Clinical Surgery

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• Answer 50 questions in 15 minutes.
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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 are the features of ulcers in patients with squamous cell carcinoma?
Pleomorphic adenoma(commonest) and Warthin's tumour
Characteristic cold-induced changes associated with vasospasm
Early mobilization is important - They should keep the area clean and wash carefully -especially after the clip/sutures have been removed - They are able to bathe immediately - They may need to be off work for 6 weeks if their job involves heavy lift
Rolled or raised edge - Often on sun-damaged skin


2. How can the extent of the obstruction be determined?
High success - 50 to 70% will heal at 3 months - 80 to 90% at 12 months - The patient should be warned to avoid trauma to the affected area - Four-layer compression bandaging - Encourage rest and elevation of leg - Once healed - grade 2 compression s
The five Ms - Mechanical - obstructive symptoms - Malignancy - Marred Beauty - cosmetic reasons - Medical treatment failure - thyrotoxicosis - Mediastinal(retrosternal) extension - unable to perform FNAC or monitor change clinically
Non-surgical : regression is uncommon - except those arising in pregnancy and so they are best treated surgically - though occassionally a silver nitrate stick can be attempted - Surgical : curettage with diathermy of the base or complete excision b
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


3. What are the specific complications of inguinal hernia repair?
A lipoma is a benign tumour consisting of mature fat cells.
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
Least common - Occurs on hairless skin - Irregular area of brown or black pigmentation
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


4. Where does a liposarcoma arise from?
Extrahepatic : caused by increased resistance to flow e.g : portal or splenic vein thrombosis - Intrahepatic : due to cirrhosis - right heart failure - sarcoidosis and schistosomiasis(the latter is the most important cause worldwide - ova of the para
It arises de novo
Pre-hepatic - Hepatic - Post-hepatic
Primary Raynauds is due to vasomotor malformation - Secondary Raynauds occurs as a consequence of pathology affecting the vessel wall


5. What is the embryological origin of a thyroglossal cyst?
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
TIMEC - Trauma/Tumor - Infection/Inflammation/Ischemia - Metabolic -Mechanical - Endocrine - Congenital
Results from persistence of part of the thyroglossal tract - which marks development descent of the thyroid gland
Pigmented freckles around the lips and inside the mouth - associated with intestinal intussusception and gastrointestinal bleeding from colonic polyps


6. What are the principles of management of enterocutaneous fistulae?
May require the placing of postoperative drains
A blind-ending track -typically lined by epithelial or granulation tissue - which opens onto an epithelial surface
Debridement of dead tissue which can be performed by the tissue viability nurse since it does not require anaesthesia and reconstruction using a variety of fascial and muscle-containing composite flaps.
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


7. What are the questions that should be asked when taking a history for a lump or ulcer?
Superficial spreading at 70% of malignant melanomas
Chronic Liver disease - Right Heart Failure - Intra-abdominal Malignancy - Hypoalbuminaemia
Barrett's oesophagus - Stricture especially chemical - Achalasia - Plummer-Vinson Syndrome
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?


8. What is a furuncle?
A furuncle results from infection of hair follicles with Staphylococcus aureus
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
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
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


9. How would you treat pyoderma gangrenosum?
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
Lymphangiomas can be:Cystic - Solid or diffuse - Cutaneous
Depends on local guidelines but essentially: Pneumococcal vaccine - Haemophilus influenzae type B vaccine - Meningococcal vaccine - Annual 'flu' vaccine - Consideration for lifelong penicillin or penicillin as required when infection present - Warn a
A furuncle results from infection of hair follicles with Staphylococcus aureus


10. What are the two types of ptosis?
Unilateral - Bilateral
Duplex Ultrasound - Angiography - CT/MRI
Cirrhosis - Malignancy - Lymphatic rupture or damage
A seborrhoeic keratosis is a benign overgrowth of the basal cell layer of the epidermis.


11. What needs to be taken into consideration when marking the stoma site?
Non-surgical : risk factor modification such as establishment of good diabetic control and for recurrent infections eradication of nasal carriage of staphylococcus aureus with antiseptics and/or antibiotics such as chlorhexidine and mupirocin - Surgi
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
Angiolipomas - Hibernomas - Bannayan-Zonana Syndrome
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


12. What are telangiectasias?
Primary disease occurring in isolation
Dilatation of normal capillaries - Can be secondary to skin irradiation - Can be part of hereditary haemorrhagic telangiectasia
Temperature - Capillary Refill - Peripheral Pulses
They are often multiple and most commonly arise in the head of the epididymis. Occassionally they occur as a complication of vasectomy - in which case they are full of sperm and are termed spermatocoeles.


13. What are the main points to be elicited during a clerking of the surgical patient?
For patients who refuse radiation therapy or relapse after an adequate course - pregnant patients or those wishing to become pregnant within 4 years - patients under the age of 40 years and those with nodular or large goitres
Non-surgical : cryotherapy - topical application of 5-fluorouracil - retinoic acid - Surgical : Shaving of affected skin
True umbilical herniae occur through the umbilical scar and are usually congenital in origin and particulary common in patients of Afro-Caribbean origin
Demographics - Presenting Complaint - History of Presenting Complaint - Medical and Surgical History - Drugs and any other allergies - Family History - Social History - Systemic Enquiry


14. What are the acquired predisposing factors for basal cell carcinomas?
Sunlight - Carcinogens - Previous radiotherapy - Malignant transformation in pre-existing skin lesion
Calcium channel blockers e.g nifedipine - Prostacyclin analogues - Alpha blockers - 5-HT antagonists
Inspect - Protrusion of the tongue - Swallowing - Palpate(from the back) - Continue Accordingly(Neck Decision Circle)
Conservative - Medical - Surgical


15. What is the differential diagnosis of a midline neck swelling?
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
Resection of a lobe including its bronchial origin with re-anastamosis of the proximal and distal bronchus
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling
It helps to give an indication as to What the exact aetiology is.


16. What is the surgical treatment of pressure sores?
White lines and streaks inside the mouth
The five Ms - Mechanical - obstructive symptoms - Malignancy - Marred Beauty - cosmetic reasons - Medical treatment failure - thyrotoxicosis - Mediastinal(retrosternal) extension - unable to perform FNAC or monitor change clinically
Discolouration - Discharge - Depression - Deviation - Displacement - Destruction - [Duplication - unlikely in the exam]
Debridement of dead tissue which can be performed by the tissue viability nurse since it does not require anaesthesia and reconstruction using a variety of fascial and muscle-containing composite flaps.


17. What is a skin flap?
Venous disease
Should The Children Ever Find Lumps Readily
Wound complications - Recurrence - Damage to adjacent neurovascular structures
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.


18. What is the adequate treatment for minimal lesion(less than 1cm) in thyroid cancer?
Superficial spreading at 70% of malignant melanomas
Mneumonic : BEDD - Base - Edge - Describe structure visualized at the base of the ulcer - Discharge
Unilateral total lobectomy and isthmusectomy
Complications should be divided into specific to the amputation and general for any operation - and also immediate within 24 hours - early up to 1 month and late beyond 1 month


19. What do you know about the pathophysiology of pressure necrosis?
Dohlman's procedure - endoscopic diathermy resection of the posterior pharyngeal wall or endoscopic stapling with less risk of fistula formation and consequent mediastinitis
These can be divided into large and small vessel arterial disease: Large vessel - atherosclerosis and thrombangiitis obliterans - Small vessel - Diabetes Mellitus - Polyarteritis nodosa and rheumatoid arthritis
Prolonged weight-bearing and mechanical shear forces act on areas of soft-tissues overlying bony prominences - leading to both occlusion and tearing of small blood vessels -reduced tissue perfusion and ischaemic necrosis.
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair


20. What is lid lag secondary to ?
Depends on local guidelines but essentially: Pneumococcal vaccine - Haemophilus influenzae type B vaccine - Meningococcal vaccine - Annual 'flu' vaccine - Consideration for lifelong penicillin or penicillin as required when infection present - Warn a
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
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris
Soft-tissues(lipoma -dental cyst) - Dental origin(infection) - Muscular origin(hypertrophy of masseter muscle) - Bony origin(winged mandible -transverse process of atlas/axis) - Neoplasia(infratemporal fossa and parapharyngeal tumours)


21. Simple cyst Treatment
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
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
Aneurysms are most common in: Men - Aged more than 60 years - Smokers - Hypertensive patients - Often strong family history
A blepharoplasty can be performed where excess skin and fat are removed.


22. What is the signifcance of an arterial bruit or venous hum over the liver?
An arterial bruit may indicate alcoholic hepatits and carcinoma. A venous hum is associated with portal hypertension and if this is secondary to cirrhosis with a patent umbilical vein(or varices in the falciform ligament) - this is known as the Cruve
Inflammation : inflammatory bowel disease -especially Crohn's disease - Diverticular disease - tuberculosis - Malignancy : Often following spontaneous rupture and abscess formation by the tumour - Radiotherapy : Pelvic irradiation can damage the inte
The five Ms - Mechanical - obstructive symptoms - Malignancy - Marred Beauty - cosmetic reasons - Medical treatment failure - thyrotoxicosis - Mediastinal(retrosternal) extension - unable to perform FNAC or monitor change clinically
Depends on local guidelines but essentially: Pneumococcal vaccine - Haemophilus influenzae type B vaccine - Meningococcal vaccine - Annual 'flu' vaccine - Consideration for lifelong penicillin or penicillin as required when infection present - Warn a


23. How would you demonstrate a patient's ankle brachial pressure index?
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
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
Mnemonic : PACT - Prominent nodule in a multinodular goitre - Adenoma - Cyst/Carcinoma/Lymphoma - Thyroiditis
Early mobilization is important - They should keep the area clean and wash carefully -especially after the clip/sutures have been removed - They are able to bathe immediately - They may need to be off work for 6 weeks if their job involves heavy lift


24. What is a cystic hygroma?
A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck.
If the vessels are normal in calibre - the clinical features may be caused by relatively overactive alpha receptors in the wall - leading to abnormal smooth muscle contraction or changes in elasticity
Cardiac failure - Metabolic disorders leading to hypoalbuminaemia such as Cirrhosis and Nephrotic syndrome
True umbilical herniae occur through the umbilical scar and are usually congenital in origin and particulary common in patients of Afro-Caribbean origin


25. If the patient has noticed pale stools and dark urine - what other questions would you ask?
Dilatation of normal capillaries - Can be secondary to skin irradiation - Can be part of hereditary haemorrhagic telangiectasia
Weight loss - Change in bowel habit - Loss of appetite - Back pain
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
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


26. What are the indications for surgery in goitre?
Infections within the oesophagus especially candidiasis and herpes simplex - Pharyngitis - Occasionally ulceration over the lower third of the oesophagus
The five Ms - Mechanical - obstructive symptoms - Malignancy - Marred Beauty - cosmetic reasons - Medical treatment failure - thyrotoxicosis - Mediastinal(retrosternal) extension - unable to perform FNAC or monitor change clinically
A seborrhoeic keratosis is a benign overgrowth of the basal cell layer of the epidermis.
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema


27. What is the non-surgical treatment of a ganglion?

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28. Raynaud's phenomenon
If the vessels are normal in calibre - the clinical features may be caused by relatively overactive alpha receptors in the wall - leading to abnormal smooth muscle contraction or changes in elasticity
Characteristic cold-induced changes associated with vasospasm
It will show you if it is malignant or inflammatory
Low approach - Lockwood - Transinguinal repair - Lotheissen - High approach - McEvedy


29. What is secondary lymphoedema?
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
History and Clinical Examination - Investigate if prominent nodule or features suspicious of malignancy such as cervical lymphadenopathy or recurrent laryngeal nerve palsy
Similar to those in the right iliac fossa except for the bowel where a mass in the Left iliac fossa could indicate: Diverticular mass Which is often tender - Carcinoma of the colon - Faecal mass
It is a point halfway along a line joining the ASIS and the midline Which is equal to the location of femoral artery


30. What are the cause of cervical lymphadenopathy that you know of?
Autosomal dominant - 1 in 500 - Chromosomes 4 and 16 are affected - Age of Presentation is between 30s and 50s
Primary disease occurring in isolation
Vascular symptoms - Risk factors for arterial disease - Fitness for surgery
Mneumonic : LIST Lymphoma and Leukaemia - Infection(further subdivided into Bacterial - Viral - Protozoal and Toxoplasmosis) - Sarcoidosis - Tumours


31. What is the operative mortality of AAA repair?
Demographics - Presenting Complaint - History of Presenting Complaint - Medical and Surgical History - Drugs and any other allergies - Family History - Social History - Systemic Enquiry
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
A dermoid cyst is a skin-lined cyst deep to the skin. They may be congenital or acquired.
Arising inside the parotid gland - Arising outside the parotid gland


32. How are they classified?
Lymphangiomas can be:Cystic - Solid or diffuse - Cutaneous
Less than 0.5
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
TIMEC - Trauma/Tumor - Infection/Inflammation/Ischemia - Metabolic -Mechanical - Endocrine - Congenital


33. 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
Anxiety - Hyperthyroidism - Hyperhidrosis erythematosus traumatica - Phaeochromocytoma
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.
Iodine deficiency - Increased physiological demand - Goitrogens(less common) - Defects of thyroid hormone production


34. How do you stage malignant melanomas?

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35. When are spider naevi considered to be pathological?
More than five is considered as pathological in chronic liver disease
Dilatation of normal capillaries - Can be secondary to skin irradiation - Can be part of hereditary haemorrhagic telangiectasia
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
Often surgeons place two drains - one in the axilla and one at the site of surgery within the breast tissue - The drains are usually left for 3 to 5 days or until the drainage volume is less than 50mL in 1 day. - Patients can safely be sent home with


36. How would you perform an ascitic tap?
The procedure should be performed under sterile condition and if the ascites is not clinically apparent or easy to locate - it should be done by a radiologist under ultrasound guidance to prevent inadvertent injuries to intra-abdominal structures.
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.
Any cause of deep venous insufficiency can lead to ulceration: Valvular disease - varicose veins - deep vein reflux - communicating vein reflux - Outflow tract obstruction - often post-DVT - Muscle pump failure - primary such as stroke and neuromuscu
Blood Tests:Haematological - FBC - ESR - Biochemical : TFT - ACE Levels(raised in sarcoidosis) - Serological : 'monospot' or Paul-Bunnell test looking for atypical mononuclear cells in infectious mononucleosis - Radiological : Ultrasound - CT Scan an


37. What do you know about solitary thyroid nodules?
Arising inside the parotid gland - Arising outside the parotid gland
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
Commonest form of thyroid abnormality - Secondary to hyperplasia of the gland to meet physiological demand for thyroxine - Secondary to defective production of thyroid hormone
More common in females - Occur most commonly in the fourth or fifth decade - 10% in middle-aged are malignant but 50% are malignat in the young and the elderly - FNAC is the most important investigation


38. What are multiple -painful lipomas known as?

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39. How would you rehabilitate a patient following the placement of a stoma?
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
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
Unilateral - Bilateral
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


40. What are the cardiac causes of digital clubbing?
Cyanotic congenital heart disease - Infective endocarditis - Atrial myxoma (rare)
Complications should be divided into specific to the amputation and general for any operation - and also immediate within 24 hours - early up to 1 month and late beyond 1 month
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
The primary lesion could be treated with excision with 1cm margin and Moh's staged chemosurgery with histological assessment of margins and electrodessication - for lesions of the eyelids -ears and nasolabial folds. Radiotherapy is applied for unrese


41. What is exopthalmos secondary to?
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
Excision of a single lobe of the lung
A seborrhoeic keratosis is a benign overgrowth of the basal cell layer of the epidermis.
Retro-orbital inflammation and lymphocytic infiltration leading to oedema and an increase in retrobulbar orbital contents


42. What are the predisposing factors for Raynaud's phenomenon?
Primary Raynauds is due to vasomotor malformation - Secondary Raynauds occurs as a consequence of pathology affecting the vessel wall
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
Blood Tests:FBC - to look for raised white cell count in infection - Liver function - to look out for hypoalbuminaemia or evidence of hepatic dysfunction - Clotting - functional hepatic impairment - CRP/ESR - increased in infection/inflammation and i
Site and size of varicosities - including the presence of saphena varix - Skin for changes and scars - Swelling of the ankle


43. What are the major indications for renal transplantation?
Lord's plication - Jaboulay's operation
Renal transplantation is indicated in end stage renal failure - the commonest reasons in the UK are:Diabetes mellitus - Hypertensive renal disease - Glomerulonephritis - Polycystic kidney disease
Heamolysis - Hereditary e.g : gilbert's syndrome
Transfemoral radiological embolization of the testicular vein - using either a spring coil or sclerosant


44. What are the specific complications of parotidectomy?
malignant change?
Non-Surgical - Reassure and 'Watch and Wait' - Surgical - Reason : Pain/Cosmesis and this is done with suction lipolysis via a small - remote incision Which is performed under local anaesthetic as a day case.
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
Leave alone if asymptomatic and if patient does not want intervention - Intervene only when extensive or for cosmetic reasons with local radiotherapy and/or chemotherapy using interferon-alpha -doxorubicin and intralesional vinblastine.


45. Describe the vascular supply of the transplanted kidney?

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46. What are the features of an inguinal hernia?
Non-adherent dressing over ulcer plus wool bandage - Crepe bandage - Blue-line bandage - Adhesive bandage to prevent the other layers from slipping
Donor renal artery is anastamosed to either the internal or external iliac artery - The donor renal vein is anastamosed to the external iliac vein - The ureter is anastamosed seperately to the patient's bladder - The renal pelvis the most anterior st
Hepatitis - Decompensated chronic liver disease - Drugs
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present


47. It is know that the pulses are preserved in the diabetic - why is this?
Prehepatic jaundice can occur due to haemolysis - especially following a transfusion - Hepatic jaundice can result from the use of halogenated anaesthetics - sepsis or intra- or postoperative hypotension - Post-hepatic jaundice can occur due to bilia
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
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
Non-surgical - same as in incisional hernia with possible investigations : LFTs - H.pylori serology and Upper GI endoscopy


48. What is a skin graft?

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49. What are the causes of massive splenomegaly?
At two levels:ABO Compatibility - HLA Compatibility
The principles of surgery are that the sac is excised completely or inverted - and the defect in the linea alba repaired - The fat contained within the hernia can be excised or reduced - The site of the defect should be marked with the patient lying
Myelofibrosis - Chronic Myeloid Leukaemia - Malaria - Tropical splenomegaly - Kala-azar(visceral leishmaniasis)
Paraumbilical herniae occur around the umbilical scar. They are uncommon before the age of 40 years and can become large. Peristalsis can be observed through the skin when the defect is large. The neck of the sac is often tight and held with a fibrou


50. How would you prepare a patient who is going for surgery which will involve forming a stoma?
Increased sweating - Palmar erythema - Thyroid acropachy - Onycholysis - Areas of vitiligo - Pulse - Fine Tremor
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
Causes may be classified as the 3 Ps: Physiological - Pathological - decreased androgens - androgen resistance - increased secretion -increased peripheral aromatization - Potions that is drugs such as recreational drugs - GI drugs - cardiovascular dr
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