Clinical Surgery

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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. What important questions should you ask in a patient with jaundice?
Retro-orbital inflammation and lymphocytic infiltration leading to oedema and an increase in retrobulbar orbital contents
Hepatitis - Decompensated chronic liver disease - Drugs
The simplest surgical technique is to excise the papilloma with a sharp pair of scissors - controlling bleeding from the central vascular component with a single suture. Alternatively - diathermy can be used to control the bleeding at the same time a
Have you noticed any change in the colour of your urine? Have you noticed any change in the colour of your stools? - Have you noticed yourself feeling itchy?


2. Which investigations would you use in a patient whom you thought might be suffering from a dysmotility problem?
The aneurysm is surgically repaired by either an excision bypass -where the popliteal artery is ligated above and below the diseased segment and a graft interposed - or a simple resection and anastamoses without the use of a graft - Acute ischemia ca
Barium swallow may be useful - If diagnosis is in doubt - endoscopy with biopsies and brushings should be performed to exclude a carcinoma - Physiological function could be tested using 24-hour oesophageal pH studies to exclude reflux and manometry
Non-adherent dressing over ulcer plus wool bandage - Crepe bandage - Blue-line bandage - Adhesive bandage to prevent the other layers from slipping
40 X increased risk of developing lymphoma - usually B-Cell non-Hodgkin's type


3. What are the causes of neuropathic ulcers?
Bilateral subtotal thyroidectomy leaving approximately 4g of thyroid tissue on each side of the trachea
Chronic Liver disease - Right Heart Failure - Intra-abdominal Malignancy - Hypoalbuminaemia
Hyperkeratosis - Acanthosis - Hyperplasia of variably pigmented basaloid cells
They can be caused by any disease that leads to a peripheral sensory neuropathy - or by causes of spinal cord disease. Causes of peripheral neuropathy include: Systemic disease - diabetes -vasculitis -hypothyroidism and Vitamin B12 deficiency - Drugs


4. What is a carbuncle?
Sturge-Weber syndrome is the association of a facial port-wine stain with a corresponding haemangioma in the brain - leading to contralateral focal fits.
The mainstay of treatment of ascites is to treat the underlying condition and to place the patient on a weight reduction program - with the help of diuretic - and a low-sodium diet.
Chest x-ray to map the caudal extent of the cystic hygroma - CT/MRI scanning especially if it is complex
A carbuncle is an extensive infection of hair follicles by the same organism with involvement of adjacent follicles and development of draining sinuses. It is associated with diabetes and is treated with a combination of systemic antibiotics and surg


5. What is Adiposis dolorosa or Dercum's disease associated with?
Non-Surgical - mechanical pressure therapy(day and night for up to 1 year) and topical silicone gel sheets - Surgical : Revision of scar with closure by direct suturing - local Z-plasty or skin grafting to avoid excessive tension - Intralesional ster
Lymphangiomas can be:Cystic - Solid or diffuse - Cutaneous
Minor defects in neonates are common but usually repair spontaneously. In children - umbilical herniae are mor common; they tend to have a narrow neck and folds of peritoneum stuck within this neck - which can occassionally strangulate. Most cases re
Peripheral Neuropathy


6. What side effect would you warn this patient about if considering cervical sympathectomy?

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7. What investigations would be helpful in confirming the diagnosis of coarctation of aorta?

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8. What is the commonest cause of unilateral ankle oedema?
Surgical treatment is superficial parotidectomy(if superfical lobe of gland only involved) or total parotidectomy with preservation of the facial nerve(if deep lobe of gland or both lobes involved)
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present
Venous disease
Purple-blue naevus found on face -lips and mucous membrane of the mouth - Present from birth and does not change in size thereafter - Found on limbs in association with Klippel-Trenaunay syndrome.


9. What do you know about thyroid adenomas?
Almost all are follicular adenomas - Usually 2 to 4 cm and encapsulated at presentation - Indistinguishable from carcinomas on FNAC - as the presence of a capsule cannot be demonstrated - Surgical excision is needed to confirm diagnosis
They are known as adiposis dolorosa or Dercum's disease.
The Branham-Nicoladoni sign indicates the degree of shunting and cardiac impairment resulting from a large AV fistula - The carotid pulse is palpated and then a tourniquet placed around the proximal affected limb and inflated above systolic pressure
Cardiac failure - Tricuspid regurgitation - Constrictive pericarditis


10. What are the causes of bilateral ptosis?
Congenital ptosis - Myopathies - Syphillis
According to site - contents and if it is random or axial. When it comes to site - you consider where it is local or distant(Which is also known as a free flap). You have to also consider the contents which can contain any tissue capable of transfer
Via chorda tympani to anterior two-thirds of the tongue
Mnemonic: SNAiL - Superficial spreading - Nodular melanoma - Acral lentiginous melanoma - Lentigo maligna melanoma


11. What is lid lag secondary to ?
The incompetent vein is at or above the level of the tourniquet
Classic Kaposi's sarcoma - AIDS-associated Kaposi's sarcoma - Endemic(central African) variety - Transplantation-associated Kaposi's sarcoma
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris
Remove goitrogens from diet(e.g cabbage) - Thyroxine 0.1/0.3 mg per day - If thyrotoxicosis treat as in Graves' disease - Aspiration of cysts with cytology to exclude malignancy - Radioiodine for elderly patients - particularly those unfit for surger


12. What is the main statistic with regards to salivary gland tumours?
Calcification of the walls of the vessel preserves the pulses until late in the natural history of disease - and prevent the sphygmomanometer from compressing the vessels. This tends to lead to an abnormally(and reassuringly) high ankle brachial pres
Via chorda tympani to anterior two-thirds of the tongue
80% of salivary gland tumours occurs in the parotid gland - 80% of these parotid tumours being benign - with 80% of these benign tumours being pleomorphic adenomas
Low approach - Lockwood - Transinguinal repair - Lotheissen - High approach - McEvedy


13. What are the coordination abnormalities causes of dysphagia?
Klippel-Trenaunay-Weber Syndrome - Parkes-Weber syndrome
Motility disorders - diffuse oesophageal spasm and achalasia - Neurological disease such as myaesthenia gravis - bulbar palsy including MND and cerebrovascular accident with involvement of the 9th -10th and 12th cranial nerves.
Bright-red raised strawberry-like lesion - Present from birth - but 60% undergo spontaneous resolution by the age of 3 years - Only treated if obscuring a visual field or spontaneous resolution not occurring.
Axillary vein thrombosis - Damage to axillary drainage following surgery such as axillary dissection in breast surgery


14. How would you prepare a patient who is going for surgery which will involve forming a stoma?
Extrusion of peritoneum and abdominal contents through a weak scar of accidental wound on the abdominal wall - Represents a partial wound dehiscence where the skin remains intact
Psychosocial and physical preparation - Explanation of indications and complication - Involving a Clinical Nurse Specialist in Stoma Care preoperatively who would normally mark the site - Marking of the stoma site
Cyanotic congenital heart disease - Infective endocarditis - Atrial myxoma (rare)
Rolled or raised edge - Often on sun-damaged skin


15. What are the specific early complications of amputations?

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16. How are the causes of jaundice classified?
Pre-hepatic - Hepatic - Post-hepatic
Palomo operation
Characteristic cold-induced changes associated with vasospasm
Cervical sympathectomy and amputation of the affected phalanges - Cervical sympathectomy may not be a permanent solution and may only relieve symptoms for 2 years or less - Amputate only if digits are threatened with gangrene


17. What are the three objectives to be taken note of in the inspection part of the arterial examination?
Calcium channel blockers e.g nifedipine - Prostacyclin analogues - Alpha blockers - 5-HT antagonists
Colour changes - Trophic changes - Vascular angle
Presence of multiple neurofibromas in a patient - in combination with other dermatological manifestations(six cafe-au-lait psots) - It is an autosomal dominant condition with two types: 1 and 2.
As the perfusion of the leg begins to decrease in a patient with peripheral vascular disease; the ratio begins to fall.


18. What is the pathogenesis of peripheral neuropathy?
Peripheral neuropathy has several effects: Slowly progressive sensory loss - with numbness and tingling of the feet and sometimes also hands. The sensory loss is often glove-and-stocking in distribution and may also be associated with motor impairmen
Barium swallow may be useful - If diagnosis is in doubt - endoscopy with biopsies and brushings should be performed to exclude a carcinoma - Physiological function could be tested using 24-hour oesophageal pH studies to exclude reflux and manometry
It will show you if it is malignant or inflammatory
The elective mortality from open AAA repair is 5% but this figure may be lower in specialist centres - If the patient suffers a ruptured aneurysm and reaches the hospital - their operative mortality rises to 50% - but only 50% of patients reach hospi


19. What is a neurofibroma?
Truelove classification - Gastrointestinal symptoms : passage of bloody stools more than 6 times per day - Systemic signs : tachycardia and pyrexia - Laboratory findings : anaemia and CRP more than 30
A neurofibroma is a benign tumour derived from peripheral nerve elements.
Central causes - RHF - hypoalbuminaemia -nephrotic syndrome and hypothyroidism - Peripheral - venous disease such as DVT - Klippel-Trenaunay syndrome - chronic venous insufficiency or post-phlebitic limb - Rare - angio-oedema - arteriovenous malforma
It arises de novo


20. What are the risk factors for arterial disease
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
A blepharoplasty can be performed where excess skin and fat are removed.
Lobectomy - Pneumonectomy - Non-anatomical resection are often performed for traumatic injury - Sleeve resection
Primary Raynauds is due to vasomotor malformation - Secondary Raynauds occurs as a consequence of pathology affecting the vessel wall


21. Why is surgical treatment advised in the treatment of varicocoele?
Characteristic cold-induced changes associated with vasospasm
Liver Cirrhosis - Inflammatory Bowel disease - Malabsorption - Gastrointestinal lymphoma
Subtotal colectomy with ileostomy plus or minus mucous fistula formation in acute severe colitis - Proctocolectomy and permanent ileostomy when the patient chooses or if patient not suitable for a restorative procedure - Restorative proctocolectomy W
It is often advised as the problem usually gets worse with age and there is risk of infertility.


22. How would a patient with carotid aneurysm be investigated?
True aneurysms are uncommon and are generally caused by atherosclerosis - and occasionally by dissection -trauma -previous carotid surgery or infection - When a true aneurysm has been excluded - the patient can be reassured and discharged. - Dilated
Other risk factors and cardiovascular disease elsewhere would be excluded and the neck imaged with a duplex scan or occasionally on intravenous digital subtraction angiogram
The aorta is narrowed below the origin of the left subclavian artery and therefore blood flow to the abdomen and legs is reduced - The prominent vessels over the back are large collateral that have developed to bypass the obstruction and supply the l
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.


23. Simple cysts are found in 33% of patients by the age of 60. How should they be managed?
Simple colloid goitre - Graves' disease - Thyroiditis
The patient should have a full workup for atherosclerosis - General investigations : Urinalysis for proteinuria - marker of atherosclerotic renal disease - Blood tests: FBC for anemia - which might precipitate symptoms - Renal function for possible u
History and Clinical Examination - they usually present incidentally but occasionally with a renal mass or haematuria
Neoplasia(benign -malignant -lymphoma and leukaemia) - Stone(sialolithiasis) - Infection/inflammation(mumps -acute sialadenitis -chronic recurrent sialadenitis -HIV - salivary gland disease) - Autoimmune(sjogren's syndrome) - Infiltration(sarcoidosis


24. What are the branches of the facial nerve?
True aneurysms are uncommon and are generally caused by atherosclerosis - and occasionally by dissection -trauma -previous carotid surgery or infection - When a true aneurysm has been excluded - the patient can be reassured and discharged. - Dilated
Secondary Raynaud's phenomenon associated with other diseases
Infection - acute and chronic otitis media - herpes zoster(ramsay hunt syndrome) - Idiopathic - Bell's Palsy - Trauma - surgical -accidental - e.g basal skull fracture - Tumour - paraganglioma - squamous cell carcinoma of external or middle ear - met
Motor - Secretomotor - Taste - Sensory


25. What are the two types of ptosis?
Unilateral - Bilateral
Mainly teratoma or seminomas - other types are: Embryonal carcinoma - Choriocarcinoma - Yolk sac tumour - Leydig cell tumours - Sertoli cell tumours - Lymphoma
Urinary retention - Bruising - Pain - often very severe and patients should be discharged with adequate analgesia; chronic groin pain persists in 5% of patients - Haematoma - 10% - Ischaemic orchitis - 0.5%(prev. vasectomy predisposing cause and diss
The procedure can be performed under a regional(brachial plexus) - local or general anaesthesia - A longitudinal incision 3-4cm in length is made over the distal third of the forearm midway between the radial artery and the cephalic vein - The cephal


26. How do you treat a thyroglossal cyst?

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27. What is the treatment of a lipoma?

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28. What do you know about the epidemiology of thyroglossal cysts?
Rare - Worldwide distribution - Equally common in males and females - Rarely present at birth - 40% present in the first decade and can even present late in the ninth decade
Ultrasound compression of the false aneurysm - Thrombin injection - Surgical repair - Observation and review
Fibrous tissue invades the tunica intima and media of the vein and breaks up the smooth muscle - preventing the maintenance of adequate vascular tone. These changes are patchy and may not affect adjacent segments of vein.
Arises in a lentigo maligna - Occurs most often on the face or dorsum of the hands and forearms - Underlying lesion is flat and brown-to-black in colour with an irregular outline - Malignant area in the lesion is usually thicker - and darker in colou


29. What are the two main classifications for thyroid enlargement?
According to site - contents and if it is random or axial. When it comes to site - you consider where it is local or distant(Which is also known as a free flap). You have to also consider the contents which can contain any tissue capable of transfer
Treatment is radical surgery with follow-up using sequent calcitonin assays
Less than 0.5
Diffuse enlargement - smooth or nodular - Solitary nodule


30. What are the features of Campbell de Morgan spots?
Colour changes - Trophic changes - Vascular angle
Medical : treat underlying condition - saline cleansing - high-dose oral or intralesional steroids plus/minus cyclosporin - Surgical : serial allograft followed by autologous skin graft or muscle flap coverage when necessary
Congenital abnormalities - Aberrations of normal development and involution( fibroadenomas -breast cysts -sclerotic or fibrotic lesions) - Non-ANDI conditions such as infections -lipomas -fat necrosis
Small red capillary naevus - Develops on the trunk in middle-age - No clinical significance


31. What are the 'transudate' causes of a pleural effusion?
If untreated - 25% progress to invasive squamous cell carcinoma
White lines and streaks inside the mouth
Cardiac failure - Metabolic disorders leading to hypoalbuminaemia such as Cirrhosis and Nephrotic syndrome
The face can be affected in patients with: Syringomyelia - Frey's syndrome


32. What are the specific complications of parotidectomy?
Cardiac failure - Tricuspid regurgitation - Constrictive pericarditis
Three arteries - artery to vas deferens -testicular artery -cremasteric artery - Three nerves - ilioinguinal nerve on the front of the cord - nerve to cremaster and autonomic nerves - Three other structures - vas deferens - pampiniform plexus of vein
Immediate : Facial nerve transection - Reactionary haemorrhage - Early : Wound infection - Temporary facial weakness -salivary fistula and division of the greater auricular nerve which means loss of sensation to the pinna - Late : Wound dimple - Frey
Injection sclerotherapy with 1% sodium tetradecyl sulphate - this has a high recurrence rate and indicated for postoperative recurrence of veins - below knee varicosities if the long saphenous vein and short saphenous vein are not involved.


33. What are the specific and early complications of thyroidectomy?
(H)infection - Hypoparathyroidism which leads to hypocalcemia
Urine cytology -blood tests would be expected to be normal and a renal ultrasound scan which shows a cyst with a smooth outline -sharply defined thin wall and no internal echoes(which imply solid components)
They can be caused by any disease that leads to a peripheral sensory neuropathy - or by causes of spinal cord disease. Causes of peripheral neuropathy include: Systemic disease - diabetes -vasculitis -hypothyroidism and Vitamin B12 deficiency - Drugs
Mnemonic : CHIASMA - Congestive : cardiac failure - Haematological : reticuloses - Infection : viral -bacterial -protozoal - Amyloid - Storage disorders : Wilson's disease - haemochromatosis - Masses: primary/secondary neoplasia - Autoimmune/alcohol


34. What are the features of lentigo maligna melanoma?
An abnormal protrusion of abdominal contents through a defect in the linea alba - usually halfway between the xiphoid process and umbilicus
Patient must be standing up as he or she must be able to see the stoma - The stoma must be within the rectus abdominis muscle - Away from scars or skin creases - Away from bony points or waistline of clothes - At a site that is easily accessible to t
Arises in a lentigo maligna - Occurs most often on the face or dorsum of the hands and forearms - Underlying lesion is flat and brown-to-black in colour with an irregular outline - Malignant area in the lesion is usually thicker - and darker in colou
Mnemonic : SNAPP - Sepsis elimination : open or percutaneous drainage of collections; administration of appropriate antimicrobials - Nutritional resuscitation/optimization : patients may be fluid and electrolyte depleted and malnourished. Resuscitati


35. How do you harvest a skin graft?
Situations where skin grafts will not take - When the aim is to reconstruct the tissue that is 'like-for-like'(bone -joint -tendon -nerve -epithelial lining -etc) to promote optimal structure - function and cosmesis - When blood supply has to be impo
Lead shields to protect the eyes and gonads - Dose-fractionation - Prior chemotherapy - Regional hypothermia - Radiolabelled antibodies
Liver Cirrhosis - Inflammatory Bowel disease - Malabsorption - Gastrointestinal lymphoma
Using hand-held skin graft knives or electric or gas powered dermatomes - the latter producing a graft of even thickness from almost any site - with little expertise needed for operation. The donor site is usually one that can be easily concealed for


36. What are the causes of hepatomegaly?

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37. What is the most common type of malignant melanoma?
Complications include cosmetic symptoms but important problems are encountered in the perinatal period: Before delivery it may obstruct delivery - After delivery : respiratory obstruction and obstruction of swallowing
Superficial spreading at 70% of malignant melanomas
Thrombosis during or just after haemodialysis - which may be due to relative hypotension and damage to the intima of the vein - Venous hypertension in the hand causes swelling and ischemia of the fingertips. This should be avoided by the ligation of
Nerve to stapedius - Nerve to posterior belly of digastric - Five divisions within the parotid gland - temporal - zygomatic - buccal - mandibular and cervical


38. Which normal tissues are particularly affected by radiotherapy?
Multiple telangiectasia around the mouth and on the tongue and lips
Tissues with rapid turnover(epidermal layers of the skin - small intestine - bone marrow stem cells) - Tissues with a limited ability to repopulate(spinal cord and gonads)
It is a point halfway along a line joining the ASIS and the midline Which is equal to the location of femoral artery
Causes can be divided into pathology within and outside the SVC. Within the SVC obstruction tends to be as a consequence of thrombosis within intravenous jugular or subclavian lines(CPV Lines) - especially when hyperosmolar solutions are infused for


39. What is the prophylactic treatment of pressure sores?
Regular skin inspection - Frequent turning of immobile patients( 2 to 4 hourly) - Massage - Toileting - The use of special mattresses and cushion which redistribute the pressure on at-risk areas
Stoma diarrhoea - related to water and electrolyte imbalances - hypokalemia being the commonest and most important consequence - Nutritional disorders - Stones - both gall stones and renal stones increase in frequency following an ileostomy - Psychos
Treatment involves the use of artificial tears and saliva - use of systemic steroids and careful follow-up due to increased risk of lymphoma development
Some 50% are present at birth and they are thought to represent a congenital abnormality during the evolution of embryonic lymph nodes into the adult type


40. What are single lumps in the breast more likely to be ?
Onset and Continuous Symptoms - When did you first notice it? - What made you notice it? - Predisposing events? - How does it bother you? - What symptoms does it cause? - Has it changed since you first noticed it ? - Have you noticed any other lumps?
Fibroadenomas - Breast cysts - Fat necrosis - Breast cancer
Less than 0.5
A keratoacanthoma is a benign overgrowth of hair follicle cells that produces a central plug of keratin. It is rapidly growing - forming within 6 weeks and regressing after 6 weeks - leaving a depressed scar. Clinically and cytologically they may loo


41. What symptoms - a patient with an epigastric hernia might have complained of at presentation?
Non-Surgical : Leave alone if asymptomatic(particularly in young patients) - Surgical : Complete excision of lesion with histology(.
Cardiac disease - hypertension -myocardial infarction -ischaemia -mitral valve disease - cardiomyopathy -endocarditis - Respiratory disease - Pneumonia - lung cancer - sarcoidosis - Other: Hypothyroidism and idiopathic ( lone AF)
Epigastric pain - which may increase after meals - May be acutely painful after physical exercise - Nausea and early satiety - Reflux and non-ulcer dyspepsia
Mnemonic : SPRUE - Site of enlargement : from the right costal margin towards the right iliac fossa - Percussion Note : dull - Respiration Movement: it descends - Unable to get above it - Edge : may be smooth or irregular


42. What are the cause of cervical lymphadenopathy that you know of?
Mneumonic : LIST Lymphoma and Leukaemia - Infection(further subdivided into Bacterial - Viral - Protozoal and Toxoplasmosis) - Sarcoidosis - Tumours
Through an inguinal approach - with early clamping of the testicular artery and vein within the spermatic cord before the testis is mobilized out of the scrotum - this prevents intraoperative seeding of tumour up the testicular vein
Remove goitrogens from diet(e.g cabbage) - Thyroxine 0.1/0.3 mg per day - If thyrotoxicosis treat as in Graves' disease - Aspiration of cysts with cytology to exclude malignancy - Radioiodine for elderly patients - particularly those unfit for surger
The pain is caused by a reduced blood supply to the distal aspects of the limb. The pain gets worse at night because the perfusion of the limb is further reduced when the patient is lying down - This is due to: Decreased cardiac output at night - Red


43. What are the causes of atrial fibrillation?
The pain is caused by a reduced blood supply to the distal aspects of the limb. The pain gets worse at night because the perfusion of the limb is further reduced when the patient is lying down - This is due to: Decreased cardiac output at night - Red
Refers to congenital disease or primary lymphatic failure. It is three times more common in women and the pathology originates from within the lymphatics. It is also known as Milroys disease.
Lined by stratified squamous or ciliated pseudostratified columnar epithelium - May also contain thyroid or lymphoid tissue - which can undergo malignant change - If malignancy occurs - usually of thyroid papillary type.
Cardiac disease - hypertension -myocardial infarction -ischaemia -mitral valve disease - cardiomyopathy -endocarditis - Respiratory disease - Pneumonia - lung cancer - sarcoidosis - Other: Hypothyroidism and idiopathic ( lone AF)


44. What is a chemodectoma?
Dissection of the hernial sac from surrounding tissues and definitioni of tissue bordering the defect on all sides to 2-3cm - Closing the defect(if small) and/or using mesh overlapping adequately( more than 5 to 8cm) over normal tissues to allows for
CHIASMA - Congestive : portal hypertension - hepatic vein obstruction - Haematological : reticuloses - Infection : Viral - bacterial - protozoal - Amyloid - Storage disorders : Gaucher's disease - Masses : primary/secondary neoplasia - Autoimmune : F
Non-surgical : can be left alone on patient's wishes as it is a benign lesion - Surgical : as the keratoses lies above the level of the surrounding normal epidermis - it can be treated by superficial shaving or cautery.
A chemodectoma is a tumour of the paraganglion cells of the carotid body located at the bifurcation of the common carotid artery. They are usually benign(but locally invasive) - but occassionally - they are malignant with potential to metastasize to


45. What features of the lump would make you suspicious that it is breast cancer?
Irregular or nodular surface - Poorly defined edge with areas which are more like normal breast tissue in between more abnormal areas - Consistency : breast tumours are usually firm - rather than hard - Tenderness : usually non-tender - Fluctuation :
The incompetent vein is at or above the level of the tourniquet
Sturge-Weber syndrome is the association of a facial port-wine stain with a corresponding haemangioma in the brain - leading to contralateral focal fits.
The main points to mention are: testicular damage should be mentioned as a specific risk factor - the operation can be performed under local or general anaesthetic and often as a day case - The Royal College of Surgeons has recommended the Lichtenste


46. What is a dermoid cyst?
Essentially to treat complications not amenable to medical therapy such as:Intra-abdominal abscesses that cannot be drained radiologically - Enterocutaneous fistulae - Stenosis causing obstructive symptoms - Control of acute/chronic bleeding
Weight loss - Change in bowel habit - Loss of appetite - Back pain
The commonest presentation is a painless lump or a dull ache in one testis in a young man - Occasionally there is a history of trauma accompanying the discovery of the mass - 10% present with an acutely painful testis - If para-aortic nodes have beco
A dermoid cyst is a skin-lined cyst deep to the skin. They may be congenital or acquired.


47. What are the different histological subtypes of a sebaceous cyst?
More than five is considered as pathological in chronic liver disease
Wound complications - Recurrence - Damage to adjacent neurovascular structures
Epidermal Cyst - Trichilemmal Cyst
Is there evidence of a new or old stoma site? Is there evidence of a small incision to one side of the scar(from a drain - this may have been due to a bowel operation) - Are there also scars in the groins? - Are there striae gravidarum


48. How would you treat a pharyngeal pouch?
Non-surgical : Leave alone if small and asymptomatic - Surgical : minimally invasive surgery or surgical excision
Ligation of the incompetent SFJ or SPJ with stripping of the involved vein and stab avulsion of varicosities - Ligation of incompetent perforating vessels - Subcutaneous endoscopic perforator surgery
Wound complications - Recurrence - Damage to adjacent neurovascular structures
Retro-orbital inflammation and lymphocytic infiltration leading to oedema and an increase in retrobulbar orbital contents


49. What is the differential diagnosis in basal cell carcinoma?
This removes the possibility of recurrent disease appears to improves the outcome for patietns with significant eye disease and eliminates the need for annual TFT monitoring to assess remnant function. It does - of course - demand thyroxine replaceme
Situations where skin grafts will not take - When the aim is to reconstruct the tissue that is 'like-for-like'(bone -joint -tendon -nerve -epithelial lining -etc) to promote optimal structure - function and cosmesis - When blood supply has to be impo
The two main differential diagnoses to consider are; Benign - keratoacanthoma - especially if it is sloughing at its centre - Malignant -Squamous cell carcinoma - particularly the nodulo-ulcerative type with a rolled edge
Is there evidence of a new or old stoma site? Is there evidence of a small incision to one side of the scar(from a drain - this may have been due to a bowel operation) - Are there also scars in the groins? - Are there striae gravidarum


50. What is the non-surgical treatment of a patient with an epigastric hernia?
A skin flap consists of tissue - or tissues - transferred from one site of the body to another - while maintaining a continuous blood supply through a vascular pedicle.
Non-surgical - same as in incisional hernia with possible investigations : LFTs - H.pylori serology and Upper GI endoscopy
Mouth and lips are hyperpigmented
Infections within the oesophagus especially candidiasis and herpes simplex - Pharyngitis - Occasionally ulceration over the lower third of the oesophagus