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Surgical exam for MRCS
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Surgical exam for MRCS

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  • 1. What is the examiner trying to demonstrate? <br /> 2. How could you confirm the diagnosis? <br /> 3. The scrotal problem does not cause him any trouble. Do you think it needs treatment? <br />
  • 1. What is the diagnosis? <br /> 2. What treatment would you offer this man acutely, if any?
  • 1. What is the diagnosis? <br /> 2. What are the options for treatment? <br />
  • 1. What is the diagnosis? <br /> 2. What are the options for treatment? <br />
  • 1. What is the diagnosis? <br /> 2. What are the options for treatment? <br />
  • 1. What is the diagnosis? <br /> 2. What are the options for treatment? <br />
  • 1. What are the possible causes for this discolouration on the dressing? <br /> 2. What other features on examination would point to the diagnosis? <br />
  • 1. Describe the important features of this xray? <br /> 2. What is the diagnosis? <br />
  • 1. What reasons do you think he had to, over the phone, book the patient directly for theatre? <br /> 2. What was the diagnosis? <br /> 3. What are the options for treatment? <br />
  • 1. What is the diagnosis? <br /> 2. What are the options for treatment?
  • 1. Can you identify the hardware insitu? <br />
  • 1. What is the diagnosis? <br /> 2. How should you proceed? <br />
  • 1. What is the diagnosis? <br /> 2. What part of the bowel is incarcerated and obstructed by the hernia.? <br /> 3. What are the options for treatment? <br />
  • 1. What is the likely diagnosis? <br /> 2. What may have been a precipitating factor from the history? <br /> 3. Are any further imaging studies required before operating?
  • 1. Name some examination techniques to differentiate the possible diagnoses? <br /> 2. What information would you like prior to operating?
  • 1. What has occurred? <br /> 2. What structures are at risk when operating to remove this? <br />
  • 1. What have you found? <br /> 2. What problems do these devices have? <br />
  • 1. How would you mark a patient pre-operatively for a planned stoma? <br /> 2. How would you perform a mesh repair of this parastomal hernia? <br /> 3. How would you create an end colostomy after an elective abdominoperineal excision of the rectum? <br />
  • <br /> 1. What does the photo show? 2. How would you manage this man? <br /> 3. What would you discuss when consenting him for the procedure? <br />
  • 1. What does the CT show? <br /> 2. How would you manage the problem in the emergency department? <br /> 3. What are the options for operative mangement? <br />

Surgical exam for MRCS Surgical exam for MRCS Presentation Transcript

  • Case 127: ?Two hernias This man presented for treatment of his paraumbilical hernia. He also had a scrotal problem
  • 1. What is the examiner trying to demonstrate? That he can 'get above the lump' in the scrotum. 2. How could you confirm the diagnosis? Physical examination is often all that is required. Transillumination will confirm the nature of the problem as easily as ultrasound will. However, the cause of the hydrocoele may occasionally be due to an underlying testicular tumour and an ultrasound here is important. 3. The scrotal problem does not cause him any trouble. Do you think it needs treatment? No. As long as a sinister underlying cause is excluded the patient can be reassured and observed as to the size of his hydrocoele. As a rule, if a patient does not have any problems attributable to a benign condition, do not offer to 'help' by suggesting surgery.
  • Case 128: Worsening pain in the groin This gentleman presented acutely with a sudden increase in groin pain. He had noticed a slowly enlarging lump in the right groin over the past few months. The pain and size of the lump would decrease at the end of each day as he got home from work, sat down, and relaxed.
  • 1. What is the diagnosis? From the history, the possibilty of an inguinal hernia would have to be considered likely. The recent increase in pain should be considered to be due to incarceration until proven otherwise. 2. What treatment would you offer this man acutely, if any? The photo shows a lump in the right hemiscrotum above the right testis. This is the scrotal lump that you cannot 'get above'. On examination, the hernia was indeed not reducible and an urgent open hernia repair was carried out. The incarcerated omentum was oedematous but not ischaemic so mesh was used to repair the defect. An urgent operation should always be performed in this case. Delay will only compromise the incarcerated contents vasularity and prolong the patients pain.
  • Case 129: Rapidly growing skin lesion
  • 1. What is the diagnosis? The history of this lesions rapid growth should always raise the possibility of a keratoacanthoma. The rounded edges and central keratin plug support this diagnosis 2. What are the options for treatment? This lesion should be excised. It is large, possibly too large for a keratoacanthoma (these often only reach 2cm's at their largest) and the distinction on macroscopic examination is often impossible.
  • Case 130: Subcutaneous lump This patient presented with a subcutaneous lump which was not particularly painful but slowly enlarging. This was an intraoperative photo This was the ultrasound ordered by the referring doctor
  • The macroscopic pathology specimeb.
  • 1. What is the diagnosis? A simple lipoma 2. What are the options for treatment? Lesions superficial to the deep fascia and less than 5 cm's in size are almost always benign and many of these can be left alone if the patient is happy. Larger lesions and those deep to the deep fascia should alarm the surgeon to possible sarcoma. These should be imaged and referred to a sarcoma surgeon for careful consideration of preoperative biopsy and possible neoadjuvant radiotherapy +/- wide excision. Not all fatty lumps are lipomas. In this case the patient noticed that the lesion was growing and was concerned, the lesion was superficial and less than 5cm's. therefore they should be offered excision.
  • Case 131: Lump below the ear This man has had this lump for many years and it has not changed much. He also has a smaller lump in a similar position on the opposite side.
  • 1. What is the diagnosis? Warthin's Parotid tumour or adenolymphoma. These lesions are benign, are seen most commonly in elderly men and are bilateral in 10% of cases. 2. What are the options for treatment? With this history of a lump which has not changed, become painful or resulted in facial nerve involvement, it could be observed. A resonable approach would be to obtain a needle biopsy to confirm a Warthin's tumour.
  • Case 132: Blue-Green colouration on the dressing The dressing was taken down from a patients laparotomy wound. It was day 7 post operation.
  • 1. What are the possible causes for this discoloration on the dressing? The possibility of an enteric fistula should always be considered, especially if the dietitian has put blue food colouring in the enteric feed to try and demonstrate such a fistula. However, the most likely cause for this is a pseudomonas aeruginosa colonisation/infection of the wound. 2. What other features on examination would point to the diagnosis? A strong pungent odour. Some say it is a fruity odour, however it is more like the smell of sweaty socks dipped in ammonia.
  • Case 133: Persistent bile stained vomiting in a neonate This baby had been vomiting several times a day since birth and was becoming dehydrated.
  • 1. Describe the important features of this xray? This is a plain radiograph of the abdomen. The abnormality shown is a dilated stomach and that part of the duodenum which is above an obstruction. Other parts of abdomen do not contain gas. 2. What is the diagnosis? This 'double-bubble' appearance with no distal gas is characteristic of duodenal atresia.
  • Case 134: Small bowel obstruction - No prior surgery and no hernias This 80 yr old man presented with a distal small bowel obstruction. You rang your boss and told him that there were no scars, no hernias and the patient had some abdominal tenderness. He had a microcytic anaemia. Your boss said to book the patient for theatre without further investigation.
  • 1. What reasons do you think he had to, over the phone, book the patient directly for theatre? Tenderness. This usually implies a compromised loop of gut that either requires release, or if left too long, resection. The fact that the patient had a 'virgin' abdomen and no other cause for obstruction in the setting of an anaemia increases the likelihood of the cause being a carcinoma obstructing the ileocaecal valve. 2. What was the diagnosis? A right colon carcinoma obstructing the ileocaecal valve 3. What are the options for treatment? Formal right hemicolectomy, with proximal tie of the ileocolic vessels and resulting lymphovascular clearance. A primary anastomosis is usually possible - especially if operated early before the bowel and the patient deteriorate.
  • Case 135: Painful prolapsed lump This man presented with a two day history of perianal pain and a lump.
  • 1. What is the diagnosis? Circumferential prolapsed haemorrhoids. There is a central infarcted internal haemorrhoid. 2. What are the options for treatment? The options are either conservative or surgical. Conservative treatment would consist of analgesia, salt baths, topical creams and gels, suppositories stool softeners etc. Once there is a strangulated and infarcted haemorrhoid surgery is often required. Although an operation is painful, a limited excision of the offending infarcted haemorrhoid will speed recovery, reduce the level of pain and hopefully lessen the rare incidence of significant perianal sepsis which may eventuate if a necrotic haemorrhoid is neglected.
  • Case 136: Prior surgery This man had prior surgery.
  • 1. Can you identify the hardware insitu? A. Clips from laparoscopic cholecystectomy B. Transampullary biliary stent to relieve obstruction from presumed ductal stones
  • Case 140: Really painful scrotum This young boy presented with an extremely painful scrotal condition which he had concealed from his parents for two days.
  • Case 140: Really painful scrotum This young boy presented with an extremely painful scrotal condition which he had concealed from his parents for two days.
  • 1. What is the diagnosis? A torted testicle with established ischaemic necrosis 2. How should you proceed? This testicle should be excised. This will decrease any pain and also lessen the incidence of the development of testicular antibodies against the opposite sided testicular contents. The other testicle should always be explored and fixed to prevent the other side torting at a later date - a preventable and disastrous outcome for the patient.
  • Case 141: Vomiting, constipation and an abdominal lump This man had noticed that his hernia at the umbilicus had become more prominent over the past 4 days. Now it was painful, tender and not reducing as it usually would when he lay down. He had not used his bowels, nor passed flatus for 48 hrs.
  • 1. What is the diagnosis? Incarcerated and obstructed paraumbilical hernia. 2. What part of the bowel is incarcerated and obstructed by the hernia.? The mid transverse colon - as seen to be the cutoff on the abdominal Xray. 3. What are the options for treatment? The treatment is operative. Open reduction of the hernia, inspection of the colon for viability, if viable, return to the abdominal cavity, hernia repair +/- mesh.
  • If the colon is not viable then this will require resection. The options then include a right hemicolectomy and primary anastomosis. This operation has the benefit of using small bowel for anastomosis with its excellent blood supply, and also resects the caecum which was obstructed and can occasionally become compromised due to distension. When a colonic resection is performed many surgeons would elect not to insert mesh to reinforce the hernia repair for fear of infection, although there is no firm evidence for this.
  • Case 149: Xray for abdo pain This man presents with a 4 hour history of severe upper abdominal pain. He was quite well previously apart from a shoulder problem for which he has been taking analgesics recently. This man is unwell, shocked with generalised peritonitis.
  • 1. What is the likely diagnosis? Perforated peptic ulcer 2. What may have been a precipitating factor from the history? The analgesics may have been NSAID's. 3. Are any further imaging studies required before operating? No, this man is shocked with generalised peritonitis. The indication to operate is clear. The soiling of this gentleman's peritoneal cavity must be severe and this needs to be addressed.
  • Occasionally when operating a perforated sigmoid diverticulitis is encountered necessitating a Hartmann's resection and stoma formation., This should be explained to the patient and relatives preoperatively. There is a case for conservative treatment of a perforated peptic ulcer. These patients must be haemodynamically stable, preferably with localised peritonitis and usually a relative contraindication to operative intervention eg significant cardiac failure. A water soluble contrast study showing no further leaking from the ulcer is good evidence to pursue a conservative approach.
  • Case 150: Baby lump This young boys parents were worried about a lump in his right scrotum. Further history : the lump is always there, it does not seem to change when he cries, it is not really tender, the boy does not complain of pain associated with the lump.
  • 1. Name some examination techniques to differentiate the possible diagnoses? get above the lump, transillumination, palpation of the testis separate to the lump, reducible, fluctuant. 2. What information would you like prior to operating? Possibly an ultrasound to confirm the testis is normal, and to confirm the diagnosis. If clinical examination is clear, then this is probably not neccessary.
  • Case 151: Palmar lump This man is a keen gardener and 12 weeks ago whilst working in the garden thought that he got a splinter in his palm. This remained painful and gradually developed into a lump.
  • 1. What has occurred? A foreign body granuloma 2. What structures are at risk when operating to remove this? Mainly the nerves. The palmar digital nerves become more superficial and they are branching at this point to the respective digits.
  • Case 152: Oncology patient You are asked to take blood from this patient but cannot find a suitable vein for venepuncture. You notice a scar on the anterior chest wall and an unusual finding in the lower neck.
  • 1. What have you found? A buried subcutaneous infusion port for vascular access. Usually used for chemotherapy. Sometimes known as an infusaport. 2. What problems do these devices have? Insertion: bleeding, pneumothorax, failure, difficult to feed into central vein, arrhythmia Medium term: infection, sepsis, blockage, thrombosis, pulmonary embolus, port volvulus and inability to needle port, extravisation of chemo and resulting skin necrosis. Removal: bleeding, breakage of catheter and foreign body pulmonary embolus, air embolus, seroma, infection.
  • Case 153: Stoma This 57 year old man was having increasing discomfort from his stoma and associated leakage
  • 1. How would you mark a patient pre-operatively for a planned stoma? Involve an experienced stomal therapist for patient education as well as marking of an apppropriate site. The stoma should be sited away from scars, on a flat part of the abdominal wall where it is visible and accesible to the patient lying or sitting. The stoma is traditionally placed through the rectus muscle in an attempt to reduce the risk of hernia development. A point 1/3 of the way from the umbilicus to the anterior superior iliac spine may be suitable for many patients with normal body weight. In the elderly and obese patients the site may need to be considerably higher and may even be above the level of the umbilicus.
  • Examine the patient lying down and ask them to lift head and shoulders off the bed, palpate the edge of the rectus muscle and mark this line. Then select a point away from scars and on a flat part of the abdominal wall. Mark this point with a cross. The patient should be able to see this point and place a finger on it whilst lying and sitting. When the final position is chosen mark it with permanent pen in a circle approximately 15-20mm in diameter (remember it will enlarge once a disc of skin is excised. Always remember that a poorly sited stoma can have a major impact on the patients quality of life and every effort should be made to provide a well sited and created stoma.
  • 2. How would you perform a mesh repair of this parastomal hernia? This operation is performed under general anaesthesia with prophylactic intavenous antibiotics and attention to DVT prophylaxis. The appliance is removed and the area cleaned with soap and water. The abdomen is then prepared and draped. A pack is folded and placed over the stoma and an adhesive drape used to secure the pack in position. A midline incision is made and deepened to the linea alba. For adequate exposure a long incision is required. The subcutaneous fat is then dissected off the anterior rectus sheath until the stoma is reached.
  • The subcutaneous fat is dissected off the colon with particular care paid to the mesentery. The colon is then dissected off the anterior rectus sheath, rectus muscles and freed into the peritoneum. With the colon returned to the peritoneum the defect in the rectus sheath is closed around the bowel. A sheet of prolene mesh is then cut to shape with a slit and a circle removed. The mesh is positioned around the bowel and sutured into position. The wound is lavaged and a drain is brought out on the contralateral side of the abdomen. The wound can then be closed and dressed to prevent contamination from the stoma.
  • 3. How would you create an end colostomy after an elective abdominoperineal excision of the rectum? The patient should be marked and educated by a stomal therapist during pre-operative planning. As a stoma is a certainty with APR there is an argument to create the trephine before performing a midline laparotomy. This ensures that the trephine passes straight through the abdominal wall and that there is no slippage between rectus fascia and the subcutaneous fat and skin. .
  • If the trephine is to be made after laparotomy then a straight Kocher's clamp is placed on the linea alba and the dermis. These are then held together in the left hand. A disc of skin is excised at the marked site. A vertical incision in the subcutaneous fat is then made with diathermy and deepened to the anterior rectus sheath with the assistance of stoma retractors. A generous vertical incision is then made in the anterior sheath. A Robert's clamp is used to split the rectus muscle vertically taking care to avoid the inferior epigastric vessels. With the posterior sheath exposed a vertical incision is again made here. A pack should be held in the left hand and the index finger can be pressed up into the trephine site. This aids dissection and allows diathermy to be used throughout with risk to the underlying bowel
  • The site is checked for haemostasis. Usually the passage of two fingers through the trephine ensures that it is of sufficient calibre. Babcock's forceps are passed through the trephine and used to grasp the stapled closed end of colon. It is bought out and held in position by the Babcock. There should be no tension and sufficient length to allow for post operative abdominal distension. The operation is then completed, the midline wound closed and dressed. The stoma is then matured by excisiong the staple line and suturing the bowel to the dermis. This is a bowel anastomosis like any other and should be performed with care. Several sutures should be placed and held on artery clips before excising the staple line to prevent the bowel retracting into the peritoneum. After placement of sutures they are tied down to create a fluch stoma and finally an appliance is fitted.
  • Case 154: Pain in the perineum A 33 year old man presents with 2 days of increasing pain adjacent to his anus. He has no other bowel symptoms and is otherwise well.
  • 1. What does the photo show? An acute perianal abscess has been drained and a seton inserted through a fistula. 2. How would you manage this man? The primary therapy is examination under anaesthesia with incision and drainage of the abscess. The patient should be placed in lithotomy position. A digital rectal examination is performed to assess the extent of sepsis and its relation to the sphincters and levator ani. The internal opening of a fistula may be palpable. Rigid sigmoidoscopy is then performed to look for proctitis. The perineum is then prepared and draped. Anoscopy using an appropriate retractor (eg. Park's, Hill-Ferguson) allows inspection for an internal fistula opening.
  • The abscess is then drained with incision over the most fluctuant point and away from the anal verge. A small disc of skin is excised to maintain drainage and prevent early closure. Probing is discouraged as may lead to iatrogenic fistula creation, however if an internal opening is identified then a seton should be inserted if possible to prevent early recurrence. A large cavity should be managed with insertion of a DePezzer catheter which is left for several weeks. Broad spectrum antibiotics with anaerobic cover may be indicated in diabetic patients and those with Crohn's disease. Patients should be advised to maintain a good bowel habit with a diet high in fresh fruit and vegetables, adequate fluid intake and frequently fibre supplementation.
  • 3. What would you discuss when consenting him for the procedure? Informed consent requires discussion of the nature of the disease and it's natural history. The management options and potential benefits and limitations of each should be covered. The specific issues for this man will be the risks of recurrence and fistula requiring seton insertion. He should be warned that he may have a drain tube or a seton left in situ and that he will require dressings and salt baths possibly for several weeks. Careful surgery should not endanger the sphincter mechanism however undrained sepsis may.
  • Case 156: Back pain and collapse A 65 year old man is bought in by ambulance hypotensive after collapsing at home. His main complaint is back pain and he is too distressed to provide much more information.
  • 1. What does the CT show? There is a large abdominal aortic aneurysm with evidence or rupture into the retroperitoneum. Blood is seen spreading into the right side and pushing the kidney forward. There is also significant mural thrombus. 2. How would you manage the problem in the emergency department? The patient requires urgent diagnosis and operative management. Delays within the emergency department are not justified beyond instituting basic resuscitation. Two large bore (16G) IV cannulae should be inserted into large veins in the cubital fossa of each arm.
  • Blood should be taken for full blood examination, electrolytes, renal function, coagulation studies and cross matching 6 units of blood. The anaesthetists, operating theatre staff and intensive care unit should be informed and preparing for an urgent operation. A cell saver should be used if available. 3. What are the options for operative mangement? The standard management is midline laparotomy, vascular control and then aortic replacement with tube graft or bifurcated aorto-bi-iliac graft. There is increasing experience with urgent endoluminal stent grafts however this is only appropraite in a specialist centre and for a select group of patients.