this ppt slides are for quick revision of general surgery specimens in final practical exams for undergraduates as well as postgraduates.

1. SURGERY
SPECIMENS
DR. YASH SHARMA
DEPARTMENT OF GENERAL SUREGERY,
MEDICAL COLLEGE KOLKATA.

2. IMPORTANCE OF SURGERY SPECIMENS
• Anatomical presentation and variations
• Surgical anatomy
• Intraoperative Diagnosis
• Correlation with disease course
• Surgical procedure
• Assessment of outcome
• Follow up planning

3. • Body Organ with anatomical site
• Surgical procedure
• Points in favor of clinical diagnosis
• Gross pathological appearance
• Diseased part
• Discussion
BASICS OF SPECIMEN

4. SPECIMENS
1. Breast
2. Thyroid
3. Stomach
4. Small intestine
5. Appendix
6. Colon
7. Gall bladder
8. Spleen
9. Penis

5. LETS START

6. 1.

9. • Identify the specimen ? SPLEEN
• Surgical procedure performed? Spleenectomy
• Points in favor ?
• Color - purple
• It has two ends
• three borders
• two surfaces
• 2 angles
• hilum

11. • 2 ends- 1 -The anterior or lateral end is expanded and is more like a border. It is directed downwards
and
forwards, and reaches the mid-axillary line.
2-The posterior or medial end is rounded.it is directed upwards, backwards and medially
• 3 borders 1-The superior border is characteristically notched near the anterior end.
2-The inferior border is rounded.
3-The intermediate border is also rounded and is directed to the right.
• 2 surfaces- 1.The diaphragmatic surface is convex and smooth.
2.The visceral surface is concave and irregular.

12. • Two Angles- 1.Anterobasl angle- It is the junction of superior border with lateral
or anterior end.
2.Posterobasal angle- junction of inferior border with lateral or
anterior end of spleen.
• Hilum- hilum lies between superior and intermediate borders it is pierce by
branches and tributaries of splenic vessels
• Anatomical Position - The spleen is soft , highly vascular and dark purple in colour. The
size and
weight of spleen are markedly variable, related to 9th to 11th ribs
and lies
in longitudinal axis of 10th rib

14. • Arterial supply and venous drainage

15. • Vascular arrangement ??
A. Distributive
B. Magistral

16. • Indications of spleenectomy

17. • Steps of spleenectomy
• Incision  Left subcostal incision / kehr’s / midline
• Release of all splenic ligaments  Gastrospleenic, leinorenal, spleenocolic,
phrenicocolic
• Assess for mobility 
• Approach towards hilum
• Identification of splenic artery and vein
• Clip / ligate artery first then vein  benefit of size reduction and less blood loss
• Deliver the specimen from incision
• Look for any hemorrhage
• Keep a drain in spleenorenal pouch
• Abdomen closure

18. • Complications
OPSI  OVERWHELMING POST-SPLENECTOMY INFECTION
• As there is reduced IgM, tuftin, properdin and other antibodies, phagocytosis of encapsulated bacteria is
defective. So, the postsplenectomised patient is more prone for Pneumococcal septicaemia (mc), N. meningitides,
H. influenzae infections
• Splenectomy there is a 1–2.5% risk of developing overwhelming septicaemia from encapsulated bacteria, usually
within 2 years of operation. The risk is higher in young children (4–10%) and after splenectomy for haematological
disease adults. The mortality rate of post-splenectomy sepsis is higher in children (50%)
• Features—Prodromal phase—fever, chills, sore throat; hypotension, shock; DIC; respiratory distress, coma,
death

19. • Immunization

20. 2.

23. • Identify the specimen ? thyroid
• Surgical procedure performed? thyroidectomy
• Points in favor ?
• Shape  Butterfly
• It has two lobes
• 1 isthmus
• 1 pyramidal lobe (sometimes)
• Tracheal grove
• 2 borders
• 3 surfaces

25. • Borders
• Anterior border – thin related to anterior branch of superior thyroid artery
• Posterior border – broad, rounded , related to branches of inferior thyroid artery and parathyroid
glands
• Surfaces
• Anteriolateral – convex, covered by sternothyroid, sternohyoid, superior belly of omohyoid and medial
border of sterocleidomastoid
• Medial surface – related to 2 tubes – trachea and esophagus
2 nerves – ELN and RLN
2 muscles – inferior constrictor of pharynx and cricothyroid
• Anatomical position – present in midline of neck specifically in thyroid region
lateral lobes extending from oblique line of thyroid cartilages to 4 or 5th tracheal ring
Isthmus lies over 2nd, 3rd and 4th tracheal rings

27. • Vascular supply
Arterial supply Venous drainage

28. • Indications of Total thyroidectomy

29. • Types of thyroidectomy
Total thyroidectomy  Removal of entire thyroid gland
Near total thyroidectomy  Removal of both lobes leaving behind minimal tissue around
the RLN
Subtotal Thyroidectomy  Removal of both leaving behind 6-8 grams of tissue
Hemithyroidectomy  Removal of isthmus with 1 lobe
Hartley Dunhill surgery  Removal of isthmus with 1 lobe entirely and 2nd lobe partially
• Minimally invasive approaches
video assisted thyroid surgery
TORT- Trans Oral Robotic Thyroidectomy TOETVA (NOTES)
Endoscopic thyroid surgery  Transoral Endoscopic (scarless)
 BABA / ABBA

30. • Capsules of thyroid gland –

31. • Steps of Thyroidectomy –
• Position  supine with neck extended
• Incision  collar incision with help of Garrotte mark
• Raising the skin flap
• Incision of deep cervical fascia
• Raising the fascial and strap muscle flaps
• Identification and division of  Middle thyroid vein  Superior and Inferior Thyroid vessels
(arteryvein)
• Identify and avoidance of injury to RLN, SLN, ELN and ILN
• Dissection of isthmus
• Control of bleeding and placement of drain
• Closure of incision

32. • Avoidance of Injury to LNs –
• 1. External Laryngeal Nerve - REEVE’s space
JOLL’s triangle
Sternothyroid – laryngeal Triangle
Cernea Classification
• 2. Recurrent laryngeal nerve – Beahrs triangle / riddle triangle
Simons triangle
Trinagle of Lore
Relation with Zuckerkandle tubercle

36. • Complications of Thyroidectomy

37. 3.

40. • Identify the specimen ? Gall bladder
• Surgical procedure performed? Cholecystectomy
• Points in favor ?
• Shape  pyriform
• Parts  It has fundus, body, infundibulum, neck and cystic duct
• Hartman's pouch
• Cholesterosis  Strawberry appearance
• STONEs  cholesterol, pigment, ,mixed
(There is no submucosa )

43. • Calots triangle vs Hepatocystic triangle

44. • Vascular supply

45. • Indication for cholecystectomy

46. • Cholesterol stone formation

47. • Steps of laparoscopic cholecystectomy
• Creation of pneumoperitonium  co2 insufflation
• Standard 4 port approach
• Patient position  reverse trendelenbergs and left lateral

50. 4.

52. • Identify the specimen ? appendix
• Surgical procedure performed? Appendectomy
• Points in favor ?
• Shape  vermiform, cul de sac like structure
• Luminal opening on one side, mesoappendix
• Abdominal tonsil

54. • Position of appendix

55. • Vascular supply

56. • Indication of appendectomy
• Acute appendicitis
• Recurrent appendicitis
• Carcinoid tumour : at the tip. <2cm
• Mucocele of the appendix
• Appendicular graft; ileal conduit
• On table colonic lavage
• ? Interval appendectomy after drainage of abcess or in appendicial mass  not recommended

57. • Etiological factors of acute appendicitis
• Bacterial infection  E.coli
• Obstruction of lumen of appendix  fecolith,
worms
foreign body
fibrotic stricture
tumor
adhesion
• Dietory factors
• Familial

59. • Incisions of appendectomy

60. 5.

63. • Identify the specimen ? Sigmoid colon, Rectum, anal canal and anus
with growth
• Surgical procedure performed? APR
• Points in favor ?
• Luminal opening on both sides
• Presence of tinea coli and haustration
• Presence of epiploic appendages
• Presence of perianal skin with anal canal
• Silk sutures present on mesenteric border of specimen

65. • Vascular supply

68. 6.

71. • Identify the specimen ? Stomach with growth in antrum ? neoplastic
• Surgical procedure performed? distal gastrectomy
• Points in favor ?
• Gastric mucosal fold
• Effaced around ulcer  neoplastic ( converging towards base  benign )
• Ulceratoproliferative lesion with Elevated margins  neoplastic
• Lesion extending beyond serosa  neoplastic
• Pylorus visible

73. • Blood supply of stomach

74. • Lymphatic drainage of stomach

75. • Lymph nodes stations

76. • Classifications of stomach
• 1. LAURENS CLASSIFICATION

77. • 3. BORMANN’S CLASSIFICATION ( for advanced Gastric Ca)

78. • 2. JAPANESE CLASSIFICATION (for early Gastric Ca)

79. • Staging of Ca Stomach