1. Case 1: Troublesome stomaThis 57 year old man was having increasing discomfort from hisstoma and associated leakage from a stoma appliance that wasdifficult to apply.
2. 1. What abnormality is shown?.A parastomal hernia2. Methods for repair?-consider stoma closure restoring intestinal continuity-resiting stoma to another area with non attenuated abdominal walltissues-local repair. This may include amputation of some bowel length,suture plication of the abdominal wall defect, mesh repair toreinforce the abdominal wall tissues.3. What is the elastic garment around this patients waist?-abdominal binder for symptomatic relief
3. Case 2: Sudden onset abdominal painThis 77 year old man collapsed at home complaining ofabdominal pain.
4. 1. What abnormality is shown?.Leaking Abdominal Aortic Aneurysm.2. Methods for repair?-Open repair with interposition dacron graft, whichmay have to be bifircated if the aneurysm extends downone or both iliacs.- Endoluminal repair is becoming more accessibleespecially in specialised centres and with careful patientselection
5. Case 3: Right sided abdominal painThis 77 year old man with a prosthetic mitral valvepresented complaining of right sided abdominal pain.
6. 1. What has happened to cause the pain?.Right sided rectus sheath haematoma. This patient willmost likely be fully anticoagulated because of his heartvalve. A spontaneous haemorrhage like this is uncommonbut can be difficult to treat.2. Treatment?Observation in ICU, resuscitation, transfusion, correction ofanticoagulation, analgesia and occasionally angiographyand embolisation.3. What is the subcutaneous mass in the anteriorabdominal wall?Paraumbilical hernia, probably unrelated.
7. Case 4: Painless post auricular swellingThis man presented with a mass behind the left ear.
8. 1. What is the differential diagnosis?.Includes:sebaceous cystlymphadenopathylipomainclusion dermoiddermoid cystsimple cystThe differential is large. However it can be narrowed by consideringthe lumps physical characteristics. It is smooth, does not involve skin,there is no punctum, and if felt it is soft, fluctuant and importantly isquite transilluminable.2. Further treatment?A simple cyst would be uncommon in this area so it was excised andsubmitted for histopathology - this showed a simple cyst.
9. Case 5: Significant abdominal wound infection7 days after a laparotomy this lady was very unwell with infectionspreading from her abdominal wound. Blood gases were taken on heradmission to the intensive care unit
10. 1. What do they demonstrate?.Extreme metabolic acidosis.Maximum respiratory compensation.Significant base excess.Adequate oxygenation if breathing room air.2. What do you think of her wound infection now?In the absence of another clear cause, the wound infection isobviously causing significant systemic sepsis. In fact, the infection hasprobably evolved into a necrotising fasciitis process and may be lethal.Rapid resuscitation, IV antibiotics and wide surgical debridement willprobably be necessary.There is some evidence that hyperbaric oxygen therapy has somebenefit in treating these very unwell patients.
11. Case 6: Bile in the drain tube10 days after a laparotomy for a perforated gastric antralulcer, there was bile draining from the drain tube.
12. 1. What xray has been performed?.A fluoroscopic sinogram (contrast injected down the drain tube).2. What does it show?The film shows contrast flowing down the drain tube and filling acavity around the second (descending part) of the duodenum. Thecontrast is also seen entering the duodenal lumen. (on the film seenjust to the medial aspect of the cavity)With a perforated gastric antral ulcer the options are to patchrepair the defect with an omental patch (also taking an ulcer edgebiopsy to exclude malignancy). However, with a larger ulcer a distalgastrectomy may be required (as in this case) with the consequentrisk of duodenal stump leakage.
13. Case 7: Painful legThis man was involved in an industrial accident. His legswere crushed across the thighs for 8 hours before he wasable to be rescued. He sustained no other injuries.
14. 1. What complication has occurred?Compartment syndrome of at least the posterior compartment2. What other clinical settings may result in this condition?Prolonged ischaemia from any cause. Embolic, thrombotic, traumatic,and associated with lower limb fractures and the resultant swelling.3. What operation has been performed?Posterior calf compartment fasciotomy4. What are the indications this operation?Confirmed, or in the correct clinical context, the suspicion orpredicted occurence of this problem as a prophylactic measure.
15. Case 8: Acute shortness of breathThis 24 year old man presented with sudden onset pleuritic rightscapular region pain and shortness of breath. A chest xray wasobtained and prompted the emergency department to perform aprocedure.
16. 1. What does the xray show?The xray shows a right sided pneumothorax without evidence oftension (complete collapse, medisatinal shift, flattening of the domeof the diaphragm). A pigtail catheter has been inserted however thereis incomplete re-expansion of the lung.2. How would you manage the problem in the emergencydepartment?The management of a symptomatic spontaneous simplepneumothorax is insertion of an intercostal catheter with connectionto an underwater seal drain (UWSD). These drain chambers includethe ability to apply regulated suction to the pleural cavity. Manysurgeons would apply 20 cm water suction initially which can then beceased 24 hours after re-expansion of the lung with daily chest xraysto confirm the abscence of recurrent collapse.
17. 3. He returns 6 months later with the same problem. How wouldyour management differ now?Spontaneous pneumothorax typically occurs in thin fit young adultswith a male preponderence. They also occur in patients withunderlying chronic lung diseases in particular bullous emphysema andasthma.Recurrence in a young man would be considered an indication forpleurodesis. VATS (video assited thoracoscopic surgery) pleurodesis isperformed under general anaesthesia with double lumen intubation.Inspection of the apex of each lobe may reveal a congenital bullawhich should be excluded from the bronchial tree by excision usingand endoscopic stapler or simple endoloop application. Thepleurodesis is then effected by abrasion and application of an irritantsuch as alcoholic iodine. two intercostal catheters are then leftattached to the UWSD with suction.
18. Case 9: Bile in the drain post cholecystectomyA 55 year old woman is referred to you 10 days post cholecystectomy.The procedure was performed for acute cholecystitis and thedissection was difficult. The original surgeon reported finding"aberrant anatomy". There has been persistent drainage of bile fromthe drain left at operation at approximately 500ml/day.
19. 1. What type of xray is this and what does it show?A sinugram has been performed with instillation of water soluble contrastvia the drain tube. The contrast is seen to flow into a cavity thatcommunicates with the left and right hepatic ducts.2. How would you manage this problem?The immediate concern is assessment and resuscitation of the patient whomay have severe biliary peritonitis. If the drain has created a controlledfistula then this allows time to obtain further investigations to define theanatomy and plan definitive management.3. How would you classify this injury?The Strasberg classification is the most practical and widely usedclassification. It incorporates the Bismuth classification which was initiallydeveloped to classify hilar cholangiocarcinoma.This injury is a Strasberg E4 or Bismuth 4 with resection of the commonhepatic duct including the confluence resulting in separation of the right andleft ducts.
20. Case 10: Abdominal pain and bloatingA 32 year old man with Crohns disease presented with severalmonths of progressive abdominal pain and bloating. His symptomswere related to meals and as a result he had lost significant weight.He had previously undergone ileocolic resection with anastomosisand on this occasion you resect the area of the anastomosis and openthe specimen shown below.
21. 1. Describe the specimen shown.The specimen is an opened segment of bowel withneoterminal ileum on the left and an ileocolic anastomosistowards the right. At the anastomosis there is evidence ofstricturing with significant submucosal fibrosis andthickening that extends proximally for at least 10 cm. Themucosa overlying the anastomosis is deeply ulcerated.There are also linear ulcers in the mucosa of the ileum.
22. 2. What are the histologic features of Crohns disease?Crohns disease is a chronic inflammatory disease characterisedby transmuarl involvement with mucosal damage, non-caseating granulomas and fissuring with the formation offistulas.Crypt abscesses occur but are not specific for Crohns. Deepulceration may be adjacent to relatively normal bowel wallindicative of the discontinuous distirbution of the disease.Sarcoid-like granulomas may occur in up to half of patients andcan be found in any layer of the bowel wall and even inotherwise normal appearing bowel.Deep fissures may lead to fistula formation between loops ofbowel or other adjacent organs. Extensive submocosal fibrosisleads to sticture formation
23. 3. What investigations would you perform prior to operationin this man?It is important to confirm the diagnosis of recurrent Crohnswith stricture formation before embarking on resection. Thiscan be done easily by colonoscopy and intubation of theterminal ileum. Colonoscopy also allows assessment of theextent of disease. Further assessment of the small bowel mayrequire enteroscopy, radiologic enteroclysis or MRI(investigational at present).Finally the patients overall fitness needs to be assessed. Inparticular the effects of malnutrition resulting from poor intakeand malabsorption, chronic disease and probable chronicsteroid use. Simple assessment is based on serum albumin andmeasurement of iron stores and vitamin B12. Other nutrientsshould be measured and replaced as appropriate.
24. Case 11: Statistically speakingA 52 year old woman has a 25mm mass in her left breast. It feelsmalignant and this is confirmed by core biopsy. She has no palpablelymph nodes in the axilla and basic staging investigations are normal.She raises the question of sentinel lymph node biopsy (SNB) to avoidan axillary dissection. Her lymphoscintigram is shown below.1. What is a sentinel lymph node?2. What are the common orimportant risks of axillarydissection you would discuss?3. She asks you about the 7% falsenegative rate. What does the figuremean?4. How would you calculate thesensitivity and specificity for a test?
25. 1. What is a sentinel lymph node?The sentinel lymph node is the first node draining aparticular anatomical location. The location of a sentinelnode is able to be reliably determined by a combination ofthe injection of a radiolabelled traced and blue dye. Thestatus of the sentinel node is used as a marker of the statusof the entire nodal basin.2. What are the common or important risks of axillarydissection you would discuss?Major morbidity from axillary dissection is uncommon. Theproblem that many women complain of is anaesthesia orparaesthesia in the axilla, lateral chest wall and medial armwhich is related to division of intercostobrachial nerves.
26. Disruption of the long thoracic nerve to serratus anterioror the nerve to latissimus dorsi results in a more significantfunction deficit. The medial pectoralnerve supplying pectoralis major is also at risk.The rate of clinically significant chronic lymphoedema ofthe arm is as high as 10-15%.Seroma development in the wound is more common butusually resolves with repeat aspiration.Shoulder stiffness usually responds to physiotherapy andit is part of the breast care nurses and surgeons role todiscuss appropraiate exercises pre-operatively.
27. 3. She asks you about the 7% false negative rate. Whatdoes the figure mean?The false negative rate means that of all those axillas trulyinvolved 7% will be falsely thought to be negative. It is thereverse of sensitivity (93%). This will lead to incorrect downstaging of the patient resulting in potential undertreatment with adjuvant therapies.One other issue needs to be considered in order to makesense of the false negative rate. That is the incidence ofinvolvement of the axilla in early breast cancer. If only 20%of patients with early cancers have axillary disease and 93%of these will be correctly detected then only 1.4% (7% of20%) of all patients will have an incorrectly staged axilla.
28. 4. How would you calculate the sensitivity and specificityfor a test?You will need to draw up a table with 4 potential resulttypes. True positives, false positives, false negatives andtrue negativesSensitivity equals true positives divided by true positives+ false negatives =TP/(TP+FN)Specificity equals true negatives divided by truenegatives + false positives =TN/(TN+FP)
29. Case 12: Pain and lump in the breastA 24 year old woman has been breast feeding for 2 months.She now presents with a painful, red mass in the lowerouter quadrant of her left breast.
30. 1. What is the likely diagnosis?Lactational breast abscess2. What advice would you give her about breastfeeding?Continue feeding to encourage drainage of the breast. Anabscess develops when there is a relative obstruction toflow from a lobule of the breast related to inspissatedmaterial in the ducts. Organisms most likely ascend the ductafter gaining entry through the nipple which may becracked or damaged from feeding .The baby will not be harmed by feeding from this breastand should be fed from the effected side first. If feeding istoo painful then the breast should be manually expressed.
31. 3. Outline you management plan for this womanAfter a thorough history and examination the nextinvestigation should be an ultrasound to confirm thepresence and size of an abscess.Differentiation from mastitis without abscess may bedifficult clinically.Heat packs and massage, particularly in a warm shower,may also help. Analgesia and antibiotics are usuallyrequired.Unless the overlying skin is thin and necrotic it is notusually necessary to incise and drain a breast abscess.
32. Rather it is preferable to aspirate it with a large boreneedle often with US guidance. This procedure may needto be repeated on a daily basis until the abscess resolvesbut creates less risk of a milk fistula and cosmeticdeformity.The possibility of an inflammatory cancer always needs tobe considered although this is unlikely in a lactatingwoman. As a result she should be followed up with clinicalexamination and imaging after resolution of the abscess.
33. Case 13: Growing neck lumpThis 85 year old man is referred to you with an enlarginglump in the left neck.
34. Further information - see the following images
35. 1. Describe the lesionThere is a hemispherical raised lesion which is deeply purple in color,smooth in contour, which seems to be involving the overlying skin.2. What is the differential diagnosis?Malignant lesion - primary skin lesion or metastatic nodal diseaseinvolving skin. Less likely would be an infected sebaceous cyst.3. What else would you examine?The skin of the head and neck, complete ENT exam, and other lymphnode groups.4. What do you see?Pigmented skin lesions consistent with melanoma.5. Now what is your likely diagnosis?Nodal involvement of metastatic melanoma.
36. Case 14: View at LaparoscopyCan you identify the structures?1. What type of retractor ismarked by "A"?2. What segment of the liver isshown by "B"?3. What is under the lesseromental fat at "C"?4. What organ is close to letter"D" just out of screen?5. Which lobe of the liver isdemonstarted by "E"?
37. 1. What type of retractor is marked by "A"?Nathenson liver retractor2. What segment of the liver is shown by "B"?Segment 1, under the pars flaccida of the lesser omentum, otherwiseknown as the caudate lobe.3. What is under the lesser omental fat at "C"?The region of the gastro-oesophageal junction and the oespophagealhiatus in the diaphragm.4. What organ is close to letter "D" just out of screen?The spleen5. Which lobe of the liver is demonstarted by "E"?The left lobe
38. Case 15. Hand pain and numbnessThis lady has had pain and numbness in the radial three fingers forover 20 years. These symptoms are worse at night time. She oftenwakes at night and shakes her hands for relief.
39. 1. What syndrome is this typical of?Carpal tunnel syndrome2. What complication is seen?Thenar muscle wasting.3. Confirmatory tests?Nerve conduction studies - are always helpful to exclude otherdiagnoses. .4.Treatment?Conservative - splints, analgesia, treatment of any predisposingcause, steroid injection into and around the carpal tunnel. All of thesewould be unsuitable in this case because of the significant symptomsand demonstrable thenar muscle wasting.Surgery - Open or endoscopic division of the flexor retinaculum. Acarpal tunnel release
40. Case 16: Intermittent abdominal pain and a lumpA 56 year old man has had several abdominal operations in the past.He presents complaining of a discomfort associated with a smalllump which has developed in the midline wound near the umbilicus.
41. 1. What is the likely diagnosis (shown at "C")?Incisional Hernia near the umbilicus.2. What operation do you think was performed through theright upper quadrant scar?Marked "A"(He says he cant remember, however it was when he was ababy.)A Ramstead pyloromyotomy for pyloric stenosis. He was thefirst child in his family, and his father had pyloric stenosis.3. With the patient lifting his head off the bed, what is markedby "B"?Divarication of the rectii, there has been no incision here
42. Case 17: Discharging lump in natal cleftThis young man presents with a 12 month history of anintermittently painful and discharging lump at the lower back.
43. 1. What is the likely diagnosis?A pilonidal sinus.
44. Case 18: Wrist swellingThis lady had a lump on the back of her wrist which wasgetting bigger and more painful.
45. 1. What is the likely diagnosis?Dorsal wrist ganglion. Clinical examination wouldconfirm this, showing, a soft fluctuant mass,transillumination, no punctum, and usually fixed to theunderlying dorsal wrist capsule. Sometimes they canarise from the extensor tendon sheaths.
46. Case 19: Dead toeThis 69 year old man presented worried about theapperance of his toe.1. Describe the appearance ofthe toe marked A?2. What do you think has beenmarked with a cross at B?3. What is C4. What is seen in thebackground marked D?5. If there was a strong pulsefelt at B, what do you thinkthe patients main predisposingcondition would be?
47. 1. Describe the appearance of the toe marked A?This toe is gangrenous. The characteristic colouration, shrunken prune-likeskin appearance and nail bed pallor confirm this.2. What do you think has been marked with a cross at B?There is a cross marked with pen. This is most likely over the dorsalis paedisartery.3. What is C?This is a permanent ink mark outlining the extent of cellulitis.4. What is seen in the background marked D?A hand-held doppler transducer. For assessment of the pulse site andwaveform.5. If there was a strong pulse felt at B, what do you think the patientsmain predisposing condition would be?Diabetes. Demonstrating a predominant microvasculopathy.
48. Case 20: Minor head injuryThis young man fell from his bike 12 weeks earlier. He sustained aminor head injury in that he bumped his head at the point marked bythe arrow. He now presents with a painful and pulsatile mass at thatsite.
49. 1. What do you think has happened?The likely diagnosis is a traumatic false aneurysm of thesuperficial temporal artery.2. What treatment would you recommend?Pseudoaneurysm arising from the superficial temporalartery (STA) is very rare and is most commonly caused byblunt trauma. Most pseudoaneurysms of the STA usuallypresent as a painless pulsating mass, with concomitantsymptoms according to location, and their size may rapidlyincrease.The treatment of choice is ligation and resection.
50. Case 21: Abdominal X-rayThis Xray was taken in the emergency room for abdominal pain.
51. 1. What prior abdominal operation has the patient had?Cholecystectomy - probably laparoscopic because clips areless useful at an open operation so are not usually seen.
52. Case 22: Subcutaneous foreign body
53. 1. What is the subcutaneous linear mass running alongthe chest wall?An axillofemoral bypass graft2. It is not pulsatile. Does this change your diagnosis?Probably not, however this suggests that the bypass hasoccluded.