MEE

My PG
Notes

Surgical incisions, Needle and Suture Materials

/e
Surgery

,1
es
SIMPLE SUTURES CONTINUOUS SUTURE HORIZONTAL MAT TRESS VERTICAL MAT TRESS
• Used to produce eversion or inversion of wound edges
ot
Final knot is done by
• Done for accurate approximation
aberdeen knot
N
EE
M

Classification of Suture Materials

PG

Suture Types (Color) Generic Structure Classification Representative

Product/Brand
Catgut Collagen from animal Natural, absorbable, twisted Surgical Catgut
y

intestines multifilament (mono.) Chromic Catgut

M

Silk (Light Blue) Fibroin from silkworm Natural, non-absorbable Perma-Head

(Bombyx mori) braid multifilament Softsilk
Polypropylene (Royal Isotactic crystalline Synthetic, non-absorbable Prolene,
Blue) stereoisomer of PP monofilament Surgipro
Polyamide (Sea Green) Nylon 6 and nylon 6,6 Synthetic, non-absorbable Ethilon,
monofilament Dermalon
Stainless steel (Silver) 316L (low carbon) stainless Metal, non-absorbable mono Ethisteel,
steel alloy and multifilament Flexon
Polyglycolic acid/ 90% PGA, 10% PLA Synthetic, absorbable braided Vicryl,
Polylactic acid (Purple) multifilament Vicryl Rapide
Polydioxanone (Grey) Polyester p-dioxanone Synthetic, absorbable PDS II
monofilament
446 Polyglycolic acid Poly- Copolymer of glycolic acid and Synthetic, absorbable Maxon
trimethylene carbonate trimethylene carbonate monofilament

notes
 My PG
MEE
Notes

Lymph Nodes

Most Common Lymph Nodes

Involved

CA penis — Inguinal nodes

CA testis — Inter aorto caval
(right); paraaortic (left)
CA bladder — Obturator LN
CA prostate — Obturator LN

/e

Surgery
,1
es
ot
N
EE

Tumor Classifications Most Common Symptom

M

Bloom Richardson Ca Breast Abdominal pain CA Small bowel

grading Abdominal pain CA colon
PG

Chang staging Medulloblastoma Abdominal Pain >weight CA Stomach

Duke staging Colorectal carcinoma loss
Gleason staging ca prostate Abdominal Pain >weight HCC
y

Jackson staging Ca penis loss

M

Masaoka staging Thymoma Biliary colic CA Gallbladder

Noguchi classification Adenocarcinoma lung Bleeding PR CA Rectum

Nevine staging ca gallbladder Bleeding PR CA anal canal

Reiss and Ellsworth REtinoblastoma Dysphagia >weight loss CA Esophagus

classification Jaundice Periampullary
Esson Prognostic index carcinoma(including
Robson staging RCC CA head of
pancreas)
Shimada index Neuroblastoma
Painless progressive Cholangiocarcinoma
Sullivan modification Adrenocortical
jaundice
of Macfarlane system carcinoma
*Rockall scoring is used for risk stratification in case of
upper GI bleed[2018] 447

notes
 My PG
MEE
Notes

GIT

Zenker Diverticulum
zz Common in >60 years and
MC in males
zz Pulsion type diverticulum.
zz Usually on the left
zz MC symptom is Dysphagia
[Intermittent]
zz Other symptoms are
regurgitation of undigested
food and Halitosis

/e
zz 30% have associated GERD

Surgery
and 50% associated with

,1
Cervical web
zz MC complication- Aspiration Pneumonitis

es
zz Morton-Bartney’s classificationfor Zenker:
<2 cm Small
ot
2-4 cm Medium
N
>4 cm Large
zz Diagnosis by Barium study
EE

zz Treatment:
<2 cm Myotomy/ Botulinum Toxin
M

>2-3 cm Dohlman’s Procedure [Endoscopic]

2-4 cm Myotomy/ Botulinum Toxin +
PG

Diverticulopexy
>4 cm Diverticulectomy Followed by
Cricopharyngomyotomy
y
M

Epiphrenic Diverticulum
zz Pulsion type diverticulum
zz located in distal 10 cm of esophagus
zz Motility disorder causing outflow obstruction
is the cause
zz DIAGNOSED BY Barium studies.
zz Treatment:
 Treat motility disorder
 For small diverticulum (maxi. cases →
Diverticulopexy
 For large diverticulum → Diverticulectomy
451

notes
 MEE
My PG
Notes

Esophagus

Tracheoesophageal Fistula

/e
Figure:  Classification Tracheoesophageal Fistula
Surgery

zz Incidence- 1:3500

,1
zz MC in males.
zz Associated with VACTERL (vertebral, anorectal, cardiac, tracheal, esophageal, renal, and limb)

es
anomalies
zz Diagnosis by presentation - infant with excessive salivation and coughing and Choking during
ot
first oral feeding.
zz Cardinal feature for diagnosis → Inability to pass a Nasogastric tube
N
zz Management:
 Waterson criteria based on weight and presence of pneumonia and anomalies
EE

 If the distance between the two ends is less → Open Thoracotomy with Extrapleural dissection
[done usually for the distal TEF type]
 When there is long gap between the two segments → circular/ spiral esophagomyotomy is
M

done to gain additional length

If the gap is longer than Jejunum is used to connect the two segments.
PG



GastroEsophageal Reflux Disease (GERD)

GERD results from the failure of the endogenous antireflux mechanisms[ LES and spontaneous
y

zz

esophageal clearance]
M

zz LES is not an anatomic structure rather it is a zone of high pressure[depends on length of Intra-
abdominal esophagus which normally is 2-5 cm] located in lower end of Esophagus
zz GERD is commonly associated with Hiatal Hernia due to abnormal anatomy of sphincter.
zz Heartburn is MC esophageal symptom(80%) > Regurgitation (54%)
zz Cough (27%) is MC extraesophageal Symptom
zz Reflux brings the pH of Lower Esophagus to <4 Intestinal Metaplasia → BARRET’S ESOPHAGUS.
zz Investigation- 24 hour pH monitoring (a pH of <4 is considered an episode of acid reflux)
zz Treatment:
 Lifestyle modifications → frequent small meals during day and avoid Fatty meals
 Medical management → Antacids, PPI and H2 blockers
 Surgical management → same as Hiatus hernia
 Fine transverse old in the body of esophagus due to contraction of longitudinal muscles is called Feline
452 esophagus[2018]

notes
 My PG
MEE
Notes

Hiatus Hernia

/e
zz Esophagitis is MC complication.

Surgery
,1
zz Investigation of choice is Barium meal
zz RETROCARDIAC AIR FLUID LEVEL seen in X ray

es
zz Treatment: Surgical mostly
ot
OTHER Surgical options are:
N
• Colli’s gastroplasty
• Ellison’s repair
• Hill repair
EE

• Watson gastroplasty
M
PG

Barret’s Esophagus

zz Intestinal metaplasia of lower end of

y

Esophagus due to exposure to Very low pH

M

zz Contents.
zz Diagnosed by Endoscopic biopsy and studying
the Biopsy with Alcian Blue staining
zz Presence of Goblet cells is important to make
diagnosis.
zz Management:
 Needs aggressive Medical management
with 2 yearly follow-up
 Cases progressing to dysplasia are treated
with RFA
 Cases progressing to Anaplasia are
treated with Esophagectomy.
453

notes
 MEE
My PG
Notes

Benign Prostatic Hyperplasia

zz MC benign tumor of males after 65 years
zz Clinical features:
 Irritative symptoms
ff Frequency
ff Urgency
ff Nocturia
 Obstructive symptom
ff Hesitancy
ff Intermittency
ff Thinning of stream
ff Retention
INVESTIGATIONS: TREATMENT

/e
MEDICAL SURGICAL
Surgery

,1
• Digital Rectal examination (DRE)-Smooth • Hormonal→5-α • TURP
elastic enlargement of prostate is noticed. reductase inhibitor ƒƒ Gold standard in open

• Symoatholytic→α1 surgery
(hard, indurated prostate→cancer)

es
blocker (Prazosin, ƒƒ Ion free solution is used
• USG- Transrectal USG is better but TAS is ƒƒ If distilled water is
terazosin)
usually done
used→can cause Dilutional
• PSA-
ot
Hyponatremia→managed
ƒƒ produced by normal prostate
with Na repletion
N
ƒƒ normally 0-4 ng/ml ƒƒ Complications:
ƒƒ >10 suggestive of Carcinoma and >20 is ff Retrograde ejaculation
EE

diagnostic of carcinoma (MC)

ƒƒ PSA + DRE →95% accuracy ff Hemorrhage

• Uroflowmetry ff Clot retraction

M

ƒƒ Non-invasive procedure ff Water intoxication(TURP

Syndrome)
ƒƒ Requires a minimum volume of 120 ml
PG

• Open Prostatectomy
urine for the procedure to be interpreted ƒƒ For large prostate (>75
ƒƒ Qmax→ >15 ml/sec →normal grams) or bladder stone/
ƒƒ Qmax→10-15 ml/sec→Equivocal diverticula
y

ƒƒ Qmax→<10 ml/sec→suggestive of BPH

M

Prostate Cancer
zz Risk factors:
 Advanced age
 High fat intake
 Deficiency of Vitamin- A,C and E
 Deficiency of Zinc, Selenium, Lycopene
zz Asymptomatic mostly(initial stages)
zz Can present with localised or metastatic disease
zz The most common site of spread of prostate cancer is the pelvic lymph nodes and bone
zz Prostate cancer is graded according to the Gleason scoring system.
488

notes
 My PG
MEE
Notes

zz Gleason score, preoperative PSA level, and digital rectal exam are used to estimate the likelihood
of whether the cancer is localized, locally advanced, or metastatic
zz Prostate cancer with a high Gleason score (8 to 10) or a high PSA level (>20) is much more
likely to have spread
zz Treatment:
Localized disease Radical prostatectomy (retropubic, perineal, or robotic-assisted laparoscopic approaches),
brachytherapy,
external-beam radiation therapy.
Low-risk disease Radical prostatectomy (open or robotic) can be performed with unilateral or bilateral
cavernosal nerve sparing (Walsh prostatectomy)- done to limit postoperative erectile
dysfunction (ED).
High-risk disease Either non–nerve-sparing surgery or external-beam radiation therapy + androgen
deprivation(B/l orchidectomy or LHRH agonist) may be performed

T1a Observation + follow-up

/e
T1b to T2 >70 years

Surgery
<70 years

,1
Radical prostatectomy
T3, T4 androgen deprivation (B/l orchidectomy/ LHRH agonist) + Flutamide

es
Penis ot
PHIMOSIS PARAPHIMOSIS
N
• Congenital or acquired • Iatrogenic(catheter induced)
EE

• Inability to retract prepuce over glans • Occurs due to Tight ring around glans leading to
• Ballooning of prepuce during micturition vascular insufficiency and gangrene in severe cases
• Treated with steroids or Surgical • Treated with Ice bag application + Hyaluronidase
M

excision(Circumcision) injection
PG

zz Peyronie’s disease→ Idiopathic fibrosis causing Chordee→Nesbit Operation is done

zz Priaprism→Painful persistence of Erection→Shunt surgery is done
y

Epispedias Hypospedias
M

• Rare • Common
• External opening in dorsal • External opening in ventral aspect of penis
aspect of penis • Associated with ventral Chordee,
• Associated with dorsal • Associated with Hooded prepuce (penis only on dorsal aspect)
Chordee • Surgeries done:
• Penopubic type(asso. With ƒƒ Magpai (meatal advancement glanduloplasty)
Ectopia vesicae) ƒƒ Mathew (for distal penile involvement)
• Treated with repair of ƒƒ Mustardee
epispedias and correction on ƒƒ Koyanagi
incontinence ƒƒ Denis Brown (done in two stages, for proximal/mid penile)
ƒƒ Asopa and Duckett (for proximal/mid penile)

489

notes