Ebook Clinical surgery pearls (2/E): Part 1

CLINICAL SURGERY PEARLS



CLINICAL SURGERY PEARLS
SECOND EDITION

R Dayananda Babu MS MNAMS
Professor and Head
Department of Surgery
Sree Gokulam Medical College and Research Foundation
Venjaramoodu, Thiruvananthapuram, Kerala, India

Foreword

Mathew Varghese

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Clinical Surgery Pearls
First Edition: 2010
Second Edition: 2013
ISBN 978-93-5090-396-4
Printed at


Dedicated to
My late parents for their love and affection –
Mr Raghavan and Mrs Mallakshy
My only sister – late Ms Damayanthy
My wife – Professor (Dr) Geetha Bhai and
to my beloved son Deepak D Babu

for their moral support
My teachers for their wisdom
My patients for their trust and support
My students for their assistance



Foreword
Professor R Dayananda Babu is known to me for the past forty years. I have great admiration for his wealth
of knowledge in the subject of surgery.


He has written the book Clinical Surgery Pearls with careful and persistent effort. The overriding goal has
been the mobilization of information relative to the science and skills of surgery. In addition to defining
the frontiers of surgical knowledge, it affords the student to assimilate the fundamentals in an easy way.





This book will be an enormous help to those who are studying surgery at both undergraduate and
postgraduate levels.
I wish the book a great success.

Professor (Dr) Mathew Varghese
MS FRCS Ed

Emeritus Professor of Surgery
Government Medical College
Kottayam, Kerala, India

Preface to the Second Edition







The first edition of this book was published in 2010. It is gratifying to note the wide acceptance of this
book as an exam cracker by undergraduates and postgraduates alike; and, therefore, I was forced to bring
out the second edition within 2 years of the initial publication. I am happy to note that now this book is
recommended by many universities.
There is no need to stress the importance of refreshing a book like this. I was forced to spend many hours
in rectifying the errors which have crept up in the first edition. The old chapters have been thoroughly
revised and updated. The new American Joint Committee on Cancer (AJCC), 7th edition, has been used for
staging and management, instead of the 6th edition of AJCC as used in the first edition. At the end of some
of the important cases, colored boxes have been used under the title “What is new—For postgraduates,
the unique unorthodox style, the student-oriented approach and the question-answer format are still
retained.”
I am grateful to Professor John S Kurian, who is Professor of Surgery at Government Medical College,
Kottayam, Kerala, India, for the effort he has taken to find out the errors and for coming up with suggestions
for improvement. I also thank Dr Deepak George, for his valuable suggestions for improvement of many
of the chapters.
I also thank the publisher M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for bringing
out a high-quality second edition book quickly.

R Dayananda Babu

Preface to the First Edition









This book is the final result of my continuous teaching and learning process with my undergraduate and
postgraduate students in surgery. Whenever I interact with my students, I realize their problems and
deficiencies and find out the solutions, so that it reaches them. Whenever I read a chapter, a series of
questions will come to my mind and then I will try to answer those questions. That is exactly the reason
why this book is in question-answer format. The flow charts and tables in this book are evolved in the
classrooms and bedside teaching area.
Whenever I read a topic, I try to define the condition. I feel that when you define something, half the
problem is solved; and, therefore, the first chapter is devoted to definitions. There are more than 100
definitions in this book.
Another important aspect of any learning process is to find out the concepts behind the disease process
and management. These concepts are converted to an easily digestible capsule form in this book for the
students. As an examiner at undergraduate and postgraduate levels, I realized that most of the time the
students miss many important clinical points during case presentation, not because they do not know
them but because they do not have a checklist. Therefore, I have given the checklist for all clinical cases.
The questions for the postgraduate (PG) students are marked as PG in brackets so that the undergraduate
students can skip them if they feel so.
More than 50 clinical cases are discussed in this book (both long ones and short ones). Each case starts

with a clinical capsule and questions are formulated based on the clinical capsule. There is a separate
chapter for radiology and imaging and about 32 skiagrams are discussed. Important tables and charts
are included as a separate chapter for ready reference.
This is a clinical book of definitions, checklists, tables, flow charts, questions and answers. All my classes
are distilled into a book and the title is Clinical Surgery Pearls. The preparation of this book took seven long
years of hard work, and I completed this book single handedly. All the clinical photographs are taken by
me with a small Kodak digital camera. The highlighted boxes and charts in this book will make it easily
readable. I am sure, the unique style and the student-oriented approach will make the learning process
a pleasant experience.

R Dayananda Babu



Acknowledgments



I am grateful to:
• All my patients, for permitting me to take clinical photographs.
• My favorite student Dr Suraj Rajan, who has drawn the medical illustrations in Adobe photoshop and
who is now working in the US. He also read the first “raw copy” and gave suggestions from the “student
point of view”, which is incorporated as student review. I am short of words to thank him.
• All my Professors and teachers in surgery. I remember my great teachers like Professor CKP Menon,
Professor KJ Jacob, Professor Mathew Varghese, Professor Balsalam, Professor Mohankumar, Professor
KY Roy and Professor CK Bahuleyan.
• My wife Dr Geetha Bhai, who helped me in proofreading and editing this book and without her help
this could not have been possible.
• All my postgraduate and undergraduate students in surgery.
• Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director) and Mr Tarun Duneja (DirectorPublishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India.

• Mr PM Sebastian (Branch Manager, Jaypee Brothers, Kochi) and Mr Arun Kumar (Senior Sales Executive,
Jaypee Brothers, Kochi) and all the staff of Kochi Branch for bringing out this book in time.
• Finally, Mr Subramanian, for spending time with me and doing the DTP work of this book.



Contents
SECTION 1: Definitions
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Definitions..................................................................................................................................................................................... 3
SECTION 2: Long Cases

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Case 01: Toxic Goiter................................................................................................................................................................21
Case 02: Solitary Thyroid Nodule (STN-Nontoxic).........................................................................................................45
Case 03: Papillary Carcinoma Thyroid with Lymph Node Metastases ...................................................................52
Case 04: Multinodular Goiter ...............................................................................................................................................68
Case 05: Early Breast Cancer .................................................................................................................................................74
Case 06: Advanced Breast Cancer.......................................................................................................................................95
Case 07: Epigastric Lump .................................................................................................................................................... 106
Case 08: Right Hypochondrial Lump without Jaundice .......................................................................................... 119
Case 09: Right Iliac Fossa Mass (Suspected Ileocecal Tuberculosis) .................................................................... 128

Case 10: Suspected Carcinoma of the Cecum............................................................................................................. 134
Case 11: Appendicular Mass .............................................................................................................................................. 146
Case 12: Obstructive Jaundice .......................................................................................................................................... 152
Case 13: Varicose Veins ........................................................................................................................................................ 168
Case 14: Peripheral Occlusive Vascular Disease.......................................................................................................... 188
Case 15: Lymphoma ............................................................................................................................................................. 207
Case 16: Renal Swelling ....................................................................................................................................................... 224
Case 17: Pseudocyst of Pancreas ..................................................................................................................................... 235
Case 18: Retroperitoneal Tumor....................................................................................................................................... 241
Case 19: Testicular Malignancy ......................................................................................................................................... 248
Case 20: Portal Hypertension ............................................................................................................................................ 261
Case 21: Mesenteric Cyst .................................................................................................................................................... 278


Clinical Surgery Pearls

SECTION 3: Short Cases

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Case 22: Non-thyroid Neck Swelling .............................................................................................................................. 285
Case 23: Tuberculous Cervical Lymph Node................................................................................................................ 288
Case 24: Cervical Metastatic Lymph Node and Neck Dissections........................................................................ 296
Case 25: Carcinoma Tongue with Submandibular Lymph Node ......................................................................... 308
Case 26: Carcinoma of Gingivobuccal Complex (Indian Oral Cancer) ............................................................... 319
Case 27: Parotid Swelling.................................................................................................................................................... 324
Case 28: Submandibular Sialadenitis ............................................................................................................................. 335
Case 29: Ranula, Plunging Ranula, Sublingual Dermoid and Mucous Cyst...................................................... 340

Case 30: Thyroglossal Cyst, Lingual Thyroid, Ectopic Thyroid, Subhyoid Bursa and
Carcinoma Arising in Thyroglossal Cyst ....................................................................................................... 343
Case 31: Branchial Cyst, Branchial Fistula, Cystic Hygroma .................................................................................... 349
Case 32: Soft Tissue Sarcoma ............................................................................................................................................ 355
Case 33: Neurofibroma, von Recklinghausen’s Disease........................................................................................... 364
Case 34: Lipoma (Universal Tumor)................................................................................................................................. 370
Case 35: Sebaceous Cyst/Epidermoid Cyst/Wen/Dermoid Cyst........................................................................... 373
Case 36: Ulcer .......................................................................................................................................................................... 378
Case 37: Malignant Melanoma ......................................................................................................................................... 388
Case 38: Basal Cell Carcinoma/Rodent Ulcer ............................................................................................................... 402
Case 39: Squamous Cell Carcinoma—SCC (Epithelioma) ....................................................................................... 407
Case 40: Carcinoma Penis ................................................................................................................................................... 414
Case 41: Congenital Arteriovenous Fistula/Hemangioma/Compressible Swelling ...................................... 422
Case 42: Unilateral Lower Limb Edema ......................................................................................................................... 432
Case 43: Hydrocele of Tunica Vaginalis Sac (Epididymal Cyst, Spermatocele,
Varicocele, Hematocele, Chylocele, etc.) .................................................................................................... 441
Case 44: Inguinal Hernia/Femoral Hernia ..................................................................................................................... 450
Case 45: Incisional Hernia (Ventral Hernia, Postoperative Hernia) ...................................................................... 469
Case 46: Epigastric Hernia (Fatty Hernia of the Linea Alba) ................................................................................... 474
Case 47: Paraumbilical Hernia, Umbilical Hernia in Adults and Children.......................................................... 477
Case 48: Desmoid Tumor, Interparietal Hernia (Interstitial) and Spigelian Hernia ....................................... 483
Case 49: Gynecomastia/Male Breast Carcinoma ........................................................................................................ 486
Case 50: Fibroadenoma/Cystosarcoma/Breast Cyst/Fibroadenosis/Fibrocystic
Disease/ Mastalgia/Mastopathy/Chronic Mastitis ................................................................................... 494


Contents

SECTION 4: Radiology and Imaging
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Radiology Questions and Answers ................................................................................................................................. 503
SECTION 5: Important Tables and Charts

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Index

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General ...................................................................................................................................................................................... 559
Trauma ...................................................................................................................................................................................... 567
Burns ...................................................................................................................................................................................... 574
Neck ...................................................................................................................................................................................... 578
Breast ...................................................................................................................................................................................... 579
Abdomen ................................................................................................................................................................................. 583
Vascular ..................................................................................................................................................................................... 594
Limbs ...................................................................................................................................................................................... 599
Anorectal .................................................................................................................................................................................. 604
...................................................................................................................................................................................607

xvii


Sayings of the Great

1. Take up one idea
Make that one idea your life
Think of it, dream of it, live on it
Let the brain, muscle, nerves and every part of your body be full of that idea
Leave the other ideas alone.
—Swami Vivekananda


2. Give the best you have and the best shall come back to you.
—Holy Bible


3. Reading maketh a full man, conference a ready man and writing an exact man.
—Francis Bacon









4. All truth passes through three stages
First, it is ridiculed
Second, it is violently opposed

Third, it is accepted as being self-evident.
—Schopenhauer





5. The world is not divided into the rich and poor, the successes and failures,
but into learners and non-learners.
—Benjamin Barber


1

Section

Definitions



Definitions

1. Abdominal Apoplexy
Spontaneous hemorrhage into the peritoneal cavity.
Causes:
a. Tumors –Hepatoma
–
Spleen
–
Other organs

b. Arteriosclerotic lesion in older individuals
–
Superior mesenteric artery:
Mesenteric apoplexy (spontan­­eous rupture)
–
Right colic artery
–
Branches of celiac.
c. Hemorrhage from congenital aneurysm in
young patients — bleeding from splenic artery
aneurysm in pregnancy.

2. Abscess, Cold Abscess
Abscess: It is a localized collection of pus in a
pathological space lined by granulation tissue.
Cold Abscess: Soft fluctuant swelling without signs
of inflammation, which is mistaken for a cyst. This
is lined by granulation tissue and caseous material.
It is due to tuberculous infection and contains
tubercle bacilli. It is not hot. Brawny induration,
edema and tenderness are absent.

3. Acute Abdomen
Any sudden spontaneous nontraumatic disorder
affecting the abdomen for which urgent operation
may be necessary and undue delay in diagnosis may
adversely affect the outcome.

4. Activities of Daily Living (Adl)
It is critical to assess the functional status of the

prospective older candidate for surgery prior to
scheduling an operation.
The activities are:
1. Feeding oneself
2.Bathing
3. Toileting (continence)
4. Transferring from bed to chair
5.Dressing
6.Grooming.
Instrumental ADLs are more complex:
a. Food preparation
b.Shopping
c.Blanching.

5. Agenesis/Atresia
Agenesis: Failure of the development of an organ
or structure.
Atresia: Failure to canalize viscera.


Clinical Surgery Pearls

6. Amylase
A serum amylase level four times above the normal
is indicative of acute pancreatitis.

7. Ankyloglossia
Inability to protrude the tongue due to involvement
of the muscles of tongue by carcinoma. The tongue
deviates to the affected side.

8. Apathetic Hyperthyroidism
Asymptomatic mild hyperthyroidism occurring in
the elderly recognized only by laboratory findings.

9. Arc of Riolan (Meandering Mesenteric Artery)
The left colic artery near the splenic flexure
bifurcates; one of the branches passes to the right
in the transverse mesocolon to anastomose with
a similar branch of middle colic artery to form
the Arc of Riolan. This has got important role in
supplementing the marginal artery (Fig. 10.1).

10. Bacteremia, Pyemia, Septicemia
Bacteremia: Circulating bacteria in the blood
without producing disease.
Pyemia: Circulating infective emboli composed of
masses of organisms, vegetations and infected clots
in the bloodstream.

4

Septicemia: Circulation of bacteria in blood
producing disease.

11. Barrett’s Esophagus
It is a metaplasia of the lower esophageal mucosa
due to replacement of the squamous epithelium,
by columnar epithelium, endoscopically having

salmon pink appearance replacing the whitish
squamous epithelium pathologically showing
intestinal type of epithelium with goblet cells.

12. Biliary Colic, Cholecystitis
The term colic is inaccurate for gallbladder. It
produces constant pain in most cases as a result
of obstruction to cystic duct. The pain last for 1–5
hours, and rarely shorter than 1 hour duration (Right
upper quadrant pain radiating to right upper back,
right scapula or between the scapulas). Pain lasting
beyond 24 hours suggests acute inflammation—
Cholecystitis.

13. Boil, Furuncle, Furunculosis, Folli­culitis,
Carbuncle
Folliculitis: Affection of the root of one hair follicle
alone by Staphylococcus is called folliculitis.
Boil/Furuncle: Infection of the root of the hair follicle
with perifolliculitis caused by Staphylococcus is
called Boil/Furuncle.
Furunculosis: Multiple boils with intervening normal
tissue is called furunculosis.
Carbuncle: Infective gangrene of skin and sub­
cutaneous tissue caused by Staphylococcus
(multiple boils with involvement of intervening
tissue also).

14. Breast Carcinoma—Definitions
Skin tethering and fixity: The skin tethering is due to

early involvement of ligaments of Cooper.
Manifested as puckering of the skin. The underlying
lump can be moved independently of the skin to
some extent.


Definitions

Skin fixity: It is because of invasion of carcinoma
along the ligaments of Cooper to the skin.
The lump and the skin cannot be moved
separately.
Retraction (Recent) of nipple: Extension of growth
along the lactiferous duct and subsequent fibrosis.
Peau d’ Orange appearance is due to blockage
of the lymphatics draining the skin—cutaneous
lymphedema. The hair follicles are more firmly
fixed to the subcutaneous tissue than the rest of
the skin. The hair follicles appear to be retracted
and the between areas swell giving the orange
peel appearance.
Terminal Duct Lobular Unit (TDLU): The functional
unit of the breast is the terminal duct lobular
unit. All cancers of the breast and most benign
conditions arise within TDLU (Fig. 5.4).
Skin Involvement: T4b
Edema (including peau d’ orange) or ulceration of the
skin of the breast or satellite skin nodules confined to
the breast. Dimpling of the skin and nipple retraction
is not considered skin involvement.

Inflammatory carcinoma breast: It is a clinicopatho­
logical entity characterized by diffuse erythema and
edema (peau d’ orange) of the breast without an
underlying palpable mass, involving the majority
of the skin of the breast. This is due to tumor
emboli within dermal lymphatics. The biopsy should
demonstrate cancer within the dermal lymphatic or
in breast parenchyma itself. Neglected LABC (locally
advanced breast cancer) is not inflammatory Ca.
Extensive in situ component: If more than 25% of the
main tumor mass contains in situ disease and there
is in situ cancer in the surrounding breast tissue,

the cancer is classified as having an extensive in
situ component.
Chest wall infiltration: Chest wall includes ribs,
intercostal muscles and serratus anterior muscle but
not the pectoral muscle.
Supraclavicular nodes: These are seen in a triangle
defined by the omohyoid muscle and tendon,
internal jugular vein (medial border) and the clavicle
and subclavian vein (lower border). Adjacent nodes
outside this triangle are considered to be lower
cervical nodes (M1).
Multifocal: Tumor foci in the same quadrant are
called multifocal.
Multicentric: Tumor foci in different quadrants are
called multicentric.
Microinvasion: (Ti mic): Microinvasion of 0.1 cm or
less in greatest dimension.

Micrometastasis: Tumor deposits greater than 0.2
mm, but not greater than 2 mm in largest dimension
having histologic evidence of malignant activity
namely proliferation or stromal reaction.
Isolated tumor cells: Single cell or small clusters of
cells not greater than 0.2 mm in largest dimension
with no histologic evidence of malignant activity.

15. Bruit
It is the sound produced by the turbulent blood
flow through a stenotic arterial segment which is
transmitted distally along the course of the artery.
When a bruit is heard over the peripheral vessel,
stenosis is present at or proximal to that level.
It is heard loudest during systole and with greater
stenosis may extend into diastole. The pitch of the bruit
rises as the stenosis becomes more marked. Absence
of bruit does not indicated absence of occlusion.

5


Clinical Surgery Pearls

When the vessel becomes completely occluded, the
bruit may disappear.

16. Burns, Scald, Fat Burn
Burns: Injury by dry heat.
Scald: Injury by moist heat.

Fat burn: Injury by boiling oil.

17. Bursae: Bunion, Clergyman’s Knee, Golfer’s
Elbow, Students Elbow, Housemaid’s Knee,
Tennis Elbow
Bursae: These are fluid-filled cavities lined with
flattened endothelium similar to synovium. Usually
seen in relation to joints. When they develop over
pressure points, they are called adventitious
bursae (see examples). They prevent friction
during movement. Fluctuation, fluid thrill and
transillumination are positive.
Housemaid’s knee: It is a subcutaneous bursa
between patella and skin.
Clergyman’s knee: It is a subcutaneous bursa
between skin and ligamentum patella.
Students elbow: It is a subcutaneous bursa between
skin and olecranon.

6

Golfer’s elbow: It is medial epicondylitis Tender­ness
can be elicited at the medial epicondyle at the
common flexor origin.
Tennis elbow: It is lateral epicondylitis (Common
extensor origin at the lateral epicondyle is affected).
Bunion: It is a subcutaneous bursa between skin and
head of 1st metatarsal bone.

18. Carbuncle

Read boil.

19. Cellulitis, Erysipelas
Cellulitis: Spreading inflammation of subcutan­
eous and fascial tissue caused by Streptococcus
pyogenes. Commences in a trivial infected wound.
It has “No edge, No fluctuation, No pus and No limit”.
Morison’s aphorism: Cellulitis occurring in children is
never primary in the cellular tissue, but secondary
to an underlying bone infection.
Cellulitis of the scrotum: Always rule out extravasation
of urine.
Erysipelas: It is cuticular lymphangitis.
Milian’s ear sign: Facial er ysipelas spreads
and involves the pinna because it is cuticular
lymphangitis. Subcutaneous inflammations stop
short for the pinna because of close adherence of
the skin to the cartilage.

20. Claudication, Rest Pain
Claudication: (I limp). Claudication is the cramp
like muscle pain which appears following exercise
when there is an inadequate arterial blood flow.
It must fulfil three criteria
1. It is a cramp like muscle pain (usually the calf )
2. Pain develops only when the muscle is exercised
3. The pain disappears when the exercise stops.
Rest pain: It is the continuous pain caused by severe
ischemia. This pain is present at rest throughout the
day and the night. The pain is relieved by putting

the leg below the level of the heart.


Definitions

21. Clergyman’s Knee
Read bursae.

22. Cold Abscess
Read abscess.

23. Compressibility, Reducibility
Compressibility: When the contents of a swelling can
be emptied by squeezing but the swelling reappear
spontaneously on release of pressure.
Reducibility: When the contents of a swelling can
be emptied by squeezing but does not return
spontaneously. This requires additional force such
as cough or effect of gravity. For example, Hernia.

24. Compound Palmar Ganglion
Compound palmar ganglion: It is a tuberculous
affection of ulnar bursae, with a swelling in the
hollow of the palm, extending to the lower forearm. Cross fluctuation can be elicited between the
palm and lower forearm.

25. Constipation, Obstipation

joint contain loose bodies. May communicate with
joint. It is also seen in the following conditions:

• Subcutaneous emphysema (surgical emphy­
sema)—gas is present in the subcutaneous tissue.
Four types:
a. Traumatic: Fracture ribs, injury to nasal fossa,
breach of continuity of larynx, tracheostomy,
fracture skull involving sinuses
b. Infective: Gas gangrene
c. Extraneous: After fluid administration, closure
of surgical wound, etc.
d. Complicating rupture of esophagus
• Fracture of bones
• Extravasation of gas in pneumoperitoneum
• Pseudo gas gangrene (air entrapped in the
subcutaneous tissue after laparotomy).

28. Cyst
Cyst: It is a pathological fluid-filled sac bound by a
wall. It may be true or false, congenital or acquired.
True cyst: It is one in which the sac is lined with cells
of epithelial origin.

Constipation: A bowel frequency of less than one
every 3 days. (Fewer than two per week).

False cyst: It is a walled off fluid collection not lined
by epithelium. False cyst may be inflammatory or
degenerative.

Obstipation: (Absolute constipation): Absence of
passage of both stool and flatus.

Examples of false cyst

26. Cough Impulse
Cough Impulse: Expansile impulse seen or felt over
a swelling when the patient coughs, cries or strains.

27. Crepitus
Crepitus: (Grating or crackling sensation imparted
to the examining fingers) may be present when the

• Dental/Radicular cyst
• Encysted pleural effusion
• Pseudocyst of pancreas
• Cystic degeneration of tumors
• Brain cyst.

29. Dermoid
Dermoid: Cyst formation due to sequestration of
epithelium deep to the skin surface.

7