsy
● Pre-stenting before ESWL (Extracorporeal Shock Wave
Lithotripsy
Uses : Keeps ureter open all the time , helps ureter dilate.
Prevents stricture/narrowing during healing process.
It is a foreign body and thus the body tries to push it and these
movements help stones to come out
Complications of stent
● Repeated UTI
● Hemorrhage
● Whole length of DJ stent will form stone
● Forgotten DJ stent
Question: CI of ESWL
- Absolute: Pregnancy and bleeding disorder
- Relative: UTI, unrelieved distal obstruction, cardiac
pacemaker, uncontrolled HTN, severe renal failure
Dilated Loops of bowel
Which part : Jejunum because of Valvulae
Conniventes
Site of Obstruction : Jejunoileal Obstruction
Cause : Ileal stricture , adhesions , growth ,
postoperative bands
Treatment : Conservative initially if not better --
Laparotomy

Types of Intestinal Obstruction? Causes ?

How will you separate based on clinical features
?
 Cannonball secondaries
Multiple radio opaque shadow in right lower zone and
left upper and middle zone
Causes: - Metastasis
- Benign lesion:
• Fungal infection—Histoplasmosis, coccidioidomycosis,
aspergillosis.
• Parasitic infection—Filarial infection, hydatid disease.
• Sarcoidosis.
• Wegener’s granulomatosis.
• Rheumatoid nodules.
The important primary sites are: (PUBLIK-TS)
- Prostate
- Uterus and ovary
- Breast
- Lungs
- Stomach/Intestine
- Kidney
- Testis
- Thyroid
- Soft tissue sarcomas - osteosarcomas.
T- Tube Cholangiogram
T Tube cholangiogram is a fluoroscopic study
performed in the setting of hepatobiliary disease. A T
shaped tube is placed in CBD ,anchored to the
abdominal wall and then connected to close drainage
system. 20 ml of non iodized dye is pushed through
tube slowly. And then Series of X Ray are taken.

Indications
● Stones in CBD
● Dilated CBD in USG
● H/O jaundice , pancreatitis , cholangitis

Good opacification of intrahepatic and common bile ducts.The pancreatic

duct is also opacified. No filling defect or contrast leak identified.Normal
https://radiopaedia.org/images/280218
drainage of contrast to the duodenum. 38
T- Tube Cholangiogram
● Showing Filling defect in distal CBD
● Done in 7th-10th postoperative day
● T tube is placed after cholecystectomy or
choledochostomy in CBD.
● Use of cholangiogram :
a. To look for retained stone after
gallbladder is removed
b. Demonstrates small lesions , stricture or
dilations
● T tube helps in drainage of bile and
healing process, prevents stricture
formation
● Leave T tube for 6 weeks followed by stone
extraction from track itself
● If can’t be removed - ERCP (Endoscopic
Retrograde Cholangiopancreatography)
Multiple Filling Defect

Air Bubble Retained stone

On changing position of Doesn’t move

the patient defect moves

Position : By Trendelenburg and Reverse

Trendelenburg position
 Bobby pin in stomach
Treatment : Conservative
Take serial X Rays to determine the position of
the object
If not moved - LAPAROTOMY
Sinogram
Contrast X Ray where we are
pushing dye from external opening
Diagnosis - Perianal sinus
Treatment - Excision of Tract
Condition leading to it - Perianal
abscess
 Filling defect in transverse
colon
● Apple core deformity in transverse colon
● Ca Colon (annular/napkin ring sign)
● DD: Stricture (crohn’s disease), TB
● Contrast used : Double Contrast ( Barium + Gas )
● Type of Contrast:
Single contrast : Barium / water soluble contrast
w/o air or C02
Double contrast : uses positive contrast (Barium
or Barium like agent *Gastrografin ) and negative
contrast (air or CO2 ) to increase sensitivity of the
examination.
Specimen
 Appendix
● This is a formalin preserved specimen of appendix
● It’s a hollow tubular structure with 1 end that is blind and the
other end has a lume; vermiform
● Mesoappendix present by its side

● Indications of appendicectomy:
❖ Appendicitis
❖ Carcinoid tumor (</= 2 cm and at the tip without involving the
base= simple appendicectomy, >2cm or involving the base: right
hemicolectomy)
❖ Mucocele of appendix

● Complications of appendicetomy:
❖ Wound infection (most common post op complication)
❖ Paralytic ileus
❖ Intraabdominal abscess
❖ Portal pyaemia
❖ Adhesive intestinal obstruction (most common late
complication of appendicectomy)
 BPH
● Arises from: periurethral transition zone i.e median lobe (carcinoma
of prostate arises from peripheral zone)
Obstructive Irritative Symptoms
Symptoms

Hesitancy Frequency

Decreased flow of Urgency

urine

Sensation of Nocturia
Indications of TURP in case of benign
incomplete voiding
prostatic obstruction:
❖ Absolute
Post-void dribbling
● Intractable urinary retention
● Renal insufficiency
● Gold standard surgical treatment: TURP
❖ Relative
● Irrigation fluid used: 1.5% glycine
● Failure of medical therapy
● Electrolyte solutions like NaCl are not compatible with
● Recurrent cystitis
electrocautery, hence not used
● Bladder calculi
● Complications of TURP: Retrograde ejaculation, impotence,
incontinence
 Carcinoma of colon
● MC site: sigmoid colon
● Difference between right sided ca colon and left*

Right colon Left colon

Fungating or cauliflower type growth Annular, constricting growth

Less occurrence of obstructive symptoms as stool is Symptoms of obstruction are more common
relatively liquid in consistency

Ulceration of lesion occurs- chronic blood loss

Presenting complaints: Presenting complaints:

-malena - Decrease in stool caliber
-anemia - Alteration in bowel habit: constipation
- fatigue - Palpable lump
- abdominal pain
- Mass in RIF

Relatively better prognosis Poor prognosis

● Diagnosis: Barium enema: apple core/ napkin ring deformity

*Pritesh Singh, Surgery essence, 7th edition

Carcinoma of oesophagus
● Types: SCC, adenocarcinoma
● Most common type: SCC
● Most common site: Middle ⅓ rd
● Risk factors:
For SCC: Alcohol, smoking, ingested carcinogens (nitrates,
nitrosamines),
Plummer- vinson syndrome

For adenocarcinoma: GERD - Barrett’s oesophagus, Obesity,

Scleroderma

● Investigation:
First investigation in suspected cases: Barium swallow- apple
core deformity
IOC: Endoscopy with biopsy

● Treatment:
Localized: surgical resection
Locally advanced: Chemoradiation +/- surgical resection
Mets: Chemoradiation
Indications of oesophageal resection: *

1. Malignant:
● Ca oesophagus
● Lymphoma

2. Benign
● Neuromuscular dysfunction (achalasia, esophageal spasm)
● Scleroderma
● Acute perforation
● Acute caustic injury

*https://emedicine.medscape.com/article/1891153-overview
Cholecystectomy
Q. Indications of
cholecystectomy?
● Cholelithiasis
● Cholecystitis acute and
chronic
● Acalculous cholecystitis
● Mucocele of GB
● GB polyp ( symptomatic or >
1 cm, or with porcelain GB
or sclerosing cholangitis ) This is a formalin
This is a formalin preserved specimen of gall
preserved specimen of Q. Complications of bladder, with gretishwhite,
gall bladder, with cholecystectomy thickened walls indicating
thickened walls and ● Injury to CBD or cystic duct chronic cholecystitis
stones in the lumen ● Bile leakage
● Haemorrhage from cystic
artery and liver bed
● Surgical site infection
 Carcinoma of stomach
● Formalin preserved specimen of stomach--
presence of rugosities

● Indication of gastrectomy:
❖ Ca stomach
❖ Leiomyoma
❖ Leiomyosarcoma
❖ Bleeding ulcer

● Complications
❖ Nutritional disturbances
❖ Dumping Syndrome
❖ Haemorrhage
❖ Fistula formation
Kidney with ureter
● Formalin preserved specimen of kidney with ureter

● Indications of nephrectomy:
❖ Renal cell carcinoma
❖ Donor nephrectomy for transplant purpose
❖ When there is a permanent loss of renal function due to
diseases like
- Hydronephrosis
- Chronic pyelonephritis
- Reno-vascular HTN
- Nephrosclerosis
Surgical
Procedures
1. Surgical Procedures
Catheterization in male patient
https://www.youtube.com/watch?v=ynUqLCmg-XA

2. Chest Tube placement

https://www.youtube.com/watch?v=IdmMR8JxmFo

3. Venesection
https://www.youtube.com/watch?v=qiZTJ6JHuVs

4. Excision of sebaceous cyst

https://www.youtube.com/watch?v=v29EyjxHMc8 / Incision and
Drainage of abscess

5. IV cannulation technique
https://www.youtube.com/watch?v=vE99rZ7JT3Q

6. Central Venous Catheter insertion Read from Makhanlal

https://www.youtube.com/watch?v=DgQbQSBYeQU Focus mainly on Indications , Compl
7. Circumcision
https://www.youtube.com/watch?v=aawTQAqU4mk

8. Hydrocele surgery
https://www.youtube.com/watch?v=N3csxLEs5No
9. Mesh repair
https://www.youtube.com/watch?v=YG_9bv2A-UM

10. Vasectomy
https://www.youtube.com/watch?v=fTeqIUX4c3A

11. Intubation
https://www.youtube.com/watch?v=8AOB2PtHfVM

12. Appendectomy
https://www.youtube.com/watch?v=zPP8sy1C6-4
NG tube insertion

Makhanlal Saha- Bedside Clinics in surgery- 2nd edition- Jaypee Brothers Medical Publishers
 Insertion of IV cannula

Makhanlal Saha- Bedside Clinics in surgery- 2nd edition- Jaypee Brothers Medical Publishers
Surgery Essence- Pritesh Singh- 7th edition- Jaypee Brothers medical publishers
 Chest tube
insertion

Makhanlal Saha- Bedside Clinics in surgery- 2nd edition- Jaypee Brothers Medical Publishers
Abscess drainage - ischiorectal

Makhanlal Saha- Bedside Clinics in surgery- 2nd edition- Jaypee Brothers Medical Publishers
 Breast abscess

Makhanlal Saha- Bedside Clinics in surgery- 2nd edition- Jaypee Brothers Medical Publishers
Excision of sebaceous cyst

Makhanlal Saha- Bedside Clinics in surgery- 2nd edition- Jaypee Brothers Medical Publishers
Excision of lipoma

Makhanlal Saha- Bedside Clinics in surgery- 2nd edition- Jaypee Brothers Medical Publishers
 Urinary
Catheterization

Makhanlal Saha- Bedside Clinics in surgery- 2nd edition- Jaypee Brothers Medical Publishers
 CVP line

Makhanlal Saha- Bedside Clinics in surgery- 2nd edition- Jaypee Brothers Medical Publishers
 Circumcision
Indications
- Religious.
- Phimosis.
- Paraphimosis after doing initial dorsal slit.
- Balanitis and balanoposthitis (common in diabetics).
- Early carcinoma of prepuce or glans penis—both diagnostic as well as therapeutic purpose.
- Certain sexually transmitted diseases, e.g. herpes infection.
Procedure
In children, it is done under General Anaesthesia (G/A). In adults, it is done under local anaesthesia. After cleaning and
draping, LA (1% lignocaine (plain) is injected circumferentially near the root of the penis) is given (ring block). Dorsal skin is
cut up to the corona and later circumferentially and ventrally. The skin is cut with inner layer. Care is taken to see that
optimum (less) skin is cut ventrally to prevent the occurrence of chordee. Frenular artery as well as dorsal vein is transfixed
and ligated ventrally using chromic catgut (2-0 or 3-0). Small bleeders are also ligated. Skin is apposed to the cut edge of
corona using interrupted chromic catgut sutures. Postoperatively, antibiotics and analgesics are given.

Complications
- Reactionary haemorrhage due to slipping of ligature from frenular artery and dorsal vein.
- Infection.
- Stricture urethra near the external meatus in children.
- Chordee due to removal of excess skin on the ventral aspect. x Rarely priapism can occur.
Vasectomy
Suturing Technique
How to hold the needle

https://www.bbraun.com/en/products-and-therapies/wound-clo
sure/knotting-expert-club/surgical-instruments-best-practices.h
tml#haemostats
Continuous and mattress suture
 Short Case
1. Ingrown toenail We had these cases in our exam.
2. Diabetic foot 1. Stoma : ileostomy; Explain what you see , types of stomas,
indications, complications, how will you identify colon, diff b/w
3. Stomas
ileostomy and colostomy
4. Fibroadenoma/ Breast lump 2. Diabetic foot : Explain by doing proper clinical examination ( insp,
5. Ulcer , sinus and fistula palpation) of ulcer , your marks depend on how well you explain
6. Corn , wart what you see,some were asked to check neurological status by knee
7. Sebaceous cyst hammer
8. Ganglion - how to know an ulcer is healing? : it has sloping edges, and
9. Inguinoscrotal swelling: Hernia, presence of granulation tissue
- On the base, there is reddish tissue, what is it? : granulation tissue
Hydrocele Venous ulcer: which vein? And it’s importance (saphenous vein thyo)
10. Lipoma 3. Fournier’s gangrene: examination and asked about diff type of ulcer
11. Neurofibroma (punched out ulcer, venous ulcer etc)
12. Phimosis 4. Indirect hernia: examination of swelling) differentiate b/w
13. Undescended testis hydrocele and hernia
14. Hemangioma 5. Lipoma: diff b/w lipoma and sebaceous cyst
15. Keloid
16. Hypertrophic Scar Read about examinations from S. DAS.
17. Fournier’s gangrene In short cases you have to describe what you see
Examiner will ask theory related to the topic
Examination of swelling
https://www.youtube.com/watch?v=sYPFJyoS4ww&list=PLKsR6XZ5Hv6BOqgBm8ap-B0oDZo4JEX
Np

Examination of an Ulcer
https://www.youtube.com/watch?v=n-HiorhQiJ4&list=PLKsR6XZ5Hv6BOqgBm8ap-B0oDZo4JEXN
p&index=2

Examination of Scrotal Swelling

https://www.youtube.com/watch?v=Qzv1bFtaV4E&list=PLKsR6XZ5Hv6BOqgBm8ap-B0oDZo4JEXN
p&index=3

Examination of Inguinoscrotal swelling

https://www.youtube.com/watch?v=aqz0q36x46g&list=PLKsR6XZ5Hv6BOqgBm8ap-B0oDZo4JEX
Np&index=4

Examination of abdominal lump

https://www.youtube.com/watch?v=aqz0q36x46g&list=PLKsR6XZ5Hv6BOqgBm8ap-B0oDZo4JEX
Np&index=4

Examination of Breast Lump

https://www.youtube.com/watch?v=JpLTnqYJV0s&list=PLKsR6XZ5Hv6BOqgBm8ap-B0oDZo4JEXN
p&index=5
Examination of Peripheral Vascular Disease
https://www.youtube.com/watch?v=1mot-2fYyDo&list=PLKsR6XZ5Hv6BOqgBm8ap-B0oDZo4JEXN
p&index=7

Examination of stoma
https://www.youtube.com/watch?v=k1BCFl8F5Zs
For examination part start from 7: 23

Must know about Keloid and Hypertrophic scar

https://www.youtube.com/watch?v=owaCNan8lOg

Examination of Sebaceous cyst

https://www.youtube.com/watch?v=4oYLY9HH0oM

Examination of Undescended testes

You have to go according to scrotum examination mentioned above
Extra for undescended testes is in this link.
https://www.youtube.com/watch?v=P7QsGHkVcig

Examination of Diabetic foot

https://www.youtube.com/watch?v=vwIyulPnXcg
 Other Spotters
1. Case of appendicitis
- Diagnosis,
- Calculation of Alvarado score, <5: not sure; 5-6: Compatible; 6-9:
probable; >9 confirmed
- Treatment: appendicectomy

2. Picture of a burn case :

- Calculation of % BSA of burn: Wallace’s Rule of 9
- IV fluid used: RL
- calculation maintenance fluid required: Parkland formula
3. Breast Ca Picture showing Peau de orange with nipple retraction
- Significance:
Peau de orange: invasive ca breast with obstruction of subdermal lymphatics
Nipple retraction: involvement of Cooper’s ligament
- Treatment: Mastectomy
 Common questions in Long Cases
Chronic Cholecystitis/ Cholelithiasis
- Must know it all in details
Anatomy of biliary tree, especially calot’s triangle; remember cystic artery has TWO branches- anterior
and posterior, CBD Diameter , functions of GB
- Pathophysiology, types , symptoms , causes , d/d , management , complications ,
- Demonstration of murphy’s sign
- Steps of laparoscopic cholecystectomy

Appendicitis/ Appendicular lump

- Must know everything including appendix anatomy , arterial supply, different signs seen, d/d ,
management, treatment , complication of appendectomy, Modified Alvarado score .
- What is shift to left? : appearance of immature neutrophils
- Modified Alvarado score does not contain shift to left so it’s total score is 9. We use this score in our
setting. Why was it modified?
- Ochsner Sherren regimen?
- Type of incisions in appendicectomy, steps of open appendicectomy
- USG appearance: a non compressible, aperistaltic, blind ending tubular structure, with a diameter of
more than 6mm
- Tzanaki score
RIF Tenderness 4 ,
Rebound Tenderness 3
TLC more than 12000 2
Positive USG finding 6
Total 15 ; > 8 : 96 %
You will surely be asked to do abdominal examination , so do it by proper method. Don’t skip steps.
Renal stone/Ureteric stone
- Types , causes, C/f , management, complications
- Also read about RIRS ( Retrograde Intrarenal surgery
- ESWL < 1200hf of stone - easily breakable (hf - Hounsfield units)
1000-1200 hf borderline
>1200 hf - hard to break
- ESWL complications , indications

Hernia
- Anatomy of inguinal canal, and femoral triangle
- Types : differences between direct/indirect , define richter hernia , maydl hernia , littre’s hernia
- Examination of hernia (Inspection , Palpation including different signs seen)
- Management , Also read about laparoscopic management

BPH
- Anatomy, pathology , Clinical features , Management , Complications of surgery
- DRE finding of BPH and prostatic Ca (Please make sure to perform a DRE- with patient’s consent of course; failing
to do so would lead to an unhappy examiner and you losing marks)
- Also read about urodynamic study, Prostate Specific Antigen

Acute Pancreatitis
- Must know it all - definition according to bailey and love(to some examiners) causes, symptoms , scoring
systems , USG findings, d/d , management , complications.
Does anyone have any questions?
 Thank you
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