Ebook Surgical diseases: Part 2

(BQ) Part 2 book “Surgical diseases” has contents: Liver and gallbladder, pancreas and spleen, abdominal wall and hernia, oesophagus and stomach, intestine, rectum and anal canal, thoracic and neurosurgery and urology.

FIGURE 8.1: Amebic liver abscess FIGURE 8.2: Amebic liver

abscess-Anchovy sauce pus

Amebic liver abscess is common in India and other tropicalcountries and is caused by Entamoeba histolytica.Commonly it is single large abscess in right lobe but oftencan be multiple Pus is chocolate colored, anchovy-saucetype Often abscess can be secondarily infected by bacteria.Right sided pleural effusion is known to occur It can beacute or chronic or can be calcified Amebic liver abscesscan rupture into peritoneum, lung, pericardium or into intestinewhich often can be fatal Treatment is antiamebic drugs likemetronidazole, chloroquine, U/S guided aspiration or opendrainage

Portal hypertension due to cirrhosis can cause massiveascites It is due to increased portal pressure, alteredaldosterone mechanism, lymphatic blockage or hypo-proteinemia Caput medusae is dilatation of veins aroundthe umbilicus due to communication between paraumbilicaland anterior abdominal veins.

FIGURE 8.4: Caput medusae

FIGURE 8.5: Hydatid cyst of the liver

Hydatid cyst of the liver is caused by Echinococcusgranulosus It attains a large size slowly over few years.Three finger hydatid thrill may be positive Pain and jaundicecan occur If cyst ruptures anaphylaxis can develop U/S isdiagnostic Praziquantel and albendazole are useful.Cetrimide and hypertonic saline are the scolicidal agentsused for hydatid cyst During surgery spillage of scolicesshould be avoided as it may lead into development ofsecondary hydatids elsewhere Colored mops are placed inthe peritoneal cavity to identify the spilled scolices

Oesophageal varices due to portal hypertension are gradedbased on size and luminal prolapse Acute bleeding iscontrolled by Sengstaken Blakemore tube in place It can

be kept in place for 72 hours Recurrent bleeding is controlled

by sclerotherapy, endoscopic variceal banding andendoscopic intravariceal injection of Butyl-cyanacrylate

(glueing) (most often for gastric varices) Shunt surgeriesare not commonly used for acute variceal bleed

FIGURE 8.8: CT picture of hepatoma

CT scan picture of hepatocellular carcinoma (hepatoma).Hepatoma is common in patients with cirrhosis and hepatitis

B and hepatitis C infection It is unicentric and right lobe iscommonly involved Painless large palpable liver which issmooth, hard, nontender are the features Hepatic bruit,ascites and jaundice may develop later CT scan is a must.Early case is treated by hemihepatectomy Chemotherapywith adriamicin is useful Hepatic artery ligation, intra arterialchemotherapy are other modalities available

FIGURE 8.9: CT picture of secondaries in liver

CT picture of the abdomen showing multiple liver secondaries

in both lobes Common sites of primary to cause liversecondaries are stomach, colon, pancreas, small bowel.Extraabdominal conditions like carcinoma breast, melanoma

or carcinoma kidney can also cause liver secondaries Liversecondaries are multiple, hard, nodular and umbilicated due

to central necrosis

FIGURE 8.10: CT picture of hydrohepatosis

In severe obstructive jaundice there will be dilatation of biliary radicles along with the dilatation of extra biliaryradicles Liver will be soft, smooth called as hydrohepatosis.Common causes are growth in the pancreas, in the CBDand Klatskin tumor

intra-roundworm in gallbladder Patient presented with features ofacute cholecystitis and needed cholecystectomy.

FIGURE 8.12: U S showing stones in the gallbladder

Figure shows ultra-sound picture of stones in the gallbladder.Gallbladder with stones and post-acoustic shadow is obvious.Patient requires cholecystectomy (laparoscopic or open)

FIGURE 8.13B: Multiple gall stones with

thickened gallbladder due to cholecystitis

Gall stones are common in females It may be cholesterolstone mixed stones or pigment stones Causes are metabolic,bile stasis, increased bilirubin production or drug related.Presents as biliary colic, acute / chronic cholecystitis, andCBD stone with acute cholangitis or pancreatitis U/S is diag-nostic To confirm or rule out CBD stones CT scan or ERCP

is essentially done Treatment is laparoscopic tomy If CBD stones are present, ERCP and stone extractionshould be done prior to laparoscopic cholecystectomy If ERCP

cholecystec-is not possible then open cholecystectomy with CBD ration for stone extraction must be done Occasionallycholedochoduodenostomy or choledochojejunostomy may berequired

explo-FIGURE 8.13D: Solitary gall stone

with thickened cholecystitic

gallbladder

FIGURE 8.14: T tube in the CBD after choledochotomy

For gall stones along with CBD stone, after cholecystectomy,choledochotomy is done Indications are CBD diameter morethan 1 cm, recent history of jaundice, on table palpable CBDstone, US showing CBD stone, on table cholangiogramshowing CBD stone or when in doubt Once choledochotomy

is done CBD stone is extracted using Des’jardin’scholedocholithotomy forceps CBD is then closed by placing

a T tube which is kept for 10-14 days After doing T tubecholangiogram, T tube is removed

FIGURE 8.15: Sclera in obstructive surgical jaundice

Obstructive jaundice is commonly due to CBD growth, CBDstone, carcinoma pancreas, Klatskin tumor, extrinsiccompression or parasitic infestations Patient presents withsevere jaundice, pruritus, fever, loss of appetite or weight.LFT, US abdomen, CT scan are the required investigations.Treatment depends on condition For CBD stones CBDexploration is needed For carcinoma pancreas, Whipple’soperation is done ERCP and stenting is often needed asinitial method to decompress the biliary tree

FIGURE 9.1: Acute pancreatitis—on table finding

Acute pancreatitis is often life threatening condition.Common cause is biliary stone disease It is classified asacute interstitial pancreatitis and acute necrotizingpancreatitis Second type is further classified as sterilenecrosis and infected necrosis Infected necrosis has gothigh mortality rate Hemorrhagic necrosis with ‘chicken broth’

fluid is typical Presents with sudden severe pain often after

an alcohol intake which radiates towards back, slightly

FIGURE 9.2: CT picture of

pseudocyst of pancreas

FIGURE 9.3: On table aspiration

of pseudocyst, note the nish color

brow-Pseudocyst can be communicating or non-communicating.Presents as a swelling in epigastric region which is smooth,does not move with respiration, nonmobile, pulsatile{disappears on knee-elbow position}, resonant or impairedresonant on percussion CT scan is the study of choice US

is commonly done Cyst should be formed with thick walland should be more than 6 cm in size to treat surgically.Surgical treatment is cysto-jejunostomy/cystogastrostomy

FIGURE 9.5: Pancreatic stone—specimen

Chronic calcifying pancreatitis can be parenchymal fication as shown in X-ray or ductal stone as shown in Figure9.5 specimen Ductal stone is better than parenchymalcalcification Presents with pain, exocrine insufficiency,diabetes mellitus Treatment for parenchymal calcification

calci-is total pancreatectomy Stone in the duct calci-is removed withpancreatico-jejunostomy

FIGURE 9.6: CT picture showing pancreas with dilated CBD

In periampullary growth and carcinoma head of the pancreasCBD will be dilated with hydrohepatosis CT scan is done tosee the operability of the tumor If operable, pancreatico-duodenectomy is done

FIGURE 9.7: Whipple’s operation—specimen

Specimen of pancreaticoduodenectomy showing gallbladder,

C loop of duodenum, distal stomach and head of the pancreaswith tumor It is done for periampullary carcinoma orcarcinoma head of pancreas Operability is assessed by

CT scan On table adequate plane should be developedbetween portal vein and neck of the pancreas to confirm it

as operable After resection, choledochojejunostomy,pancreatico-jejunostomy and gastrojejunostomy are done

FIGURE 9.8: CT picture of cystadenocarcinoma of pancreas

Cystadenocarcinoma of pancreas occurs commonly in bodyand tail of pancreas It attains large size and presents asbackpain with retroperitoneal mass in epigastric region.Jaundice is uncommon in cystadenocarcinoma of pancreas

CT is conclusive Treatment is distal pancreatectomy It hasgot better prognosis when compared with carcinoma head

of pancreas

FIGURE 9.9: Splenic injury—on table

Figure shows lacerated wound over the spleen which requiredsplenectomy Splenorrhaphy can be done in clean incisedwound especially in children so as to save the spleen Otheroption is partial splenectomy Patient should receivepneumococcal vaccine to prevent the possible chances ofOPSI (Overwhelming Post Splenectomy Infection) OPSIhas got high mortality

ITP {Idiopathic thrombocytopenic purpura} is an acquiredcondition; due to formation of antiplatelet antibodiesdamaging patient’s own platelets It can be acute or chronic.

It is common in young females Presents with bleedingtendency which is often life threatening Spontaneousregression can occur in many cases Methylprednisolone,prednisolone, danazol, azathioprine, immunoglobulins,vincristine, antiRh antibodies, FFP or splenectomy aretherapeutic options

showing purpura in legs

FIGURE 9.10B: ITP

showing purpura in leg

Tuberculosis of spleen is rare It is often associated withimmunosuppression or diabetes Secondary infection canoccur leading into fulminant sepsis Primary focus may bethere in the lungs Treatment is antituberculous drugs withguided aspiration of pus or splenectomy.

FIGURE 10.1: Patent vitello-intestinal duct

Patent vitello intestinal duct can cause fistula, sinus,intraabdominal cyst, band with volvulus or intestinalobstruction or Meckel’s diverticulum Partially obliteratedvitello-intestinal duct towards umbilical end, causing prolapse

of the mucosa is called as umbilical adenoma or Raspberrytumor Anomalies are treated by surgical intervention

FIGURE 10.2: Umbilical hernia

It is herniation through a weak umbilical scar It is common

in newborns and children Presents with a swelling inumbilicus with impulse on coughing In newborn 90% casesregress spontaneously If hernia persists after 2 years, ifdefect is more than 2 cm or in adult, surgery is required.Surgery is done through subumbilical incision Defect isclosed using nonabsorbable interrupted sutures

It is common in premature infants showing a defect towardsthe right of the intact umbilical cord Defect showsevisceration of the intestines without a peritoneal sac It isoften associated with intestinal atresia and nonrotation.Treatment is surgical closure of the defect with resectionand anastomosis of eviscerated bowel.

FIGURE 10.4: Exomphalos major

Omphalocele is failure of entire or part of gut to return intocoelomic cavity In major type, liver, small bowel and largebowel are outside It is covered with amniotic membrane,Wharton’s jelly and peritoneal layer Exomphalos major haslarge sac, defect is more than 5 cm, primary closure is notpossible; umbilical cord is attached to the inferior aspect.Initially wrapping of the content using polythene silastic siloand gradual twisting and later with release incisions closure

of the abdominal wall is done

FIGURE 10.5: Abdominal wall abscess

It may be due to infected hematoma / umbilical sepsis orfrom distant spread Tender, soft, localized swelling; should

be ruled out from strangulated abdominal wall hernia.Treatment is incision and drainage under general anesthesiawith antibiotic coverage

FIGURE 10.6: Abdominal fecal fistula

Fecal fistula can develop after surgery for acute peritonitis,especially for ileal perforation or colonic diseases If it occursthrough the main wound it is called as category 4 fecalfistula In this patient, surgery was done for abdominaltuberculosis with intestinal obstruction and perforation.Patient underwent ileocaecal resection which eventuallyresulted in fecal fistula Patient recovered well after 3 months

of hospitalization with antituberculous drug coverage

FIGURE 10.7: Epigastric hernia

On table finding of epigastric hernia Initially it is sacless,but later develops a sac with enterocele as content It isoften associated with duodenal ulcer Treatment isdissection of sac with defect closure using non-absorbablesuture material

FIGURE 10.8: Ventral hernia

Herniation of abdominal content through midline just above

or below the umbilicus It often attains large size, may getobstructed / strangulated It needs surgical intervention withplacement of preperitoneal large mesh

FIGURE 10.9: Incisional hernia adherent to skin

Incisional hernia is common in lower abdominal scars, infemales, after laparotomy for acute conditions and after majorsurgeries for malignancies (gastrectomy/colonic resection/pancreatic surgeries) and in patients with malnutrition,anemia, chronic cough or jaundice Treatment is correction

of precipitating factors and mesh repair Layer by layerclosure, keel operation are the other procedures done

FIGURE 10.10A: Femoral hernia FIGURE 10.10B: Femoral hernia

with Richter’s type of gangrene with perforation

Femoral hernia is common in females It lies below andlateral to pubic tubercle More commonly leads intogangrene Richter’s hernia is gangrene of a part of thecircumference of the bowel wall It is common in femoralhernia Exploration is done by vertical or inguinal approachwith repair by approximating inguinal ligament to Cooper’sligament or conjoined tendon to iliopectineal ligament Oftenplugging of mesh into the femoral ring is also done Whengangrene occurs resection and anastomosis is done

Direct hernias are commonly bilateral and is always acquired.

It is common in adult and elderly It is treated using mesh(hernioplasty) Precipitating causes like BPH should betreated first Here sac descends medial to the inferiorepigastric artery through the posterior wall of the inguinalcanal

FIGURE 10.12: Complete inguinal

FIGURE 10.14: Large inguinal hernia with catheter

Left sided large inguinal hernia with Foley’s catheter in place.Patient is having urinary symptoms due to BPH Patientshould undergo TURP for BPH and later hernioplasty should

be done for inguinal hernia

FIGURE 10.15: Strangulated inguinal hernia with gangrenous

omentum

Patient presented with strangulated inguinal hernia {leftsided} who underwent immediate surgery On table therewas strangulated omentum which was excised.Herniorrhaphy was done later Strangulated omentocelepresents with irreducibility, pain and tenderness over thegroin with toxicity

FIGURE 10.16: Inguinal hernia with enterocele

Figure shows hernial sac with small intestine as content(enterocele) Enterocele if obstructed can causestrangulation and gangrene which needs resection andanastomosis Clinically enterocele gets reduced withgurgling and it is resonant on percussion

FIGURE 10.17: Recurrent hernia

Its incidence after herniorrhaphy is 10%; after hernioplasty,1-2% It is caused by smoking, cough, constipation, oldage, anemia, BPH and ascites Infection, hematoma andstraining in early post operative period are other causes.Preperitoneal mesh repair is done in this patient

FIGURE 11.1: X-ray picture of achalasia cardia

It is the failure of relaxation of cardia causing functionalobstruction at oesophago-cardiac junction It is common infemales Dysphagia, regurgitation and weight loss are thefeatures Barium swallow shows pencil narrowing of the loweroesophagus (Bird-beak appearance), dilatation of proximaloesophagus, absence of fundic gas bubble and megaoeso-phagus Achalasia cardia is a premalignant condition.Heller’s cardiomyotomy is the treatment of choice