Surgery Sheet Scheme

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Surgery Surgery Surgery Surgery Sheet Sheet Sheet Sheet Scheme Scheme Scheme Scheme

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General sheet

_Il..o l,aI I.. _s.. _oo l..l> " Yes or No " _I Il. ,I> t.

Don't say .,.> .. _ V .sI ,>
But say:
.: I ;t,> | _ , v ;_.l ;_> Y _i Y _ a t.

Personal history:

;Ask about 7 for male & 8 for female

1 11 1. .. . Name: Imp. for "Medical registration & to be familiar with the Pt.".
_.V. ,.V i>l. V .

1 11 1. .. . Personal history
2 22 2. .. . Compliant.
3 33 3. .. . Present history.
4 44 4. .. . Past history.
5 55 5. .. . Family history.
6 66 6. .. . General examination.
7 77 7. .. . Local examination.
8 88 8. .. . Investigations & complications.
9 99 9. .. . Etiology & D.D.
10 10 10 10. .. . Treatment.
Example
Example
Example
2 22 2. .. . Age: Imp. as "Some diseases are more common in a certain age".

Infancy: 0-2 years "Congenital anomalies".
Childhood: 2-12 years "Mumps".
Adolescence: 12-20 years "Tuberculosis".
Adulthood: 20-40 years "Hernia".
Middle age: 40-60 "Gall bladder".
Old age: over 60 years "Malignancy".

3 33 3. .. . Sex: Imp. for "Diseases confined to sex".

Females: Breast carcinoma, Gall bladder stones, Femoral hernia.
Males: Peptic ulcer, Bladder carcinoma.

4 44 4. .. . Residence: Imp. for "Endemic diseases".
" _o _, _l. l,aI l. l. _,lc .. iI. lo cl. _, _l. .. V "

5 55 5. .. . Occupation: Imp. as "Job may be a predisposing factor for some
diseases".

Jobs with straining may predispose for Hernia.
Jobs which require long standing may predispose for Varicose veins.

6 66 6. .. . Marital status: Imp. for "Sexually Transmitted Diseases".
_.o _o >.o l i.c _sL >l _sL .. l ei.c
Female _o>I .oI I,. _oa.... V V , _ _.o _o lIoa....

7 77 7. .. . Special habits: Smoking "Most Imp. Habit in the Surgery sheet".
V V _>i.. . _.o _o . _>i l>,. l .Ic l _ ,I IL. l. V V ei _.

Alcohol = Predisposes for Liver cirrhosis.
. . . I> l, o> V lL..l. l..,. _ _. l..l.oI

Drug abuse = Injections may cause serum hepatitis.
= Tablets may cause peptic ulcers.

8 88 8. .. . Menstrual history: "Age of Menarche, Regular or Not &
Menopausal or Not".

A "sex of Pt.", named , aged ,
from , "Occupation", married
years ago & has children, the last one
is years old, smoking cigarettes
per day since years.

Personal History is written as the following form

Compliant:

Most annoying symptom. "_s...oI ..l> _II >l>I"
Written in the patient own words. "Swelling = Lump".

Present history:

I. Analysis of the Complaint "L.LIl. .I _,ls."
Most complains either Swelling, Pain or Both.

Pain

Onset _.o _o i. .
Course " Progressive or regressive".
Duration , i Ils. .
Site.
Referred or Radiate .,. _, o .
by e,. _II , .
by s.,. _II , .
Characters "Colicky, dullache"
, e ,IV _.
Swelling

Onset, course & Duration.
With Pain or Not L loI ,I _ l
Number.
Cause of appearance.
Associated with other swellings.
Investigations & ttt.
. ,.>I _ c s,L _Ic . .

II. Analysis of Symptoms related to Part affected. "Local Complications"
III. Analysis of Symptoms related to Other Parts affected. "General Complications"
Past history:

Similar condition.
Il>I l,aII lIl... >l> :
i.c ..l e V V ei _. l.o _Ila.
Vc lI i>l,. l , o. ei>l,. l , i ioI ,Ic o..

Common disease. "DM, Hypertensionetc."
History of Drug allergy.
History of previous Operation.

,I V V _s...oI _ >>. V V ei _. ,Ioc _oc

Family history:
... l l,aI V V .I,c _o i> i.c ..l , Il>I

+
General Examination

. l, s. _ _ , _Ic Case

Vital Signs:

Pulse Rate =Normal Range "60 90 / min".
Temperature =Normal Range "36.5 37.2 C".
Blood Pressure =Normal Range "90 150 / 60 90 mmHg".
Respiratory Rate =Normal Range "14 20 / min".

u.S.; _,ao g Irrelevant
N, 6 S, E, Relation to surroundings, Other swelling.

Local Examination

Inspection Palpation Percussion Auscultation

1 11 1. .. . Inspection: " _.,a. .l. _II "
_oc exposure _, . _II sL.oII l,Ic .. .
l,aI . _ position _ .
l,aI _,o, _Ic . .

o Number

o Surface.
o Site.
o Size "in cm."
o Shape.
o Special sign.
o Skin over.

o Edge: well defined, ill defined.

o Relation to surroundings:
Skin.
Muscle. "Superficial, Deep or Within"

_oa, l,aI _I> contraction II muscle .

The mass is More prominent = Superficial to muscle.
The mass is Less prominent = Deep to muscle.
The same size = Within the muscle.

Artery & Nerves.

o Other swellings.
3 T, 6 S, E

M, 2 C

2 22 2. .. . Palpation: " " i,|. .>l. _II
Confirm _II .,a. .. : .

o Temperature:
By Dorsum of the hand.
Compare the area with the disease with the contralateral side.
o Tenderness:
sL.oI _Ic La l,aI _Ic _. V V . _oVo _ ,,a. _>
" V V ,I _ _.a, ."
o Thrill
As in thyroid cases & incompetent saphenofemoral junction cases.

o 6 S "Surface, Site, Size, Shape, Special sign & Skin over".

o E "Edge".
+
M & 2C if the case is swelling.

o Mobility.

o Consistency " Solid or Cystic then if solid = (Firm, Hard or Soft)".

o Compressibility & Reducibility.

3 33 3. .. . Percussion:

_Il> l.o _,so l,aI ,.> _Ic V _s.. i, .
Il. L.> wrist i>.. _. Middle Finger .
_s.. _oo Resonant .Dull

8 88 8 |

This is How to Take
A complete surgical sheet

4 44 4. .. . Auscultation: clo.Il.

Murmur: Systolic "Aneurysm".
Continuous "A/V Fistula".
Gurgling "Enterocele".
Bruit " vascularity of thyroid gland".

+
Investigations & complications

+
Etiology & D.D.

+
Treatment

9 99 9 |

e Why move up & down with deglutition?
As it is enclosed in the pretrachial fascia.

e To differentiate between thyroid swelling & thyroglossal cyst

I ... I l,aI > mandible .l.I IL, .o .IL i,l.
_s.. l.II > o .>. I thyroglossal cyst .
I _s.. _.>.o thyroid swelling .
D.D of Neck Lumps
Thyroid Cases

To diagnose a case of Thyroid, Answer the following Questions =

Is it a Thyroid swelling or Not?
Toxic or Malignant or Not?

Why it is a Thyroid swelling?

1. It is in the Anatomical site of thyroid gland.
2. Moves Up & Down with deglutition.

Enlarged lymph node Thyroid enlargement Tumor Thyroglossal cyst

e The most Important thyroid cases are either:
1. Simple goitre or solitary nodule.
2. 1ry thyrotoxicosis or 2ry thyrotoxicosis,
3. Autonomous toxic nodule.

10 10 10 10 |

So during operation we legate vessels near their upper end.
So during operation we legate vessels far as possible from lower end.
Anatomy of importance
Artery related to upper pole of thyroid gland:
Superior thyroid artery from external carotid artery.

Artery related to lower pole of thyroid gland:
Inferior thyroid artery from thyrocervical trunk.

Nerve related to upper pole:
External laryngeal nerve from superior laryngeal nerve.

Nerve related to lower pole:
Recurrent laryngeal nerve from vagus.

Anatomical site of the isthmus at tracheal rings 2, 3 & 4.

Rt. laryngeal nerve
hooks around
Rt. subclavian artery.
Lt. recurrent laryngeal
hooks around
Arch of aorta.

3. Boundaries of muscular triangle:
1. Anterior border of sternomastoid.
2. Midline.
3. Superior belly of omohyoid muscle.
Floor: thyroid and cricoid cartilages and thyroid membrane.
Contents: a. Infrahyoid muscles except omohyoid.
b. Thyroid gland.

4. Attachments of pretracheal fascia:
1. Superiorly: oblique line of thyroid cartilage and arch of cricoid.
2. Inferiorly: it invests the inferior thyroid vein and is continuous with
fibrous pericardium.
3. Laterally: it blends with carotid sheath.
11 11 11 11 |

c l, Il>I loIlL thyrotoxicosis _o _s.. malignant .
Thyroid Sheet Spot

.,.I i>l. c . l _Ic

1. Personal history:
Old age = suggest malignancy.
Sex = More common in females than males.
Residence = iodine I _s. _o _.la.. l>I _Ll.o
Do not forget to ask about the menstrual cycle.

2. Complaint:
Neck swelling & Neck discomfort.
Symptoms of thyrotoxicosis or malignancy.

3. Present history:
If the swelling has enlarged quickly in a short period = Malignancy.
Hge on the cyst or Pain referred to the ear = Sign of Malignancy.

I I Pt. I a. Psychic trauma I L o Swelling l.Ilc _s.. Graves 1ry .

4. Past history:

l.o _Ila. ei.c ..l I ei _. i.c ..l Il>I l,aI l.

Il. ,I li>l,. l _ , . l,Ic _.o .,ao , i>l,. l

e " _o l> Amidarone, lithium & antithyroidal drugs .IsII Thiouracil ."

12 12 12 12 |

How to ask about
Symptoms of
Thyrotoxicosis
l,aI _Ic L _II ,,a.I _Ic

. _>.. :.I l.. _>.. :.I _Ic . el .l>\ I Il..
>o _oa. lo ia. V icl ..
ei _I ls

e Thyroid hormones increase heart rate & cardiac contractility.

. ,a. :. L lo ia. " _ V " lo V Il.. _ _. .l>\ I
l _s. l l
L .I V V _ lo _VI :.,. .,

e Thyroid hormones increase all metabolic processes & increase appetite.

. ,,l. .. ,. a..
_>.. l . > V las. :
V V l..I _ ,.lL.. _La...
V.I l.. lc :. l.l,> _>..

e Thyroid hormones increase catecholamines so increase sweating.

. :.o s.. l,l.I
a.. :.o. l>l>I V . | i,

. .,.> _ V .sI ,> .c .,s. :. _ .c .. V _ lo _o :.,.c V

e Thyroid hormones affect the mental status so a much increase causes
nervousness.

. :o. l.> l... , V _ V :o. V _>,. .L ,. _,. :I

. :,.,a. ... V V _,.. >l>I ... l.l,>
_.l> . :.,c _ V .sI ,>

e Thyrotoxicosis may cause exophalmos & diplopia.
13 13 13 13 |

Take care:
How to ask about
Symptoms of
Malignancy

e o cV _ _V. V _o l.o > _o
e ,... _II _,.l,aI .Ic under ttt .
e lo Il>I _s., cV _o >l> _,so I :

1. Simple nodular goitre.
2. Solitary nodule, or
3. Malignancy "If it has an irregular surface".

e I V li.c .,sI c Il>I _s., l.o > lo :
1. 1ry thyrotoxicosis.
2. 2ry thyrotoxicosis, or
3. Toxic nodule.

. l. I _Ic Pressure symptoms

, a,II L ia. _s..I _ .a _o _.la.. .,s.
i> o :,Ic ,a, . _s... l

. I _Ic l. Metastasis

> i.c Il. ei.c I
, i lIls.
.I o V i> o :I .>
llao _s,,. , >I
_ ,Il. _>.. i

_>.. l. ,I _ :.L. L.LIl. _,

,>V .sI _ . :I _> :a>,. :oc
e I c .,.... _s., _o c _,so I malignancy .
_s., I _,. simple goiter I solitary _.Il. .

14 14 14 14 |

D.D. between
1ry Thyrotoxicosis
8
2ry Thyrotoxicosis

C I pulse l,c _ Thyrotoxicosis >iI _Ilc _s.,.
I .> _oo _. water hammer .

I i, Pt. I i.c _>. Forearm
" _> _o _. _a,.LI pulse l. "
I e _s., .,.> I water hammer pulse .

Secondary Primary
Plummer's disease. Grave's disease.
Asymmetrical. Symmetrical.
Firm & nodular. Soft and smooth.
Age 30 50. Age 20-30.
Mass before toxicity. Mass at same time of toxicity.
I _o > >l> ,
thyrotoxicosis I _
tachycardia .
_o > >l> , I
thyrotoxicosis I _ eye
signs . .>o .. l.Ilc
Psychological trauma .
15 15 15 15 |

_Ic

General Examination Spot

Vital signs General Examination Systemic Examination

Vital signs:
o ABP = increased.
o Pulse rate = tachycardia.
o Temperature = increased.
o Respiratory rate = increased.

General Examination:
o Appearance = normal.
o Built = under built.
o Conscious = conscious but
Apathy.
o Decubitus = orthopnea as in
HF.
o Emotion = nervousness.
o Face = staring look if primary.

Systemic Examination
Head: e Tremor "Tongue & Eye".
e Jaundice, exophalmos & eye signs.

Abdomen: liver or spleen enlargement if 1ry.

Upper limb:
e Tremor, Warm hands "in Thyrotoxicosis" & Acropakie or
clupping "Abnormal shape of the nails".
Lower limb:
e Pulse = mostly dorsalis pedis felt at naviculus bone.
e Hyper reflexia.
e Pre-tibial myxedema "ls.. _.ls.. o l.I .L."
16 16 16 16 |

Don't Forget
Local Examination Spot

Inspection:

e Whole head & neck are exposed up to supra-clavicular fossa.
e The neck is Fully extended "I l,aI >".

_,>..I c _.I _o _oo
1. Smooth 1ry toxic goitre.
2. Nodular 2ry or solitary toxic nodule.
3. Irregular malignancy.

, _oo _II .,a. . _

o Asymmetry.
o Lumps.
o Dilated veins.
o Pulse.
o Scar.
o Discoloration.
o Infiltration over the
skin.

I scar ... , ei ia. l. trauma ,Ioc ,Ioc V ,
I discoloration .. _Ic _oc l,aI l.. irradiation V V
. l _ ei _. i>l, radioiodine V V

Prelaryngeal Sub hyoid Goitre Thyroglossal Pretracheal
lymph bursitis & cyst lymph
nodes Laryngeocele nodes
D.D of masses
moves up and down
with
Deglutination
17 17 17 17 |

Q & As

Q When thyroid swelling does not move with the deglutition?
A 1. Huge goitre.
2. Malignant goitre.
3. Retrosternal goitre.
4. Riedel's thyroiditis.

Q How to know if there is Retrosternal extension or Not?
A By:
Inspection: lower border is not invisible.
"Sternal notch " I .l. _o l.Ilc
Palpation: lower border is not palpable.
Percussion: direct or indirect on manubrium & medial
ends of clavicle Dull.

Q What are symptoms of mediastinal compression?
A Hoarseness of voice or cyanosed oedematous face.

Q Causes of STN?
A 1. Simple nodule.
2. Toxic nodule.
3. Adenoma.
4. Malignant nodule.
5. Cyst.
6. Localized form of thyroditis.

Q Causes of Hard Goitre?
A 1. Cancer thyroid.
2. Tense thyroid cyst.
3. Calcification.
4. Riedel's thyroiditis.

Q What are the suggestive malignant goitre?
A 1. Recent rapid increase in size
2. Hard consistency.
3. Fixation to the surroundings.
4. Local pain referred to the ear.
5. Fixed hard cervical lymph nodes.
6. Signs of distant metastasis.

Q Manifestation of thyrotoxicosis?
18 18 18 18 |

A
From history: palpitation, nervousness, irritability, intolerance
to hot weather, increases appetite associated with loss of
weight, polyuria & menorrhagia.
From general examination: tachycardia, arrhythmia, tremors
& eye signs of thyrotoxicosis "lid lag, staring look,
exophthalmos, rim of sclera, loss of convergence".
From local examination: dilated veins, expansile pulsation,
warmth, palpable thrill & audible bruit.

Q May cervical LNs develop metastasis from a thyroid carcinoma while
1ry is not felt?
A Yes, in occult papillary carcinoma of the thyroid gland, this was
thought in the past as some form of ectopic thyroid gland and was
called lateral abarrent thyroid.

Q Manifestations of suspicious of an inflammatory goitre?
A
In acute and subacute thyroditis: short duration, pain, may be
fever, warmth and tenderness over the gland.
In Hashimoto thyroditis: locally the gland is similar to SNG
but the course of the disease is characteristic; early
thyrotoxicosis followed by hypothyroidism.
In Riedel's thyroditis: the gland is irregularly enlarged, hard,
fixed to skin, trachea & sternomastoid; very similar to
anaplastic carcinoma of thyroid.

The first lymph node to be felt in cancer thyroid is
prelaryngeal lymph node "Delphian".

19 19 19 19 |

Q Causes of iodine deficiency?
A 1. Decreased intake in endemic areas.
2. Increased demand as in periods of stress in females as "puberty,
pregnancy & lactation".
3. Decreased absorption from GIT.

Q Causes of defective synthesis of thyroid hormones?
A Enzymatic deficiency & goitrogens "cabbage, antithyroid drugs ....etc"

Q What is Pendred's syndrome?
A ei.c ,. _,o Deafness, Dwarfism & Cretenoid goiter .

I ... , cretenoid goitre

Congenital deficiency of peroxidase enzyme.

Q Complications of simple nodular goitre?
A 1. Pressure on surrounding
structures.
2. Disfigurement.
3. 2ry toxic goitre "30%".
4. Heamorrhage in a cyst.
5. Malignant transformation
"follicular type".

On Trachea On oesophagus On Recurrent On carotid On sympathetic
laryngeal nerve receptors chain

Dyspnea Dysphagia Hoarseness of Fainting
Horner's
Voice attacks syndrome
Physiologic goitre can be reversible if the cause of
iodine deficiency is eliminated.

Pressure Symptoms
20 20 20 20 |

Q Causes of dyspnea?
A 1. Postural due to pressure on trachea.
2. Exertional in case of toxic goitre complicated by heart failure.
3. Heamorrge on a cyst.

e Thyroid function tests:
1. Estimation of serum T3 and T4 total & free.
Free T4 = 8-26 ng/dl.
Free T3 = 3-8 ng/dl.

2. TSH level in blood decreases in thyrotoxicosis.

3. Radioactive iodine uptake it is not commonly done nowadays.

4. Thyroid scanning by radioactive iodine or T-99.
Warm normo active.
Cold hypoactive.
Hot hyperactive nodules.

5. TRH suppression test.

6. Thyroid antibodies.

In case of Hge on a cyst, dyspnea is sudden
because of sudden enlargement of the gland &
reflex spasm of pretracheal muscles.
How to treat?
A emergency needle aspiration
I
123
is the radioiodine used as its half life 13 hours
as opposed to 8 days of I
131
.
Dose: 5 micro curi.
Another one: Technetium 99 "Iodine _o _>".

21 21 21 21 |

Q Effect of injury of recurrent laryngeal nerve?
A e Unilateral = hoarseness of voice.
e Bilateral and partial = stridor & suffocation.
e Bilateral and complete = aphonia.

Q Effect of injury of external laryngeal nerve?
A Loss of high pitched voice "due to paralysis of cricoid muscle".

Q What are causes of weight loss inspite of good appetite?
A 1. Thyrotoxicosis.
2. DM.
3. Parasitic.
4. Infection.
5. Malabsorption syndrome.

Q What are causes of Polyuria?
A 1. Increased metabolism.
2. Glucosuria.
3. Increased intake of water secondary to polyphagia.

Q Causes of Eye Signs?
A 1. Upper eye lid retraction due to spasm of Muller's muscle as
thyroxin makes this muscle oversensitive to effect of
circulating catecholamines.

2. Absence of convergence on looking to a near object =
paresis of medial recti muscles which is responsible for
adduction of the eye globes.

3. Absence of forehead corrugation is caused by true
exophthalmos.

True exophthalmos is due to exophthalmos producing
substance which causes deposition of oedema fluid and
round cell infiltration in retro orbital space.

22 22 22 22 |

Hyperthyroidism

Referred to manifestations caused
by the increased level of circulating
thyroid hormones.

Thyrotoxicosis
A syndrome caused by the
increased level of circulating
thyroid hormones + others not due
to increase level of it
"Exophthalmos & pretibial
myxedema".

Q Other causes of thyrotoxicosis?
A 1. Thyrotoxicosis factitia intake of thyroxin.
2. Infantile thyrotoxicosis a baby born to thyrotoxic mother.
3. Jod Basedow disease high intake of iodide in a colloid goitre.
4. De Quervain thyroditis.
5. Hashimoto thyroditis "in early cases".
6. Some tumor secreting thyroxin e.g. Struma ovarii.

Hyperthyroidism & Thyrotoxicosis
23 23 23 23 |

Treatment

1. 1ry toxic goitre:
Mainly medical "antithyroid drugs + beta blocker"
Examples of antithyroid drugs: carbimazole, thyouracil, prechlorates &
thyiocyantes.

e Mechanism of action of carbimazole:
Prevents oxidation of inorganic iodine
Prevents coupling of iodine with tyrosine.
Immunosuppressive action on thyroid stimulating Ab production.

e Dose: 10 mg / 6hrs until the patient is euthyroid then dose is reduced
to 5 mg TDS as maintenance.

e ee e Other indications:
1. Preoperative preparation.
2. Children and adolescents.

3. Refusal for surgery.
4. General contraindication for
surgery.

e ee e Used for 12-18 months.

e ee e Disadvantages:
1. Failure rate 50%.
2. Some goitre enlarges.

3. Drug toxicity "Aplastic anemia &
agranulocytosis".
4. Prolonged drug therapy need.
Beta blocker as indral or propranolol.

e ee e Action of propranolol:
Inhibits the peripheral adrenergic properties of thyroxin
especially on the heart.
Inhibits the peripheral conversion of T4 to T3.

Radioactive iodine may be given as alternative to medical ttt in patients
over 40 years.
Surgery is indicated in large goitre, failure of medical & recurrence
of symptoms after successes medical ttt.
24 24 24 24 |

Don't Forget
2. 2ry toxic goitre:
Mainly surgical "subtotal thyroidectomy"

e ee e Preparation before surgery:
Antithyroid drugs e.g. neomercazole until the patient is
euthyroid.
Propranolol for regulation of heart rate.
Lugol's iodine.

e ee e Principle of subtotal thyroidectomy:
Removal of both lobes + isthmus leaving postero medial parts of
lobes on each side to protect recurrent laryngeal nerve and
parathyroid glands "leaving 4 Gms on each side".

In case of SNG amount to be left is 8 gms on each side.

e ee e Complications of subtotal thyroidectomy:
1. Tension hematoma "slipped ligature from the superior
thyroid artery".
2. Dyspnea.
3. Injury to related nerves.
4. Thyrotoxic crisis.
5. Hypoparathyrodism "accidental removal of parathyroid
glands".
6. Hypothyroidism 20 30 % if removed totally.

Antithyroid drugs as preoperative preparations are
contraindicated in Retrosternal goitre as they cause
enlargement of the gland which may lead to mediastinal syndrome.

25 25 25 25 |

Thyrotoxic crisis:

o It is an acute exacerbation of hyperthyroidism.
o Occurs if the patient is not adequately for operation.
o Symptoms: Hyperpyrexia, restlessness, severe tachycardia &
dehydration.
o It is Dangerous as:
Tachycardia may cause HF.
Hyperpyrexia may cause Brain damage.
o Treatment:
Symptomatic ttt:
1. I.V. fluids to correct
dehydration.
2. Cooling by icepacks.
3. O2.
4. Diuretics for heart failure.
5. Digoxin for arterial
fibrillation.
Specific ttt:
1. Carbimazole 15 mg / 6 hrs.
2. Lugols iodine 10 drops / 8 hrs.
3. Indral 40 mg / 6 hrs orally.

Why we don't give indral as intravenous shots as it can lead
to heart block, so if it is given i.v., the pulse is monitored by ECG.

Medical ttt is indicated in
1. Preoperative.
2. Children.
3. Refusal surgery.
4. General contraindication of surgery.

3. Toxic nodule:
Hemithyroidectomy or radio-iodine.
Surgery is easy and curative


26 |

Radio-iodine:

e Mechanism:
Emits beta rays which destroy thyroid cells without affecting
much the surrounding tissues due to their low penetrability.
e ee e Type:
I131 and not I123 because it emits only gamma rays which are
ineffective.
e ee e Dose: 160 uCi per 1 gm of thyroid tissue.

e ee e Advantage:
No risk of hypothyroidism because the thyroid tissue
surrounding the nodule is suppressed and so will not uptake
iodine.
e ee e Disadvantage of radioiodine activity:
1. Isotope facilitates must be present.
2. Indefinite follow up is essential.
3. Thyroid insufficiency in 80% aer 10 years.
4. Recurrence if low dose is given.
5. Risk of inducing carcinoma in adults if given in childhood or
adolescence so not given below 45 years.
6. Risk of hypothyroidism and fetal anomalies if given in
pregnancy.

e Contraindications:
1. During pregnancy.
2. During lactation.
3. Young age.
4. Toxic nodular goitre ineffective.
5. Iodine allergy.

In pregnancy: for ttt of thyrotoxicosis we give the
least curative dose of propiothiouracil


27 |

Lugol's iodine
It is 5% iodine and 10% KI in water.
Mechanism:
o Inhibition of protease enzyme which release
thyroid hormones from thyroglobulins.
o Inhibition of organic iodine formation.
o Prevention of the stimulant effect of TRH on
adenyl cyclase enzyme.
Used for 10-14 days.
If given >14 days rebound hyperemia in the gland.
occurs.

Solitary toxic nodule
Incidence:
3-4 times in female than in males.
Its signicance is due to high incidence of malignancy 15-20%.
Incidence of malignancy is 3 times more common in males than in
females.

Thyroid status by investigation:
In case of toxic nodule = thyrotoxicosis.
Other types of nodule = euthyroid status.
Malignant thyroid tumors are never hyper functioning.

Thyroid status by thyroid scanning:
80% are cold.
20% warm or hot.

Thyroid status by sonography:
30% are cystic.
70% are solid.

28 |

varicose vein Cases
To diagnose a case of Hernia, Answer the following Questions =

1. Are these Varicose Veins or Not? "Dilated, Tortuous veins with
Disfigurement + Pain in the affected limb".
2. Unilateral or Bilateral?
e Unilateral usually 2ry.
e Bilateral usually 1ry.
Course of the veins affected?
e Course of long saphenous or short saphenous 1ry.
e Irregular Pattern & do not take the anatomical arrangement 2ry.

Are the perforators competent or Not?
Presence of complications.


1. Long saphenous vein:
Begins at the medial end of dorsal venous arch of foot.
Then becomes in front of the medial malleollus.
Then turn around the knee.
Continues in the inner aspect of the thigh to end in the saphenous
opening.

2. Short saphenous vein:
The same beginning then becomes behind the lateral malleollus.
Then it reaches the popliteal fossa where it pierces in the deep
If 2ry Are the Deep System is occluded or not?

29 |

fascia & joins the popliteal vein.

Varicose Vein Sheet Spot

_ . lc .,.I i>l.

Occupation " I> _Ic ,. ., ,I>.. .s,L l,aI " .
Sex Female " o i .Io> " .

6. Complaint:
> " _s. " ,. oo I> l,aI _> _ .
I _o _..,. Complications " > ei.c ,a. l.I I> ,. ,. .,>.. I>
."

7. Present history:
The special character in this case is:
Pain which increases by prolonged standing & decrease by
lifting his leg while lying down.
How to reach to the Pubic tubercle?

_oa, l,aI _o .L adduction against force II lower limb .
I _.o tendon of adductor longus muscle i>I elao IL
_V. lo Bony prominence .
l. :cl. L> This is the Pubic tubercle .

30 |

You may find

e If the pain decrease by walking it is a 1ry varicose vein.
8. Past history:

l,aI l. I V V ei _. I .> Il>I l.o _Ila. _.o I .>

_s...oI _ >>. ..>. o> ei _. .o :I>
iII V,.o i> " DVT "

,.I _ . lia. i ,. ,Ioc .Ioc .L iI>I .>. _s> i>l.. .. .L

i>l.. I,L . :Ils. l,Ic _.lo .,ao , " _,..V " _ , .L

I female lIl. : _.o _o .L _o>II .o i>l..

e Estrogen increases coagulability of blood.

l. L.>I lo _, V V ei _. L.>. l,aI "A-V fistula" .


ei.c e l,aI i.. l>l> _V. _oo weak mesenchyme _s., _Il.Il. 1ry .

Kyphosis Flat foot Varicocele Hernia Visceroptosis

Il>I I 2ry _IV ...I _Ic .


Inspection:

Manifestation of Weak Mesenchyme

31 |

You may find

1. Flat foot 1ry.
2. Swollen red limb 2ry.
3. Pulsation in veins A.V.F
4. Veins crossing the groin 2ry.
Palpation:

1. Cord like thrombosed vein.
2. Tender nodule + hotness thrombophlebitis.
3. Thrill at the sapheno-femoral junction incompetent
sapheno-femoral valve.

Auscultation:
, I pulse _ clo.Il. ao.l bruit .

Secondary V.V Primary V.V Comparison
,. .. l.Ilc _o _.
lo, .
female I
,. .Io> . _oo
25-35 years old.
,. .s,. .
1. Personal History:
Disfigurement.
Unilateral pain.
Skin complications.
Disfigurement.
Bilateral pain.
2. Complaint:
Severe pain.
.a., e,. _.oI .
Pain mild in severity.
>,, IIs. _.oI .
3. Present History:
May find
DVT,
Trauma or
Dilated veins crossing
the abdomen.
May find
Saphena varix,
Hernia,
Piles or varicocele.
4. General
examination:
1ry & 2ry
varicose vein

32 |

Tests of importance

1. Trendlenberg test:

I .. l.c Ioa.. Sapheno-femoral junction V V ,,I. .

sI I> l,aI ,,. " I _s. l.c vein ."

II _ Pubic tubercle L. L,.. >l>. l.>. l.> lo Tourniquet .

s, l,aI . I : ei ia. _,.s, Tourniquet .

I I vein sI .>. _o c.. Vo _ l. _.,

Incompetent saphenofemoral valve

2. multiple tourniquet test:

I .. l.c Ioa.. perforators V V o,I. .

I _ l,aI ,,. vein L. 3 tourniquets .

I .>. i> S-F junction I i> knee I .>. i> knee .

I _lo , l.c perforators .

I , _Io., _II >I . l,aI . vein .

This is the site of the incompetent perforator.

l,c , , l. V.V I _ ei.c perforators competent .

3. modified Perth's test:

Il>I I Ioa.. 2ry V.V I .. l.c deep system V V i.o
. _II VaI s,L i>. l.c l,Ic _.o .

L. Tourniquet _oa, l,aI _I> exercise ioI _,l .

I I . varicosities _ _s., occluded deep system .


33 |

Q & As

Q Why walking in 1ry decreases pain but in 2ry increases it?
A I _.oI l.. exercise calf & thigh muscles contract
i,,. ei l.c I pressure I _ deep veins .

I _o loloI _ iI el>. superficial II deep _aI _,I
+ Ls.I I _o deep veins I _o iI Ls... superficial II deep .

I I deep _>, ,,I. shift .
I I deep I _ iII o>. _>, sso superficial veins .

Q What are the complications with 2ry V.V?
A 1. Venous complications: "Hge., Calcifications & superficial
thrombophlebitis".
2. Skin complications: "Pigmentation, Dermatitis & Ulcers".

Q How dermatitis occurs?
A Theories:
1. Haemosiderin. "The most important".
2. Fibrin.
3. Abnormal A-V connections.
4. WBCs cause destruction.

Q How skin complications occur?
A Incompetence of medial ankle perforators which causes increase of
venous hypertension above the medial malleollus & rupture of some
venules extravasation of haemosiderin granules "pigmentation,
irritation & dermatitis"
Also Extravasation of fibrinogen & fibrin = fibrosis & tissue
anoxia = decreased vitality.
So, ulceration to minor trauma may occur.

34 |

Q Are all cases of 2ry V.V show obstruction of the deep system?
A , l , _oo .V V thrombus _> _.I recanalization .

Q _>, lo ia. .,L recanalization I vein >,. normal

A ,. .V V partially obstructed I valves Ila. _o .. .

Q What is the area which is more liable to show ulcers?
A Gaiter area.
o Above the medial malleollus.
Because it is rich in perforators which drain the skin
directly to the deep veins.

Q Are all cases of 2ry V.V must had DVT?
A _.Lo .I . _oo V V .

Q What are veins crossing the groin & why it is a sign of 2ry V.V?
A Superficial circumflex iliac, superfical pudendal & superficail
epigasteric.

Because these veins are tributaries of long saphenous &
so when become dilated, we know that the deep system
occluded, so the blood flow becomes from saphenous to
these veins.

Q Types of A-V fistula?
A 1. Congenital Localized & Diuse.
2. Acquired Traumatic, Pathological & Artificial.

DVT is usually a silent disease.

35 |

Vascular Traumatic Neoplastic Infection Others

Venous ulcer direct trauma T.B Rheumatoid ulcer
Ischemic ulcer bed sore Syphilis Neuropathy
Lyphadema ulcer chronic osteomylities

Marjolin's ulcer
"Epithelioma on top of ulcer or burn"

Primary skin ulcers
"Epithelioma, Melanoma & basal cell carcinoma"

Ulcerative deep malignancy
"Bone tumours"

Q How to Differentiate?
A By history, general examination & local examination.

The most important differences:
e Venous ask about history of DVT.
e Ischemia Claudication pain, color change & atrophic tissue.
e Neuropathy
V _oo . ei.c , _oo .
.. _,o.. ei _. ei.c l Il. .
V V s.l. Vl. .l.> Il. .
. _o .l.> ei, _o .l.> I> _o l. .>. ,oIl. .l.>

e Malignant From the course "rapidly in size in shot time".
e Others From the shape of the edge.
D.D of leg ulcers
The most common
is
Venous ulcer

36 |

Venous ulcer

Comment on
Edge slopping.
I edge : I _o > ulcer i>I II _ L>,. .

Floor red granulation tissue.
I floor : I , ulcer II _ .,a. ls,l. _ .
If pink Healthy.
If yellowish Unhealthy.

Margin pigmentation, other ulcers & lipodermatosclerosis.
I margin : I _o > _o ulcer I _o >I e skin II _ I >,. ulcer
I _,. .,. _s,. normal skin .

Base indurated.
I base : I .>. lo floor .

Discharge: serum, blood or pus.
. l . _ dressings l,aI cl.. .

I Vc ulcer _.I, l,aI gradual pressure elastic stock .
_s., _oo elao grafting .

Expansile impulse in cough
+
thrill
in the femoral triangle
=
Saphenofemoral incompetence

37 |

Q What is D.D of swelling in the femoral triangle in cases of V.V?
A 1. Iliofemaoral DVT.
2. Arteriovenous aneurysm.

3. Saphena varix.
4. Lymphadenitis secondary to
venous ulcer.
Q What is Saphena varix?
A It is a bluish rounded or ovoid subcutaneous mass in upper
part of femoral triangle, soft, cystic, compressible with
expansile impulse and thrill on cough.

Q What is meant by Blow out?
A Incompetent valves of perforator veins.

Q How do you detect them clinically?
A By:
Presence of saccular varicosities in the anatomical sites of
perforators.
Presence of defect in the deep fascia at the anatomical sites
of perforator veins.

Clinical tests:
o Manual localization of blow out + multiple tourniquet test.
Venography.

Q Sites of the perforators?
A e In the leg: 3 perforators above the medial malleollus 2, 4 & 6
inches.
e In the thigh: above the knee, at the mid thigh & at
saphenofemoral junction.

Q What is meant by ankle flare?
A Fine venules passing around medial malleollus.

Q What is the significance of pulsating varicose?
A It is 2ry to A/V stula.
The best investigation for that is venography.

| 38 38 38 38

Q Mention the different types of pain that may occur in a case of V.V?
A 1. Dull ache or heaviness the usual type.
2. Burning pain in superficial thrombophlebitis.
3. Throbbing pain late in superficial thrombophlebitis.
4. Bursting pain in DVT.

Q What is the value of duplex scanning?
A e Demonstrate if the deep system is patent or occluded.
e Demonstrate the presence of incompetent perforators.
e Differentiate between the 1ry & 2ry V.V.

In 1ry: deep veins appear patent, wide, with dilatations
opposite their valves.
In 2ry:
o Before canalization: deep veins are occluded "not
seen" & there are tortuous, irregular collaterals.
o After canalization: deep veins appear as thin lines
with no evidence of valves.

Treatment

Conservative Injection sclerotherapy Surgery

Doppler and duplex are easier & less invasive
than venography.
Lines of ttt in V.V

| 39 39 39 39

Indications of conservative:
1. Mild cases.
2. Cases refusing surgery or unfit for surgery.
3. Cases with occluded deep veins.
4. Preoperatively and postoperatively in cases doing surgery.

Indications of injection sclerotherapy:
1. Mild varicosities cosmetically distressing the patient.
2. Residual varicosities after operation.

e The principle occlusion of the vein by fibrosis not by thrombosis.

e The material to be injected Sodium tetradecyl sulphate 3%.
Ethanolamine oleate 5%.
Sodium morrhuate 5%.

e Complications:
1. Embolization into the deep system leading to DVT and
pulmonary embolism.
2. Extravasation into subcutaneous tissue leading to its
necrosis and sloughing.
e Precautions:
1. Injection should be strictly intravenous.
2. The vein should be empty.
3. The maximal amount to be injected 1 ml per seings.
4. Ladies on contraceptive pills are discarded "more liable
to get DVT".

Indications of Surgery:
1. Incompetent saphenofemoral junction.
2. Large varicosities.
3. Incompetent perforators.


| 40 40 40 40

e Operations that can be done in:
o Great saphenous system affection:
Large varicosity = stripping of great saphenous vein.
Incompetent S-F junction = Trendlenberg operation.
Incompetent perforators = sub facial ligation of perforators.
Incompetent S-F junction + incompetent perforators =
Trendlenberg + sub facial ligation.

o Short saphenous system affection:
Large = stripping.
Incompetent perforator = sub facial ligation.

o Varicosities outside the course of long or short saphenous
veins:
Large = subcutaneous stripping or punch excision.

Contraindications to surgery:
1. Thrombophlebitis for 3 months aer cure.
2. 2ry varicose veins aer DVT with uncanalized deep veins.
3. Pregnancy and pelvic tumours.

Q How do you treat V.V secondary to pregnancy?
A e During pregnancy conservative ttt is done.
e After delivery the varicosities usually disappear.
e Residual varicosities can be treated by continuation of
conservative measures or by injection sclerotherapy if
they cosmetically distress the patient.
The veins ligated in Trendlenberg operation
are
the saphenous vein and its tributaries.

| 41 41 41 41

Hernia Cases

To diagnose a case of Hernia, Answer the following Questions =

Is it Hernia or Not? "Site, Impulse on cough & Reducibility".
What is its type?
Is it recurrent or Not?
What is the content?
Is it complicated or Not?

Why it is a hernia?

Because the mass has an expansile impulse on cough & disappear
when the patient lying down.


1. Boundaries of inguinal canal:
Floor = Inguinal ligament.
Roof = Arching fibers of conjoint muscle.
Ant. Wall = Extensor oblique aponeurosis.
Post. Wall = Fascia transversalis.

2. Boundaries of Hassel Bach's triangle:
Laterally = Inferior epigasteric artery.
Medially = Sheath of rectus abdominus muscle.
Inferiorly = Inguinal ligament.

Deep Ring = in fascia transversalis.
Superficial Ring = in external oblique aponeurosis.

| 42 42 42 42

The internal inguinal ring
1/2 inch above the midpoint of the inguinal ligament.

The inguinal ligament
Measured from anterior superior iliac spine to pubic
tubercle.

The external ring
Above and lateral to the pubic tubercle.

3. Boundaries of femoral opening:
Ant. = Inguinal ligament.
Post. = Pectineal ligament.
Medially = Lacunar ligament.
Laterally = Femoral vein.

Hernia Sheet Spot

.,.I i>l. c _ . l

Occupation "I,s. l>l> _,.,. l,aI s,L"
Chronic smoker as smoking cause chronic cough.

10. Present history:
The cause may be

e Chronic cough.
e Chronic constipation.
e Straining at micturation.
e Lifting heavy objects.
e Weak mesenchyme.


| 43 43 43 43

Signs of Obstruction
Signs of Strangulation
The hernia becomes
11. Complications of hernia:

a. Irreducible: = If there is

e Adhesions between the contents and the sac.
e Narrow neck of the sac.
e Expulsion of new contents in the crowded sac.
e A sliding hernia.

b. Obstruction: = due to adhesion.

Absolute constipation Distension Colic Vomiting
"Stool & flatus" due to reflex due to reflux
hyperperistalsis pylorospasm

c. Strangulation:

Sudden obstruction of arterial blood supply (cessation)
by the neck of the sac or by a band of adhesion
Strangulation may cause gangrene of the content, peritonitis,
septicemia, & death.

Irreducible Tense Tender Severe pain With manifestation
Of
Intestinal obstruction


| 44 44 44 44

_Ic

d. Inflammation:
When one of the content of the hernia is an Organ.
Inflammation when this organ is inflamed.

The content is appendix = appendicitis.
The content is fallopian tube = salpingitis.

e. Rupture of the hernial sac "rare".

f. Hydrocele of the hernia.


Appearance = commonly in obese.

Chest = chronic obstructive airway disease & asthmatic bronchitis.

Abdominal examination:
Divercation of the recti muscles.
Abdominal swellings or masses.
Scars of previous surgery.
Signs of prostatic enlargement.

Lower limb: varicose veins & flat foot.

Example

| 45 45 45 45

I _,. sI content
Intestine or omentum


_oa. l. palpation . s. l.c I oblique hernia

Hold the neck of scrotum = if it is

Completely above your fingers inguinal.
Completely below your fingers scrotal.
Felt partly above and partly below inguino-scrotal.

_,.o c neck of the scrotum

o Deeper pigmentation.
o Corrugation of the skin.
o At origin of pubis.

Omentum Intestine
Comparison
Doughy. Soft.
1. Consistency:
No gurgling. Gurgling.
2. Sensation:
Dull. Resonant.
3. Percussion:
Last part more
difficult.
First part more difficult.
4. Reduction:


| 46 46 46 46

Q & As
Any abdominal organ can be a content of hernia
except the pancreas.

Q Why you did not do the external ring test?
A Because it is painful, insensitive & may widen the external ring.

Q Where is the defect in:

o Umbilical, paraumbilical & epigasteric hernia?
A In linea Alba.

o Direct hernia?
A Hassel Bach's triangle.

o Indirect hernia?
A Internal ring.

Q What are types of oblique inguinal hernia?
A 1. Bubonocele hernia in groin only.
2. Funicular type descends into the scrotum but the testes are
felt separate from the hernial sac.
3. Scrotal descends into the scrotum and the hernial sac surrounds
the tests which is not felt through the content of the hernia.

Q Why it is important to look for enlarged prostate in old patient in
inguinal hernia?
A Because if it is present, it must be treated first to avoid recurrence of
hernia.


| 47 47 47 47

Symptoms of
enlarged prostate

Frequency of Difficulty weak stream
micturation in micturation of urine

Q What are the conditions in which you find strangulation without
obstruction?
A If the content is
Part of the circumference of the intestinal lumen "Richter s hernia".
Michael's diverticulum "Littre's hernia"
Other than intestine "omentum or fallopian tube".

_>, l.c sliding hernia , V l.Ilc :

,. .. l,aI ,. lIls. ,. l,.,I .
There is double micturation.
Incomplete reducibility.
Pressure on the sac causes a desire of micturation.

The importance of sliding hernia is that if it not recognized during
operation the sliding organ may be injured or devascularized during
dissection of the hernial sac.

Q What is Mydle's hernia?
A It is W shaped hernia, that when hernia is strangulated, the
strangulated loop may not be in the sac so, It is important during
surgery to pull on the loop if two loops exists.

Q How do you do the repair of fascia transversalis?
A By plication of the fascia transversalis or double breasting of the
fascia transversalis.


| 48 48 48 48

Bassini repair "suturing the conjoint muscle to inguinal ligament" is the
most popular type of repair of posterior wall of inguinal ligament.
Q If the patient has bilateral inguinal hernia, How to proceed?
A Herniorraphy one side is repaired and then the other aer 6
months, to avoid stretching over the abdominal muscles.

Q What are the causes of a recurrent hernia?
A 1. Untreated preoperative condition: chronic straining e.g. prostatic
enlargement& obesity.
2. Intraoperative causes: repair with absorbable suture material,
tense repair & lax repair
3. Postoperative causes: hematoma, infection & early return to hard
work.

Q What are the causes of residual swellings after reducing the hernia?
A 1. Sliding hernia.
2. Incomplete reducibility due to adhesions between the contents
and the sac.
3. Hydrocele of the hernial sac.
4. Associated lipoma of the cord.

Q How do you treat an incisional hernia?
A IF it is
Small defect Do anatomical repair.
Large defect Do hernioplasty, Keel operation & Catell's
operation.

Keel operation: the sac is not opened (inverted) & the defect is
closed by a series of inverting sutures.
Catell's operation: the sac is opened &the defect is closed by
multiple layers from surrounding tissues.

Rare types of external abdominal hernias:
Lumber, obturator, interstitial, spegelian and perineal.


| 49 49 49 49

internal abdominal hernia include:
Diaphragmatic hiatus "97%" and internal strangulations.
D.D. of inguino-scrotal swellings:

1. Oblique inguinal hernia.
2. Hydrocele "congenital, infantile, encysted, or hydrocele of a hernial sac"
3. Cord masses "varicocele, filariasis, lymphcele of the cord, lipoma of the
cord and bilharzaisis".
4. Testicular swellings undescended testis at the scrotal neck.

Complications of maldecended testis:

1. The presence of an oblique inguinal hernia in 75% of cases.
2. More liable for trauma especially if in the inguinal canal.
3. Increase incidence of malignancy.
4. More liable for torsion.
5. Infertility if bilateral.

Swellings above the inguinal ligament:

1. Bubonocele hernia.
2. Undescended and ectopic testis.
3. Cord masses.
4. Enlarged lymph nodes.
5. External iliac artery aneurysm.
6. Swellings from the skin and S.C tissue e.g. lipoma.

Swellings of femoral triangle:

The most important are

1. Femoral hernia.
2. Saphena varix.

3. Femoral artery aneurysm.
4. Enlarged inguinal lymph
nodes.
The less important
1. Femoral ectopic testis. 2. Neurofibromatosis of

| 50 50 50 50

femoral nerve.
3. Sarcoma of the muscle.
4. Arthritis.
Types of oblique inguinal hernia:

1. Congenital: due to persistent patency of the whole processes vaginalis
testis appears suddenly, descends to the bottom of the scrotum from
beginning, and completely surrounds the testis.

2. Infantile: in which the processes vaginalis is patent to the level of
external ring

3. Acquired: bubonocele, funicular & scrotal.

Q What are the principle lines ttt of hernia?
A First: you should treat the underlying cause of increasing the intra
abdominal pressure.
Surgery is the main line of ttt

1. Herniotomy legation and excision of the sac at its proper neck.
,i.c l.c lsLVI , ,IoaIl. _s... .strong muscles

2. Herniorraphy as above + repair of the defect by local
surrounding tissues.
> l.,sI I l,. _s... ei.c i .good and healthy muscles of abdominal wall
I _ss. lo _oo defect . fascia I fascia lata .

_,so i> I Il> _ .L good muscles ei.c big defect _ recurrent
old age I _oc

3. Hernioplasty Herniotomy + repair of the defect by prolene
mesh.

Prolene as it is unabsorbable sutures.


| 51 51 51 51

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