Ebook Nutshell series for general surgery: Part 1

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Nutshell series for

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FMGE/d b/

R Rajamahendran
MS MRCS (Edinburgh) FAGE FMAS Dip Lap
MCh Surgical Gastroenterology (Postgraduate)

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Nutshell series for

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Madras Medical College, Chennai, Tamil Nadu, India

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Founder and Faculty
Koncpt Postgraduate Medical Coaching Center, Tamil adu
Faculty, Global Institute of Medical Sciences, China
Faculty, Karol Institute of Medical Sciences, Chennai and Delhi
Faculty, ADR Plexus Postgraduate Medical Coaching Center, Chennai

Panchadcharam Harinath MD (Russia)

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Molecular athologist
Senior Lecturer
Liaoning Medical University
China
Forewords
Seyed Abdul Cader
D Arunkumar

®

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD
New Delhi • London • Philadelphia • Panama

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®

Jaypee Brothers Medical Publishers (P) Ltd

Headquarters
Jaypee Brothers Medical Publishers (P) Ltd
4838/24, Ansari Road, Daryaganj
New Delhi 110002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Email:

Overseas Offices

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Jaypee Brothers Medical Publishers Ltd
The Bourse
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Suite 835, Philadelphia, PA 19106, USA
Phone: + 267-519-9789
Email:

Jaypee Brothers Medical Publishers (P) Ltd
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Mobile: +08801912003485
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Phone: +00977-9841528578
Email:

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Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com

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Jaypee-Highlights edical ublishers Inc
City of Knowledge, Bld. 237, Clayton
Panama City, Panama
Phone: +507-301-0496
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Phone: +44-2031708910
Fax: +02-03-0086180
Email:

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© 2013, Jaypee Brothers Medical Publishers

All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher.
Inquiries for bulk sales may be solicited at:

This book has been published in good faith that the contents provided by the authors contained herein are original, and is intended for educational
purposes only. While every effort is made to ensure accuracy of information, the publisher and the authors specifically disclaim any damage,
liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures
and tables are courtesy of the authors. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug
or device.
S

Nutshell series for FMGE/DNB/NEET-PG—General urgery
 

First Edition : 2013
 

ISBN 978-93-5090-505-0
Printed at

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Dedicated to
my dear friend

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Late Dr S Karthikeyan, MD, Anesthesia

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Also my parents, wife and children
and
Especially to the students of Zhengzhou edical University,
Zhengzhou, China who really motivated me to write the book.

tahir99 - UnitedVRG


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Foreword

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KIMS

Being the Academic director of karol institute of medical sciences (
), which has coached thousands
of students in preparation for the C screening tests and postgraduate entrance examination with a very
good track record of successful candidates since 2005, felt this book to be very concise, illustrative and
with a very simple and systematic narrative.

s
s

The authors have gone into laborious and painstaking work in bringing out this book. They both have a
spectacular flare in teaching students and to make them understand the subject conceptually. After going
through the book, I felt both elated and satisfied at the same moment.

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eyed Abdul Cader md
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irector
karol institute of medical sciences
Chennai, Tamil Nadu, ndia
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highly recommend this book for F GE and NEET candidates as these materials have already been
successfully used for our students in their preparation for the examinations. wish them the very best in
their efforts to create a knowledgeable and conceptually educated medicos.

tahir99 - UnitedVRG

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Foreword

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The need for an easily understandable, concise and illustrated guide in surgery has been felt by all
concerned at different levels of the medical field in India.

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Dr Rajamahendran and Dr Harinath are highly qualified and experienced faculties teaching in our
Academia Grandiosa edicinae (AG ) which is renowned for F GE and PG E teaching programs since
2008. Their unique way of presentation and materials made a quick impact among students and gasped
number of students across ndia.

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KIMS

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Authors association with AG , A R-Plexus and
successfully taught for more than 3000 students
yielded in more 750 toppers in F GE and more than 500 toppers in various PG Es till now.

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Arunkumar md

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Associate rofessor
Academic director
Academia Grandiosa edicinae
New elhi, ndia
irector
A R-Plexus
Chennai, Tamil Nadu, ndia
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t gives me an immense pleasure to know that these two authors have been endeavored to author an
illustrated guidebook in surgery. assure this book will be an essential aid for successful exam-preparation
and highly recommend it for F GE, NEET-PG and other PG Es.

tahir99 - UnitedVRG


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Pre

ace

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F GE: Foreign medical raduate xamination ( edical ouncil of ndia— C screening test) and NEET:
National Eligibility Entrance Test are standard examinations conducted by National Board of xamination
(NBE) to validate the standard of ndian students with the international ones.
M

Unimagined raise in the standards of F GE and other postgraduate entrance examinations including
NEET brought an absolute necessity for candidates to acquire concept-based knowledge in the subjects
than a superficial MCQ-based knowledge.
We are presenting this admirably concise and illustrated Nutshell Series for FMGE/DNB/NEET-PG—
General Surgery to annihilate the deficiency of concept-based guides with MCQ review; that created a
dilemma in candidates to choose the way of exam-preparation and maximize its efficiency while currently
available texts fail to provide with any enthusiasm among students.
M

S

Nutshell series: urgery for F GE covers all the chapters systematically in a succinct and didactic
fashion of presentation to aid in the glory of its users.
Our own experience in a unique way of teaching and as an examiner at different levels has been distilled
here as an ultimate synopsis of surgery for exam-preparation.
This guide is presented in tabular format with highlighted high yield points and equipped with more
than 350 detailed illustrations that will enable the users to understand the core concepts clear and make
the revisions faster.
MCQs are organized by the end of each chapter give users orientation towards the examination patterns.
We extend our appreciation to our inspired and esteemed professors and colleagues from Germany
and Russia for their zest in illustrated presentation of teaching.

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IMS

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MD

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We hope and believe this book is going to serve the purpose of students and doctors who are setting
their goals higher to achieve ‘Topper Ranks’ in examinations like F GE, NEET, A
, PG , ERP , A C,
P
CE and N CE.
We appreciate your feedback to improve the scientific and writing accuracy of our publications and to
help us build up a highly knowledgeable society of doctors.
Feedback can be mailed to: , ,

R Rajamahendran
Panchadcharam Harinath

tahir99 - UnitedVRG


tahir99 - UnitedVRG

A

cknowledgments

Special thanks:
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MD

D

r G Bhanu Prakash,
, Professor of athology, Zhengzhou niversity—who is a renowned teacher in the
field of undergraduate teaching in China, USMLE and FMGE programs all over the globe. He successfully
taught more than 5 USMLE batches yielded in more than 500 top residents in USA. He is the first one to
introduce multimedia lectures for foreign students in hina and currently associated with more than 1000
ndian students. We extend our appreciation to him for the involvement and contribution to this book.

R Rajamahendran
Panchadcharam Harinath

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M

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M

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SM

MD

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I first of all thank my co-author Dr Panchadcharam Harinath who motivated me to write this book and
made excellent designing of the book with extraordinary pictures. The Legend who introduced me to the
world of F GE r yed,
, Russia, irector of arol nstitute of medical sciences, elhi and Chennai,
needs a special thanks than anyone else. He motivated and encouraged me like anything to do this job.
He is the creator of many extraordinary teachers in this FMGE field. Also, I would take this opportunity to
thank Dr Banuprakash Kulkarni, Director of Global Institute of Medical Sciences in China and Hyderabad,
for giving me opportunities to show my talent in abroad.
would like to thank my Professor
Chandramohan, Ch, urgical Gastroenterologist, role model
for our specialization. also thank my Assistant Professors, r Amudhan,
h; Dr Benet Duraisamy,
Ch, and r Prabhakaran, Ch, for giving me encouragement and support in all my academic activities.

y thanks to all the students in arol nstitute of edical sciences, Global nstitute of edical ciences
and oncpt Postgraduate medical oaching enter for bringing me to this level in teaching field.
give a special thanks to all my friends who always stood behind me in my bad times and saying the
encouraging words, “ f you cannot, then no one else,” which lifted me to the level of writing my 5th book
in a short period of time, especially r Antan Uresh umar, Ch, Urology, Founder, koncpt Postgraduate
medical oaching enter and Dr Raja Rajan, MCh, Urology, Stanley medical College.
y thanks to all my teachers, well wishers, my parents, my loving wife r hanthi CP and my cute
little daughters—Saadhana and Rajahansa.
—R Rajamahendran

KS

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Family:
• r Panchacharam and Family (Chief ngineer and Project manager, Al Jafr, A): Father and teacher
who imitated me to embrace the world of knowledge and brought me to this position.

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xiv

Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

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• Evgenia Kratenko (HR Manager, Avon, Russia): Greatest moral support, care and encouragement for
my works.
• r P Aravinth B ech: Brother and technical support for designs and applications.
• r Arumugam and family (Chennai): Familial support and care.

Working circle and friends:

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• r Ravikumar Giri: Technical assistant and co-designer.
• r ohit umra, BA: Administrator and manager.
• Associate Professor Arunkumar,
: ecturer in tanley edical College, Chennai and Academic
director of AG .
• Associate Professor Nirpam Adhalka, MS, DNB (Urology): Lecturer at khanpur medical ollege. A
good friend and advisor.
• Dr Arun Mukherjee, MD: Friend and advisor.
• r Vikram kalra,

,
(Nephrology): An experience and good friend.
• r
eepesh,
: Good friend, colleague and contributor of this book.
• r A Ramprasath,
: Good friend, colleague and contributor of this book.
• I am thankful to all my friends and people who are helpful and supportive in our projects.

Mentors:
c

KSM

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MM

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MM

MM

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• Professor Evgenia ogan (Pathology,
A): Renowned name in Pathology ircle of Europe and the
one who encouraged me to study a lot and apply the knowledge in researches.
• Professor V Pirozhkov (Pathophysiology,
A): Great teacher who changed my paradigm of
pathophysiology.
• Professor EA arev ( ariology,
U): Passion for knowledge and teaching.

• Professor Glasichev (Physiology,
A): Esteemed teacher and a great personality.
• Professor GG Manishramani (WHO, onsultant of Geriatric Medicine): Ex-HOD, Department of Internal
edicine, A C, elhi. ost respected personality and my mentor in ndia.

Teachers who showed the path to universe of knowledge:
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KSM

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KSM

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• Professor Tatiyana Boronikhina (Histology, MMA): onderful teacher who showed the correct path
in early stages.
• Associate Professor TP Nekrasova (Pathology,
A): Remarkable and sweet teacher who made me
a pathologist.
• Associate Professor Galina N Goryainova (Pathology,
U): Teaching with personal care.
• Associate Professor vetlana V Chava (Anatomy,
A): trict but very encouraging.
• Late Dr L Ribakova (Anatomy, MMA): Known for her sweetest way of teaching.
• Professor EV Budanova ( icrobiology,
A): nique application of teaching with a strict plan.
• Professor Gubareva AE ( iochemistry, MMA): Well known for her successful teaching by posing questions.
• Associate Professor Enikeeva (Pharmacology,
A): Viva-based teaching that made us explore more.
• Associate Professor Ala N aistrenko (Topographic natomy, KSMU): Confident and punctual teaching
• Associate Professor E Evgevivna ( eurology,
U): simplified and easy teaching.
• r RN alra,
,
( ardiology, FRCP): Taught me morals of medicine in a practical way.

—Panchadcharam Harinath

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1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Oral Cavity




 

 

 

 

 

 

 

 

5

 

Etiological Factors for Oral Cavity
Carcinoma 32
Level of Nodes 33
Drainage of Each Tumor Site Specific 33
Pathology of Oral Cancers 34
Carcinoma Tongue 34
Carcinoma Hard Palate 35
T
Staging of Oral Cancer 35
Types of Neck Dissection 35
Reconstructions 36
Mandibulectomy 36
Carcinoma Lip 36
Basic Points for Head and Neck Cancers 37
Syphilis in Oral Cavity 37
Cancrum Oris 37
Epulis 38
Ludwig’s Angina 38
Cysts of Jaw 38
Impacted Tooth 39

 



 

11

 

Carotid Body Anatomy
Branchial Cyst 44
Cystic Hygroma 45



 



5. Head and Neck (General)

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Advanced Trauma Life Support (A ) 20
Head Injury 21
N
Guidelines for C Scan in Head Injury 22



 

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3. Trauma

 

 

 

 

 

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Severity of Shock 12
Resuscitation 12
Hemorrhage 13
Transfusion 13
Blood Products 13
Complications of Blood Transfusion 14
Complications from Massive Transfusion 14
Points to be Emphasized 15
Better Indicator for Transfusion 15
Septic Shock 15
Organ Transplantation 16
Types of Allograft Rejection 16
Graft versus Host Disease (Gv ) 16
H Matching 17
Immunosuppression 17

 





2. Shock, Blood Transfusion and
Organ Transplantation

32

Ulcer 1
Sinus 1
Fistula 2
Swellings in Skin 2
Infections in the Hand 4
Nutrition in Surgery 4
Types of Enteral Nutrition 5
Parenteral Nutrition 5
Indications of Total Parenteral Nutrition
Fluids and Electrolytes 6
Hypercalcemia and Hypocalcemia 7
Hypernatremia and Hyponatremia 7
Fluid Therapy: Two Types of Fluids
Crystalloids and Colloids 7
Choice of Fluid 8

Primary Treatment for Head Injury 22
Types of Head Injury 22
Extradural Hematoma 22
Acute Subdural Hematoma 22
Chronic Subdural Hematoma 23
Subarachnoid Hemorrhage 23
Cerebral Contusions 23
Thoracic Trauma 24
Flail Chest 25
Emergency Thoracotomy 26
Abdominal Trauma 26
Investigations of Abdominal Injury 27

Spleen 27
Pancreas 27
 







1. Basics in General Surgery

ontents

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xvi

Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

Cold Abscess in Neck 46
Triangles of Neck 46

 

70

8. Parathyroids and Adrenal Glands




 

 

 

Anatomy 48
Submandibular Gland 49
Salivary Gland Tumors 49
Classification of Salivary Gland Tumors 50
Benign Mixed Tumor
(Pleomorphic Adenoma) 50
Warthin Tumor (Adenolymphoma) 51
Mucoepidermoid Carcinoma 51
Adenoid Cystic Carcinoma (Also Called
Cylindroma) 51
Acinic Cell Tumor 51
Minor Salivary Gland Tumor 51
Investigations for Tumor 52
Parotid Surgeries 52
Frey’s Syndrome 52

 

48



6. Salivary Glands




 

 

 

Postsurgical Complications 66
Perioperative Complications 67
Hypoparathyroidism 67
Surgery for Intrathoracic Goiter 67

 

 

 

 

 

78



9. Breast Disorders




 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parathyroids 70
Hyperparathyroidism 71
Primary Hyperparathyroidism 71
Secondary Hyperparathyroidism 72
Tertiary Hyperparathyroidism 73
Adrenal Glands 73
Pheochromocytoma 73
Malignant Pheochromocytoma 74
Cushing’s Syndrome 75
Conn’s Syndrome 76

 

 

 





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Anatomy 92
Surgical Anatomy at a Glance 92
Lower Esophageal Sphincter (L ) Zone
Factors Causing 93

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10. Diseases of Esophagus

 

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Embryology 56
Anatomy 57
Recurrent Laryngeal Nerve 58
Simple Goiter 59

Reason for Nodule Formation 59
Clinical Indicators of Malignancy in
Nodular Swelling 60
Retrosternal Goiter 60
Types of Toxicosis 60
Primary Thyrotoxicosis 61
Secondary Thyrotoxicosis 61
Preparation of Thyroid Crisis 61
Thyroid Storm 62
Thyroiditis 62
Hashimoto’s Thyroiditis 63
Reidel’s Thyroiditis 63
De quervain’s (Subacute) Thyroiditis 63
Infective Thyroiditis 63
Thyroid Cancers 63
Papillary Carcinoma 64
Follicular Cancer 64
Hurthle Cell Carcinoma 65
Medullary Carcinoma 65
Anaplastic Carcinoma 66
B-Cell Non-Hodgkin’s Lymphoma 66
Metastatic Cancer Thyroid 66
Important M q Points in
Carcinoma Thyroid 66

 

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7. Thyroid Disorders




 

 

 

 

Anatomy 78
Lymphatic Drainage 78
Benign Breast Diseases 80
Mondor’s Disease 81
Duct Ectasia/Periductal Mastitis 81
Important Points 81
Carcinoma Breast 81
Types of Carcinoma Breast 82
Invasive Cancers 82
T
Staging of Breast 84
Treatment Modality 85
Advantage Over Radical Type 85
Radical Mastectomy: Halstead’s Radical
Mastectomy 86
Chemotherapy 86

C
Regimen 86
Hormone Therapy 86
Tamoxifen 87
Radiotherapy 87
Distant Metastasis 87
Phyllodes Tumor 88
Skin Involvement 88
Prognostic Factors of Carcinoma Breast
Breast Conservation Surgery 89

tahir99 - UnitedVRG


xvii



Contents

Investigations 93
Gastroesophageal Reflux Disease 93
Barrett Esophagus 94
Hiatus Hernia 94
Tracheoesophageal Fistula 95
Perforations in Esophagus 96
Motility Disorders 96
Classification 96
Dysphagia 96
Diffuse Esophageal Spasm (D ) 97

Achalasia Cardia 98
Odynophagia 98
Diverticulum Esophagus 98
Esophageal arices 99
Cancer Esophagus 100
Malignant Tracheoesophageal Fistula 100
Plummer- inson Syndrome
(Paterson-Brown-Kelly Syndrome) 101
Schatzki Rings 101

 

 

 

 

 

 

 

 

 

 

 

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13. Hepatobiliary and Pancreatic System

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Hirschsprung’s Disease 118
Meckel Diverticulum 118
Diverticular Disease 119
Polyps 119
Colonic Cancer 119
Percentages 120
Management 120
Small Bowel Tumors 121
Small Bowel Carcinoids 121
Inflammatory Bowel Disease (I )

Local Complications of I
123
Treatment for I
123

Gallbladder and Biliary Tract 144
Moynihans Hump and Caterpillar Turn 144
Anomalies of Gallbladder 145
Cystic Duct ariations 145
Functions of G
145
Investigation 145
Gallstones 146
Pigment Stones 146
Complications 147
Limey Bile 148
Treatment Options 148
Common Bile Duct Stones 148
Treatment Options 148
 

118



12. Intestinal System

 



 

 

 

 

 

 

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Anatomy 103
Helicobacter Pylori Infection 105
Duodenal Ulcer 106
Causes of Recurrent Ulcer 108
Cancer Stomach 108
Histological Types 108
Gastric Lymphoma 111
Gastrointestinal Stromal Tumor (G
Upper G Bleeding 112
Epithelial Polyps 113
Congenital Hypertrophic
Pyloric Stenosis 113
Borchardt’s Triad 114
Bariatric Surgery 114

 

103

11. Stomach and Duodenum




 

 

 

 

 

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Extraintestinal Manifests 123
Tuberculosis of Abdomen 124
Short Bowel Syndrome 125
Superior Mesenteric Artery (S )
Syndrome 125
Enterocutaneous Fistula 125
Acute Appendicitis 126
Mucoceles 127
Carcinoid Appendix 127
Intestinal Obstruction 128
Meconium Ileus 128
Congenital Atresias 129
Small Bowel Obstructions 129
Cause of Distension 129

Adhesion: Causes 129
Paralytic Ileus (Inorganic Cause) 130
Large Bowel Obstructions 130
Salient Points in Large Bowel Obstruction 130
Acute Mesenteric Ischemia 131
Ischemic Colitis 131
Pseudo-obstructions 131
Cancer Rectum 132
Anal Cancer 132
Fissure- n-Ano 134
Normal Fecal Continence Require 135
Anorectal Abscess 135
Pilonidal Sinus 135
Pruritus Ani 135
Imperforate Anus 136
Rectal Prolapse 136
Solitary Rectal Ulcer 137
Abdominal Compartment Syndrome 137

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Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

Missed/Retained/Residual Stones
(< 2 Years) 149
Choledochal Cysts 149
Extrahepatic Biliary Atresia 149
Differential Diagnosis of Jaundice in
Infants 150

Primary Sclerosing Cholangitis 150
Hemobilia 151
Carcinoma Gallbladder 151
Pancreas 154
Pancreatic Function Test 154
Pancreatitis 154
Chronic Pancreatitis 155
Surgeries 155
Pseudocyst Pancreas 156
Ranson’s Criteria 156
Pancreatic Tumors 156
Endocrine Neoplasms 157

 

177

 

180





16. Urological Surgery

Kidney and Ureters 180
Methods of Stone Removal 181
Ureteroscopy 181

Percutaneous Nephrolithotomy (P
) 182
Renal Cell Carcinoma 183
M Points 184
Renal Cell Carcinoma 184
Wilm’s Tumor 185
Differentiating Feature Between
Neuroblastoma and Wilm’s Tumor 185
Angiomyolipoma of Kidney 185
Genitourinary Tuberculosis 186
Renal Trauma 186
Polycystic Kidney Disease 187
Ectopic Ureter 187
Congenital Pelviureteric Junction
Obstruction 188
Medullary Sponge Kidney 188
Renal Transplantation 188
Renal Casts 189
Xanthogranulomatous
Pyelonephritis 189
Nephrectomy Approaches 190
Ureterocele 190
Carcinoma Bladder 190
Management of Bladder Cancer 191
Bladder Calculi 192
Rupture of Bladder 192
Tuberculosis of Bladder 193
Anatomical Division of Prostate 193
Complications of T
194

Absolute Indications for
Surgical Treatment of B
194
Solutions in T
194
Medical Treatment of B
194
Cancer Prostate 195
Tumor Markers in Carcinoma
Prostate 195

161

 

 

 

 

 

 

 

 

 

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174

Anatomy 174

Splenic Function 174
Splenic Trauma 175
Splenectomy 176
Hematological Indications 176
Complications of Splenectomy 176
 





15. Spleen

 

cc

 

V

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ips

 

 

 

 

 

 

 

 

 

 

 

 

Functional Anatomy (Couinaud’s
Segments) 161
Acute Liver Failure Causes 162
Modified Child-Pugh Classification 163
Chronic Liver Disease 163
Investigations 163
Portal Hypertension and Cirrhosis 163
Transjugular Intrahepatic
Portal Shunt (T ) 166

Prevention of Recurrent Bleed 166
Shunting Surgeries 166
Transplant Candidates 167
Pyogenic Abscess 168
Amebic Abscess 168
Differential Diagnosis of Amebic and
Pyogenic Features 168
Hydatid Cyst 169
Benign Liver Tumor 169
Fibrolamellar ariant of H
171
Budd-Chiari Syndrome 171
Liver Transplant 172

 



14. Liver




 

 

 

 

c

 

 

 

cnl

 

 

 

 

 

 

 



 

tp

 

 

 

 

 

 

 

 

 

 

 

 

Overwhelming Postsplenectomy
Infection 176
Hematologic Effect of Splenectomy
Splenic Tumors 177
Splenic-Gonadal Fusion 177

Splenic Artery Aneurysm 178
Splenic Infarction 178
Idiopathic Thrombocytopenic
Purpura (I ) 178

 



xviii

tahir99 - UnitedVRG


xix

19. Cardiothoracic Surgery
 

 

 

 

 

 

 

 

 

Burns 234
Major Determinants of the Outcome of
a Burn 235
Superficial Burns Have Capillary Filling 236
Degrees of Burns 236
Management of Burns 236
Topical Treatment 237
Cosmetic Surgery 238
Facts about Skin Grafts 238
Cannot We Graft Every Wound? Why do
We Need Flaps? 238
Types of Flaps 238
Axial and Random Flaps 238
Local Flap 239
Terms in Plastic Surgery 239
Cleft Lip/Palate 239
 

 

ur

 

 

 

 

 

 

 

 

 

 

 

V

234



20. Burns and Cosmetic Surgery

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

 

Mediastinum 227
Bronchogenic Cyst 227
Lung Sequestration 228
Pancoast Tumor 228
Lungs and Pleura 228
Empyema of Lungs 228
Foreign Body in Lung 229
Bronchogenic Cancer 229
Selection of Conduit 232
Myxoma 232

 

17. Hernia, Umbilicus, Abdominal Wall and
Peritoneum
213


 





227

 

Clinical Features 196
Management Plan 196
Seminal esicles 197
Hypospadias 197
Paraphimosis 199
Injury to Urethra 199
Compare the Two Types of
Urethral Injuries 200
Peyronie’s Disease 202
Testicular Tumors 202
Germ Cell Tumor Staging and
Treatment 203
More About Testicular Malignancy 203
Worth Mentioning about
Cryptorchidism 203
Tumor Markers 203
Varicocele Testis 205
Undescended Testis 205
Congenital Hydrocele 206
Tuberculosis of Testis 207
Infections of Testis 207
Tuberculosis of Kidney and Bladder 207
Vesicoureteral Reflux (
) 207

Contents



 

V

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

V

 

 



 

 

 

 

 

244

 

 

 

 

 

222

Raised Intracranial Pressure 222
Intracranial Tumors 224
Gliomas 225
Cerebral Metastasis 225
Meningioma 225
Pediatric Brain Tumors 226

ascular Surgery

Venous System 244
Tests for aricose eins 244
Short Saphenous Incompetency 245
Perforator Incompetence 245

Deep ein Thrombosis 245
Few Line about Duplex Scan 247
Points from Bailey and Love 247
Arterial System 247
Popliteal Artery Aneurysm 248
Mycotic Aneurysm 248
Amputations 248
Gangrene 249
Arterial Stenosis and Occlusion 249
Subclavian Aneurysm 249
Ainhum 249
Seldinger’s Technique 249
Buerger’s Disease/Thromboangitis
Obliterans 250
V

 

 

 





18. Elective Neurosurgery

21.

 

 



 

 

 

 

 

 

Anatomy of Inguinal Canal
(House of Bassini) 213
Types of Hernia 214
Hesselbach Triangle 214
Surgeries for Femoral Hernia 215
Sliding Hernia 215
Surgeries for Hernia 217
Desmoid Tumor 217
Rectus Sheath Hematoma 217
Divarication of Recti 218
Retroperitoneal Fibrosis 218
Peritonitis 218

Subphrenic Abscess 219
Mesenteric Cysts 219

tahir99 - UnitedVRG




xx

Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

Lumbar Sympathectomy 250
Raynaud Disease 250
Arteriovenous Fistula 251
Lymphatic System 251
Limb Reduction Procedures 252
Points for Memory 252

261







23. Pediatric Surgery

 

 

dh

 

V

 

 

Omphalocele 261
Gastroschisis 261
Exstrophy of Bladder (Ectopia esicae) 262
Congenital Diaphragmatic Hernia 262
Points from C
262

 

 

 

 

 

 

 

 

Epidemiology of Common Cancer 255
Tuberous Sclerosis 255
Neurofibromatosis 1
( on Recklinghausen’s Disease) 256
Neurofibromatosis 2 256
Skin Cancers 256
Basal Cell Carcinoma 256
Squamous Cell Carcinoma 257
Treatment of Skin Cancers 258

 

255



Index





22. Oncosurgery

V



 

 

 

 

 

 

 

 

 

 

 

 

Malignant Melanoma 258
Prognostic Factors 259

Satellite Nodules Treatment 259
Soft Tissue Sarcomas 259
Spontaneous Regression 260
Radiation Induced Cancers 260
Sentinel Node Biopsy 260

265

tahir99 - UnitedVRG


+

A

S

nalysis

nalysis of attern
P

A

S

L

atest FMGE yllabus and

yllabus

M

Surgery is a high yield subject in FMGE that covers 15% of MCQs in average. According to the latest syllabus
of F GE, surgery is subcategorized into important 23 chapters:
(1) Basics in General Surgery; (2) Shock, Blood Transfusion and Organ Transplantation; (3) Trauma; (4) Oral
Cavity; (5) Head and Neck (General); (6) Salivary Glands; (7) Thyroid Disorders; (8) Parathyroids and Adrenal Glands;
(9) Breast Disorders; (10) Diseases of Esophagus; (11) Stomach and Duodenum; (12) Intestinal System; (13) Hepatobiliary and Pancreatic System; (14) Liver; (15) Spleen; (16) Urological Surgery; (17) Hernia, Umbilicus, Abdominal
Wall and Peritoneum; (18) Elective Neurosurgery; (19) Cardiothoracic Surgery; (20) Burns and Cosmetic Surgery;
(21) Vascular Surgery; (22) Oncosurgery, and (23) Pediatric Surgery.

tahir99 - UnitedVRG




xxii

Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

I

S

 

I



I



New syllabus is reflecting in the change of pattern towards more clinically oriented MCQs since 2011.
There were many MCQs devoted to “Basic Surgery” especially fluid therapy and burns in recent years.
t is worth emphasizing that Basic surgery, hock, Burns, Gastrointestinal Tract (G T), Urology and Breast
are proved to be the high yield chapters according to analysis of pattern.
Our book is designed for quick and easy review of surgery in the following algorithm:
 Familiarizing with chapters
 mproving concepts
 Emphasizing on high yield topics
 Reviewing FMGE MCQs
We hope and wish that our book fulfills all the expectations of students and aid them in their “success”.

tahir99 - UnitedVRG


ur ery
g

Basics in General

S

1
Ulcer
• An ulcer is a break in continuity of the covering epithelium either in skin or mucus membrane due to molecular death.

Parts of ulcer
• Margin
• Edge—that connects floor to margin
• Floor—is one that is seen
• Base—is one on which the ulcer rests. May be bone or soft tissue

Types of ulcer


1.
Sloping ulcer
 Healing ulcer

Inner part is red

2.
Punched out

Syphilitic gumma ulcer

Trophic ulcer

Due to end arteritis

4. Raised + beaded and rolled out


Basal cell carcinoma (BCC)
(rodent ulcer)

3.
Undermined edge

Tuberculosis

5.
Everted and

Squamous cell carcinoma

us

Sin





•
•
•
•
•



xamples:

E



• Definition: It is a blind track leading from the surface down into tissues.
Preauricular sinus
Pilonidal sinus—in midline in anal region
Osteomyelitis
Tuberculuos sinus
Actinomycosis—multiple sinuses in faciocervical

tahir99 - UnitedVRG


2

Nutshell Series for FMGE/DNB/NEET-PG—General Surgery

la

stu

Fi

o An abnormal communication between lumen of one viscus to lumen of
another viscus (internal fistula) or
o An abnormal communication between one hollow viscus with the exterior, i.e.
body surface (external fistula)

Examples of internal fistula:




• Tracheoesophageal fistula
• Colovesical fistula

Examples of external fistula:







• Orocutaneous fistula
• Branchial fistula
• Thyroglossal fistula

C

m

omplications:

•
•
•
•









Non-tender
Semi-fluctuant
Mobile (slip sign)
Skin is free



C

haracteristic feature:

L

A

- ipoma

• /c benign tumor in the body
• Universal tumor—occur anywhere in body





 Dermoid cyst



 Sebaceous cyst



 Lipoma

s

s

Swelling in kin

Sarcomatous change
Saponification
Calcification
Submucous lipoma in intestine causes intussusception and intestinal obstruction

B-Dercum disease
Treatment: Excision or enucleation

- ysts
C

C



• Multiple painful lipomas (adiposis dolorosa)



• Cyst is a collection of fluid in a sac lined by epithelium or endothelium.
 Epididymal cyst

♦ Meningocele


 Hydrocele

 Cystic hygroma





 Ranula



C

ysts that are transilluminant:

D-Dermoid cyst






3. Implantation dermoid
4. Teratomatous dermoid



1. Sequestration dermoid
2. Tubulodermoid

1-Sequestration dermoid
sites of sequestration:

•
•
•
•
•

Forehead
External angular dermoid
Root of nose
Sublingual dermoid
Anywhere in midline at fusion

C

M






Free skin
Not transilluminant
Fluctuant
Indentation of bone

C

linical features:



•
•
•
•









• Occurs at line of embryonic fusion
• Epithelium gets sequestrated

Contd...

tahir99 - UnitedVRG


3

Basics in General Surgery

Contd...










•
•
•
•
•



• Arises from embryonic structures
1. Thyroglossal cyst
2. Post-anal dermoid
I

3- mplantation dermoid

Arises from all germinal layers ecto, endo and mesoderm
Occurs in ovary, testis, retroperitoneum and mediastinum
Contains hair, teeth, cartilage and muscle
Can be benign or malignant
Teratomatous dermoid

E







• Due to minor pricks or trauma, epithelium get
buried into deeper subcutaneous tissue
• M/c site is fingers

s

s

Swelling in kin
4-Teratomatous dermoid

2-Tubulo-dermoid

-Sebaceous cyst





• It is a retention cyst due to blockage of the duct of sebaceous
gland causing cystic swelling.
• Not seen in palms and soles
C

haracteristic feature
Smooth, soft and non-tender, mobile
Moulds on finger indentation
Punctum—70% cases
30 percent cases the cyst opens into hair follicles and punctum
not seen.









1.
2.

3.
4.

F-Punctum with sebum: Mcq points in sebaceous cyst





• Gardners syndromeassociated with multiple
sebaceous cysts
• Fordyce’s diseaseectopic sebaceous glands in lip
and oral mucosa.

s

t

n ec ion in general
f

I







• Parasite seen in the cyst—demodex folliculorum

• Cock peculiar tumor—surface gets ulcerated leading to painful
fungating mass
• Sebaceous horn—hardening of slow discharge sebum via the
punctum.

 Erysipelas

 Boils (furuncle)

 Pott puffy tumor

 Suppurativa






A





 Hidradenitis



 Carbuncle

 Abscess



 Cellulitis

-Follicular infections

Boils/furuncles:




• Hair follicle infection
• Due to Staphylococcus
C

arbuncle:







Infective gangrene of skin and subcutaneous tissue
m/c Staphylococcus aureus
m/c site is nape of neck

m/c in diabetics



•
•
•
•

B-Hidradenitis suppurativa













1.
2.
3.
4.
5.
6.

Chronic fibrous and infective disease of skin-bearing apocrine sweat glands.
Apocrine glands are those, which open into hair follicle
m/c in diabetics
m/c in axilla
m/c due to staphylococci
Treatment: Excision with grafting.

Contd...

tahir99 - UnitedVRG