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Clinical Surgery

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1. What is the treatment of a chemodectoma?
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La
Surgical excision with preoperative embolizatoin if the tumour is large - Ultrasonic surgical dissection may also be used - Radiotherapy is used for patients unfit for surgery or for large tumours
20%
Commonest in children and young adults(P for Paediatric)

2. What is a dermatofibroma?
A dermatofibroma is a benign neoplasm of dermal fibroblasts.
Raynaud's phenomenon - Thrombangiitis obliterans - Takayasu's arteritis
Superficial spreading at 70% of malignant melanomas
Debulking or bypass procedures - Direct lymphovenous anastamosis - Stripping a piece of intestinal mucosa - exposing the rich submucosal plexus - this can then be used to replace a leg lymph node which then forms new connections with distal lymphatic

3. What important questions should you ask in a patient with jaundice?
Palomo operation
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?
Indications for amputation can be remembered as the 4Ds: Dead - ischemic - peripheral vascular disease - thromboangiitis obliterans - AV fistulae - Damaged - trauma - unsalvageable limbs - burns - frostbite - Dangerous - Malignancy - bone and soft ti
Auscultation - Percussion of the thyroid gland and downwards for retrosternal extension

4. What are the secondary causes of Raynauds?
Simple colloid goitre - Graves' disease - Thyroiditis
Autosomal recessive - 1 in 5000 to 40000 - Chromosome 6 is affected - It presents perinatally
Mnemonic: BADCaT - Blood disorders e.g polycythemia - Arterial e.g atherosclerosis - thrombangiitis obliterans - Drugs e.g beta blockers - oral contraceptive pill - Connective tissue disorders e.g rheumatoid arthritis - systemic lupus erythematosus -
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

5. What do you know about the epidemiology of hypertrophic scars?
Affect any age - Males = females - All races may be affected
Optimize tissue perfusion and oxygenation - Treat infection as it arises - Use topical dressings as required and provide nutritional support specifically vitamin C - zinc and multivitamins. - Other techniques include hyperbaric oxygen -hydrotherapy a
Use of truss or corset - Weight loss and management of other risk factors
Treatment with radiotherapy and doxorubicin gives best survival of 1 year

6. Where is the midpoint of the inguinal ligament?
Halfway along inguinal ligament that is between pubic tubercle and ASIS Which is equal to the location of the deep inguinal ring
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling
Immobility and prolonged bed-rest are the most important factors - particulary secondary to conditions such as: Cardiopulmonary disease - Trauma - Neurological disease such as paraplegia - Bone and joint disease - Prolonged operative procedures - And
Affect any age - Males = females - All races may be affected

7. What are the specific early complications of amputations?

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8. Which patients might be considered for carotid endarterectomy?
Symptomatic carotid stenosis of more than 70% - Trials demonstrated that for patients with severe stenosis surgery reduce the relative risk of disabling stroke by 48%
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
Chronic Liver disease - Right Heart Failure - Intra-abdominal Malignancy - Hypoalbuminaemia
It is the result of a weak posterior wall to the inguinal canal - Arise medial to the inferior epigastric vessels at operation - This weakness causes the abdominal contents to bulge through the wall into the inguinal canal but the hernia is not withi

9. What are the surgical treatment principles of incisional hernia?
Weight loss - Change in bowel habit - Loss of appetite - Back pain
These are due to a defect through the linea alba adjacent to the umbilicus and usually due to obesity stretching the fibres.
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
Chest infection due to pulmonary aspiration - Diverticular neoplasia in less than 1% of cases

10. What are the complications of the surgical removal of a branchial cyst?
An intravenous injection of contrast into the veins in the arm can illustrate the degree of obstruction - A CT Scan of the thorax may demonstrate the cause of the obstruction and the length of the SVC affected
Recurrence of the cyst - Developement of a chronic -discharging sinus
Hands and Eyes
Sacrum - Greater trochanter - Heel - Lateral Malleolus - Ischial Tuberosity - Occiput

11. What is the classification of testicular malignancies?
Mainly teratoma or seminomas - other types are: Embryonal carcinoma - Choriocarcinoma - Yolk sac tumour - Leydig cell tumours - Sertoli cell tumours - Lymphoma
Below Knee - Above Knee
Barium swallow Which is usually diagnostic - Rigid endoscopy if neoplasia suspected
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

12. What is the risk of rupture for an aneurysm more than 5.5cm?
The characteristic presentation is insidious with progressive weight-loss and dysphagia - The patient initally hass difficulty swallowing solids and often describes the food getting stuck in the lower part of the oesophagus - They may also describe o
Duplex - shows area of reflux and deep venous occlusion - Venography - ascending which identifies deep venous patency and perforator incompetence and descending which identifies areas of reflux - Varicography - shows sites of communication - Ambulato
10% per year
It helps to give an indication as to What the exact aetiology is.

13. What are the pathological features of thyroglossal cyst?
An abnormal sac containing gas -fluid or semisolid material - with an epithelial lining
Trauma - Hypersplenism
Liver - fatty change - chronic active hepatitis -cirrhosis and amyloid deposition - Gall bladder and bile ducts - gallstones - sclerosing cholangitis - and cholangiocarcinoma
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.

14. What are the secretomotor branches of the facial nerve?
Resection of a lobe including its bronchial origin with re-anastamosis of the proximal and distal bronchus
Via greater superficial petrosal nerve to lacrimal - nasal and palatine glands
Scar confined to wound margins - It is found across flexor surfaces and skin creases
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

15. How does radiotherapy work?
It is a point halfway along a line joining the ASIS and the midline Which is equal to the location of femoral artery
The causes of pain in the leg can be divided into: Musculoskeletal such as pathologies of the knee -ankle or hip - Neurological such as spinal stenosis which leads to spinal claudication - Vascular such as intermittent claudication and deep vein thro
High-energy X-rays interact with tissues to release electrons of high kinetic energy - which cause secondary damage to adjacent DNA via an oxygen-dependent mechanism. The damage is either repairable or non-repairable - the latter manifesting itself a
Urine should be tested for raised bilirubin - Full Blood Count - Evidence of anemia in GI malignancies or associated infection - Renal function - any evidence for hepatorenal syndrome - Liver Function Tests -Clotting - functional assessment of hepati

16. How would you diagnose a branchial cyst?
A hypervascular mas displacing the bifurcation of the carotid arteries
Characteristic cold-induced changes associated with vasospasm
Clinical examination - Fine-needle aspiration which would show an opalescent fluid containing cholesterol crystals or pus.
Remnants of a patent processus vaginalis - Arise from the abdominal cavity lateral to the inferior epigastric vessels at operation - passing obliquely through the deep inguinal ring and travelling along the inguinal canal with the spermatic cord - Ma

17. What features of the lump would make you suspicious that it is breast cancer?
Mouth and lips are hyperpigmented
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
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 :
Debulking or bypass procedures - Direct lymphovenous anastamosis - Stripping a piece of intestinal mucosa - exposing the rich submucosal plexus - this can then be used to replace a leg lymph node which then forms new connections with distal lymphatic

18. What are the surgical principles in the treatment of a femoral hernia?
Reduction of the contents of the sac - Excision of the sac - Repair of the defect - taking care not to narrow the femoral vein while tightening up the femoral canal
Gradual elastic compression stocking - grade 2 compression - Encourage weight loss and regular exercise
Surgery is indicated for: Symptomatic aneurysms - Those containing thrombus - Those greater than 2cm
White lines and streaks inside the mouth

19. Why is total thyroidectomy preferred in the surgical treatment of Graves' disease?
Gumma of tertiary syphillis has a typical punched-out ulcer - over the anterior surface of the lower leg and has a yellow coloured 'wash leather' base. - Scalloped border
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
Solar keratosses are squamous cell carcinoma in situ
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

20. What is the pathogenesis of a congenital dermoid cyst?
Skin : as above - Lungs : pneumonitis - pulmonary fibrosis - Heart : Ischemic heart disease - Arteries: radiation arteritis -Spinal cord : myelopathy - Gonadal damage : infertility - Thyroid : hypothyroidism due to depletion of follicular thyroid cel
White lines and streaks inside the mouth
Those related to anaesthesia
It is due to development inclusion of epidermis along lines of fusion of skin dermatomes and are therefore commonly at: The medial and lateral ends of the eyebrows - The midline of the nose - The midline of the neck and trunk - Suspect if you see a c

21. What are the features of ulcers in syphillis?

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22. How do patients with a pharyngeal pouch usually present?
It can be classified according to cause: Malignancy - Infections - e.g filiaris - tuberculosis - Post Surgery or Radiotherapy - axillary dissection in breast surgery and inguinal irradiation
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
Xeroderma pigmentosum - Dysplastic naevus syndrome - Large congenital naevi - Family history in first-degree relatives
Patients are usually symptom-free for a long period of time followed by dysphagia and hoarseness - associated with regurgitation of undigested foods - and associated weight-loss

23. What are the signs in the mouth of Hereditary telangiectasia?
Solar keratosses are squamous cell carcinoma in situ
Collagen antibodies are present in 45% of patients - There is an association with HLA-B5 - Angiography has typical appearances of normal proximal vessels with distal occlusion and 'corkscrew' collaterals.
Multiple telangiectasia around the mouth and on the tongue and lips
It reduces intravascular hydrostatic pressure and the stockings increase extracellular hydrostatic pressure - together reducing the level of tissue oedema.

24. Why do these neuropathic ulcers form?
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 insensitive - mechanically abnormal - dry foot is at risk from unperceived external trauma e.g from shoes and from repetitive painless injury e.g foreign body in shoe. Progressive skin loss and ulceration may occur.
Hyperthyroidism - Late Hypothyroidism - Later Hyperparathyroidism
Carcinoma of the stomach and oesophagus - lymphomas and with endocrine disorders such as acromegaly - Cushing's - diabetes complicated by severe insulin resistance

25. What is the non-surgical treatment of pressure sores?
Optimize tissue perfusion and oxygenation - Treat infection as it arises - Use topical dressings as required and provide nutritional support specifically vitamin C - zinc and multivitamins. - Other techniques include hyperbaric oxygen -hydrotherapy a
Mnemonic: DELFT(D) Feeding e.g feeding gastrostomy/jejunostomy - Lavage e.g appendicostomy - Decompression - bypass of an obstructing bowel lesion distal to the stom - Diversion - protection of a distal bowel anastamosis and urinary diversion followi
Mnemonic: BADCaT - Blood disorders e.g polycythemia - Arterial e.g atherosclerosis - thrombangiitis obliterans - Drugs e.g beta blockers - oral contraceptive pill - Connective tissue disorders e.g rheumatoid arthritis - systemic lupus erythematosus -
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present

26. What are the indications for lung resection?
In the presence of jaundice if a mass(the gall bladder) is palpable in the right upper quadrant - the cause is unlikely to be due to gallstones.
The tumour arises from epidermal cells that normally migrate to the skin surface to form the superficial keratinizing squamous layer. Full-thickness epidermal atypia is seen and tumour cells are seen to extend in all directions into the deep dermis a
90% of lung resections in the Western world are performed for bronchial carcinoma. Other indications include traumatic injury - bronchiectasis - chronic infection including tuberculosis - benign tumours e.g carcinoid and metastatic tumour
Treatment with radiotherapy and doxorubicin gives best survival of 1 year

27. Which normal tissues are particularly affected by radiotherapy?
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)
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
The major differential diagnoses would be with a renal tumour and adult polcystic kidney disease and if there is any doubt of a tumour - then the cyst fluid may be sent for cytological analysis
Diffuse enlargement - smooth or nodular - Solitary nodule

28. What do you know about the epidemiology of keloid scars?
All patients should undergo triple assessment that is Clinical Examination - Radiological assessment usually ultrasonographic - Pathological - most commonly cytological following FNAC
Gumma of tertiary syphillis has a typical punched-out ulcer - over the anterior surface of the lower leg and has a yellow coloured 'wash leather' base. - Scalloped border
Lobectomy - Pneumonectomy - Non-anatomical resection are often performed for traumatic injury - Sleeve resection
May affect people from puberty to 30 years - Females are more affected than males - Black and Hispanic Races are effected the most.

29. What is the aim of the tourniquet test?
Unilateral total lobectomy and isthmusectomy
The tourniquet test is designed to reveal the presence and site of incompetent veins - especially at the sites of connection between the superficial and deep venous systems.
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
Duplex Ultrasound - Angiography - CT/MRI

30. What is the difference in the clinical course of hypertrophic and keloid scars?
Hypertrophic scars tend to appear soon after injury and usually regress spontaneously - while keloid scars appear months after injury and continue to grow
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
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
Left spermatic vein is more vertical where it connects to the left renal vein - The left renal vein can be compressed by the colon - The left testicular vein is longer than the right - It frequently lack a terminal valve which serves to try to preven

31. What is an incisional hernia?
An aneurysm is an abnormal dilatation of a blood vessel - A true aneurysm involves all layers of the arterial wall - A false aneurysm follows a partial laceration of the vessel wall causing blood to leak out of the vessel into the surrounding tissues
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
If the ulcer fails to heal - careful consideration should be given to excluding other causes such as malignant Marjolin ulcer and the area may need to be biopsied - Otherwise a split skin graft should be considered with excision of the dead skin and
Palomo operation

32. What is the classification of liposarcoma?
These are due to a defect through the linea alba adjacent to the umbilicus and usually due to obesity stretching the fibres.
Cervical spondylosis - Pancoast's tumour - Cervical disc protrusions - Ulnar nerve neuropathy
Procedure usually performed as a day case - Need to wear tight-fitting stockings for 6 weeks preoperatively - No driving for 1 week - Does not alter the skin changes - including skin flares - May not improve symptoms such as aching - Risk of recurren
Well-differentiated - Myxoid and round cell - Pleomorphic liposarcoma

33. What are the causes of a false aneurysm?
50%
Cirrhosis - Malignancy - Lymphatic rupture or damage
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
Traumatic - Iatrogenic(following angiography and bypass)

34. What is the surgical treatment of a ganglion?
Demographics - Presenting Complaint - History of Presenting Complaint - Medical and Surgical History - Drugs and any other allergies - Family History - Social History - Systemic Enquiry
Recurrence of the cyst - Developement of a chronic -discharging sinus
Complete excision to include the neck of the ganglion at its site of origin
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.

35. What kinds of analgesia would be appropriate for this patient?
Ischaemic ulcers can be extremely painful and even removing the bandages from around the ulcer can cause pain that lasts for several hours. The analgesic ladder would be appropriate in this situation starting from simple oral agents -stronger oral ag
An abnormal communication between two epithelial surfaces(or endothelial surfaces such as in arteriovenous fistula)
Derived from capillary endothelial cells or from fibrous tissue - It is linked to human herpes virus 8
Mainly teratoma or seminomas - other types are: Embryonal carcinoma - Choriocarcinoma - Yolk sac tumour - Leydig cell tumours - Sertoli cell tumours - Lymphoma

36. What other part of the body can be affected by hyperhidrosis?

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37. What is the shorter version of the surgical sieve?
TIMEC - Trauma/Tumor - Infection/Inflammation/Ischemia - Metabolic -Mechanical - Endocrine - Congenital
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
Psychological and social implications - Haematoma and wound infection - including gas gangrene - Deep vein thrombosis and pulmonary embolus - Phantom limb pain - due to the sensory cortex 'believing' the limb is still present - Skin necrosis
Via the bloodstream(R is equal to red is equal to blood)

38. What are port-wine stains?
10% per year
Duplex - shows area of reflux and deep venous occlusion - Venography - ascending which identifies deep venous patency and perforator incompetence and descending which identifies areas of reflux - Varicography - shows sites of communication - Ambulato
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.
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

39. What is the differential diagnosis of a lump in the groin?
Via greater superficial petrosal nerve to lacrimal - nasal and palatine glands
Mnemonic : L-SHAPE - Lymph node/Lipoma of the cord - Sapheno-varix/Skin lesions(sebaceous cyst/lipoma -etc) - Hernia - inguinal or femoral - Aneurysmal dilatation of the femoral artery - Psoas abscess or bursa - Ectopic/undescended testes
0.5 to 0.8
Benign skin lesion: Keratoacanthoma - Infected seborrhoeic wart - Solar keratoses - Pyogenic Granuloma - Malignant skin lesion - Basal cell carcinoma - Malingnant melanoma - Congenital: Xeroderma pigmentosum - Acquired - Environmental agents - Pre-ex

40. Which are the most benign parotid tumours?

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41. What are the signs in the mouth of Lichen Planus?
Undermined edge - Violaceous - Necrotic ulcer with hypertrophic margins
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
White lines and streaks inside the mouth
Autosomal dominant - 1 in 500 - Chromosomes 4 and 16 are affected - Age of Presentation is between 30s and 50s

42. What is Sjogren's syndrome?
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
Autoimmune condition - Intermittent or constant swelling of one or all of the salivary glands
Neo-rectum is created in a pelvic reservoir - Stage 1 : resection of colon and/or rectum - Stage 2 : Construction of an ileal reservoir - Which is anastamosed to the anus - this is usually covered with a diverting loop ileostomy proximal to the pouch
Diet should be normal - Bag should be changed once or twice a day(needs to be emptied more frequently than this if it is urine or fluid faeces) - Ileostomies should have the base plate under the bag changed every 5 days and the bag changed daily - Ps

43. Simple cysts are found in 33% of patients by the age of 60. How should they be managed?
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.
It reduces intravascular hydrostatic pressure and the stockings increase extracellular hydrostatic pressure - together reducing the level of tissue oedema.
The pressure cuff is inflated over the upper arm and the systolic pressure measured at the brachial artery using a Doppler probe - The cuff is then placed over the calf. - When the dorsalis pedis pulse has been located with the Doppler - the cuff is
History and Clinical Examination - they usually present incidentally but occasionally with a renal mass or haematuria

44. How can the extent of the obstruction be determined?
General : malaise -fatigue - loss of appetite - nausea and vomiting - Skin : as above - Bone marrow suppression : particular if irradiation to the pelvis and long bones - Gastrointestinal : diarrhoea
An intravenous injection of contrast into the veins in the arm can illustrate the degree of obstruction - A CT Scan of the thorax may demonstrate the cause of the obstruction and the length of the SVC affected
Form of telangiectasias - Central arteriole with leg-like branches Which blanch on central pressure - Found over upper torso - head and neck in adults - Associated with chronic liver disease and pregnancy
Males represent 1% of all breast cancers. Features that would be suspicious would be: Older age - Unilateral gynaecomastia - Firm or hard nodules within the breast tissue - Remember to examine the axillary and supraclavicular fossae for lymphadenopat

45. What elements are ascertained in a thyroid history with regards to symptoms arising from the swelling?
Reassurance - if symptoms are not distressing for the patient Medical - aluminium hexachloride solution painting for axillary hyperhidrosis Surgical - Axillary - excise hair bearing/intradermal Botulinum A Neurotoxin - Palmar - cervical sympathectomy
Fine-needle aspiration cytology for diagnosis - MRI to exclude deep-lobe involvement
Duration and change in size - Cosmetic symptoms - Discomfort during swallowing/dysphagia - Dyspnoea - Hoarseness - Pain
Diffuse enlargement - smooth or nodular - Solitary nodule

46. What is the differential diagnosis of a midline neck swelling?
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling
Are you having difficulties swallowing liquids - or solids - or both? - Did the problem start suddenly or was the onset gradual? - Do you ever regurgitate food? - Can you eat a full meal? - How long have you had this problem for? - Where does the foo
Haemorrhage - Hoarseness - Hyperthyroidism
Superior thyroid artery - Inferior thyroid artery - Thyroidea ima(in 3% of people)

47. What are the treatment options available for Basal Cell Carcinoma?
Vaginal Hydrocoele - fluid accumulates in the tunica vaginalis - Hydrocoele of the cord - fluid accumulates around the spermatic cord - Congenital Hydrocoele - Infantile Hydrocoele
They are known as adiposis dolorosa or Dercum's disease.
Well-localized abscesses are treated by incision and drainage under antibiotic cover - Larger lesions are treated by radical excision and full-thickness skin grafting usually harvested from the groins or abdomen
Tumours raised above the skin : excision with 0.5cm margin(maximum) - Tumours not raised above the skin - Wider margin of excision - particularly if at inner canthus of eye -nasolabial fold and ear. A frozen section may be necessary to ensure adequat

48. What about umbilical herniae in children?
Cervical spondylosis - Pancoast's tumour - Cervical disc protrusions - Ulnar nerve neuropathy
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
Via the lymphatic route(Y for yellow = lymph)
It helps to give an indication as to What the exact aetiology is.

49. Why are 98% of varicocoeles left-side?
In the presence of jaundice if a mass(the gall bladder) is palpable in the right upper quadrant - the cause is unlikely to be due to gallstones.
Left spermatic vein is more vertical where it connects to the left renal vein - The left renal vein can be compressed by the colon - The left testicular vein is longer than the right - It frequently lack a terminal valve which serves to try to preven
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
Wound complications - Recurrence - Damage to adjacent neurovascular structures

50. What is the 'reconstruction ladder'?
This is the array of plastic surgeon techniques of increasing complexity that is available to the surgeon and Which is used according to their suitability for individual patients
Weight loss - Change in bowel habit - Loss of appetite - Back pain
The cyst may be surgically excised - whole if possible - although this may be difficult if there has been previous infection - Bonney's blue dye can be injected into the fistula/sinus allowing accurate surgical excision and therefore reduces recurren
Small red capillary naevus - Develops on the trunk in middle-age - No clinical significance