Clinical Surgery, El-Matary

'It is more blessed to give than to receive.

Freely you have received; freely give.

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@ Copyright 2013 by Mohammed El-Matary
All rights reserved. No part of this book may be used or reproduced in any
manner whatsoever without written permission, except in the case of brief
quotations embodied in critical articles or reviews.
The publishers have made every effirt to trace the copyright holders for borrowed
rnaterial. If they have inadvertently overlooked any, they will be pleased to make the
necessary aruangements at thefirst opportuniQ.
1't Edition 2006

znd Edition 2oo7
3'd Edition 2oo8
4th Edition 2oog
sth Edition 2o1o
6th Edition 2o1o
7th Edition 2012
8th Edition 2013
For further lnformation, visit our web site:

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Dedication
Allah the all merciful, I beg Thee
To acceptthis effort
For the soul of my mother
She was your gift for me

Acknowledgement
The author wishes to acknowledge with gratitude:
Dr. Said Abdel-Baky,
Professor of Surgery - Ain Shams University
Who had helped in reviewing of this book & who have
contributed with his suggestions and ideas for the new edition.
Specia! Thanks to:

Kareem Mohamed Ali, M.B.B,Ch
Ain Shams University
Amira Ahmed, M.B.B.Ch

Ain Shams University
This book provides an update for medical students who

need to keep abreast of recent developments. I hope also it
will be useful for those preparing for postgraduate
examination.
This book is designed to provide a concise summary of

clinical surgery, which medica! students and others can use
as study guide by itself or with readings in current textbooks,
monographs, and reviews.
Summaries of relevant anatomical considerations are

included in every chapter, taking into account that this book
is written primarily for those who have some knowledge of
anatomy, physiology, biochemistry and pharmacology.
The author is extremely grateful to all the contributors for

the high standard of the new chapters, and hopes that you,
the reader, will enjoy going through these pages as much as
he had.
M. El-Mutury
Table of Contents
I Swelling Sheet I
2 Thyroid Sheet 28
3 Inguinoscrotal Sheet "Hernia" 79
4 lnguinoscrotal Sheet'Varicocele" r06
5 InguinoscrotaI Sheet "Hydrocele" tt7
6 Breast Sheet 132
7 Lymphatic Sheet 166
8 Ischemia Sheet t9t
9 Varicose Veins Sheet 221
lo Abdomen Sheet 242
ll Ulcer Sheet 289
t2 Orthopedic Sheet 299
t3 Nerue Iniury Sheet 314
t4 Parotid Sheet 320
l5 CIeft Lip 8t Palate Sheet 328
t5 Hypospadius Sheet 329
t7 Undescended Testis Sheet 329
* Name (i)l) 4+l dL-'l
* Age i.u as arie
" Sex
* Marital status t 6ujl
(s i n g I e- m a rri ed-w i d ow- d ivo rced) f ci.l cr egi:"
f |He fls dl$e
qt
t $ A, jrr-,t
* Specra I habits of medical importance, riAq
t i.L, ds d[q f fjr.ll oi 6-.;trl* pls
t 4.ll ,'.lL,r f EJnill o.ta s$i cQ
f Crl-.;S-c al 6-yi"S -.r*ii
r-r.
" Address S 416St*l clt

* Residence fdlfA ,rt, . .[9L cfobJ.rSlS.
" Occupation, f +l di5.ii

* lf
?) menstrual history f ci.l 6sJl ,$4lA Lbl
f ,*l iJtrJl ,ilhi ;J'a il
f Arts3j^ 6_.p.rll
I p3; plS dlbr O-rSi.r.S I 4+l rg ,JS o+:*
fU$'(" '
f eLieL' - cj*ar 1+l ri 6&l f s++L d.lY3l P,
f 4+1. drsll C.rel.iJL dlrsi-,|
L,i*i3...11 q! .F,yJl .Eilf

-dLb,JJl
HPI: duration + ei.l F+L, ,:ds iy -.lrrt
1) Petl
Mnemonic for pain ) Socrates:
S) site.
O) onset.
C) character.
R) radiation or referred.
A) alleviating factor, associated symptom.
T) timing.
E) exacerbating factor.
S>
. Site t es.sll Ots. #J
) Localized to swelling or shooting distally

(tumor compressing the nerve or infiltrating it)
. C.h.er.+.sf.er 4+l 4Js*i o.t 6-s.Sll
Dull aching pain ) chronic conditions. di3

Throbbing pain ) pus formation. e$
stitching is.i,s-i
. Radiation, !,filJ.d*
. What increases & what deCreases it 4.aE# - ossj+,rlll +l
. Onset GJJ+ Y3 6.trl3 6.Jr qJ,ar
. Course f Jr l-o
6j YS s.-.1+
. Duration 4+l $ 4Jq
A. sp.e.ei+.t ed $v mp.t p..ltts dLle

. &i; A*ije.rt-i
v lLr.. ob
- The most reliable way to obtain precise information on the location of pain is to
ask the patient to point to the exact site of the pain and where it radiates. Pain
may be localized or diffuse and can be referred. Localized pain is either
musculoskeletal in origin or is indicative of disease, trauma or inflammation in
the affected region. Pain may be referred to the corresponding sensory
dermatome.
Ae.gSSlt OtS. gll
. Size > (lemon size, orange size ...) a;t .ri te 'r-
. Onset €l-,1lieJSlsll c&i3sl

- Accidental ) breast swellings
- Acute onset: ) sudden (within minutes) ) Perforation.
) rapid (hours or days) ) acute inflammation.
- Gradual onset (weeks or months): ) chronic inflammation
or neoplastic swellings
. Course: 4+ L. cpj Ys +.ti
- Progressive: ) neoplastic swellings.
- Stationary: ) chronic inflammation.
- Regressr've: ) inflammatory conditions.
- Fluctuating: ) chronic inflammation with acute exacerbation.
4+l $ tell+
P..Hrnli.qn,
- Short: (days or weeks) ) inflammatory.
- Long: (months or years) ) neoplastic.
- Srnce bifth ) congenital.
N.B: Lumps with shorter duration + pain = acute inflammatory,
Lumps with longer duration + slight poin = chronic inflammatory.
Lumps with longer duration & no pain = benign tumor.
with shorter duration +/- sliqht pain = maliqnant tumor.
. O_thel ewe_l!_i;1gq: dl$e
sjtj 6;sX .,.i
) Multiple lipoma, Neurofibroma.
) Lymph nodes ) in inflammatory conditions.
) Metastasis in malignancy.
.E ffepl. qn..th
I e. g en e.r.d..e e n ditis n'
ul; cr;*,ri - {3J.dl d!*ij - cr.ie.Jil -drii-.
Toxic symptoms: ) FAHM

Malignant symptoms: ) cachexia.
TB: ) night sweatinE, night fever, anorexia & loss of weight.
. A.p.p.+.+p..n f..qns.q.s,
AeJSJSll i!+.r 4+l JS3ii
) Trauma, lifting heavy weight, emotional stress.

. What inc what decreases it
l+ 'a:ri
3l tlr3;i 4+t 1,!
3) Disturbance of function
4) Review of Other systems:
- GIT: e.g nausea, vomiting, abd. pain, change
in the bowel habits
- Respiratorv svs.: e.g cough, hemoptysis
- CVS: dyspnea, chest pain, palpitations
- Urogenital: loin pain, dysuria,
- Nervous sYs.: change in behavior, loss of
consctousness
- Musculoskeletall ms, bones or joint pain.
5) History of investigations or medications

P-a-Et-hls-t-q-ry
. Similar attacks.
. Common diseases: (DM, Hypertension, TB, B, Hepatitis, DW)
. Drug allergy & intake
. Blood transfusion
. Previous Operations
4
T.B Hypertension Diabetes
ld; +
f! r ar3 id 611--1 ellL= dlJe # ..JS- dl$e
dblL,jA*4 criS
f ,+ .i- f ,+.i-
J:j+; c!-r. qill cJI-r ! +.rl
?\i z)-c Crlil f a;l crlil
6).e
J J\' ll J.iL.*
--i d3'+-= 3
4lJJt ;;r:iJ 6).c c.,.s,i f ql rI 4ie '+ I a;l ri 4ic. !+
l{anafifie f6lS glS 4j-! iJ," Fl f plS rJlS ,J!l=l JAI
Ji.-leA,ili;e OJI
SGcL:. €i dl.:- ,'o,"i
u;:l cj:+ll ct:l_r (.,Lscl
Y
,l^
caL^sll t'r- 1
Bilharziasis
D.V.T
I
d-L3.r.ll j Clgr-r. S,'F-?JrJ dyJJ,rll! o.tS LhI l+-Jl+l+ dlll+

pr CI!;i-,r dllSrl
ea...jllll Jl dJ+ll ,.i pr dlJLr.3 ors 43le..;iJt ,',tJ
eia lj.c 6r !t<-t1
Drug allergy !16)le o.ril
4+l JE 4&-,1;
A-Eij.6-.;gr; L;rl .riti ,..Ji:. ,4!t6J Ll&+ eISL
9l3r ci i'. i;*t *r Ar.ie Ds rr+ Ae_,till d,,lji
Others
ors &l ill ,rlltir

e-... lsS &3elLe crJ.re
cil.teL:. Llu1d,ar - sL ij. - 4+l 4jLe
6-+rtcF 'r.gn 3i
t-amily-his-tsjy
. Similar condition in one of the members of the family.
. Consanguinity
Browse's introdttction to the symptoms & signs of surgical disease/ Chlhistory taking / P1---+ 10
lE4amination
G-enp-ral:
rIr
31i.1""{
L ' essions.
Complexion ) (3 colors) Jaundice, pallor & cyanosis.
Chest & heart
Abdomen.
Extremities
Pulse, blood pressure & temperature.
Head, Neck, Spine (esp. in breast swelling) ) 3 dJJ#tj
Loeal: 4jJ^J .,le .-E : cl$ll ,,Jo C*
di, , rLJt*{t P\'--'

*a'
Cd=iJt 1n=
E-Xp-O-S_U-fe ) til area of LN drainase
[n-qpe-g-ti-qn=
From zdifferentplanes & .-*.3 -l
A..Sl.elling ql
1. Number: {
-e'
- Single or multiple i
.5,
-i
- Multiple swellings may be lymph nodes, .r{
oa
lipomas...
2. Site
- The anatomical region of the swelling.
3. Size
- ln cm (best)
4. Shape
Butterfly
H,,. S-ki...+..q.Y..e rFJns.;

Normal, Stretched, Pigmented,
Show sign of inflammation (redness, edematous...),
Dilated veins, Ulcer, Scar...
p.
-c*. .$p.e r.al. .q-ign
q
;
Expansile impulse on cough ) hernia.
Pulsation ) aneurysm, vascular swelling.
Moves up with deglutition ) thyroid.
Moves up with protrusion of the tongue ) thyroglossal cyst.
Transmitted pulsation Expansil lsation
,/r\
,//
*
ks1)
<Mt
<..o./t/t'
ation:
.1.r.W.+fmfh: +lt r€lir asis
. Temp J in inflammatory swellings and vascular swellings
z.
LJJtjii
For
warmth
T.gndgf[g$$: oLrll a+: ,] c# -r '+ll A is-.;s'

. lnflammatory swellings are mostly tender
. Neoplastic swellings are not tender.
. How to locate the point of maximum tenderness?
b.
v,
/\
3..,. l) asJS
lar, nodular, lobulated...etc.
{*.P-d.ggl by starting to palpate away from the swealling towards it 'tll qJ.,,++ aSJS
. lll-defined (finding no border), Well-defined (finding
a border all around), Pedunculated.
NB.
Slippery (moves in front of my advancing finger k# rr;: €+J) -+ Lipoma
5,,. 9.p..+. g
i s f .q n.c..v' $l Js+ iS;s
' Cystic or solid.
tests for cystic swellings:
. Fluctuation test:
- lf it contains fluid ) it will fluctuate
- lt should be done in 2 perpendicular planes
-
Keep pressing by receiving fingers against one pole
- Exert sharp pressure at opposite pole by displacing fingers.
fingers
h"J il"t "fLr^P

co'"'ia
displacing fingers Ke
receiving fingers
Flactuation test
[S. pseudo-fluctuation can be elicited in lipoma
l0
. Paget's test:
- It is used in small or tense swellings (< 2 cm).
- lt compares the consistency at centre with that at periphery.
- Solid swelling ) harder at center (due to greater concentration
of solid tissue).
- Cystic swelling ) softer at center
&
Paget's tett
. Bipolar test:
- For pedunculated swellings
- Fix by the upper hand and receive by it
- Press by the lower hand
,r:
11
ln small swellins: (MODIFIED FLACTUATTON TEST)

2 fingers are placed on the swelling
The finger of the other hand tap the swelling in the center
Wave is felt by the 2 fingers on each side.
Fluid thrill:
ln big swelling: tapping on a side of the swelling )
percussion wave is felt on the other side.
Cross fluctuation test (to detect weather two adjacent cystic
swellings are communicating or not):
Percuss the swelling by a finger & recive the impulse by a
finger of the other hand placed on the 2nd swelling e.g.
psoas abscess.
Solid swellins mav be
- Solid and soft ) like a lobule of the ear.
- Solid & firm ) like tip of the nose.
- Solid & fleshy ) like relaxed muscle.
- Solid & hard ) like forehead.
ln case of soft swelling it could be compressed to
differentiate between reducible and compressible.
ffl
JI\
i(,
-{
I
t I
a\ aS 6rDtI
t2
. Trans-illuminationTest:
- lf the swelling is cystic: ) differentiates opaque from
translucent
- Translucent cysts = clear fluid ) cystic hygroma, menigocele,
ranula, epidydmal cyst.
- Opaque cysts = blood, pus.
Trans-illumination
T rans-illumination test
6,.. Rp I atip..n q. (M...q.bilifv). ;

. What are freely mobile swellings?
. Skin=
- Not related to overlying skin ) skin can be pinched
- Attached to overlying skin ) can not pinch up Skin.
. Muscle,') Ms contraction )
- Less prominenf = deep to the muscle.
- More prominenf = superficial to the muscle.
- Swellinq of the muscle
* lf mobile in both cases ) superficial & not attached.
* lf moves across muscle when it is relaxed & become
fixed on contraction ) swelling of the muscle.
* lf mobile when the muscle is relaxed then becomes
limited on contraction ) attached to fascia.
. IVerves,'arising from or attached to a nerve)
- Can be moved across but not along the axis of the nerve.
- May be tender.
- There may be distal signs of motor or sensory affection.
. Vessels,'arising from or attached to a vessel)
- Can be moved across but not along the axis of the vessel.
- May be pulsating.
- There may be distal signs: varicosities, ischemia
. Tendons.' attached to tendon of a muscle) moves across the
tendon & becomes fixed when muscle is contracted.
. Bones,') fixed and immobile from the start.
l3
7. Drainin g..L;gr.ph Nodes:

No examination of a swelling is complete without the
examination of the draining L.IVs
$'. S.
p. p..si aI. Si g ns. ;
1- Pulsation:
Expansile pulsation ) it arises from the wall of an artery
Transmitted pulsation ) it lies very close to an artery.
llow to differentiate?
'z fingers, one from each hand are placed on the swelling:-.
1) When the 2 fingers are raised and separated with each beat
of the artery ) Expansile Pulsation
2) When the 2 fingers are only raised ) transmitted pulsation
Transmitted pulsation Expansile pulsation
Grasp the swelling and ask the patient to cough:

Transmitted =fonvard thrust without f in size. Expasile = 1 in size in all direction,
2- Thrill: ) felt over aneurysm and A-V fistula

3- lmpulse on cough: in swellings which are
- ln continuity with abdominal cavity (hernias, ilio-psoas abscess
- ln continuity with pleural cavity (empyema necessitates)
- ln continuity with spinal cord (meningocele).
4- Reducibilitv: Swelling reduces or disappears as soon as it is
pressed upon in a certain direction and reappears again on
coughing or straining (e.g. hernia).
5- Compressibilitv: = Flattening under pressure and regains its
original size on release of the compression. (e.9.
Hemangioma, saphena varix).
t4
Percussion:
1. Over the swelling:
Resonant -+ over gaseous swelling (hernia, laryngeocele)
Dull -+ over cystic & solid swellings
2. Around the swelling (to determine its relation to surrounding organs):
The dullness of liver swelling is continuous with the normal
hepatic dullness
Auscultation:
Systolic murmur -+ aneurysm
Machinery murmur -+ A-V fistula
Venous hum + portal HTN
lntestinal sound -+ hernia
_Ireh era t_o r.y I nys. st_ige_ti o.n e_;

Hbo/o, urine and stool analysis, blood sugar, blood urea.
ReCiolegieel Inv.estisetiens i
Plain & contrast X- ray.
do S gp.. pi c I nyp_p_tlgeli o.np;

Gastroscopy, duodenoscopy, colonoscopy, cystoscopy
A..n e t-o-miee.l..hrh-e re. i s the

srYsl-l-i-ng?l
It is diagnosis of the region (Skin, S.C, muscle, tendon, vessels, nerve) or
organ (spleen, liver, gall bladder) which is affected.
Patho
Congenital, traumatic, inflammatory, neoplastic ....etc.
Associated condition
T.ir:; ,ji;Gi;; ;lil;iC oioncnitis, liver cell failure, Ascites....etc.
Browse's introduction to the symptoms & signs of surgical disectse/ Chlexomination of a swelling
(lump)/ P 29
15
Qtestions d Answers
Q. What anethehazardr of smoking?
A.
O CY S : ather o scler o si s, cor or,ary hear t di sease.
a Chest: etnphy sema 8l-bronchi a[ carcinoma
o CIT: peptic ulcer
a C ancq :c ar,cer ( [i p, tongu e, esophagu s, Hyp emephroma ) ni cocine )
nitrosamine ) which is precancerous
Prelmancv:
ornaterr,al : e-g. :placenca pr evi a
o Fetus :e.g. :Arisk of mortality
Q .Why we use the dorsum of thehand to feel the ternperatureT.

A.
Because ternpelatuteteceptors are more in the dorsum of the hand.
Q. When swelling is said to be freely mobile?

A
When it moves in a[[ direction as subcutaneous swe[[ings.
Q. When the swelling moves in one direction?

A.
Swelling at:
. Muscle : e.g.:desmoid tumo/
. Tendon: e.S. : ganglion
. Nerve: e.g. .neurofibroma.
. Attew : e.s. : aneurysrn
Q. When swelling is said to be fixed?
A.
SwelLing, at bone: e.s. : osteoma
Q. What are the difference between radiating pain {referred pain ?

A.
. Radiatinlr pain:
At the sice of the lesion and the patient feeLs pain in other site also as
acute cholecystitis pain in Rt Hypochondrium radiation to the shoulder. lt
is the extension of pairr co another site whilst the inicial pain pestists.
. kefefied palr-
The patient feeLs the pain in a site other than the site of the lesion as: in
acute appendicitis che pain at first around the umbilicus on[y (not over the
appendix) then shifts to the Rt lliac fossa.
T6
Q. What is the mechanism of referedpain?

A.
Convergence-proiection theory: The brain is accusromed ro receive
impu[ses from the skiry not frorn theviscera
Facilitation theory: afferent from the affected vescera lowers rhe pain
threshold of cells receiving impu[ses from the skin, so slight scimulation of
the skin produces pain
Q .What is the differencebetweenparaesthesia 8t anesthesial

A.
. Paraesthesia ) abnormaL sensation e.g. ting[ing7 numbness...
o Anesthesia ) sensory [oss
Case 7. Subctttaneous Lipoma

Q. Whatis the diagnosis?
A.
Subcucaneous [ipoma on che dorsum of the right arm not cornplicated.
Q. How didyoureach this diagnosis?

A.
Because rherc is a sweLling u,hich is :
vVery slowly growing swelling.
z- Soft in consiscency (pseudofluctuant).
3- Slippery edge.
*rt ate the points of differencebetween [ipoma and sebaceous cystl

ft .
lnspection: the punctum in the sebaceous cyst 8l- not in [ipoma.
. Palpation : f[uctuation test *ve in sebaceous cyst/ while [ipoma is pseudo
fluccuacing
Q. Whatis the e,xplanation of the slippery edge of the lipomaT

A.
Because lipoma is present within a very [oose compressed tissue (false
capsulel and true capsuLe and it moves in-between so that pressure on one
edge rnoves it, it is soft so it becomes invaginated in front of my advancing
finger
Q. Why is [ipoma is described as pseudo fluctuantT.

A.
This is because fac g[obules forming the [ipoma are very soft and fat changes
to semisolid at the body terrrperatu.e.
t7
Q. Does the lipom a may become firm or hardl And whenl

A.
f esl lipomalr,ay become firrn or hard.
Itbecomes firm if it is fibrolipoma or when it is subfascial. Ltbecomeshard
when it is subperiosteal..
Q. How doyou elicitfluctuation in avery small swellingl

A.
ByPaget's tesq the swelling is fixedby theindex and thumb of the left hand
and pressure is applied on the center of the sweLling by the index of the right
hand. Andwe compare the centre and the periphery of the swelling.
Q. What are the diffuentiating points between a subcutaneous and a

subfascia[ [ipoma?
A,
Subcqtaneous [ipoma Sub facial lipoma
. Hemispherical more than . Flat more than
Shape
f Iat hemisoherical
Surfae . Lobu[ated surface . Smooth surface
Edge
. Slippery . Less slippery
Attachment to . A*ached to multiple r \ot attached

overlyinc skin ooincs
. Soft (pseudofluctuant) r firm
Consistenry
Q. How didyou detect the skin attachmentT.

A.
Skin attachment is detected by pinching and $[iding.
Q. What are the different sites of [ipoma?

A.
Lipoma known as the "universal tumor" because it can occur at any site in the
body (except rhebrainl eyeLid and penis), the common sites are:
r" Subcutaneous lipoma 6. Subserous [ipoma

z. Subfascia[ lipoma 7. Extradura[ lipoma
3. lntermu scuLar [ipoma 8. Retroperitonea[ lipoma
4. L,ntramuscular lipoma 9. Subsynovial
5. Subperiostea[ ro. lntraglandu[ar
18
Q. What is the site in which [ipoma consideredpre*ancerous?

A.
ketropeitonea[ lipoma some authors be\ieve that [t is ma[ignanr from the start.
Q. Mention the multiple skin swellings you knowl
A.
r. Mulciple Lipomata 6. Muldple Neurofibromara
z. Multiple Sebaceous Cysts t. Multiple Papillomata
:. Multiple Naevi 8. MultipleWarts.
+.Multiple Hemangiomara q. Muldplel(eloids
s. MultipleLyrnphangiomata ro. Multiple Boils
rr. Mulciple Skin Metastases
N.B. This doesn't include the multiple subcutaneous swellings which are not originacing from
the skin or ics appendages e.g. genetalizedlyrnph node en[argernr.er't/ multip[e exostoses/
multiple hernias...
Q. Mention the commonest mu[tiple skin swellings?.

A.
Mukiplenawi.
Q. What is the treatment of this patient?
A.
The treattnent of [ipoma is usually conse,rvative.
The indications of excisiorl are:
r) CosmeticaLly annoying the patient.
z) Complicated.
3) Painfu[.
4) Causingpressure on a surrounding structure.
Q. What are the complications of a lipoma?
A.
o Cosmeticdisfigurement.
o Pressure on a surrounding sttucture.
o Calcification.
o Myxomatous degeneration.
o Malignant transformation ([iposarcoma) if retoperitoeal.
o Pressure on the spina[ cord not the brain.
o lntescinal obstruction or stridor.
Q. What do you know about Dercum's diseaseT.

A.
Dercurm's disease is a painf ul diffuse [ipoma, also called "adiposa do[orosa". lt
affects fernales in the form of painfuI f atty deposits in the thigh.
t9
Q. When [ipoma becomes painfulT.

A.
Lipoma beoomepainful in the following conditions
o Adipose dolorosa (Dercum's disease)
o lnfection
o Malignancy
o Lipoma pressing on anearby nerve
Q. What ane the sites rlevet to be affe*ted by [ipornal And why?

A.
Penis, brain &-eyelid .becausethey dontt contain fat
Browse's introduction to the symptoms & signs of surgical disease/ Ch3 skin &subcutaneous
tissue / P 78
Case 2. Hemangioma
Q. What is the diagnosis?

A.
Cavernous hemangioma of the.. . (mencion the site) .../ not complicated.
Q. How didyou rcach this diagnosis?

A.
Because it is;
r- A skin swelling dating since birth lrnay be shody afterl.
z- Ltis pink in color.
3- CompressibLe.
Q. Exptain:Why hemangioma is compressible?

A.
Hemangioma is compressib[e as the b[ood which it contains empties into the
veins communicating with it.
Q. What ane the othq compressible swellings!

A,
r- Lymphangiomas z- Aneurysms. 3- SaphenaVarix, 4-Vaicocoele.
s- pneumatocoele. 6- Laryngeocoele 7-Tracheocoele. 8- Pharyngeal pouchl
20
a. Wheret".t"
A,
At theheadand neck region.
Q. Does hemangioma occur in inrcrna[ organsl
f eq for example the liver is the commone st internal

organ affected,.
Q' wha t ate the crassificadons of thehemangioma you know?
r) Capillary Hemangioma:
. Port wine stain,
. Strawberry angioma
. Salmon patch
. Spider naevi
z) H_emangioma ( Caverno
)/enoys- us hemangi omaf
3) Arrcrial Hemangi oma (Ciroi j
^r", rysm)
tfteation:
I. Supefiicial
z. Deep
3. Combined supefiicial and, deep
b,
r Portwine stain
z- Cavernous hemangioma
3- Venous racemose aneurysm
4- A-V fistula
Q. Describe the featuresof cirsoid aneurysm?
A.
Cirsoid aneurysm is:
r Apulsating comp ressible red, swelling.
'- f:Jrz:r,most commonlv in che head Ind neck (scalp especially temporal
Q. Wha t ate rhe complications of a Hemangiomal
o Hemorhage.
o zry infection _> septicemia
21
a. Mention the diffet"-rr Ii

A.
r) Lnjection of a sclerorrrr. -^."rir[

zl Embolization injection.
il Surgical excision
4l Laser photocoagu [ation
Q. whatis thematerial usually usedininjection scler otherapy?
A.
Lt is Bucrylare material.
Q. what is embolizationiniection and how it acts?
A.
l't is inieccion of a special mateial inro rhe of
feeding artery the Hemangioma
through angiography.
This mateial produces occlusion of this aftery and so necrosis of the
Hemangioma.
Q. what are rhe cornmonesr materials used.in embo[ izationl
A.
Celfoam and silicon particles.
Q. What are the differerrt types of hamartomas?
A.
r. Hemangiomas
2. Lymphangiomas
3. Neurofibromas
4. Benign naevi.
Q. Definehamartoma?
A.
Hamartoma is a malanranged norma[ tissue. I,t is characterized
growth sirnilar to the surrounding structures,,.
by a rate of
Q. What ane the different types of lymphangiomal

A.
There are two wpes:
r C ap i II ary Lymph an gi om a ( ry rnph angi om a ci r c um s cri p t u m )
z- Cavernous [ymphangioma cy stic hygr oma) (
Q .what is the mosr characteristic sign of aptichygroma?

A.
is the on[y trans[ucent neck swe[ling.
l,t
Q. When does ir becom e opaquel
A.
When ir becomes infected
22
Q. lr [ymphangioma compres sible or notl

A.
Lymphangi oma i s p arti alLy compr es sible.
Q. WhV [ymphangioma is partially compressible?.

A.
Because.lyrrph.r?gioma is formed of multiple cysts communicating with each
other. Lt ts partlally col}].pressrble.
' Lt is cornpressible ) because the outer cysts empty cheir content of
[ymph into the inner cysts.
. lts cornpressibility is partia[ ) becauseit does not empty fteeIy inco
[ymph vesselswhich arevery sma[[.
Q. Mention the types of neurofibroma you knowl

A.
\ eurofi broma inclu des the f ollowir,g, types:
r) Solicary neurofibroma
z) C ener alized neur ofi bromatosi s (von Reck[inghausen's di sease of neru es)
3) Molluscum fibrosum
+) P lexif orm neurof i broma (p achy dermato coelel
s) Elephandasis neurofibromatosis.
Q. M"ntion the types of benign pigmentednaevt (moles)?
A.
Beni gn pi gmente d naevi include the fo [[owir,g types:
r. Lntradermalnawus
z. ]unctionalnaevus
3. Compoundnaevus (giant naevus)
+. Bluenaevus
s. Ha[o r,aevus
6. Spindle cellnaevus.
T. Lentigo
Q. Mention the age of onset of benign pigmentednaevi?
A.
They appear in childhood and adolescence, ranely do they pteser.t ac birth.
Q. Mention whatyou know about congenital giant naevus?

A.
Ltis present since birth, may occupy-vexy large areas qf the bo4y, usualLyhairy,
and it is of bad prognosis as' ir rnay 'change m-alignan t in ryo/" of Lises.
Browse's introduction to the symptoms & signs of surgical disease/ Ch3 skin & subcutaneous
tissue/ p53.
Case.3 Derunoid Cgst
Q. What is the diagnosisl

A.
lmplantation dermo id cyst.
Q. Why you diagnose this swelling as an implantation dermoid cystl

Because it is:
r Achronic slowly growing painless cystic swelLing.
z- kelated to puncturc injury ot scar of previous injury.
Q. Enumerate the type.s of dermoid cyst?.

r) S equestr ation derrnoi d cy st
zl lmp[antation dermoid cyst
3) Tubulodermoid cysts
a. Thyroglossal cyst
b. Branchia[ cyst)
4) T er atornato u s derm oi d cy st
Q. What are the type.s of sequestration dermoid cyse7.

A.
Sequestracion derm oid cysts occut at the [ines of fusion of the body:
r. Eace:External and internal anguLar dernoids
z. Ear:Pre &t post-auricular dermoids.
3. Neck: Midline anteriorly (sublinguaLl subrnental 8[ suprasternaL).
4. Trunk: Midline anteiorly andposteriorLy.
NB. Sequestration dermoid cysts r.evet occur in [imbs as chey develop fro- buds (no [ine of fusion)
Q. Where does imp[antation dermoid cyst usually occurT.

A.
ln the hand of manua| workers (especially tailors)
Q. Does imp[antation dermoid cystrnay Seiatrogenic1

A.
f es, itrlr'ay 5e iatrogenic if we use a skin graft in hernioplasty operation.
24
Q. What ate the complications of segue.sffarion dermoid qstsl

A.
r. As any cyst (rupture, infection. ...1
2. Cerebral compression: very rare (dumbbell or hour g[ass dermoid)
Q. Whatis thercsult of transillumination test in dermoid cysts?

A.
They are opaque.
Q. What is the tteatrnerrt of this case?

A.
The treatrnent of this case is excision of che cyst to ptevent complications
esp eci ally secondary infecti on.
Mnemonic to describe swellang ) Scalp:

S ) site, size, shape, surface, skin overlying, scar, special signs.
C ) consistency.
A ) attachment to surrounding structures.
L ) illumination.
P)
25
Case4.sebacous cgst
I what's your diagnosisT

Sebaceous cyst
I lvWry?
- By history: slowly growing painless swelling in an adult chat beconres

painfu[ if infected.
By exarn: ter,se cystic swe[ling attached to skin at punctum, discharging
&ied sebum
O. Mention the points of difference between dermoid qst and
sebaceous cyst|.
A.
Dermoid cyst is. Lax cystic and has no attachme4t co the skin ar all while
sebaceous cyst is tense cystic and has an attachment to the skin ac the
punctum.
. What is the punctum of the sebaceou s cystl
B
[t is a black dot that represents
'the the head of the dried sebum which obstructs the
opening of the ducts of sebaceous glands.
*rt do you know about sebaceous horn?

8.
[t is o.ne pf ch7 comp[ications qf sebaceous cyst and it is dried sebum,
protruded from the punccum over the skin
*rt do you know about Cocl{s peculiar tumor?
8.
[t is one of the cornplications of sebaceous cvsts and it is u[ceration of
sebaceous cyst ) simu[acing squamous ceLT carcinoma, but its base is not
indurated.
Does sebaceous cyst affects arry area of skin?
f,.
Lt affects any area of skin except pa[m and sol.e as they are devoid of sebaceous
glands.
Browse's introduction to the symptoms & signs of surgical diseose/ Ch3 skin & subcutaneous
tissue/ p74.
Topics related to oral dr.scussion:

1 - M u lti p le ne u rofi b romafosis
2-Ganglion
26
Case Sheet for Thvroid
Personal H:
. Name:
'Age:
- 15-20 years: physiological goitre (diffuse), papillary carcinoma (nodular)
- 20-30 years: SNG, 1v toxic goitre.
- 30-40 years: 2ry toxic goitre
. Sex.'
- Begnin thyroid swelling ---+ 9:1 more in females.
- Malignant thyroid condition --- 3:1 more in females.
. Marital sfafus.'
. Specral habits of medical importance
. Address:
. Resr'dence.'Oasis is endemic area.
. Occupation:
. Menstrual history: ---+ 2ry amenorrhea either due to thyrotoxicosis or
pregnancy?
9-s-mp.!-arn-t= L.i,.il/.ll dlil+ Cl !! i,.i-Fllliil+

+ Duration
HPl= o:^t 1^;U sijS 6J- JAI

1-. Pain
. Site, Character, Radiation, What increase or decrease, Onset, Course,
Duration, and what associates.
. Sife--- localized to swelling or radiating to the ear
2.S..tvp]lirtgi
a) Sife
b) Size ---+ (lemon size, orange size ...)
c) Onset q,U in/
o Accidental (e.g S.N.G)
. Acute ( bacterial thyroditis )
28
d) Course:
- Progressive
- Regressive.
- Stationary
- Fluctuating.
e) DuratiOnlbgl;;r /sl
- Short: (days or weeks).
- Long: (months or years).
- Srnce birth ---, congenital.
Other swellings:
--+ Lymph nodes -+ in inflammatory conditions.
-' Metastasis in malignancy.
s) Effect on the general condition:
-
Toxic symptoms:
- Malignant symptoms: ---+ cachexia.
h) Apparent cause: --+ i.e. relation to pregnancy, menstruation, lactation
& emotional stress.
i) What increase & what decrease it
Pressu re m a n ifestatio ns
- Trachea + Positional dyspnea
e.Us g;+3 Ll d,l.l+ +.* tsri: i..15 'rll.,t.,r -
- Esophaqus + Dysphagia fel+$ cre itg:.-,/ & -
- RLN ---, Hoarseness of voice ''u' llert Li 3l.,;$ d,-r -
- IJV---* Black outs which increases on bending forward
fl- )lJ olg t-t r,r.il rl.2s 3l rlsj'., Jitji. g9J.ii!' -
- CCA ---+ Dizziness oe-ll O l.C+i r-#ri drLr.gi'rllJrr.''
- Vaqus -> ear pain C$rS eF F.g+ cxri -
- Svmpathetic chain --- Horner's $

,rtatS r-i.al
e Ap dJi.J gyrl;S c$c .$ ir-1ts, ;U -
Toxic manifestation
- Insomnia gcieul rro eF JriJ d.a.6Jl3 f {cl., eE cfU3 6.r3*i,c -

- Night mares f6!r Or.*ll d,a.i ei"l+l$ dlua & -
- Fine tremors fdl-.+lep j{li 4+.ll !ts. s cl+t opl*t dlLia & -
- lrritability
(riil U JIsl dlllals dliJ+ 6e,'u1< dl3LEUis &r Cl+srlt 1#,e eift s:lt -
-o.tjn:e
- Palpitation
Y3 r_*+.rll e. il$J:.yJ t trst *lt c,6r rgj i.EL fet;l3,;f liJiJ dlLiA & -
AsE..;,r
s:jl
- High cardiac output heart failure c,.,ij l-iJs ,'tlrrlu d--;s dltru -
- Heat intolerance
e * c,Eri^ yJ rli&lloi !i$l e.+8,'rt{, €!+il|4+l ir+! Ol d+ua -
S+lt 6;1.,J'ri dulolg U*lLtlar#b
- Thyroid paradox +S o.*i:"._, 6r3r.:u efiL JiSt cJSi -
) Eye
- Exophthalmos oyl,--tt gsaq -
Al.rie i1l
- Diplopia #l ,rJ" sJi"s! 0Si4J &iit L. blt +sîq -
- Female menorrhagia then amenorrhea

;JUJIei&- a-Ei,Ll dlUa
- Male impotence dElyl dli! )o-l st aii)llse AJs.L dt:l & -
> G.[-I
- Diarrhea j_#ll rrly rre dtrlj,'6_ilrs, 8-l elS lt--tl uiii tJd.r -
D Urinarv
- Polyuria dsr irr.*llJ'ES cb.*,i -
> Skn
- Sweaty, warm Ot3*s oitr el.r.la Ol r.l"a+ -
d{t ,'.-r Ur.s. eJ ef -
30
- Myopathy
, cr..r 61113 JIJ tirilt+ &t ...-l ir ,',lLt Y3 .rgdr drjl t-. qj di*ill CJli -
cJgYl .fi c++ll &*1s.L+
F Bone
- Osteoperosis dl"lge ,j -# dlUA &-
Slow thinking, apathy, tendency to sleep,

Loss of appetite, increase body weight, Oligomenorrhea,
constipation, intolerance to cold weather.
4. 9f h.er.. $y. s.t.e..ms.
- Lung metastasis: cough, hemoptysis & chest pain
- Bone metastasis: bone ache & pathological fracture
- Liver metastasis: jaundice & Rt. hypochondrial pain
5.Histqrv-.ef.i.+..v..esfigef ip.ns..er..l
P-a-qt-his-t-ery
. Similar attacks.
. Common diseases: (DM, Hypertension,l,B, B, Hepatitis, DVT)
. Blood transfusion
. Pervious Operations or radiotherapy to the neck
F-amrly-his-tq-ry
. Similar condition in one of family members:
o Pendred $
o MEN-Il lsipple $)
. Consanguinity
Browse's introduction to the symptoms & signs of surgical disease/ Chl lthe neck/ thyroid gland
skin/ p289 ---> 290.
31
Examination
Gerreral:
Pt. is alert, conscious, oriented to time, place, & persons. average built, quiet facial
expression, normaldecubitus, average intelligence, & s/he is cooperative.
U ndenrveig ht ---+ hyperthyroid ism &ma I ig na ncy

Overweight ---+ hypothyroidism
Decubitus:
Orthopenic in thyrotoxic HF
Facial expressions.
I rrita ble --+thyrotoxicos is.
Lazy ---, myxoedema.
( Complexiofi ---+ (3 colors):
Jaundice antithyroid drugs or liver metastasis in carcinoma
---+
Pallor ---+ thyroid dysfunction (hypo or hyper) or malignancy

Cyanosis ---+ retrosternal goitre (RSG)
I Chest
T Abdomefl ---+ Hepatosplenomegaly in Graves', Hashimoto
I Extremities
- Tremors, skin temp. and sweating, clubbing
- LL: State of muscles, edema, pretibial myxoedema.
I Pulse, blood pressure & temperature.
I Head:
1. Scalp Multiple swelling (metastasis).
2. Hair: loss of hair in the outer part of eye brow (myxoedema).
3. Tonque: Tremors.
I Eye:
I How to examine Exophthalmos
[1.l From the front of the patient we found

- Rim of sclera above the cornea --- false exophthalmos
- Rim of sclera above and below the cornea ---+ true exophthalmos
32
margin
Frazer's Test: To see the obliteration of sulcus of Orbital
[2.|
with slight closed eYe.
orbital ridge with
[3] Naffziqer Test: To see the level of supra & infra
cornea
141 Ruler Test:

To see the level of
supra & infra
Orbital margin with
cornea bY a Ruler.
[5.l Ruler: To measure distance between lateral Orbital margin

and apex of cornea ( Normally = 15-17 mm).
[6] Exophthalmometer:
How to examine eye sign

- Dalrymple sign
Rim of sclera between cornea & upper eye lid
- Stellwag's sign
lnfrequent blinking
Tremors on closing the eyelids lightly.
- Joffroy's sign.
34
- Eve movements:
- Mobius sign
Failure of convergence
- Von Graefe's sign
Lid lag
- Jaundice (liver metastasis), chemosls.
- Corneal ulcers or oPhthalmitis.
35
- Rosenbach's sign :
- Fine tremors of the upper eyelid when eyes are gently closed.
- Topolansky's sign :
- Congestion of the pericorneal region of the eye in patient with
grave's disease
- Jellinek's sign :
- Brownish pigmentation of the eyelid , especially the upper lid

Iroeal: 4jj.J _& ,-i! _. --1LFll _=L "L
OSU[g--* from the nipple upwards
,U1,l-jc
itt--il J*i. 1.L<i J
g=&
[n-qpe-s-ti-qni
From 2 different planes
sides with the Patient sitting) + i-K
'Jlit , Jl t-,Jl
-JL.,J
u:&!+*
---
36
A*..$..vr.elline;
1. Site
- Swelling in the front of the lower part of the neck
2. Size
- Measuring ..... .
3. Shape
B, S_kin Oyp_rlylns;
Dilated veins crossing the manubrium (retrosternal goitre)
Scar of previous operation (recurrent goitres)
-c..,
. Sp I.el. S-tsn q ;
e p.
Moves up with deglutition.

Moves up with protrusion of the tongue ----) thyroglossal
cyst.
Fix the mandible & ask the patient to protrude his tongue (for swelling
in the midline or near the middle)
Pulsation --+ look tangentially.
P-alp-etis-n-
. Palpatian may be from
front by:
- Crile's method, (Thumb
placed over the lobe not to be
palpated and palpate the lobe
by the other hand while patient
swallowing).
Crile's rnethcld
37
- Palpation of Thyroid gland from behind by:

. Lahey's method. (Push Thyroid to one side by hand
then examine by other)
Lahey's method
With the neck flexed
Place the thumbs upon the nape of the patient
The other finger tips meeting at the midline anteriorly.
Start by palpating one lobe at a time.
Always tilt the head to the side you palpate to relax the
fascia for better palpation"
Palpate the swelling as usual......
. Examination of the lower border.
Examination of lower border

Examination of the isthmus:

Stand behind the Patient.
Put one of your hands on the head of the patient'
Tilt the head of the patient forward.
Put the index of the other hand on the midline of the trachea and
palpate.
Ask the Patient to swallow.
Examination of isthmus
$..rvplli+.e
1. Warmth:
g rs4 ar
2. Tenderness.' dt+Jt a.t r* P -t +Jt d4t Af
- lnflammation + mostl! tender
- NeoPlasm --+ not tender.
3. Surtace: +Jt LljH isf
- Smooth, nodular...etc.
39
4. Edge: ,t1ll ,r,;;r lSts

- Find out the lower edge --+ if ill defined ----, retrosternal goitre
- Well circumscribed except backward.
5. Consistency: u+4 ke
- Cystic or solid.
-Firm -Soft -Hard
6. Relation (mobility) :
1. Skin (fixed or not), pinch the skin over the swelling.
2. Sternomasfold
a) Superficial or deep:
- Bilateral: ask patient to flex the neck against
resistance.
- Unilatera!: Ask patient to rotate his head
against resistance
b) Fixed or not:
- Turn the head to the tested side, pinch the muscle
from the swelling & ask the patient to swallow.
- lf you pinch the muscle freely and not moved with
swallowing ---+ not fixed.
3- Trachea
Attachrnent to the swelling ---+ from the front,
Fix the thyroid cartilage by one hand & rock
the thyroid gland vertically over the trachea
r Tubes
1) Carotid artery
Pulsation ---+ site & volume
(felt against carotid tubercles
on the transverse spine of 6th
cervical vertebra.
Carotid pulsation
40
2) Lymph nodes
No examination is complete without examining the draining LNs
(upper & lower deep cervical, prelaryngeal & pretracheal LNs).
Prelaryngeal
LN
deep cun'icai
Pretrarhetrl
tN
,il,_
-h,xamlnatron
olt
Lowcrdcep,ctwico' Lymph Nodes
3)
Trachea
- Position --+ central or deviated
- lmportant in anathesta as the tube may iniure the trachea
4t
Palpate the 2 carotids
One is palpable
Both superficial temporal One superficial temporal

arteries are palpable artery will be palpable
- Kocker's test: Slight compression on lateral lobes produce
stridor so may be Tracheomalascia
- Pemberton's sign?
- reversible S.V.C obstruction produced by retrosternal goitre
c inret'
?3Bi{HiJlHIS he level of the
head if nothing is considered
ve , it is consid blue or pink
effusion of the neck an nous obstruction)
P-gf-C-U-qSj-g n-.. ---+ d i rect ove r th e m a n u b ri u m ( retroste rna I go itre ).
Au-q-c-u!ta-tjp-n-.
Over the apex of the lateral lobes for machinery bruit ---+ thyrotoxicosis.

ReCiglpgiq_el lnyggtis_e_tio[J_Q.: ptain X- ray, cr scan, rhyroid scan.
Ihyfp_ifl F_gn_cJig_1 _T__e_91s.:

13, 14, rsH
An.elg.m!.g..al; a thyroid swelling (site. Moves with deglutition & butterfly in shape).
.Pa.th.g !.9.9 !.g..el ; n od u a r, n eop a sti c . . . etc.
I I .
Functiona!:
"""""""'ilVfj5i,' nVpo or euthyroid.
E.g. A case of thyroid swelling most probably Due to simple nodular goitre with euthyroid
state.
Browse's introduction to the symptoms & signs of surgical disease/ Ch I lthe neck/ thyroid p29l-295
42
Qtestions GU Answers
1- What is your diagnosis? & Why?
2- What are the investigations?
3- What are the painful thyroid swellings?
4- What is the TTT of simple nodular goitre?
5- What are the differences between 1ry & 2ry toxic goitre?
6- What are eye manifestations of toxic goitre?
7- What is the TTT of 1ry toxic goitre?
8- What is the TTT of 2ry toxic goitre?
9- What are the preparations before operation?
10- What are the causes of solitary thyroid nodule?
11- Why thyroid moves up with deglutition?
12- Why retrosternal goitre is common in males?
Q. What do you know about thyroid ernbryologyT.

A.
. lt starts at 24 days and is completed at7 weeks.
o it is a composite from z embryo[ogical origins
r. The floor of the pharynx:
o Between the rct and znd pharyngea[ pouche s which is marked by
foramen caecum of the tongue.
o This forms the thyrog[ossal ductwhich is displacedforwardby
theHyoid bone and to one sidel usualty theLeft.
o The duct forms the isthmus and the two lateral [obes.
o s s at cv s'r
*; Y;A:;Ti,* :!:;:Zi::: :il,i'":,::;,:i'l'JrI

acquied condition
z. The Ultimobranchial bodv:
o The name sugsests that this body arises from the fifth
pharyngealpouchl but the 5'h pharyngealpouch is rudimentary.
o Lt is desctibed as the venta[ portion of the fourth pharyngeal
pouch which is invadedby the neural clest which wil[ forrns the
C cell,s.
43
Q. Wher e is the anaromi cal site of the thyroid gland in theneck?

A.
[t is in thernuscular triangle of the neck.
Q. Mendon whatyou know about tiangles of the rreck?.

A.
heneck
Each side of the neck is divided into anterior SL
posterior triangles by the sternomastoid muscle.
{.P_o_eteriel_t_r_iang[_e;
. Boundaies:
r. Posterior border of sternomastoid muscle.
z.The clavicle.
3. Antefior bordq of trapezius muscle
. I{oof:
r. Skin.
z. Superficial. f ascia (contain platysrna, E.).V 8tr- cutaneous nerves).
3. Deep f ascia (investing layer of deep cervicaL fascia).
. F[oor:
- Musc[es: splenius capitisl levator scapul,ae 8t sca[enus muscles
(postefi o1 rnediu s1 81, anterior).
- Fascia: prevercebral f ascia.
o Contents:
r- lnferior 6eLLy of omohyoid muscle.
z-Arter.ies:
rStdpart of subc[avian artery.
z. Ttansvetse cervical artery.
3. 5 upr ascap ular artery.
r-Veins:
r. 5ubc[avian vein.
2. Tr ansver se celical vein
3. Suprascapular vein.
4-Nenzes:
r. Accessory n.
2. Cewi c al. p\exu s, an s a cewi c ali s I 8t phreni c nelv e) .
3. Brachia[ plexus (roots 8[trunks).

s- Lvmph nodes:
SupracLavicular L.Ns.
44
* At -tetiez -tr! ang Le-: C$rb,'.s r*h

. Boqndaries:
oAnterior border of sternom astoidmuscl,e.
oLower border of themandible.
oThe midline.
. Subdivision:
o'/, of submenta[ triang[e.
oMuscu[ar triangle.
oCarotid triangle.
o Digastric triangle.
* S-,.rbm e$al-si anslel
Apex: syrnphysi s menti.
Borders:
Anteior bellies of digastric muscles.
Base: hyoid bone.
F [oor: rnylohy oi d mu sc [e.
Contents: su bment aL Lymph nodes.
{. D iSa_s_tri c_
--i arsle.;..
Boundaries:
r. Lowq horder of the mandib[e above.
z. Two beLlies of digastric muscles
3. Stylohyoidmuscle below.
Floor:
r.
MylohyoidmuscLe in front.
z. Hyoglossus muscle behind.
Contents:
r. Submandibular gland.
2. Eacia| artery.
3. Hypog[os sal nerve.
* MqEgslaLqiawLc:-
Boundaries:
r. Sternomastoid rnuscle,
z. Supeior belly of omohyoid rnuscle
3. Themidline.
Contents:
r. Strap musc[es.
z. Thyroid.
{.-C-ars-tj{-et,allde;
Boundaries:
r. Sternomastoid musc[e.
z. Posterior belly of digasticmuscle.
3. Superior 6elly of omohyoid muscle.
45
Contents:
r. Descending hypoglossi.
2. Descending cervicaLis.
3. Carotid sheath (ansa cervicales in the front gl, sympathetic
chain behindJ.
4. Most of ECAbranches.
Q. Mendon wha t you know about deep f ascia of the neck?
A:
Deep fascia of the neck
*PLeg_aEbe_a|_E_aeia;
o Attachrnent
. Above -
- To hyoid bone.
- Obliqu eline on thyroid cartilage.
Below :-
- Fibrou s peicardiurn.
- Aotic arch.
On each side
- Euses with carotid sheath.
- Lt splits to form a capsule around thyroid gland, rhis caps ule is
thicker anteriorly.
N.B: What are the thick patts of the pretracheal fascia?
- The posteromedialpartwhichis called ligamenr of Berry, other
unpopu[ar namelatera| ligament of the thyroidgland
- Anterior part of the fascia, (that is why the gland enlarges post. At first).
;t l_nrr_"_E gins D_egp_ E_aE gia:
- Lt forms al,ayer in the anteior 8t posteri or triangles of the neck

o lnferior
- lt splirs ro be attached to manubrium sterni &-clavicle.
. Superior
- [c is attached to mandibl,e, mastoidprocess
8tr- base of the sku[[.
- Splits to form capsule around rhe parorid gland which is
incomp[et e superiorly.
Sursieal importance: Tumor of the parotid elevates the ear
o Posterior
- [t comes from ligamentum nuchea (interspinous [igamenr)
- The f ascia splics to su/roun d the sternomasroid &- trapizius.
o Arrteior
- [t joins ics fellow in rhe midline
'.!'-C-ar-o-t-id-5h-eaCh_l
- lt is a tube of deep fascia exrending from rhe base of rhe sku[[
down to the root of theneck.
r) Lnternal )ugular vein: Iaterallv.

z) Common carotid and intern al carotid arteies (not the external):
mediallv.
3) Vagus newe: behind the interval between rhe internal. jugular
vein and common carotid artery.
. Sttuctures Embedded in lts W alls:
r. Syrnpathetic trunk: embedded in rhe posteior wal[.
z. Ansa cervicalis: embedded in the ante,:ior waII
. Superficial Relations;
a.
Thyroid gland.
lnfrahyoi d m u s c les ( scernolry oi d, sternothyr oi d, omohyoi d ).
5ternomastaid musc[e.
b.
-
Styloid appatatus.
-
Posterior belly of digastric.
-
Parotidgland.
. Deep Re[ations:
- Transverseprocesses of all cewical, vercebrae and the covering
prevercebral muscles.
- Lnferior thyroid artery: uosses deep to it at C.6 (on both sides).
- Thoracic duct: crosses deep to it at Ct bnleft side).
Blood Su of the Th id Gland

A.Ar-tsti-al-5sp-ply:
o Superior chyroid:
- Branch from the external carotid artery.
- [c is rclated to the external laryngeaL tetve.
- When thenerveinjureditleads ro loss of high pitchedvoice (81-
voice f atigue).
iniurv of the extetnal [arvnqea[ r.e.ve.
47
o Lnferior thyroid:
- Arises fro- the thyrocervical trunk which is abtanch of the
flrstpart of the subclavian artery.
lts termin aI branches neat the gland are in close rclation to the
r ecuff ent L aryngeal rLerv e (in b etw een, ab ov e 1 b elow termin aL
branches).
We ligate the artery away from the gland while it passes
behind the carotid sheath.
It is ligated in continuity i.e.ligated and not divided to avoid
haemotho r ax if slipped ligatwe occurs.
Anothq opinion to ligate thebranches of the artery after
i dentif i c ati on of the r ecurr errt I aryr'ge aI nerv e [i gati ng the
1ranches of the thyroid gland and presewing the branches of
theparad'ryroid gland
Most of che auchors believe thac bilateralligation of theinferior
thyroid artery doesn't affect blood supply of patathyroid gland.
'nn:";;tH: ili"J"d
from the aortaor
theinnomina te artery as
these arteries arises frorn the 4'h branchial arch as the thyroid
g[and in the neck then descends to the chest
. Accessory tracheal A esophageal ateries.
They run in [iagament of Berry which is thicken ed parr of
pretracheaL f asciawhich ioin trachea to thyroid gland.
The postromedial part of the thyroidlobe is left after subtotal
Thyroidectorlry and it has its b[ood supply fro- thesevessels
B. Ven-o- s-s- dr-4u]4gq
o Superior thyroidv.
- To the internal iugular vein.
. Middle thyroid v.
T o the internal iugular v.
Middle chyroid v. is the shortest v. so it should be the fhstvein
to be ligated and divided).
Lt is nearer to the Lower po[e of the thyroid gland
l.trnay be mulcipLe or rnay be absenc
Lf thevein is torn befor e ligation, bleeding and ai embolism
rnay occuf
. Lnf eri ot thYt oi d v eins
- ]oin theleftinnominatevein.
. Accessory trachea[ 8l-esophageal branches.
48
Q. 14/hv rcfrurrent laryngeal nente hool..s around the aorcic arch in the left
side andright subclavi an attery in rhe right side?
A.
- Because these vessels are formed in the neck from the 4th branchial arch
which forms the aorta in che Left side and subcl avien in the right side
- Lf therc is failure of formation of the right subclavien artery/ rhe righr
tecufient laryngeal r,erve will be non tecuttent laryngeal nele, and it will
pass from the vagus to the larynx directly.
- This nron tecutrent laryngeal nerve may be injuried during ligation of the
midd\e thyroid vein.
- P atients wich ttor. recutrerrt laryngeal nerve rlr,ay have dysphagea [usoria
Thyrdd-$lmqJg h*moo" {rtH|

+
o OOz consumption
o \Lnergy produccion in a[[ tissues
O 4g[ucose consumption by the cell
O Enhance pr otein catabo [i sm
o Lower serum cholesterol level
o 5 en si ti ze che h e ar t to cir c ul ating c atech o ami n es
I
o 5 ti m u late phys i o [og i c al mental and s exu al srowth.
49
Q. What ate the organs which tal<e lodine fro- the blood?
A.
Active (with a pump )
- Thyroid
Passive:
- Breast - Salivaty gland
- Stomach - l(idney
Q. What ate painfu[ thytoid diseasesl
A.
o Hge in a cyst of SNC (commonest cause)
o Acute thyroiditis (rare)
o Malignancy > latel referred to ear throug;h Arnoldnetve
Case 1, Simpfe Nofufar Qoitre
Q. What is meaning of goitel

A.
Coitre from the Latin word (gutter: throat)

A.
Simp [e nodu lar goivenot compLicated.
Q. Why do you diagnose this swelling as goitle?

A.
This swellingis goitrebecause it is a swellingl
r.no past history of thyroid ds
z.nodular surface
3.[n the lower part of the front of the neck deep to the sternomastoid
(which is the anatomical site of the thyroid gland)
4.Taking the shape of the thyroid gland (butterfly in shape),
5.lt moves up and down with deg,lutition.
Q Why you diagnose this case as simple goiteT.

A.
As therc aner.o manifestations suggestive of thyrotoxicosis,,
no manifestacions
suggestive of ma[ign arlcy and no manifestations susgestive of inflammation.
50
Q What is the cause of up and down movement of goirr e wrth deg[urition?

A.
r The cause of this movement is the ptesence of the thyroid gland wirhin the
pretracheal fascia which is attached to the thyroid cartilage and hyoid
bones.
. When the digastric rnuscle corrfiact it pu[[s Hyoid bone upward which pu[[
the thyroid cartilage which pulls pretracheaL f asciawith irc concents
Q. ls thetrachea considercd to be one of the contents of the ptetacheal

fascia?
A.
f.J o, the f ascia is pretr acheal
Q. What are swellings which rntove up and down with deg[utition?

A.
o Thyroid -+ thyroglossal cyst, ectopic thyroid gland, parathyroid gland
tumors.
o Larynx---+ prelarynsea[ L.N .1laryngocoel.e, cold abscess of the larynx.
o Trachea --) pretracheat L.N., tracheocoele.
o Subhyoid bursitis.
Q. How is the thyroidgland descend down after deglutition ?
A.
By the contraction of strap muscles (sternohyoid, sternothyroid, omohyoid)
Q. When does the goitrelose the up and down with deglutition?
A.
ln the fo[lowing conditions:
a. Huge goitre,
b. Matigpant goitre
c. Retrostern al goitre.
Q. Mendon the rlerve supp! of digastric muscl e and strap muscles.

A.
Digastri c rrrusclei
. Postetior belly: branch fro* facial nerve.
. An:-rztior belly: trigemina[ n. via my[ohyoid r'ele.
5 tr ap m u s c es ( sternohy oi d, sterno thyr oi d 1 om ohyoi d )
I
. Ansa ce;rvicalis (Cr, zr 3)

- Ct (Descending hypoglossi) from hypoglossa[ nerve
- C2,3 (Descending cervicalis)
51
Q. What are the differentiating points between solitary nodule in the

isthmus and thyrog[ossal cystll
A.
The thyrog[ossal cyst moves with deglutition and protrusion of the tor.sue/
while solitary nodule moves wirh deg,lutition only.
Q. What is the commonest comp[ication of thyroglossa[ qst andwhy?

A.
lnfection is che commonesc complication and this is because the cyst is rich in
lymph ati c.s from the neck
Q. What do you know about thyrogloss[ fistula?

A.
[t is one of the comp[ications of thyrog[oss al cyst.
It is acquiredl never congenita[.
Occurs either due to:
r- lnfection and spontaneous tuptute-
z- Drainage of infected cyst.
3- ltadequate excision of the cyst
Clinically:
o [t is an opening in che mid[ine of the neck or iear to the midline.
. Above it crescent of skin which increases with des,lucition
o Moves upwardwith deglutition.
o [t may dischargeviscid fluid or pus.
Q What arethe clinical featutes of thyrotoxicosis?
A.
1- From historv:
Palpitatiorl/ r'ervousr.ess/ irricability, incolerance to hot weather, /]
appetite associatedwith loss of weightl polyuria and menorrhagia
11- From Seneral examination:
Tachycardial arrhythmia, tternots/ eye signs of thyrotoxicosis ([id
lagl staring [ook, exophcha[mos, scl.eral show...)
[ 1 1- From local exarnination:
D ilated v eins, exp ar,sile p u [saci on s / w arrrrth/ p alp able chri [ [ an d
audible bruit
Q. What ate the c[inica[ signs you know considered to be investigations ?
A.
o Sleeping pulse
o mild -8o -9o
O modetate--+9o -roo
o sevele --+ <roo
o Tendon jerk
52
Q. What are the manifestations that make you susp ett an inf[amm atory
goitre?
A.
{. ln acute and subacute thwoiditis.'shorc duration, pairy may be fever
(with or withou t rigors)1 wanrnth and tenderness over the g[and.
.3. [n Hashimoto thyroiditis: LocalLy the gland is very similar to S.N.C.
but the coutse of the disease is charactqistic; early thyrotoxicosis
f olLow edby hy p othyr oi di sm.
NB: in Hashitoxicosis there is deqeased uptake of Lodinel butin rry
thyrotoxicosis therc is increased uptake of lodine
..?. ln Riedle thyroiditis: The gland is ireguLarly enlarged, hardl fixed to
skiry trachea 8t sternomastoid i.e. very similar to anap[astic carcinoma of
thethyroid.
Q. Mention what do you know about the etiologry of simp[e nodular
goifiel
A.
. kepeated fluctuations of TSH levels (due co rcpeated cycles of stress) producing
nixedpatterns within the glandsl with areas of activefollicles and others with
inactive follicles
. As aresult of recurenthyperylasia and hypewascularity, hemorrhagemay occur
produ cing necrotic nodu les
. Repetition of hypetplasia and involution results in nodular Coitrq most nodules are
inactive and the activefollicles atepresenc in inter-nodu[ar tissue.
Q. Mention the causes of iodine deficier'q?

A.
a. Decreased intake as in endemic ateas/
b. lnqeased demands as in peiods of stress in fernales lpubertyl ptegnancy/
lactation)
c. Deqeased absorpcion from the C.[.T.
Q. What afe the caus es of defective synthesi s of thyroid hormones?
A.
a. Lnzymatic deficiency, and
b. Coitrogens (Cabba ge1 P.A.S., antithyroid drugs and iodides in large
amounts "iodide goitre").
Q. What do you know Pendred's syndromel

A,
It is inbotn enot of iodine metabolism due to peioxiade enzyme deficiency
within rhe gland and in which there is goitre (critinoid goil.re) / deafness /
dwarfism I rnental deterioration.
53
Q. Mendon the types of simp[e goitreyou know?

A.
a. Simple diffuse goitre:
I-Parenchymatous:
- Physiological goitre. - Endemic goicre.
- Sporadic.
l[- Co[[oid goitre:
b. Nodular goitre: simple multinodular goitre
Q. Which of thes e types is reversiblel
A.
Endemic goitre can be revercibLe if the cause of iodine deficiency is e[iminated.
O. What is the cause of the inqeased female predominance of

physio[ogical Soite?.
A
The cause is pregnancy, lactation which increase the body need of iodine and
a[so some auihoTs \elieve that there is est:oger, receptor in che chyroid of the
females
Q. What is the casse of col[oid goigel
A.
stage of diffusehyperplasiawhen TSH stimulation has fa[[en of
Ir is a late
and when lrr,arry follicles are inactive and futl of co[[oid as pacient rnay receive
large doses of iodine ! it witl inhibit TSH and protease ! hyperinvolution of
the gland.
Q. Mention the comp[ications of simplenodular goitle?
A.
a. Ptessure on surrounding structutes (dyspnoea and dysphagia)y
b. Disfigurernertt/
c. zry toxic goicre (zo"/")1
d. Mati gnant cransformati on (t-2o/o'1, { Fo [ [i cu lar carcinoma)
e. Hemorhage in a cyst (considercd an emergency)
t. lnfection (very rare)
g. Retros ternal extension.
Q. What are the pressute symptoms of goitre?
A.
Pressure on trachea ) dyspnea .
Pressure on the esophagu s ) dysphagia
Pressure or,recutterrtlaryngealnele ) hoarseness of voice
Pressure on carotids ) fainting attacks
Pressure on internal jugular ) btack outs which increase on [eaning forwatd
Pressure on s athetic chain ) Horner syndrome
f
';l:l:;,:::;i,yz:;i,?,,;l#,i:i,ii,il"i,!ii;#::,hepa,ien,riesdown,he
,-rion how goitre calrse dyspneaby
differenr mechanismsl
,3'
che goitreon rhe sachea.
complicated by heart
failure
ssion on trache a)reflexspasm
of
obstruction.
Q' wha3j?" presentadon of haemonhage in a cyst? and whatis the
A.
l't pr esent by u dd en onser
.s of dy spnoea which pr ecipi tated, byco ugh
The mechanism is sudden .nturs*; or shouc.
pretacheal muscle.s ;i'Iil grand lead. to reflexspasm
from pain. of
Q. What is rhe managem ent ofthis pati

A. ent?
Emer gency needre as p irati
on or ev en e,,et
sents ub rotar thyroi d.ecromy
Q' wr'" t ate the investigations of
sirnpl enod.ular goi*e?
.
to the routine raboratory invesrigacionsT

l:":10"'"n we d,o thyroidfunccion
r. Estimarion of serum level
of rr, T+ (Total or
anribodies (if we suspect Hashiino
to
ftee) , T.S.H. st Thyroid
U/S very sensitive to d,etectnodules thyroiditis).
about 4nnm.
3. by rudioactive iodine recentlyit
4. ffi;tcanning is done in toxic goitre only.
the se*tm levet of rc."r ot

: ffi:,i:, f:r:;;!;'"
A.
r,ee thyroid
The serum level of
fteeT3 andr4is more preferablerhan
And this is because serum lever ofrotal.
level of ,o:ulri and ri-;"bound
so it is liable to "?ruy to plasma protein
fallacies by chan S,e ofplasma proteir
.
55
o. Whatunllbe thercsults of thyroidhormone level in S.N.C?

A.
-lhyroidhormone levelwil| be normalin 5.N.C.
Q. What is the freatment of this patient who suffers from S.N.C.?
A.
Most pacients with mu[ti nodu[ar goice.r are asymptomatic and do not
need, ( peratron.
* Partial thyroidectomy [if one [obe is rnore significantly involved than the
other , total \obectony on the rnote affected side with either subcoal
resection or no intewention on theless affectedside (Dunhillprocedurell.
* Subtot al thyroidectolny is done to preserve a part of the gland on both sides
equal one lobe for seuetion of thyroxine.
{. Total thyroidectomy * replacementthetapy
i. Recently: a[cohol iniection in large nodu[es catJses their necrosis and
rcduction of the size of the gland.
Q. What is the airn of paftial chyroide*tomy in TTT of S.N.C?
A.
The aim is removal of the nodular parts leaving an equivalent of 8 gm of
relatively norma[ thyroidtissue (size of normallobe) on each side.
Q. What are the complications of subtotal thyroidectomy for 5.N.C.?

A.
A. Complications of thyroidectomy:
A. Operative complications:
r. Comp[ications of anaesthesia.
z. Shock.
3. Hemorrhage: primary.
4. Lnjury of important sttuctutes:
r. Fsternallaryngealnerve ) [oss of high pitchedvoice (see
beforel
z. I{ecurrentlaryngealnerte ) may bepartial or complete,
unil ater aI or biLater aI.
C-ornplete unilatet a[ ) hoarseness of voice
Cornplete bilater a[ ) aphonia
Partial unilatetal ) dypna on extercion
P artcial bilateal ) stri dor
'; *;l;'"
I. Eaily comolications:
Hemorhage:
- Due to Slippage of superior thyroid a. ligature

(tension hematoma)
- The hematoma may compress tachea or carotid
vessels.
- Treatment )emersency removal of sutures of
skin and deep fascia (in 6ed) )return ro opetative
room.
z. Secondarv hemorrhagre.
z. lnfection.
3. Pulrnonary complications: DVT - pulmonary embolism.
2. Late comp[ications:
r. Hyporhyroidienu ( zo : 4o96 of cases )
2. Hypo-patatElyroidisrn (in [ess than o.5%o of cases) ) Tetany
. Firsc
) Circum-ora[ numbness
. Then ) carpo-pedal spasrn 8t Laryngismus srridu[ous.
. Ltrnay be due to: removal or devascularization or
3. $'#1i-, ies thesrernum 8L manas ed, by tocal

5:
Q. What is the danger of haematoma after thyroidectomy?.
A.
o [t can lead to suffocation as it is enclosed within the pretacheal muscles.
Q. Mention the different causes of dyspnea aftu thyroide*tomy 7

A
a. Tension hematoma in deep cewicalfascia.
b. Laryngealedema due to trauma by endovacheal tube or secondary
extensiv e mani p u [ati on of larynx during sur gery .
c. Bilateral tecufierrt laryngeal newe injury.
d. Tr acheomalacia ( lead to v acheal collapse I
Q. What is meantby ttacheomalacia andwhatis the causel
A.
. Tracheoma[acia is softening of the igid tracheal rings causing loss of self-
rctainedpatency of the trachea.
. The cause is large goitre ) ischemia and pressure necrosis of cartilaginous
rings of the trachea (this appe ars after operation when the patient develops
stridor)
57
Q. What type of adioactive iodine is used in thyroid scanning?

A.
. ["'as it has ahalf life of ryhours, but expensive ar'd unstab[e as opposed to 8
days of [u''
Q. What is the dose of radioactive iodine used in thyroid scanning?

A.
. 5 uCi (5 micro Curi)
Q. Do you know another radioactive subst ance that may be used in
scanning?
A.
o f eslTechnetiumee ic is more safe and cheap.
Q. What ate the manifestations of external laryngeal ne'rve &,rc*urerrt
laryngeal nent es inj ury?.
A.
. External laryngeal n. iniury ) Loss of high picched voice due to paralysis of
cricothyroid musc[e
. Unilateral RLN injury ) hoarseness of voice which is improvedby time due
to compen satory crossing of the contralateral cord to the other side.
. Bilateral RLN iniury ) suffocation which should be treated at once by
immedi at e tr acheo scomy.
O. What long term treatrrrrerrt do you presuibe to the patierrt

postoper atively! And why?
A.
I rnust advise the patient to take L thyroxine (Elroxin) for tife. To avoid
fecufieice,
Q: Why t?r;ufience occttrs if the patient aftu sursery doesn't have
eltroxin for lifel,
A.
Aftq swsery/ the residual part of che chyroid gland secretes an amount of
thyroxine less than norma[. The [ow Level of circu[ating thyroid hormones
srimulates the seqetion of T.5.H. (feed back mechanism). lncreased T.5.H.
secretion stimul,ates the thyroid gland which gets enlarged.
Q. What is the dose to be g;wen?
A.
o.r - o.2 mglday.
Q. How do you adjust the dose of the drugt

A.
By fo[tow up estimation of I the pulse and zl serum thyroid hormones.
58
Q. What is histopathological surprise?

A.
{. Definition:
- Accidentally discovercd malignancy from hisroparhologic al rcport of a
rernoved benign thyroid lump
t Tteatment
- tf follicular carcinoma: completion of thyroidectorny (re-operation to
remove che remaining thyroid tissues to facilitate radioactive iodine
scanning and destruction of any rnetastatic foci )
- lf papillary carcinoma )re-operacion with total thyroidectomy as the
tumor is mu[ticentric and excision of juxca-thyroid LN
Browse's introduction to the symptoms & signs of surgical disease/ Ch I I the neck/ thyroid
p295-296
Case 2: TOXIC gOIfKE

Q. Whatis your diagnosis?
AT.
Toxic diffuse goite (try toxic goitre)
Az.
Toxic nodular goite (2ry toxic goive)
a. 'nVhy this is a case of goitte?

A.
patint is young agey with true exophthalrnusl past history of thyroid ds
r.Site: in the lowq part of the fronc of the neck deep to the stemomascoid
(which is the anatomic al site of the thyroid Sland)
2. Shape: which is the shape of che thyroidgland (huctefily in shape)1
3. Movement: moves up and down with deg[ucition.

4. Disturbance of function of the thyroid g[and in the form of chyrotoxicosis.
O. What are the toxic manifestations you find?

A.
The toxic manifestations are the fo[[owing:
{. From history: Palpitation/ r.ervousr'ess/ iritabilit'.l intolerance to hot
weather/ loss of weight inspite of good appetite, polyuria, menorrhagia
..e. From qenera[ examination: Tachycardia, atrhychmia, ttefftots/ eye signs
of thyrotoxicosis
{. From [oca[ examination: Dilated veinsl expansile pu[sations/ warmth/
p alp able thrill, au di6le bru i t.. .
59
a. Mention the causes of weight [oss inespite of good appetite?

A.
r. Thytotoxicosis
2. DiabetesMe[litus
3. P arasitic infestacion
4. Malabsorption syndrome
a. Explain the mechanisms of polyuria in toxic Soitre?.
A.
r. Lnqeased COP > 4 renal blood flow ) 4 CFR
2. Secondary DM ) glucosuria.
3. f intake of water /ry to polyphagia
4. O Mecabolic rate.
Q. How to differentiatebetweenprimary and secondary toxic goitre?.

A.
T oxic Diftuse Coitre |twl Toxic Nodular Coir.re (2rv)
As,e U suallv vouncr adult lzo-ro ) U sual[v elderlv lao-so )
. Thyrotoxicosis and . Thyrotoxicosis occurs on

Coicre start
Onset top of a nodu[ar goitre.
simu [atan eously.
. Mav . Cradua[onset.
be sudden onset.
o lntermi t tent ft errri ssions 8t
Coutse o No remissions
exacerbationsl
Deyee of
toxicity
++++ +
Metabolic ++++ +
manifestations
|.Jervous
manifestacions
++++ +
CVS
manifestations
+ ++++
Ly.
manifestations
++++ +
True
Usua[[y ptesent
manifestations
Pretibial
rrwxoederna
M^y be present
a Moderate or marked
Local a Slight enlargement.
enlatgernent.
examination: a Smooth surface.
a Nodu[ar surface.
Coitre a syrnmecricaI
o Aswmmetrica[.
60
a. What are themosr imporrant thyrotoxic symptoms 6[ signs?

A.
Svmptoms:
' Loss of weight in spite of good appetite, intolerance ro hoc weather, and
palpication.
SiSns:
r Tachycardia, arrhythmias, and eye signs of thyrotoxicosis.
Q. What are the eye signs of thyrotoxicosisl

A.
A- Exophthalmos which may be:
r (apparent)
E alse
z-True (actual)
lv//hich are differcntiated by \afizigar mechodlErazelsmethod, Ruler mechod.
B- Signs of tue exophthalmos:
r. Ste[[wa$'s si!m: lnfrequent blinking (staring [ook)
z. Dalnrmp[e's sigrns: Apparent rim of sclera above the cornea.
3. Von Craefe's sism: Lid [ag the upper lid does not fol[ow the eyeball on
looking downwards.
4. loffrov's sism: Absence of forehead corugation on [ooking upwards
5. Mobius sign: Absence of convetgence on looking to a near object
6. Rosenbach's sism: tterrrrots of the eyelids.
T. Topo[anskv's sism: congescion of the pericornealregion of the eye
8. le[[inek's sisn: brownish pigmentation of the eyelid, especially upper
Iid
C- Desrree of exophthalmos: by
r- Exophtha[mometer.
z- Ru[er.
Q. Are the eye signs always bilateal?
A. No
Q. What is the exopharhamos and what is proptosis?
A.
. Exophthalmos-* prorrusion of che eyeball due to thyroid disease.
o Propto5is --+protrusion of the eyeball a[so but dse to diseases other rhan
thyroid disease.
6l
Q. Mention the pathogenesis of each of these eye signs'

A.
. True exophthalmos is due to exophtha[mos producing substance which
causes deposition of oedema fluid and round cell infiluation in the reto-
orbital space.
. lnfrequent blinking/ apparent rim of sclera above cotr'ea/ lid las,8t apparenr
exophthalmos are all due to upper eyelid retraction caused by spasm of
Mullels muscle (thrnoxine makes this muscle oversenstized to the effect of
circu lating catecholamines )
o Absence of forchead corrugation is causedby tue exophthalmos Myopathy
of occiptofrontalis.
o Absence of corrvergence on looking to a neat object is due to paresis is of
medial recti mus cles which are tespor,sible for adduction of the e,ye globes
Q. Mention the types of toxic Soitreyou know?

A.
Ttere arethreetypes of toxic goitre
r) Toxic (diffuse goite (rry toxic goitre) (Crave's disease)
z) Toxic nodular goitre (2ry toxic goitre) (P[ummer's disease)
3l Toxic nodule.
Q. Are the above three types the only causes of thytotoxicosis?
A.
No. there atetate causes of thyrotoxicosis:
r. Thyrotoxicosis factitia : Due to intake of thyroxine (..5. for weight
reductionl
z. Lnf antile thyrotoxicosis: A baby born to a thyrotoxic mother
3. )adBasedow disease: Due to high inake of iodides in a col[oi d goite
+. De Quervain thyroiditis (in some cases)
s. Hashimoto thyroiditis (in early cases) only in s%oof cases.
6. Some tumors secrete thyroxine eg. st/uma ovarii.
a. What is the cause of try thyrotoxicosisT
A.
Thyroid stimulating antibodies (Ts Ab) e.s. Long Accing Thyroid Stimularor
(LNf S)/ (LAfSp) {i.e. it is an Auroimmune disease}.
Q. What is the cause of zry thyrotoxicosis?
A.
Lt occurs on top of simple nodu[ar goitre. Hyperactivity is either present in the
nodules themselves or in the internodular tissue due to autonomous activity or
stimulatedbyTs Ab.
62
Q. Mention the types of autoimmune thyroditis ?
A.
o \on goiterous (rry rnyxoedema)
. Coiterous (try thyrotoxicosis, hashimoto)
a. Whatis the evidence that try thyrotoxicosis is an autoimmune
diseasel
A.
a. Ts Ab are presentin 8oo/o of thyrotoxic patientsl
b. Lymphocytic infiLtation of the thyroid sland;
c. Enlargem ent of other members of RES e.g. thymus, spleen, L.N.
Q. What ane theinvestigations that should be done for this patient?
A.
r- The routine laboratory investigations.
z- Thyroid function tests.
a.
A.
What arc the [ines of treatrnent of a case of diffus e toxic goitre?
Thelines of treatment of toxic diffuse goite ane:
r Medical treatrnent: which is the main [ine.
z- 5 ur gica[ tr eatrnent -
3- Radioactive iodine.
a. What are the [ines of medic al treatmentl

A.
r-Rest. 4-Beta blockers as proprano[o[
z-Sedacion. s- antichyroid drugs.
3- High protein diet.
a. What is the mechanism of action of neomercazole?
A.
a. Prwents oxidation of inorganic iodine
b. Prevents coupling of iodinewith tyrosine
c. lmmunosuppressive action on Ts Ab production.
a. Whatis the dose of neomercazole?
A.
The starting dose is ro mg 3 times /day ar.d chis is concinued untiI che patient
becomes euthyroid then we give 5 mg 3 time s per day as a mainten ance dose.
a. What is the duration that you glve neomercazole for the treat-rnent
of rry toxic goitre?
A.
[t is given for rz-r8 months.
63
O. Whatis theTeason of this long duration?

A.
As the course of primaty thyrotoxicosis is (remission and exacerbation) we
giveneomercazol.e for this [ong duration waiting for sponraneous remission.
a. Do you know othq technigu e in medical tteacmenrT
A. Block and replacement ther apy
O. Mention the disadvantages of antithyroid drugs?.
A.
r. Eailurerate 5oo/o.
z. Some goiters enlarge.
3. Drug toxicity (Aplastic anemia and agranulocyrosis).
4. Prolonged drug therapy.
Q. What is the point of view of the surgeons who Stu"thyroxine with
anti-thyroid drugs in treatment of toxic goitlel
A.
They claim chat antithyroid drugs cause secondary rapid enlangement of the
thyroid gland as they decrease seturn level of T3 and T4 which in turn > 4
TSH level and this is dangerous in retrosternal goitre and Thiouraci\
transmitted goitre.
O. why thyroid swelling may be enlargedl howevq surgeons gle
thyroxine?
A. Due to TSH teceptot antibodies.
O. What rs the mechanism of action of propranolo[?

A.
a. [t b[ocks the peripheral adrenergic actions of thyroxine especial[y on the
heart.
b. [t inhibits the peripheral conversion of T 4 to T3.
Q. Mention the indications of surgi cal fieatment in a case of try
thyrotoxicosis?
A.
lndications are:
a. Eailure of medical teatment.
b. keculr,ence of syrnptoms after successful rnedical trearrner,t.
c. Large size of the gland.
d. Recrosterna| toxic goitre.
e. Severe case from the start: pulse > r2o / min as this patient wi[[ noc
go into spontan ous rernissions.
64
Q. Mention the indications of radio-iodine in rry tltyrotoxicosis?

A.
Radio-iodine can be used as an alternative to medical treatment in patients>
41yearc of age.
Q. What is the freatrnent of a case of toxic goitre associat ed wrth ttue
exophthalmos?
A,
* stance (EPSI is thought to be seqeredfrom rhe
etion isrcIated to the seqetion of T. 5.H.
{. is rern inated abruptly (by surgery or radio-
iodine), therupid deqe4se in blood Lwel, of thyroxine wi[[ induce arapid and
marked increase in T.S.H . secretion and subsequently a rapid and marked
incl'ease in the secretion of exophthalmos producing substance thus [eading
to malign ant exophtha[mos.
{. The ideal treatment is to control thyrotoxicosis yadually by antithyroid
drugs andwe add sma[[ dose of thyroxine uncil exophtha[mos is static for 6
months.
Q. Wh"t is the tteatrnent of a caseof second ary thytotoxicosis?
The ueatment is subtota[ thyroideccomy (main line of rreatmenr].
Q. What is the aim of subtota[ thyroide*comy operation in thyrotoxicosisl

A.
[n subtotal thyroidectomy wetemove both [obes *isthmus, Ieaving
postromedia|parcs of lobes on each side to protecttecurtentlaryngealnetve &
parathyroid gland
Weleave about 4'5 gm of thyroid tissue on each side; so the total amount on
both sides equal one norma[ [obe.
Q. What about the preparation of thyrotoxic patient for surgeryT

A.
. We give
. Ancithyroid drugs e.g. Neomercazole
. Propranolo[ (LnderaL) for regulation of heartrate,
Uncil thepatientis euthyroid then we add Lugo['s lodine r5 oral
drops tds for 14 days before operation to make the gland less
vascular and firm.
Q. What is the most common diagnostic investigation?

A.
. I{adioactive iodine.
65
Q. What is the value of ora[ examination in thyroid diseasel

A.
. Associ ated inf [amma tion // thyroiditi s// .
. Lndirect [aryngoscopy.
. Tongue.
. Thyroglossa[ ectopic thyroid.
Q. What is the most importantpteoper tivepteparation?
A.
. Lndiect laryngoscopy.
Q. What contraindications of antithyroid drugs in preoperative

are the
pteparation of toxic goiue andwhy?
A.
Lnretrosternal goitre because antithyroid drugs cause enlargement of the thyroid gland
and this enlargement may casse ptessute manifestations e.g. mediastinal syndrome.
a. Whatis the composition of Lugo['s iodine?

A.
[t is composed of 5o/" iodine and too/o K[ (potassium iodide) inwater.
Q. How does Lugo['s iodine make the glan d less vascular and firrn?
A.
- [t inhibits TSH andptocease enzyrne so the colloid accumulate.s in the folliclesl which
become distended and compress the surrounding blood vessels.
- 5o the gland becomes firmer andlessvascular.
NB:
- ltreaches the maximum effect after rc-t4 days then declinq so it should be
used duting the last ro-t4 days ptiot to sutgery.
- Lf used for rnore than 14 dayq rebound hyperernia of the gland occurs
- [t is used or'ce for life.
Q. What ate the advantages of surgic al teatment?.
A.
. The advantages ate:
o Rapid cure of rhepatient
o Avoid side effects of che drugs e.g. side effects of neomercazole.
O. What are the complications of subtotal thytoidectorny for toxic
goifie1l
A.
A. Operative comp[ications:
r. Comp[ications of anaesthesia.
2. Shock.
3. Hemonhage: pimary.
4. Lniury of important structures:
6
r. Externallaryngealnerve ) loss of high pitchedvoice (see

before)
z. Recurrent Laryngea|nele ) may bepartial, or complete,
unilater al or bil ater al.
3. Trachea.
4. Esophagus.
B. Post-operative complications:
t. Early complications:
a. Reactionarv hemorrhasre:
- Due to S[ippage of supefior thyroid a.ligatute.
- The hematoma may cornptess fiachea or carotid
vesseLs.
- Treatrnent )ernergency rernova[ of sutures of skin
and deep fascia (in bed) )return to opetative room.
b. Secondary hemorrhaEe.
z. lnfection.
3. Pulmonary complications: DVT- pulmonary embolism.
2. Late comolications:
r. Hypothyroidism: ( zo : 4oo/o of cases I
. Rarcly due to extensive rernoval of chyroid dssue but
commonly due to a[ternation of autoimmune ptocess Leading
to destruction of thyroid tissue.
tTreated by L-thyroxin
z. Reeument thlnotedeosis: in [ess than 5o/o of cases usually due co
inadequate rernoval.
3. Thyrotoxie crisis fth+,roid storrn!:
- lt is life threatening of hyperacutehyperthyroidism.
4. Hlgo-patathyroidism (in less thano.f/o of casesl )Tetany
. First ) Circum-ora[ numbness
. Then ) carpo-pedal spasm 8tr- [aryngismus stridulous.
. lt may 6e due to: removal or devascularization or parathyroid
glands.
s. Keloid sc,at: if incision overlies the sternum 8l- managed by local
stercid injection.
Q. What do you know about thyrotoxic crisis?
A.
. Thyrotoxic crisis is a life-chreatening condicion of hyperactue
hyp er ttryroi di sm tha c may occ u r p os c-op er ativ ely e sp eci ally unpr ep arcd
toxic patient or spontaneously or rarely it may be the fist presentation of
thyrotoxicosis if the patient is expos ed to stress.
. lrcc[inica[manifestations,
67
[t is sympathetic hyper stimu[ation:

- Hyperyytexia (> +o"c)
- Heart failure Tachycardia (severe)
- Hypertension. Excessive sweating.
- Corna ) death lrri tabili ty 8tr- convu [si ons.
. Treatmer,t ) Emergency:
a- Symptomatic
- Coo[ing of patient icepacks, antipyretics.
- LV fluids to correct the dehydration.
- Oz and diuretics for heartf aiLure and digoxin for
atria| fibri[lation.
- Sedation.
b- Specific treatrnent:
oCarbimazole r5-2o mg /6hours.
oLugo['s iodine ro drops / Shows or lV &ip of I( iodide.
o Propran olol 4o rlr's/ 6 hours or ally (inder aI can be give by
LV drip undq monitoring.
oLV hydrocortisione.
Q. What are thehazards if ir,deal [V shots in thyrotoxic

qisisT.
A.
o Lndera[ [V shots can lead toheart block and this is the Teason
thac is we give it in the for- of an intravenous drip with
simu[taneous monitoring of the pulse on E.C.C.
a. What are othe.r [ines of treatment of toxic nodu[ar

Soifie (2ry toxic goive)?
A.
o Antithyroid drugs.
a. When do we use anitthyroid drugs in treatment of

s?i,c;olndary thyr otoxicosi s?
A.
We andthyroid drugs in the fol[owing conditions:
use
r. Preoperative preparation of patients for surgery.
z. When patient refuse sursery.
3. When there are coittaindication for surgery.
68
Q. Can radio-iodinebe used in treatment of toxic nodular

goitte1,
A.
o Radio-iodine is less effective in treatment of toxic nodular
goitre as fibrosi s will prevent penetration but it can be used
only in high risk patient e.g.heartfailure.
Q. What is the tteatmerrt of toxic nodule?

A.
a Surgery (hemithyroidectomy) is the main line of tteatrlr,ent.
O Medi cal tr eatmerrt i s indi cat ed in pt eop er ativ e pr ep arati ory in
young patients and in pacients refusing or unfit for surgery.
Radio-iodine can be glven to pacients ovet 4s yearc as an
akernative to sur1ery and radio-iodine will be very effective as
the toxic nodule will be the only part that will take the iodine
with no risk of hypothyroidism.
. iot radio-iodine is the seatment of choice of toxic nodule if
ther e at e no contraindi cati ons )
a. What is the mechanism of action of radio-iodine in

treat'nr,ent of toxic goitre?
A.
r. When radio-iodine is concentrated by the gland wi[[ emit B
irradiation.
Lt destroys the major part of the gland (according to the dose)
without affecting the adjacent structutes (due to short
penetration).
It emits [ittle amount of gamma irradiation.
Q. Mention the types of radio-iodine and which of them is

prefeable in tteatment of toxic goitle!
A.
42, rz8, rz3, I r3r is the preferable as it can emit beta rays
L ryt1
while Lr4 can emit only gamma ruys which areharmful.
Q. What is the dose of radioactive iodine in the tteatrnent

of toxic goite?
A.
o ro mi[[i curi iodine r3r , another dose lr,ay be given after 3
rnonths if therc is no good response.
NB. We use ro micro curi for isotope scanning.
69
Q. Mention the disadvanageso@

A.
I. Ovq dose ) myxedemainT5-8oo/o of cases aftu toyeats.
z, N eed isotope f acilities.
3. Difficult to calcslate the dose as it is according to the
weight of the gland.
4. Low dose ) Recurrer,ce.
5. Teratogenic ) so not given to pregnant women.
6. Carcinogenic so not given bel,ow the age of +S years (ft is
proved not carcinogenic for 3o years).
T. Less effect in secon dary thyrotoxicosis becausefibrosis wi[[
preverlt penetration.
8. lmprovement is expectedwirhinh 8-oweel<s.
g. lndefinice follow up is essential..
ro. Recurrence of toxicity if low dose is given.
Q. When radio-iodine is conrrainidcated?

A.
ln the following conditions:
r. During ptesnancy (risk of foetal anomalies and foetal
hypothyroidism).
z. During lactation (risk of hypothyroidism to the baby).
3. )oung age (risk of inducing thyroid carcinoma).
4. T oxic nodu lar goitre (ineffective) .
s. lodine a\Iergy.
Q. What is meantby rctosrernal goitre?
A.
This is anatomical diagnosis in which the thyroid lies behind
the scernum.
Q. What are the qvq,es of rerTo sternalgoitre?
A.
Resosternal goitre is classified inro 3 types:
rl
. Rises with deglutirion 8[ rhen descends again
through the thoracic goitre.
el lv\ediasriual saitr€:
. Complecely preserrt in the chesr but connected
with tlryroid by r,atrow band of tissue 8l- ake irs
b [ood supply fro- thyroid vessel,s.
70
. Completely preserrt in rhe chest &- separated

from the main gland.
. [c anises from ectopic thyroi d tissue whfuh takes
its b[ood supply from mediastina[ vessels.
Q. What is the pathologi cal natute of rcfioste'ral goitte?
A.
. Retrosternal goitrernay be:
. Simple goitre.
Toxic goite
'
.
Malignant goitre.
Q. What is the clinical picture of retrosternal goifie?.
A.
Symptoms
'/AaY be
asymptomatic.
. History of cewical goive which has disappearedbut
sevete ob tructive symptoms ptesent:
r. Dyspneal cough 8t stridor.
z. Dysphagia.
. Toxic manifestacions rr,ay be found.
Signs
. lnspection: engorgement of neck veins, cyanosis SL
edema of the face 8t neck due ro compression on
innominateveins and dilatedveins on chesr.
. Palpation: thelower bordq is not felt.
. Percussion: dullness over themanubrium sterni.
. Special tests: Pemberton's sign: patient elevates the
arm above the level of headl it is considercd positive
when fascial plethora lblue or pink effusion of the neck
and/ or the f ace due to venous obstruction.
Q. Who is affe*tedntoteby rctrostetnal goitreT
A.
Rerostemalgoi eismore common in ma[es and chis is due to
strong sffap muscles and short neck than females.
Q. What atethe DD of shadow in the supeior mediastinum?

A.
r. goitre.
Retrostem al z- Thymoma.
3-Lymphoma. 4-Enlaryed LNs. S- Aortic
aneurysm.
7l
Q. What is the treatmerrt of retosternal Soitre?.

A.
. Subtotalthyroidectomy from the neck (piecemeaL)because the

vascul.arity in the neck but if huge or incra-thoracicmedian
sternotomy rnay be needed.
. [f toxic subtotal thyroidectomy after preparation by lndral is
done but not anti thyroid drugs to avoid theinqease of the size
of the gland.
a. What are the suggestivefeatures of malignanq in a

goiuel
A.
* Frorn historv:
Short duration or [ong duration with recerrt l.apid
enlargement, pain rcfened to the ear, hoarseness of
voicq symptoms of distant metastases.
* From examination :
Hardness, fixity to the tacheal fixity to
sternomascoidl attachment to overlying skin, absent
carotid pulse (Berry's sign), enlarged deep cewical
lvmphnodesl signs of distanc rnetastases.
a. What is the differential diagnosis of hard thyroid

swelling?
A.
Hard thyroid swellingrnay be;
t Cancer chyroid
z. Riedle thyroiditis
3.Tense c,yst
+. Calcification in simp[e nodular goitre
Q. When the LNs are enlarged second^ry to goitre?

A.
. LNs ate enlarged if goitre is:
r. Malignant e.g. (papillary carcinoma - lymphoma)
z. lnf [ammat ory e.g. acute thyroi diti s
( - Hashimoto thyroi dids )
72
Q. May cenrical LN". develop merastases from a thyroid

ca while rry is not feltl
A.
f es, in occult papillary carcinoma
of the thyroid gland. This was
thought in the past as ectopic thyroid gland and was called
"latera[ abeffant thy'oid".
Q. What is the fhst LN" to be felt in car'cer thyroidl

A.
Pr el arynge al, pr et acheal ( D e [phi an ) tw"ph no de
Q. What is the classification of thyroid neoplasm?

A.
Benign (Follicular Adenoma)
Medullary Carcinoma
6%
Undifferentiated (Anaplastic) I 0%
Q. WhatisDe Croot staging?

A.
. Stage [ ) Tumor with single or multip[e intra-
thyroid foci.
. Stage [[ ) Tumor wich mobile neck LN .s
. Stage lll ) Tumor with fixed neck LN.s (+ local
invasion).
. Stage lV ) Tumor with discant mecascasis.
73
Q. What are the complicarions of cancer thyroid?

A.
r.1pread.
2. Othq complicarions:
aJ Local (infiltration of surroundings :
o Recurrent laryngeal n. ) hoarseness of voice.
o Sympathetic chain ) Horner's $.
o Trachea ) dyspnea nor related ro posture.
o Esophagus ) dysphagia.
o Sternomastoid musc[e.
b) Ceneral:
o Cachexia
o Metastasis (jaundice, cough, hemoptysis, pl,eural
effusion......)
Q. How wouldyou elicitfixity to the tachea!

A.
. By fixing the trachea by one hand and trying to move the
gland up and down with the other hand.
. Normally: there is a s[ight rar.se of movement.
Q. How do you elicit fixity to the sternom astoidl
A.
. By asking the patient to swallow while pinching the rclaxed
sternomastoid,
. Normally I do not feeL something pulling on the
sternomastoi d betw een rny finger s.
Q. What are the investigations for malign ant goitle?

A.
A. E-or-dr-gn=o-sjsl
r. Lab:
Thyroid function
-norma[ thowever TSH rnay be
raised.
z. lmasingr:
a) U/5:
Cystic -+ aspiation (Criteria of malignancy)
Solid--- FNABC
b) lsotope scanning: cold nodule but extremely rare
hyperfunction ) thyrotoxicosis.
t+
3. Biopsv:
A) FNABC
o go o/o accutacy
o Can't differcntiate between foLlicular adenoma
and follicular carcinoma because FNABC can't
detect capsul.ar and b[ood invasion
c) Hemithyroidectomy and paraffin section in fofiicular
neop[asia
d) [n an anaplastic 8tr- obviously irernovable carcinorna ,
incisional ot coteneedle biopsy is justified
E-or-s-tasirlsl
I. CT scan.
2. CXR )[ung metastasis.
3. Bone scan ) bone metastasis (not done except after tota[
thyroidectomy).
4. AbdominalU/5 ) liver metastasis.
5. Dhect
Laryngo scopyt bronchoscopy, esophago scopy.
3. E.g52le:opr-cr-atjrtt-e-w-epiletjgq-
CBC/ EBS/ l(ETs, LETsICXR/ECC
4. E=orj-o-llew-qp-l
r. Tumor markers:
o Calcitonin in medullary carcinoma.
o Thyroglobu lin in differenti ated follicuLar carcinoma.
z. Positron emission tornosnaphv (PET)
o lndication: in follicular carcinoma treated with
thyroidectorny with post-operative ise of
chyroglobu lirt level.
5. E-q-p$ecDjDS.--- ln medullary carcinoma (familia[ type)
)calciconin, calcium,VMA )if high )tota[ thyroidectomy
evenif thyroid is normal by other investigations.
Q. What is the treatment of cancer thyroidT.
A.
r. Ptoohylactig) avoid predisposing factors as neck irradiation
z. Treatment of the tumor:
A. Di
L- Sw*ery:
a- Thwoid qland:
. Total thyroidectomy (rernoval of both [obes and isthrnus)
which is followedby rc yean surviva! rate of over 8oo/o
75
b- Manaqement of LNs:
. [n children ) no prophylactic block dissecrion of LNs.
. [n adults ) prophylactic block dissecrion of cenfial, Sroup of LNs
is done.
. [f one LN ;r affected block dissection of LNs in the neck is
done.
. ln thepast: cherry pick dissection of L\s was done.
I l- I{adi oa ctiv e i odine:
F Aim:
r- Destroy remnants of norma[ thyroid tissue if present.
z- To ablate ar'y rnetastasis from the tumor.
F Methods:
. Af tq tota[ thyro i dectorny w e w ait ti [[ manifestati ons of rnyexderna
appeaf
- Pre-therapy scan: sma[[ dose of radioactle iodine is given
and tota[ body scan is done.
- Lf there is rnetastasis: large ablative dose of radioactive
iodine is given.
- Post-therapy scan: done after the ablative doseby few weeks.
B- Anap[astic carcinoma:
r- Unfortunatelyl themajority of cases aneirresectable at
time of presentation
-Tracheostomy or isthmus resection (or surgica[
debulkins;).
- I{adiocherapy and chemotherapy (down staging).
2- Rare cases are operable ) the tumol shou[d be excised as
cornpletely as possib[e (tota[ thyroidectomy) and then
fi eated by r adi ati on and chemother apy.
C- Medqllary carcinoma:
r) Tota[ thyroidectomy (rernoval of both [obes and
isthmus of thyroid sland).
zl LNs management:
- MeduLLary carcinoma is associated with high
incidence of nodal involvement.
- Centra[ neck node dissection should be done in
alLpatients.
- Modifiedradica[ neck dissection for prirnary
tumor ) r.s cm in diameter andwhennodes are
invoLved
31 ln sporadic type ) preserve allparathyroid gland
while in fami [ial typ., we pteserve only r/ z
parathyroid gland (for fear of
hyperparuthyroidism).
76
4l Lf familiar type )
treatment of
pheochromocytoma fug bombined alpha A beta
blockers).
3. Treatment of complications:
r) Ttacheostomy for tracheal infiltration.
z) Castrostomy for esophageal infiltration.
3, lsolated metastatic deposits of fo[[icular andpapillary
carcinoma shou [d be surgically r emoved ar,d tr eated wi th l'3'
af ter total thyr oi dectomy or chyr oi d ab lati on wi th
radioactive iodine.
4. Po st oper attv e bllow uo:
r) Lveryj months by thyroid scanrringl clinica[ examination and
cumor marker (ic is helpf uI to measure setum lwel of
thyroglobulin which are usually increased > znglml in patients
with residual tumor after total thyroidectonty.
z) Aim:
- T o detect local spread. - Distant metastasis.
- Post operative comp[ications as firyxedema and
RLN injury.
Browse's introduction to the symptoms & signs of surgical disease/ Ch l lthe necH
thyroid p303-306
Q. what are the Wes of recurent goiter?.

A.
Ealsetecurrene: dueto
. FB. Raction:
a granuloma around silk ligature or sma[[ piece of gauzeleft
Accidently
. lnadeguate intial remoual:
Partial: --+ leavins patt equal to norma[ Lobe size on each
side (4xz.5xzcm)
Subtotal : + leaving a part less than normal lobe (in simple
goiter leave r/s of norm al on each side)
Total z + leave t/8 of norma[ [obe on each side (subtotal)
o /lon-remoual of a certain part of the srland:
r. lsthmus
z. Pyr arni da[ [o be--+ if pr esert sho u [d 6e r ernov ed cornpletely
Ttueter,utte7r.cf,,'.
. Comrnonlyz due to persistence of the sanfieetiological factors
of the prinary goitr,r
a) lodine deficiency
b) Dyshormonogenesis
cl Neoplastic
. lackof post operaaveadministrationof Tr &T+inSNC:
(thyroid hormones keep thepost operative TSH not flactuating )
77
INIGI]NIOSCIB0T'AI
SHIIBT
(HIIIBNIA)
I{istory
o Name
. Age
- lndirect inguinal hernia : at any age
- Direct inguinal hernia : at old age
- Femoral hernia:adult
- Congenital inguinal hernia : at birth
. Sex
- lndirect inguinal hernia : male>female
- Direct inguinal hernia : male only
- Femoral hernia: common in females.
o
Marita! status
-
Repeated pregnancies lead to weakened abdominal wall and increase
intra abdominal pressure
o Address, Residence
o Occupation: jobs with straining or carrying heavy objects + hernia
. Special habits of medical importance: smokers with chronic cough
are liable to herniation
g-Omplaintl L.i.t3,"*ll dlr.Ll,-Jl q! c,-'r--lrll.Eil+
Usually swelling in the groin or the scrotum
HPI:
ui.l #t-,cdS i.,,;l.l JFt
1. R*i+;.
Site, Character, Radiation, What increase or decrease, Onset,
Course, Duration, Severity, and what associates.
2.S..rspJli.+g;
a) Sife
b) Srze )(lemon size, orange size ...)
c) Onsef Etit futJ
- Accidental
d) Course: Progressive
e) D u rati o n :.grJll ;JE ;bl
- Srnce bifth > congenital.
0 Other swellings:
s) Effect on the general condition:
h) ) Apparentcause.
i) What rncreases? Strain & What decreases it? Resf
j) Relation of posture and straining to size of swelling:
- lf the swelling appears first at the lower part of abdominal
wall, then enlarges towards the neck of scrotum, and the
size of which varies in relation to posture and straining,
being much reduced in size on lying flat on the back, and
reappears on standing especially with straining. This
confirms the diagnosis of hernia.
- On the other hand, if the swelling appears early at the
bottom of the scrotum and enlarges until it fills and expands
the scrotum completely, and its size never changed in
relation to posture and straining. This confirms the
diagnosis od acquired hydrocele, or ather
non red u ci ble swel I i ng.
3. Pjp..tg.rhanss.. s -f. fu nsti.o.p. ;
Ask ahout the eomplications:
-.r.,,
- lrreducibility te t^t ei..ti cts 4.eJSlsll -
- Manifestations of intestinal obstruction (acute abdomen,
vomiting, absolute constipation & distension)
6..-t sl il* arq r:lt ''l3l Cf.
j i -
4. 9th gf.. py..s..t.e..m.$. ;,
A. Precipitatinq factors:
Chronic cough
Chronic constipation
Straining at micturation
B. Slidinq hernia is suspected when:
Long standing
Irreducible
Double micturation
Pressure on hernia causes desire to micturate
5.Hiq.tsrv..ef.ip..v..esligntisn.+.er...m.edip-elis.+.s.
P_ast_hislory
. Similar attacks.
. Common diseases: (DM, Hypertensiov(,TB, B, Hepatitis, DW)
. Blood transfusion
. Pervious Operations t 6*.tl+ Ag d*4r & t*! C:^ 94.,1i.,1^1e '''t''
Ea-m-ily-_hi-slp_t[
. Consanguinity
80
lE4omination
Pt. is alert, conscious, oriented to time, place, &

persons, average built, quiet faclal expression,
G..g.B.q.{.?.1.i normal decubitus, average intelligence, & s/he is
cooperative.
. Complexion ) (3 colors) Jaundice, pallor & cyanosis.

. Chest & heart (COPD like asthma or bronchitis )
. Abdomen.
Swelling (hepatosplenomegaly, ascities )
3 cabLr lntestinal obstruction: distention borborigmi

Scar of previous operation
Muscular weakness: divarication of recti
P/R for SEP
T Extremities (L.L flat foot , varicose veins or edema )
a Pulse, blood pressure & temperature.
I Head, Neck, Spine ) 3 dJ-,".
!i
r Scrotum: if associated varicocele.
_LOSal; 4..,r^r,Jo ri! r OI;,JI ,,J" C-
{:eE; 9.-,\Jl'at g-L^j

Q-i.> 's{r
t *ojt
81
E-f<pg-s-Ufe ) while the patient is standing with exposing the area from the
nipple to the knees.
a. Why is the patient examined standing?

A.
I To know full extent of hernia sac.
I To inspec t di ect herni a and v aricocele.
Exposure
Types of
Hernia
Epigastric H.
Paraumbilical H.
Direct inguinal H.
Umbilical H.
Oblique inguinal H. Femoral H.
82
lnsp-e-etio-n--l(L'-st--ster-dins-th-eo--siring)-
From 2 different planes dL &ll ,* e !l A4K +
&.sl.i_,
A, .S-a*l\ing.
1. Sife
o For diagnosis
. Examples:
- Umbilical hernia everts umbilicus.
- Paraumblical hernia: just above or below umbilicus
distorting it. Crescent look upward if above, downward if
below umbilicus.
- Epigastric hernia : separated from umbilicus by interval
2. Size
- ln cm (best)
3, Shape
- lrregular, Oval, Rounded, Pyriform (indirect inguinal hernia)
. .-,.r\,-::\-
Z.
-..# Rounded
83
.B,. S.{ci t.t_...o.p. er!.g ing;

I siqn:
- Expansile impulse on cough (increase in size in all directions).
P-alp-ati-o-nl
l.,.S.lvpJline
a. Warmth: +ll 'Gl+ I.SJS
b. Tenderness: OtgJI a+_l & dP r +ll ,A as>
c. Surtace: +ll 4-=l-.1,., as-.,;s.
Smooth.
d. Edge: qJl ,, 'i.-' aS,.

pedunculated.
e, Consr.sfe ncy : dxJ_ l+ iS=,;s,
-Soft---+intestine
-Doughy--+omentum
. Special character
Grasp the swelling and ask the
patient to cough:
Expansile- t in size or tension ) hernia.
f. Draining lymph nodes: ) inguinal & para-aortic
84
2: Scrotal Neck Test: +ll cJ! iS-,,l,-

-
Bilaterally at the same time to detect weather the swelling is
inguinal, scrotal or lnguinoscrotal
-
lnguinal )
hernia
-
lnguinoscrotal )
hernia or varicocele
-
Scrotal )
varicocele.
Q. Where is the neck of scrotum?
A. lt is the junction between the scrotal cavity and the abdominal
cavity which is located opposite the root of penis, and at which
the rugose darker scrotal skin changes into a smooth less
darker abdominal skin.
3: -rnternel Bins,.Teqf;
- Ask the patient to lie down and reduce the hernia, some
authors believe it is better that the doctor reduces the hernia
to know the content and direction of reduction.
- Localize the internal ring:
oLocalize the ASIS: (How)
o Follow the iliac crest from the back till the most
prominent point anteriorly.
a
o Ask the patient to flex, adduct the thigh against
resistance ) then follow the tendon of adductor
longus (most medial structure) the 1st bony
prominence just above it is the pubic tubercle.
oLocalize the mid point of inguinal ligament (How)
o Mid way between ASIS and pubic tubercle.
oThe internal ring lies 112 an inch above the mid point of
inguinal ligament.
oAsk the patient to stand while pressing the finger against
the internal ring occluding it.
o Ask the patient to cough then:
o Observe the appearance of any inguinal swelling.
-lf the hernia appears ) direct hernia.
- lf the hernia does not appear )remove your
thumb and ask the patient to cough again )
lf appear) oblique inguinal hernia.
N.B. - lf the doctor reduces the hernia, direction of reduction and
the content whether intestine(gargle) or omentum (doughly)
well be observed
- Saphina Varix compressible , but , hernia reducible
85
Site of
internal ring
4-ExternaI Nns.Tp.sti
While the hernia is reduced the patient stands, invaginate
the skin of the scrotum by your little finger opposite the neck
of the scrotum and introduce it through the external ring.
inquire the patient to cough,
.lfimpulse hits your finger tip, thi s with oblique hernia,
,While if it hits the back of your fi nger, then it is direct
hernia
/>
a Y<
L/
86
S:T.h..r.ee.Hi+.sp..rs..Tp..q.fi .(Ziema.nlp..f p.s.,t).

-
While the hernia is reduced and the patient lies on his back.
Put one finger opposite the internal ring, the other finger just
medial to the first one (opposite to the ing. canal), while the
third finger below the inguinal ligament and opposite the
femoral canal. Ask the patient to stand and then cough and
watch which finger receives the hits (impulse) on cough:
.lf it hits the first finger -- oblique hernia.
.lf it hits the second finger -- direct hernia.
.lf it hits the third finger --- femoral hernia.
- Index finger: opposite the internal ring

- Middle finger: opposite the inguinal canal
- Ring finger: opposite the femoral canal
Three fingers test

(Ziemanfs test)
6-Pubic Tubercle Test:
Used to identify hernia in the groin is it inguinal or femoral?
Follow the tendon of adductor longus till it ends.
Get above it to the most prominent point.
- if the neck of hernia above and medial ) inguinal
- lf the neck of hernia is below and lateral ) femoral
7: Redusihility;
- Swelling reduces or disappears as soon as it is pressed
upon in a certain direction and reappears again on coughing
or straining (e.9" hernia).
87
8- Examine
Spermatic cord
- Beaded = B or T.B
- Matted= filarasis
Scrotum
-Scrotum (ant, post aspect)
Shape, symmetry and swelling
- ln all cases both sides of the scrotum should be
palpated
- Back of the scrotum for T.B sinus
- Starting with the healthy side, first with the patient
standing & then in the recumbent position
- Palpation of the epididymis(size, consistency,
presence of sulcus, between it and the testis)
- tunica vaginalis (early hydrocele detected by
pinching test. i.e. you
feel double layers)
Iesfis
- Size
- Consistency
-Testicular sensation
Penis ) for ulcer or scar of
chancre
- Penis esp. external
meatus (site, discharge
by pressing the glans)
- Perineum
- Other hernial orifices.
Percussion:
Mainly in abdominal hernia:
lf the contents (intestine): resonant i.e:
Enterocele
lf the contents (omentum): dull i.e: Omentocele
Auscultation:
lntestinal sound is heard in Enterocele
Transillumination:
Hernia in infant only is translucent
88
Sp e cia I Inv e stig ations
Laborato
Pregnancy test, tumor markers
Plain X ray & Doppler, Duplex U/S.
Analsm!-cel;
It is diagnosis of the region which is affected (inguinal, femoral, and scrotal).
-efiehgisel;
1ry, 2ry, congenital, paralytic...
Pelhg!_og|cel,
Hernia (oblique or direct).
Associated condition:
l.e. complications ) irreducible, strangulation.
89
Westions s%nswers
Case 7. Inguinal Hernia
A,
Rt. ob[ique inguinalhernia, uncomp[icatedl containing intestine (omentum), no
other herni as, as soci ated with chroni c co ugh.
a. Why you diagnose it as ahernia?

A.
Because it is a swel[ing
r) At the anatomic aI site of ahernia,
z) Cives an impulse on coughT and
3) lt is (or was) reducible on lying down and by the patient fingers.
3)
Why oblique and not direct andwhatis the differencebetween them?

R
[t is obli quebecause:
t) lt descends inco the scroturn,
z) On doing the interna[ ring test, there was no swelLing to appean on
coughing, and
r) The patient is a young mal.e
fence.
lncidence 8oo/o zo %o
Age 8[sex Any age.male>fernale Old age. usually rnale

Side Less comm on 5ilater al 3o"/o More common 5ilatera| 5oo/o
Shape Pyriform H emi spheri c al ft ounded)
Direction of descend D ownw ar d 1f orw ar d and rnedi aL Eorward
Descent into scrotum Can descend Lxtternely rare
Reduction U pw ar d, b ackw ar d and later ally Backward
lnt ring test Does not descend Descend
Exc ring cest Wide ring and show impulse actip of Norma[ring and show impulse
little finger at medial side of little finger
Complication More common Less common
a. Why this is inguinal and not afernoralhernia?

A.
It is inguir,albecause
r) The hernia is above inguina[ ligament,
z) The neck of the herniais above 8[ media[ to pubic tubercle and
3) Because thehernia descends into the scrotum (if so).
90
Q. What are the clinic al types of oblique inguinal hernia.s?

A. the Wes atei
separate from the hernial sac.
hernial sac surrounds the testis which is not fe[t through the contents
of thehernia.
Q. What is the etiology of oblique inguinalhernia?
A.
Thereis predisposing f actor 8l-precipitating factors:
. The predisposins factor: is the preser'ce of a preformed sac : persistent
p atent pt o cess u s vagi na[i s.
. The precipitatins factor is: any cause of inueased intabdominal ptessure
e.g. lifting heavy weightsl chronic coughing and constipation or straining
at micturation acquircd pulsion sac may a[so occur
Q. Does any patient with patent processus vaginalis develop obligue

inguina[ hernia?
A.
No. the hernia develops only when there is a precipitating factor (such as
inqeased incra-abdomina[ ptessute due to lifting heatry weight for example)
on top of predisposing f actor (patencprocessus vaginalis ) .
Q. Describehow didyou do theinternalring tesd.

A,
a. Ask the patient to lie down andreduce the
hernia, then
b. Ask the patient to stand while occluding the
interrnal ring (by pressing the finger ilz an
inch above the mid inguina[ point) l then
cough then:
- observe the appearanceof;ffil:i:::;::;
Q. What is the swf ace anatomy of interna[ ring and external r.ir,g1,
A.
i. lnternal ring: [t lies t/z inch above the mid point of inguinal ligament
ii. External ring: [t lies r/zinch above &.medial ro the pubic tubercle.
91
Q. How to reach pubic tubercle?

A.
By asking the patient to put the thigh in fLexionl adduction and. internal
rotation against resistance.
And fofiowing the tendon of the adductor longus muscle (the most medial,
muscl.e) the fir,st bony prominen ce thatmeetyour finger is the pubic tubercle.
a. Didyou do the exte,rna[ ring test? Andwhy?

A.
No. I don't 8t this is because it is a painfu[ test.
Q. When does dhecthernia descendinto the scrorum?

A.
Directhernia can descend into scrocum in the following rare conditions:
r. Funicu[ar type of direct hernia.
z. Paralysis of the conjoint tendon.
3. Lf it arises Lateral to rhe conjoint tendon.
Q. How can you know the neck of scrorum clinicallyl

A.
By'
o Root of penis.
o Change of the color of skin.
a. Where is the defect in obligue inguin aI hernia d, dhect inguinal

hemia?,
A.
. ln oblique inguina[ hernia the defect is rhe incerna[ ring.
' [n diect inguinal hernia the defect is the posteior wall of the inguin al canal
(H asse\b achs tri angle) .
O. What arethe boundaries &,sub divisions of Hasselbach's ttianglel

A.
' The boundaries: are the Lateral bordq of the tectus abdominis muscle
medially, the inferior epigastric artery latenlly and the inguinal [igament
inferiorly.
' Subdivision: [t is subdivided into media[ and lateral parts by means of
the rnedi a[ umbi [ica[ [igament.
92
Q. What ane the conrenrs of this hernia and why?

A.
b
r) Curgle during reduction,
z) Sofc in consisteilcy/
t) Reducibility ftust difficult then easy,
+) Auscukation revealed intestinal sounds.
z- OmcntuxLbceaqse
r.No gurgle
z. D oughy in consi st ency.
l. Reducibility fhst easy ther. difficult.
Q. What ane the common contents of aherniain general?
A.
'
Any abdomina[ organ can be a content of a hernia except the pancreas
b ecau se it i s r eu op eritoneal and v ertebrae behi nd i t
' lntestir'e/ omerrtumlfluid. Are the common content of hernia..

N.B, Eluidis stated in some references to be the commonesc content of ahernia
Q. What is hydtocoele of the hernial sacl And what is hernia of
hydrocoele?.!
A.
. Hydrocoele of thehernial sacl- Part of the sac near its neck becomes blocked
by apiece of omentum and accurnulates fluid.
. Hernia of hydrocoele: in cases of vaginal hydrocoelel a defect occurs in the
dartos fascia of the scrotum through which a paft of the hydrocoeLe
herniates.
Q. Mention the causes of rcsidual swellirrs aftq rcducing thehenial

A.
r) 5[iding hernia,
zl lncompletereducibility due co adhesionsbetween the contents and the sac
il Hydrocele of theherniaL sac
4) Associated [ipoma of the cord
Q. How carlyou detectprostatic enlargementl
A.
A- Clinically:
t. P.R. examination
B- lnvestigations:
z. Cystosrap@ (lVP)
3. Cystoscopy
+. TRUS (transrectal U/5 guided biopsy)
Q. What is the importan ce of examining for the presence of enlarged,

ptostatel
A,
t This is because if it is ptesent/ it must be teated first toavoid recurenee of
thehernia.
Q. What arethecomplications of hernial
A.
r. l'lrreducibility :
o Eailure to reduce thehernia in the absence of any other
complications. lt is due to adhesions wirhin the sac or
overerowding of its content. Ltpredisposes rc obstruction and
strangulation
z. Obstrqction:
o
Obstructedhernia is an errterocoeleinwhich the [umen is
obstructed from outsideby the neck of the sac or band of adhesions
or from inside by fecal impaction.l,tpredisposes to strangu[ation.
3. Strangulation =
o Obstruction of the blood supply to the hernial contents.
o Obstruction is causedby the defect or by a band of adhesion.
This leads to gangrene of the contentsl peitonitisl septicemial
death.
4. lnflammation =
o lnflammation of the contents e.g. appendicitis, saLpingitis or
inflammation of the coveings e.g. skin
5. I(upture of the hernial sac (rare)
6. Hydrocele of hernia[ sac
O. What is the clini cal differcnce between obstruct ed and strangu I ated
hernias?
A.
. This is difficultbecauseboth arev?,ry acute conditions with thehernia being
painful fueducible &- tender.
. lmpulse on cough is weak in obstructedhernia because it is large but is [ost
in strangu lated hernias.
. Theherniais tense in strangulation but not in obstruction.
. Symptoms and signs of intestina[ obstruction are present in obstructed
hernias and rnaybepresent in strangulated hernias.
. The degtee of shock and toxemia are more severe in strangulated hernias.
. Howeverl both conditions ate considered surgica[ ernergencies and
necessitate ax ursent interference to relieve the cause of obstruction and to
dealwith the contents.
94
lf the content of thehernia is one of the fol[owing:

r. Omentum
z. Pa:r.of the circumfercnce of the intestina[ [umen (Richter's hernia)
3. Micke['s diverticulum (Limre's hernia)
4. Fa[[opian tube 8t ovary
Q. What is the common est cause of inflammation of the hernial saal
A.
. LLI fitting truss.
Q. What are the comp[ications of truss?
A.
T Adhesion
I [nfection
I
Orisk of scrangu[ation
I Pressure atrophy on [oca[ musc[es.
Q. What is Richtelshernial
A.
' lt is a hernia in which the concent of the hernia is part of the circumference
of an intestinal [oop. [t is more common in femoralhernia.
Q. What is Mayd['s hernia?. And what is its importance?
A.
lt is the W shapedhernia.
I
I lts importance is: if this hernia is srrangul,ated, the gangrenous loop mighr
not be within the sac, it rrtay be within the abdomen so it is imporranr
during surgery to pu[[ on the rnedia| [imbs if two loops.
Q. What is pantaloon herniaT.
A.
It is a combination of indirect and diect inguina[ herniasl on one side and
the inf eri or epi gastri c v es sels Li e b etw een rhe tw o herni as.
It is also calledhernia en bisac.
Q. What is a sliding hernial
A.
lc is a hernia in which a viscus (usually an extraperitonea| structure) "s[ides"
to form part of chewall of the hernial sac.
I The commonest s[iding sttuctute on both sides is the urinary bladdet.
I The caecurn can descend on the right side, sigmoid co[on can descend on the
left side.
95
Q. How do you suspect clinically the presence of a sliding hernial

A.
. From history, there is a double micturation (if the sliding organ is the
urinary bladder) and the patient finds it necessary co press on the hernia to
complete hi s mi cturati on.
. From examinationz there is usual[y arcsiduaL swelling aftu reduction of the
hernia (incomp[ete rcducibility). Also, pressute on the sac causes a desfie to
mi ctur ate how ev er 1 the s ur e di agnosi s i s i ntraop et ativ e.
Q. What is the importan ce of such a sliding hernia?

A.
. [f not recognized during the operation, the sliding organ lray be injured or
devascularized du,ing dissection of the hernial sac.
Q. What is taxis? And what are its complications?

A.
. [t is manual reduction of complicatedhernia.
. ls doneby flexion, incerna[ rotation of the thigh to relax the externa[ oblique.
. Valium or pethidine.
' Co[d colrrpresses
. Trial of reduction after Ll2hour
. [t is more useful in children wich early strangulation.
. lts complicacions are:
r. Muy cause shock.
z. Muy causeruptute of the gut.
3. Pefioration in crial of reduction.
4. Reduction enbisac into an intra-parietal sac.
s. Reduction en mass.
6. Reduction of gangrenous [oop.
Q. What ate the geneta[ principles of operations for hernia?

A.
. There are three types of operationsl hetniotomy, herniorhaphy and
hernioplasty.
Q. What is herniotomy ? heniorhaphyl herniopl asty

A.
. Herniotomy: Excision of thehernial sac.
. Herniorrhaphy: Excision of the hernial sac * repah of the defect using the
Local tissues
. Herniop[ascy: Excision of che hernial sac ar'd repah of the defect using
tissues other than the [oca[ ones or synthetic graft.
96
O. Lf your patient has bilaterul inguinal herniasl how would you

proceedl And which side to opetate upon first?
A.
. Lwill repai one side only and then the other side after 5 months. This is to
avoid ovet stretching the abdomina[ muscles if both sides wete repaired in
the same time.
. We usually staftby)
a. The bigger hernial
b. That withnarrower neckl or
c. Themore painfuI side.
Q. What are the indications of hernioplasty!

A.
r. Recurrent herntas
z. Wide defecrs
3. Weakmusc[es as in old age
Q. Whatmateia[ can be used as a graft in hernioplasty?.

A.
. The materialmay be:
A. Endogenous e.s. skin graftT f ascialata graft or
B. Exogenous (synth etic) as prolene, dacron, teflon, merselene St PTFE grafts.
Q. What is the treatrrr,errt of this case of oblique inguinalhernia?.
A.
. O.l.H. in children and adoLescents ) inguina[ herniotomy (excision of the
hernial sac.They do not needrepah as theyhavevery goodmuscles)
r Q.[.H. in adults ) lnguinalherniorrhaphy
. O.[.H in elderly andrecurrent cases ) lnguinal hernioplasty
Q. Do you open the inguina[ cana[ in adols ecerrtl

A.
. Up to + yeats of agel there is no need to open the canal. as the externaL ring
Iies exactly opposite the internal ring i.e. there is no canal.
Q. What is the effectif injury of ilioinguina[ ne;rvel

A.
. lt d,epends on site of injury:
. During appendicectorny -+ paralysis of conjoint tendon -+ D.l.H
. During hernia operation i numbness of the scrotum 8t inner aspect of
che thigh
97
Q. What is the operation for obligue inguina[ herniain adulrs?

A.
' is not recurrent and the l,ocal muscles are sttong/ we do inguinal
Lf the case
herniorhaphy, and if the case is recufferrt or the [oca[mus cles are weakas in
senility and de\iLity/ we do hernioplasty.
Q. What are the pfinciples of inguin alherniorhaphyl

A,
' Excision of thehernial sac * Repair of the defect by the \ocal, tissues.
Q. What suture material do you use in therepai?.

A.
. The suturerr,aterial to be usedis prolene (non absorbabl,e suture).
Q. What ate the principal item s of rcpair in inguina[ herniorhaphyl

A.
. lnguin aLherniorrhaphy should includ,e three main itemsl
r. Narrowin g the internal lingl
z. Repair of the f ascia ttansversaLisl and;
3. Reinforcement of the posterior wall, of the inguinal canaL.
Q. How do you rcpah the fascia transvercalisl
A.
. There are two methods:
r. P[ication of the fasciatansversalis
z. Shouldice repah (double breasting of thefasciatransvetsalis).
Q. what are the complications of hernioraphyl
A.
' zryhydrocelebecause of tightening of external ring or interna[ ring or both
Q. Mention somemethods of rcinforcemertt of postericr wall of inguinal

canal.
A.
r. Bassini repair: suturing the conjoined muscLe to the inguina[ ligament.
z. Cooper's [igament repair: suturing the conjoined muscle to Cooper's
(Pectinea[) [igament.
3. [[iopubic ttactrepair: suturing the conjoined muscle to i[iopubic tact
4. Darning of fasciatansvercalis.
5. Bloodgood repair: suturing a triangular flap reflected from anterior rectus
sheath to inguina[ [igament.
Q. What is the most popular type of rcpair?
A.
. Bassini rcpair (: 5uturing the conjoined muscle to the inguina[ [igament)
98
Q. Whatpart of the conjoinedmuscle do you includein the rcpair.-

A.
' The tendinous and aponeurotic parts (Transversus Abdominis Aponeurosis).
Q. Whac is the disadvancage of Bassini repair?

A.
' [t is non-physiologic as itprevents thenorma[ shutter mechanism.
a. What addidonal procedures may be done during the inguinal

herniorrhaphyT.
A.
r. Tantter's release incision: An incision in anterior rectus sheach to relax a
ter.se repait
2. Suturing the externa[ oblique aponeurosis behind the cord (Ha[shred's repah).
J. Orchidectom)A rnay be done in elderly.
Q. What are the indications of hernioplasty in inguin alhernial

A.
. Recurr enthernias and o\d patients (weak rnuscles)
Q. What is the principle of hernioplasty in inguin alhernial

A.
' Excision of the hernial, sac * Repair of the defect using tissues other than
thelocal ones (i.e. using agraft, usually aprolenemesh Sraft).
Q. What is the principle of operation for direct inguina[ herniaT.

A.
' [c isnearly the same as in O.L.H./ but the sac inscead of being excisedlis
inveted (invaginated) except if it is huge or funicular sacwhereitis excised.
' T-he principles of repah are the sarne as in O.t.H. except that there is no
need to rLarrow the internal ring as it is not widened except if associated
with an ob[ique inguinal hernia.
Q. What are the causes of recurrer..ce of aherniaT.

A.
r. Untreatedpreoperative condition: chronic straining (asthmatic bronchitis,
prostatic enlargement . . . etc.), debility, obesity
z. Lntra-operative causes: improper hemostasis, tense repair, Iax repair, tepair
wi th abso rb abLe sutur e rnateri aL
3. Postoperative causes: hematom a, infection, earLy teturn tohard work
99
Case 2: Paraumbilical Hernia

Q. What is diagnosis?
A.
' This is a case of Paraumbi[ica[ hernia, uncomp[ic ated.
Q. Why this is aherniaT.
A.
. Becaus e it
is a swelling;
r) At the anatomic al site of ahernia,
z) Cives an impu[se on cough, and
3) [t is (or was) rcducible on lying down andby the patient fingers.
Q. What ate the type.s of umbilicalhernias?.
A.
True umbi [ica[ hernias:
o Congenital umbilical hernia (exompha[os major and minor) :
present at birth.
o lnfantile umbilica[ hernia (fro- weak umbilica[ cicatrix) : preserrt
shortly after birth.
o Adult umbilica[ hernia (from stetch of the abdominal waLL by
incr e ased i ntrab domi na I contents) : present in adult life.
Para umbi Ii c al herni as :
Due to a defect in the Linea albaclose to the umbilicus.2types
r) 5upraumbilical,
z) lnfraumbilical
Q. What ate the causes of hernia in general1
A- Congenital [PreLormed sacl
r. U nob litr ated processus vagina[is congeni ta[ sac ) :
(
) Congenita[ inguinal hernia.

z. U nob [i sated phy siologi cali umbi [i ca[ herni a congeni ta L def ect)
( :
) Congenita[ umbi [ical herni a (exomphlalos ).

B- Acquired
r.Raised intra-abdominal ptessute (precipitating factors) due to:
- Chronic cough. - Strainjng due to constip ation, prostatism.
- Obesity. - Abdomi r'a| swelling (Splen ornegaly) .
z. Weak anterior abdominal wall due to:
- kepeatedpregnancy. - Obesity. - SeniLity.
3.Paralysis of wall:
a- Crid iron incision with Rutherford Morison extension
) Lnjury of ileo-inguinal nerve (supplying conjoint tendon)
) Direct inguinal hernia
100
Q" How obesity wouldpredispose ro abdomin alhernias?

A.
By
r) Lncroase in abdomina[ conrentsl and.
z) Deposition of fat betwcen therirruscLe fiberc thus weakening themuscle.
Q. This patientis obesel doyou adwse her (himl for somethingbefore

the operationl
A.
' Yeq L advise her (him) to reduce weight first, otherwise thehernia might
tecut.
Q. What is the explanation of complaining of dyspepsia in patientwith

paraumbilicalhernial
A.
' This is due to traction on the greater ornentum which is commsnly the
content of this hernia.
Q. Whatis the commonest comp[ication of paraumbi[ical hernial and

whyl
A.
. The commonest complication is hreducibiliry.
Due to:
r. Adhesions
z. Multiloculations
3. Srnall defect in relation to the size of hernia.
a. What is the danger of such fueducibilityl
A.
. [t ptedisposes to obstruction and strangu[arion.
a. What is the treatrnent of this case?
A.
. Herniorhaphy.
Q. What type of repair do you dol

A.
. lt varies according to the size of the defect as fo[[ows:
o Sma[[ defect -+ Anatomical repair OR Mayo's repair
o Large defect + Hernioplasty (prolenemesh Sraft)
101
Q. Whatis thepinciple of Mayo's rcpah?. Ls it ideal?

A.
. Doublebreasting of the abdominal wall aponeurosis.
. No, it is not because itis followed by ahigh rate of tecufience.
Case 3: Other Tgpes of Hernia
I. I]IDIG/ISTIIIC HI]IINIA
O. How to differcntiate between paraumbilical and an epigastic
heniaT.
A.
. [n paraumbilicalhernia, the defect is above or below the umbilicus so that
the umbilicus is distortedl while in epigasvic hernia, there is a bridge of
norma[ abdominal musc[es hetween the defect and the umbilicus. Besides,
epigastic herni a cou [d be multiple
Q. What is the treatment of epig astrichernia?

A
. lt varies according to the size of the defect as fo[[ows:
. Small defect-+ Anatomica[ repair ORMayo's repair
. Larse defect -+ Hernioplasty (prolenemesh r,aft)
II. INCISIONAI, HItrIINIA
Q. Mention the catrses of incisionalhernial

A.
. There ane:
r. Preooerative causes' Chronic straining (asthmatic bronchitis,
pros tati c enl ar gernent. etc. ), debiLi ty, ob e si ty
z. lntr aopet ativ e cas ses, Lrnpr op u haemosta si s 1 tense r ep air, lax r ep air,
rep ai wi th abso rb able sutute materi al
3. Postoperative causes Haematornal infection, early returr' to hard work
Q. How do you tteat an incisiona[ hernia?

A.
I Sma[[ defect + Anatomical rcpair
I Large defect + HerniopLasty (prolenemesh 5laft)r
l(eel operation
l(attell '5 operation
t02
Q. What is Keel opetation, l(attell opeationl

A.
' l(eeL operation: the sac is not opened (inveted) St the defectis closedby a
seies of inverting sutures.
. l(attell's operation: The sac is opened 8[ the defect is closed by multiple
layerc from surrounding tissues (6 Layers)
III. FI]DIOIBAI IIItrISNIA

Q. U/hV the fernonlherniaismorc common infernalel
A.
. Due to:
r. WidepeLvis (widefemoral canal) * sma[[ BVs
z. f intra-abdomina[ ptessuteby pregnancy
3. Laxity of abdominal muscles 8t tendons inpregnancy
Q. What are the type.s of femoalhemia?.
A.
. Consenital: femora|hernia of Cloquet (Narathe'shernia) in congenica[ hip
dislocation (CHD)
. Acquhed: more common
Q. What is the pinciple of treating femoralhernia?.

A.
, Remove the sac of fat 8t close the femoral canal with sutures
Q. Why ffuss is contraindicated in femora[ hernia?

A,
. HemiatotreducibLe
. frlot fit to upper thigh
Q. What are DD of swelling in femoral tianglel

A.
r) Reducible swe[[ins
o Saphinavarix (thrillon cough + V.V.)
o Femor al arcery aneurysm lexpansile pulsation, proximal pressure -> +
swe[[ing)
o Psoas abscess (cystic, cross fluctuation, disappears on hip flexion)
o lnguinalhernia (above pubic tubercle)
z) lreducible swellinq;
. Skin tumor . LN"
o Subcutaneous [ipoma o Eccopi c testis
r ) Stranqulated femoralhernia
lymphadenitis
+ Abscess
103
o Trauma -+ torsion
-+ Rupture adductor [ongus tendon
-+ Anterior hip dislocation
IIT. INTI]IBNAI IIBITNIA:
Mention whatyou know about interna[ hernia?
ft
Herniacion of intestine through peitoneal fossae ot defect in the
tlr.esel:-try.
Examp[es:
. ALI diaphragmatic hernias
. Hernia chrough foramen of Wins[ow (epiploic foramen)
. Retrocecal hernia through rettoceca| tecess.
. Paraduodenal hernia (through peri,tonea[ fossae near the duodenum
. Detect in (transverse mesocolory rneser'try of S.\ broad [igament of the
uterus)
T
CIP : lntestinal Obsruction
T
lnvestigrations: plain X-ray etect 8tr supine
. Tteatment:
Preoperative prepatation: ryle, line, catheter. . ..
Divide the constricting agent excepE if the fossa is vascular as
(p ar adu o denal rnes entry/ W inslow )
kelease the contents

Or: resection anastomosis of the gangrenous [oop
*^t ate the boundaries of the inguina[ ring?
R
Boundaries of the inguinal cana[:
o Floor : inguinalLigament,
o Roof : arching fibres of conjoinedmuscle,
o Anterior wall: external ob[ique aponeurosis.
o Posteior wall : f ascia ttansvetsalis, conjoint tendon.
The deep inguinal ring is in fascia ttansvetsalisl while the supefiicial
inguinal ring is in externa[ oblique aponeurosis.
*"tis the boundries of the femoral canal?.

8
. Boundaries of the fernoral openinsr:
o Anteriorly: inguinal (Pouparc's) ligament,
o Posteriorly: pectinea| (Cooper's) [igament
o Medially: lacunar (Cembernat's) [igament
o lateralLy: femoral vein
104
INIGIIIIIIOSCIBOTAI
SHIIBT
(V/TIBIC0CBIII)
Inguino-S crotaf Case S fieet

2. '/aricocefe
I{istory
Occupation: prolonged standing may predispose to varicocele

Marital status: sub-fertility may complicate varicocele
9-g-mp.!-eln-t.. ri.it*4lt dt+b Ct U cr-,,,,,.tt.Eit+

Usually swelling in the groin or the scrotum
HPl= ,j^l friL,,",i< i,r;AI

1. Pain
Site, Character, Radiation, What increase or decrease, Onset, Course,
Duration, Severity, and what associates.
2.S..rypJling
a) Onset q,U lrrl
- Accidental
- Acute
- Gradual
b) Course:
- Progressive
- Stationary
- Regressive.
- Fluctuating
c) Duratisn ;Asgl 6in a/ji
- Short: (days orweeks).
- Srnce birlh ) congenital.
d) Site
e) Size ) (lemon size, orange size ...)
0 What increase & what decrease it?
g) Effect on the general condition:
h) Apparent cause.
i) Other swellings:
106
3 . Di.q.f.u.rh *n.e.e. s f. fsn.e.f i.p..+

Ask about the complic tions:
- Sexual affection e.g. infertility.
4. 9thgr.. $y..q.tp.mq,
- lncreased intra-abdominal pressure as
o Chronic cough
. Constipation
. Straining at micturition
5.Hiqf sry-.sf.i.+..v.ssIigef ie.n.q..er...m.edip-+1i.e.+..s.
P-a-ql,his-t-o--ry
. Similar attacks.
. Common diseases: (DM, Hypertension, TB, B, Hepatitis, DVT)
. Blood transfusion
', Gonorrhea
Filariasis
. Urinary troubles
, Past history of trauma
F-a-m1ly-his-tq,ry
. Consanguinity
Pt. ,s alert, conscious, oriented to time,

General: place, & persons, average build, quiet facial
expression, normal decubitus, average
Body built. intelligence, & s/he is cooperative.
3 i5!-,t Decubitus
{: Facial expressions.
(. Chest & heaft (COPD like asthma or bronchitis
3 d,l+t J. Abdomen. (hepatosplenomegaly, ascities )
)
LI Extremities (L.L flat foot , varicose veins or edema )

Head, Neck, Spine > 3 d##\:i
: PR: for SEP.
107
LgCaf_: 4+.r.+ . ir 3 osll ,'I- J-,

Exp-g-s-u-t9. ) while the patient is standing with exposing the area from the
nipple to the knees.
[n-qpe-s-ti-qn lU i s! -qt-en di ng -th-e-n -q

ifi rn g)
From 2 different planes + (dta.:Jt C) !l aJS
& 'n-:"J"
A.Sys.e[ins
Fullness in RT or LT scrotal compartement
The testis hangs lower down
Theres is dilated veins over the skin of the scrotum
H...S-hi...n..q.v..erJvins;
- Normal, Stretched, Pigmented,
- Show sign of inflammation (redness, edematous.. . ),
- Dilated veins, Ulcer, Scar...
C,.Spsp..ial.s-ig+;,
- Expansile impulse on cough (increase in size in all directions).
P-ajpatis-E
l,..S..rvpJli+.g
a. Warmth; +ll _'sl+ ISJF.
b. Tenderness: OSll ++:,-,1c, c# _r 'lll ,;t+ iS;.
c. Surtace; +ll i.=l: iS=,;s.
Smooth, granular, nodular, lobulated...etc.
d. Edge: +ll ', "i i iS;s'
lll defined, well-defined, pedunculated.
cr! as-=
" ":"uf::I""H:
2:..S9r.q.t+l.,Np..qk.fesf ; +lr .Js+ asJS
- Bilaterally at the same time to detect weather the swelling is
- lnguinoscrotal ) varicocele
108
1\
Ask the patient to lie down and elevate the scrotum

Ask the patient to cough--* thrill
7'ry varicocele 2'ry varicocele

Thrill present Not present
Decrease by elevation of scrotum No change

f. Draining lymph nodes: ) inguinal & Para-aortic
3;H.ew..pign;
- lf while holding the varicocele lightly between the finger's and the
thumb, the patient is instructed to bend forward, tension within the
varicocele becomes appreciably less. Positive Bow's sign indicates
that the patient is likely to benefit from the operation.
4;..E...xa.mi.tte.;
. Penis ) for ulcer or scar of chancre
, Scrotum
- ln all cases both sides of the scrotum should be palpated,
- Starting with the healthy side, first with the patient standing & then
in the recumbent position
- Palpation of the epididymis (size, consistency, presence of
sulcus, between it and the testis)
- tunica vaginalis (early hydrocele detected by pinching test)
. Testis
- slze
- consistency
- testicular sensation
. Spermatic cord
- Beaded Or matted
- swelling in its lower part or thickening
109
-Le ho_re!_q
rv n veqtr g ations:
I
RaCiqlqg iqel lnvestige_tionq;

Anatomical
It is diagnosis of the region which is affected (inguinal, femoral, scrotal RT,LT).
1ry,2ry.
Pethelpsipel
varicocele
i.e. complications ) sub fertility.
Browse's introduction to the symptoms & signs of surgical disease/ Ch 13 external genitalia P350
questions sf, Answers

Case: Primary Varicacele
a. What is the diagnosis?
A.
It is a case of Left prirnary varicocoele not cornp|icated.
a. How didyoureach this diagnosis?
A.
By the fo[lowing:
. Sympcoms:
o Pain:-
Dragging pain due to relaxation of dartos ar.d cernasterc musc[e.
110
o Swelling:-
Suotal swelLing.
o Sisns:
o Ceneral: patientis ta\[ and thin.
o Local:
. lnspection:
/ Sqotalful\ness.
/ Lett side of scortum hangs lower than right side
/ Scrota[ skin show dilatedveins.
. Pa[pation:
/ Scrota[neck test: fullness at the neck of che scrotum.
/ VNicosicies: felt as bag of warrr..
/ Thrill on cough due to turbulence of blood flow.
/ Swelling which disappear when the patient lie down and
the sqoturr. i s el,ev ated.
Q Why is it a prirr,ary varcicoele 7
A.
As there is:
r. lmpulse S[ thril[ on cough.
z. Swelling deqease in size when the patient lies down.
3. Disappear on elevation of scrotum.
Q. Mendon the types of varicocoeleT.
A.
Types of varicocele are:
r Primary vNicocele.
z- S econdary v aricocele.
Q. What is the cause of try varicocele?

A.
There is predisposing f actors and precipicating factors:
o ASe:
- Between puberty and 35 years
o Conglenital weakmesenchyme:
- l/y'hich might be associated withhernia 8t varicos e veins, piles.
o Lnqeasevenoqs ptessute
r. Prolonged sanding.
z. Scraining as in constipacion.
3. Venous consestion due to unreLieved sexual exciternent
111
Q. What is the cause of zry varicocele?

A.
Ltis d.ue to venous obsrruction
r. The commonest cause is hypemephroma (it spreads in the rena[ vein like
fingers in glove).
z. ketroperitonea[ tumors.
j. ketroperitoneal fi brosis.
a. What ate the differcntiating points between try ar.,d zry varricocoele1.
A.
try varicocoele zry varicocoele
From history
Ase rs-2\ years 2 4oyears
Onset Cradual Sudden
Duration Lonq Short
Site Usually LT (qs%) Rt or Lt
From exarnination
On lvinq down Emptv Doesn't ernuty
On couqhinc Thrill No thril[
Abd. Exam No swellinq U sua i Iy r eveal s hypernephroma
Q. Whatis the explanation of the higher incidence of prirr,ary varicocele

in the left sidemore than the right side?
A.
Because of the fol[owing reasoTls
r. ular vein.
z.
3.
4. Left suprarenal gland secretes adrena,Iine near the mouth of the Left testicular
veir.
s. The left common iliac vein is crossed 6y the righc common iliac artery this causes
higher ptessure in the veins of the vas & crernasteic vein
6. High pressure in che left rcnal vein as it is compressed between the supeior
rnesenteic artery 8L aorta (nut cracker effect)
7. Thelefttesticular artery arches over theleftrenal vein in t6 o/o of cases.
8. Valves at the end of the left testicular vein are usually ma[formed while on the
right side are usually cornpeter.t
tt2
Q. Mention the comp[ications of try varicocoele?.

A.
r. Subferility lzo %" of cases)
2. Thrombosis) thrombophlebitis
Either acute or sabc/inica
- [n acute form it causes severe pain.
- [r is teatedby restinbedl analgesic, ancibiotics, 8i- rest of affecred organ
(elevacion of the scrotum).
3. Se*ordaryhydrocele
- Due to chronic congestion of the testis.
4. Testiculat attophylll (very late)
- Chronic congestion ) f venou s pressute ) ! arteria[ blood supply )
testicular atroPhY.
- The testis becomes softer in consistency 8l- srnaLlq in size.
s. Neurosis
Q. What is the cause of subfertilityl
A.
. Thermal Theory:
- The tefitperature differcncebetween scfotum 8f rectum has to 6e z.5oc.
- Lf less this might impair spelmatogenesis.
Even if unilat:eral due to transmission of heat by contactwith the other side.
Q. 14/hat is the $rade of varicocle?
A.
A.
oGrade [: ptesert only withV alsalva.
o Cr ade ll: pr eserrt wi thou t V als alv a.
oCtade lLL. visible through the skin (bag of worms).
B. Subc[inica[ (not palpablel: detected by Doppler reflux on Valsalvarnar'euvet.
a. How can you treat a case of rry varicocoele 7.
A.
I There arc zlines of treatment:
r. Conservative treatment for all cases.
z. Opetative treatrr'er't for some cases.
a. Cive indications of ssrgery in rry varicocoeleT-
A.
o E ailure of medicaL treatment (Severe symptoms that can't6e tolerated).
o Complicationot
b
Subferility. z- Recurrent thrombophlebi ti s
3- Failure of medica[ commission. 4- Neurotic patient
113
a. What are investigations do you ask for in rhis case!

A.
Semen anaLysis (for medico-Iegal irnportanc e)) stress pattern.
I Dup\ex scan ) detects reversed blood ftow 8t bil,atea\ity.

I 5 q otal or Tr ansr ectal U / S :
- Best test to evaluate the semin al vesicles and ejaculatory ducts.
- Va I u ab e in vi su ali zins, and gradi ng v ari coceles.
I
AbdominalU/5 ) to exclude zry varicocele e.g.hypenephroma.
O. Whatis the importance of semen analysisl

A.
Sermen ana[ysis is of a rnedico-lega[ importance as if the patient complains of
infertility after the operation; the analysis is repeated and compared with the
preoperative one. Ltrnay reveal alow count in both repotts and thus infetility
is not rcgarded to the operation.
Q What are the tesults of semen analysis you expect in this pati ent?.
A,
Semen analysis in this patientmay show stress pattetr. which include:
. O[igospermia.
. Tetatospermia
. Athenospermia.
Q. What are the differerrt approaches fot varicocoele?

A.
r. Open surg,ery:-
A.
. The most common[y used approach.
B.
C.Retroperitoneal approach lPalomo I
z- Lap ar oscopi c v anico selectorny

3- P etcutaneous venous emboli zation
Q. What is the advantage of the Pa[omo's operation over the lower
apptoachesl
A.
Testicular artery has not yetbranches at this level, and is distinctly
sep ar ated from interna[ sperm atic vein
lso[ating the intern al sperrnatic vein at the level whqe only one or two
large veins are preserlt
tt4
a. What is the mechanism by whichhypemephroma causes secondary

varicocoelel
A.
Hypernephroma extend inside therenal vein like finger in g[oves resulting in
obstruction of the testicular vein ) secondaryvaicocele.
a. tVhy zry varicocoele is more common on the Lt. sidel

A.
Because on the Left side, the left testicul,ar vein drains into the rcnal vein, while the
right tescic ular vein drains into the infeior ve(ra cava. So, zry varicocoele on the left
side occurs when there is tumor thrombosi s of the left rcnal veiry whereas on the
right side, thrombosis shou[d extend to IVC to occlude the right testicular vein.
115
INGIINIOSCBOT'AI,
SHI}I}T
(HYDBOCBrrr)
3, tfifrocefe
tfistory
Perspnal-H-;
.
Name, Age, Sex, Marital status, special habits of medical importance
.
Address (for filariasis), Residence, Occupation.
OomBl-a-inti !! o-,-.llcjl .Bilr
,_j.iL..lt dLr.Ll ,rJl
. Usually swelling in the groin or the scrotum
HPI:
CdS 6-;-c.;At
-j.l "J-,
1. Be.i.n
2. S..welling
a) Site
)
b) Size (lemon size, orange size ...)
c) Onset Etl la.!
- Accidental
d) Course:
- Progressive - Stationary
e) Duration;-bs! i;r ful
- Srnce bifth > congenital.
0 Other swellings
g) Effect on the general condition
h) Apparentcause.
i) What increase & what decrease it?
(lncrease at end of the day) (Decrease in the early morning)
3. D...ip.ts.rD..+nc..e.ef .fltn.e.ti-o.n
4. 9ther.$v.q$em$.
s.Histsrv..q.f.i+v.ps.tis+.tiq.+q..qr.m.-e.di.c..+.tiqp.s
Past-Hjsto-ry-;
. Similar attacks.
n Common diseases: (DM, Hypertension, TB, p, Hepatitis, DVT)
. Blood transfusion
. Peruious Operations (post herniorrhaphy hydrocele)
. Gonorrhea
. Flariasis
, Urinary troubles
. Past history of trauma
tt7
Eamrly_Hislo_ry:
. Consanguinity
Pt. is alert, conscious, oriented to time,

G..e.n.e.{-?-li place, & persons, average built, quiet facial
expression, normal decubitus, average
intelligence, & s/he is cooperative.
asthma or bronchitis )
megaly, ascities )
varicose veins or edema )
. Pulse, blood pressure & temperature.
. Head, Neck, Spine > 3 dJJ#E
. Scrotum: if associated varicocele.
. PR: for SEP.
I=rg.q.?-l-:---,4-,r^r Glc
,-i! r rrLl,Jl & +
E_XIO_s_Ufe ) while the patient is standing with exposing the area of the nipple
to the knees.
lnSp-e-eti-o-n--:-(L'st--st-an-ding-t]r-en--sitrngl-
From 2 dif ferent planes cJL &ll ,* e !l a-K +

.=lc GJ*i J
A*..$.vys[ins
1. Site
- Scrotum+ side (RT-LT).
2. Size
- ln cm (best)
3, Shape
- Globular
t18
8' r_lyj ng;

S..ki...n..-o..y-e

-C*..$.pep.I.+1..-s-ig.+i
- No Expansile impulse on cough
P__alp_ati_o_ni
l.S..wpJIl+s
a. Warmth: ';ll -r+h asJS
b. Tenderness: OIJI +;3 .rlc .+c. r +ll ,:t+ iS'p.
c. Surtace: Smooth +ll 4-=l-.1l i.S>
d. Edge (pedunculated) 5!l ' .'i; -' iS.,;s
e. Consisfency (cystic) OJ$" ! aS-l.
A.S..grstel.I[es-B..tgp..t ; +lI ds+ {S;'

- Bilaterally at the same time to detect weather the swelling is
- Scrotal ) varicocele or hydrocele.
B.Hip.qlp.f..f-1..*-c...tg3tip..n..f.e.s.t:..(cysticswelling)
Fix swelling and make it tense It will receive impuls
Press by this hand
119
C.T.{flnp*ll+mi+4flp..+..T.gs.t: (swelting dt ,.+\i+lt sl! ,,,irrr iF )

Translucent cysts = clear fluid ) hydrocele.
- Opaque cysts = blood, pus,
Trans-illumination test
3. P..f .+ining. -ly_mp..h..+.g.d.eg; ) I n s u in a I & pa ra-ao rti c
4. Examine
Penis ) for ulcer or scar of chancre
Penis esp. external meatus
(site, discharge by milking
the urethera)
I Perineum
r Other hernial orifices.
a Scrotum
- Scrotum (ant, post aspect)
- Shape, symmetry and swelling
- ln all cases both sides of the scrotum
should be palpated
- Starting with the healthy side, first
with the patient standing & then in
the recumbent position
- Palpation of the epididymis(size,
consistency, presence of sulcus,
between it and the testis)
- Tunica vaginalis (early hydrocele
detected by pinching test
. Iesfib
- Size - Consistency - Testicular sensation
. Spermatic cord
- Beaded = B or T.B - Matted= filarasis
120
Sp e cia I I nv e stig ations
La b o_ra t o.ry I n ve s_tigat i o n s :

Pregnancy test, tumor markers
Radiolosical I nvestisations:
------- ---------(, ----(J
Anatomical
. lt is diagnosis of the region which is affected (scrotum)
Etiolgsige! :
. 1ry,2ry, congenital.
Pelhp_!-og!qel
' HYdrocele.
. i.e. complications )infection , hemorrhage. Rupture
Browse's introduction to the symptoms & signs of surgical disease/ Ch l3 external genitalia P347-349
t2t
Case 7: Vaginal Hgdrocoele
Q. What is your diagnosis?

A.
.Rt. primary vaginaltrydrocele not complicated.
Q. Why this is aprimary vagina[ hydrocele?
A.
. Symptoms
Painless swelling in one f the scrotal compartrnenc (gradual onsetl progressive
course/ long duration)
. Signs
E lnspection)Swe[ling in one scrota[ compartment
[J Palpation ) nontendel cystic, trans[ucent and pwely sqotal swe[ling.
Q. What is vagin athydrocele?
A.
[t is accumu[ation of serous fluid between the two Layers of che tunica
vagina[is.
Q. What are its types?
A,
. lt is of two types:
. rty vaginal hydrocele: of unknown aetiology
. zU to any disease of testis, epidedyrnis or spermatic cord
Q. What ate the types of hydrocelel
A.
A. hvdrocele of tunica vagrinalis:
r. Congenica[.
z.lnfantile.
3. Vagina[ hydrocele (rry or zry )
B. Hvdrocele of spermatic cord:
r. Encystedhydrocele of the cord
z. Diffusehydrocele of the cord.
3. Hydrocele of hernial sac.
C-Rane wpes:
r. Hydrocele of canal of Nuck (in fernalesl.
2. Tyrehydrocele: recufient after eversion.
3. Hydrocele enbisac: one below sqotal neck and one above.
t22
Q. What is the etiology of primary vaginal lrydrocelel

A.
. ldiopathic.
, The most accepted theory is lry filariasis of the cunica leading to transudation
of serous fluid from theviscera| andparietal Layers of the tunica.
Q. How didyou know that itis pwely scrotal?

A.
. By grasping the neck of the suotum by two fingerry thumb in front and
index finger behind the neck, it was found that the swe[[ing is complerely
below the fingerc.
Q. How didyou know that it is a cystic swellingT.

A.
. By doingthe bipolar fluctuation test)
. One hand's fingers are placed around the neck of the scroturn/ ar.d the other
hand's fingers ho[d the botcorn of the swelling.
. The latter squeezes the swelling where an impuls e is perceived by the other
hand's fingers atthe top of the swelling.
Q. What ane thevalue.s of transillumination inhydrocele?

A.
. lt differentiates between lrydrocele which is trans[ucent and ocher opague
cysts. [t a[so \ocaLizes the testis in case of vaginalhydrocele.
a. What is the value of localizing the site of the testis inhydroceleT.

A.
. To avoid its injury if aspiration is done.
. The size of the testis could also be assessed
Q. What is the etiology of secon d^ryhydtocele?

A.
.lc occurs secondary to diseases of the testis,, epidedymis and sperrnatic cord e.g.
inf lammations, ma[i gnan cy and v aricocoeLe.
t23
O. What arc the clinical differences between try and zry vaginalhydrocele?
A.
lry vaginal hydrocele 2ry vaginal hydrocele
Usually Large andTense . Usual[y Srnal|and Lax
Testis cannot befelt o Testis can 6e felt
. the disease in rhe testis, epidedymis
or cordis rcvealed
. Aspiationreveals exudate (high
specific gravity (> ror8), high
protein content (+-8 Smo/d.
o coa.qu[ates due to its fibrin content)
a . How canyou detect secondary vagina[ hydrocelel

A.
'of
hydrocele?
e:
r. Henia of the hydrocele sac: in long stan ding cases the sac might
herniate through the Darros musc[es thatrnay rupture.
2. Hematocele.
3. lnfection.
4. Rupture usually traumacic buc mighr be sponraneous
s. Calcification.
6" Bilateral huge cases mighc lead to atrophy of the testis. Ln unilareral
cases )no atrophy ashydrocele distends inwidescrorum.
a. What are the lines of treatrnenr of rry vasinalhydrocele?
A.
. There ane two lines of tteattnent)
r. Operation The ideal tteatrnent
2. Aspiration [n unfit patiencs
O. What arc the operations you know for rry vaginal hydroceleT.
A.
. There ane three known operationsl
t. Lord's operation (plication of tunica vaginalis).
z. Subtotal excision of the tunica vaginalis:
. [t is done in cases of:
. Ca[cified tunica.
. Locu[atedhydrocele.
. Recurrent hydrocele after eversion of tunica
3. Eversion: M^y be complicatedby recurrence.
t24
a. How eversion of the tunica prevents recurrer'ce of hydrocele ?
A.
. Lversion makes the parietaL layer of tunica albuginea sutured behind the
epididymis and so the pocential space between the parietal and visceral [ayers
is no more present
O. What are the complications of asphation?

A.
' Comp[ications of aspiration incLude;
t.l{ecurrence (rcoo/o).
z. lnfection.
3. Hemorrhage.
4.Puncture of the testis.
Q. What is rhe aetiology of congenitalhydrocele/ infantile hydrocele and

congeni ta[ ingu in al herni a?
A.
. si stent u no b [i t er atd pr oces su s vagina [i s.
P er
'Which of them wiLl develop is according co:

- Communication with peitonea[ cavity.
1Ze of thls
Size this communrcatlon.
communicati
Congenital Congenital Infantile
inguinal hernia hvdrocele hydrocele
Etiology cornpletely o The cornpletely o The
persistent persistent cornpleteLy
unobliterated unobLtterated persistent
ptocessus pfocessus unob[iterated
vagina[is vagina[is pTocessus
vaqina[is
Communication . communicates . communicates . does not
withpeitonea[ with the with the communicate
cavity peritoneaL peritoneal cavity s with the
cavity at the at the interna[ peritoneaL
internal rinq rinq cavity at all,
Size of openinig . Alarge . A sma[[ opening
opening that that does not
al\ows the alLow
developrnent of development of
ahernia ahernia
125
Q. How do you differcntiate clinically between congenit aL and infantile

hydrocelel
A.
. From history:-
o ln cong enitalhydrocele:
Mother telLs thar the swelling is maximum at the evening and diappear at
the early morning (f[uctuationin size).
o ln infan tile hydroceLe:
fJo fluctuation in size.
Q. How do you explain this?
A.
. [n congenital hy&ocele1 the sac communicates with to the peitoneal cavity
and that is why it empties its content of ftuid into the peritoneal cavity
during lying down at night sleep.
. ln infantilehydroce\el on the otherhan$ the sac is does not communicatewith
the peritoneal cavity.
Q. How do you differentiate clinically between congenital hydrocele

and cong enital inguina I herni a?
A.
. Congenita[ inguina[ herni a is rcducible and increases in size on straining
(cryins).
. On the otherhandl congenitalhydrocele is not rcducible and does not inqease
in size on strainingbesides its diurnalvariationin size.
Q: Can sansi[[umination differcntiate between congenital hydrocele

and congenital inguinal herniaT.
A
. Noz because both are trans[ucent. Congenita[ inguina[ hernia is trans[ucent
due to the thin wall of the sac and thethin wa[[ of theintestine inside.
Q. What are the othq intrascrotal cysts you know?

A.
. Sperrnatocoelel Pyocoelel Acutehaernatocoele, Lncystedhydrocele of the cordl
Cystic tetatorna/ Breaking down gumma/ Cysts of embryonic remnants of
the epidedymis.
Q. What is spermatocoeleT.
A.
. [c is a rerention cyst situated in the head of the epididymis due co obstruction
of the vasa efferentia.
126
Q. How do you differentiate between spermatocoele and rry vaginal

lrydrocelel
A.
Th e clinical, differcnces inclclde
Spermatocoele 1ry vagina! hydrocele
. Eel,t adherent to the lower . Can notbefelt
Thetestis \order Of the cvst
Transi[[urnination . Opalescent . Trans[ucent
Consistencv I Lax cystic . Tense cystic
a. What do you mean by transi[lumination is "opalescent" in

sperrnatocoele?
A.
. This wordmeans that che cyst is amidway between trans[ucent and opaque.
Q. How canyou explain this type of transi[lumination in spermatocoelel

A.
. lt is due to its content of sperms.
Q. What ane the features of encystedhydrocele of the cord?

A.
. [t is scrota[ swe[ling.
. Cystic, painlessl t:anslucent swelling.
. Separated frorn the testis 6y incervaL.
. [t is mobi[e across the cord.
. lts mobi[iry is resticted on downward traction of the testis. {traction
resr ).
a. How do you differcntiate clinically between lrydrocele and

varicocoele?
A.
Hvdrocele Varicocoele
o Consistency . Cystic . Soft
. Cornpressibiliry r \ot compressible . Comprcssible
o E[evation of the scrotum . No change in size . Decreases in size
o Transi[[umination . Trans[ucent , Opaque
t27
Q. [Jow car. you differcntiate between spennatocele &- encysted

hydrocele of the cotdl
A.
Soermatocele Encystedhydrocele of the cord
On cransi[[umination OpaLescent TransIucent
On oullinq the testis Move wich it Restricted mobilitv
Presence of sap No gap beLween ic 8[ che Cap between it 8l- tescis
tesCis
a. How to differettiate between encysted hydtocele of the cord and

hydrocele of hernia sac?.
A.
. EncystedhydroceLe of the cord isseparated fron the testis by interva[ and is a
pureLy sqota| swefiing while hydrocel.e of hernia sac is an inguinoscrotal
sweLling.
Case2: lEmptl Scrotaf Compartment

DD: Undescended testis, ectopic testis, retractile testis
Q. How to diff ercnti ate between therr,?.
A.
r. Retracti[e testisi
. On sguattins -) tescis descends in che scrotum
. Repeced exarnination on warrrtwater
2. Undescendine testis 3. Ectooic testis
Scrotum . Not well developed with
deviation of median scrotal . Well developed
raphe towards the affected
side
Testis . Can be felt in one of the ectopic
sites
. Difficult to be felt ' lt becomes more apparent with
contraction of the abdominal
muscles
lmpulse on cough . There is associated hernia . Usually not present
in 90% of cases
t28
Q. Whatanethecauses of undescending tesis?

A.
. Dysgenesis (sma[[ rescis)
. Short spermatic cord
. Shorc testicular artery
. Band of adhesions
. Hernial sac
. Lnadequace inguinal canal or rings
z. Hormonal causes
. P itui tary defi ci ency :
. D efi ci ent rnatern aI gonadorrophi n
. Testis not sensitive to gondotrophin
Q. What is the etiology of ectopi c testis?

A.
. The actua| cause is unknown
. Lockwood's theory:
Rupture gubernaculum testis, so one of che accessory tai[s is in work +
the testis goes to one of the following sites:
- Superficia[ inguina[ pouch -Perineurn
- Root of the penis - Femora[ triangle
Q. What ate the complications of undes cended testis?

A.
I Psychological,
I Liability ro rrauma 8t corsion
I Epi di dymorchi ti s du e to urinary tt act anoma[i es
r 5 terility in bilater aL c ases:
o Due co hyalinization of seminepherous tubules, whichleads co
irreversible destruction by the age of 16 years
Liability to malign ancy (seminoma):
o 3o times rnote than normal due to disgenesis
Hernia lgo%" of cases)
Q. What ane the investigations to localize the site of ectopic testis?

A.
r [-lltrasound: simple but not accurate/ as the testis is sma[[ 8[ sotid
. Laparoscopy2 thebest
t29
Q. Whatis the TTT of undes cended testisl

A.
. ln bilaterul case:
o Hormonal therapy: HCC 5oo units LM twice weekly for 6 weel<q if f ail,ed
o Orchiopexy:
-Wait 6 months between the z sides
-Done as early as possible to avoid distruction of seminephrous tubules by
abdominalheat
- Methods of orchio pe-xy.
. Bivan (non-absorbable sutures 8L narrowing the neck of the scrotum
. De Neto (pouch in Dartos musc[e)
. [n unilateralcases:
. We do orchiopexy for the affected side
Browse's introduction to the symptoms & signs of surgical disease/ Ch l3 external genitalia P343-j47
130
Greast Case Sfreet

tfistory
Personal H:
. Name
. Age:
o Fibroadenosis -+ puberty & menopause
o Hard fibroadenorna -+ 20-30 years
o Soft fibroadenoma -+ 30-40 years
o Carcinoma --> 40-60 years
. Marital status
. special habits of medical importance
. address, Residence
. Occupation: exposure to radiation
o Menstrual history
o age of menarche & menopause
o condition of menses (regularity, amount, duration)
. Lactation ) Lactating or not and date of last lactation
. Contraception
C-omplaintr ,.i.i:.*."It dL.Ll cJl U c,-,r.trll.Eili
HPI:
.r:.t A4U, ,:S ;;r- -6f
1. R+in
- Sife ) localized to swelling or shooting distally
(tumor compressing the nerve or infiltrating it).
- Character
Dull aching pain ) chronic conditions.
Throbbing pain ) pus formation.
NB: painful breast lesions:
2. S..rv.e..lling
a) Sife
b) Size ) (lemon size, orange size ...)
c) Onsef .stit i+!
- Accidental - Gradual
- Acute
t32
d) Course:
stic swellings.
inflammation.
mrnatgry
v'y uunAtUODS.
conditions.
ammation with acute
exacerbation.
dition:
_ Toxic symptoms: ) FAHM
) cachexia.
crease it
a, pregnancy, or lactation.
3.
&,:,U/Jrl4e &
' l,ll
lky, pus, pasty
reddish, yellowish
- Location
Skin changes:
Nipple ) Retraction. fi*lrll ot{l
o,i #.1qrl
Areora ) Frorid red, raised, eroded
& m-ay have vesicres
tJ3r?Hiffi" iijii
''
_ Dimpting
oi'tn" breast .,; dr;d
fdl_;Jia
erg 6jj dlUA & -
- Skin nodules
rue q
- Fungation, r""rrtiotfsl 6' &$B d -
f€rl,l d+ *
- Brawny eder a c'A
'sl
4'
tau''ef r* ,pl 4 -
- siste Joseph nodul
".
er, i.JSlS
!6.,,l..J1
4. -
9f h.qr.. p. y..$.f p..m.$. Cre
Distant mefasfasrs
1- Lung: chest pain,
dyspnea, cough, and
2- Liver:j"r1l,::: ,*"iling haemoptysis.
,ijpain
3- Bone: bony pain, .*"rri-rg
in Rt. Hypocondrium.
o, pathorogicar fracture.
133
5.Hip.tsry-.sf.i.+..y..esfie.af ie.n.-s..er. ications

P__ast_hislo_ry
. Similar attacks.
. Common diseases: (DM, Hyperl6nsion, TB, B, Hepatitis, DVT)
. Blood transfusion
. Pervious Operations
E_a_m_ity__hLs_to_U
. Similar condition in one of the members of the family (e.9.
carcinoma)
Browse's introduction to the symptoms & signs of surgical disease/ Ch 12 the breast P312
Pt. ,b alert, conscious, oriented to time,

place, & persons, average built, quiet facial
General: expression, normal decubitus, average
Body built.
3 i.i..L*l Decubitus
{: Facial expressions.
pallor ) anemia
Chest & heaft

Lung metastasis, masses or tenderness
Abdomen.
3 cll+1. (Liver, spleen, ascites, Sister Joseph, aortic & iliac LNs
PR & PV examination ) masses e.g. Krukenberg tumor
Extremities
UL ) brawny edema - Pathological fractures
Pulse, blood pressure & temperature
fever ) in breast abscess
Head, Neck, Spine) 3 i,J#E
) Head:
Skull for metastasis
Jaundice: liver metastasis
Cyanosis: mediastinal LN
) Spine ) for metastasis.
t34
,..Irgg-Al:- q,*^r,ile ,-i!: tul+ll ,=J' +

Expo-s-ure
From above to umbilicus (upper limbs are
exposed)
Umbilicus exposed: Sister Jossef sign
(metastasis in umbilicus.)
Upper limbs exposed: axillary LN
The patient is examined while sitting
Both sides are examined and compared
Starting with the normal t,
lns p-e-eti-o-n _
-
(
-s-itti ng - -o-nty )-
From 2 different p1anes +
under surface of the breast
(cu)l e!+l ,fu ,.!:d e!+l u+"-)l) !l a-K e^
Ask the patient to lean fonrard (obserue degree of
protrusion of breast) then ask her to raise the arms
(dimpling, lump or skin changes becomes more prominent)
(Notice that both breasts are pendulus)

Both breast are symmetrical overlying skin is normal, no pigmentation, no dilated
veins, no scars. With apparent swelling at ..., with size .......shape of.......
l3s
l*.S..rspJlinsi
1. Site
- The anatomical region of the swelling
2. Size
- ln crn (best)
3. Shape
Irregular

. Nipple: Direction, Retraction, Displacement, Discoloration
. Areola: eczyma.
. Skin proper:
- Dimpling
- Pau de orange
- Umbilicus (Sister Josef)
- UL & Lymphedema. (Brawny edema).
. DiSCharge: (€r3ll ..;-'r.a's 14ll cr','rLl)

P-alp-ati-o-n - - ( -s-rtting - -the n- -
lytng )-
I:IFJI ;J.r-a 'J.-rl 6^ tip of fingers ll -r flat of hand 11+ ,-!tl- 6+- Y
(ki--! + Cf a-ls. Ell 'l ii( r-r-i 6rl-,3 fJ g i.^5tj fuU'll O:sj Oi !++)
136
7. .s.q.m. pa.r.f.m.e n ts. i

.4 compartments in breast) (upper inner)
(Upper outer)
(Lower inner)
(Lower outer)
. Nipple and areola.
tail.
.'Axillary
lnfra-mammary.
SwetlingJl 6+-,ll iur-=ill d.Si l-lEJtrrt- #i ttas"Jo+J.r.rc.",o-ill cD.
Ask the patient to squeeze her breast if there is bloody discharge. Zonal pressure is
done
1g)Ar.-a
1. Warmth: tJll 'sl+ 1SJS

2*.T.gnd3f+.9$.q,: tul+ll e+_,
. lnflammatory swellings are mosfly tender
& c# _r ,rtt cA+;sJS
. Neoplastic swellings are not tender.

. How to locate the point of maximum tenderness?
3r.H-d.gg: lll '='i..' isJS
I ll-defined, Well-defined.
4*.S.g.ff+.q.Q: +ll i.=l: is;s.
5.',.-Q.p..nsisf--en-qy :,-r+11+ is-.p

I Gysfib or sofrU.
T Flugtuation test:
- in 2 perpendicular planes
- Fixation is a must.
Pa_qefis tesfi
- For swellings < 2 cm
- A solid swelling ) hard centre more than periphery
- A cystic swelling )Yielding center, firm periphery
Solid gwelling may be
- Solid and soft ) like a lobule of the ear.
- Sotid & firm i like ear pinna.
- Solid & fleshy ) like relaxed muscle.
- Solid & hard ) like bone.
6-. Rsl*flp. +.s..mehilify). ;
a) Skrn;
- )
Not related to overlying skin skin can be pinched
- )
lnfiltrates the skin moves with movement of skin.
- Nipple & areola
b) Breast lissuq
Fix the breast tissues by one hand and move the swelling by
another hand
* pectoralis major:
Compare the range of movement of the lump before & after
contraction of the muscle by asking the pt. fo press by her
hands against her waist:
- Attached to pectoralfascia ) limited movement but not fixed
- Attached to muscle ) fixed
- Nof attached ? Mobile
.} Serratus anterior:'
Compare the range of movement of the lump (in the lower
lateral quadrant) before & after contraction of the muscle by
asking the pt. fo press against your shoulder or on the wall
* External oblique:
- Can't be tested if infiltrated
dl Bones; ) fixed and immobile from the start (while the pt. is relaxed)
138
7*.D....r.+inins..LJrr.r.ph.N.q.ds.q..(Ax.llLe.ry..*-.S.upr.+.s.leyis-q-la.D;
No examination of a swelling is complete without the
examination of the draining LNs (See lymphatic sheet)
Post. group
Apical
Medial group
The pectoralis maior

Origin: sternocostal head,
clavicular head
lnsertion: lateral lip of bicipital
groove.
N.S: medial & lateral pectoral
n.(from med. & tat.
cords of brachial plexus
respectively).
Action: to press her hands
against her waist.
So ask the patient: to press her
hands against her
waist.
(4IYY| aS,r=) ,-sl!^,,J.+ e!+l .=!=
The serratus anterior

Origin: 8 digitations with upper
8 intercostal muscles"
lnsertion: med. Border of the
scapula.
NS: N. to serratus ant. from
roots C5, 6, 7, (=Long thoracic
n., =N. of Bell)
Action: keeps the stability of
scapula with the Use of upper
limb.
So ask the patient: to press
her hands against your shoulder
and show and examine. ri_.l
c#s 4!+l+
Others are the external e, rectus sheath
Browse's introduction to the symptoms & signs of surgical diseuse/ Ch 12 the breast p3I3-317
Sp ecinf I nve stig ations
-L-e D-o-rets n yesti g-eliq n q;

ry !

Tumor markers (estrogen & progesterone receptors)
P_elh elpg ee l l nyeqtigetio n q;

r
Biopsy (FNAPC, tru-cut needle, Open)

Cytology from discharge
ReC ie ! _os i
qel I n yeetjgeti o n g;
Plain & contrast X- ray, Mammography, Glactography, U/S, CT
Anatomica! ) lt is diagnosis of the region
Pg_th g!O_ g
ig_el > Con gen ita l, tra u matic, i nfl am matory, neoplastic .... etc.
Associated conditions > T.B., diabetes, chronic bronchltis, Ascites....etc.
t4t
Westions stAnswers
Breast Lump
Q. Whatis the ernbryolosy of thebreastl

A.
It Nises from the milk fine which extends from the axilla to the rnid- inguinal
point.
o [t is consideredtobe arnodified sweat gland
o Lt is fonrted of:
o Epitheliaf, element from ectod,erm
o The connective cissue from rneso derm
o The nipple is at first flat or retracted at birth then it becomes protruded
Q. Whatis the ar,atornrry of thebreast?

A.
L-xtext:
. [t extends from the zr'd to the 6th rrb.
O Lt extends from the sterrlunt to the mid axilLary lir'e.
o Lt lies superficial to deep fascia.
a Axillary tail of Spence passes deep to the deep fascia
o The apening in the deep fascia is known as foramen of Langer at rhe level
of the thirdrib.
|{ippte protrud.e forward 1 downward, and lateral , at the LeveL of 4'h intercastal
space 1it gets lower by ug
. Areola ; dark area of skin 7 becomes rnote pigmented with presr,ar,cy/
M5H
lS-Jtes-o-v-et
r,.T).e..pe.c.tetali.s..naip.r.Lllilt
- Origin: elernocastal headl clavicuLar head
- lnsefiion: lateral tip of bicipital Sroove.
- N.5: rnedial &lateralpectoraln. (from rned.8[ [at. cords of brachial
plexus respectivelyl,
- Action: ta pressherhand,s against her waist.
142
-2,-The-pgn-at-qE-antp.tipt.-Lds.)-:
- Origin: 8 digitations wirh upper 8 intercosta[ musc[es.
- lnsertion: med. Barder of the scapula.
- NSt N. to seffatus ant. from roots C' 61 7t (:Long thoracic n.,
- N. of BeLI)
- Action: keeps che stability of scapulawitk the Use of upper [imb.
l,---O...ther..s.are.the,-.exEe-rna.l..sb..[ie$-9t.T-e.g.Eussheath
Lt-bitwtet-e-af -theslarr-d;
o
Thebreastis formed af :
r. Fibro fatty tissue.
z" Acini which makes up [obules &t [obes.
o The [obes of the gLand are radially arranged.
. Each [obe is drained,by a separate duct.
. AII the collecting ducts (ro - 15) open into tlrc nipple.
. Lobes and ducts are affar.g,ed. radical[y so , in absce,ss ) radial incision to
Vgdamage of lobes and ducts .
. Anyfibrosis affectbreast
)ln cooper ligament )dimpling"
) [n [actiferous duct )retractednipple.
Ljgamgn-t-t--o-t-C-p9p-e-r-!suspensoryligarnentof thebreast
. Bands of connective tissue called Ligaments of Copper.
o [t is \etween the overlying skin 8lthe pectora[ f ascia.
B-l-"-qd-S-tJpp-l-y-qf -theBt_e-asl-
+ Artptj_al_Eltpply_
. The lateral thoracic aftery
- From -,Idpartof the axil1ary aftery.
o Themedial perforators
- From theinterna[ mammary artery in the d, {d et +d spaces.
- The interna[mammary artery arises from subc[avian artery.
. Lateralperforators
- From the zndr3rd A 4th intercostal arteries
=)V_e_n_o_qE_Drajnage
. Superficial. veins ) Cross mid[ine.
o Deep veins ) accomp arry the arteries.
. Lntercostalveins
- Drain into azygus systent on the rt. side &-herniazygus on theLt" Side.
- They ate cornrnunicacing with thepara-vertebralveins.
143
+ Ly,nph-dr-ainassl
. frlipple 8l- areola + Breast rissue ) (Ant. Axiltary LNs ) Medialsroup of LNs
) Apica| LN (subareolar Lymph plexus of sappy)
. Skin without Nipple 8tr- areola
) Radiatmanner
. Deep part of Breast ) [ymphatics through pectoralis major ) interna[ mamrruarv
LN sl- post. intercosta[ Lfd (deep pectoral lyrnph plexus on p"ctota[is minor)
. Lower rnedial part ) Lymphatics in rectus sheach 8[ falciform tis. > TTrerz.sra.ris
in Liver
T-c-axijlary_Sr_o_rJp_s__oJ_hrn_rp_b_D_o_dee j
r. Pectoralsroup (Ant.,|)
- Behind thepectoralis major.
- Drains :6reast, chest above the leveL of umbi[icu s of cor.responding side
z. Humoral sroup (Lat.) )
- [t lies a[ong the axillary vein.
- Drains the upper [imb
3. Subseapular group (Post.) )
- [t lies over the subscapularis muscle"
- Drains postedor abdominal waIL a6ove the umbi[icus of the corresponding siia
4. Cerrteralgroup (Med.) )
- lt |ies over themediaf, wa[[ 8[ floor of axilla.
- lt is the station \efore apical L/.J affecrion
- lf affected )Compress intercostobranchialr'erve causes pain in upper fimb
s. inftaclavicular (Apicalgroup) D
- At the apex of the axil1a.
- The last station and rnay receive lyrnph vessels directlrT from the breast
N..B.i
+ fte
Axi.l[aw l*-ci.a[-te.nt
ln pacient [ying on his back wich the arm abducred :
r Anterior[y: clavipectotal facia which fuses wirh facia of
axillary vessels
z. Posteriorly: on subscapu[aries
3. r\pex :upw ard and medi ally
4. Base: downward and lateruI|y andis cpen
S ln b[ock dissection of axillaw.e reserve this tent
t44
Q. Mendon the congenital anomalies of the breasr yor.r [<now?

A.
F Nipple anomalies:
. Athelia ) absence of rhe nipple.
. Polythelia ) mukiple nipples not necessary along the milk line
. I(etractednipple
F Abnormal number:
o Amazia ) absence of the breast 8t usua[ly the pectoralis major is nor
dwe{oped
. Polynrazia ) multiple breasts may bep/esent along the mi[k [ine.
F Virsinal hvpertrophy: which is abnormal response of breast tissue to
estrogen. TTT: by rcduction rnarnrnop[asty or ausmentation depending
upon the patient
Q. Mention the qvq,es of breast inflammations notrclated to [accation?

A.
. Mascitis neonatorum:
- [t is enlargemenc of breasc of rrcwly bom.
- lt is due to estrogen of the mother.
- TTT: Leave him alone as it is self-limited.
. Mastitis of pqberry
- [t is a painful.enlargedtender breast att4years.
- [t may be unilateral or bilateral.
- Self-[imited.
. Ptemamrnaw abscess
- lnfection of MONTCOMERy sland.
- TTT: incision 8t drainage.
. Retrornamrnarvabscess
- Deep to pectoral fascia.
- Due to infected rib {osteornyelitisl or infectedhaematoma or
tuberculous empyema.
- Draina1eby Thomas incision in the rnammary groove.
. Abscess on top of traumatic fat necyosis or heynacoma.
. Traumatic mastitis:
- Due to iltfit brassier
. a or tulnof:
Q. What ate the types of breast inf[arnmations rcIarted to lactation?

A.
. Mi[k congestion and acute Lactational mastitis.
145
Q. What is mi[k congestion and what are its causes?

A.
Accumu[acion of mitk in che breast, and irc causes atel
. At the start of [actation due to lack of experience of themorher
. During teething of the baby due to cracking in the nipple
. During weaning
o. What is the c[inica[ featute of milk congestion?
A,
. Pain
. Swelling
. No pus on squeezing
N.B: fevu maybepresent dueto sequestrated antigens (milk)
Q. How you treat a case of milk congestion?
A
. Resufar nursing after the baby.
. TTT of crackles.
. wacuation of the breast by electric bump or manua[
Q. What is pathenogenesis of craurnatic fat necrosisl

A.
. Trauma to fat ) Clycerol (absorbed)
) Tatty acids: chelates Ca ) (soap)
o This soap invites foreign body reaction.
o The result is one of z forms:
r- A cyst chat contain thick oily fluid.
z- A hayd mass ([ess freguent) that rcsernblebreast carcinoma andrequire
biopsy to sett[e the diagnosis
Q. What is the clinical picture of uaumatic fat necrosis?

A.
. Hardtittegulal painless rnass. History of trauma maybeptesent.
Q. What is the troatment of traumatic fatne;c,rosis?

A,
. Excisional biopsy.
146
Q. What are the
r) AND1 ) aberation in normal developrnent 8l- involurion of breast.

z) Fibrocystic disease of thebreast.
3l Sectormastitis.
+l Mamm ary dysplasia.
s) Chronic insterstitial mastitis ) misnorner as in this condition therc is no
evi dence of i nf [ammati on.
Q. What is the clinical picture of fibroadenosis?

L
+T
[t ocqurs afger puberw or beforemenopause, mu[cip[e painfu[ lumps rhar
' rmay be unilateial or 6ilateril and itis'relacizd ro menscrual cycle.'
Sunptonrc;
. Ltmay be comp[etely asympcomatic.
.These changes are usually CYCLIC.
1-
r Exagger
trxagger ated.
ated pr e-rnenstt al tensi
e-rnen str u aL ten s i on
. Du[[ aching or stitching pain
' 4 Pre-menstrually St by breastmovement Str- V post-men strually St by
breast support.
2- Breast lump lCvsts or sclerosins adenosisl:
' May disappear when the patient is reexamined I week after menstrual cycle
3- Breast discharqe:
Mcr.ve\Iow.
.
Sometiinesbrown ot Sreen.
g Local E-amination:
1- Breast Lump:
' /Aay be solid ot cystic/ fteely mobilel commonly bilaceral. and diffuse.
.Better to be feltby tip of fingers not by flat of the hand.
'You feel as there is disk of glandular tissue deep in thebreast / away fro-
nippLe and areola.
2- Discharyg.
.With Serrtle squeeze.
. Coloiless fluid or blue greenish discharge.
3- Axillary LNs:
. May beelascic, enlargedltender andmobiIewich shotry dissiburion.
. Sector mastitis (theory )viral infection 1or chernicalirritantl.
147
Q. Whatis thepathology of fibroadenosis?

A"
+
r. Adenosis ) Clandul,arhyperplasiawirh f number of acini.
z. Fibrosis ) fibrous tissuereplaces elastic 8[fatty rissue
3. Fibrosis ) obstructs duct ) retention cysr formation.
4. Ltrnay 6e uniLateral or bilareral. or affecting sector of breasc.
S. Epitheliosis ) Epithelialhyperylasia in smalL ducts.
6. Lxtensiv e epitheli o si s E intra - du ctal p apiLlary growth whi ch i s terrned
papi[lomatosis
T . P.ar ely 1 ther e' s'Arypi cal epitheli al hyp erplasi a" ) pr ec ancer o u s
B. Lxtensive fibrosis rnay tesernbl,e schirous carcinoma 8t caL\ed "sclerosing

adenosistt
9. Round cell infiltration.
ro. Cyst formation ) The cyst might be:
- Sma[[ (microcyst).
- Large rnacrocyst.
- The cysts rnay coalesce to forrr (blue domed Cyst of
Bloodgoodl: ALarge cyst corrtains altercd blood.
+
. Mostof the surseons:
Consider the fifuoadenosis not precancerous.
Exceptif there is marked papil[omatosis or atypical epithelialhyperplasia.
is the treatrr'ent of fibroadenosis?
Reassurance of the patient from cancer phobia is the most imporrant

A. Changelife-style:
r. Eirm bra.
2. Avoid coffeel tea and choco[ate.
3. Regular intake of 4oo lU of vitamin E may behelpful.
B. Medica[treacment:
r. Analgesic.
z. Regu[ation of the cycle.
3. Prim-rose oiI sing[e evening dose.
4. P arlodel 2. 5 mg ta\/ twi ce / day ( anti pro lactin ) .
5. Danazol cab!l! ([ast [ine of TTT as itcauses acne 8l-hirsutism)
6. Psychotherapy.
C. lndication of the surserv:
r. Biopsy ) if doubtfuI diagnosis.
z. Excision of the cyst > large cyst (cyst of Bloodgood).
3. Cysts are treatedby asptrationl recurrerrt cysts are excised for biopsy.
148
I.
Q. Whatis the clinica[ pictwe of duct papil[oma ?
A.
Type of Patient
. 3o-4o years f emale with bleeding per nipple.
Symptoms
r.Blood stained nipple discharge.
(Commonest symptom).
z. Swelling ) rctention ryst.
Signs: f.Jo pain.
r.Bleedingr per nipple:
. By pressure oi the swelling.
. Lf therc is no palpable swelling zotalptessutewrllrwealthe
discharge.
z. Swellins:
. Smalb fusiform, usually lateral to the xeolawith its [ong axis
pointing to the nipple.
3.Axillary LNs: ate not enlatged.
Q. What is the treatment of duct papi[[oma?

A.
. [t's a pte-cancetousT so the fieatment is:
r. Micro-docheotorrry ftemove the affected
duct) through chcumareolar incision and
wedge of the tissue 2.s cm aroundit.
z. Histopathology.
Q. How can you identify the affented ductirtraopetacively?

A.
r- By the [ump.
2- Lf there is no lump, the ductis idencifiedby passing needle through the
di scharging nipp [e opening.
149
Q. What are the type.s of fibroadenoma?

A.
P ei - c anali cular (H ar dl Lntr a- c an ali culN ( 5 of t I
Aqe: zo3oyears Aqe: to-<ov.utt
Mactoscopicpictute: Macroscopic picture:
r. Size: small r. Size:Iarge
z. Swface:smooth. z. iufiace: lobulated.
3. Color: whitish 3. Co[or: whitish
4. Consistencv: firm orhard. 4. Consistency: soft
5. Cut section: whorly appeatar.ce. 5. Cut section: might show central
6. Capsule: z capsules true arrd f alse necrosis
caqsule and a pedicle. 6. Caosule: incomolete caosule.
Microscopic picture: Microscopic picture:
- Formed mainly of fibrous tissue - Contains rnore glands
- Fibrous tissue proliferatron occurs around - Eibrous tissue proliferation invaginates
the acini 8f ducts. the ducts.
Complication: Complication:
- Never turn ma[ignant. - Liabl,e to turn co sarcorna.
Q. What is the clinical picture of fibroadenoma?

A
Tvpe of Patient
r- Hard fibroadeonoma zo - 3oyears fernale.
z- Soft fibroadenoma 3o-so years female.
Symptoms
. Painle.ss lump that is discovered accidentaLly.
5isrns
r. Breast swe[[insr:
i- Pei-cana[icu[ar:
-
Usuafiy small non tender, firnl well-circumscribed with smooth
surf ace 8[ with high mobiliry in breast tissue (breastmouse).
ii- lntra-canalicular
- Muy reach huge size, soft, mobi[e swelling in breast.
z. Axi[[arv LNs: not enlarged.
150
Q. What is qystosarcoma phylloides?.

A.
O
characterizedby:
I- Highly cel\ular.
2- Rapidty growing andreaching a Large size (zo - 3o cm).
3- It might ulcerate through skin but nor amached to ir.
- Cyst: rnay cystic degenetation if hugely enlarged due to

be
insufficient blood supply (but usualLy it is not cysticl
- Sarcoma: itis rarely ma[ignant.
- Phvlloids: the cut surf aceresembles leaf .
- So, itisbetter named "Phylloides Tumor"
Q. What is the tteatmerrt of fibro adenorraT.

r. Eor pefi-canalicular
- [t is enucl.eated through circurn-areolar incision.
z. For intra- canaliculat:
- Lf srnall, excision is better with a part of the normal breast tissue as a
safety margin.
- Lf Large (Cystosarcoma phyll,oides) ) wide loca| excision (to ptevent
tecurreflce) or if the tumor is occupying the whol.ebreast ) simple
mastectomy.
Browse's introduclion to the symptoms & signs of surgical disease/ Ch 12 the breast P322
15r
Case3: Cancer Breast

A.
This is a case of breast lump, clinicaLly a carcinom a of the breast stase r.
Q. How didyou teach this diagnosis?
From History: therc is pain[ess mass of shorr duration, rupidly progressive
coulse
Examination: therc is hard swelLing felr by both finger tips and flat of the
handl fixed to bteast cissue and to pectoralis majorl pteser'ce of skin
manifestations of cancer breast, preser,ce of hard axiLlary [ymph nodes.
Mendon the incider'ce of bteast cancerl
ft;
Ln western co untri es acco untin S 3- S o/o of deaths.
Breast car,cer is the commonest malign ancy in Egyptian femal,es $5o/o of rora[
ma[ignancies).
*"t ate the predisposing factors of cancet breastl

B.
a) [t has been proven that o/o
of breast car,cets ane due to mutation
s- ro
in suppressor genes (autosom al inheritance)
r. Mutation in z suppressor genes:
BRCA-I (on chromosome d { BRCA-tl (On chromosome
r3)
[t usua[lv occurs:
-
Atyounger ase
-
Multifoca[ 8tr- bilateral
z. Mutation in tumor suppressor Ser'e P53: producing Le Fraumini $
- Breastcancet. - Ovarian car'cet.
- Carcinoma of the colon. - Lymphoma (or [eukemia).
b) Positive familyhistor/ ir'creases the risk:
.
[n mother or siscer > 4 the risk by ,.1times.
.
[n bothmocher &-sister ) A therisk l,4tirnes.
z, Endocrinal factors:
- The [onger thepeiod of exposure to unopposed esttosen/ themorc the
risk of developing breast car'cer as in:
A. Eaiy menarche (< rryears).
B. Latemenopause (> so years)
C. First ptegnanq occul,s aftet the age of 30years.
D. Ora[ contracepti v e pills & hormon al rcplacrarrlrerrt thet apy ( H RTI their
rcleisnotyet known.
152
3. Prc*ancerous lesions:
I Ductpapilloma (especially if multipte) ) O therisk r.S-zrimes.
zl Aqpical epithelialhype.rplasia) 0 the risk 2 - f times.
3l Lobular or ductal carcinoma in situ ) A the risk by s - ro rimes.
4. Obesity 8[ 4 fat intake:
- As thereis peripheral conversion of steroidhormones into estradiol [Er)
by arornatase enzyrne in f acty tissues.
- Patient with breast car'cet in one sidel 4. the risk to develop cancer in the
other breast.
- Bil,ateralbreast car.cet occurs in about 15 - zo %o.
(Up to 25 - 50 o/o if in [obular carcinoma)
6. Race:
- More in white women than Asian or Africans
- Womenwhohad radiation therapy to the chest (inc[uding breasts)before

age of 30 ale at an inqeased risk of car,cet breast.
8. Alcoholic intake:
- lt inctease therisk of car,cer breast
9. Physical inactiviw:
- Women who are physically inactivehave an increased risk of breast carret/
because physical activities rnayhelp to reduce risk by preventingweight
gain.
Q. When fibroqstic disease is consideredprecancetous?

A.
+
ost of the surqeons:
Consider the fibroadenosis not precancelous.
t1 there is marked iflomatosis or a cal ithelial
Q. Cive the sites of breast car,cer and theit incider,cel

A.
. Upper outet quadrant 6oo/o.
. Upper inner quadrantrzo/o.
. Lower outer qu adt ant too/o.
. Lower inner quadr ant 60/o.
. Areola and nipple rzo/o.
153
Q. Mention the classificarion of cancer breast?

A.
A-Carsin-oma.pf .ghe-D.(,r.qg-.Qrisrn-lD-taetal.earc.i.no..nral;
. /xlon infiItrating i.e. Ductal carcinoma in situ.
Sotid
Cribriform
. ,rfrr*?f,#t#**I carcinoma fnot othenaise specified/

Special subtvoes
MeduLlary carcinoma.
Masti tis carcinomatosi s.
Comedo cancinoma.
Cofioid carcinoma (mucinous).(ic has good prognosis in the
breast unlike CIT col[oid carcinoma which has bad
prognosis )
PapiLlary carcinoma.
Tubular cancinoma (good differentiation )
B- Carcinoma of Lob,s\e Origin (Lobular Carcinoma).
. Non infiItrating i.e. [obular carcinoma in situ. ( it usually arise from
minute ducts in che lo6es I rarely from the acinar cells
.
lnfiltrating.
C- Carcinoma of thenipple (Paget's disease of Nipple).
Q. What are the differences between Pagec's disease of the nipple 8[

eczerla of the nipplel
A.
Eczema Paq.etts disease
Bilateral Unilateral
Youns [actating fernale O[d non-[actatinq
itchinq No itchins
lntacc nipp[e Eroded nipple
No [umps May be on under[ying [urnp
Responds to short term steroids Not respondinc to treacment
154
Q. What ane the skin manifestarions of cancer breast?

A.
- Due to infiltration of milk duct.

- Not diagnostic as it occuts in any fibrotic process e.g. chronic
breast abscess 8l- duct ectazia.
b. fu@Lilerodedin paget's disease of the nipple.
c. SEnproper:
. Skin Dimplingr:
- Lt's the earliest skin sisn.
- Due to contracture of Cooper's ligament
- Not diagnostic as it occurs in any fibrotic p'rocess e.g. chronic
breast abscess 8l- duct ectazia.
. Skin Puckeringl.
. Cancer enCuirasse:
- Late stage of rctrograde lymphatic permeation.
- 5kin isvery thiclgleathery, brownish Stmetallic simulating
shields of war
. Skin Ulceration:
- Can be differcntiated from benign tumols by probing test.
. Peau d'oranqe:
- Due to obstruction of lymphatic.s so [ymphoedema of skin occurs
except at site of hair follicles 8t sweat glands.
. Skin Nodules:
- May appear away frommother cancinorna.
- Due to retrosrade Lyrnphatic perneation.
- Diagnostic (sure sign of malignancy).
. Sister loseph Nodules:
- Lymph atic spread to umbilicus.
. Brawny Edema lLymphoedema of the Arml:
* Due to:
o Obstructi on of lyrnph. V esseLs by:
- Tumor metastasis
- Surgica[.
- lrradiation.
oObstruction of axiLlary vein.
Specia! forms:
oMastitis carcinomatosa:Skin is redl watrn &L edematous.
155
Q. What is the earliest skin manifesration?

A.
. Dimp[ing and puckering.
Q. What is the pathogenesis of dimpling-and puckering,? And is it

pathognomonic of breast cancerl
A.
. Contracture of the Cooper's [igamenr caused by surrounding fibrosis.
. No, it can occur in any fibrotic process e.g. chronicbreastabscess.
Q. How car. you bettq see the pteserrce of dimpling and puckering of
breast skin?
A.
. They canbebetter seenif the patientraisesher arrn up.
Q. What is the pathogenesis of retraction of the rripple?

A.
. [t is due to entangling of the milk ducts by fibrosis.
' Again it is not pathognomonic of cancer breasc, as it car' occur wich any
fibrotic lesion.
Q. What is Peau d'orange? Ar'd what is its pathogenesisl and is it
pathognomonic of breast cancerT.
A.
. [c is ederna of the breast skin pitced at sites of hair follicles and sebaceous
and sweat g[ands.
. lt is due to obstruction of the lymphatics of che skin causedby a surrounding
tumor or fibrosis.
. Noz it can occur in any fibrotic process e.g. chronicbreastabscess.
O. How can it be renderedrnore obvious?

A.
. By gently squeezing the skin.
Q. What is cancer en cuiasse?

A.
. [t is a late sign of car.cer breast where the skin becomes hardl thick,
indurated, stretchedr like the shields of wars.
. [t extends outside thebreast to the chest and arms.
156
Q. Describe tetheting and fixarion of the breast lump ro rhe skin?

A.
' Both tethering andfixation indicate adherence (attachment) of the cumor to
the skin. Ln tetheringT moving the lump, ourside its arc of mobility, causes
the skin to indent.
' On the other hand. Ln fixity, the [ump cannot be rnoved ac a\l withour
moving the skin.
Q. What are the different caus es of brawrry edema of upper timb?

A.
. Obstruction of lymph. Vesselsby either
- Tumor metastasis
- Surgical
- lrradiation
- Obstruction of axil[xy veinby turnor/ or infection/ or sursicalrcrnoval
Q. Describe the lymphatic spread of cancer breast

A.
. Lymph atic spreadis by embo[isacion and perrneation co the fo[lowing
L'Ns''
r. Axillary lymph nodes hso/d
z. Lnternalmammary (minima[)
3. Posteriar irrtercostal (minima[)
4. Occasional [ymph nodes
al S upr aclavicular L.N r.
b) Lnterpectora[ L.N. of l{otor
*, do you palpate the under surface of the [ump?
8
' Becauseitis rcunded in benign [esion 8l- flat in carcinoma
Q. How to know that abreast lump isfixed to the breasttissueT.

A.
. By ho[ding thebreastby onehand and trying co move che [ump within chebreast
6y the other hand in two perpendicular dheccions.
Q. How to know that abreast [ump is fixed rc the pectoralmusc[es?

A.
. By moving the [ump while che patientis pressing with her hands againsther
waist. Lf the mobi[ity of the [ump becomes restricted, then it is attached to
themuscle.
Q. How to know that abreast [ump is fixed to the chestwall?

A.
. The breast [ump is not mobi[e in both directions from the stant-
157
Q. What are the investigations of a case of cancu breastl

A.
I.
r. Soft tissue mammosnaphv: /To eualuate the whole breast and other breast/
2. Ultra Sonosrraphv: /Differentiate solid tumors from cystic/
4 Eor cystic swellinqwe do: Aspiracion
asic fluid.
after aspiration.
) Eor soLid swellingwe do: FNABC

3. Biopsy:
al FNABC: sirnple, inexpensive andvery accurate.
b) Core-cutbiopsy.
cl Open biopsy.
+. MRI
.
of breast:
Co[d standard of woman with synthetic prosthesis.
z. Ep-:"-5-c-aslns
r. Sentine[ Lymph Node Study:
. By iniection of rnethyleteblue ot radioactive isotope ) fo[[ow-up ) dll
wefind the sentinelLyrnph node.
. Then itis excised andfrozen section is done for it to know whether affected
by the cartcer or not.
z, Luns > CXR.
3. Liver ) abdominalultrasound andliver function tests.
4. Bone ) bone scan(Tcg9).
5. Brain ) CT scan and MRl.
3.E-o-:--P--t-q:qP-qr-4t-iy-e.Prcn.afil:pn
. CBCIEBS/ LETs,l(FTs.
+. E : .F.o-[.[-o"-gr:"-g p
-o-
r.Tumor markers: CAr5-j and CEA.
estl ogern and pr o ges trone.
Q. What are che indication 8t value of mamrnography in the diagnosis

of cancer breast?
A.'
lndications anei
r.
Screeninig of high r,iskpatient.
z.
When there is pain, nipple discharge or axillary L.N wich no palpable mass.
3. To identify contralatqalbreast [esion or othq multifoca[ [esion in the same
lreast after *ve biopsy.
Value in diasmosis of breast cancer:
r. Mammography rnay show some radiologica[ findings in cancer breastl e.g.
rniqocal.cifications, star-shaped mass, swe[[ing Larger than the surroundings.
Howevery chese changes aneflot conc[usive of cancet bteast.
ls8
Q. What are the disadvantages of marnm oyaphyT.

A.
.'
Exposure ta irradiacion
Ealse-veresults
. Ealse lve results
. [t is less sensitive in young Ladies due to A breasc density ,
Q. 14/hat is the value, of Dup\ex sonography in the diagnosis of cancer

breastl
A.
. Dup\ex sonography of the breast reveals a characteristic pattern of vasculature in
cases of cancor breast.
. However, there is sci[[ false -ve and false *ve resu\ts. U/5 is 6ettq in young Ladies
so it is bettq to do for allladies mammography *complernentary U/5.
Q. 14/hat is the value of MRI in detectitgrecurrence after surgery?

A
Can detect recurrence aftu 4 months after surgery \ecause early therc is excess fibrosis
and granu[ation tissue, it can detect tecstrencz better than mammography
Q. 14/hat are the out [ines of cancer breast treattnentT.
A.
Outline of Breast CancqTreatrnent
Early breast cancer Aduanced breast cancer
(Potentiallv curable) (fncurable)
Tz Nr Mo or less More than Tz Nr Mo
Definition
Manchester staqe I or l[ Manchester staqe [[l or lV
Aim Cure Pa[[iation
Mainly [oca[ disease -r
Disease status Mainly sy sterni c di sease
mi cro-metastas'is
Swgery -+ radio-therapy Cherno th er apy 8tr- en docri na I
Primary treatment (Local treatmentl ther anv I Svstemi c treatment )
Adjuvant treatment 5 imp [e'mastectarfty 8l- radi o-therapy
Endocrinal &L chemotherapy
(Palliative) have lirr.tced ro[e in [ocal convoI
Q. Mention the diffe.rent operations that canbe done in operable car'cer

breast?
A
r. Extended radicalmastectomy (Not donenow)
z. Radicalmastectomy (Halsted) (not done now)
3. Modified radical rnasteccomy
4. Sirnp[e mastectomy * radiothetapy (McWirter's technique not done now)
s. Lumpectomy + radiotherapy to breast, 8t draining lymph nodes
6. QUART (Quadrentectorny + Ax\LLary dissection + Radiotherapy to
remaining breast & remaining lymph node areas)
159
r t Theaim is to remove:
I
cm aroundrhe r inctuding nippre d{- areora *
2 #;:t';!i::;of 5 rumou
3. Fascia from low.er bord.er

of clavicre abovero g{-
including theupper quarter
"J!.,T"iii,*::,:l*
X,*jl;l ,:l:,i,;"il'-"a;. rry ,o ,he an eio,
NB. Pecilti;;; is
axilla.
( Au chinclos's tecrini o u
either ,.ôu"d (Patey's.""t@
9. lalh, t is the ',conserva dve !oreast SUrgery,, and
vvr ro(/, v^Ltve
A. when it can be done?
des:
to rhe breastr gt drainin
crion * Radiocherapy
s lymphnodes
io ,t. *-;i;;r"
areas)
es of operable breast cancer
when the
than 4cm in diameter.
ent to enable tumour excision
without
ar or the pagec,s variety
of cancer
t causing deformity)
n involvement.
ould be available.
red.
,ffi
z. Axillary cleirance +
3. l\adiotherapy
Q' wha t are the types and indicacions of
radiotherapy?
e of Radiarion:
' ?_.", X- ,uy (Externalbeaml.
t lrrsz wire implanc (lnter"t;t;.i'B"r_).
160
r. Post-operative after conselvative surge;ry to the remaining breasttissue

5y radical dose (5ooo I(ADI.
z. Post-oper ative after radical mastectomy on the chest waLI by adjuvant
dose (r5oo I(AD) if:
a- High grade tumor or large tumor.
b- Heavy LN positivepatients.
c- Media[ tumors for possibility of internalmammary LN affection.
d- Extensiv e lymphov ascular invasi on.
Q. What is Mc writq technigue?
A.
. Downstaging of the tumor fro- stage j to stage z by preoperative
radtotherapy (not done now[ downscaging by chernotherapy is done with
Littl,e 4in survival.
O. What is the adjuvant systemic therapy?

A.
' [t is a systemic therapy given in adjunct to [oca[ therapy in operabl e cases of
breast cancer
a. Mention the types of adjuvant systerric therapy and its indications?

A.
I. Adj uv ar:t chemo the r apy ) combinaci on chemo ther apy is gi ven in
prernenopausal patients wich positive axillary lymph nodes.
And-estrogen (Tamoxifenf ) is given in postrnenopausal patients.
a. What is the commonest combination chemotherapy grven in cancer
breasd.
A.
The commonest combination is cyc[ophosphamide * methotrexate + S-
flurouracil.
a. Whatis the mechanism of action of tamoxifenl
A.
. Tamoxifen is anti-estrogen (agonist-antagonist) competes with estrogen
celluLar horomone receptots making the cumor cease to ptoliferate.
Q. What is the tate of respor,se to hormonal therupyl

A.
I ER +ve ) 6o %o
! ER+PR lve )rooa/o
I to o/o of patient wtth rece nse because teceptols ate in the
nuc[ei N.B: LHRH agpnist as oophereccorny
a. What are the differcnc lines of hormonal therupy done in stages l[[
st lv?
A.
Hormone (endocrine) ther apy includes
r- First line of treatment: camoxifen zo rnglday. First line of creatment:

z- Se.condline of treatment: tamoxifen zomglday.
- BilaceraL oopherectomy by: Alternacive hormonal
a- MedicaL suppression (LHRH). asents:
b- Surge;ry r- y',Jornatase
c- Radiotherapy. inhibitors.
- AdrenaLectomy (rarely done) by:
a- Surgery.
z- Raloxifene.
b- Medical teatment by aminoglu tathemide * cortisone.
. The 2 nd
line of treatment is needed if the primary line of treatment was successful then
the patient loses the response & does not do adrenalectomy except if she responded
Q. What is the tecor,structive surgery of the breasd.

A.
. Timins blayins, an importantrole in physical and emotional outcomes amons
surviva[s:
- rry @t the tirne masteccomy).
- Delayed
. Technigses:
- Myo-cutaneous flaps:
)
Latissimus dorsi.
)
Transversereatus abdominis myocutaneous flap (TI{AM)
- Prosthesis 8tr- tissue expander.
- (5ilicon gel implant).
- Skin sparing operation rnrray be done to preservenippLe and areol.a
rnay be done.
- Better tattoo or skin f[ap from [abia minora or medial side of the
thish (pismented]
Q. What is the tteattr,errt of spread of breast car,cer?.
A.
Treatrnent of spread of cancer breast ) creatrnent of comp[ications
symp tom ati c tr e atrnent) :
(
r. Hypercalcemia:
. Corection of dehydration 6y LV ftuids * frusimide
. Predniso[one * biphosphonates
z. P atholog:tcal ft actwes:
. lmmobi[ization * interna[ fixation
. Radiotherapy Lo the fracture site.
costeroids and radio ther apy

4. Spinal cord comEession:
'Surgica[ cord decompression with sabilization followed by ndiotherapy
5. Superior vena cava obsffuction: radiotherapy is the treatrnent of choice
6. Plew al eff usion: syscemi c ther apy and chest tube dr ainage
T. Liver metastasis; treatedby chemotherapy.
8. Lvmphedema: can be geated by complete decongestive therapy.
Browse's introduction to the symptoms & signs of surgical disease/ Ch 12 lhe breast p31B-319
Q. Mendon whatyou know about ca,,cer breasti,,,,,,ales?

A.
. lt's arare disease.Eirscly recognized by English surgeon IOHN Adernein smith
Papyfus.
. Risk factoys :
- BRCA zz-3o/o risk factors.

- Pro[ongedheat exposure due to testicular atrophy
- Previous chesr waLl fuadiation as in ttt of previous ma[ignancy
- Conditions with relativehypercstrogetemia.
-Testicular atophy - Exogenous estrogen - Obesiry
-Liver disease
. C/P:
- Pain[ess [ump beneath rhe Areola at Soyears.
- \ipple discharge or retraction or u[ceration.
Swead:
-
B[ood borne metastase.s are common. - Poor prognosis.
o DD:. Cynecomasria 8[mecasrasis from orher tumors.
a Treatment:
- Lumpectomy is not done but modified radical masrecromy if detected
early and if carcinoma in situ
Q. What do you know abour gynecomastia?
A.
Definition
t [c's painLess enlargernent of rnale breast due to increased gl,andul.ar elernents *
Lipomastia.
Etiologrlr
r. ldiopathic. (the commonesr cause)
a- Neonata[ ) from exposure to high rnaternaL estrogen.

b- Pubertal ) rcsolves in zyears.
OId as,e ) V testi cular function.
t63
3. Patholosica[:
a- 4 Estrogren:
r-
Feminizing tumoTs of testis (Serco[i cell turnor).
z- Feminizing tumors of adrena\s.
3- Parama[ignant syndrorne as bronchogenic carcinoma.
b- V Testosterone:
r- Orchidectomy.
z- Testicular atrophy: mumps/ Iepsory andheat exposure.
c- ! Metabolism of estog;e\ liver cell f ailwe.
4. latroqenic:
r-Digitalis.
. L- Aldactone.
3-Reserpine.
4- Cimitidnine.
5- Estrogen therapy as in cancet ptostate.
S. Cenetic: I(linefilter syndrorne.
ClinicalPiccure
-History of drug incake.
-Abdomen ) hepaco- spler,omegaly
-Tescis ) atrophy
lnvestigrations
,. Blood tests (inc[uding liver function tests and hormone studies)
z. Urine tests
3. Consu[tation with an endocrino[osist - a physician who specializes in the
functioning of hormones and how the hormones affectmu[tiple organs.
4. Mammogcram - alow-dosex-ray of the 6reast.
Treatment
A-Lf ,tn:
TTT of the cause.
B- lf try:
1. Subcutaneous mastectomv:
2. Suction lipectorny:
This is a form of liposuction chat allows for tapeing of the edges of the tissue
without unwanted side effects.
3. Endoscopic surserv:
- This rlewer procedure uses a srnall, flexible tubewith a [ight and a carneta
lens at the er'd (endoscope) to examin e the inside of the breast.
- Tissue is then removedwithouc p[acing alargel opet/ surgical incision.
r64
TYDIIDIIATIC
SHI]BT
I[istory
Personal H:
Name .
Age .
- Young age ) TB.
- Adult )acute leukemia & Hodgkin.
- Elderly ) Secondaries, other lymphomata & chronic leukemia.
. Sex ) Malignancy more in males.
. Marital status
. Address, Residence, Occupation
- Area of bad hygienic condition > TB
- Brucellosis in those with contact with animals.
o Special habits of medical importance
- Alcohol )because alcohol induce pain in Hodgkin disease
. lf ) menstrual history
O-Omplaint:- d,ji,r.ll dlb Cl q! o.Jll i:erl + Duration
HPI: +i.l .I..,'.i< 6.'r .Ai
1. Pain
Course, Duration, Severity, and what associates.
: N.B.' Alcohol induce pain in Hodgkin dr'sease I
2.Svv..ellirtg
a) Sfte
b) Size ) (lemon size, orange size...)
c) Onset EU ln/
- Accidental -Acute -Gradual
d) Course:
- Progressive - Regressive.
- Stationary - Fluctuating
e) Duratisn;.b'el ;in ful
- Short (days or weeks).
r66
0 Other swellings
g) Etfect on the general condition:
- Symptoms of TB ) (night sweat, night fever anorexia,
loss of weight) & chest troubles
- 1ry septic or malignant focus in the draining area
- Cachexia in malignancy
h) Apparent cause.
i) What increase & what decrease it
3. Disturbance of function
1- Cervical
-Manifestationofinfiltrationofbrachialplexus>
paralysis or sensory loss in the UL
c+;S dl*l LJ-rsi *rt + t dl+l s.e e--.J sp -
- Accessory n. > Stiffness of movements of neck
(' ,Jtii<
.t+JS,rti':< dJ.l +r+ qf ei.J sf -
- RLN ) hoarseness of voice.
,,u rtcf J# err -
- Dyspnea, dyphagia, arm ischemia or edema
2- Mediastinal ) Mediastinal syndrome (dyspnea, cough).

d-rs Cl o.6jill 6ri;So d -
3- Abdominal ) Swelling, back pain, edema, dilated vs,
ischemia of LL.
-
lf arterial obstruction ) ischemia of LL
-
lf venous obstruction ) edema ,D.V.T
4- lnguinal or axially ) lymphedema, dilated vs, pain,
ischemia.
els-,r-,
sp Clg sl ersX eP -
4. 9fh.e..r..sv$f..em$
. Liver pain & swelling in Rt. Hypocondrium & jaundice.
dLl+ d Cf)s sl etr ef -
. Bone: Bony pain, swelling or pathological fracture.
,q Ec
Ui Ci.J cf -
. Lufig: Chest pain, dyspnea, cough & haemoptysis.
pr3 d.rS Or -
t67
. Effect on general condition:

o lnflammation:
o Fever
1. Hectic fever: as in acute lymphadenitis
2. Niqht fever: as in T.B
3. Glandular fever: {fever+rash} as in l.M.N
4. Pel. Ebstein fever: (Brucellosis, lymphoma)
o Cachexia
5.,Hjp..tp..ry.sf .inyesf r.se.ti..e.n$..-o..r..mp-d-i.qsf lp..n$,
Past historv
. Similar attacks.
. Common diseases: (DM, Hypertensioil,TB, B, Hepatitis, DVT)
. Blood transfusion
E-anu'lY--hlsle-U
. Consanguinity
168
E4amination
Pt is alert, conscious, oriented to time,

Gene-rnl: place, & persons, average built, quiet facial
Body built. expressio n, normal decubitus, average
3 !.!-.t Decubitus intelligence, & s/he ls cooperative.
Facial expressions.
Complexion -+ (3 colors) Jaundice, pattor & cyanosis.
- Jaundice + Hodgkin lymphoma (LNs in porta hepatis)
- Pallor -+ anemia
- Cyanosis -+ mediastinal LNs
Head
- Eye : for jaundice (if LNs in porta hepatis )
- Lip : for pallor and cyanosis (if LNs in mediastinum )
- Tongue :paralysis (if infiltration of hypoglossal nerve )
- Parotid region : for swelling (Mikulicz) autoimmune
. Neck
- Thyroid gland : for enlargement
- engorged neck veins ) mediastinal syndrome
Spine
- For metastasis & tenderness (Brucellosis)
Chest & heart
- sternum )tenderness as in Leukemia
- (Despine's sign ) Bronchial breathing below level of T4 in
mediastinal L.N. enlargement)
Abdomen.
3 drL,,;'t - Hepatosplenomegaly as in Leukemia
- Testis: if testicular tumor.
-PRorPV
- Ascites
- aortic & iliac LNs
Extremities
tender bone ) lymphoma, leukemia
fever ) Hodgkin lymphoma
-unequality of the pulse if the L.N compress the vessels
Examine all accessrble L.Ns. as examination of any swelling
r69
Lgp-O_I_:-.4+l+ GJc ,-ii _r,_rblt & J^.,

lnspe-eti_o_nl
From 2 different planes & .gl,i _,

A. Swellins rrrrt..d
1, Site
- The anatomical region of the swelling
- T.B : upper deep cervicat L.Ns
- Hodgkin : lower deep cervical L.Ns
- 2ry $ : epitrochlear LNs
2. Size
- ln cm (best)
3, Shape
"\ .z
Inegular
4. Number
- Single or multiple (localized or generalized)
N.B: if multiple describe the largesf one
B- $-ki. .n..-o..y. .e rt$ +g,i
. .
Normal, Stretched, pigmented,

Show sign of inflammation (redness, edematous).
Dilated veins, Urcer, scar, red rines of inflamed rymph vessers........
c.o .th..e.r.-L-y-mp.h..ned.e$..rn..th..e.hsdy
- lf generalized Lymphadenopathy look for other LNs in the body
- lf localized lymphadenopathy took for infection or malignant focus
at
draining area.
P-alp-atlo-ni
.!-*..]fe.fm.fh: +lr xJ+ 4sJS

. Temp t in inflammation
2r.f.gn.d..gfn.g$S: oldt
.
3,,Jc. a-=.
c# _e ltr (Jt# isJS
lnflammatory ) mosfly tender
. Neoplastic ) are not tender.
3r.E.d.gg; tJIl
','i;.' is-p
. lll-defined, Well-defined.
170
4r.S..*f-f.A.g.g: +ll i-l+ i.sJo

, Smooth, nodular.
5*. dri+ll+isJ,-
. ".p..+pig.tgn.qy,
-C.
Cystic )cold abscess.
' Solid )calcified 1ry T.B or non Hodgkin
.' Firm )acute lymphadenitis , 1ry T.B , 2ry T.B and lymphoma
Soft )degenerated non Hodgkin
f *.Bsl*ti-o.+...tq..p..+.sh.sf h..er..Gf .-+-u.llipl0.

' Discrete (2ry T.B , early Hodgkin )
' Matted (1ry T.B ) fused but can be counted
. Chain ( T.B)
. Amalgmated (Non Hodgkin) fused and can't be counted
7,Relationtq..sp..rrgsp.liling.s.tr.B..c.-tu.r.9$.i
. See before in swelling sheet
.8.,. o-th.e r.. sry-e lli.+se.i
- lf generalized Lymphadenopathy look for other LNs in the body
- lf localized lymphadenopathy look for infection or malignant focus at
draining area.
- ln cervical Lynphadenopathv: examine :
1) oral cavity (tongue , teeth , cheek , lips ,tonsil)
2) thyroid
3) face
4) scalp
5) parotid
6) pharynx &larynx
- ln axillarv lvmphadenopathv : examine :
1) Breast
2) upper limbs
3) Ant. Wall of trunk until level of umbilicus
4) Post. Wall of trunk till level of umbilicus
- ln supraclavicular lvmphadenopathv: Virchow's gland
- lnquinal Lvmphadenopathv :
1) Lower limbs
2) Genitalia
3) Perineum
4) Anal canal
5) Gluteal region
6) Ant. Abdominal wall below level of umbilicus
t71
P_-e_r-c-us-s-io-ni
S..f.e.rn.u..m.. fs r. i
. Mediastinal mass
. Tenderness as in leukemia
A-us-c-u-ltatlo-n:
. Despine's sign: bronchial breathing auscultated below level of T4 on back
OJ ln Lc-a tty- - lmps-tant- - Lymph- - Nod-es :
9.e rvisnl. lv mph . nP.lil P..q.
Circular chain
lnner circle
-Two palatine fonsils.
-Lingualtonsil.
-Adenoid.
Outer circle:
-Submental LN: in the middle behind symphysis menti
-Submandibular L.N: midway bet- symphysis menti
and the angle of the mandible.
. Titt the head to the side we examine it
. Rotting of the L.N to differentiate it
from submandibular salivary gland
. L.N roll because if is sup to deeP
fascia but salivary gland is not rolling
-Pre auricular or parotid LNs: in front of the auricle.
-Posf- auricular LNs: superficial to mastoid process.
-OccipitatLNs; at the apex of the post- triangle of the
neck over the occiPital bone.
Vertical grouq:
-Superficial ceruical LNs: along the ext- iugular vein'
S u pe rfi ci a/ fo Sternomastoid.
-Deep ceruicalLN; along the internal jugular vein from

the ant border of Sternomastoid, upper and lower
deeP cervical LNs-
-Pre-taryngeal LNs: on both sides of thyroid cartilage'
-Pre-tracheal LNs; in front of trachea in the
suPrasternal notch.
772
Head is tilted
Prelarvngeal
I- N-
["rpper dccp cervical
>"\ Prctraelreatl
t_N
'\'\
*=<1;r,'1,
--
L,xamtnatlon
Ivlovc fi
tionr sids of
Lymph Nodes
Occipital L.N
t73
,l
174
Axilla.ry..L-,N.;i
. lnclude 5 groups:
o Central or medial group: along the base of the axilla.
o Pectoral or anterior group: deep to the pectoralis major
muscle.
o Apical groap. in the apex of the axilla.
o Lateral or humeral group: along the upper part of the
humerus.
o Posterior or subscapular group: along the subscapularis
musc!e.
group
.J
I
*t
\- "4
o
v
Lat. Apical group
Medial group
175
lngsin.el.- .N;
Superficial inguinal LN
Horizontal qroup ) Below & parallel to the inguinal lig
Veftical qroup
-Along the saphenous vein.
-The only glands in the body which may be normally
palpable.especially in bare footed person
Deep inguinal LA/ s (Clouquet)
-Deep to the fascia lata & on the inner aspect of the
femoral vein.
lnguinal L.N
ET
{
*
:
supraclavicular LN
li, 8,,.. 9.a..tq h..m.en.t ar.sa
.
1 ,Cervical LNs ) head & neack

2 .Left supraclavicular LA, > All body except Rt breast, Rt UL,
Rt half of head
3 ,Axillary LNs ) UL + breast
4. lnguinal LNs ) from umbilicus till toes
x Brotese's introduction to the symptoms & signs of surgical disease/ Ch 7 the lymphatics P 209
t76
Sp e ciaf I nv e stig ations
La hg fetgry l nyestig_eti o n_s-

CBC, & differential leucocytic count, blood sugar, blood urea.
Tuberculin test
ReCiqlps |ce l |nyeslig_etionq;
Plain & contrast X- ray.
CT scan, & spiral CT
In v-e-s-rye ! nYe.etis etrsne ;

- Biopsy - Staging laparotorhy .
AnatOmiCal > lt is diagnosis of the region which is affected.
.PgIh g l_o. S.i g_el, i nfl a m matory, n eoplastic .. .. etc.
Associated condition ) T.B., Ascites....etc.
(D.(D. of [ifferent L)mpfr fifofe (Disea. es
A.
1. 2ry T.B
2. lymphomas (Hodgkin &non Hodgkin )
B. start qeneralized from the start
3. leukemia
4. 2ry syphilis
5. lnfectious mononucleosis
6, AIDS
Localized
1. Acute septic lymphadenitis
2. Chronic lymphadenitis
3. TB lymphadenitis (caseous)
4. $ (first stage).
t77
Symotoms and sions Local examination Investigations

+ ve symptoms or Search for 1ry Search for occult
signs in the draining focus anywhere focus. Before
area. draining that diagnosing I ry lymph
L.N node dis.
Skin Rashes and Small size (few
Syphilis condylomata lata mm) generalized. W.R.
Firm and
z.liaarafa
Matted, localized * Biopsy'T.B. giant
Tuberculosis T.B. toxemia and 1st firm, then soft cells."
chest troubles (cold abscess, * Tuberculin (good
then T.B. sinus). -ve). * Chest x-ray.
Pel-Epstein fever,
Variable in
size
pruritis, pain on Localized, then Biopsy (Doorthy reed
Hodokins disease generalized, firm, giant cells).
drinking alcohol.
and discrete.
Large or
Bleeding tendency *Blood picture,
Leukemia Moderate size
* Bone marrow
and bone ache, L.N., Firm,
anemia. discrete puncture.
generalized.
*Rapidly progressive Amalgamated
ymDho-sarcoma course. L.N. Biopsy.
* lnfiltrative (Fixed to all
surrounding).
Reticulum cell Multiple, firm,

Rapidly become gen- discrete mobile,
sarcoma. eralize in randomized Biopsy.
early localized
way of dissemination.
then generalized.
5. Metastasis.
6. Early lymphomas
7. Lymphogranuloma inguinale
8. Filarial lymphadenitis
178
Lympfraf,enopatfiy
Case f . Cervicaf Lymp frafenopdtfr)
Q. Wha t is your diagnosisl

A.
t ft swelling at the side of the neck, mosc probably a lyrnph node swelling
Q. How do you rcich this diajnosis?
A.
. Becau se the swel[ing has the fol[owing characters:
o lt is the commonest swelling of the neck
o The swe[ling lies in the anatomica[ site of alyrnph node Sroup
o The swetling is actually composed of multiple swellings
o The surface of the swelLing is nodular
o The swe[linq lies deep to the stenomastoid musc[e
Q. ls it a case of loca\ized or'generalized lymphadenopathy?
A.
. lt is a [ocalized Lymphadenopathy case, since examination of other
Iyn ph nodes of the body is ftee.
Q. What ate the causes of localized lymphadenopathy in the neck?
A.
r. Non specific cervical inf[ammatory lymphadenopathy
2. T.B. lymphadenitis (fibrocaseous type)
3. Metastases
4. Early [ymphomas
Q. Whac is the cause of cervical lymphadenopathy in this paci ent?.
T.B Ifodgkin's Non-Hodgkin's Secondary
Lvmohadenooathv Lvmohoma Lvmohoma Metastases
Age
Child/young adult Young adult Adult or elderly Adult/ elderly
Site in the neck Usually upper Usually lower Upper or lower Upper or lower
cervical L.Ns cervical L.Ns cervical L.Ns Cervical L.Ns.
Consistency Soft, cystic or hard rubbery Soft, firm or Hard Stonv hard
Relation to each Matted may be rosary Discrete (except early discrete and
Amalgamated
Other beads verv late) late Amalsamated
Relation to Mobile (except Early mobile
May be fixed Fixed
surroundings very late.) and late fixed
Other features Node in the center Catchment area
May be skin
T. B Toxemia is bigger than usually reveals a
ulceration
surrounding lrv tumor
Browse's introduction to the symptoms & signs of surgical disesse/ Ch 11 the neck P271-278
t79
Case 1: TB lgtttphqdenopathg
a. What are the types of T.B. lymphadenitisl

A.
.There ate two types
r. Fibrocaseous T.B. [vmphadenitis (Localized cype) it is lynph borne
. [n the fibrocaseous type/ infection is [ymph borne, rcaching the nodes
through the afferenc lymph atics, and so/ the first part to suffer is the
cortex of the node
. Examples include:
2-. Lymphadenoid T.B. lvmphadenitis (generalizedtype) it is blood borne.

On the other hand, in the lyrnphadenoid typq it is blood borne, reaching
the nodes through the b[ood vesselsl and so1 the ftrst part to suffu is the
meduLl.a of the node.
ln lymphadenoidT.B., therc is no periadenitis, no matting/ no caseation,
no cold abscess, no ca[cifi cation, no sinuses/ no beading in the [yrrph
vessels.
Q. Describe themicroscopic picturc of a T.B. lymphadenitis

A.
r. Central zor.e of eosinophilic structureless necrosis containins T.B. bacilli
z. Midzone of epithelioid cel[s and Langhans giant cell Periphetal zor.e of sma[[
round ce[[s
Q. How doyou freatfibrocaseous T.B. lymphadenitis?
A.
r. Ceneraltreatmenti
o SANATORTAL TTT + Anti-T.B. druss (rifampicin 6oo ms +
l.N.H. 3oo ms daiLy)
z. Local treatmerrt
o Excision: For [ocali zed single Sroup persisting after 6 month of medical
tteatment
o Cold abscess:
tenderness 8l- redness
predisposes to a T.B. sinus.

o Certain precautions ane caken to avoid a T.B. sinus formation;
180
o Aspiration is scopped when there is blood in the aspir,ate &-reaspirate

when it refills fuorn rcsidual lymph node tissue not caseated.
o zry infected cold abscess: Drainage
o T.B. sinus: Repeated dressing with streptonrycinpowder
Q. What are the abscesses that arc aspirated and not drained?.
A.
. Arnoebic Liver abscess (fo'r fear of amoeba cutis)
. Brain abscess (for fear of introducing infection to the brain and CSF [eak)
. Cold abscess (for f ear of T.B. sinus)
Browse's introduction to the symptoms & signs of surgical disease/ Chl1 tke neck P272
Case 2: lgnphonta
Q. Mention the staging of lymphornal
A.
Hodgkin's lymphoma:
I. Stase r: Localized to one group of lymph nodes
2. Stasg z: Limired to mole than one sroup of L.Ns. on the same si.de of the
diaphragm
3. Stagre -r: The disexe is present on both sides of the diaphragml but tlre
involvement is limitEd to L.Ns. spleen andWaldyer's ring
4. Staqe u Lrwolverlent of bone rlrtdttowl lung, Liver, CLT/ skin and any organ
9_the1 .t_!411 :L-N.z 9p!g:l etWC!!:vgt tjts
Each stas:e is further subdivided into 'A't or t'Btt according co absence or i
presence of associated systemic syrnptoms fFevery SweatingT Weight loss/ i
PruritisT AnemiaT Bone pain/
Non Hodgkin lymphoma'

Lukas 8l Collins Classification
lt is based on the cells of origiry thus non Hodgkin's [ymphorna is
divided as
r. CelL type {Thymus derived:T -celll.
z. CeIl type (bone marrow derived: B-eell) .
3. CelL type (Unclassifiabl,e).
181
a. Comment on Pe[ Ebstein fevei

A.
. [t is a periodic fever (z weeks on and z weeks off). lr was originally
descri\ed as a feature of Hodgkin's [ymphoma, but this is a mistake. [t
is a character of Bruce[losis. Eever in Hodgkin's [ymphoma is an
inegular fever.
Q. What is the macroscopic pictwe of lymphoma in a given lymph

node?
A.
. Lf node is bisected, there is loss of its norma[ architecture (therc is no
cortex and rnedu[[a)
Q. What ate characters of staging [aparotomy?

A.
[t is noc danetowadays because the accuraq of spira[ CT.
. Meticulous inspection and palpation of abdomina[ organs
' Biopsy from both [obes of theLiver
. Splenectomy
. frlode biopsy: Para-aortic, coeliaqrnesenteric, andi[ea[ L.Ns.
' Open biopsy from the iliac qest
' ln fernales, rnedial tetto-uterine fixation of che ovanies
a. What investigations do you ask for in a case of lymph adenopathyT.
A.
o Hodgkin's [ymphorn a: Anemia, lyrnphopoenia

o Septic lyrnphadenicis :eosinophilia in Leucocytosis
o Leukemias :Marked leucocytosis in
o T.B. : Leukopoenia with rclative lymphocytosis
b) Serololrica[ tests
o Clandu[ar fever. Pau[ Bunneltestfor WR test andfor
o Syphilis: VDRL
o ChestXrav (for metastases/ [ymphomas)

o Ultrasono$raphv &t CT (liver, spleen andpar aortic L.Ns.)
o Lvmphanlriographv (for Lymphomas and zry L.Ns.)
3. Other investiglations
o Bone maffow aspiration: lt may show infi[tration in [eukaemia
or [ymphomas. [t is only positive if the bone is infiltrated.
t82
.
biopslu: we car- find Reed Sternberg cell. l,t is a giant,
multinuc[eated, containing z-8 nuc[ei arranged in a mirror image
in the centet of the cellwith prominent nucleoli.
o Aspiration of cold abscess ) bacteriological study for T.B.
o Staqinsr [aparocomy: in Hodgkin's [yrnphoma
Q. How doyoutteat Hodgkin's [ymphoma?

A.
> Radiotherapy
axillary * mediascinal nodes )

o lnfradiaphragmatic disease -- > Lnverced f fieLd irradiation (Para-
aottic * pelvic * inguina[ -r splenic axis)
o MOPP (Muscine * Oncovin * Procarbazine * Prcdrrisone)
Q. Whatis the clinical pictwe of non Hodgkin lymphoma?

A.
I
Affecc usualy eLder rnales) 6o years *rapid progressive coutse
I
LNs start in upper deep celical LN, painlessl softl fitm ol hard
amalgam atedl first mobile, Later on fixed to deeper and superficial sttuctures
Stmay uLcerate through skin
Ln late cases rr,any LN group s ate affected together with spleen ,liver ,bone
rnalrow/ ClTmucosaT skin (mycosis fungoids)
Q. Describe microscopic pictute of Non Hodgkin [yrnphoma?

A.
. The norma[ nodular architecture is completely [osc and replaced with
malignant ce1ls of differcnt shapes &L different degree of differcntiation with
central hemorrhage 8l- necrosis.
Q. What is the treatrnr,errt of non Hodgkin [yrnphoma?
A.
(Mainly by chemotherapy as it is multicenteric)
Chemoth erapy: C.V .P. (cyclophosphamide , vinuestine 1 predinisolone )*/-
adjuvantradiotherapy
No role of sutgery apart from LN biopsy or gascric and intestinal resection
in C tT [ymphomas
Q. ls the prognosis good?
A.
. No it has a bad prognosis due to high grade ma[ignancy and the usual old
age with 5 ad general condi ti on.
183
Q. What is Burki tt's lymphoma?

A.
ls a highly malignantB cell tumor thatrnay involve sites other chan LNs 8l
R.E.5.
There is strong evidence that it may be due to EBV 8l- may be related to
malNia.
r [t is commonbetween ages z- t4yeats.
I Commonly mulcifocal, affect the jaw (5oo/")1 ovaniesl retroperitoneal tissues
sl- cNs
Hiqto.pa.ghq[p.Snr.; Dark blue lymphocytes &- starry shaped faint histocytes
5 rany sky appearancel .
(
T.IeafrD.e.tqi By combination chemotherapy 8l tumor debulkiry: if possible
a. What is the differcntial diagnosis of lymphadenopathy with

enlarged spleen?
A.
r. Leukemia,
z. Llrmphomas
3. Cland ular fevel TB, Bruce[losis
4. Coincidence of sp[enomegaly with chronic non-specific lymphadenitis
O. How do lymphnodes differ between [eukemia and lymphorna?

A.
. [n leukemias, the different groups are equaL in sizq in [ymphomas they
are unequal.
Browse's introduction to the syrnptoms & signs of surgical diseasd ChL1 the neck P277-278
a. Can you firrd metastatic lymph nodes in the neck without a

clinically detected pirnary in the catchment area?.
A.
. Y esr in caseof si[ent areas whichinclude:
r. f.Jasopharynx
2. Pyriform areaof thelarynx
3. Postcricoid area of the larynx
4. Papillary carcinoma of the thyroid gland (lateral aberant thyroid)
184
. a. Comment on matted and arnalgarn ated lymph nodes?

A.
[n both conditions the lynph nodes are adherenc to each othq. The
differcnce is that rnatted lymph nodes are costttable ;Matted [yrnph
nodes is a character of fibrocaseous T.B. Lyrnphadenitis, and it is due to
periadenitis causing fibrous adhesions between the lymph nodes, so
they are councab[e.
While; amalgama ted lymph nodes are not. Amalgam ated lymph nodes
are acharacter of ma[ignant [ymph nodesl and it is due to infi[tration of
ma[ignancy \etween the Lyrnph nodes, so they are not countable.
a. p[an fo, examination fo, the source of zr.dry ceruical

lymphadenopathy?
A.
r- Examine the skin of the scalpl f acel earl neck.
z-look in the nose
3-[ook in the mouth at tongu e/ gsrns/ mucosa Bltonsi[s
4-palpate the parotid/ submandibular 8t thyroid gland
s-examin e the arms 8t chest wall inc[udin g the breast
6-examine the abdomen & genita[ia
Browse's introduction to the symptoms & signs of surgical disease/ Chll the neck P278
Q. DD f swelling in the neck? (deep to the deep f ascial
F In the arrt. triangle that doesntt lnove lr'ith sx'allorving

. solirl:
' ALyrnph gland-
. Carotid6ody tumor.
. [Yslic
. CoLd abscess.
. Branchial cyst.
F In tlre posterior triangle that doesntt rnove rr'ith
srvallort'ing
'Solirl
o A lvmph gland
185
.0ysli0
. Cystic hygroma.
o pharyngea[pouch.
o occasionally a secondary deposit of a papiL1ary thyroid carcinoma.
. Pulsatile:
c Subclavian aneurysm
F In the ant triangle that morres trrlth swallorving
. $olirl:
.Thyroid gland
. Pretrachea[ LN (Detphian LN )
- 0yslic
oThyrsglossa[ cyst
Browse's introduclion to the symptoms & signs of surgical diseuse/ Chll the neck P287
Case 2: Lympfroedema
Q. What is lyrnphoedernaT.
A.
Chronic ederna fro- chronic |yrnphatic obstrucrion
Q. What is its sitel
A.
Subcucaneous tissue of the [imbs7 breast, scroturn/ vulva.
Q. Wha t cau se lymphoedema?

A.
..499
r. Lymphoedema congenic a :
at birth. (usua1ly aplasia)
z. Lyrnpho ederna pr ecox : at pub er ty . ( u su aLIy hyp op, asi a)
3. Lymphoe derna tarda: in adult.
ln which the number of [ymph vessels is reduced in the

affected limb.
Examp[e in the thigh there are or'e or two vessels instead
of the usua[ five or more.
Ll-Aplasia > No [ymph vessels are dernonstrated.
186
ociated with incompe tent valves.
. Ltmay be due rc:

r' kepeated arack s of suepcococca[ [ymphangitis (i.e.
cellulitis).
z. Filariasis (commonesr cause).
3. Lrradiation.
4' surgical excision of LN s which drainrhe [imb (as after radicar
mastectomy).
s' obscrucdon of the lymphatic by malignanr rumor
Q. Whar is the pathology of lymphoede;na?
A.
' Lymphoedema of any cause )tynph stasis in superficial ryrnph.rrics only.
' This ptedisposes co recu'.ent streptococcal [ymphangiris )each atack
obli ter ates more lymph atic) so lim b
ed.erna incr eases pr gr es siv ely
. Pathology passes with stag,es; o .
4
r. Stasre of soft pittinq edema :early
z. Sqace
Stasre of o lymphorrhea: due ro ..uptute of
1ymphatic vessers disch.rrging
lymph fluid with i." high ptoteinconrent in its
sub utaneous tissue.
3' Shse of fibroels:. (non pitting ed.etna) the increased.
t a tissue (never.a.ffect tissue deep rc the deep ascia t excites
protein conren
, [l::,"^ ! f I
rough, thickened tike elephant skin ; (elephanriasis) rhe skin is

pigmentation and fibrosis.
fro- severe 5.C fibrosis )skin
Q. Describe filarial lesions?
A.
. lt includes:
r. Legl- Iymphoedema and, elephanciasis
z' Scrorum Sfvufva : rymphoed.ema and erephantiasis
3. Spermatic cord:
o Funiculo- epidydirnitis (acuteand chronic)
o Lymphocele of spernatic cord,
o
Diffusehydrocele of spermatic cord,
4. Tunicavaginalis : secondary hydrocel,e
187
Q. Describe the clinical picture of [ymph edema!

A.
. U. may 6e a resident in fiLarial distticts (|Aansour a I Sharkjya)
. Elephantoid fever.
' Progressive leg swelling wich a crease found at the ank[e due to aboence of
joint
edernabecause skin over the joint
drains dfiectLy onto the Lymphatics and
not 5.C lyrnphatics , skin over the dorsum of the foot can not be pinched due
to fi brosis (Sternrner's sign).
' lc is classified clinically by Bruner cl.assification as follows:
Grade Clinical features
Excess interstitial fluid and histological abnormalities of lymphatic but no
Latent clinical lymphedema .
Oedema pits on pressure and swelling disappear on elevation and bed
1
rest
2 Oedema does not pit on pressure and not reduced on elevation
Oedema is associated with irreversible skin changes , fibrosis, papillae
3
(elephantiasis)
Q. What are the complications of [ymphoedemaT.
A.
r. Recurrent cellulites and [ymphangicis
z. Blebs which become infected )pustules.
3. Lymphoed ema ulcer from rupture infected ble6.
4. Huge disabling [imb interfering with activity.
s. Lymphangiosarcoma(very rNe).
Q. How do you investig ate the case1.

A.
. Lymphangiography:
o BLue dye is injected in the 1tt web space of the fooc to color the Lymphatic
vessel on che dorsum of the foot )then lymphaticvessels is canulated and
injecting ultrafluid [ipidolin [ymphatics on che dorsum of the foot
o lt shows stateof [ymphaticvessles in lymphoedernaand asses extent of LN
affection in tumors
. For filariasis:
- Nisht blood fitm
- LN biopsy
. Lymphocintigraphy scanning of lymphatics and nodes using TCgg
' Cf scan )excludepelvic or abdominal mass
. MRI )provide clear image of [ymphacic channels and LNs
188
Q. What is the reafinent of lymphoedema?

A.
. Treaement is mainly conservatirre.
Pallia-tiv,e
lndicatad in early ca,$Es
r- Rest SL elevation of thc affecced [imb. z- Pressure bandage.
3- lnterrnitte.nc [imb compression pump. 4- Diuretics.
5- Andbiotics for infeceion 6-Trcatment of the causc (filariasis).
Sgrrs-":ar
The only indication is disability as reeulcs of ouryery are noe promising
r. I(nodoleon's operation z. Swiss-ro[[ qake operacion
z. Amputation
Drawse's introduction to the syruptoms & sl]guas af sarglcal dlsessd eh 7 $mphaties/ P211
189
ISCHIIUIA SIIBIIT
Histo
Personal H:
Name, Age, Sex, Marital status, specia! habits of medical importance, Address,
Residence, & Occupation (long stay of foot in dampness Trench foot), if ? ) )
menstrual history
- Age Child) )
Congenital $ or arterial embolism
)
Middle age )
Burger's, Raynaud's, & D.M. are common.
)
> Old age Atherosclerosis is the commonest.
)
- Sex Berger's disease Occurs only in males. )
)
Raynaud's disease Occurs only in females.)
- Marital sfatus )
lmpotence with Leriche syndrome
)
- Occupation Raynaud's phenomenon high frequency vibration )
) )
- Special habits: Smoking Essential feature in Buerger's disease Ask )
about duration & number of cigarettes per day.
) Accidental injection of maxtonfort intrabrachial ) spasm
& gangrene in the hand.
O-qmplalntr f L.i.i3..,.ll dtil+,Jllq! o-,-trll Eilr + Duration

HPI: f d.t eiL, cds 6-,1-c Jit
1- P.***:.
. Claudication pain:
1. Site. 6. Course.
2. Claudication distance. 7. Duration.
3. Radiation. 8. Time & time of rest.
4. What I or J. 9. Severity.
5. Onset. 10. What associates
. Resf pain:
1. Site. 5. Course.
2. Radiation. 6. Severity.
3. Onset. 7. What 1 or I.
4. Duration. 8. what associated
. Sudden pain of acute ischaemia:
- Site ) at the point of occlusion then shoots distally.
2. F..tgglJ'*..*9.'.
- Localized swelling as Arterio-venous fistula
- Tumor or aneurysm.
1. Site.
2. Onset.
191
3. Course.
4. Duration.
5. Effect on general condition.
6. Size.
7. Other swellings.
8. What 1 or J.
9. Apparent cause.
3. Disturbance of function o-*l o-.11 ir:
Skin:
- Trophic changes )
thin, atrophic, stretched, dry, scaly, Loss
of hair. & non-healing of ulcers. f 613'3lli-; ',.i I 6s-.; el$+
- Color changes > f J:tiil elJ+ O-d Relation to posture, emotions
& cold weather & course (continucus or
intermittent)
(pale + bluish -+ blackish).
- Sense of coldness.
Narls: ) Loss of luster, fissured & brittle. r eij+ clltlii
Subcufaneous fissues ) | limb circumference & thin tapering toes.
A/erves;
- Sensory changes ) Paraesthesia, Hypo or
hyperesthesia
f A-.,!l 4;;Yl .,lc Gii tl
Muscles: ) Motor changes: "-=!
"r-a,,;.9;
- Weakness (in chronic ischemia) /n'
il:'_,,.
.rl . \
I s>4.sj .,J-Yl )Jl J JiSi .J*:.si.,Jo 5r G.i,t- ill J
\
- Paralysis (in acute ischemia & Gangrene).
Ganqrene: )
lf present, ask about the site, duration,
& relatiOn to trauma. r:-l cleL!-
Veins:
- l{istory of migrating superficial thrombophlebitis et!-;j cr[l-:
CJJ J (#
- History of DVT c,r:-,r!$ elsrl 3,rj"ii*ll '"'\ii, Elj'-:j ':11.,
Bones: sawing Pain f cLlJ.c .,.l -,,1;i,J,,S+
Joints'. t dL-ti. uJ F-l
Brain: Transient ischemic attacks (T-l.As) e.g. Hemiplegia,
blindness, fainting.
4 - 9.Hh.9.T....9YsI-e.. sLg. i.
Ask about manifestafions of ischemia in other parts of the body.
- Genital lmpotence ) Leriche syndrome.
- Heart ) HF, angina pectoris, & rheumatic heart.
- Brain ) Loss of memory. Fainting, blindness or hemiparasis.
- Eye ) Flashes of light.
- Lungs ) Chest pain cough & haemoptysis.
192
: [l+'"'3 Bilffi l3"#fltili?n" in reration to

meals (post-cibal angina) "ooomen
s . IL+*F..9r..y....ef....+r,.y..ep.H+.g.eH,.+.-o-p..p.....9.T....$.-e.S*9.*-t-+.9.Tr..9..;.
P-a-st - his-tory-i
. Similar conditions or recurrence.
. Common diseases: (DM, Hypertension, T,B, B, Hepatitis, DVT).
. Drug allergy & intake.
, Blood transfusion.
. Histoy of trauma (A-V fistula).
E-a-nruty- -hLslo-q[i
. Consanguinity.
Examination
GeneraL: Pf. is alert, conscious,
oriented to time, place, &
persons, average built,
. Body built. quiet facial expression,
. Decubitus. 3 i4.L*t normal decubitus,
average intelligence, &
. Facial expressions. slhe is cooperative.
I Complexion )
(3 colors) Jaundice, pallor & cyanosis.
I Head,Spine)3drl+tj
I Neck ) congested neck veins (H.F), cervical rib.
I Chest & heart.
(A-V fistula > HF)
Complete cardiac examination
Abdomen.
For aneurysm, auscultation over
the major vessels, renal mass
! Extremities.
I Pulse, blood pressure, & temperature.
Palpate all accessible pulses: (rate, rhythm, volume & equality on
both sides, condition of the arterial wall & thrill)
Bl. Pr. )
ln U.Ls in both sides
t93
,,tgg?.L.t. ^++
-E-:!P.g.-s.!+.[? i., rro m tJ m b i t i c u s downwa
rd
Inverted Champain boffle
1. Both L.L are not symmetrical.

2' There is rocari_zed swering in f"rorrr
fossa (aneurysm) v
"' triangre or popritear
- Comment on Site, Size, Shape, Number.
3. Overlying skin:
s Color changes:
- Pallor - cyanosis - mot,ing
e Trophic changes: - green, brown or black.
- skin is dry, thin, shinny with ross
of hair & trophic utcer.
Gangrene
- Site.
- Extent. z- stte: dorsum of foot or
- Characters. digits.
- Type (moist or dry 3-Size: variable.
septic or aseptic) 4-Shape: variable.
- Line of demarcation 5-Edge: punched out.
& separation. 6-Margin: Btack.
7- Floor: Gran u lation
fissue.
8-Base..Mobite.
) Fungar infection between the
toes (Buerger,s disease)
'v'B'
*tc.rir'+-rJ+ll 6^*..:
(Color change * temp"iatr.i"l
194
1- Color change )
notice effect of position (elevation &
dependency i.e. Buerger's Test & dependency test)
F.p..e*r.gg.f.:..9....Ip.p.F )
Patient lies on back, raising the atfected
limb ) pallor.
Buerger's Test
Psns. *fls.*s. v ...P..e :.H

) The patient lies on back, drops the affected
limb below the level of bed ) cyanotic and
congested.
;;L<-11 .i t f
[*:- lgaa" u\l
Wr,4-.t-.ltrV)n
2- Skin Temperature)
ln both limbs from below (after exposure for 5 minutes),
determine the site of change of temp. (Level of ischaemia).
Level JJ6A^ !-L

comparison aJiii , a^366
+t+: ,& [51i , , '- .,,i
195
Muscl€s:
Examine muscle tone, muscle state, passive movement, and
motor power.
Power and active movements
- power (weak di
Power
<'o
6lr
J
lsjso
L' q.-oJt
Movement (fine a-+1"-o el-=+) , (gross nJ+-,,.,!: r;rE)

Aortic block ) limitation of hip movements.
Femoral block ) limitation of movements of the knee.
Popliteal block ) limitation of movements of the ankle.
ll
f*'.
*!:J."
--
. .,ol{
Fine movement Gross movem
Muscle wastinq ) Vastus medialis 1't ms. to be affected in

Leriche $
196
Nerve: ) Examine the sensation all over both limbs (pin prick),...
-3
\
I-.Inequality in sensation
i\
Y.s**.:.:.
- Palpate veins for superficial thrombophlebitis (Burger's disease).
. DVT.
t97
- Palpate arterial pulsations in both L.Ls.

- lf in doubt, simultaneously teel your pulse & Compare with
the patient's pulse).
- Both sides should be compared.
- At each side, note the force of Pulsations, the vessel wall,
or presence of thrill.
= Different arteries & their sites for feeling pulse ) see below.
F.:...en+*s....p..*)r....glg-e-f .r.....fl IIsI].+ng.g..,' or edema

Sp-eeial--te-sl-:
.lI e..,rv..e x. :..p., .

yep.e * H. .. . r e.f ,+ .}. I * r,,.9.... F*rRe 1.
- Elevate the limb to empty the vein and then place it down
flat on the bed & estimate the venous filling time:
.
Normally: 5 - 10 seconds
o
Prolonged : in ischemia
N.B. Some prefer to lower the ltmb below the level of the bed
r9.+.n*.IIp..Ty.....9.*.H-c..slpj*.g.+.....Ees.t:.:.
- Note the effeet of pressure on the nail bed skin.
- Normally Pressure causes blanching.
- Release of pr. is followed by lmmediate return of normal color
- Slow return of color indicates a sluggish capillary circulation and
failure of blanching ) the part is gangrenou
Capillary circulation
test
. Addison's test:
- Done in case of upper limb ischemia.
- The shoulders are placed backwards.
- The patien ith the
arm pulled n turn Addison's test
upwards a
(Some prefer to tilt the head to the opposite side).
- The radial oulse mav be weakened or obliterated in case of
cervical rib'or scalede syndrome.
198
Arterial-p_uls_ati_o_ns:
Artery Sife Felt against

Dorsalis Lateral to tendon of extensor hallucis logus. Navicular
pedis bone
Midway bet post border of med malleolus and
med border of tendo-achillis esp. when the foot med
Posterior
is dorsi-flexed and inverted or felt midway bet. rnalleoius or
tibal
The med malleolus & med tubercle of calcaneus
calcaneus).
Peroneal 1 cm med to lat malleolus
The patient lying on the back, flex the knee at
Lower part of Right angle, the 2 thumbs on tibial tubrosity, put upper part of
popliteal all fingers in the middle of lower part of popliteal tibia
Fossa.
Place the patient on his face with the knee
Upper part of lower part of
popliteal flexed Feel pulse in the upper pad of popliteal
femur
fossa.
Put thigh in flex with abd & ext rotation a point
just below inguinal lig midway bet ASIS & Head of
Femoral
femur
symphysis pubis.
Along upper 213 of a line bet nnid inguinal point &
Superficial shaft of
The adductor tubercle (between muscles of
femoral femur
front medial aspect of thigh)
Along a line from xiphoid process to 1 cm below body of
Abdominal
& to the Lt. side of umbilicus. lumbar
aorta
vertebrae
Along a line between end of aorta & mid inguinal
Common & point (Upper 113 of line represent common iliac Sup. pubic
Ext lliac A ramus
a & lower 213 of this line represent ext- iliac a)
Put 2 thumbs on the deltoid muscle & all fingers upper part of
Axillary
feel pulse humerus
Upper part of Just post to Biceps in the groove bet Biceps & middle 113 of
brachial triceps m humerus
Lower part of ln the cubital fossa fiust med. to biceps Tendon) Lower 113 of
brachial humerus
lower paft of
Radial
radius
Between Tendons of flexor carpi ulnaris & flexor lower part of
Ulnar
digit. Superficalis ulna
199
Site
Its 3rd part is felt in supraclavicular fossa above
the middle 113 of clavicle
Along the ant. Border of Sternomastoid m.
(above & below upper border of thyroid
cartilage).
ln front of tragus
Fern oral artery

[':r
t.
rt
200
Dorsalis pedis a. )
Poplitial artery
Superfecial temporal arterY Carotid pulsation
20r
lnar
Midway between medial malleolus &
Axillary pulsation I
Post. Tibial artery
Lower part of brachial r
202
Auscultation:
- Along the course of fhe vessels (systolic bruit in case of aneurysm
or stenosis).
- To detect the site of arterial obstruction.

- The rnain vessel is occluded by pressure while Stethoscope over
the vessel, release the pressure (loud sound )
vessel is patent.
Nothing heard *
obstruction at the site of stethoscope)
Browse's introduction to the symptoms & signs of surgical disease/ ChTthe arteries/ Pl75
Chronic ischemia:
Either affects the upper limb as in:
- Cervical rib. Raynaud's disease.
- Burger's disease. Peripheral arteritis.
Or lower limb as in:
- Atherosclerosis. Burger's disease.
- Diabetic (presenile ischemia). peripheral arteritis.
ecial Inves ations

) Laboratory investigation :
CBC, Hbo/o, blood sugar, lipid profile, blood urea.
> ECG
) Rad iological i nvestigations :
Doppler & Duplex US.
Plain X- ray.
MRA.
) Angiographic investigation :
Angiog ra phy, d ig ital su btraction an giog raphy.
203
1. Etiological) atherosclerosis or Burger's disease.

2. Anatomical ) lschemia of UL or LL.
3. Pathological ) Acute or chronic ischemia.
4. Functional diagnosrs
Deqree of ischaemia: Advanced ischemia is diagnosed by:
- Short Claudication time & distant.
- Long time of rest pain.
- Fixed color changes.
- Loss of Sensation.
- Small Burger's angle.
- Long Venous filing time.
- Sluggish capillary Circulation.
Level of arterial obstruction;Diagnosed by:
A. History:
- Site of Claudication.
B. By examination:
- Site of change of temperature.
- Site of muscle weakness.
- Site of sensory loss.
- Site of loss of arterial pulsations.
C. By investigations:
5. Complications ) gangrene ) moist or Dry septic or aseptic
6. Associated condition ) DW, T.8., diabetes, chronic bronchitis...etc
204

A.
Chronic atherosclerotic limb ischemia of theright (left or both) Iower [imb.
Q. how youteach this diagnosis?

A.
Because the patient is old age:

. Hehas symptoms suggestive of atherosclerotic ischemia in some
viscera| organs (coronary ischernia, cerebtal ischemia).
o Some accessible anteries (e.g. rudial 8tr- caroti d attefies) Ne felt rigid
tortuous suggescing atherosclerosi s.
o The level of obstruction is high.
Chronic ischemia:
Becausetherc atethe symptomsStr- signs of chronic ischemia as fo[[ow:
Svmptoms
. Claudication pain (Ltis a cramp-[ike pain in che musc[es that appears on
exercise and disappears on rest).
. Rest pain ([t is a sevele burning pain in the toes and dorsurn of the foot due to
r'ele ischernia).
Siqns
. Color changes.
. Trophic changes(hair loss which is the first trophic change to appear
atrophic dry scaly skin with fissuredtoenails, ischernic trophic ulrcersl thirt
taperingtoes -due to [oss of subcutaneous fat- teniapediq paronychi at dry
gangrene).
. Coldness ar.d [ost distalpulses.
Q. What is the differcntial diagnosis of legpain?

A.
r.Artery: ischernia.
2. Vein: varicosevein.
3. Nerve: sciatical peripheral neuropathy.
4. Bone: Elatfoot, osteoarthritis of knee.
205
9' m"t is differential diagnosis of claudicarion pain

A.
I. Chronic ischemia.
2. Osteoarthritis -, pain on the first scep.
3. Lumbar prolapsed + pain not rerieved by standing
stilr.
4. Venous claudication -+
f On prolonged standing.
J On lying flat.
s. Flat foot ---+ pain on standing or walking (due to pressureon planta r newes).
Q. What is Boyd's classificarion?

A.
' crade I ) claudication passes off on continued walking.
' Crade l'l' ) the pain persists but Jo"" ,ror force the patiinr co srop walking.
' Ctade lll ) The pain increases and. forces the patienr to srop walking.
Q. 14/hrt is the parhosen esis of claudication pain?

A.
' lt is due to muscle ischaemia, which lead.s ro accumulation of metabolites
failed to be washedby bloo{ leading to stimularion of nerveendings during
exercise and gadually washed duringrest.
' The site of these claudication pains indicates the IweI of arterialocclusion
as
follow:
Cluceal claudication (Bilate,al) : Aorto-i liac obstrucri on
Thigh claudication : l[iac obstruction
CaIf claudication : F emoro-p opliteal obstru cti on
Sole claudicarion =: Ti bi o-per oneal obstru cti on
Q. M/h"t about restpain?

A:
' [t is a severe burning pain in the toes and dorsum of che
foot due to nerve
ischemia. l.tincreases more during night or by warmthand
is increased on
elevation of che foor.
' The padentfeels comfortableby uncovering the 1imb,Ioweringhis
leg and
rubbing rhe dorsum of the foor.
t Ru bbing act by the following mechanisms:
! Rubbing dorsum of foor leads to stimularion of propioceptive
I (CATE THEORy)) fibers.
Nerve fibers carryingpropfioceptive gt pain sensations have the same
termination in the spinal cord, i.e. thesame
Sate.
5o, stimu[arion of proprio ceptive fibers-"k", the,,gate,, busy
for receiving
pain srimuli.
206
. Resc pain indicates that:

This patienthas a sevete limb ischemia.
Cangrene is imminenc.
This patient is for doing direct arterial surgery if the condicion s are feasible.
Browse's introduction to lhe symptoms & signs of surgical disease/ Ch7 the arteries/ P18I
Q. What is che claudication distance andwhat is the claudication timel

A:
. lt is che distance at which the pacienc starts to expeience pain
' lt is the cime chat patient can walk on treadmi[[ untiI the onset of pain.
t They rcfl.ectthe degree of ischaemia.
Browse's introduction to the symptoms & signs of surgical disease/ Ch7 the arteries/ P180
Q. What is the rest tirrnel

A
. Time of restneeded co start wa[king again ic grad,ually increases as the
disease prosresses.
Q. What pu[ses arelostin this patient?
A
. Peda| and popliteal. pu[ses (for exarnple)
Q. What is the "disappearing pulse"T
A
. [n early ischaemia, pu[sationsrnay befe\tbutthey disappear on exercise.
This phenomenon is ca[[edthe disappearing pu[se.

Q. What are the co[our change.s you [ook for in a case of ischaemia?
A:
These arel
I. POSTURALEAIO UR CHANCES:
. They are pteser't in moder ate and sevete ischaemia.
. Jhef include: Pallor on elevation of che foot and cyanosis on
dependency.
z. FXED COLOURCHANCES:
. They are ptesent in severe.ischaemia
. They ane unrelated to posture (i.e. presentwhatever che position of the
timb)
. Jlre colour of the foot may be:
(Pal\ol Rubor, cyanosis, dusky; rnottled, purplel bright red speckling)
j. CAPILLARY CIRCU LATIoN:
.
Press and see how color f ades.
.
It is [ooked for in che nai[ bed.
. [t is slucqish in ischaemia and [ost
Browse's introduction to the symptoms & signs of surgical disease/ Ch7 the arteries/ Pl75
207
Q. What is Burgels anglel

A:
' it is che ang[e at which the [imb becomes pale on e\evationl we look fot pallor
in the sole of the foot.
' [t signifies seveity of ischemia. So, if it is below zo", itindicates a severe
ischemia.
Browse's introduction to the symptoms & ical disease/ Ch7 the arteries/ P775
Q. Whatis guttering of veinsT.

A
. Normally, on elwation of the Leg, superficia[veins of leg empty but not
completely.
. ln advanced ischaernia, on elevation of the \eg at ro-r5o.
. Veins empty completely ar,d appear as pa{eblue gutterc.
Browse's introducti.on to the symptoms & ical disease/ Ch7 the arteries/ FI75
Q. How do you rnr'easure the"vertous rctllling time"?

A-.
' The leg is elevated unti I the veins ernpty and then it is all,owed ro be
dependant and che time needed for the veins to rcfilL is recorded.
|r)orma[[y7 they take ro-r5 seconds.
Up co 30 sec.: mild ischaemia.
> z minutes : impending gangrene.
Browse's introduction to the svmatoms & ical disease/ Ch7 the arteries/ Pl75
Q. What ane the charactets of ischaemic ulcefi.

A:
' Painful non-hea[ing ulcer.
' Site ---+ commonest on coes and dorsum of foot (least b[ood supply)l around
the malleoli.
. Edge --- punched out.
. fAargin ---+ hyperemic.
. Floor -+ granulation tissue or pus.
Q. What argt[re functiona[ discurban ces you look for in chronic [imb
ischaemia?
A.
. lmpotence (as in LeRiche Syndrorne).
. Sensations: Sensory losslhyperesthesia (Ln aneas c[ose to gangrene).
. Muscle atrophy and [oss of strength( Vascus rnedia|is is the first muscle co
be affected)
. Flexion deformity of the knee (due to rest pain).
208
Q. When do you expect to find sensory loss in chronic tirnb ischaemia?.

A:
r. From the cause: Diabetic neuropathy.
z. From the cornplications: lmpendin g gansrene.
Q. ln which cases you can feel the artefial walll
A:
r. Sy sternic atheroscl.erosis.
z. Monckeberg sclerosis (degeneration of media followedby calciurn deposition).
3. Polyarteritis nodos a (Crape-like swe[ling).
Q. What are the causes of warrn [imb in a case of ischemia?
A:
r. Covered [imb.
z. Lnfected [imb due to hotness of inflammation.
3. Undq treatrr,errtby sympathectomy which leadto cucanous vasodilatation
4. Diabetes Mellitus in which thepatientis aheady sympathectomized.
Q. How do you know thelevel of occlusion in any case of ischaemia?
A:
Thelevel of occlusion can be determined from the fol[owing:
r. Level of claudication.
z. Level of co[dness.
3. Level of hair [oss.
4. Level of absent pulse.
s. P r esence of impote nce with bilater al L. L. i scha emi a s usgests aorto-i [i ac
block ( LeRiche syndromeJ.
Q. How canyou evaluate the degtee of ischaemia?

A
From the following:
Degee of pain:
. Claudication distancq claudication time/ peiod of rest after
claudication
c Presence of rest pain = sevete ischaemia.
Degree of co[our changes:
. Burger's angle < 2oo = gevete ischaemia.
. Presence of fixed co[our changes : swere ischaemia.
o Venous refilLing time:
o N. = up to ro soc.l ro-3o sec. : mi[d ischaemia
o ) zmin. : seveteischaemia
o Capillary fiLlins, cime (> 30 sec. : severe ischaemia) .
o Reactivehyperaemia test
o (A sphygmomanometer cuff is inflated around the limb zso mm
Hg for 5 minutes and then measure the interval. between
rcIeasing the cuff and the appealanae of red f [ush in the skin.
o ln the normal limbl it appears within rz seconds. ln a severely
ischaemic [imb, itmay never appear.
209
:
Ptesence of gangrene or ptesar.srer,e sevete ischaemia.
:
Loss of touch sensacion ievu.ischaemia.
*"tis ptegangrenel
B.
r. Rest pain * co[our changes.
z. Ankle /Brachial Lndex { o.: (criticalLy ischemic limb).
Q. What investisations do you ask for?
A:
lnvestilrations for dialmosis:-
- Dopplel Duplex.
- Angiogr aphy (it is only a pteoperative investigations
which is not done un[ess operation is planned).
. MI(A.
Other svstem eva[uation (very important):-
-GBC/EBS/KET/LFT.
- ECC/ CXB,/ Chestwallnapping stress test.
a. Comment on ang i ogr aphy?.
Or.
[t is indicatedin:
Only preoperative investigations not performed unl.ess operation is planned).
[t is concraindicated in:
r) Disal occlusion. z) Extensive gangtene.
Tvpes of ansriogrraphv:
Conventional angio5raphy: Using Seldinger needle and arteial catheter
Digital subtraction angiography: After iniection of an intravenous conffast
medium ([t is [ess invasive),
MI(A (Magnetic resonance angiogr aphy).
. The value:
lt shows the fo[lowinq :
r. Site of obstruction.
z. Length of obstruction.
3. Degtee of obstruction.
4. State of the artery.
5. State of collateral circulation.
6. State of distalrun off.
r. State of collateral circulation.
z. State of distalrun off.
I. z. Hemorrhage.
3. Arterial spasrn. 4. Thtombosis.
5. Dislodgment of atheromatous plaqu e and embolization.
6. Dissecting aneurysm.
2t0
Q. How the blood flow detectedby theDoppler ultrasound used in a

case of limb ischaemial
A
l.t gives accurate information about:
r. The diameter and cross sectional ateas of the artery.
2. Blood flow rates andvelocities.
The blood fLow detectedby rhe Doppler ultrasound used
o To detect b[ood flow along an artery: triphasic normallyl monophasic
in ischemia
o To detect blood ptessute at sites where arteial pulse cannot be
palpated e.g. ank[e ptessute.
3. Presence of stenosis.
Q. What are the values of determining rhe blood ptessure by Dopplei.

A-.
. Ankle / brachialindex:
\orma[[y therescingABI > r.
Below o.9 : ischaemia.
Between o.9 andr : equivocal.
Below o.3 : rest Pain.
r. Ankle pressuterespor,se cuwe: This denotes the stace of cotlatera[ circulacion.
z. Segmentalpressure: gives an indication of the site of obsrruccion.
3. Helpful in deciding che level of ampurarion: e.g. if rescing pressure in
popliteal attery > roo mm Hg, abelow knee ampucacion will succeed.
+. Monitoring the success of arteria[ reconstruccion.
Q. What are its valuesl
A
[t gives accurate informacion about:
r. The diameter and cross sectional areas of the attery.
z. Blood flow rates andvelocities.
3. Presence of stenosis.
Q. What is the treatment of chronic atherosc[erotic [imb ischaemia?

Az
A. Conse,rv ativ e management : -
The conselativemanagement is indicated. lt inc[udes:

1. Care of patient:
- Cood diec.
- Cessation of smoking.
- Corect anemia.
-Weig;ht reduction.
- Contro[ DM 8t any associated disease.
2t1
2. Care of foot lrespeciallv in diabeticsl:

- Cood hygiene
powdercd 8l- Lefr- Carefully
exposed.'
washed, dried and
- Avoid cutting angles of the nailq avoid tight shoes.

- lnfection s ane treated properly.
- Light exercise as walking (improves collaterals), should
not be heavy not to produce ischemic pain.
3. Some drusrs:
-Disease associated > HTN , DM.
N . B. some antihyp ertensiv es p ar ti culxly B B rnay exacerb ate
claudication.
- Raised blood lipids: statins.
- Anti-platel.et agents: aspiiry Trental@.
-Vasodilators as CCBs.
B. Endovascular sutseryi-
t Percutaneous Trans[uminal Angi oplasty (success rate 95o/o)
* lndications (as endarterectomv)
- Short segment affection in a big vessel.
- Noc donein occlusion below kneelevel.
* Complications;
- kecurrence. - A-V fistu[a.
- Hemacoma.
z. Lntraluminal Stent: (after ba[[on angiopl,asty)
C. Surgical teatment
(Surgery in this case aitns in saving the limb and thus called limb salvage surgery)
lndications of sur$erv /:[ate ischemia)
= r. Scarting gangrene (co avoid spread of gangrene).
z. Pregangtene.
3. Severeclaudication pain interferingwich patient/s work (differs
according to each patient).
4. Ulcers resistant for healing.
212
Patients with distal run off Patients without distal run off
Direct arterial surgery
Endarterectomy
(Short segment affection in big vessel)
Sympathectomy Amputation Intravenous or

(no O in blood supply but Indications: intraarterial
redistribution of blood) . Spreading or massive gangrene PG may be
. Spreading infection. useful.
. Severe uncontrollable pain (patient
himself asks for amputation)
Q. Comment on dhect arterial surgeryl

A:
T
r. Resc pain is an absolute indication.

z. CLaudication pain is arelative indication (if incapacitating the
patient).
3. lschaemic ulceration that does not respond to conservativemeasutes.
4. I{apid deterioration of an aheady ischaemic [imb.
Types:
r. Atteial bypassgrafting.
o Types of materiaLs used,in arterialbypass grafting may bei
o S)unthetic: not suitabLe for the peripheral usebecause the smaller caliber
of these grafts tend to thrombose easily.
o Natqra[:
) Dacron (woven or knitted).
) Cortex made of polytetafluroethyLene (PTFE).
) Saphenous sraft (in situ or reversed).
) lnternal mammary artery.
) Umbilicalvein.
) Banked arteial $raft.
z. Thrombo-endartercctotny (not done now).
?. Ancioo[asw
-- UsTnsi intgrventionalradiolosy, ba[loon transluminal dilatation of a stenotic
lesioriis done.
A be split after this bal[oon dilatatiop.
R" .applied. [t is indic atedin thevery localized (sinsLel
les lesions.
2t3
Q. Comment on sympathectomy in chronic athercsclerotic timb ischemia?

A:
I
f therc is no distal run off (nor e for surgery) and therc are srnal ulcers
or mi[d rest pain.
z. )any surgeons combine syrnpathectorny with dhect arterial sursery.
4. V aso sp asti c di sor der s as Rayna u d' s di sease.
. l.Contraindications in chronic atherosc\erotic
After amputation to help heaLing of the flaps.
[imb ischemia:
r. Lntermittent claudicacions (worsens the musc[e ischaemia) .
z. Cangrene (ineffective).
3. Diabetic p atient (peipher aI neurop athy) .
The tvpes of svmpachectomv
P ar av er tebr al. symp atheti c b loc k:
Ternporary lz-l daysl if ro/" lignocaine is used.
Perrnanent if 5 %o of pheno[ in water is used removing znd and 3rd lurnbar ganglia.
By doing thereflexvasodilatacion test (describe) or by doing ternporary

syrnp ath ectomy (P ar av ercebr aI syrnp atheti c b o c k by t%" i gno cai ne ) .
I I
Lf the [imb becorneswarm andrcd, this means that thercwas some arterial
sp asm and the p ati ent w o uld b enefit from sym p athectortl;y .
Q. l4zh+t.arg the ipdications of amputation in chronic atherosclerotic

limb ischemia?
A:
There are two types of amputation to be done in chronic [imb ischaernia:
r. Conservative amputacion:
. Lf the b[ood supply to che area adjacent to the anea of gangrene is good or
can be improved, aline of dernarcation appears and separation occurs. ln
these cases/ cor'servative amputation canbe done by eithu excision of a
toe at the line of separation or mid tarsa[ or trans tnetatansa[ ampucation
is done if gangrene affects the forefoot.
2. Ursrent Hilrh amputation :
Be[ow knee or above knee depending on whether the popliteal pulse is felt 01 not.
This is indicatedin
. Spreading gangrene endangering thepatient's Life.
. Ll ncon tr ollable infecti on and toxaerni a endang ering the p atient' s lif e.
. Severe pain deteriorating the general condition of the patient.
a. Comment on gangrer,e?
A:
. Definition: Lcis death andputrefaction of tissues.
. The causes of qantrrene
r. lschemic : Acute and chronic ischemia
2-. Traumatic:
. Dir,ect lbedsoresl pressute sores/ and crushes)
o Lndir.ect (arteial injuries)
3. Physicochemical iniuries: Burns, caustics and frost bite
4. \europathic: Syringomyelia and leprosy
5. Venous sangrene
2t
ry (occurs in chronic [imb ischemia).

Moist aseptic:occu/s in chronic [imb ischemia on top of an edematous [imb
Moist septic: occurs in chronic limb ischemia on top of secondary infection.
inal si
r. Lost function.
z. Lost sensation.
3. Lost pulsations.
4. Lost capiL[ary circulation.
5. Lostheat.
6. Changed colow.
The gangrenous partpasse.s through avariety of shades, pallor, dusky Srafr
mottl,ed/ purple, uncil it finafiy becomes black, greer,/ or brown.
Q. What ane the cardinal signs of acute ischaemia?

A
. P ar aly si s l p ain, p alLor, P ul.s el.e s sr.ess / P ar aesthes i a and co I dness
to differentiatebetween acute embolic ar'd acute thrombotic

*#;*
A.
EMBOLlC THROMBOTIC
History Cardiac troubles lntermi tce nt clau di cati on
Commonest Bifurcation of common femora[ Lower end of femoral

site
Source of Ptesent Absent
emboli
Loss of Within 4-6 hows e.g. patient lJoesn't occut within hours as
unable to move toes collaterals have had time to be
function established
Angiography Cornplete abrupt occ[usion of the artery with no run off
(if in doubt)
No collaterals 5ome collatetals
M^y be crescentic Not crescentic
Artery above is norma[ Artery above shows atherosclerosis
Q. What is atherosclerosis?
A:
t ft degenerative disease due to aging affecting the whole arteria| systetr'
. lrc pathological,process is the atheromal which is a subintima[ col[ection of a
Iipoid plaque causing elevation and ulceration of the overlying endothelium.
. [t affects Large and medium sized anteries.
2t5
Q. Whatis cruciate anastomosis?

^. Cross-shaped anastmosis lies on che uppr.r parc of rhe back
gluteal. arteies.
the first perforator
al ci cumflex f emot al ar teri es.
B[ood reaches the lowq [imb in case of occlusion of external iliac or femoral
artery through this anascomosis.
Q. What is yout diagnosis?

L
Chronic [imb ischaemia of boch Iowq [imbs and both uppq [imbs.
*, doyou diagnose chronic [imb ischernia in this case?
R
Becausethere arethe symptomsSl, signs of chronic ischemia as fo[[ow:
Svmptoms
. Claudication pain ([t is a cramp-[ike pain in the muscles that appears on
exercise and disappears on rest).
. Rest pain (lt is a sevete burning pain in thetoes and dorsum of the foot due to
r,ele ischemia).
5isrns
. Color changes.
. Trophic changes(hair [oss which is the fhsttrophic change to appeat
atrophic dry scaly skin with fisswedtoenails, ischemic trophic ulcers, thin
tapeingtoes -due to [oss of subcutaneous fat- taeniapedis, paronychiq dry
gangtene).
.
Coldness and lost dista[pu[ses.
Q. What is the etiology of ischemia in this case?
A.
Most probablyl itis due to arteritis.
a. What arc the causes of atteitis?
A.
r. Bur s di sease ( thromboangi tis obli t er ans) .
ger'
z. Takayassu's disease (pulseless disease of femalesl.
3 . Co [ [agen di seases; sy stemi c lup u s 1 scler o derma, rheumatoi d.
4. Poly afteitis nodosa.
5. Endareritis obliterans: aftu radiotherapy and in syphilis.
6. Temporal arteitis.
7. Lnfective arteritis.
8. Ciant cell arteritis.
9. Other cau ses: Eh[er-Dan [os7 H enoch-S chon liery Behcet' s di sease.
2t6
Q. Why didyou diagnose it atteritisl

A.
/'rrcrids Athercsclercsis
Age of thepatient UsuaLly young UsuaLIy elderLy
(zo-5o years) (> so years)
Usually boch [ower and Lowet lrmbs
Limbs affected (v.ry rareLy it affects upper
both upper limbs
limbs)
Site of arter.ial Usua[lv disca[ occlusion Usuailyproxima[ occIusion
(popliceal pulse fell (popliteal pulse not felt)
occIusion
Manifestations of Absent Muy be pteser't (ischemic

tisceral ischaemia heant, cerebral renal and
intestinal ischemia)
Manifestations of May 6e present

(systemic lupus, Absent
collagen diseases s cler o derma, rheum atoi d)
Athercsclerosis risk Absent N\ay be present

( di ab ece s, hy p er ten si on 1
factors obesicy)
Q. 14/hat investigations do you ask for in this case1,

A.
Besides the routine investigations (la\oratory investigations and ECC ),, we ask
for investigations to detect the aetiolosy of this arteritis:
e.g. rheumaroid factor for rheumatoid arthritis and antinucfear antibodies for
systernic lupusl skin biopsy for scLeroderma.
z. NteriaLbiopsv
Biopsy is not taken from the main artery but from a sma[[ peripheral arteriole
asby a skin biopsy.
(Angiographyl Dopplel 8L Duplex are not indicated as the disease is usua[[y a distal
occlusion)
Q. What is the treatment of this case?.

A.
r. Treatment of the primary cause of ateitis.
2-. Corrsentativemeasures for the ischaemic [imb.
' lmprovins the Senera[health:
Cood diet, good sleep.
Correct anemia.
Contro[ any associated disease.
2t7
. Prorcction olthe ischemic [imb:

- Carefully washed, dried andpowdered.
Nails and corns ate cut cautiously.
lnfections aretreatedptoperly. -Lefthoizontal.
Left exposed. - Cangrenous areas arekept dry.
. Painrclief.
Lxercise for a period < inducir, ,rtr., trental prostavasiry 8tr- aspirin.
! _ 3- l:t"'
lSease"
Stop smoking. - Weightreduccion.
- Proper contro[ of diabetes Prcper contro[ of any associated disease.
3. Sympathectomy may bebeneficial in some cases.
+. Consewative amputation of gangrenous toes and fingers.
a. Comment on Burgerts diseasel
A.
" This is an occlu sive disease of sma[[ arteries (dbialst planters, radial,)of unknown
caLtse/ occurring in smoker young adultrnales.
' Pathologicallyl thewholeneurovascu[ar bund[e is inf[arned (panvascu[itis and
neuritis) with occ[usion of the affected arteies.
. The disease is patchy in distribution and episodic in its course.
. The disease does not affectfernales and does not affectnon-smokers.
. [t is ueatedby;
r. Smokin$ must be stopped.
z. Srzmpathectomv: Cives good resu[ts.
3. Amputacion:
. Cangr ene usualLy invo[ves toes or fingers so that a conservative amputation will be
enough (e.g. amputation of a toe, trans metatarsal amputati on if severaL toes are
affected buc a [ong planter flap is required).
. Lf the foot is involvedl6e\ow knee amputation is indicated.
Q. Enum et ate vasospa stic di seasesl
A.
r. Raynaud's disease. z. Acrocyanosis. 3.Erythrocyanosis.
4. Erythromya[gia. 5.Sudek's atrophy.
Q. Whatis Allen's test?

A.
. [t is used to determine dominant b[ood supply of the hand either radial or ulnar artery.
r Ask the pacient to close his hand firmly andpress upon both radial Sf ulnar arteries
to occlude chem. Ask the patient to open his hand andrelieves the pressure on one
artery and observ e the r ate of the normal color of the handl t epeat the test with
pt essure relieved from other artery.
Browse's introduction to the symptoms & signs of surgicul disease/ Ch7 the arteries/ P192-196
218
Other Oral Qs
Q.causes f chronic leg ulcersl
A.
I. Chronic traumatic ulcer eg- wounds, burns , iradiationsl bed sotes .
z- lnflammatory ulcers: - chronic osteomylitic
-chronic specific uLcer (rare): TBfir actinomycosis
3- Neop[astic ulcerc: t ry skin tumor cell carcinoma
-1>Squmaous
l+AAa[iSnanc me[anoma
) Malign ant ulcer on top of chronic begnin uLcer
) U Lcerating deep rnalignancy as osteos atcorna 1 fibro
sarcoma
4- Vascular ulcer: - lschemic
- Venous
- Lymphederna
s- f.Jeouropathic ulcets: eg diabetic foot ulcer
6- Blood disease: sickle ceLl crisis
7' A.L disease:iLE, Rh. arthritis
Browse's introduction to the symptoms & signs of surgical disease/ Ch7 lhe afiertes/ P186
Q. Caus es of ischemic ulcetationsT.

A.
. lange artery obliterationl. - Athercosclerosis
- Embolism
o Sma[[ arterv obliteration: - Scleroderrna
Burger's
- Embolism
- Diabetes
-Trauma
219
VAIBICOSD ITBINTI
SHIIBT
Histor
Personal H:
Address, Residence, Occupation, & if )
menstrual history.
- Age )
lry W. more bet 20-40 years.
- Sex )
1ry W. more in females.
- Occupation )
Prolonged standing.
)
- Marital state W occur commonly with pregnancy.
O_Omplaint:_ d.i3.,,.11 dl+t+ cJl q! rtrr.J.ll Erti
- Pain, Disfigurement Or complications + duration.
HPI: ei.l frtL,''':< 6-.F-;Af
. Analysis of the condition in a chronological manner: its
oNsETi coARsE AND DURAT|ON.
1. lf the patient mentioned that he observed these veins in his lower limb,
stress on the following.
- Where is the initial site if their appearance on his limbs, proximal
or distal, unilateral or bilateral and any observed veins on the
abdominal wall, on the genitalia or the buttoks?
- ls there any history of previous direct trauma?
2. lf there is a history of pain in the limb, try to conclude the following
characters:
- lf it is a localized aching type of pain in the calf region, initiated by prolonged
standing for many hours and partially improve by walking, while completely
relieved y lying flat, especially with elevation of the lower linnb. (this is
usually seen in cases of primary v.v.).
- While, if the pain is severe and expressed by the patient as a sense of
bursting type of pain at the calf region or throbbing pain at the ankle region.
This pain usually initiated by standing for a short time and worsen on
walking, and usually accompanied with considerable edema, while lying flat
for sometime, usually relieves it (this is seen in patient with 2ry post
phlebitis v.v.).
- From the analysis of the pain characters and the varicose distribution, you
can reach to which type of varicosities you face, even in silent cases of
DVT. But your data could be confirmed if you ask and find a positive history
of DVT or any predisposing factors preceding that history as:
i. Ask about previous history of acute massive swollen painful limb
(DVr).
221
ii. Ask about previous history that necessitate prolonged

immobilization as in fever, gastroenteritis, fracture, operation...etc.
iii. ln females, ask about any congenitar troubres as well as
contraceptive pills "increases the coagulability of blood", or loops
"ascending endometritis and parametritis".
iv. Ask about any associated flat foot, varicocele, hernia and
piles. The presence of any of them may be a part of congenital
weak mesenchymal defect aharacteristic for 1ry v.v.
Past_hislory_l
. History suggestive of congenital mesenchymal weakness
(varicocele, piles, flat foot or hernias). Predisposing
. History of pelvic or abdominal swelling factors
of
. History of trauma (A-V fistula). DVT
. Contraceptive pills, abortion, puerperal sepsis.
. Similar conditions or recurrence.
. Common diseases: (DM, Hypertension, TB, B, Hepatitis,
DVT).
. Blood transfusion.
. Past history of previous operation (pelvic or complicated).
Farnilv historu:
. Similar condition in one of the members of the family (may be positive in
1ry V.V)
. Consanguinity.
Browse's introduction to the symptoms & signs of surgical disease/ Ch7 the veins/ P20
Examination
General: Pt. is alert, conscious, oriented to
time, place, & persons, average
. Body built. built, quiet facial expression,
. Decubitus. I| {FL-t
normal decu bitu s, average
. Facial expressions, ) 3
. Complexion )
(3 colors) Jaundice, pallor & cyanosis.
. Chest & heart (A-V fistula HF).)
Abdomen:
o Visceroptosis, masses, scars of operations.
o Dilated veins crossing the groin.
o Abdominal hernias.
a Back: kyphosis.
! Scrotum: varicocele.
I P / R: piles.
! Extremities.
I Pulse: water-hammer pulse & Branham's sign (in A-V fistula)
I Blood pressure: hyperdynamic circulation (in A-V fistula)
r Temperature.
Head, Neck, Spine > 3 d#E
LoCaI: 4lr+&,
I'IIII"III!III!'I
i6 jOl;,Jl ,+ C-, 5\
-P e ./ 1..1 r
'a, r-\'i
Exp-o-sure ) from Umbilicus downward ) to erpd#'t'iG6toln.
Why: to inspect upper 3 tributaries of saphenous vein crossing

)inguinal ligament ) superficial circumflex iliac, superficial epigastric,
Superficial external pudendal.
(lf 2ry v.v. & obstructed femoral vein above the sapheno-femora ljunction)
Sopedicial circumflex
iliac v.
e*mal
223
a. Both L.L. are symmetrical (because of congenital arterio-venous

fistula causes local gigantism).
b. There is localized swelling:
1. Blow out.
2. Dilated vein:
) )
Medial side of thigh long
saphenous.
) )
Lateral side of thigh short
saphenous.
) Describe shape of varicosities:
o Mild tubular varicosities.
o Tubular.
o Serpentine.
o Saccular "blow out".
) The saccular type is usually seen:
o At the saphenofemoraljunction denoting
saphenofemoral incompetence (saphena varex).
o Opposite incompetent perforators above and
below the knee.
) Observe the region of the ankle for any brownish
pigmentation, eczema or ulcer "describe it".
) Observe the foot for any flat foot or local gigantism.
) Observe the circumference of the Iimb for edema
(usually massive in postphlebitic limb).
Overlying skin normal ) no:
- UIcer. - Scar.
- Pigmentation. - Edema.
224
Z-----Pa-lp-ati-on:''''oit ctS Cr
I . l{*}h**g....-ts.s.9,
Of the veins crossing the groin to detect the direction of filling.
\t,f
V
-i:iil*- < -'i

Directlon of filllng
2. TIr..f*.I*.:. clt -sll "J' d

Put your hand on sapheno-femoral junction:
a)Thrill on coughing )
incompetent valve.
b) Machinery thrill over pulsating surelling ) A-V fistula.
:1. T.h.* s. mF- eP h+ sh* f'.*.e.. ;. Thrill
Hot, tender, cord like.
4. HSSe..p....p*#1..1. (defect in deep fascia at the site of blow out)

Mark the site of blow out Deep rascia
while patient standing, then sup. vten
palpate at the mark while
patient lies down.
lf palpable fascial defect )
site of incompetent
perforator.
225
pitting or non-pitting
({i';+s{seJl.+)
7 . P.r.e***p..9....+mph...*g$s.p..i.
No examlnation of a swelllng ls complete wlthout examination of dralning I..Ns
3 -= - -pe-r-c-ussjon:- - -( I-a Bp-ing )- I
(SchwarEz & Chervier)
1- Schwartz test:
- lf you percuss the upper end of distended vein and an impulse
is received at its lower end ) incompetent valves in-between.
2- Chervier tesf.'
- lf you percuss the lower end of distended vein and an impulse
is received at its upper end ) the dilated vein belongs to:
) Lono saphenous (if you percuss on medjal aspeot).
) Shor"t saphenous (if you perouss on lateral aspect),
226
ah
1.'
b\
J
Schwa
4- Auscultation: continuous machinery murmur over A-V fistula.
5--- - -Sp-eeia L - te-sl:
E-:-fs--d--e-t_e-e-t_-si!_e_s__s_f _i-n-s-e-m12s-!en!_p_er_t_o_r_e_t_e_r:
k T r.e r,.flJ S-
pu
-u...f 9.... Ie.p. _t .; .
- Pt. lies down.
- Empty the full veins.
- Tourniquet below the saphenous opening.
- Stand up.
- If no filling ) then filling occurs on release of tourniquet )
incompetent sapheno-femoral junction.
- lf filling occurs and increases after release of tourniquet )
Incompetent sapheno-femoral & incompetent perforator below.
227
-3-
U/uu<* l*;;
<..s/r/r
Empty the v. v. while pt. is lying down
- Pt. is standing
- Reflliing of the v,v. after
removing of the tourniquet
Apply tourniquet below saphenous opening
?. ; tts.I I*p I 9.... F. ep.r.+. *.silr...e H. ;

- Pt lies down.
- Empty the full veins.
- Three tourniquet are applied:
a) Below saphenous opening.
b) 10 cm above the knee.
c) Just below the knee.
- Stand up.
- Any vein fills rapidly under any tourniquet) i ncom petent perforators
Lf/abdl
-_o.-o
<,,o/t,/r
Empty the v. v. while pt. is lying down
r
?
3
"""
- Manua
""
1 Lo ca]. i (.99e.; f.**g.e f....S:p.g. P. ). j.
r Wri i ii;' ffi t6lii' ffi ffi ailU;' i;ffiffi t#tes ;y6;ffi r ili; v;in a n d
=.?H..*.9.I1.....
notice filling. lf filling occurs inspite of pressure by fingers )
underlying incompetent perforator
E=_Ie-C-e-te-S-t-1l-a_t-e-E-c-y-_o-_f_-d--e-_ep_S-y-=!-em-=.
1- Modified Perth' s test : (,gp-j..99.9-i..y..9)
- t6r.;i:;iq ffii';;;,.;ilci'iiG' ttiiiili' iliiiiii'Hi' i; starioiriU
- Ask him to do exercise 5-10 min.
- lf veins disappear )
patent deep system.
- lf veins increased & pain appears )
2ry case with obstructed
deep system.
il
dl
>I
:
229
2- Perth' p....f,S.-s-F:. (subjective)

- EH;1il'iiinOag" is apptied fromioes to upper 1t3 ofthigh and
patient is asked to do excersie for 5 minutes.
- lf patient feels pain )
occluded deep system
3 -
. IIe.f -r..rTlp.rL.:..e....Hs.e.H'..'.
ln patients having incompetent perforators, modified Perth's test
shows that venous engorgement remains indifferent after exercise.
Browse's introduction to the symptoms & signs of surgical disease/ Ch7 the veins/PL97-200
Special investigations
Laboratory i nvestigation :
Rad io log ical i nvesti gati on s :
Doppler & Duplex US.
Plain X- ray.
A n g i og ra ph i c i nvesti g ati on :
Venography.
Provisional dia osis

1. Etiological ) 1ry or 2ry.
2. Anatomical ) Short or long system + which perforators are incompetent.
3. Complications.
4. Associated condition > DVT, T.B., diabetes, chronic bronchitis....etc.
230
How could you differentiate between venous edema and filarial

Iymphoedema
Venous ederna Filarial

Acute phase : Acute phase :
. Sudden severe painful swollen . Only in the filarial type
limb. . Recurrent attacks of general
. Tense tender calf muscles. constitutional man ifestations.
. Positive Homan's sign. . Diffuse swollen red painful limb.
Chronic phase : Chronic phase :

. Pain is severe on standing. . No pain, just heaviness.
" Oedema does not preserve the . Oedema preserve the ankle
ankle crease. crease.
. The skin is thin, stretched, and The skin is thick, hyperkeratotic,
easily ulcerate. warty, and does not ulcerate.
. Accompanied with pigmentation, No pigmentation, eczema or
eczema and ulceration around the ulceration around the ankle.
ankle.
No associated varicose veins.
. Secondary varicose veins are Early it is pitting but later
common association. becomes non pitting.
. Oedema always pitting.
lnvestigation : lnvestigation :
A,cutephase; Acutephase:
. Radioactive labeled. . Mid night blood film.
. Fibrinogen scanning. . Shows the microfilaria.
Chronic phase: Chronic phase:
. Venography. . Lymphangiography.
Treatment: Treatment:
. Essentially conservative. . Early, conservative.
. Surgery.
23r
Q. What is your diagnosis 7

A.
rry varicoseveins affecting the [ong saphenous vein with incompetent
complicatedby
Q. How you reach this diagnosis?

A.
- The typeof patient:- patient around 30years works as .................wirh

prolonged standing.
- - Pain: is mjld compared to the marked pain that occurs in zry varicose
veins.
- Swelling: Evening ankle oedetnawhich resoLve after night
sleep ...... comp ared to persistent diffuse leg oederna that
is not rcLieved by night sLeep in zry varicoseveins.
- Disturbance of function: Skin complications are ofcen
pteserrtin zry varicoseveins and ane extremely rarein try
varicose veins.
- No past history/ suggestive of deep vein thrombosis or prolonged
recurnbence or fever (in zry varicose veins, this history tr,ay 6e *ve)
Therc are signs suggestive of generalized elastic tissue deficiency e.g.

ky pho si s, vi s c er op to si s, f at f o o t, v ar i co co el.e,, pi\e s, herni a, etc.
I
\o pe[vic or abdominal swelLing that rnay be a cause of zry varicose veins.

Distribution
o Usually bif,ateral
o \ever cross the groin
. Affects saphenous veins
Pattern
. Mainly tubular varicosities
Ederna
. Minim al ankle ederna
Skin complications
o Very rare.
232
Q. ln which cases Veins crossing the groin ptesent

A.
. [n case ofiliofemoralDVT.
Q. Mention the differcnt types of pain thatmay occut in a case of varicose
veins?.
A.
DuLl ache or heaviness: this is the usua[ typq occurs in the [e.-g and foot
assra\/ated by [ong sanding and sitting and relievedby elevation of the foot.
I Burning pain: in superficia[ thrombophlebitis.
! Thro b bing pain: late in sup erfici a[ thrombophlebi ti s.
I Bursting pain: in DVT.
Q. What ate the comp[ications of varicoseveinsl

A.
. Skin comp[ications ane often ptesent it zry varicose veins and are extrerneLy
rare in rry varicose veins.
I These arevein comp[ications and skin comp[ications:
O Yein c
ophlebiti.s.
j-
' - rombosed veins (phtebolith).

5kin complications:
- Pigmentation.
- Dermatitis8-gczerna.
- U Lceration (venous ulcer)
- Malign ar'cy
- TaLipes equines
Q. what is meant by talipes eguines?
A. af,:t ,-.,. US
Q. Whereis thecommonest sitefor theseskin complications &why?.

A.
. Skin comp[ications occut most commonly inLower t/l of theLeg above the
rnedial mal[eolus.
I This area called C aitre' s area.
! The complications commonly oce.fisinthis area Becauseitisvery rich in
perforator veins which drain the skin directLy to the deep veins of the l,eg
(rnedial ank[e perforators) and it is che most dependantpaft.
233
a .Whatis the pathogenesis of theseskin complicacions?

A.
lncompetence of themedial ank[e perforators )venou shypertension in the
superficialveins above the media[malleolus ) rupture of some venu[es )
r) Extravasacion of haernosedrin granu[es ) Pigmentation and irriration
which \eads to dermatitisl
z) Lxtravasation of fibrinogen ) converted to fibrin) fibrosis ) tissue
anoxia and decreasedvitality ) ulceration after minor tTauma.
3) Due to ! venous ptessure ) capil[ary dilatation ) RBCs get ouc in the
S.C f at
)phagocyted ) hemosedrin in 5C tissue )pigmentation 8l- irritation
) eczetna.
Q. How canyou diagnosevenous ulcerl

A.
. From its characters especially its site (Caitre/s area)and pigmentation at its margin.
' ltmay presettwichout varicosevein in 5oo/o of cases.
Q. What are the comp[ications of venou s ulcer?.
A.
t- lnfectin.
z- Hemorrhage.
3- Marjoline ulcer (malignant transformation).
4- P eri o sti ti s Stosteomyli ti s.
5- Talipes equinus.
Q. What is the significance of pulsating varicoseveirrsT.

A.
These an e v ani cosi ti es secondary to an teri oveno u s fi s tu [a.
Q. Whattypes of arteriovenous fistu[as do you know?

A.
l.Congenital: -
r. Localized.
2-. Diffuse.
. This congenitaL typ. is characterizedby Local gigancism (l(lipple trenaury
syndrorle) and portwine stain.
lL. Acquhed:-
r. Trastnatic (6utchu's thigh).
2. Artificial.
234
Q. What is the significan ce of a swelling in the femoral tiangle in a case

of V.V?
A.
This sweLLrngmay 6e:
. SaphinavNix.
. Atteio-venous ar.eurysrn.
. Lymph adenitis secondary to venous uLcer.
' Ui ofem or aL DVT .
.
Any other swelLingleadingto zry varicoseveinsby compre.ssion of femoralv.
Q. what is saphinavarix?.
A.
[t is a sacculan di[atation of upper end of Sreat saphenou s vein opposice
incompetent saphenofemora[ valve. [t is a bluish rounded or ovoid
subcutaneous mass in upper part of femora[ triangle, soft, cystic, cornpressiblel
with expansile impulse and thri[[ on cough.
Q. Comment on blow out?
A.
. Definition DiLated superficialvein in front of incompetentperforator.
. Clinical prcture
r. Presence of saccular varicosicies at the anatomica[ sites of perforator veins.
2. Presence of defects in che deep fascia at the anatomical sites of perforator
veins.
. C[inicaL tests:
a. TrcndLenbwg test.
b. Mu[dp[e tourniq uet test.
c. Manua[ localization of blow oucs.
. lnvestisrations: Venography, DoppLer ultrasound and Duplex scanning.
Q. What is the significance of thevein crossing the shin of tibia in case of
varicoseveinsT.
A.
. This vein represents a communication between the long and short saphenous
veins.
. Since itlies over the shin of tibia, itis liabLe to trauma leading to its ruptute
which nay Lead to sevete hemorrhage.
Q. Hor^, can you detect incompe terrt v alves?.
A.
" By Schwartz's test in which varicose veins are petcussed by index finger of one
hand andpalpated distally by-fing,erc of othq hand.
. lf the valves of the superficialveins are incompetent/ awave is transrnitted
distalLy.
235
Q. How caflyou detectpatent deep systernr,1-

A.
. By doing the modif iedPerthes' test ..... (Desuibe)
Q. Whatinvestigations do you ask for in this caseSt what are the values of
these investigations?
A.
' Dopp[er ultrasound and Duplex scanning, Venography.
. Thevalues of these invescigations:
r. They demonstrateif the deep systemis patent or occl,uded.
z. They demonstr ate the presence of incomp etent perforators.
3. They differentiatebetween rry and zry varicoseveins.
Q. How venography is done 8t how can differentiatebetwe,et rry and zry
varicoseveins?
A. (obsoletenowadays)
t fr tourniquetis appLied around the ankle to occlude the superficial.veins and the
conffast medium (hypaque) is injected into one of theveins on the dorsum of
the foot.
. Descending venoSraphy and transosseous venogtaphy ane other toutes fot
venogtaptty.
, [t differentiates between rry and zry varicose veins as fo[[ow:
Ln rryV.V:
Deep veins appear patent/ wide, with di[atations opposite theh valves.
lnzry V. V:
a) Before canalization, deep veins are occluded and not seen but there ane
tortuo u s ir egular collater aLs.
b) Aftq canalizatiory deep veins appear as thin lines with no evidence of
valves.
Q. What are the diffuent lines of treacrnent of varicoseveins?
A. Varicose Vein
Treatment
Trendelenburg's
operation
Q. Comment on conselative teatmentT

A.
I
r. Mitd cases &earLy uncomplicatedcases.

z. Casesrefusing sursery or unfir for surgery.
j. Cases with occluded deepveins (zry V.Vsl.
4. Preoperatively and postoperatively in cases doing sur1ery.
' Methods:
r. Reassurance.
2. Remova[ of any predisposing faccors (Avoid prolonged standing or sitcing).
3. Be\ow knee or above knee elastic stocking.
4. Leg elevation during s[eep.
S. Drugs: veno-tonics that support thevein wa[[ e.g. Daflon, vitaminsSt
antioxidants.
Q. Comment on injection sclercthqapy?
A.
. [t is indicatedin:
r. Mitd varicosities cosmetically disressing the patient.
z. Residual varicositi es after operation.
. The pfir'ciple
Occ[usion of theveinby fibrosis not by thrombosis. The sc[erosantrnaterialis
injected into the ernpty vein so that the waLI adheres to wal,r without an intervening
clot or thrombosis which wiLl certainly recanaLise.
. Themateials used:
r. Ethano[amine oleate 5o/o.
2-. Sodium tetradecyf suLphate j%".
3. Sodium morrhuate 5o/o.
. The comp[ications
r. Syncope due to drug sensitivity.
z. Extravasation leading to s[oughing 8[ necrosis of the overlying skin.
3. DVT (tnuy occur if large amount of scleros ar,trnateria|reaches the deep
systent undiluted.
. Thecontraindications:
r- Septic thrombophlebiti s, S econdary V .V .
z- Avoid injection of long Saphenou s itself .

Q. How to avoid comp[ications of injection sc[erothenpy?
A.
dbv:
venous.
ettinq.
eliadleto sec DVT).
i\ute the rnaterial.
237
Q. What ate the indicationsSt the consaindications for surgery in varicor,e

veins?
A.
. The indications:
t. Presence of complications.
z.Large rry V .V s.
3. lncomp etent saphenof em or al, j uncti on 8[ lncompet ent p erf orarols.
. Tlpcontraindications:
r. Thrombophlebitis for threernonths after cure.
z. Secondary varicose veins after D1/T.
3.Pregaancy:
During presnancy/ conservative treatment is done. After de[ivery1the
varicositi es usualLy disappear. Residua[ varicosities canbe treatedby
continuation of conservativemeasutes or by injection sclerotherapy if they
cosmeticaLly distess the pacient
+.Pelvic tumors.
Q. What ate the types of operations to be done in varico se veins?

A.
l.t depends on the casel
t-
. Largevaricosity of the Sreat saphenou s vein )stripping of the Steat
saphenou svein.
iunction ) Trcndlenburg operation in which che fo[lowing veins are

ligated: SuperficiaL external pudendal veiry superficial circumflex iLiac veinl
supefiicial epigastricveinl anterolateralvein of the thigh and posteromedial
vein of the thigh.
lBlowouts) ) Subfascial [igation of the perforators ltripLe ligation).
[- Short saphenous svstem affection:

. Largevaricosity of the short saphenou s vein ) stripping of the short
saphenous vein.
. Mi [d varicosity of the short saphenou s vein * lncomp etent perforators
(Blowouts) ) Subfascial [igation.
Ir-
Largevaricosity ) subcutaneous stripping or punch excision.
238
Q. What is flat foot and how can you examine itl

A.
' Flat foot is [oss of arch of the foot.
. Types:
i. /AesenclT mal: due to weak mesenchyme.
ii. Paralytic: due to paralysis of muscles acting on the foot.
iii. Ossou s: due to dislocation of the foot bones.
N.g. Newborn and young infants have flat foot due to undevelopedrnuscle
tone and movement.
Exa-mjne the p-acienc while scanding and
comment on the arches, the stage of _the _musi[es of the legs and fodt, the gait
,rO any stiffness of the ioint related to foot.
. Confirm your diagnosis by doing foot print.
Q. What is ha[[uxvalgusl
A.
HaLlux valgus is l,ateral deviation of the axis of big toe due to sublaxation of r"
rnetatatsophalengea[ joint secondary to weak rnesenchyme. [t comp[icates by
developrnent of advirtitious bursa which if inflxned it will be terrned "Bunion" .
Browse's introduction to the symptoms & signs of surgical disease/ Ch7 the veins/P198-206
239
Q. 14/ha t is your diagnosisl

A.
zry varicoseveins of the lefc Uig;ht) le9,.
Q. How you reach this diagnosis?
A.
o From History;
A.There is a pasthistory suggestive of deep vein thrombosis after prolonged
tecurnbence.
B.
-Pain: is marked ............cornpared to the mi[d pain thac
occuts in rry varicoseveins.
- Swelling: Persistent diffus e leg oedema that is not relieved
by night sleep ........comp ared to Evening ankle oederna.
which resolves after night sleep in Lry vanicoseveins.
- Disturbance of function: 5kin complicacions are often
preser.tin zry varicoseveins and are extrernely rarein rry
vaticose veins.
o From Ceneral Examinationl
r. rThere are no signs suggestive of generalized elastic tissue deficiency
e.g. kypho sisl visceroptosis, flat foot, varicocoelel piles,, hernial etc.
)-. Water hummer pulse,,heartfailure (A-V fistul,e).
3. Scar of injury,, bullet or stab wound in upper thigh rir,ay be present (A-
V fistula).
4. OrganomegaLy or pelvic mass may bepresent.
. From Loca[ Examinacion;
. Disribution
- May
Usua[[v unilateral
cioss thegroin
- Affd,cts
- any veln or venule
. Pattern
- Main[y serperrttr.e and spider
' Ederna
- Marked diffuse leg oedem
. 5kin complications
- Often present
Q. What is venous Claudication?
A.
. After DVT, withrecanalization of iliofemoralvein durins walking arteial
inf[ow exceLds the capaci,.y ven6us 6ucflow,,and because pain i5 associated
with exercise andreli "frest so it is iaLled claudication.
Therest of questions 81- answets are similar to those of rry varicose veins.
240
AIIIX}MIIIt[
SHIIIIT
His tor
P_e_rs_on_a_L_H:.
Address, Residence, Occupation, & if ? ) menstrual history.
-._C..al_c..Ula.f..9h9lgg.qt!y..e..J.a.qndi.c..e:Middleagedf emales.
- M a.lign a.n t .p. h sLr.u.stj.v.e. ja.v. n.d p..e ; o d m a e s
i
I I .
- .Q.iffh.eSjs.l usually in adults.

)
- .Spp..eiaL.h.ap. j.tS Al coholism n ci rrhosis.
)
i
- R.es.i.denc..e
- .9.gp..Upa!.[en ) Farmer.
- Me.n.s..tf.Ua.l.if.f-e.S.U.lafily > in liver cell failure
)
- _Cqnt!'.a_c..ep..t!y.e. pills may cause
1. Cirrhosis
2. Portal vein thrombosis
3. Budd-Chiari syndrome
e-qmplaintl L'i-l3s.ll dL,.l+1,Jl q! rf.-rll .Eil+ + Duration
HPI: CriS 6..;.0
'.;rl
ei.l f,J-,
1 . Pain:
Sit;;"Cffiiicter, Radiation, relation to meals, What increase or
decrease, Onset, Course, Duration, Periodicity, and What
associates.
a) Site
- GU )Middle line in the epigastrium.
)
- DU to the right of the middle line in epigastrium.
- GB )right hypochondrium.
- Appendix )around the umbilicus.
- Colon )right & left iliac fossa & below the umbilicus.
b) Character.
- Obstruction (bowel or ureter) )
colicky pain.
- Burnirlg ) reflux or PU.

- Stappino ) PU.
- Stitchinq ) Perisplenitis.
c) Radiation
- GB ) inferior angle of right scapula.
- Pancreas ) back.
- Ureteric colic ) external genitalia & upper part of the thigh
242
d) Relation to meals
- GB ) Fatty meals ) f pain.
- GU ) pain after meal by Tzhr.
- DU ) pain after meal by 2hr.
e) What increase
- GU > food.
- GB ) fatty meals.
- Acute inflammation ) any local or general disturbance.
0 What decrease
- DU ) food & alkalis.
- GU ) vomiting.
g) PeliodjcllU
- DU ) attacks for 2-6 Wk & free interval of 2-6 Ms.
2 - .9..v..e*.I*r,..9
a) Site.
b) Size ) (lemon size, orange size...)
c) Onset qlit leJ
- Accidental - Gradual
- Acute
d) Course:
- Progressive - Stationary - Regressive. - Fluctuating
3 - Disturbance of funetion:
3 esophagus:
. Dysphagia.
. Water brash.
. Heart burn.
3 stomach:
. Appetite. at;itcEYlrJc ,:l:te-
. Weight.
. Vomiting.
3 srnall intestine:
. Diarrhea.
o constipation
. Audible intestinalsounds.
3 Large intestine:
. Distension.
. Dysentery.
. Bleeding. (Hamatemesis-melena-bl per rectum)
3liver:
. Jaundice.
o Bleeding tendency.
. Discoloration
7 pancreas
o Sfeafo rrhea
1. Dvsphasia (Difficultv in swallowinsl

f;lsXJ Ji ;fiQ-ll t
CUI ei L.Jr,a ellin &
- To solids or to fluids:
o Solids: mechanical obstruction (cancer stricture)
-
o Fluids: functional obstruction (achalasia bulbar
palsy)
-
- Onset: ff /"t alq
o Acute: in inflammation.
o Gradual: in cancer.
- Course:f ! lt.u-A
o Progressive in carcinoma.
o lntermittent in achalasia.
o Stationary in stricture.
- Duration:f9l ti cy !
o Short duration: in carcinoma.
o Long duration: in achalasia.
2. Water brash:
- Sudden filling of mouth with alkaline secretion due to
regurgitation of saliva collected in the esophagus.
dl;le ,td ,:l .i U Cl.ci ,lt- ,J. blll+ o*ri
3. Heart bUrn: r ;rt Jl i sJo JE lllia ilr
4. Appetite: ggtJsYt(* ,!4J*r
- DU > good for every thing.
- GU ) good but the pt is afraid to eat (sitophobia).
- Carcinoma of stomach ) pt dislikes meat.
- GB diseases ) pt afraid of fatty meals.
- Polyphagia.
- Perverted appetite (Picca).
5. Weiqht: ffut ;1+.oslt lfil,rtLit
6. Nausea: feeling of desire to vomit.
7. Vomitins: expulsion of stomach contents
into the mouth:
- Spontaneous or induced.
- Preceded by nausea or not.
- Onset ) immediately after meals e.g. GU
) by the end of the day - pyloric stenosis
'
""
o ('ry'Jff
:t*i:,;,,*,fi'fi*,i "' l"#Br,ii
) Foeculent = lntestinal obstruction
- Effect on pain ) Relieves pain in GU
) No relieve in pyloric stenosis.
- Frequency.
244
8. Diarrhea: -* d aifut rettss ;iets jJrtl

- Stool consistency.
- Frequency, number of motlons per day (first ask
about patient's normal habit)
9. Constipation:
10. Audible intestinal sounds:
11. Flatulence & distention: t &:is eb4
'Abdominal distension, which comes soon after meals.
- lt is present in gall bladder & colonic dyspepsia
12. Dvsenterv ) Passage of mucus & btood
with stools with TENESMUS. rt cj-,rt'
jlJCl e^ 4r'i'3
13. Bleedins:
a- Bleedinq per rectum: .,rfll Cl;rrl,rr.llt.ia &
Passage of fresh blood, the cause is usuaily in the hind
gut, however severe bleeding anywhere in GIT from
the nasal sinuses to the anal sinuses can present to us
with bleeding per rectum.
b- Melena: ,'..jjl gj.t3ru,ljl.,;6 dtljl &
Passage of soft black tarry offensive stools due to upper
GIT bleeding (from orophirynx to end of midgut)
c- Hematemesis: o.rS &3 Fr cs+J
Vomiting of blood usually coffee ground due to formation
of acid hematin or bright red in severe haematemesis
r #itt Ci CI.JI Y., e..slt ef edl
f !$ tts 4ij.s eJt
t il YS d dij 4ll lJLe C.t3*.ll rrrJ Lrl
14. Jaundice:
gljU. b dslt CulJ Jf,ats,i/ 4t+c dJLt
a) Onset ) Acute : viral hepatitis, calcular obstruction
) Gradual: malignant obstruction, cirrhosis
b) Course ) Progressive: malignant obstruction, cirrhosis
) regressive: viral hepatitis
) lntermittent: calcular obstructive jaundice,
periampullary carcinoma, hemolytic
jaundice, chronic active hepatitis
cl Duration ) Short: viral hepatitis
) Long: cirrhosis
) More than 2 years exclude malignancy
245
d) Urine ) Dark: hepatocellular & obstructive

) Pale: hemolytic
e) Sfoo/ ) Pale clay: in obstructive.
) Dark: in hemolytic
) Slightly pale in hepatocellular
0 Anorexia, nausea, vomiting:
) Occur at the onset of viral hepatitis.
g) Fever ) Hepatocellular: pre-ectric phase of viral
-' hepatitis
) Hemolytic: during hemolytic crisis.
) Obstructive: Charcoat's triad.
h) Bleeding tendency: from skin, orifices in:
a- Obstructive jau ndice
b- Liver cell failure
i) Pain ) Hepatocellular: dull-aching pain in Rt.
hypochondrium in case of viral hepatitis
) Hemolytic: bone pain and abdominal pain in
hemolytic crisis
) Obstructive:
a- Biliary colic (Calcular obstruction)
b- Epigastric pain radiating to the back
(malignant obstruction)
j) Pruritis: in obstructive jaundice
15. Steatorrhea ) bulky, offensive, floatin stools.
4 - other ilf.ggg.I.ng..:.
Ui i; iii" iiiiito m s,
""""""
Genital symptoms:
9.:...1t*:-t-o..ry-...9.f ...-{.+y.S-s..!*g*.k*-q.t]P or rrEdications
P__as_t_his!ory_:.
, Similar attacks.
r
r Q DM, l-lypertenslgn, TB, B, Hepatitis, DVT)
r flp
phoid
intake e.g. Chlorpromazine ) intrahepatic cholestasis
rS,
. Previous Operations.
Familv
.-- -- - historv:
--- --
.-----
Consanouinitv
. Similar dondition in one of the members of the.family: GIT diseases with F.H.
o Congenital hypertrophic pvloric stenosis
o Familial polyposis
o Fibrocystic disease of pancreas
Browse's introduction to the svmptoms & signs of surgical disease/ ChIS the abdomen/P39|
246
Examination
Pt. is alert, conscious,
oriented to time, place, &
Body built ) Marked loss of weight in persons, average built,
malignancies. q u iet facia I express ion,
I Decubitus ) orthopnea ) in massive ascites. normal decubitus,
T Facial expressions. average intelligence, &
T Blood pressure s/he is cooperative.
I Pulse
- Water hammer pulse: in liver cell failure due to Vasodilator material &
anemra.
- Bradycardia ) obstructive Jaundice.
Temperature ) Fever in.
- Ascending cholangitis.
- Pyelonephritis.
- Viral hepatitis.
Complexion ) (3 colors)
(Jaundice, pallor & cyanosis)
- Jaundice ) hemolytic ) lemon yellow
) hepato-cellular ) orange yellow .,.
) obstructive ) olive Yellow t)
! Chest & heart ) spider naevi, Gynaecomastia
I Extremities:
- Clubbing (What are abdominal causes of clubbing)
. Primary biliary cirrhosis.
.'
Polyposis.
lnflammatory bowel disease.
'. Hepatoma.
Malabsorptionsyndrome.
- Palmar erythema.
- Flapping tremors.
- Scratching marks ) due to itching in obst.
Jaundice.
- Edema in LL ) hypoproteinemia in Chronic Liver diseas(ClD)
- Skin rash ) bleeding tendency. /
) Purouric rash.
) Pellagric rash.
. Head & Neck: Clubbing
- Congested neck veins in:
.'
Hyperdynamic circulation in L.C.F.
Massive ascites.
.
Bilharzial cor-pulmonale.
- Wasting in temporalis ) in CLD.
Enlarged parotid )
endemic parotitis in CLD
Enlarged LN in lymphomas.
247
. Manifestations of liver cell failure (L.C.F.)

. Manifestations of hypopvitaminosis
'1.Silky hair.
?. Vvasting tempcrali$ ms,
3. Jaundice.
4. Pallor.
5. Cyanosis.
6. Foeter hepaticus.
7. Parotitis.
\
L Cong. neck viens.
O Qnidar naanri
12. Flapping tremor.

18" Clubbing.
14. tldater hammer pulse.
15. Ascitia.
16. umbitical hernia.
17. Oedema in L.L.
18. Feminin hair.
1 9. testicular atrophy.
248
LOeaI: dJ^J .,lc, .-$:,t$ll .+ +

) from nipple till mid thigh.
a lnspection from 3 different planes.

o To see mobility of abdomen with respiration.
Obll ..s. I i g.c a.r.t-,,tt+ arJLl3 A-ljl+ 1.1rij ri.
" For expansile impulse with cough. dL&ill ,J" C

Sub*castalangle
(N=90)
Pigmentation
Diverication of recti
Umbilicus
(Discoloration,
Nodules,
$hifted,Hernia)
Hair distribution
Dilated viens
Things to be seen by inspection
249
t --. . +h*pl+*.+.*I.... s.er,. F..e*r. :.

o Normal abdominal contour:
- Gently convex from side to side & from above downwards
) 4-=lJFll CrYl.- rls #
o lf there is bulge: 4iL .il"
- Localized bulqe:
(Site, size, shape, number, movement with respiration, intra, or extra
abdominal by asking the patient to rise up without support)
- Generalized bulge:
. Fluid )
Ascites )
symmetrical diffuse + full flanks
. Fat )
obesity )
symmetrical diffuse + NO full flanks
. Flatus )
distension )
symmetrical diffuse + NO full flanks
. Fibroid or large abdomina! tumor
. Fetus )
pregnancy
o Retraction )
T.B peritonitis (dry type).
Retracted abdomin
2. Movemen t H*.!h....f 9.9pt.T3.9t9,..1].;
1. Normal: freely mobile
2. Decreased or absent: in
A. Rigidity: due to peritonitis
B. Diaphragmatic paralysis
C. Abdominal distension with Ascites
3. Visib].e intestinal. movements : (Peristal.s is)
- Pyloric obstruction: from left to right in epigastrium
- Small intestinal obstruction (step ladder)
- Colonic obstruction (horse-shoe crossing the midline from Rt. to Lt.)
f .,. ..Fpts.+.p.I.T * s ..p*I.9.p-g*e+,P.,:.

- Aortic aneurysm, Rt. Ventricular enlargement, pulsating liver.
250
P.' .F-1#.se.e.9?I P.*sIe

Normal 70-90'
6 . ivar".t'l:?i":?'"H:'Jl:"'"n'
D
Ask the patient to rise up without support ) separation of two
recti forming a gap which you can put the tip of finger easily: it is
due to chronic increase of intarabdmoinal pressure
7 . Umbi1icus:
. Position: ) normal ) midway between symphysis pubis &
xiphi-sternum
Shape:
-
lnverted (normal),
-
Everted (chronic f in intra-abdominal pr.) = umbilical hernia.
-
Deep )
obesity.
)
Nodule sister Joseph.
Sister Joseph
, frorn patent urachus.

from patent vetello-intestinal duct.
) from pilonidal sinus.
2sr
P-.'..,...r.te.rIrtp-I....p...rif *.c...?.-s-.:.
- (Epigastric, paraumbilical, inguinal, femoral, incisional)
9. Skin:
. Scar ) (operation, cautery)
. Stria ) (Ascites, pregnancy, obesity, Cushing $)
o marks )
Scratch (obstructive jaundice)
. Pigmentation ) (Cullen sign, Grey Turner sign)
. Petechie, ecchymosis
. Hair distribution: feminine (apex down) > CLD
I 9.,.... P* I.e tefl... y-e-+.tl p. ;.
Gaput medusa IVC obstruction
Site Around the umbilicus Mainlv at flanks
Presence on
-ve +ve
back
Crossing the +ve
-ve
oroin
By milking:
Direction of Away from the umbilicus From below upwards
blood
Thrill +ve -ve
Venous hum Kenawav sion -ve
L 1.,.... H:t -ts r.+.*I.
d!t; 1 cyrt ,O!'lt .J...r .,.iif , elgl i.r

A.SUpgtftgial...orCr &s cP u+ + ohlt,,J" i.ilt.r qi
To detect tenderness.
To palpate superficial mass.
To get confidence of the patient
To detect rigidity and guarding.
To detect hyperesthesia (Boas'sign in acute cholecystitis, triangle
of Sheren in acute a icitis
Risiditv Guardinq
Definition Voluntary contraction of
Reflex spasm of abdominal abdominal muscles on
muscles attempting to palpate over a
tender area
During Does not disappear Disappear
exoiration
Site Accordino to the cause Usuallv bilateral
2s2
I .Irl
/\ -t-'\
B.Deep
l. l-iver:
A.
1 . Rt 1obe of Liver ) from Rt iliac fossa
;u-; J* J[.,i#.ii;:'.1ll-.J.'cilt ,,,,..' cl:sr 6ur , a-Jt3 .9+.c ur"ii o!*x ,J_*
if enlarqed ) ptosed or Enlarged
Diff Bv ) heavy percussion in mid clavicular line
2 . Lt lobe ) From mid line
""""""if
i-i.'i6.# ii;, & Rt lobe isn't felt ....liver is shrunken
When liver is enlarqed we have to comment on:
Edge: sharp &well defined
Surface: Smooth, nodular, or granular
Consistency: firm
Cm below costal margin: (....) cm
B- Bimanua! method:
. By putting the left hand under the lower ribs and lifting them forward.
C- Dipping method:
, ln tense Ascites, fingers tips are pressed with a quick stabbing motion into
the abdomen, a tapping sensation is felt by the organ due to displacement
by fluid.
253
-1- Rt. lobe of liver

-2- Lt. lobe of liver
-3- Spleen
Epigostrium
Hypochondrium
Umbilicol region
Lumbor region
llioc fosm
Hypogoskium
The names of the regions of the abdomen
2.Sptqen: )rx3x5xgx11
Start from Rt. lliac fossa due to presence of Phernico-colic Lig
(from diaphragm to coJon and prevent downward enlargement
of the spleen).
When spleen enlarqed towards lt iliac fossa? )
lf the lig was
torn by pervious operation or malignancy
Then comment onl
Edge
Surface
Sl2e )
normai 1X3X5 r-Cl+ 'sl,+l
9, 11e-cJ.-a
Spleen has to be 3 times its size to be
palpated
- Notch ) The site of fusion of spleenules.
Loss of notch ) malignancy (Hodgkin's)
254
. lf I can't palpate it:

-*-s dJd G-r_: cJL.rtl 41i1 ,''-i JL.ill .9+l
Elirnanua-l
exafilenation
for
spleen
e
.le -!6l .l . ,.,r^rll , ,..-ll .lc ',1J1
' Ebstai rhaFgin '.:=: !1.,t ;
a-,= j
Hooking method
-
lf still not palpated: Do percussion on (Traub's area).
lf there is ascites ) dipping method.
-
What is Traub's area?
It is area of tympanetic note overlying the fundus of the stomach
Boundaries:
- Upper border: lower border of Lt. lung (Sth rib in MCL > gth rib in MAL)
- Lower border: Lt. costal margin (Lt. 8th rib in P.S.L > 11th rib in MAL)
- Left border: Anterior margin of spleen (gtn, 1Oth,11th ribs in MAL)
- Riqht border: Left border of left lobe of liver (Sth rib in MCL > Bth in PSL)
Dullness over Traub's area:
- Full stomach or fundal tumor.
- From above: consolidation, pleural effusion.
- From Left: enlarged spleen.
- From right: enlarged left lobe of liver.
- From below: (abdominal condition e.g. Ascites, abscess...).
2s5
I
Lt. lobe of liver
Traub's atea
3. Kidnev:
Renal angle )
sacrospinalis, Last rib.
lf there is kidney swelling )
post ballottement
.ttr J-r-_r g.5e -lll el+l cij:l......,-,-1 ;,p le Li:.r
Rt lobe of liver, Spleen & Kidneys can be felt by bimanual method
Renal angle
between last rib
&
Erector spinae ms
Palpation of rena! angle

N.B. Examples of acute urine retention:
i. Postoperative retention of urine:
a. Following anorectal, genital or perineal operations (e.9.
after delivery and haemorrhoidectomy). lt is due to reflex
penorectal spasm secondary to pain or as a condition
reflex.
-
Treatment: (never rush to catheterization)
)
lf you had ensured that the patient took the
proper sedation think about changing the
condition around him by letting him to go to the
WC with assistance and then allowing him to
hear the sound of running tap-water (over 90%
of patients will get relieved by this simple way.
)
lf this failed try with hot foment on suprapubic
region.
) lf failed give prostagmine or dorryl to stimulate

bladder contraction provided that you should
eliminate any possibility for bladder neck
obstruction.
) After that the last resort will be confined to
bladder catheterization.
b. Old-aged male patients with history of prostatism are
liable to get retention of urine either spontaneously or
after any operation. ln the latter the predisposing factors
are mechanical obstruction and recumbency leading to
pelvic congestion, preanaethetic medications will
increase the hypotonia together with postoperative reflex
polyuria.
- Treatment:
) Try catheterization 1"t if failed do suprapuic
cystostomy.
c. Acute retention following circumcision:
- Early: during the 1"t day, it is due to reflex spasm
from the pain. Give analgesic and antihistaminic, if
not relieved resort to catheterizatian.
- Late: on the sth day, it is usually 2ty to local
infection.
) Treatment: local wash and removal of the dried
crust by any watery antiseptic lotion as savlon
together with systemic antibiotics and
analgesic, lf not relieved do suprapubic
cystostomy but never catheterization.
4"
Rolling in left iliac fossa d.etJ ctr+ dJe o',i3Yl rr+l
lf lfeel something like cord ....may be:
- Bilharizioma. - Spastic colon.
5. @ll. .Hadden
crrb Lateral border of Rectus abdominismuscle ) (linea semilunaris)
el-.ell e. eLEilt ,j!,1-l Ol ,jt
Ot+ll cfis cp JEjll gl cFrj ri alls gl3,all #h st Thumb dl+.hi..ht
Murphy's sign:
. Ask the patient to take deep breath while exerting pressure on
surface anatomy of gall G.B (junction between Rt. Costal margin
& linea semilunaris) )
sudden catch in breath with a gasp (i.e.
chron ic cholecystitis)
6. Dralnlng. Lyrnph. .nodeO ) Virctrow's LN & paraaortic.

7" Urlnary Hadder,
8. Filamal genhlla:
ln surgical practice this is usually confined to examination of the male
genitalia, since females with disorders of this region are managed by
gynaecologists. The examination is best performed with the patient in
the supine position.
'9@.
- Beaded = B or T.B
- Matted= filarasis
. Scrotum
- Scrotum (ant, post aspect)Shape, symmetry and swelling
- ln all cases both sides of the scrotum should be palpated
- Starting with the healthy side, first with the patient standing &
then in the recumbent position
- Palpation of the epididymis(size,
consistency, presence
of sulcus, between it
and the testis)
- tunica vaginalis (early hydrocele
detected by pinching
test. i.e. you feel double
layers)
'.@
- Size
- Consistency
- Testicular sensation
Penis ) for ulcer or scar of chancre

- Penis esp. external
meatus (site, discharge by
pressing the glans)
- Perineum
Other hernial orifices
9. Bae*q + Pott's disease or psoas abscess.
) normally abdomen is resonant in percussion

r SOlid OrganS: ) parattet to the orsan
I Swellinq:. ) from resonant to dutt
. Ascitis:
Ascitic fluid less than 500 cc cannot be detected clinically:
. Minimal Ascites (500-1000cc)
. Moderated Ascites (1000-2000cc)
. Severe Ascitis (>2000 cc)
) Moderate amount: Shifting dullness
) Tense: transmitted thrill
) Minimal: knee - elbow
Now the patient
Air &
intestine
Fluid
Shiftting dullness 1
shifting dullness 2
Au-s-g-ulte-tr-en.
- lntestinal sounds )
intestinal obstruction ) loud, sharp, frequent
)
paralytic ileus ) dead silent
- lf there is Portal hypertension ) Venous hum on epigastrium f with
respiration )lt is called (Kenawey sign) cs:l-.,! /r
- lf there is (Hepatoma):) (Ma'mon sign arL /.1
- lf there is aneurysm ) Murmur
Brohtse's introduction to the symptoms & signs of surgical disease/ Chl5 the abdomen/P389
259
P.{B=
How to make it ?
1- Examination of the abdomen is incomplete without a rectar
examination. For this purpose, the patient rs mosf commonly
positioned in the left lateral decubitus position, although some
prefer the knee-chesf position.
2- Oral consent
Ot+ll uJ" Ul ,-i3t 6t lte . t
C1;,c;
tt" a\_l ri! 6tsll .Y

.ijrl A.rli, 3 .r +,, ,te;l . dlj:l+ 4+tr c,FiiL C .f
fclqliJirll 6[l .t
ry+ lndex + PR ,Jtcf grc +t+ttr,.b.hii+ AJSi u crj r
lndex dl qji$ oS rr,r.3
Inspection
- The examination starts with inspection of the perineum for external skin tags,
perianal inflammation, sinuses, fissures, medial to the ischial tuberosity (base
of the ischiorectal fossa).
Digita! examination
- Digital examination of the rectum is performed in both the elective situation
and patients with an acute abdomen.
- The actual rectal examination is carried out with a lubricated gloved hand.
- The tip of the index finger is placed inside the anal canal and directed initially
towards the umbilicus before turning posteriorly towards the sacral concavity.
Examples of some finding of rectal examination:
1. Deep rectal tenderness is encountered in acute appendicitis, salpingitis and

peritonitis.
2. A ballooned empty rectum may be found in patients with small-bowe!
obstruction
3. Patients with large-bowel obstruction due to severe constipation, a mass of
impacted faeces is encountered.
!n the elective situation, the rectal walls (anterior, lateral and posterior)
are first felt for mucosal lesions (polypoidal growths, ulcers, etc.).
ln males:
- The prostate gland is examined through the anterior wall. Normally, it should be
possible to move the rectal wall over the prostate gland. The median sulcus
between the two lobes of the prostate gland is also palpable. ln benign disease
the prostate may be enlarged or fibrotic, whereas in cancer of the prostate the
gland feels craggy with loss of the normal outline and infiltration of the anterior
rectal wall. No other structure should be palpable through the rectal walls.
ln females:
ovaries and tubes are felt laterally only when enlarged and pathological.
Tumour deposits in the pelvic peritoneum may be felt as a hard shelf anteriorly.
When the digital examination is complete, the glove is inspected for the presence of
blood and a Haemoccult test performed before the glove is discarded
,Oroans palpable by PR:
- ln both male and female: coccyx, sacrum, ischial spine and anorectal ring.
- ln male: prostate.
- ln female: cervix, pireneal body and ovaries.
BI
{l
"A
$
(t
b\
v
o
l,
Browse's introduction to the symptoms & signs of surgical disease/ Ch17 the rectum &
anal canaU P449
tlNtltJ)tlf [QA.I.,PQLNlrl$QII()IJNI0AI.IUHIIt'tlAIlQll
o Planes of the abdomen:
The abdominal cavity is divided into 9 regions by 2 horizontal planes and 2
vertical planes:
',' ft ## firfri;!f{1!9!1int (berow) to midcravicurar point (above)
'z' !ra3:#!?r*c;f##r prane at the rever of L1 vertebra.

3. Supracrestal line:
. Lower horizontal plane at level of A.S.l.S.
26t
=i-
5-
1- Rt. Hvpochondrium 2- Epiqastrium 3- Lt. Hvpochondrium

Liver, G.B, Rt. Kidney Stomach, duodenum, Spleen, tail of pancreas,
and suprarenal gland, pancreas (head & body), Lt. kidney & suprarenal
Rt. Colic flexure transverse colon, aorta gland, Lt. colic flexure
4- Rt. Lumbar 5- Umbilical 6- Lt. Lumbar

Ascending colon, Small intestine, Descending colon, Lt.
jejunum, Rt. Kidney omentu m, retroperitoneal Kidney (lower pole)
(lower pole) structure Jejunum & duodenum
7- Rt. lliac fossa 8- Hvpoqastrium 9- Lt. lliac fossa

Coecum & appendix, Rt. lleum, urinary bladder if Sigmoid colon, Lt. ureter,
Ureter, Rt. ovary distended Lt. ovary
Enlarged uterus
SUIIIiAQli AIIItlltlQ,UI. glll -rillliB

The upper border:)represented by a line joining the following points:
1- Apex of the heart.
2- A point at the xiphisternum.
3- sth rib in right M.C.L.
4- 7th rib in the right midaxillary line.
5- gth rib in right scapular line.
The lower border: ) is marked by a line joining the following points:
A point on the Lt. 5th intercostal spice altne Lt. latera] vertical plane.
2- A point on the Lt. costal margi r at the tip of the 8th coastal cartilage.
3- Mid way between xiphisternum and umbilicus.
4- Tip of right 9th costal cartilage.
5- Following the costal margin to the mid axillary line.
Rioht border: ) from 5th rib to 7th and 11th rib in midaxillary line
-1-
262
!|IJ IlIIll()f i ANA tQ,lIY 0ll f|l-?I-!i llN

- To map out the spleen the tenth rib is taken as representing its long axis;
vertically it is situated between the upper border of the ninth and the lower
border of the eleventh ribs. The highest point is 4 cm. from the middle line of
the back at the level of the tip of the ninth thoracic spinous process; the
lowest point is in the midaxillary line at the level of the first lumbar spinous
process.
f|ultljlt(]li aN/rr0uI OF ll'trH I{IDNflx
a- posterior surface markings of the kidney: ) bounded by 4lines (Morris's
parallelogram)
2 vertical lines: 3, 9 cm from median plane
2 horizontal lines: at level of T11 and L3
b- anterior surface of the
Riqht kidnev Left kidnev
Uooer end 11 "' soace 1 1'n rib
Lower end 5 cm above iliac crest 6.5 cm above iliac crest
i (kidney or a t! o .: swelling J L,-l I r r r /'r r tjl I I
Iiver or spleen)
,JS!l 4p,t*.,i t, dlUA r
1- lntra abdominal
2- Move with respiration
3- Occupying anatomical site (...)
orr,Je 5l9#l_I elta + r:
; SPleeA ' Liver
4. Doesn'aiil-;nsite :-4. Doesnti iitl Inglo 4. Fill angle
' 5. Ballot
5. Doesn't ballot : 5. Doesn't ballot , :
6. No band of resonance 6. No band or resonance ' 6. band of resonance

: in
:
:
: & thete iq Nqlqh fro4! qt ( - -

G.B mass has the followinq characfers,'
1. lntra abdominal mass.
2. Moves up & down with respiration.
3. Pyriform in shape.
4. lts surface is smooth & its edges are rounded & well defined except superiorly
where it disappears beneath the Rt. costal margin.
5. lt does not fill the renal angle & it does not ballot (not renal mass).
6. Dull on percussion lts dullness is continuous with the liver dullness.
263
S ial investieations
. Laboratory investigation:
- CBC, Hbo/o, PT, PTT
- Blood sugar.
- LFT ) Enzymes (transaminases, Alkaline phosphatase, yGT)
) serum Aibumin
) Total & direct bilirubin.
- KFT ) serum creatinine, BUN, S.urea.
- Blood electrolytes.
- Serological investigations for bilharzias, hydatid,........
- Stool & urine analysis.
- Tumor markers: e.g. alpha feto-protein.
" ECG
. Radiological investigations:
- Abdonnino-pelvic U/S.
- Plain X- ray (chest) (abdomen supine & erect).
- Barium (swallow, meal, follow through).
- CT scan, Spiral CT.
- MRI.
- Cholecystography.
- PTC.
. Endoscopic investigation:
- Upper Gl endoscopy.
- Esophageal manometery.
- ERCP.
- Lower Gl endoscopy.
- Sigmoidoscopy.
Provisional dia
1. Etiological ).
2. Anatomical) lt is diagnosis of the region (Skin, S.C, muscle, tendon, vessels,
nerve) or organ (spleen, liver, gall bladder) which is affected.
3. Pathological ) Congenital, traumatic, inflamnnatory, neoplastic ...etc.
4. Functional diagnosis ) compensated or not
5. Complications ) haematemesis, anemia,
6. Associated condition ) DVT, T.8., diabetes, chronic bronchitis...etc.

A.
. CaLcular obstuctive )aundice.
Q. How didyoureach this diagnosis?

A.
' lasndice:
Due to pteser,ce of yellowish discolouration of the tissues and body fluids
(except the brain. CSE/ teats/ saliva and milk) due to excess of bilirubin in
the blood.
. Obstru ctive:
Because therc are the fo[lowing manifestations:
r. )aundiceis deep.
2-. Associated pruritus.
3. Stools is pale.
4. Uline is dark andfrothy.
. Calcular:
-By History
o Age: MiddLe agp
o Sex: Moreinfemal.es
o Onset: Acute
o Course: Remissions 8L exacetbations
o Duration:Vaiable
o Pain: Usually preserrq Biliary colic
o Pruritus: Usually ptesertt
o Pasthistory: Biliary dyspepsia and colic
- By C en er al Exarninacion
o Depth of jaundice Moderate to deep yeLlow
o Weight [oss:S[ight
o Lowet lirnb oedem a; Absent
o Lowq Lirnb Phlebochrombosis:Absent
-AbdominalExaminati on
o Liver.Enlarged and smooth
o Palpablega[l bladder: Uncommon
o Ascites: Absent
26s
Q. Comment on bilirubinl
A.
. The normal level ranges ftom 0.2 to 0.7 mgo/o.
' lf che bilirubin becomes > 3 tng o/o the jaundice wiII be manife sted. Lf the
bilirubin is ) r mgo/obutless than3 mgo/o, this is calLedsubclinicalorLatent
jaundice.
t There ate two types of bilirubin:
Lndhect bilirubin : unconjugated bilirubin : haembilirubin
Dhect bilirubin : conjugated bilirubin : cholebilirubin
Indirect bilirubin Direct bilirubin

Produced in The spleen as a resu[t of [n the liver cells as a resu[t o]
destruction of RBCs coni ugati on of uncon jugated
(hemolysis). bilirubin with glucoronic acid
Obstructive jaundice High because of the

regurgitation of
cholebi [irubin from the
bile canaliculi into the
blood.
Haemolytic jaundice High due to theinqeased

production as a result of
increased hemo[ysis.
Hepatocellular High as the diseasedliver cells High as The obstructed

jaundice are unable to conjugate the intrahepatic bile
unconj uga ted bilirubin, so ic canaliculi resu[t in
becornes eLevated in the b[ood. regurgitation of
conjugated bilirubin into
the blood.
Passage into the urine Doesn'c pass as it is not water P asses because it is
soluble and is carried in the watersol,uble.
blood bound co albumin and
this binding makes the
moleculelarge co be filteredin
the glomeruli.
266
Q. Whatis themost irnportant differential diagnosis of obstuctive

iaundicel
A.
'
Calcular and rna[i gnant obstruct ive j aundice.
Q. What are the characteristic features of rna[ignant O.r.
differentiating it from calcular O.) .7
A.
. History
- Age: Usually oId
- Sex: more in ma[es
- Onset Cradual
-
Course SrcadiLy progressive
-
Duration Not more than z years
Pain M"y bepresentl epigastric pain radiating to the back
-
-
Pruritus Severe
-
Past history f..legative
. Cenera[ Examination:
- Depth of jaundice: Deep olive Sreer.
- Weight [oss: Progressive
- Lower limb oedem a: May be due to:
o LVC obstruction
o Lowq Limb Phlebothrombosis
o Trousseau's sign
' Abdominal
Liver
Examination
- P aloable qallbebLaddq
Mav nodular
- Common
- Asiites Anfu in metastases
Q. How canyou differcntiatebetween acute cholecystitis and subhepatic
appendicitis?
A.
Acute cholecystitis 5 u bhepati c appendi ci tis
- Tenderness is superficially - Tenderness deeply seated.
located at g'hcost al cartiLage. - Murphy/s sign is -ve.
- Murphy/s sign is lve. - Boa's sign is -ve.
- Boa's sign is *ve. - Shereenhyperthesia is *ve.
- Shereenhyperthesia is -ve. - No du[lness atthecoastal
- On percussionl dullness margin.
under g'hcosta[ margin if che
qa[[ bladder is distended.
267
Q. What about the size of gall bladder in the case of O).?

A.
. lt follows the Courvoisier's
law:
Th9 ga\ bladder is usually not palpable in calcular obstrucriv e jaundice as the
gatlbladder is the seat of chronic disease and fibrosisl and it is usually palpablein
obstructiveiaundice due to cancerhead of the pancteas as the gallbladder'is
healthy and di scensi b [e.
. This lawhas the following exceprions which represerrts
r. Palpable callbladder with calculus obstructive iaundi : a Metabo[ic stone
with ahealthy disrensi .srll der.
z. tnq.ljaundice and anocher or.e in the cystic duct
causing amucocele of the ga[[btadder. c. Asrone of Hartman's pouch,
obstructing both CtsD and cystic duct (Mirrizi Syndrome)
3- Cancethead of pancreas withoutpaloable qallbladdq: a. An associated
cancer head wi th c alcular cholecy stiti s.
4. Cancerhead with metastasis ar porca hep causing obstruccion of the
bile duct above thelevel of the s,allbladder which thuJcannor be distended.
noma at porta hepatic (l([atskin rumor)
Q. What is the investigation of choice 8t whar is its values?

A.
' ERCP : endosco pi c r err ogr ade chol,angi o-panc reatog aphy)
(
' The values:

. Diagnostic values:
r- Visualization of biliary tree and pancreatic duct
z- Sampl.e of bi[e ot pancleatic juice
3- Visualization 8t biopsy of tumor that invadethe duodenum
. Therapeuticvalues:
r. Stone extraction
2. Passing a catheter through a stricture to provide externalbi'tixy drainage
3. Passing stent through stricture to provide internalbilixy drainage
Q.what is the ptecautions of ERCP?
A.
' Prophylactic antibiotic $rd generation cephalosporins) to avoid complications
of ascending cholangitis.
Q. When do you doPTCSl, what ateits precautionsT.
A.
' Done when ERCP failed co give enough data about the obstructing agent.
. [t can visualizebiliary tree above obstructing agent.
' PT should be donebeforc the procedure to avoidhemobilia or hemoperitoneum.
268
Q. What is the value of plain X-IW in obstru ctive jaundicel

A.
. [t may show radiopaque gallstonesl calcificarion of the gallbladder.
Q. What are the type.s of cholangiographyT.
A.
r. lnsavenous cholanqiosrraphy :
Biligram is injected L.V 1 thebile ducts and ga[lbLadder are visualizedbut
they appear very faint. That is why it is not more usednowadays, in addition
to the side effeccs of biligram.
Cholan
The arnpula of V atu is cannulated with the aid of fibercptic endoscope and the
bile duct is injected urographin. The extrahepatic bile ducts are visualized.
3. Percutaneous Transhepatic Cholanqiosraphv (PTC) :
AChibaneedle, rs cm \ong, is inselted in the 8ch space rnidaxillary [ine to a
point 2 cm to theright of the vertebral column. Theneedleis withdtawfl
until reveals 6ile. Conray 280 is injected and thebilixy tee is visualized.
4. Preoperative Cho[anqiosrraphv :
This should be done routir'ely in cases of cholecystectomy. The cystic duct
is cannu[ated, a catheter is passed through it into the common bi[e duct and
Hypaqueis injected.
S. Preoperative poscexp[oratory cho[ansrioscraphy :
ls doneintaoperative after exploration of common bi[e duct to reveal any
residual stones.
6. Postoperative cho[ansrioqraphv (T-Tube Cholansriolraphv) :
ls done on the tench day after cho[edocholithocomy to reveal any missed stone
Q. Whar is the tteatment of this case of ca[cu[ar obstluctive jaundiceT.

A.
. Pre-ooerative:
Liver f ailure is teated if present.
High intake of glucose.
Deqeased prothrombin level should be corectedby parer'teta[ injection of Vit
K.
B[ood culture 8t sensitivity and ptoper antibiotic s are given if therc is
evi dence of cho [angi ti s
Proper hydracion by L.V . fluids and forced diuresis by Mannitol infusion to
safeguard against hepatorenalfailure to which thesepatients are susceptible
. There aremainly zmethods;
IECW + paeillotomy:
This merhod shou[d be sied fhst, un[ess the stones are large in size ot there is
a stricture behind chem.
269
gh an endoscope, the duodenalpaptnais stones are either

a. AILowedto pass spontaneously, OR
b. Exfiactedby rneans of Dormia basket or ba[[oon catheter.
2. Choledecolithotomy,
This means operative incision of the CBD to rerlrrove rhe stone.
[t is done when the endoscopic rernoval of scones was not indicated or foi[ed.
Supraduodenal choledochotomy is done and the stones are retrievedby srone
extraction forceps.
Cholecystectomy is done in the sarlr'e setting but can be delayed to another
occasion if the patient was unfit.
Q. How can you suspeetmissed stone 8t how can you deal ltth id.
A.
rl can suspect missed stone as fo[[ow:
'. excessive bile secr etion
from T-tu be.
Patient without T-tube: persistence of jaundice.
. There arernany methods to dealwith missed stones:
r. tt(Ltr 6L naoi[lotomv *
hoscopv : Waiting untiI a tract of T-tube is well developed and
the stones are removed through a choledochoscope.
3. Chemica[ Dissolution of the stones by injectingmateials through theT- tube
to dissolve the stone (e.g,.hy&oxy chenodeoxy cholic acid).
4. B urhene Techni q ue: W aiting unti I a tr act of T-tu be i s w ell developed and
the stones anerernovedby a special stone basket introduced through this
tTact.
5. O p er ativ e interv enti on.
Q. What is the value of hypotonic duodeno graphy in obstru ctive jaundicel

A.
. lt may show :
r. Rose thorning of the medial wall in car,cer head of pancreas.

z. Filting defect in the region of the ampulla in periampullary carcinoma.
Q. What is meant by "mis sed stor'e"?

A.
. This means that after operative cho[edocho[ithotomy, and on doing
postoperacive (T tube) cholangiography, filting defects of missed stor.es are
seen in the cho [angi ogram.
Q. What is the cause of iaundice if associated with generalized

Lymphadenopathyl
A.
. [t may 6e due enlarged L.Ns atpottahepatis.
270

A.
. Bilhari ziaL splenomegaLy.
Q. What is the pathology of Bilharizial splenomegalyT.
A.
.
There is atriad of:
I. BiLh ari zi al p eip or tal f i brosi s.
2. porta| hypertension.
3. Congesti v e splenornegaly .
Q. Why this is a"swelling of the spleen"?.
A.
. Becaus e it is a swelling that has the following charactersl these chanacters
are arrar.ged according co priorities:
r. lntrabdominal: this canbe detectedby
Rising up test.
Movement wi th respirati on.
2-. Anatornic al site of che spleen in the Lefchypo chondriurn.
3. ShNp anteior \order with anotch (pathgnomonic).
4. No ba[[ottetrer't.
s. I cannot insinuate ny fingers between the swelling and the costal margin.
6. No band of resonanceby percussion ovet the sweLling.
7. Not filting the renal. angle and cannotbepushedto therenal angle.
Q. 14/hy didyou diagnose it bilhari zial splenomegalyT.
A.
I. Historv:
The type of the patient: young adultma[e anaernic f armer from endemic area.
Pasc history of Bith ariziasis.
History of haemat ernesi s.
Ceneral exarnination:
Showedrnanifestation(s) of Livu insufficiency (ascitesylegoederna, spider
naevi' palrnar erytherna, f [apping- trentots/ bleeding tendency, iaundice,
g-ynaecom aztat foetor hepaticuslhepatic precorna or coma).
3. Loca[ examination:
SpLeen:
The characters of the enLarged spLeen are those of the cor'gestive
sp lenome SaLy (i.e. chat i s cau sed 6y portal hyp ertensi on ) these chan acter s
.
incLude fine spleen; smoothT rcguLar surf acel Sharp bordq with anotchSt
enlarges towards Rt. [[iac fossa directedby phrenicocolic [igament
271
Theliver is enlargedwith a sharp border and nodu[ ar surface (or is

shrunken).
' Pres-ence of other manifestacions of potalhypertension {Ascir es, Caput
Medusae).
N .B. There ane no manifestations of haemolytic anaemia or leukaemia or othet

blood diseases.
Q. What ate the stages of bilharizia[ splenomegalyl

A.
'. Stage I > Hepatom egaw.
Sage [[ ) Hepatosplenomegaly.
Stage llt ) Shrunken liver * SplenomeSaLy.
.' Stage tV > as [l * Ascites.
. StageV ) as tV + Liver ceLl failure.
Q. Comment on thelivq palpation in this casel
A.
. We should comment on palpation by the following points with the sarne
arrar!,gemer!-r.
' [t has a sharp bordert Lt is f elt 3 fingers in the rniddl,e |ine and z fingerc in
rnidclavicular linebelow che costa[ rnargiry finely nodular surf ace and is not
tender with no pulsations. (Lf theLiver is tendq start the comment with it).
Q. What are the characters of ma[ign ant spleen in pa[pation?

A.
. [t hasheadborderl [t is of Rounded border 8l- no notchT Spleen enlarges
towards Lc. iliac fossa due to infilration of phrenicocolic ligament with
Lwegular surface.
Q. What ane the causes of an enlarsed not palpable liverT.

A.
. Normally theLiver is not palpable (except in infants); enlargedLiver canbe
palpated except in the fo[[owing conditions:
r) sofc Liver as in Rt. sidedhearrfailure,
z) igidity of overlying muscles as in amoebic and pyogenic Liver a6scess,
3) Upward enlargement of the Livq as in amoebic hepatitis (due co
p erihep ati ti s [i mi ti n g the downw ard en [argement ) .
Q. What ane the causes of enlarged tender liver?
A.
I
lnf [ammatorv : V ir al hep ati ti s, amoe bi c and py o geni c liv er absces s.
r Conqesti on: conseste d Liver di seases
I
Malilmancv.
272
Q. How do you detect the size of rhe liver climcallyl

A.
r. By palpation.
L. By percussion:
. Lower bordq: Light percussion is done frornbel,ow upwards in the
rnidcl.avicular for right lobe and middle line for the Left lobe. lt is a [ight
percussion.
' Upper botder: From above downwards on the ittercostal spaces in the
midc[avicular line.it is a heavl percussion to avoid theresonant note of the
Iungs.
N .9. The tidal percussion is on doing percussion for the upper bordel when
du[[ness is reachedl patient is asked tohave a deep breath SL hold it. lf it is the
uppq 6ordq of liver, du[lness disappears.
Q. What ate the causes of leg oedema in bilh arizial Splenomegalyl

A.
Hypoalbuminaemia due to:
r. Lack of intake due to poverty.
z. Malabsorption due to congestiv e enterop at@.
3. B[eeding frorn varices or congestivegastropathy.
4. Liver ceLI f ailute.
Q. What is the aetiology of gynaecomastia inlivq cellfailurel
A.
. Defective rnetabo[ism of estrogen 6y the Liver {deqease activation of
testostefone.
Q. What is the aetiology of bleeding tenden cy in liver cell f ailure?
A.
r. Defective synthesis of prothrombin by the liver
2-. Diminishe d factor V / VLL/ X
3. Thrombocytopenia due to hypersp[enism
4. Thromboasthenia due to coating of platelets by abnormal globulins formed bv RES
Q. Wha t i s hep atic encephalop athy?
A.
. lt is a chronic f[uctuating neuropsychiatric disorder.
. lt occurs whenToxic products as (Ammonial aminobutyric acidl methionine
and rnercapan) which are normaLly detoxifiedby the Liver; bypasses the Liver
to the systemic circulation in large amounts andhence can reach the brain
and can affectit.
r This can occurs by;
Liver decompensati on and col[at er als
5 ur gi c ally q e ated p ortosystemi c sh unt op erati on
273
O. H"", *" thesesubstanc es affer;t brain cells?

A.
production
I. Through interfercncewithl(reb's cycLe leading to diminished enerSy
neededfor the brain celis e.g' ammonia'
L. Acti ng as f a\s e neu rotran smi tter s e'g' T yt amine'
3. lnhi biii ng cor ti cal f uncti ons e'g' B enzo di azepine'
Q. Wha t anerhe manifestations of hepatic encephalopathy?

A. of limbs7 flapping
. lnsom nia, euphoia, inverted sleep *rythm, cogwheerisidity
tr emor s / semi coma and finally hep ati c coma'
Q. Wha t ate the causes of pottalhypetension?
splenic vein thrombosisT Banti syndrome

z. posthepa tic causes: Budd-Ch iari syndrome (occ[usion of che hepatic vetns
by rhrombosis or ma[ignanc tumor.)7 constricti
ve peicarditis, tricuspid
fegurse
3. Hepatic causesi
!Presinusoida[:Bi[harizialpeiporta[fibrosis.
.
Sinusoida[:cirrhosis
.Post-sinusoida[: veno-occ[usive disease'
. lncreased porra[ blood f[ow: as in mye[ofibrosis.
Q. Wha t are the causes of portal vein thrornbosis?

A,
' lnfants:
U m bi [i ca I c atheteriz ati on
- Umbilica[ sePsis
' Adults;
P oral PY aemia { PYtePhlebi
d s )
- Liver tumofs.
Q. What is Banti SYndtome?

A. t1
. to potta|hypertension'
lr is vascularma[formation of the porcal vein Leading
Q. Mention som e casses of livu cirrhosis'

A. alcoholic
. posthepatiric (postnecrotic) cirrhosis, nutritiona[ (Laennec) cirrhosisT
cirrhosisl and bi[iary cirrhosis'
274
Q. What ate the comp[ications of liver crnhosisl

A.
r.
V asculat decompensation inform of portal hypertension.
z. Cellular decornpensation in the form of liver cell f ailure.
3. Malignancy (in s%" of portalcirrhosis).
Q. What is the mechanism of ascites in liver cirrhosis (in portal
hypertension)?
A,
r)
Transudation of lymph andwater from theller surface dueto obstruction
of intrahepatic [ymphatics by fibrosis and regeneration nodu[es,
z) Hypoalbuminaemia due to :
r Nutriciona[ hypoprotienoemia.
. Liver cell f ailure.
l) Sa[t 8[ watet retention due to defective aldosterone metabolism.
4) Lnqeased capillaryhydrostatic pressurein thepeitoneum due to porta[
hypertension.it is the localizing factor.
Q. What is the main cornplication of portalhypercension?
A.
. Opening of portosystemic collaterals especially that in the lower end of the
oesophagu s esoph ageal v arices) . lflhich rir,ay lead to b [eeding (haemat emesi s
(
and/or melena) which might 6efatal.

Q. How wouldyou know if aprevious attackof haematemesiswas
sevete?
A.
. Lf the patient had b[ood transfusionl this is considered a severe attack.
Q. Whatismelena!
A.
. [t is passa9e b[ack tarry soft offensive stools due co its content of digested
blood.
Q. What are the common causes of haematemesis and melaena?

A.
. Bleeding oesophagealvanices. (Commonest cause in Egypt).
. Acute gastritis.
. Bleeding peptic ulcers (acute and chronic).
. Cancer stomach.
' Mallory-Weiss syndrome.
' B[ood diseases.
275
Q. Whatinvestigations doyou ask for this case?

A.
r. Laborat ory investigation.
z. Radi o [o gr cal investi gati on.
3. Endosc opic investigati on.
4. Biobsy.
r. Laboratorv investigrations:
Blood picture: Helps in the diagnosis of:
' Haemolytic anemias (spherocytes, sickLe cells, and target cells)
. Leukemias
. Thrombocytopenia
. Pancytopoenia of hypercp[enism
r Nutritiona[ anaemia of Egypcian sp[enomegaly
' PoLycythaernia.
Osmotic fra$ilitv test: for haemolytic anaernias.
Thick blood film: malaria.
Urine and stoo[ analvsis: for Bi[hariziasis and for presence of b[ood.
Liver function test: Plasma protein level is the most important one.
' Serum Bilirubin (N : < rrngo/o)
. Alkaline phosphatase (N : 3-r5 l<AU %)
' SCOT str- SCPT (N : I
4o U %)
' Albumi" (N : 4-S gmo/o)
. Clobutin (N - z-3 gm"/")
' NC ratjo (\ - z:rJ7
Prothrombin time 8L conc. (N : il -r3 sec. &-rcoo/")
Bleedins 8l- coaqulation time (N - r-+ St +-8 min).
5 tern aI p unctur e: f or leukaerni as I hyp er spl.eni sm and lyrnphomas.
gaphy Barium swa\Low, visualization of the porta| circu[ation.

U ltrasono
3. Endoscopi c investisati ons :
Esophago scopy for the diagnosis of varices.
4. Biopsy:
From the Liver for diagnosis of Fibrosis or cirrhosis.
5. Porta[ manommetry.
Q. When do you consider portal pressure abnormal?

A.
. Norm al porta| ptessure is roo-r5o mm watel (7-rr mmHg). lf it exceeds ry
mmHg; i t consi der ed portal hypertensi on
276
Q. How can you demonstr ate the presence of esoph ageal vatices ?
A.
. Endoscopy (Esophagoscopy).
. Barium swallowswhichisrare to be donenow.
Q. What is the treatment of this case of Egyptian splen omegalyl
A.
' MedicaL geatrnent: This is given for al| cases: vitamin s, tonics, high CHO
and protein dietl Liver tonics (liver extract/ cal,cium and gLucose).
' Specific teatrnent: For oesophagea| vanices, for ascites, f or sp[enome galy, and
for Liver celL f ailure.
Q. lf the p ati errt pr ov es by esti gati ons to h av e oes ophag e al v anices 1

how wouldyou proceed?-inv
-
A.
. lt depends on history of hematemesis:
. There is pasthistory of hernaternesis: the patienc shou[d be maintained on
injection sclerotherapy, this is called chronic sclerotherapy. .Lf sclerotherapy
fai[s to preventrcbleedingl the operation wi[[ 6eindicated.
' No history of bleedinq (i.e. silent varices): there is no need for injection
sclerotherapy. EoLlow up is the main treatmer't.
Q. What is the pinciple of this elective operationl

A.
Operative decornpression of the porta[ pressure 6y:
i) Portosystemic shunt operation.
ii) 5 p I en ec torn;y dw as cal ari z ati on pr o cedur e.
Q. How do you tteat a case of bleeding oesophageal varicesT.

A.
r) Resuscitation (L.V. fLuids 8t blood transfusio\ ..).
z) fo\easures to scop b[eeding.
. l,A,edi ca[: (Vasop r essine, glypr essin, somatostatin)
. Ba[[oon tamponade (ternporary measure)
. Lnjection sclerotherapy or band Ligation, if f ail,ed:
. Percutaneous transhepatic obliteration of varices or
crans j u gu ar intr ah ep ari c p or to - sy sterni c sh u n t T tP 5 5
(
. [f no faci[ities ) urgent operation (Hassab operation or)

L
stapler)
j) Measwes to preventrebleeding.
277
Q. Whatis curative splenectornyl

A.
. Spl,enectomy is considercd crative if it is done for:
o Traumatic raptute spleen
o Splenic abscess.
o Congenital spherocytosis.
o Thrombo cytopenic purpur a.
o Sarcoma of the splee.
Q. Whatis the best non-ope/ativemeasurel
A.
lnj ection sclercther apy.
' This occurs by injection of Ethano[amine oleate, sodium morrhuate and
sodi um tetr adecyl sulf ate.
. The site of injection depends on che acuity of the case:
' ln etr.el,ser.cy scl.erotherapyl injection is done intravNiceal to induce
chrombosis.
' ln chronic sclerotherapy, injection is done peivariceal to induce fibrosis.
Q. What ane the indications of splenectomy in Egyptian splenomesalyl

A.
r. As a part of splene,ctomy vaso[igation procedure.
z. Hypersplenism.
3. Huge disabling spleen which is liabl,e for trauma.
Q. What is teatment of ascites due to liver cirhosis?
A.
r. Conservative rneasutes:
. Restriccion of sa[t.
. Diuretics-
. High protein diet.
2. Measutes for refractow ascites:
. Make sure of diagnosis.
. Make sure that the conserv ative rlr,'easutes Ne followed.
. Tapping.
. Recirculation of ascitic fluidvia a dialysis membrane and reinfusion inco a veinl
P eritoneal-j ugular shunt lLe V een and D enever sh unts ) .
Q. ls the rcr.al angleresonant or dull?.

A.
Therenal ang[e is resonant; due to preser,ce of gas in the co[on (on both sides)
atnd gastic ah bubble (on the \eft side).
278
Other OraL Qr.

Q. cornmon conditions ptesented with acute uppq abdomin al painl
A.
Oesphagitis
o Boerhaave's syndrorne
o Pefioratedpeptic uLcer
(J Acute chol,ecystitis
o Ca[[ stones 8tr biliary colic
o Acute pancreaticis
Browse's introduction to the symptoms & signs o.f surgical disease/ Chl5 the ahdomen/ P393-3
o. comrnon conditiorls preserrted with chronic uppe.r abdomin al pain?

A.
Chronic peptic ulcer
Carcinom a of the stomach
Chronic choLecystitis
Chronic panueatitis
Liver rnetastases
Splenornegaly
Browse's introduction to the symptoms & signs of surgical disease/ Chl5 the abdomen/ P393-394
Q. common conditions ptesented with acute central abdomin al pain7.

A.
. MeckeL's diveticulitis
o lnflamm atory bowel disease (acute chron's- acute u\cerative colitis)
'o TYPhoid
TB enteritis
Q. common conditions ptesented with chronic cen::,al abdomin al pain?.
A.
. Chron's ds
. TB enteritis
enteriti
. Tumors of the sma[[ bowel
. Adhesive
Adhesiv e itnt. o bs cru cti on
i
r I..lro-i
lschemiar ^{
o the sma[[ bowel
Browse's introduction to the symptoms & signs of surgical disease/ Ch15 the abdomen/ P402
cause s of generalized pain?

ft.
lritabLe 6ow el syndr orne
(J ldlecur ent adhesiv e o bstr u cti on
Mesentric ischemia
o Carcinomatosis
(J Chronic constipation
279
I Appendicitis
r Crohn's ds
I CA caecum or RT colon
I Diverticular ds
I CALI co\on/ rectum
I PlDs
Browse's introduction to the symptoms & signs of surgical disease/ Ch15 the abdomer{ P405
Q. conditions_ likely to cause pefioration of a viscus ( causing acute

Oyeritonitis)?
I PU
T Boerhaave's syndrome
! Cangerous appendicitis
I Perforated CB
! Acuta diverticulitis
I Strangu[ation
I Ulcerative colitis toxrc m
. causes of int. obstruction according to the age
Neonates:
- Atercia (duodenuml i[eum)
- Meconium plug $
-VoLvulus neonatorum
o tweeks -CHPS
o 6-o month - lntussusception
'f ennag;e
o Appendicitis
o lntussusception
o Mecke['s diverticulum
o Polyp
o Hernia
o Adhesions
. Adu\t o Hernia
o Adhesions
o lnf[ammation ( appendicitis-Crohn's ds
o Carcinoma
. Eldeilv - Carcinoma
- Sigxnoid volvulus
- Diverciculitis
Browse's introduction to the symptoms & signs of surgical disease./ Ch15 the abdomen/ P413
280
Cro r: Thor acic

g I\t. Pneumonia:
V Marked chest symptoms/ minimal abdominal tendentess and there is no rigidiry.
g Tonsi[[ar tummy:
g Chitd with acute tonsi[[itis I swal[ows pus I abdominalcolic.
g Diaphragm ati c pleuri sy.
g My o c ar di a[ inf arc ci on.
Croup z: Upper Abdomina[ problems:
V PefioatedPepticUlcer
. History of dyspepsia is present.
. Plain X-R^v shows air under the diaphragm.
V Aas@Chole,6lstitis:
. Pain in the right hypochondrium
. Eever is higher.
. U/S wi[[ confirm che diagnosis.
EI lntestina[ Obstruction:
. Repeated vomiting.
' Abso[uteconstipation.
' Multiplef\uidlevels in X-I{ay abdomen erect.
EI Non-specifi c Mesenteric Lvmphadenitis:

. Common in children.
. There is shifting cer.derr,ess
g Regiona[ ileitis.
Z Degoiliac adefitis:
. Child with septic focus in LL
. Pain in i[iac fossal psoas spasm
. Flexion deformity,high fevu and O/L
. Ter.dq nodular fixed mass in iliac fossavery close to inguinal [igament.
g Mickle/s Diverticu litis.
g P efi or ated ileal cvohoi d ulcer
. History of typhoid, ter.detness allovq the abdomen X-Ray! free gas in
peritoneum (erect lgas under diaphragm).
C,roup a: Pelvic problerns:

EI Disturbed risht ectooic presmancv:
. History of amenorhea.
. Shock.
. Vagina[ bleeding.
. Tendq ceryix.
M Acute salpinsitis:
t Eever, vagina[ discharge, tenderness often bi[atera[.
281
V Mridqtclic pain. lMittelschmerzl

g
V PLD:
. Vaginal discharge, bilateral pain, mass feLt onPY
: Uro ca
M Right ureteric-coliain
from toin I sro;n/pain does nor increas e with cough, patientwriching
on himself whiLein appendiciris pacient Lies flat asmovernentitcreases
pain.
EI Rt. Pvelonephritis:
. Eever 40"C * rigors, tender pairy dysuria.
V Disease of the spite:

. Acute osteornyelitis 8l- Pott's of dorso[umber veretebrae.
g HeroesZoster inroth, rrt}i., rzth thoracicterves.
V Others:
. Diabetic abdomen.
. FMF.
Browse/sintroductiontothesymptoms ELsignsof surgica[ disease/ Chr5the abdomen/P4fi
of hematemsis 8t rnelena?
fr.causes
-chronic P U. (spontenous-steroids)
-acute gastric erosion (asprin)
-CA srcmach
-oesphageal varices
-pufpra
-hemophilia
Btowse'sincroductiontothesymptoms 8l-signsof surgica[ disease/ Chr5the abdonen/P4rg
According to their clinica[ presentation into:
o Congestion from Ht. fail,ure

o Cirrhosis
. Lymphoma
o Budd-chiari syndrome
o Amyloidosis
o l(ala-azar
o Caucher's ds
282
Smooth generalized enlargmenrt with iaundice

o Lnfectivehepatitis
. BiLiary tact obstruction ( ga[[ stones or CAhead of pancrease)
o Cholangitis
o Potal pyemia
knobbv qenera[i zed en larqmenrt wi tho u t i aundi ce
o Metastatic deposits
o Cirrhosis
. Polycystic ds
o Hepato cellular carcinoma or cho[angiocarcinoma
S mo o th qener ali z e d enlar gmenr t w i th i aun di c e
o lAetastatic deposits
. Cirrhosis
Localized swelLinq:
o Hepatocellular carcinoma
o Liver secondry
Another c lassi fi cati on :
o lnfection
. Congescion
. Bi[e duct obstruction
o Cellular infiltration
o CelLular proliferation
. Space occupying lesion
Browse's introduction to the symptoms & signs of sargical disease/ Ch15 the abdomen/ P42l
causes of splenomegaly?
ft.
lnfection:
-bacteial: typhoid
TB
Bruce[[osis
Septicernia
-vial.: glandular fever
EBV
-sphochates syphilis
-protozoa[ bilharziasis
rnalaria
cellslar pr olif er ati on:
-ny eloi d 8t [ympha ti c leukaerni a
-[ymphoma
-perniciuos aneamia
- spher ocytosi s 8[ hemo [y tic anaemi a
-thrombocytopenic purpr a
-myelofibrosis
-sarcoidosis
283
-emboli from bacr ei aI endocarditi s

-splenic artery or vein thrombosis
-hematoma
Cellular infiltration:
-amyloidosis
-Caucher's ds
Co[lasen ds:
-feky's ds
-sti[['s ds
Space occupyins lesion:
-solitary cyst
-hydarid cyst
-lymphoma 8[ lymposarcoma
Q. cause s of rer,a[ mass?

A.
. Hydronephrosis
o Pyonnephrosis
. Malignant ds
. Solitary cyst
. Polycystic ds
o Hypqtrophy
Browse's introduction to the symptoms & signs of sargical disease/ Ch15 the abdomen/ P423
other causes for abdominal swel[ings?

!.
Panqeaticpseudo cyst
Mesenteric cyst
Retrop eri toneaL tumors
Cancer stomach
Distended gall bladdq ( in CAhead of pancrease)
Ovarian cyst Eaeces
Pregnant utetus UB
Fibroid
Q. causes of abdominal distenion?

A.
rEetus presnancy is the cornmesc cause)
(
z-Elatus 3-Eaeces
4-E at
s-Fluid (ft.r/ ency sted asci ci s )
284
6-Large so[id tumor such as: - Fibroid

- Causes of hepatomegaly
- Causes of splenomegaly
- Renal mass e.g polycystic kidney
- Recrop ertonea| sarcoma
Brotese's introduction to the symptoms & signs of surgical disease/ Chl5 the abdomen/ P431
Q.causes of ascids?
A.
r- lncrease in the porcal venous pr.: - Prehepatic
- Hepatic
- Posthepatic
z- Causes of hypoproteinemia
3- Causes of chronic periconitis
4- Chylous ascitis
causes of mass in the RT iliac fossa?
ft.
F Parietal Swellings:
M skin
: H:Hyi""#l
. Haematomas.
M S.C tissue:
: k'#Ti"roma
' Neurofibrosarcoma.
EI Muscles laver: fibrosarcoma.
EI Incisional and paralvtic hernia.
F Intraahdominal swellings:
MGIT:
.Ileum
.Caecum: colonic carcinoma.
.Ileocaecum: ileo-caecal TB, ileo-caecal actinomycosis.
.Appendix: appendicular mass or abscess.
EITubo-ovarian:
. Ovarian cyst or fumor.
. Hydrosalpinx or pyosalpinx.
. Tubalpregnancy.
ElUterus: Fibroid.
MRenal:
. Ptosed kidney.
. Ectopic kidney.
285
MVascular:
r Rt. Iliac a. aneuroysm.
t Rt'
':Tiril;rdenitis: acute and chronic(non-specific and specific e.g TB
lymphadenitis)
- Malignancy: lymphoma and metastatic carcinoma.
ElMuscular
escended testis
Browse's introduction to the symptoms & signs of surgical disease/ ChL5 the abdomen/ P428
causes of swe[[ins in the LT iliac fossaT

ft.
EISkin:
. Abscess
. Sebaceous cyst.
r Haematomas.
. Haemangioma
MS.C tissue:
r Lipoma.
. Neurofibroma.
. Neurofibrosarcoma.
MMuscle laver: fibrosarcoma.
ElHernia: incisional & paralytic.
F Intraahdominal swelling:
ElVisceral:
. Pelvic carcinoma. r Pelvic colon:
. Diverticulitis. . Bilharzial mass.
r Spastic colon.
EITubo-ovarian:
. Ovarian cyst or tumor.
. Hydrosalpinx or pyosalpinx.
. Tubal pregnancy.
r Fibroid.
MRenal:
r Ectopic kidney. . Ptosed kidney.
MVascular:
r Lt. iliac a. aneurysm.
r Lt. iliac lymphadenopathy:
1. Lymphadenitis: acute & chronic (non-specific & specific e.g. TB
lymphadenitis).
2.
Malignancy: lymphoma & metastatic carcinoma.
ElMuscular: ileo-psoas abscess.
EI Retroperitoneal sarcoma. or malienant undescended testis
Browse's introduction to the symptoms & slgzs of surgical disease/ Ch15 the abdomen/ P430
286
Lf . causes of dyspepsia!
A"
t ="oon"o"1 "tt"!il:
M Gastric
""'"."="nronic gastric ulcer. . chronic gastritis.
.
Gastric carcinoma
M Duodenal causes:
E Biriarv causls:"H:":odenar
urcer
.
: ;:T"'11o,""r,,*,
GB carcinoma.
E Pancreatic causes:
r HrN) ' Pancreatic carcinoma
";r""*i3:':93i[""ttftortar
M' Appendicular dvspepsia (chronic appendicitis)
M Colonic dvspepsia esp CA caecum
Q. conditions which preserltwithrectalbleeding but no pain?
A.
Blood rnixedwith stoo[: carcinomaof the co[on
Blood streaked on stool: carcinoma of therecturn
Blood after def aecacion: haemorrhoi ds
B[ood and mucus: colitis
B[ood a[one: diverticular ds
Melena: peptic ulcer
B[eeding*pain: fissure (or carcinoma of the anal canal)
Browse's introduction to the symptoms & signs of sargical disease/ Chl5 the abdomen/ P455
Q. ana[ conditions which pteserrtwith pain?.

A.
. Pain alone:
Eisswe (pain after defecation)
Anorecta[ abscess
Prcctalgia fugax
. Pain 8tr- bleedinq:
Fissure
. Pain 8L alump
Periana| haematoma Anorectal abscess
. Pain, a lump 8[ bleedinsr
Prolapsed haemorroids
Carcinomaof the anal canal
Prolapsed rectal polyp or carcinoma
Prolapsed recturn
287
UTCBIB SIIHIIT
of ulcers
Malignant ) SCC, BCC, ulcerative malignant melanoma
lnflammatory >TB,$
Trophic ulcer ) peripheral nerve injury
Venous ulcer ) dt. Varicose veins in !-L
lschaemic ulcer ) dt. Chronic ischemia
Historv
Personal H:
Name, Age, Sex, Address, Residence, Occupation, Marital status
& special habits of medical importance, if Q ) menstrual history
e-qmplaintt ( Sore ) L'i.ilt .,rll dL.l+ elt qt c,+!l
gili
HPI: ei"l fi{* cds iJ'. f.l
- Pain:
Course, Duration, Severity, and What associates.
- T.B )
painful.
- Venous )
painful.
- lschemic )
painful.
- Trophic )
painless.
- Neoplastic )
painless except late.
- U].cer:
;: d&'ofJiol,*l,
- Acute onset
- Gradual onset
b cou rs
lmru3?#ffiJiil[,,,,,"n
- Regressive: )
inflammatory conditions.
- Fluctuating: )
chronic inflammation with acute
exacerbation.
""'.*iHx*i,'*il1*i;y,"r"":',l"ii',1'ss[:liy
d. sife
e. Size
t. Number
g. Effect on the general condition:
h. Apparent causes:
1- Congenital:
. Hemolytic anemias (rare) (i.e. History of hemolytic
crisis)
2- Traumatic:
. Bed sores or trauma (1.e. History of trauma)
3- lnflammatory:
. T.B. ulcer (night sweat & fever + loss of weight &
appetite)
. Ulcer (skin rashes + F.H.A.M)
)
';. 1;T::;;,'i: lHfl?J i?":',," "'
. History of claudication pain.
6- Venous.' venous ulcer
. History of associated varicose veins.
7- Lymphatic: lymphoma
. History of multiple swellings all over the body
8- Neruous; Neuropathic ulcer
. History of numbness or sensory loss
- Disturbance of function:
1- Discharge.
2- Dangerous area of the face.
3- Discharging srnus
- 9-ths..r....Hxp.HF..+t9..i.
- .ll*.s.P.e.rx...ef....*.+:r..e.s. F*s.*s'*.9I19....9.7
medications
P_a_st_hislofl_i
. Similar attacks.
. Common diseases: (DM, Hypertension, TB, B, Hepatitis, DVT).
. Blood transfusion.
. Previous Operations.
F__a_mily__hlslp-ryi
. Consanguinity.
290
Examination
General:
II'I'I'II'III'IIII'III'I
$, General examination may
reveal the apparent cause as
hemolytic anaemia.
. Pulse, blood pressure & temperature.

. Head, Neck, Spine (esp. in breast swelling) > 3 dJ-,.-ti
LOCaI : 4ir^r,Jc -i! -r OL5ll .J' C^^,
ExIg-s-ure ) till area of L.N drainage.

.i
hsB-eetio-nt u4
Floor
1. Site:
- Venous ulcer )
gaiter area.
- Rodent ulcer )
face (above line
between angle of mouth and
ear).
2. Size:
3. Shape:
- Rounded.
- Oval.
- Geometrical.
4. Number:
- TB > multiple
- Malignant ) single
291
5. Edge:
- Punched out ) $, venous, TB.
- Undermined ) TB.
- Sloping ) healing.
- lrregular ) traumatic.
- Rolled in ) BCC.
6. Floor:
- Everted ) malignant.
- TB > caseous material.

ffi
- Neoplastic ) necrotic.
7. Margin:
- lnflammatory ) red, tender.
- TB ) cyanotic.
- Venous ) pigmentation & eczema.
Fknr HeaIftry Unhealflry

Anorut Reasonable "flat with the Scanty or exuberant
surface epithelium".
Stnfo@ Granular Smooth and glazed
Colour Florid red Pale red
Disclruge Minimal ornil Excessive pyogenic
ffnguicrnqrbrwu Not present May be present
Bleedingontoucl, Not easily Easily
Mlr Fishy Offensive
8. Discharge: bloody, purulent

P-a-lp-ati-o-nt aSJrs,
1. Base:
- lndurated ) venous, ischemic
- Infiltrative ) malignant
292
2' rend:'ffr;J5' a+-: & .-j:'
- neoplastic ) not tender except late.

Venous ) tender
3 Re' a t;:"i:T; i:":il: L J::: :lL rd i n s to sus pected

cause:
- Pulsation in ischemia.
- Oedema in venous.
- Sensation in neuropathy.
tymp-h--no-d-es-:
No examination of a swelling is complete without the examination
of the draining L./Vs
Special investigations
-l*hgr.?.-t9rv....*.Tlv..9.-s-F*g.*L*.gI1.;.
R*..**e }e.s *.s ? I... +.+vs.e. F.+ s*9 * g *. :. :.

Plain X- ray, Doppler, duplex U/S.
P*3helg.g*.s.+.I....*.+vs.e. P.*se}*.e*.;,
Biopsy (Excisional).
Provisional dia osrs

Anatomical
!t is diagnosis of the region which is affected.
P.*Hh.elg.e*s.+.I
traumatic, inflammatory, neoplastic ....etc.
T.8., venous, malignant ...etc.
Browse's introduction to the symptoms & signs of surgical disease/ Chlhistory &
examination of an ulcer/p32
293

A.
. An ulcq in the..... (Mention theregion of the face)1most probably arodent uLcer.
Q. How you reach the diagnosis?
A.
. Due to the presence of che pathognomonic featute.s of the rcdent ulcer which are:
The taised, ro[led-in edge: Because of the rapid growch of the tumor at che edge as opposed
to necrosis in the cerrter of the ulcet.
The pigmented edge. - Thebeaded edge.
Q. What ate the other chanacters of rodent ulcerT.

t Sitg above a [ine extendingbetween corner of mouth and lobu[e of ear.
t Size: any size.
t Shape: rcundedl ova[ or iregular.
' Edse: raisedl rolled iry beaded and pigrnented.
' Floor: covered with a ctust.
. Base: lndutated, tnay be fixed to the undeilying tissue (rnuscle, cartilage or bone)
' Marsin: nay be pigmented.
' Draininq L.N.' Usually not enlarged.
Q. How canyou differcntiate the ulcer of squamous ce[[ carcinoma of

the f ace fro- the rodent ulcer?
A.
' The ulcer of squamous cell carcinoma of the faceis characteizedby:
' Site,: Arrywhere in the f ace, usually inlower lip.
Size: Any size.
.' Shape: Rounded, ova[or iregular.
T Edge : Raised, rolled out/ evetted.
I F[oqr : Raised, inegular showing necrotic tissue.
I Base : Lndurated, rnay be fixed to the underlying tissue (rnusclel cartilage or bone)
I Marscin : Muy be pigmetted.
. Draininq L.N. : May show rnetastases.
Q. Whatyou expectthe findings in the drainins L.N. in a caseof rodent ulcer?

A.
They are noc enlarge d but they rnay be enlNged in two conditions:
r. Secondary infeccion of the ulcer leadins to zry lymphadenitis (L.N. ane srnall tendetl
discretel soft to firm)
2.. Transformation of the basal ce[[ carcinoma into squamous cell carcinoma leading to
tnetastasesin the draining L.N. (L.N. atelNge,hard,nottenderlmatted,fixedl
294
Q. What are the precancerous condirions of the skin?

A.
r. Exposure to sunlight ) Squamous cell carcinoma 8tr- Basa[ ceLI ca.
z. Leucop[akia ) squamous cell ca.
3. Senile (so[ar) keratosis ) Squamo us cell carcinoma,, S[ Basa[ cel[ ca.
4. Xerodermia pigmentosum ) Squamous ceII carcinoma 8f Basa[ ceII ca.
5. Chronic scars/ chronic ulcers, chronic fisswes ) Mariolinulcer
6. Papil[oma ) Squamous cell. ca.
T. I(cratoacanthoma ) Basal cell ca.
Q. What investigations doyou want to do in this case?

A.
ln addition to routine invescigations,
r. X rav sku[[: to show any invasion of the underlying bone (if the uLcq is overlying and
attached to underlying bone)
2. Biops)r: which show the palisade appeatancein the histo[ogical study
According to the size of the ulcer
o Lf the ulcer is large:Wedge biopsy from the edge
o lf the ulcer is sma[[: totaL excisional biopsy
Q. How wouldyou tteat the case?
A.
. Wehave two methods for the treatrnent of rodent uLcq which are equalLy
highly likely to cure the condition:
A.iurg:ew:
Ls prefered in most of the cases because:
Lt cwes rupidLy.
Ltyields better cosmetic results (radiation produces an ug[y scar).
Lf the ulcer is overlying cartilage or bone,, radiation is contraindicated
(causes necrosis of the bone or cartiLage) and
Lt does not need radiation faci|ities.
. Excision shou[d include thehealthy layer immediately bel,ow the layer invoLved
atleasttillthe deep safety margin 1cm.
. We covel the defect fasciawith
after the excision of the ulcq with Skin g:aft or skin flap
according to the extent of the depth of excision.
B. Radiotherapy:
34oo R is usedfor 4 days.
Q. What is the treatmerrt of epithelioma of thefacel
A.
As in rodent ulcer, there are two methods of treatrnent; 1urge,ry &-
Radiother apy. 1urgery is prefered in most of the cases (reasons mentioned
before).The safety margin wiLlbe r cm.
. lf the dtainins L.Ns are tnvolvedl bLockneck dissection is done on the
affected side.
. lf the drainins L.Ns. arerlottnvolvedt fo[[ow up is essentia[ for fear of
development of secondaries in L.Ns.
295
Case 2: YeftOLfS ulcer
Q. what is your diagnosis?

A.
o Ashronic [eg ulcer on the medial side of che leg ( in che gaitu area) mosc
probably venous ulcer
Q. how do you rcach ut diagnosis?

A.
. Due to the pteser'ce of pathognomnic featwes of the venous ulcer which is:
o Site : in the gaiter areaiust above themedial m[[eo[us
o History of the cause:
- DVT: painfulswo[len [imb
- Varicrreveins: but in 5oo/o of the cases/no
manifestation of W
Q.what are oth,-r ctitefia of venus ulcer?.

A.
. Site: As above
. Age: Atfirst slopping &-irregulN l later on punched ouc
o Marsin: Skin around it is pigmented
o Base: Lndurated
o F[oor: ' Lnfected: dirty granulation tissue
- N on-infected : healthy granu [ation tissue
. LN: Enlargedif infected
Q. What ate other causes of chroni c leg ulcer?

A.
r- lnf[amm atory ulcer: eg chronic osteonryelitis ulcer- tp1 syphilis
z-Traumatic ulcet
3-|.rl eop [a stic ulcet eg: s q u arn o u s cell carci noma 7 me [anoma
4-Vascular ulcet: - ischemic ulcer - venus ulcer - [ymphatic ulcer
s-Neuro trophic ulcer
Q.What arethecomplications of this ulcer1.
A.
o lnfectiory hemorrhage, osteomylitious lpei ostitis 7 margo[in jolin ulcer
1 telepi u s equine v atu s.
Q.how to differcntiatebetwennvenous ulcer Et ischemic ulcerT.
A.
o SeeVascularbook
296
Q. what arethe investigations that canbe done?.

A.
. lnv for the cause: e.g: Doppler 8t duplexl biopsy if suspecting
malignancy
Q. what is the treatment of the venous ulcer?

A.
I. Rest
2. Elevation of the [imb
3. Elastic stockings
4. Dressing wirh saline 8L not antiseptic because of the eczma most ulcers
heal in 3-4weeks (EU5OL:"edembrauniversal'solution of [ife" Canbe
used as a mild antiseptic)
r. Cockett Dodd operation: subfascial [igation of the ank[e perforators

Str-
z. Lf f ailed excise the ulcer &- covet it by cross leg skin f [ap
3. Then treatmentof the cause e.g varicose veins
) 1ee che chapter of ischemia
297
UISCB[I;INIIOUS
SHIIBT
Sfieet
Introduction:-
Age incidence of hip disorders
,@ of titrp ot diqrueis
a-2
_.: developmental (congenital)dislocation
Pw
2-5 tuberculosis arthritis, transient synovitis
5-10 perthes's disease; transient synovitis
rc-20 i slipped upper femoral epiphysis I
20-50 --f os[eoa-rtriiiis (2rv io pievious inJury oiors.f-,

50-1 00 l-o;Goartnritis tt ryt
Hip joint symptomatology
Pain
* Pain arising from hip : ft Pain referred to hip
"true hip pain" ; r'----
--{ pain"
"false hip
- -l
i- i7{--'i Hip ;oint paiioiil i spin" oisease
:----------:--=^';-:::^r.,1^
:s : Felt mainly in groin,
^-^;^ +-^^+ inner .: r^r*
^-,^^^-
front or Felt -^rîll^ ^'l;^î--^;;:----------j
mainly in gluteal region
.:h:.$ i side of the thigh :
R"f"rr"d to knee to the back or outer side of

i$I ' , If;,lif,,"t
i lt : walking : Stopping &lifting objects

:y
:
i ,--i 919-!:T:-d-ry-Y9!1s-,-- i
Limping '------------l
r r
' Unilateral t, Bilateral
i-----+------------.1 i
i__ _-_4r_rteleig_gdt_______1___f19a_{_e_leIr!_Ulg_g_q!t
: waddiing gait :
Pt. tends to :-
' use a stick in the ' Pt. leans towards the ln cases of:-
opposite hand affected side to lift the BiI. D.D.H.
. nninimizing the period of Or
sound leg clear of the
wt. bearing on the ground. Bil. Coxa vara
affected lirnb
De.torrnity of the Hip

Causes:
Synovitis , ant. dislocation. of hip @@' abd., flexion , external. rotation.
Arthdtis, post. dislocation of hip rotr=:+ add. , flexion, internal rotation
coxa vara , fracture N. femur nE:::> shortening & external rotation.
o,/E:
Fixed flexion defs ity: lumber lordosis
masked by
Fixed abd. defsrmity : 3 apparent le tltening
3 scoliosis (the curve towards heatrthy side)
apparent shortening
scoliosis (the curve toward dis. side)
Sraellin
Analysis of swelling (as any swelling)
See general sheet
fuutine C finicaf E 4amination irc Suspe cte{

cDisorders of tfie I{ip'-
A) -[.-q-c-a].- e-{ -q-f- f h e- -H-ip=
=
Exposure:
Pt. should be stripped except for a pelvic slip (and a bra. lf female)
The pt. is walking unr---> Q3i1

The pt. is standing ror----)- Jrendelenbtlrg's test
The pt. is supine ,o- exanr.ine for frxed deforrnity
The pt. is prone oE Ely's test
,,
for rectus femoris spasm in case of c-p"
N.B.: rnhile the pt" is supine, preliminary step is setting the

pelais square rnith the limbs=leaeling.
Palpation:
W.nf.mft-t.. -Denote active reaction inside the joint

-Mid inguinal point tenderness --+ sure lesion
Tendp..r+.eS.q=. (o.A.) in hip
Tenderness on pushing greater troch. --- fracture neck or dislocation
In'I{'
I{e.fgthiS.p.ig.+.;.. Absent femoral pulsation in cases of neglected
post. hip disloc" or DDH
300
M.qy.ggr..p.+.-tq.;
" Start with actiae then complete utith passizte mou.,
Flexion: 1 300
Extension: Nil
(Test uthile the knee is flexed to abolish action of hamstring)
Abd. 300 -350
& abd.In flexion : 70o
Add.: 25o -30o
N.B.; lf rotation. is limited in hip extension €t of normal range in flexion: normal joint but
spasm of ileopsoas ms. dt. Appendicitis or iliac abscess
a- Girth (circumference) t ms. wasting "Glutei"

b- Length
* Real(true):
. Supratroch.
. Subtroch:
-
Femur
-
Tibia
* False:(apparent)
Only if uncorrectable sideway tilting of the pelvis
Spp..si+l.f.eqf ;--
. Ielescoping.
. Ortolani.
. Barlow's fesf.
-B)-9y-s-t-em-ie-examin-a-tr-qn-in--c-aq-ee-e-f -TE--qf-hip--,
_Q)_E_xa_m_i_rla_tio_q-q_f "t_h_e .qp_in_e_f_qr_exftlnsi_c__c_a_tr_s_e_ef__hip_p_e_in
Browse's introduction to the symptoms & signs of surgical disease/ Ch4 Ms, tendons, bones,
& ioints p127, 128
301
Measurements
ReAl Of TfUe length me^SLfementS From ASts to nedial maileotus
To obtain an accurate comparison of true length by surface measurements , the
two limbs must be placed in comparable position relative to the pelvis
i.e :
The angle bgt. Each L.L €t the pelztis is the same
Ftxed
II adducflon
tt t
defarmif y
Sound limb
I
I adduc*ed
f
lhrouah
equol angle
if one limb is adducted & can't be brought out to the neutral position, the other
limb must be adducted through a corresponding angle by crossing it over the
1st limb before measurements are taken
similarlv if one hio is in fixed abduction
A) Fixing the tape measure at ASIS B) fafing the reading at the medial
with the flat metal end plac6d malleolus where the tip of index finger
immediately distal to ASIS & pushed is placed immediately distal to the
upagainst it. medial malleolus &
pushed up against it
lf there is real shortening determine whether:

T Supra trochanteric Or
I Sub trochanteric
302
The measurement of Bryanf's A

Nelston's line
The corustructian of shoetnaker's line
* Bryant's A;witn the pt. lying s rne
rneet the 1st iine at right angle (this is the important line
- it is rneasuned & compared on the two sldes)
- The 3rei line is unimportant; it joins the ASIS to the tip of greater troch.
. B. if there is a possi'nility that both sides are abnorrnal, measurements

of tsryant's A is I.{OT helpful)
x Nelaton's line: with the pt. laying on the sound side
- A string !s stretched on the affected side fron'r ischial tuberosity to ASIS.
- frlormaliy, the greater trochanter lies on or below that line
- IF iies above it 9the femur has been displaced upwards
* Shoetmaker's line
- A llne is projected on each side of the body from the greater trochanter
Thnough & beyond the ASIS.
- Normally, the two lines rneet at the midline above the umbilicus
- lF one femur is displaced upward (owing to supra troch. shortening) ) the
lines wiNl nreet at or near rnidline but below the umbilicus.
ttq-qfu.--$k-o-t-t-
Inci'idu.f rthe:-
il:,1?#:?ff TJ,.'-:"|lf ,**ffi 3S,:ff
' Tibia (line of knee joint to medial rnalleoitls)
On each side
Slq-e-rysfi-t-s--ef -'!qgp-qrc!$'-'-dip-qep-q4-cg-i-ry-l-i11sU-letryth;
-TO measure apparent discrepancy , the two limbs rnust be
piaced parallel to one another & in a line with the trunk
-lVleasurements are rnade frorn xiphisternum to each medial rnallealus "
303
The usual cause is:-

Fixed adduction deform ity Fixed abduction deformity at
at one hip )appearance one hip )appearance
of shortening on that side. of lenEthening on that side.
Apparent or false discrepancy in

Limb length is dt. Uncorrectable sideway
tilting of the pelvis,
sq
There's no need to measure for apparent
discrepancy if pelvis
Iies square with the limbs as determined by
position of the
two ASIS.
Examination I.qr.fire-d.d.eIpnnils
-Eixe-d-add-rlqfiq-n-d-ef-o--rm-Lty--l
The transverse axis of the pelvis (as indicated by the inter-spinous line)
can't be sef at a right angle to the affected limb but acute angle with it.
EiXe_d_ab-d-qetiq-ndef-q-f m_i_qf_lobtuseanste
Ei xe-d _f I ex-i q n -d e-f o_ r m ity;
Browse's introduction to the syrnptoms & signs of surgical disease/ Ch4 Msrtendow,
bones.& i oints/P I I 4-1 I 5
Thomas Test
tulncr?le:-
- lf there is a fixed flexion deformity at the hip the pt compensate for it (when he
lies on the back) by arching the spine & pelvis into exaggerated lordosis, this
allows the affected limb to lie flat on the couch.
- To measure the angle of fixed flexion deformity, it is necessary to correct the
lumbo-pelvic lordosis. This is done by flexing the pelvis (and with it the
lumbar spine) by means of the fully flexed sound limb.
. Tecltnlque :-
- One hand is placed behind the lumber spine to assess the degree of lumber
lordosis:-
o lf no / lordosis )
no fixed flexion. (and so, do not proceed.)
o ff / f brdosis )
the sound limb is flexed to the limit of its
range then the limb is pushed further into flexion tillthe
arehing of spine is obliterated.
- During this maneuver, the thigh of the disordered limb (if in fixed flexion) is
automatically raised from the couch as the lumbar lordosis is decreased.
- The angle through which the thigh is raised from the couch is the angle of
fixed flexion deformity"
Eixe-d-1-q-t-a-t-iqn--d_e-f-o-r-mi[y-:
- The most reliable index of the rotational position of the thigh is the patella
which normally points fonrvard or slight lateral rot.(max":150)
- lf there's fixed lateral or medial rotation, the limb can not be rotated to neutral
position.
- The angle by which it falls short of the neutral when rotated as far as possible
is the angle of fixed rotation deformity
305
1. I}g-:.-+-9-ll
The normal,range of true hip flexion about (
. Best demonstrated by flexing the hip &knee
together and not by lifting the leg with straight knee.
. Movement of the pelvis is best detected by grasping
the crest of ileum,
. Only in this way it is possible to distinguish between
true hip flexion & the false flexion done by rotation
of the pelvis.
2.3h-9-99-9l-o-+
"The normalrang of the abduction at the hip is 30o - 35o "
. The limb to be tested is supported by one and while the other hand
bridges the pelvis from ASIS to ASIS.
. ln this way true abd. At the hip can be differentiated from the false abd. That
is done by tilting of the pelvis.
3.Abduction in flexion
The normal range is about 70o
. This is often the 1st mov. to suffer
restriction in arthritis of the hip.
. The pt. flexes his hip & knees by drawing
the heels towards the buttocks. Then he
allows the knees to fall away from one
another towards the couch.
4.Adduction:
The normalrunge of adduction is about25u -30u.
. The limb to be examined is crossed over the other limb.
. Care must be taken to differentiate bet.
. True adduction & the false mov. done by tilting of the pelvis
5. Lateral rotation and medial rotation
The nomalrunge of both medial &\aterul rotation is 40o
6. F-T- !g-fr- p-
+- -o- + -- -i
of extension at the
N.B.: Extension of the hip joint beyond the neutral position is preoented
by the strong anterior capsule €t reinforcing Y-shaped ligament
N.B.; Backward tnoo. oI the thigh is due to rotation of the pelais B
extension of the spine €t not bu extension of the hip ioint
306
Examination fo, abnormal mobility

In cases of marked instability of the hip esp. in children:
to?t Telescoping test :
- The limb is grasped firmly in one hand and alternately pushed and
pulled in its long axis.
- The trunk being steadied by the other hand upon the iliac crest.
{t Ortolani & Barlow's test:
- Gentle abduction and

- Adduction of the flexed
- Hip and reduction or
- Dislocation of the head
-
-
Direct pressure on the
Longitudinal axis of the
while the hip is adducted
a\
detect any potential subl
or posterior dislocation
Examination fo, postural stabiWy

"Trendelenburg test"
*Prfurc!p_l_e__oJ_!ke_t_es!-:_
- Normally, when one leg is raised from the
ground, the pelvis tilts upwards on that side
through the action of the hip abductors of the
standing limb.
- lf the abductors are inefficient, they are unable
to sustain the pelvis against the body weight
and it tilts downwards instead of rising up on
the side of the lifted leg.
307
* Technique:
Stand behind the pt.
-
lnstruct him first to stand upon the sound lirnb and to raise the other
from the ground (having thus got the idea of what he is required to do.)
-
He should now stand on the affected leg & lift the sound leg from the
ground.
- By inspection, or by palpation with a hand upon the iliac crest, observe
whether the pelvis raises or falls on the lifted side.
Remember that the limb uDon which the pt. stands is the one under test.
Cnuses of positiae Trendelenburg test.

1. Paralysis of the abductor muscle (eg.:
poliomyelitis)
2. Marked approximation of the insertion of the
abductor muscles to their origin by upward
displacement of the greater trochanter, so that
the muscles are slack (eg.: severe coxa vara,
developmental dislocation of hip)
3. Absence of a stable fulcrum about which the
abductor muscles can act (eg.: ununited fr. of
the femoral neck).
4. Sometimes two of these factors may operate
together: for instance, in a case of upward
dislocation of the hip there may be an unstable
fulcrurn as well as approximation of the origin of
the abductor muscles to their insertion.
Browse's introdaction to the symptoms & signs of surgical disease/ Ch4 Ms,tendoms,
bones,& ioints/P I 3 0-1 3 1
308
Pain :- due to.

lntrinsic cause
extrinsic cause
Recurrent attack of locking & unlocking:-
Def.:- sudden inability to complete the movement
Gauses :- Meniscal tear
Chond romatsis synovitis
Osteophytes of O.A.
Osteochondral fr,
the whole length of the limb must be

uncovered
Inqp-e-c-tiqni
o Skin
o Swelling
o wastins: " quadriceps is the miruor of knee joint"
o Deformity
o Gait: (cB4).
P-alp-A-t-i9-t-:-:
o Warmth
o Tenderness
o Diffuse joint swelling
Mgyeg_r-e-t-t-:-:
o "zero line is straight limb"
o Flexion: 140o - 150o
-s-ta-b-ilifyi:
o Stress valgus test ) for medial collateral lig.
o Stress varus test ) for lateral collateral lig.
o Anterior & posterior drawer test ) for cruciate lig.
B-qta-tien-te-qt-(M-cM-utra-y)t:
( Of value mainly when a torn meniscus is suspected ) .
309
Diffuse Joint Swellin

* Can arise from:
A--Ihi s-k e-n ins -qf -b-q n-e,
. Detected by deep palpation if the affected side is compared with the
normal side.
_B_-T_hisk_ep_i_49_o_f _sy_4q_via!_nembrane;
. lt is a prominent feature of chronic inflammatory arthritis.
. Best detected by palpation of the supra patellar pouch
. lt has a characteristic boggy feel on palpation.
_c_-__f _l_qi{_w_ith_i4_th_e_
j_qiqt_(cf fsq_ip_+)i
* Typ_es oflfut4'
Serous : Blood
History Trauma
Bleeding disorder
Onset Slowly developed ; Rapidly developed

(12-24 hrs) (1-2 hrs after injury)
'-ttoftenie - ---i Tense
Local ex i
Not painful Painful
General i l\to febrile reaction
* How to test for lcnee effusion:

1__Elg_c_tq_etiqn__t_e_s_t j:
. The palm of one hand is placed
upon the thigh immediately
above the patella. (i.e.:* over the
supra-patellar pouch ) "
' The other hand is placed over

the front of the 7'ornt.
. Pressure of the upper hand
upon the supra-patellar pouch
drives fluid from the pouch into the main joint cavity where it pulges
the capsule at each side of the patella and imports an easily
detectable hydraulic impulse to the finger & thumb of the lower hand.
. Conversely, by pressure of this finger & thumb, the fluid can be driven
back into the supra-patellar pouch & hydraulic impulse can be
received clearly by the upper hand.
Brotuse's introduction to the symptoms & signs of surgical diseuse/ Ch4 Ms,tendons,
bones,& .i oints/P 1 3 1-1 3 3
310
2:-Be-t-eller-tap-:--
The patella is tappedbackwards sharply so that I
it strikes the femur rebounds.
. This test is -ve in the presence of fluid in two circumstances:-
1- When there is insufficient fluid to raise the patella away from
the femur.
2- When there is tense effusion.
Q:_E_rrlge__t_e_qti
' Resemble fluctuation test but squeezing the sac is from side to side.
{=_[!9_l_l_o_ry_t_e_qt_i
. Effusion obliterates the hollow present normally on the lateral aspect
of the knee.
A- Stress tests :-
. Stress varus & valgus tests
- Should be performed on the normal
extremity first for later comparison.
- The knee is flexed to 30o
- A gentle stress (valgus or varr-rs) is
applied to the knee with one hand
placed on the (lateral or medial
aspect of thigh respectively) and
the other hand grasping the ankle.
D_-_D-r_eWg_1[_e_s_t_s_;;
. Anterior drawer test
. Posterior drawer test
"For anterior cruciate lig." "For posterior cruciate lig."
311
..i. Technique:
- The pt. knee being flexed to 90o
- The foot placed firmly on the couch.
- Sit slightly on the foot to prevent it from sliding.
- With the inter-locked fingers of the two hands form a sling behind
the upper end of the tibia & clasp the sides of the leg between
the thenar eminences.
- Place the tips of the thumbs one upon each femoral condyle.
- Ensure that the pt. has relaxed thigh muscles.
- Alternately pull & push the upper end of the tibia to determine the
amount of A-P. mov. (normally, the A-P mov. ls not more than
112 cm)
C- lachman Test:
, With the knee flexed only
150 - 200.
. One hand supports the
thigh just above the knee
gripping the femoral
condyles while the other
hand grasps the upper end 1
of tibia.
. While the pt. relaxes the /)
muscles, the extent of any
anterior or posterior glide of
tibial condyles upon the
femur is determined by push & pull movements of the tibia.
-D:-9ag-9-ign-i
For posterior cruciate ligament only
(M. Murray's test)

Used onlyfor suspected teqr of the meniscus.
The maneuver is carried out bv repeat
1- Flexing the knee, first fully but in succeeding tests progressively less
fully, !fun
2- Rotating the tibia upon the femur, first laterally but in further tests
medially, and finallv
3- Extending the knee while the rotation of the tibia is still maintained.
A loud click, distinct fromthe normal patellar click and usually associated with pain, suggests a
tag tear of the meniscus. Caution : loud clicks can often be produced in normal knees. Most of
them arise from mooements of the patella, and they are not accompanied by pain.
Browse's introduction to the symptoms & signs of sargical disease/ Ch4 Ms,tendons,
bones,& joints/P1 3 3-1 3 4
313
Iryury Sfieet
I- History
(as general sheet).
I Occupational: lead poisoning of the nerve.
I Habits: alcohol neuritis.
eneral sheet)
,+l dL ,'',('o-l- -Al

Ask about the followings:
1. Trauma:
, Nature (fracture, cut wound,...etc)
. Relation to nerve injury
. Any associated injury
2. Deformity, wasting of muscles, weakness or loss of active movements,
trophic changes, sensory changes (type & site), loss of sweating, vasomotor
changes (color changes).
3. Swelling: traumatic neuroma, neurofibroma, nodules of leprosy, callus or
LNs. enlargement.
4. History suggestive of poisoning, leprosy, DM, anemia, pellagra, or syphilis.
5. ln case of carpal tunnel syndrome ask about history suggestive of
rheumatoid arthritis, gout or myxoedema.
6. Other systems affection.
of investigations & medications.
as general sheet)
leprosy, syphilis, D.M.
ll- Examination
A. Genera! Examination
. Complete neurological examination
- Search for evidences of diabetes, pellagra & lead poisoning.
B- Local Examination
Both sides are qtosed and compared sturting with the normal sidc
1. Deformity: is diagnostic.
2. Scar: (site, type of healing)
3. Wasting of muscles: along the course of muscles supplied by the
examined nerve.
4. Active movements: according to affected muscle.
5. It is lost in cases of nerve, muscles of tendon injury or joint diseases.
6. Trophic changes: shiny, stretched skin, loss of hair, trophic ulcers &
brittle nails with loss of their lusture.
314
1. Muscle power: test the active movements carried by the muscles

supplied by the nerve examined against resistance.
You shouldfeel the contract@ muscle or its tendon
2. Sensations: (close the eye of the patient). Tested by pin prick.
3. Nerve: swelling (neuroma, leprosy).
4. Passive movements: stiffness ofjoints in long standing injury.
5. Adherence of scar to deeper structures i.e. pull on the scar ) attached to
deeper muscles).
6. Examine the limb: e.g.
1. Surrounding injury.
2. Bones (mal-united fracture or callus)
3. Joint.
Tinel's sign (detect Ievel of regenerating axons for follow up).

III-Diagnosis
1.ls there a nerve injury? (According to clinical picture).
2. Type of nerve injury (partial or complete).
3. Nature of nerve injury: neuropraxia, axonotmesis or neurotmesis.
4. Level of nerve injury: according to site of trauma, extent of sensory
Ioss or extent of paralysis & palpable neuroma.
315
Exposurefrom the nipple upwards to allow uamination of roots, trunks,

divisions, cords & nerves of brachial plexus bilaterally.
1. Deformity: partial claw hand.

2. Scar: (site and type of healing)
3. Wasting of med. aspect of forearm, hypothenar eminence, palm & dorsum of
the hand (Palmar & dorsal interossei) & adductor pollices muscle.
4. Active movements:
a) Hvpothenar (Abductor diqiti minimi): abduction of Iittle fingers while
fixing the middle 3 fingers (to avoid the action of dorsal interossei).
b) Dorsal interossi: abduction of fingers on the level of a table
c) Palmar interossi: adduction of fingers on the level of a table.
d) Lumbricles: paralysis of the medial 2 lumbricles causing partial daw

hand.
e) Adductor pollicis: froment test positive as there is flexion in spite of
adduction to keep the paper.
f) Flexor carpi ulnaris: Flexion of wrist ) ulnar deviation.
s) Med. 1/2 of flexor digitorum profudus: flexion of terminal
phalanx of little & ring fingers while supporting middle phalanges
of these fingers (to avoid action of F.D.S).
1.Motor power: active movements against resistance.

2. Sensation along medial 113 of palm and dorsum of hand as well as
the palmar and dorsal aspects of the medial 1 112 fingers.
3. Palpation of the nerve in the axilla, med. aspect of arm, behind the
med. epicondyle, along the med. aspect of the front of the forearm &
the wrist.
4. Passive movemenb.
Tinel's test
Browse's introduction lo the symploms & signs olsurgical disease/ Ch5 conditions peculiar to the hand/p146-147
316
1. Deformity: ape hand

2. Scar (site and type of healing) tne axilla, arm, lat. Aspect of forearm or the
wrist.
3. Wasting of lat. aspect of front of forearm & thenar eminence
4. Trophic changes in the area of the skin supplied by the median n.
5. Active Movements:
. pronation of supinated flexed forearm with
upper arm adducted (to avoid int. rotation of shoulder).
.
Flexor Carpi Radlalisl Flexion of wrist )
ulnar deviation
.
Latera! 1/2 of Flexor Diqitorum Profundus: flexion of terminal
phalanx of index & middle finEers while supporting their middle phalanges
(to avoid the action of FDS).
. Flexor Diqitorum Superficialis:
Flexion of middle phalanx, of med. 4 fingers. Test one finger while fixing the
other 3 fingers (Grhame's test). This test depends on the anatomical fact that
the action of flexor digitorum profundus is mass action while action of flexor
digitorum superficialis is isolated.
. Lat. Half of FDP & FDS & Lateral 2 Lumbricles:
To test all flexors of all joints of the index & middle fingers.
* Ochner's clasping test: ask the pt. to clasp the 2 hands.
* Benedication attitude: ask the p. to raise his hands facing you, the
outstretched index finger and the serial flexion of the other fingers has
been linked to the attitude of the hand of a priest with his arm held aloft,
giving God's blessing to the congregation..
* Pistol hand: ask the pt. to close the hand.
- ln median nerve injury any of the above leads to pointing of index finger.
Movements of thumb:
1. Flexor Pollicis Longus: flexion of terminal phalanx while fixing proximal
phalanges (to avoid action of flexor pollices brevis)
2. Flexor Pollicis Brevis; flexion of extended proximal phalanx.
3. Abductor pollicis brevis:
. Pen touching
- Ask the pt. to touch the pen by the side of extended
thumb (to avoid the action of abductor pollices longus) while the dorsum of the
hand is fixed on a table.
o Wartenberg's oriental prayer's position:
- Ask the pt. to touch the tips of index & thumb of both sides.
- ln median nerve injury the tip of the thumb of the atfected side touching the
base of the pulp of the normal thumb
4. Opponens Pollicis: loss of apposition.
317
l.Motor power: active movements against resistance.

2.sensation: along the lat. 213 of the palm of the hand & the parmer
aspect of lat. 3112 fingers as well as the dorsal aspect of the terminal &
middle phalanges of these fingers.
3.Palpation of the nerve in the axilla, cubital fossa & lat. aspect of arm
& forearm
4.Passive movernents
Tinel's test
Browse's infioduction lo lhe svmptoms & sisns of sursical diseasd ChS conditions peculiar to the hand/ p146
1. Deformitv: Flexion of elbow, pronation of forearm, wrist & fingers drop.

2. Scar: (site and type of healing)
3. Wastino: Along back of arm & back of forearm
4. Active movements:
. Illgggi-extension of elbow.
. Brachioradialis: flexion of elbow in the midway between pronation & supinatio
. Sg.p!4!S, supination of pronated hand to avoid the action of biceps muscle.
. Extensors of wrist: extension of flexed wrist while supporting the forearm.
.@extensionoffingerswhilefixingthewrist.
'=.'i " "nffi !' ;li111il5;1 :",t'J :'iff#:?fr",.[; " "
r ca rp i s u In a r i :
U.L.
t resistance. ^
first metacarpal bone.
3. Palpation of the radial nerve in the axilla, post, aspect of arm & lat. aspect of elbow.
4. Pas'sive movements.
Tinels test
Special Notes
1. D.D of claw hand:
. Ulnar (partial) claw hand,
. Combined ulnar and medium N. injuries
. Klumpke's paralysis.
, lnjury of medial cord of brachial plexus,
. Volkmann'sischaemia,
. After burn or dupuytren's contracture,
. Advanced rheumatoid arthritis,
. Negiected tenosynovitis of ulnar bursa,
. Neurological causes (syringomyelia...etc).
318
2. UInar paradox: injury of ulnar nerue at elbow ) less marked deformity while injury at
wrist ) more marked claw hand.
3. r nerves:
a) Movements of thumb: adduction (ulnar), extension (radial) & other movements (median).
b)Sensation of rinq finqer: medial aspect (ulnar), lateral aspect (anteriorly )
median & posteriorly ) radial).
c) Characteristic deformity.
d) Froment's test (ulnar).claspinq test (median) & finoers drop (radial).
Q. What ane the f actors affecting prognosis of the injurednervel
A.
1. Neuroaparoxia has the best prognosis.
2. Better prognosis occurs with the purely motor nerves than mixed ones.
3. Nerve supplying a bulky muscle has better prognosis than that supplying a fine
muscle.
4. Good apposition of the cut ends of the nerve.
5. Asepsis: sepsis interfere with regeneration due to fibrosis, ascending neuritis and
loss of nerve tissue.
Q" 14/hat ane the evidence of rlelereseneration?

A.
1 . The 1't to recover is the crude sensation.
2. Then the motor power "starts proximally early then distally".
3. Then epicretic sensation is the last to recover.
4. Tinnel's sign: percussion just distal to the site of cut nerve corresponds to the
possible site of the regenerated nerve.
Browse's introduction to the symptoms & signs of surgical disease./ ChS conditions peculiar to the hand/ p146-147
3t9
(Parotif,Swrtt@
l- History
1. Age: mumps in children, or malignancy in old age.
2. Sex: tumors are more common in males.
3. Occupation: Occupational disease in trumpet players & glass blowers.
4. Oral hygiene.
Complaint: as usual
Present historv:
ff.,j^l i:L dis i-* -=i
1. Pain: (analysis as usual). This occurs in sialoadenitis, mumps, autoimmune
sialoadenitis, duct stone or late malignancy.
2. Swellinq: as usual but notice the effect of eating on the pain and size of the
swelling.
3. Disturbance of function:
. Manifestations of autoimmune sialoadenitis: as dryness of the mouth and
conjunctiva and rheumatoid arthritis.
. Local manifestation in the form of facial palsy (inability to close the eyes,
accumulation of food between the gum & the cheek, drippling of saliva from
the angle of the mouth),
. Manifestation of metastasis: (as usual)
4. Historv of investiqation and treatment.
Past HistorV: as usual + oral sepsis, oral breathing, hypertension ....... etc.
Familv Historvt as usual.
ll- Examination
A. General Examination:
. Aim: detection of LNs enlargement, signs of metastasis or signs of autoimmune
disease.
B. Local Examination:
I. Features of the swellings:
, Notice that the swelling elevates the lobule of the ear because the deep fascia
of the parotid is defective upwards
Examine the following:
1. Facia! nerve:
2. Masseter: Ask the pt. to clinch the teeth.
3. Sternomastoid: Ask the pt. to turn his face to the
320
4. Superficia! temporal pulsation (in front of tragus of the auricle). Weak

or absent pulsation in malignancy.
5. Oral cavity:
.
Position of the tonsil: if it is displaced medially it means enlargement of
deep lobe of parotid gland.
.
Orifice of parotid duct (Stenson's duct) opposite the upper 2 nd. Molar
tooth. ln suppurative sialoadenitis, there are inflamed, red, raised
orifice with pus comes out on compression of the swelling.
6. Relation to bone.
7. Examination of upper and lower deep cervical L.Ns.
Su 6manfi6ufar g [an[ sw e tfing
I-Historu:
.@
o Age: young or middle age (not common in children)
o Sex: males=females
. EP!:
o pain: dullaching radiating to ear or tongue
o swelling: beneath the jaw
Both worsens after eating
ll:Examination:
o Site: swelling in the digasteric triangle
o No: solitary (in order to be differentiated from the submandibular LNs)
Can't be rolled over the angle of the mandible
o lnspection of floor of mouth: May reveal redness of the duct orifice
o Bimanual examination: Reveas that swelling is in the floor of the mouth
I-IJenrgn fumors
I,Pteomorphlc adenoma
l.Hlstorvl
o Personal history: male old age
o HPI:
.
Slowly growing painless swelling in the side of the face
.
Swelling becomes more prominent on contraction of the masseter ms,
but doesn't actually increase on size on eating
321
ll-Examination:
Site: - swelling over the mandibular ramus
- welldefined
- lobulated
- freely mobile( not attached to the skin ms or bones)
- variable consistency( firm or cystic but never hard)
- elevating lobule of the ear
- no cervical LN enlargement or facial n. infiltration
Il-rilorromorphic adenomat (Warthin's tumor)

Hlstory:
Personal history: Male old age
HPI: Painless slowly growing small swelling over the angle of the jaw
Examinat{on:
Site swelling over the mandibular ramus
- May be bilat.
- Small not elevating the lobule if the ear
- Cystic in consistency
Carcinoma of the salivery gland

Hlstorvr
Personal history: male old age
HPI: painless rapidly growing swelling on the side of the face
Pain is usu. Late & radiates to the ear
Disturbance of function: asymmetry of the mouth & or difficulty in closing the
Eyes
Examlnatlon:
Swelling in the site of the parotid gland
- Usually Warm & mildely tender
- Firm or hard in consistency
- Nodular surface
- ill defined edge
- lnfiltration of the skin
- lnfiltration of the facial n.( which may range from mild weakness of the lower
Lip up to complete facial n. palsy)
Cervical LN are enlarged, stony hard, mobile then fixed
322
Oral Discussion
Q. Surface anatomy of the parotid gland?
A.
P arotid gland: Connect the followins + points
o Head of mandible
. Middle of masserer musc\e
. 2cm below 8[ behind the angle of mandible
. Center of mastoi dprocess
Parotid duct:
Lt correspond to the rniddle r/3 of horizontal line dr awn from the tragu s of
the ear to a point on the upper lip midway between the ala of the nose 8L
the angle of the mouth.

A. Swe[ling in the parotidgland most probably stones
Q. How do you rcach this diagnosis?
A.
O/H: Mostly asymptomatic
History of pain 8l- swe[ling that increases after eating
O/E: Solitary swelling in the site of theparotid gland (acc. To the surface
anacomy)
- Raising the lobule of the eN
- Firm 8t tender
- Overling skin is warml red &- edematous
- The duct (stensonrsl isred, edematous/rnay dischargepusT Stscone rr,aybe
f ek by bimanua[ examination
Q. What are the investigations needed?

A.
. lnvestisation For infection : CBC: leucocytosis, ESII C&5/
. lnvestigation For stones: -Plain x-ray
- Sialography: is thebestbecause the parotid stones
ffi hiffi::::l::"zi::;:,""!:::::*,"
Q. What ate the complications of parotid gland stones?
A.
o lnfection
. Abscess
. Fistula
323
Q. Whatts treatment?.
.
[f stone is in the substance of the g[and: Supefiacial conservative
parotidectomy
. lf stone is in the duct: rernoved through the mouth under Loca[ anesthesia
Q. Treatment of comp[icacions?
A.
r-infection:
o Beforc abscess formation: lA( antibiotics, anaelgescis, antipyretics)
o Aftu abscess formation: surgical drainage by Hi[con's tech. ( don'c wait for
fluccuation as fluctuation isvery late)
z-saliverv fistula:
o lf in the duct----1-----+ masseteic: excision with end to end anastomosis
t-----+ Premasseteic: reimplant the duct in the buccinators
o lf in the g[and -]* Consewative:Parasympatholytic drugto decrease
I+Surgical: secretlons
Avulsion of the auricu[otemporal n.
(secretory fiberc to parotid gland if f ai\ed
sup efii ci aL p ar oti dectomy
Case 2: Submandiblar gland stones
Q.what is che incidence of salivery gland stones?

A.
Submandibu[ar> parotid ( 5o: r) due to:
r d seq eti ons at e rr,ot e vi sci d wi th hi gh C a. concentrati ons
-g [an
z-duct ascends upwards inadequate drainage
3-oifice [ies in the floor of the mouth liable to be blocked by food particl,es
Q. what' s yotsr diagnosis?
A.
Swelling in the digasteric ttiangle most probabLy submandibular gland stones
Q.how do u teach this diagnosis?
A.
O/H: Hiscory of pain &[ swe[[ins that increases in after eating
O /E: 5w eLling be\ow the mandibular ramu s
- Firm &-ter.der
- Overling skin is wanrn/ rcd &-edematous
- The duct ( W anton's) is rcd, edematou s/ rnay discharge pus, 8l- stone rnay
f elt by bimanu a[ examinaci on
324
Q. how to differentiatebetween submandibular gland stones 8t

submandibu lar LN Enlar gementl
A.
r- history of pain 8[ swel[ing that increases in after eating
z-swellingis solitary 8L can't berolled over the mandible
3- inspection of the mouth floor lr,ay reveal redness of duct orifice'!
4-bimanu aL palpation reveals swelling is fitling the floor of the rnouthl
Q. what are the investigations needed?
A.
r. plain x-ray (c\osedmouth view): stone in the submandibular gland is radio-
opaque in 8o o/o of cases
z. sialogram: shows the radiolucentstones
Q. what is the treaffiient of this case?
A
lf submandibular gland stone -+ submandibular sialadenectomy
[f stone in the duct
-+ removed through mouth under [oca[ anesthesia
Neoplasm Of The Salivary Gland
Q. what isyour diagnosis?
A.
.!. Tqmor of the parocid gland:
t-ll the swelllng ls
o Swel[ing over the mandibu[ar tamus on one side
o Well defined
o Lobulated
o Ereely mobi[e( not attached to the skin ms or bones)
o V ariab\e consiscen cy( firm or cystic but never hard)
o Elevating lobule of the ear
o No cervicat LN enlargement or faciaL n. infiltration
F This most probably pleomorphic adenoma
Q What is your managem entl
A.
r. lnvestigation: - CT scan for assessment of tumors arising fuom deep part in
the parotid
- ENABC: in 9o o/o shows pleomorphic adenoma
z.Tteatment:
- tf in the superficial parc+ Conservative superficial parctidecEomy
- lf in the deep part + Totalconservative parotidectomy
ndibular ramus
ule if the ear

rphic adenoma
end
Iand
aY tange
from mild weakntuss
of the lower
d, mobil'e then
fixed
the parotid gland,--
a of the saliverygland
r_rnucoepi dermoid.:
according ro
z-adenoid c.ysttc
_A carcinoma
J /\ctnl
_
c c eIIc ar cinom
a
4-adenocarcinoma
emicroscopic pic.
the [ocal extent
of the tumot/
326
/ Treatment:
. lf operable
According to the site of rhe rumor:
r. Carcinoma in the parotid gland:
-Tota[ radicalparctidectomy* total block dissection of theneck LN
* p os top e r ativ e r adi other apy to deq ease r ecufi ence
z. Carcinoma in the submandiblar gland:
- Comman do op er ati on ( tota I r adi c al s u bmandi bul ar si aladnectomy *
hemimandibulectomy) +part of the tongue+ block dissection of the

neck LNs
. [f inoperable
P alLi ativ e r esecti on + r adiother apy
Browse's introductian to the symptoms & signs of surgical disease/ Ch9 the salivery glands p 2j9
327
Ltp G[ Qafate
!: lliqte-lvl
i (as usual)
F GOmplaint: a mother complaining from disfigurement in her baby.
1- Cleft lip is discovered since birth.

2- Ask about any abnormalities during pregnancy
3- Ask about the predisposing factors (for the mother)
t + Fever and skin rashes (German measles)
. Drug intake especially during 1"t trimester e.g. salicylates,
corticosteroids or cytotoxic drugs.
. Exposure to irradiation.
4- Ask about the complications: (for the baby):
. Difficult suckling or feeding.
. Regurgitation of fluid & food from the nose (in cleft palate)
.' lmpairment of dentition with maldirected teeth.
lmpairment of phonation and speech.
. lmpairment of hearing with repeated otitis media (in cleft palate)

5- History of investigations and treatment.
Past History: similar condition, syphilis, fever or disease to mother.
positive family history or consanguinty
ll- Examination:
A-General examination :
1- Head & Neck:

o Defect or swelling related to skull (cranium bifidum)
o Neck swelling (cystic hygroma, thyrogloassal cyst, branchial cyst or
sequestration dermoid cyst)
o Fistula (branchial fistula)
2- Chest and heart: for congenital heart diseases.
3- Back: spina bifida.
4- Abdomn and inguino-scorta! reqion:
. Renal swelling (polycystic kidney or ectopic kidney)
. Congenital umbilical hernia.
o Absent testis (undescended or ectopic)
. Site of external urethral meatus (epispadius or hypospadius)
Ectopia vesica.
lmperforate anus (if newly born)
Polydactty or syndactly.
Congenital A-V fistula.
Congenital lymphodema.
328
B-Local examination:
1. ExaJmination for cleft lip:
a) Upper or lower lip
b) Lateral or median
c) Unilateral or bilateral
d) Complete or incomplete.
e) Simple or alveolar.
2. Examination for cleft palate:
a) Type: cleft uvula, cleft soft palate
b) lntermaxillary cleft.
c) Bipartitie cleft.
d) Tripartitie cleft.
lll- Diagnosis
For exampte: u case o7 witn bipartitie cteft patare,
""iiiiiiii;;*,ikt;;kVilip
complicated by dfficultfeeding and otitis media.
tfipospafiius
A.Q-e_1r_e-r_ql_eXamina_tj-o_n:-f gtth-e_-c_qngeillA!-an_o_me!'te-9.
B.L_o_qa!_e_XA-m-il_atr-o_n:Ce_t-e_c-St_the_tql_l_o-wjnss:
1- Sit of E.U.M) ) glanular, penile, perineal.
2- Circumcision:
3- Direction of penis.
4- Local anomalies (undescended testis, I hernia and
'Unfescenfef testis
A.9sn_e_tal--examina-tign:_f q_r-th_e_-c-qngen_i!a.!-an-o-nali-e_s=
B. L_o_q al _e_Xg_m_i n-a tr-o_U
o*"'"l'fttl*;liiitY#;ped
'- and there is deviation or the median raprre ir
unilateral undescended testis
, ln maldescended testis and retractile testis, the scrotum is not
well-developed.
2- restis:
: ]i1J""i"",:f:,.x?:ffi,":liffil:i,, testis
' Testicularsensation.
3- lf the scrotum is well-developed:
ffi f,. L'X;.""flT:ru:, i?I3:.l i.',".'"l iJ,.

superficial to muscle)
4- Examination: for inguinal hernia.
5- Other local conqenital anomalies.
329

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'It is more blessed to give than to receive.

Freely you have received; freely give.

@ Copyright 2013 by Mohammed El-Matary

1't Edition 2006

For further lnformation, visit our web site:

She was your gift for me

Specia! Thanks to:

Amira Ahmed, M.B.B.Ch

This book provides an update for medical students who

This book is designed to provide a concise summary of

Summaries of relevant anatomical considerations are

The author is extremely grateful to all the contributors for

* Name (i)l) 4+l dL-'l

* Age i.u as arie

" Address S 416St*l clt

" Occupation, f +l di5.ii

L,i*i3...11 q! .F,yJl .Eilf

) Localized to swelling or shooting distally

. C.h.er.+.sf.er 4+l 4Js*i o.t 6-s.Sll

Dull aching pain ) chronic conditions. di3

. Onset GJJ+ Y3 6.trl3 6.Jr qJ,ar

A. sp.e.ei+.t ed $v mp.t p..ltts dLle

Ae.gSSlt OtS. gll

. Onset €l-,1lieJSlsll c&i3sl

Toxic symptoms: ) FAHM

) Trauma, lifting heavy weight, emotional stress.

5) History of investigations or medications

T.B Hypertension Diabetes

d-L3.r.ll j Clgr-r. S,'F-?JrJ dyJJ,rll! o.tS LhI l+-Jl+l+ dlll+

ors &l ill ,rlltir

Loeal: 4jJ^J .,le .-E : cl$ll ,,Jo C*

di, , rLJt*{t P\'--'

E-Xp-O-S_U-fe ) til area of LN drainase

H,,. S-ki...+..q.Y..e rFJns.;

Transmitted pulsation Expansil lsation

T.gndgf[g$$: oLrll a+: ,] c# -r '+ll A is-.;s'

h"J il"t "fLr^P

[S. pseudo-fluctuation can be elicited in lipoma

ln small swellins: (MODIFIED FLACTUATTON TEST)

6,.. Rp I atip..n q. (M...q.bilifv). ;

7. Drainin g..L;gr.ph Nodes:

Transmitted pulsation Expansile pulsation

Grasp the swelling and ask the patient to cough:

2- Thrill: ) felt over aneurysm and A-V fistula

_Ireh era t_o r.y I nys. st_ige_ti o.n e_;

do S gp.. pi c I nyp_p_tlgeli o.np;

A..n e t-o-miee.l..hrh-e re. i s the

Q .Why we use the dorsum of thehand to feel the ternperatureT.

Q. When swelling is said to be freely mobile?

Q. When the swelling moves in one direction?

Q. What are the difference between radiating pain {referred pain ?

Q. What is the mechanism of referedpain?

Q .What is the differencebetweenparaesthesia 8t anesthesial

Case 7. Subctttaneous Lipoma

Q. How didyoureach this diagnosis?

*rt ate the points of differencebetween [ipoma and sebaceous cystl

Q. Whatis the e,xplanation of the slippery edge of the lipomaT

Q. Why is [ipoma is described as pseudo fluctuantT.

Q. Does the lipom a may become firm or hardl And whenl

Q. How doyou elicitfluctuation in avery small swellingl

; Y;A:;Ti, :!:;:Zi::: :il,i'":,::;,:i'l'JrI