Case 1: Troublesome stoma

This 57 year old man was having increasing discomfort from his stoma
and associated leakage from a stoma appliance that was difficult to
. apply

?.What abnormality is shown. 1

A parastomal hernia
2. Methods
? for repair
consider stoma closure restoring intestinal continuity-resiting stoma to another area with non attenuated
abdominal wall tissues
-local repair. This may include amputation of some
bowel length, suture plication of the abdominal wall
defect, mesh repair to reinforce the abdominal wall
tissues.
3. What is
?the elastic garment around this patients waist
abdominal binder for symptomatic relief-

Case 2: Sudden onset abdominal pain

This 77 year old man collapsed at home complaining of

. abdominal pain

?.What abnormality is shown. 1

Leaking Abdominal Aortic Aneurysm.
2. Methods for
? repair
Open repair with interposition dacron graft,
which may have to be bifircated if the
aneurysm extends down one or both iliacs.
- Endoluminal repair is becoming more
accessible especially in specialised centres
and with careful patient selection

Case 3: Right sided abdominal pain

This 77 year old man with a prosthetic mitral valve

. presented complaining of right sided abdominal pain

?.What has happened to cause the pain. 1

Right sided rectus sheath haematoma. This
patient will most likely be fully anticoagulated
because of his heart valve. A spontaneous
haemorrhage like this is uncommon but can be
difficult to treat.
?
2. Treatment
Observation in ICU, resuscitation, transfusion,
correction of anticoagulation, analgesia and
occasionally angiography and embolisation.
3.
What is the subcutaneous mass in the
? anterior abdominal wall
. Paraumbilical hernia, probably unrelated

Case 4: Painless post auricular swelling

. This man presented with a mass behind the left ear

?.What is the differential diagnosis. 1

Includes:
sebaceous cyst
lymphadenopathy
lipoma
inclusion dermoid
dermoid cyst
simple cyst
The differential is large. However it can be narrowed by
considering the lumps physical characteristics. It is
smooth, does not involve skin, there is no punctum,
and if felt it is soft, fluctuant and importantly is quite
transilluminable.
?
2. Further treatment
A simple cyst would be uncommon in this area so it was
excised and submitted for histopathology - this showed

Case 5: Significant abdominal wound infection

7 days after a laparotomy this lady was very unwell with

infection spreading from her abdominal wound. Blood gases
were taken on her admission to the intensive care unit

?.What do they demonstrate. 1

Extreme metabolic acidosis.
Maximum respiratory compensation.
Significant base excess.
Adequate oxygenation if breathing room air.
2. What do you think of her
? wound infection now
In the absence of another clear cause, the wound
infection is obviously causing significant systemic
sepsis. In fact, the infection has probably evolved into a
necrotising fasciitis process and may be lethal.
Rapid resuscitation, IV antibiotics and wide surgical
debridement will probably be necessary.
There is some evidence that hyperbaric oxygen therapy
. has some benefit in treating these very unwell patients

Case 6: Bile in the drain tube

10 days after a laparotomy for a perforated gastric antral

. ulcer, there was bile draining from the drain tube

?.What xray has been performed. 1

A fluoroscopic sinogram (contrast injected down the
drain tube).
2. What does
? it show
The film shows contrast flowing down the drain tube
and filling a cavity around the second (descending
part) of the duodenum. The contrast is also seen
entering the duodenal lumen. (on the film seen just to
the medial aspect of the cavity)
With a perforated gastric antral ulcer the options are
to patch repair the defect with an omental patch (also
taking an ulcer edge biopsy to exclude malignancy).
However, with a larger ulcer a distal gastrectomy may
be required (as in this case) with the consequent risk of
. duodenal stump leakage

Case 7: Painful leg

This man was involved in an industrial accident. His legs were crushed
across the thighs for 8 hours before he was able to be rescued. He
. sustained no other injuries

?What complication has occurred. 1

Compartment syndrome of at least the posterior
compartment
2. What
other clinical settings may result in this
?condition
Prolonged ischaemia from any cause. Embolic,
thrombotic, traumatic, and associated with lower limb
fractures and the resultant swelling.
?

3. What operation has been performed

Posterior calf compartment fasciotomy

?What are the indications this operation . 4

Confirmed, or in the correct clinical context, the
suspicion or predicted occurence of this problem as a

Case 8: Acute shortness of breath

This 24 year old man presented with sudden onset

pleuritic right scapular region pain and shortness of
breath. A chest xray was obtained and prompted the
. emergency department to perform a procedure

?What does the xray show. 1

The xray shows a right sided pneumothorax without
evidence of tension (complete collapse, medisatinal
shift, flattening of the dome of the diaphragm). A pigtail
catheter has been inserted however there is incomplete
.re-expansion of the lung
How would you manage the problem. 2
?in the emergency department
The management of a symptomatic spontaneous simple
pneumothorax is insertion of an intercostal catheter
with connection to an underwater seal drain (UWSD).
These drain chambers include the ability to apply
regulated suction to the pleural cavity. Many surgeons
would apply 20 cm water suction initially which can
then be ceased 24 hours after re-expansion of the lung
with daily chest xrays to confirm the abscence of

He returns 6 months later with the same . 3

problem. How would your management differ
?now
Spontaneous pneumothorax typically occurs in thin fit
young adults with a male preponderence. They also
occur in patients with underlying chronic lung diseases
.in particular bullous emphysema and asthma
Recurrence in a young man would be considered an
indication for pleurodesis. VATS (video assited
thoracoscopic surgery) pleurodesis is performed under
general anaesthesia with double lumen intubation.
Inspection of the apex of each lobe may reveal a
congenital bulla which should be excluded from the
bronchial tree by excision using and endoscopic stapler
or simple endoloop application. The pleurodesis is then
effected by abrasion and application of an irritant such

Case 9: Bile in the drain post cholecystectomy

A 55 year old woman is referred to you 10 days post

cholecystectomy. The procedure was performed for
acute cholecystitis and the dissection was difficult. The
original surgeon reported finding "aberrant anatomy".
There has been persistent drainage of bile from the
. drain left at operation at approximately 500ml/day

?What type of xray is this and what does it show. 1

A sinugram has been performed with instillation of water
soluble contrast via the drain tube. The contrast is seen to
flow into a cavity that communicates with the left and right
. hepatic ducts
? How would you manage this problem. 2
The immediate concern is assessment and resuscitation of
the patient who may have severe biliary peritonitis. If the
drain has created a controlled fistula then this allows time to
obtain further investigations to define the anatomy and plan
.definitive management
?How would you classify this injury. 3
The Strasberg classification is the most practical and widely
used classification. It incorporates the Bismuth classification
which was initially developed to classify hilar
.cholangiocarcinoma
This injury is a Strasberg E4 or Bismuth 4 with resection of

Case 10: Abdominal pain and bloating

A 32 year old man with Crohn's disease presented with

several months of progressive abdominal pain and
bloating. His symptoms were related to meals and as a
result he had lost significant weight. He had previously
undergone ileocolic resection with anastomosis and on
this occasion you resect the area of the anastomosis
. and open the specimen shown below

.Describe the specimen shown. 1

The specimen is an opened segment of bowel
with neoterminal ileum on the left and an
ileocolic anastomosis towards the right. At the
anastomosis there is evidence of stricturing
with significant submucosal fibrosis and
thickening that extends proximally for at least
10 cm. The mucosa overlying the anastomosis
is deeply ulcerated. There are also linear ulcers
.in the mucosa of the ileum

What are the histologic features of Crohn's. 2

?disease
Crohn's disease is a chronic inflammatory disease
characterised by transmuarl involvement with
mucosal damage, non-caseating granulomas and
.fissuring with the formation of fistulas
Crypt abscesses occur but are not specific for
Crohn's. Deep ulceration may be adjacent to
relatively normal bowel wall indicative of the
discontinuous distirbution of the disease. Sarcoidlike granulomas may occur in up to half of patients
and can be found in any layer of the bowel wall
.and even in otherwise normal appearing bowel
Deep fissures may lead to fistula formation
between loops of bowel or other adjacent organs.
Extensive submocosal fibrosis leads to sticture

What investigations would you perform. 3

?prior to operation in this man
It is important to confirm the diagnosis of
recurrent Crohn's with stricture formation before
embarking on resection. This can be done easily by
colonoscopy and intubation of the terminal ileum.
Colonoscopy also allows assessment of the extent
of disease. Further assessment of the small bowel
may require enteroscopy, radiologic enteroclysis or
.MRI (investigational at present)
Finally the patients overall fitness needs to be
assessed. In particular the effects of malnutrition
resulting from poor intake and malabsorption,
chronic disease and probable chronic steroid use.
Simple assessment is based on serum albumin and
measurement of iron stores and vitamin B12. Other

Case 11: Statistically speaking

A 52 year old woman has a 25mm mass in her left breast. It

feels malignant and this is confirmed by core biopsy. She has no
palpable lymph nodes in the axilla and basic staging
investigations are normal. She raises the question of sentinel
lymph node biopsy (SNB) to avoid an axillary dissection. Her
. lymphoscintigram is shown below
What is a sentinel. 1
?lymph node
What are the common. 2
or important risks of
axillary dissection you
?would discuss
She asks you about the. 3
7% false negative rate.
What does the figure
?mean
How would you. 4
calculate the sensitivity
?and specificity for a test

?What is a sentinel lymph node. 1

The sentinel lymph node is the first node
draining a particular anatomical location. The
location of a sentinel node is able to be reliably
determined by a combination of the injection of
a radiolabelled traced and blue dye. The status
of the sentinel node is used as a marker of the
.status of the entire nodal basin
What are the common or important. 2
risks of axillary dissection you would
?
discuss
Major morbidity from axillary dissection is
uncommon. The problem that many women
complain of is anaesthesia or paraesthesia in
the axilla, lateral chest wall and medial arm

Disruption of the long thoracic nerve to

serratus anterior or the nerve to latissimus
dorsi results in a more significant function
deficit.
The medial
pectoral nerve supplying pectoralis major is
also at risk.
The rate of clinically significant chronic
lymphoedema of the arm is as high as 10-15%.
Seroma
development in the wound is more common but
usually resolves with repeat aspiration.
Shoulder stiffness usually responds to
physiotherapy and it is part of the breast care
nurse's and surgeon's role to discuss

She asks you about the 7% false. 3

negative rate. What does the figure
?mean
The false negative rate means that of all those
axilla's truly involved 7% will be falsely thought
to be negative. It is the reverse of sensitivity
(93%). This will lead to incorrect down staging
of the patient resulting in potential under
treatment with adjuvant therapies.
One other issue needs to be considered in
order to make sense of the false negative rate.
That is the incidence of involvement of the
axilla in early breast cancer. If only 20% of
patients with early cancers have axillary
disease and 93% of these will be correctly

How would you calculate the sensitivity. 4

?and specificity for a test
You will need to draw up a table with 4
potential result types. True positives, false
positives, false negatives and true negatives
Sensitivity equals true positives divided by
true positives + false negatives =TP/(TP+FN)
Specificity equals true negatives divided by
true negatives + false positives =TN/(TN+FP)

Case 12: Pain and lump in the breast

A 24 year old woman has been breast feeding

for 2 months. She now presents with a painful,
red mass in the lower outer quadrant of her left
. breast

?What is the likely diagnosis. 1

Lactational breast abscess
What advice would you give . 2
?her about breast feeding
Continue feeding to encourage drainage of the
breast. An abscess develops when there is a
relative obstruction to flow from a lobule of the
breast related to inspissated material in the
ducts. Organisms most likely ascend the duct
after gaining entry through the nipple which
may be cracked or damaged from feeding .
The baby will not be harmed by feeding from
this breast and should be fed from the effected
side first. If feeding is too painful then the

Outline you management plan for this. 3

woman
After a thorough history and examination the
next investigation should be an ultrasound to
confirm the presence and size of an abscess.
Differentiation from
mastitis without abscess may be difficult
clinically.
Heat packs and massage, particularly in a
warm shower, may also help. Analgesia and
antibiotics are usually required.
Unless the overlying skin is thin and necrotic
it is not usually necessary to incise and drain a
. breast abscess

Rather it is preferable to aspirate it with a

large bore needle often with US guidance. This
procedure may need to be repeated on a daily
basis until the abscess resolves but creates less
risk of a milk fistula and cosmetic deformity.
The possibility of an inflammatory cancer
always needs to be considered although this is
unlikely in a lactating woman. As a result she
should be followed up with clinical examination
.and imaging after resolution of the abscess

Case 13: Growing neck lump

This 85 year old man is referred to you with an

. enlarging lump in the left neck

Further information - see the following images

Describe the lesion. 1

There is a hemispherical raised lesion which is deeply
purple in color, smooth in contour, which seems to be
involving the overlying skin.
?2. What is the differential diagnosis
Malignant lesion - primary skin lesion or metastatic
nodal disease involving skin. Less likely would be an
infected sebaceous cyst.
? 3. What else would you examine
The skin of the head and neck, complete ENT exam,
and other lymph node groups.
4. What do
?you see
Pigmented skin lesions consistent with melanoma.
5. Now what is

Case 14: View at Laparoscopy

? Can you identify the structures

What type of. 1
retractor is marked by
"?"A
What segment of the. 2
"? liver is shown by "B
What is under the. 3
lesser omental fat at
"?"C
What organ is close. 4
to letter "D" just out of
?screen
Which lobe of the. 5
liver is demonstarted
"?by "E

"?What type of retractor is marked by "A. 1

Nathenson liver retractor
2. What
"? segment of the liver is shown by "B
Segment 1, under the pars flaccida of the lesser
omentum, otherwise known as the caudate lobe.
3. What is under the lesser omental fat at
"?"C
The region of the gastro-oesophageal junction and the
oespophageal hiatus in the diaphragm.
4. What organ is close to letter "D" just out of
?screen

Case 15. Hand pain and numbness

This lady has had pain and numbness in the radial

three fingers for over 20 years. These symptoms are
worse at night time. She often wakes at night and
. shakes her hands for relief

?What syndrome is this typical of. 1

Carpal tunnel syndrome
2. What
? complication is seen
Thenar muscle wasting.
3.
? Confirmatory tests
Nerve conduction studies - are always helpful to exclude
other diagnoses. .
?
4.Treatment
Conservative - splints, analgesia, treatment of any
predisposing cause, steroid injection into and around
the carpal tunnel. All of these would be unsuitable in
this case because of the significant symptoms and
demonstrable thenar muscle wasting.
Surgery - Open or endoscopic division of the flexor

Case 16: Intermittent abdominal pain and a lump

A 56 year old man has had several abdominal operations

in the past. He presents complaining of a discomfort
associated with a small lump which has developed in the
. midline wound near the umbilicus

What is the likely diagnosis (shown at. 1

?"C")
Incisional Hernia near the umbilicus.

2. What
operation do you think was performed
through the right upper quadrant scar?
Marked "A"
(He says he cant remember, however it was
when he was a baby.)
A Ramstead pyloromyotomy for pyloric stenosis. He
was the first child in his family, and his father had
pyloric stenosis.
3. With
the patient lifting his head off the bed, what
"? is marked by "B

Case 17: Discharging lump in natal cleft

This young man presents with a 12 month history of an

intermittently painful and discharging lump at the
. lower back

?What is the likely diagnosis. 1

. A pilonidal sinus

Case 18: Wrist swelling

This lady had a lump on the back of her wrist

.which was getting bigger and more painful

?What is the likely diagnosis. 1

Dorsal wrist ganglion. Clinical examination
would confirm this, showing, a soft fluctuant
mass, transillumination, no punctum, and
usually fixed to the underlying dorsal wrist
capsule. Sometimes they can arise from the
. extensor tendon sheaths

Case 19: Dead toe

This 69 year old man presented worried about the

. apperance of his toe
Describe the. 1
appearance of the toe
'?marked 'A
What do you think has. 2
been marked with a
'?cross at 'B
'What is 'C. 3
What is seen in the. 4
'?background marked 'D
If there was a strong. 5
pulse felt at 'B', what do
you think the patients
main predisposing
?condition would be

'?Describe the appearance of the toe marked 'A. 1

This toe is gangrenous. The characteristic colouration,
shrunken prune-like skin appearance and nail bed pallor
confirm this.
2. What do you think has been marked with a cross
'?at 'B
There is a cross marked with pen. This is most likely over the
dorsalis paedis artery.
'?
3. What is 'C
This is a permanent ink mark outlining the extent of cellulitis.
4. What is seen in
'?the background marked 'D
A hand-held doppler transducer. For assessment of the pulse
site and waveform.
5. If
there was a strong pulse felt at 'B', what do you think

Case 20: Minor head injury

This young man fell from his bike 12 weeks earlier. He

sustained a minor head injury in that he bumped his head at
the point marked by the arrow. He now presents with a painful
. and pulsatile mass at that site

?What do you think has happened. 1

The likely diagnosis is a traumatic false
aneurysm of the superficial temporal artery.
2. What
?treatment would you recommend
Pseudoaneurysm arising from the superficial
temporal artery (STA) is very rare and is most
commonly caused by blunt trauma. Most
pseudoaneurysms of the STA usually present
as a painless pulsating mass, with concomitant
symptoms according to location, and their size
may rapidly increase.
The treatment of
. choice is ligation and resection

Case 21: Abdominal X-ray

. This Xray was taken in the emergency room for abdominal pain

What prior abdominal operation has. 1

?the patient had
Cholecystectomy - probably laparoscopic
because clips are less useful at an open
. operation so are not usually seen

Case 22: Subcutaneous foreign body

What is the subcutaneous linear mass. 1

?running along the chest wall
An axillofemoral bypass graft
2. It is not
pulsatile. Does this change your
?diagnosis
Probably not, however this suggests that the
. bypass has occluded