Case scenarios in Surgery

Dr.M.RAMULA M.S.,D.G.O

30.7.2020
 CASE 1: Lump in the groin
• History: A 51-year-old woman presents to the emergency
department with a painful right groin. She reports lower abdominal
distension and has vomited twice on the way to the hospital. She
has passed flatus but has not opened her bowels since yesterday.
She is otherwise fit and well and well built. She lives with her
husband and four children.
• Examination: On examination she appears unwell. Her blood
pressure is 106/70mmHg and the pulse rate is 108/min. She is
febrile with a temperature of 38.0°C. The abdomen is tender,
particularly in the right iliac fossa, and there is marked lower
abdominal distension. There is a small swelling in the right groin,
which is originating below and lateral to the pubic tubercle. The
lump is irreducible and no cough impulse is present. Digital rectal
examination is unremarkable and bowel sounds are hyperactive.
 Investigations
Plain X-ray Abdomen Erect

Blood investigations

Haemoglobin : 14.1g/dL
White cell count 18.0 × 109/L
Platelets 361 × 109/L
Sodium 133mmol/L 135–145mmol/L
Potassium 3.3mmol/L 3.5–5.0mmol/L
Urea 6.1mmol/L 2.5–6.7mmol/L
Creatinine 63μmol/L 44–80μmol/L
Amylase 75 IU/L 0–99 IU/L
 Questions

• What is the diagnosis?

• Are there any patients at particular risk of
developing this condition?
• What is the significance of the right iliac fossa
pain in this setting?
• How will you manage?
 Answers
• This woman has a right-sided femoral hernia. The neck of the
femoral hernia lies below and lateral to the pubic tubercle,
differentiating it from an inguinal hernia, which lies above and
medial to the pubic tubercle.
• The x-ray shows small-bowel dilation as a result of
obstruction due to trapped small bowel in the hernia sac.
• The high white cell count, temperature and tenderness may
indicate strangulation of the hernia contents.
• The rigid borders of the femoral canal make strangulation
more likely than in inguinal hernias.
 Surgical Anatomy
• Anteriorly: inguinal ligament
• Posteriorly: superior ramus of the pubis and pectineus muscle
• Medially: body of pubis, pubic part of the inguinal ligament
• Laterally: femoral vein
 Management
• The patient should be kept NPO, and intravenous
fluids and antibiotics begun.
• A nasogastric tube should be passed and bloods
taken in preparation for theatre.
• The patient taken for urgent surgery to reduce and
repair the hernia, with careful inspection of the
hernia sac contents.
• If the bowel is infarcted, it will need to be resected.
 Case 2: Small-bowel anomaly
• History
• A 14-year-old boy presented to the emergency
department with a 24-h history of increasing
abdominal pain. The pain localized to the right iliac
fossa and a diagnosis of acute appendicitis was
made. At operation, the appendix was found to be
normal and the anomaly shown
 Questions

• What is the diagnosis?

• What are the characteristics of this anomaly?
• How can this present?
• How would you deal with this intra operative
finding?
TRUE/FALSE
 Meckel’s diverticulum
• located on the anti-mesenteric border of a segment of ileum.
• This is a remnant of the omphalomesenteric duct.

• A Meckel’s diverticulum may be lined by small-intestinal, colonic or gastric mucosa, and it

may contain aberrant pancreatic tissue.

• The mode of presentation may be:

• Inflammation and perforation of the diverticulum presenting with abdominal pain
• and peritonitis, mimicking acute appendicitis
• Rectal bleeding from peptic ulceration caused by acid secretion from the ectopic
gastric mucosa
• Intestinal obstruction from intussusception or entrapment of the bowel in a
mesodiverticular band or a fibrous band that may connect the apex of the diverticulum to
the umbilicus or anterior abdominal wall
• Tumours may also develop inside a Meckel’s diverticulum.
• A symptomless diverticulum that is an incidental finding at laparotomy should not be excised.
Meckel s scan
 3: abdominal distension and pain
• History
• A 70-year-old man has been sent to the emergency department from a nursing home,
complaining of intermittent sharp abdominal pain. He has not opened his bowels for 5
days.. He has a history of chronic constipation. Previous medical history includes chronic
obstructive airways disease for which he is on regular inhalers. He is allergic to penicillin and
is an ex-smoker.
• Examination
• His blood pressure is 110/74mmHg and the pulse rate is 112/min. His temperature is 37.8°C.
There is gross abdominal distension with tenderness, most marked on the left-hand side.
The abdomen is resonant to percussion and digital rectal examination reveals an empty
rectum on auscultation of the chest there is a soft systolic murmur and mild scattered
inspiratory wheeze
 Questions

• What does the abdominal x-ray show?

• What other radiological investigation could be
employed if the diagnosis was in doubt?
• How should the patient be managed?
• What is the explanation for the pathology?
 ANSWERS
• The x-ray shows a sigmoid volvulus. The sigmoid colon
is grossly dilated and has an inverted U-tube shape.
The involved bowel wall is usually oedematous and can
form a dense central white line on the radiograph.
• On either side, the dilated loops of apposed bowel give
the characteristic ‘coffee bean’ sign. X-ray appearances
are diagnostic in 70 per cent of patients.
• If there is doubt about the diagnosis, a water-soluble
contrast may be helpful in showing a classical ‘bird’s
beak’ appearance representing the tapered lumen of
the colon.
BIRDS BEAK
 Management
• The flatus tube is left in situ for approximately 48h and is often only
a temporary measure.

• Colonoscopy can be used to decompress the bowel and may

resolve the volvulus. Urgent laparotomy will be required if
decompression is not possible or in cases of suspected gangrene/

• perforation (fever, leucocytosis, peritonism, free air under the

diaphragm on erect chest radiography). The patient’s fitness for
surgery, prognosis and quality of life should be considered

• before proceeding to laparotomy. It may be appropriate to use only

conservative treatments in some patients.
Gangrenous sigmoid
SURGERY
Algorithm
 Treatment of sigmoid volvulus

• Keep patient nil by mouth

• Intravenous access and fluids
• Fluid balance monitoring
• Routine bloods and crossmatch
• Erect chest x-ray/abdominal x-ray
• Decompression with rigid sigmoidoscopy and
insertion of a flatus tube once the diagnosis is
confirmed on abdominal x-ray
 CASE 4: sudden-onset epigastric pain
• History
• A 41-year-old male presents to the emergency
department with epigastric pain and vomiting.
• The pain began suddenly 2 h previously, followed by 3–4
episodes of non bilious vomiting. He had been previously
fit and well. He is a smoker and Chronic alcoholic
• Examination
• The patient is sweaty and only comfortable while lying
still. His blood pressure is 170/90 mmHg, pulse 116/min
and temperature 37.5°C. The upper abdomen is tender
and rigid on palpation.
 Examination

• The patient is febrile with a temperature of 38°C and

a pulse rate of 116/min. He is not clinically jaundiced.
• On palpation of the abdomen, there was diffuse
tenderness with gaurding and rigidity
• . The urine is clear and rectal examination is normal.
• Xray shown below
X-RAY
 INVESTIGATIONS

• Normal
• Haemoglobin 12.0g/dL 11.5–16.0g/dL
• Mean cell volume 86fL 76–96fL
• White cell count 13.2 × 109/L 4.0–11.0 × 109/L
• Platelets 250 × 109/L 150–400 × 109/L
• Sodium 137mmol/L 135–145mmol/L
• Potassium 3.5mmol/L 3.5–5.0mmol/L
• Urea 5mmol/L 2.5–6.7mmol/L
• Creatinine 62μmol/L 44–80μmol/L
• Amylase 250 IU/dL 0–100 IU/dL
• AST 30 IU/L 5–35 IU/L
• GGT 242 IU/L 11–51 IU/L
• Albumin 45g/L 35–50g/L
• Bilirubin 12mmol/L 3–17mmol/L
• Glucose 5mmol/L 3.5–5.5mmol/L
• LDH 84 IU/L 70–250 IU/L
• Total serum calcium 2.35mmol/L 2.12–2.65mmol/L
 Questions

• • What is the likely diagnosis?

• • How should this patient be managed?
• • How should this patient be managed after
discharge?
PNEUMOPERITONEUM
 Follow up
• Postoperatively, patients should be considered
for Helicobacter pylori eradication therapy and
• Should continue on a proton pump inhibitor
• Refrain from alcohol
 5.Ulcer foot
• History
• A 54-year-old insulin-dependent diabetic woman has come to the emergency
department complaining of increasing pain in the right foot for the past week. For
the past few days she has noticed swelling, redness and dis colouration over the
base of the big toe. Her glucose control has been recently reviewed by doctor her
insulin regimen changed.
• Examination
• She is afebrile, her pulse is 86/min, her blood pressure is 130/60 mmHg and her
blood glucose is 13.2 mmol/L on BM stick testing. Femoral pulses are palpable
bilaterally. Palpable femoral & popliteal, but posterior tibial or dorsalis pedis pulses
are feebly palpable in the affected limb. The great toe is erythematous with a
large fluctuant swelling at the base.
Clinical Presentation
 Clinical examination
• This patient has poor diabetic control.
• Examination
• swelling and erythema over the base of the
first metatarsal, which may indicate an
underlying collection of pus
• X-Ray shown below
X-RAY
 Questions

• What do the clinical appearances suggest?

• What does the x-ray show?
• What other investigations does she require?
• How would you manage this patient?
• . A full vascular examination should be carried out and ankle–brachial indices
• measured. All areas of the foot, especially between the toes and the heel should be examined for
• other areas of ulceration, and the foot examined for the presence of diabetic neuropathy.
• Investigations should include:
• • Full blood count
• • Renal function and C-reactive protein
• • Blood sugar
• • Foot x-ray
• The patient should be commenced on intravenous broad-spectrum antibiotics and an insulin
• sliding scale. The priority is to release the pus and debride necrotic tissue. The x-ray changes
• (osteopenia, osteolysis, sequestra and periostial elevation) suggest there is underlying
osteomyelitis
• This will also need to be debrided in order to remove all the infection.
• O steomyelitis in the metatarsophal joint
• A duplex scan or intra-arterial angiogram should then be carried out to ascertain whether the
• blood supply to the foot is compromised and whether any revascularization procedure is necessary.
• As a rule, revascularization should be carried out prior to any surgical debridement/amputation
• in order to ensure that the blood supply is adequate for tissues to heal. In this particular
• case, however, delaying surgery would result in further damage to the foot. Revascularization
• of the foot should be carried out as soon as possible after surgery.
• KEY POINT
• Diabetic feet are at risk of ischaemia (progressive distal ischaemia) and neuropathy
• (sensory, motor and autonomic), and are more prone to infections.
 Cont..
• The x-ray changes
• (osteopenia, osteolysis, sequestra and periostial elevation) suggest there
is underlying osteomyelitis
• This will also need to be debrided in order to remove all the infection.

A duplex scan or intra-arterial angiogram should then be carried out to

ascertain whether the blood supply to the foot is compromised .
Surgical debridement/amputationin order to ensure that the blood
supply is adequate for tissues to heal.

• KEY POINT
• Diabetic feet are at risk of ischemia (progressive distal ischemia) and
neuropathy (sensory, motor and autonomic), and are more prone to
infections.
ABI
Off Loading
 6: testicular pain
• History
• A 16-year-old boy attends the emergency department complaining of sudden
onset of right testicular pain. The pain woke him from his sleep and has persisted
over the last 3 h. His mother says that he has vomited once. His previous medical
history includes a similar event a year ago, but on that occasion the pain subsided
quickly.
Examination
• On examination the left hemi-scrotum feels normal but the right side is acutely
swollen and tender on palpation. The testicle is elevated when compared to the
other side and has an abnormal horizontal lie. The abdomen is soft and non-
tender. His blood pressure is 130/84 mmHg and the pulse rate is 110/min. The
cremasteric reflex is absent.
 Questions

• What is the diagnosis?

• What should you consider in the differential?
• What is the management in this case?
 ANSWERS
• This boy has testicular torsion until proven otherwise.
• Testicular torsion is actually torsion of the spermatic cord and not of the
testis.
• This results in irreversible ischemia to the testicular parenchyma, which
can occur within 4–6 h of cord torsion.
• The presentation can vary and includes vague loin or groin pain as well as
scrotal signs and symptoms.
• There maybe a history of excessive physical activity or trauma. Testicular
torsion can occur at any age
• but commonly has a bimodal distribution. There is a small peak in the first
year of life but is
• more common between late childhood (post puberty) and early
adulthood, i.e. 12–18 years.
• .
 ETEIOPATHOGENSIS
• Normally, the tunica vaginalis envelops the body of the testis and only part
of the epididymis(which is usually fixed), and the testis is unable to twist.
• In cases of torsion, there is an abnormal amount of free space between
the parietal and visceral layers of the tunica vaginalis, which encompasses
the testis, epididymis and the cord for a variable distance. This free space
allows the now hypermobile testis and epididymis to rise in the scrotum
and twist. This accounts for the (‘bell clapper deformity’).
• If the presentation is delayed, an acute hydrocoele may develop making
examination difficult, and the scrotum may appear erythematous. Surgical
exploration is essential if torsion is considered.
• Testicular salvage rates are directly correlated with the number of hours
after the onset of pain with a significant drop off after 6 h. Urinalysis is
often negative and the diagnosis should
• be made clinically.
 Differential diagnoses
• Torsion of the appendix testis
• Torsion of the appendix epididymis
• Epididymo-orchitis
• Infected hydrocoele
• Testicular rupture
• Strangulated inguinal hernia
• A bleed into a tumour
• In torsion of the appendix testis, the tenderness is usually localized above the upper pole of
• the testis and may be accompanied by the ‘blue dot’ sign, which represents necrosis in the
• appendix. Hydrocoeles may be tender if large and will transilluminate. If a patient is suspected
• of having epididymo-orchitis, the urine should be screened for infection. There may
• Also be a history of urethral discharge or urinary symptoms such as frequency or dysuria
• If testicular torsion is suspected, surgical exploration should be carried out as soon
• as possible.
• Testicular salvage rates decline significantly after 6 h from the onset of testicular
• pain.
MANAGEMENT
 7: Abdominal trauma
• History
• You are called urgently to the resuscitation room for a trauma call. An 18-year-old
girl has fallen from her horse. During her descent, the horse kicked her, and she is
now complaining of generalized abdominal pain and left shoulder-tip pain.
• Examination
• She is talking and examination of her chest is normal. The oxygen saturations are
100 percent on 24 per cent oxygen. Initially, her pulse rate is 110/min with a blood
pressure of 84/60 mmHg. She is slightly drowsy and her Glasgow Coma Score
(GCS) is 14. On examination of the abdomen, there is an abrasion on the left side
beneath the costal margin with tenderness in the left upper quadrant. There is no
evidence of any other injuries and the urinalysis is clear. The patient is given 2 L of
intravenous fluids and the blood pressure improves to 130/90 mmHg. As the
patient has now become stable, a CT scan of the chest and abdomenis obtained.
The CT image is shown below
CT SCAN
 Clinical presentation
• On returning to the emergency department,
the patient becomes increasingly agitated. The
• nurse informs you that her blood pressure is
now 80/60 mmHg and the pulse rate is
130/min.
 Questions

• What does the CT scan show?

• Are there any alternative investigations to CT?
• What special requirements may this patient
have postoperatively?
Diagnosis
FAST
 ANSWERS
• The patient has sustained a tear to the splenic capsule, causing
intraperitoneal bleeding. The CT scan shows the fractured spleen with
surrounding hematoma.
• The shoulder-tip pain described is known as Kehr’s sign, and is indicative
of blood in the peritoneal cavity causing diaphragmatic irritation.
• Unstable patients suspected of splenic injury and intra-abdominal
haemorrhage should undergo exploratory laparotomy and splenic repair
or removal.
• Blunt trauma, with evidence of hemodynamic instability that is
unresponsive to fluid challenge, should be considered a life-threatening
solid organ (splenic) injury.
• Those patients who respond to an initial fluid bolus, only to deteriorate
again with a drop in blood pressure and increasing tachycardia, are also
likely to have a solid organ injury with ongoing haemorrhage.
 FAST
• Transfer to the CT scanner can be extremely dangerous for an unstable patient.
• Focused abdominal sonographic technique (FAST) is helpful in diagnosing the
presence or absence of blood in the peritoneal cavity without transfer to a CT
scanner.
• Diagnostic peritoneal lavage may be a valuable adjunct if time permits and
multiple other injuries are present.
• In a haemodynamically stable trauma patient, CT scanning provides an ideal non-
invasive method for evaluating the spleen. The decision for operative intervention
is determined by the grade of the injury and the patient’s current or pre-existing
medical conditions.
• Splenic embolization is a safe alternative depending on the grade and location of
the splenic injury.
• Those patients who undergo splenectomy have a lifetime risk of septicaemia and
should receive immunizations against pneumococcus, haemophilus and
meningococcus.
USG VS CT
Complications
 8.TRAUMA
• History
• You are asked to review a 78-year-old man on the observation ward. He was
admitted the previous evening with confusion. Earlier in the evening a friend
visited and reported that he had fallen over 3 weeks ago and had become
increasingly confused and clumsy.
• He takes a calcium antagonist for essential hypertension and aspirin since a
previous heart attack. He lives alone and is independent and self-caring. He is a
non-smoker, but there had been concerns over his increasing alcohol intake
following the death of his wife 5 years ago.
• Examination
• He has a normal temperature with a pulse rate of 78/min and a blood pressure of
136/86 mmHg. The cardio respiratory and abdominal systems appear normal. He is
confused in time, place and person. His pupils are symmetrical and reactive. The
rest of his cranial nerve and peripheral
• neurological examinations are normal.
CT SCAN BRAIN
 Questions

• What investigation is shown, and what is the

diagnosis?
• Which factors in the history make you
suspicious of this diagnosis?
 CSDH
• This man has a chronic subdural haematoma (CSDH) shown on a CT
scan .
• This condition is twice as common in men as women.
• Risk factors: Chronic alcoholism, epilepsy, anticoagulant therapy
(including aspirin) and thrombocytopenia.
• CSDH is more common in elderly patients due to cerebral atrophy. It
is thought that cortical bridging veins are put under tension as the
brain gradually shrinks away from the skull. This patient has had a
minor head injury in the preceding weeks, causing one of these
cortical veins to tear. The history of potential alcohol abuse and
aspirin use also contribute to the bleeding risk.
• Slow bleeding from the low-pressure venous system often allows a
large haematoma to form before clinical signs become evident.
• Initial misdiagnosis is, unfortunately, quite common.
 CSDH
• Before the advent of CT
• CSDH was known as the ‘great imitator’ as it was often mistaken for dementia, transient
• ischaemic attacks or strokes.
• The CT findings for subdural haematomas change with time.
• In the first week, the blood is hyperdense compared to brain tissue.
• In the second and third weeks, the haematoma appears isodense compared to brain tissue;
and after the third week, the blood appears hypodense compared to brain tissue.
• The term ‘chronic' is applied to subdural hematomas that are older than 21 days. When
there is no clear history of a head injury (25–50 per cent of patients), the diagnosis can be
made radiologically according to the CT appearances of the blood.
• Once the diagnosis is made, the liquefied blood can be drained via one or two Burr holes.
• Even for patients with significant comorbidities, operative intervention is not contraindicated
• as this procedure can be performed under local anaesthetic. Eighty per cent of patients
• will return to their previous level of function.
 9: assessment of a breast lump
• History
• A 47-year-old female presents to the breast clinic complaining of a
painful lump in her left breast. She has not noticed any nipple
discharge, skin changes or changes in her breast shape.
• Her mother was diagnosed with breast cancer at 50 years of age.
She is married and has no children. No other health issues
• Examination
• A 4-cm irregular lump is found adjacent to the nipple in the left
breast. The lump is hard in consistency and only mildly tender on
palpation. It is slightly mobile with no tethering of the overlying
skin. It does not appear deeply fixed. There are palpable left-sided
axillary lymph nodes which are mobile. The right breast and axilla
are normal. Abdominal and skeletal examination normal
 Questions

• How should this lump be assessed?

• What are the risk factors for
Developing breast cancer?
• To what age group does
a breast screening programme offered?
• What is a sentinel lymph node
biopsy?
Mammogram.
Mammogram
VIEWS
 RISK FACTORS
• The incidence increases with age, but at menopause
the rate of increase slows.
• Risk factors for developing breast cancer include:
• Estrogen exposure, unopposed by progesterone
• Nulliparous women in developed countries
• Mutations in the BRCA1 and BRCA2 genes
• Early menarche/late menopause
• Family history
• Saturated dietary fats
• Previous benign atypical hyperplasia
 ANSWERS
Triple assessment Pathology
Radiology
Triple Assessment

Clinical examination
Clinical examination

CNB
L.B
MANAGEMENT
Sentinel node Biopsy
 SNB

radiocolloidTc99
 Screening
• offered to women between the ages of 40 and 70 years. All women now have two views of
the breast taken at every screen – craniocaudal and mediolateral views. It has reduced
mortality rates in the 55–69-year age group.
• In patients without systemic disease, surgery is potentially curative.
• Treatment options
• Mastectomy or breast-conservation surgery, such as wide local excision or quadrantectomy.
• Axillary lymph node status is a good prognostic indicator for breast cancer and is
helpful in delineating further treatment pathways.
Management of the axilla is controversial.
• Options include axillary node sampling, clearance or sentinel node biopsy.
• The sentinel node Biopsy: is the first lymph node the breast lymphatics drain to before
reaching the axilla. Sentinel
• lymph node biopsy is an alternative to axillary sampling or clearance, which provides
information on the probable tumour status of other axillary lymph nodes.
• Technique
• injection of a technetium-based radioisotope into the breast, often in combination with a
dye.
• The sentinel node is detected with the use of a gamma camera or direct visualization on
dissection
• (the dye is usually blue) before excision.
ありがとうございます