IndexSl.No. Topic Pg.No.

12

34

56

78

910

11

12

13

1415

Shock and TransfusionWounds, Healing and Tissue repair

Surgical infection

Head and Neck

Pre and Post operative care

Basic surgical skills and anastomoses

Trauma

Skin And Subcutaneous Tissue

Breast Hernia

The peritoneum And Retroperitoneal spaceEndocrine

G I T

Bariatric and Metabolic surgery

Vascular DisordersCardiothoracic

Genitourinary

091419212628

44

1617

50

5869

8093

122

127143150211

Traditional classification of haemorrhagic shock.

Class

Blood volume lost as percentage of total

1 2 3 4

<15% 15–30% 30–40% >40%

TRANSFUSION

Whole bloodPacked red cells

- Each unit is approximately 330 mL and has a haematocrit of 50–70%.- are stored in a SAGM solution (saline–adenine–glucose–mannitol) to increase shelf life to 5 weeks at 2–6°C.

Fresh-frozen plasma- rich in coagulation factors and is removed from fresh blood and stored at −40 to −50°C with a 2year shelf life.- first line therapy in the treatment of coagulopathic haemorrhage- Rhesus Dpositive FFP may be given to a rhesus Dnegative

Cryoprecipitate- supernatant precipitate of FFP.- rich in factor VIII and fibrinogen.- stored at −30°C with a 2 yr shelf life.- given in low fibrinogen states or factor VIII deficiency.

Platelets- supplied as a pooled platelet concentrate and contain about 250 × 10/L. - Platelets are stored on a special agitator at 20–24°C.- have a shelf life of only 5 days.- given to patients with thrombocytopenia or with platelet dysfunction who are bleeding or undergoing surgery.

Prothrombin complex concentrates- are highly purified concentrates prepared from pooled plasma.- They contain factors II, IX and X.- Factor VII may be included or produced separately.- Indicated for the emergency reversal of anti coagulant (warfarin) therapy in uncontrolled haemorrhage.

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Wounds, Healing and Tissue repairPhases of normal wound healing :

1. The inflammatory phase - begins immediately after wound and lasts 2–3 days.

2. The proliferative phase- lasts from the third day to the third week, consisting mainly of fibroblast activity with the production of collagen and ground substance, the growth of new blood vessels as capillary loops (angioneogenesis) and the reepithelialisation of the wound surface.- in the early part - granulation tissue.- in the latter - increase in the tensile strength of the wound due to increased collagen(consists of type III collagen.)

3. The remodelling phase (maturing phase) :- maturation of collagen (type I replacing type III until a ratio of 4:1 is achieved).- maturation of collagen leads to increased tensile strength in the wound which is maximal at the 12th week post injury and represents approximately 80% of the

uninjured skin strength.

(a) Early inflammatory phase with platelet-enriched blood clot and dilated vessels.(b) Late inflammatory phase with increased vascularity and increase in polymorphonuclear leukocytes and lymphocytes (round cells).(c) Proliferative phase with capillary buds and fibroblasts.(d) Mature contracted scar.

The phases of healing.

Classification of wound closure and healing

Wound edges opposedNormal healing Minimal scar

Primary intention---

Reference :Bailey and Love’s Short Practice of Surgery 27th Ed Pg: 24

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Definitions of systemic inflammatory response syndrome (SIRS) and sepsis.

The ASEPSIS wound score

SSI rates relating to wound contamination with and without using antibiotic prophylaxis

ASEPSIS wound scoring takes all of the following into consideration except ?

MEET'

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The principles of safe laparoscopic surgery

The umbilicus is preferred for primary trocar insertionAn open or semi-open technique is prefered by most surgeonsOpen insertion away from the umbilicus is safer if there is a midline scarSecondary trocars should be inserted and removed under direct visionAll trocars should be placed perpendicular to the abdominal wallAll trocar sites above 5 mm in length should undergo closure of the fascial layer

Trocar and canula

Suture techniques

Interrupted suture technique.

The siting of sutures. As a rule of thumb, the distance of insertion from the edge of the wound should correspond to the thickness of the tissue being sutured (X).Each successive suture should be placed at twice this distance apart (2X).

Continuous suture technique.

Image Based Question

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:A- 1114119

A previously healthy, 25-year-old man is brought to the casualty after falling from a height, landing on his left side.There was no loss of consciousness.The patient has left shoulder and left-sided chest pain, as well as abdominal pain.Blood pressure is 114/72 mm Hg and pulse is 116/min.Physical examination shows bruising to the left side of the chest wall and abdomen.Heart sounds are normal.There is sharp, left-sided chest pain with deep inspiration but equal breath sounds on both sides.The left costal margin and the left upper quadrant of the abdomen are tender to palpation.Range of motion of the left shoulder is normal.Portable chest x-ray is normal.  Focused Assessment with Sonography for Trauma shows no pericardial effusion or significant intraperitoneal free fluid.Which of the following is the best next step in management of this patient?

Related clinical question

A.Monitor with serial physical examinationsB.Obtain CT scan of the abdomen C.Obtain dedicated radiographs of the ribsD.Obtain plain radiographs of the left shoulderE.Perform exploratory laparotomy

A 34-year-old man is brought to the casualty after a head-on motor vehicle collision.On arrival, blood pressure is 78/40 mm Hg and pulse is 134/min.On physical examination, the patient is alert but intoxicated.Pupils are equal and reactive to light.Ecchymosis in the distribution of a seat belt is present over the chest and abdominal wall.The left chest wall is tender to palpation.Breath sounds are equal bilaterally.Heart sounds are normal.The abdomen is distended and diffusely tender.Portable chest x-ray reveals multiple left rib fractures without pneumothorax or effusion.Cervical spine and pelvic radiographs are negative for fractures and dislocations.Focused Assessment with Sonography for Trauma is negative for pericardial effusion but positive for free intraperitoneal fluid.After rapid infusion of 2 L of intravenous crystalloid, blood pressure is 80/50 mm Hg and pulse is 118/min.Transfusion of uncrossmatched blood is pending.Which of the following is the best next step in management of this patient?A.Abdominal CT scanB.Contrast angiographyC.Diagnostic peritoneal lavage D.Emergent laparotomy E.Vasopressor therapy

Related clinical question

Treatment

no alternative to surgery for femoral herniaThere are three open approaches and appropriate cases can be managed laparoscopically.

1.Low Approach (LOCKWOOD)- simplest operation- suitable only when there is no risk of bowel resection.- easily performed under LA

2.The Inguinal Approach (LOTHEISSEN)3.High Approach (McEVEDY)

- ideal in the emergency situa- tion where the risk of bowel strangulation is high.- requires Regional or General Anesthesia

Laparoscopic ApproachBoth the TEP and TAPP approaches can be used for a femoral hernia and a standard mesh inserted.Ideal for reducible femoral hernias presenting electively, but not for emergency casesor irreducible hernia.

Related Clinical Question

A 68-year-old woman comes to the Surgery OPD due to a groin bulge.  She first noticed it 2 months ago and says that it gets larger with prolonged standing and shrinks with lying down, but it is not painful.  There has been no trauma to the area.  The patient has had no fever, nausea, anorexia, weight loss, abdominal pain, or urinary symptoms.  She has a history of obstructive pulmonary disease with occasional exacerbations and hypertension.  The patient has smoked a pack of cigarettes daily for 45 years.Temperature is 36.9 C (98.4 F), blood pressure is 140/80 mm Hg, pulse is 78/min, and respirations are 16/min.  BMI is 34 kg/m2.  Oxygen saturation is 95% on room air.  Cardiopulmonary examination shows mildly decreased breath sounds bilaterally.  The abdomen is soft and nontender; bowel sounds are normal.There is a 2-cm groin mass below the right inguinal ligament, which is medial to the right femoral artery; no tenderness, pulsations, or overlying erythema is present.The mass is tympanitic to percussion.Which of the following is the best next step in management of this patient? A.CT angiogram of the lower extremities B.Elective surgical repair C.Needle aspiration of the mass D.Oral antibiotics and reevaluation in 2 weeks E.Reassurance and observation

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VENTRAL HERNIA

refers to hernias of the anterior abdominal wall.- Umbilical- Paraumbilical- Epigastric- Incisional- Parastomal

Umbilical hernia

Umbilical hernia in a male child and adult. Often it can attain a large size.

develops due to either absence of umbilical fascia or incomplete closure of umbilical defect.can be congenital in newborn and infants (common in males) or acquired in adults (common in females).Obstruction and/ or strangulation is extremely uncommon below the age of 3 years.

Clinical Features

In Children :- Presents with a swelling in the umbilical region within first few months after birth, the size increases during crying.- It is hemispherical in shape.- Defect can be felt with finger during crying.

In Adults :- commonly overweight with a thinned and attenuated midline raphe.- The bulge is typically slightly to one side of the umbilical depression, creating a crescent-shaped appearance to the umbilicus.- Common in females more than men

- Spigelian- Lumbar- Traumatic

Clinial Formula

FEmORAL HERNIA

hernia appears below and lateral to the pubic tubercle and lies in the upper leg

no specific investigations are required. Ultrasonography or CT

no alternative to surgeryLow Approach (LOCKWOOD)The Inguinal Approach (LOTHEISSEN)High Approach (McEVEDY)Laparoscopic Approach

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