194 Surgical Cases.pdf 314i30

DR.AHMED DAWAII CHEAD BASRAH GENERAL HOSPITAL 2010

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INDEX OF CASES Case

Page number

Case 1: Troublesome stoma Case 2: Sudden onset abdominal pain Case 3: Right sided abdominal pain Case 4: Painless post auricular swelling Case 5: Significant abdominal wound infection Case 6: Bile in the drain tube Case 7: Painful leg Case 8: Acute shortness of breath Case 9: Bile in the drain post cholecystectomy Case 10: Abdominal pain and bloating Case 11: Statistically speaking Case 12: Pain and lump in the breast Case 13: A Growing neck lump Case 14: View at Laparoscopy Case 15: Hand pain and numbness Case 16: Intermittent abdominal pain and a lump Case 17: Discharging lump in natal cleft Case 18: Wrist swelling Case 19: Dead toe Case 20: Minor head injury Case 21: Abdominal X-ray Case 22: Subcutaneous foreign body Case 23: Lumps under the arm Case 24: Epigastric discomfort and anaemia Case 25: Total thyroidectomy Case 26: Small bowel obstruction Case 27: Painful perianal lump Case 28: Circular saw injury Case 29: Abdominal pain and diarrhoea Case 30: An incidental finding Case 31: A lump in the groin Case 32: Cold feet Case 33: Flat footed Case 34: Painful thigh Case 35: Painful left arm Case 36: Trouble getting a cholangiogram Case 37: A black spot Case 38: Scalp lesion Case 39: Discomfort between the shoulder blades Case 40: Abdominal distension

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Case 41: Small dorsal foot swelling Case 42: Weight gain Case 43: Rectal bleeding Case 44: Headache Case 45: Laparoscopic finding Case 46: Groin mass Case 47: Right upper quadrant pain Case 48: Dark urine (without answer) Case 49: Loin to groin pain Case 50: Right upper quadrant abdominal pain, fever and jaundice Case 51: Jaundice Case 52: Rectal bleeding Case 53: Fever and jaundice Case 54: Random abdo film Case 55: Skateboard accident Case 56: Femur fracture Case 57: Motor vehicle accident Case 58: Right iliac fossa pain and a mass Case 59: Operative technique Case 60: The difficult PEG tube insertion Case 61: Upper abdominal laparoscopy (missed) Case 62: Painful wrist Case 63: Sudden abdominal pain Case 64: CT angiogram Case 65: Incarcerated hernia Case 66: Abdominal pain in the elderly Case 67: Halitosis Case 68: Inguinoscrotal hernia Case 69: Urgent underwater seal-drain Case 70: PR bleeding Case 71: Punch to the face Case 72: Fall from bed Case 73: Soiling Case 74: Black toe Case 75: Malignancy Case 76: Vomiting, abdominal pain, anaemia and weight loss Case 77: Laparoscopic technique Case 78: Colonic polyp (missed) Case 79: Pancreatitis Case 80: RIF pain and vomiting(missed) Case 81: Leg deformity Case 82: "I think I've been stabbed" Case 83: Endoscopic appearance

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Case 84: Rectal anastomosis Case 85: Unusual view at endoscopy Case 86: Leg ulceration Case 87: Painful leg Case 88: Retained foreign body Case 89: 'Peritonitis' Case 90: Laparoscopic treatment of small bowel obstruction Case 91: Injury with angle grinder Case 92: Neck swelling Case 93: Scrotal enlargement Case 94: Paediatric surgery Case 95: Troublesome toe Case 96: Anterior knee pain ( without answer) Case 97: Abdominal distension and vomiting Case 98: Pale hand Case 99: Fever and abdominal pain Case 100: Sentinel nodes Case 101: Massive bleeding per rectum Case 102: Blood and mucus per rectum Case 103: Hypercalcaemia Case 104: Liver lesion Case 105: Loin pain Case 106: Arteriopath Case 107: Skin markings Case 108: Colonoscopic appearance Case 109: Colonoscopic technique Case 110: Lost stones (missed) Case 111: Chemotherapy infusion device (missed) Case 112: Farmer for surgery Case 113: Vomiting and chest pain Case 114: Dysphagia Case 115: Explain this appearance Case 116: Funny finger Case 117: Ankle abscess Case 118: Anti-Reflux operation Case 119: Distressed mother Case 120: Return to theatre Case 121: 'I have a chicken bone stuck in my throat' Case 122: Small lump on finger Case 123: Buttock pain Case 124: Scrotal lump Case 125: Distal gastric cancer Case 126: Breast operation

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Case 127: ?Two hernias Case 128: Worsening pain in the groin Case 129: Rapidly growing skin lesion Case 130: Subcutaneous lump Case 131: Lump below the ear Case 132: Blue-Green colouration on the dressing Case 133: Persistent bile stained vomiting in a neonate Case 134: Small bowel obstruction - no prior surgery and no hernias Case 135: Painful prolapsed lump Case 136: Prior surgery Case 137: Progressively enlarging lump under the jaw (without answer) Case 138: Difficult abdominal closure Case 139: Diabetic foot problem Case 140: Really painful scrotum Case 141: Vomiting, constipation and an abdominal lump Case 142: Gastroscopic problem Case 143: Intravenous drug use (without answer) Case 144: Perihepatic problem (without answer) Case 145: Numb fingers Case 146: Weightloss procedure (without answer) Case 147: Groin hernia Case 148: Xray pelvic objects (without answer) Case 149: Xray for abdo pain Case 150: Baby lump Case 151: Palmar lump Case 152: Oncology patient Case 153: Stoma Case 154: Pain in the perineum Case 155: Painless jaundice (without answer) Case 156: Back pain and collapse Case 157: Painful wound Case 158: Nothing coming up the nasogastric tube. (without answer) Case 159: Pre-op assessment (without answer) Case 160: Lump in front of ear Case 161: Car accident Case 162: Post op leg pain Case 163: Hardware at laparoscopy Case 164: Collapse Case 165: Urine discolouration Case 166: Chest pain Case 167: Leg trouble Case 168: Not again Case 169: 'My hernia wont go back in'

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Case 170: Industrial accident Case 171: Pain into the back Case 172: Facial lesion Case 173: Scalp lesion Case 174: Endoscopic technique Case 175: Fat leg Case 176: Very fat leg Case 177: Sore toe Case 178: Lump in the neck Case 179: Lumps on the arms Case 180: Chemotherapy access Case 181: Liver lesions Case 182: Hypoglycaemia Case 183: Post operative pain Case 184: Hot gallbladder Case 185: Breast lesion Case 186: Epigastric pain and fever Case 187: Severe abdominal pain Case 188: Scrotal lesion Case 189: Abdominal pain Case 190: Abdominal ultrasound Case 191: Nipple lesion Case 192: Stabbing Case 193: Wheeze Case 194: Trauma.

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Case 1: Troublesome stoma This 57 year old man was having increasing discomfort from his stoma and associated leakage from a stoma appliance that was difficult to apply.

1. What abnormality is shown?. A parastomal hernia 2. Methods for repair? -consider stoma closure restoring intestinal continuity -resiting stoma to another area with non attenuated abdominal wall tissues -local repair. This may include amputation of some bowel length, suture plication of the abdominal wall defect, mesh repair to reinforce the abdominal wall tissues. 3. What is the elastic garment around this patients waist? -abdominal binder for symptomatic relief. Case 2: Sudden onset abdominal pain. This 77 year old man collapsed at home complaining of abdominal pain.

1. What abnormality is shown?. Leaking Abdominal Aortic Aneurysm. 2. Methods for repair? -Open repair with interposition dacron graft, which may have to be bifircated if the aneurysm extends down one or both iliacs. - Endoluminal repair is becoming more accessible especially in specialised centres and with careful patient selection.

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Case 2: Painful thigh A 52 year old man has been smoking heavily most of his life. He now complains of pain in the left posterior calf and thigh after walking 50 metres.

1. What does the angiogram show? There is complete occlusion of the left external iliac artery with extensive collateral development and reconstitution of the femoral artery in the groin. 2. What further information would you like to know? On history it is important to assess the risk factors for cardiovascular disease (smoking, hypertension, diabetes, dyslipidaemia, family history) and the presence or abscence of other manifestations of this disease (ischaemic heart disease and cerebrovascular disease) and any previous therapy for these problems. Next an assessment needs to be made of the severity of claudication and its progress. The duration and progression of symptoms and their impact on lifestyle and employment are critical. A history of complications such as ulceration, gangrene and rest pain increases the risk or limb loss without intervention. A thorough examination of the entire cardiovascular system is undertaken. Then the angiogram is reviewed to assess disease more proximal and distal as well as in the contralateral limb. 3. How would you manage this man conservatively? Conservative management is based on risk factor modification (especially cessation of smoking), supervised exercise regime and primary prevention of cardiovascular complications with aspirin antiplatelet therapy. This should involve the general practitioner to assist in ensuring compliance.

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Case 3: Right sided abdominal pain This 77 year old man with a prosthetic mitral valve presented complaining of right sided abdominal pain. 1. What has happened to cause the pain?. Right sided rectus sheath haematoma. This patient will most likely be fully anticoagulated because of his heart valve. A spontaneous haemorrhage like this is uncommon but can be difficult to treat. 2. Treatment? Observation in ICU, resuscitation, transfusion, correction of anticoagulation, analgesia and occasionally angiography and embolisation. 3. What is the subcutaneous mass in the anterior abdominal wall? Paraumbilical hernia, probably unrelated.

Case 4: Painless post auricular swelling This man presented with a mass.

1. What is the differential diagnosis?. Includes: sebaceous cyst lymphadenopathy lipoma inclusion dermoid dermoid cyst simple cyst

The differential is large. However it can be narrowed by considering the lumps physical characteristics. It is smooth, does not involve skin, there is no punctum, and if felt it is soft, fluctuant and importantly is quite transilluminable. 2. Further treatment? A simple cyst would be uncommon in this area so it was excised and submitted for histopathology - this showed a simple cyst.

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Case 5: Significant abdominal wound infection 7 days after a laparotomy this lady was very unwell with infection spreading from her abdominal wound. Blood gases were taken.

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 is obviously causing significant systemic sepsis. In fact, the infection has probably evolved into a necrotising fasciitis process and may be lethal. Rapid resuscitation, IV antibiotics and wide surgical debridement will probably be necessary. There is some evidence that hyperbaric oxygen therapy has some benefit in treating these very unwell patients.

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Case 6: Bile in the drain tube 10 days after a laparotomy for a perforated gastric antral ulcer, there was bile draining from the drain tube.

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 a cavity around the second (descending part) of the duodenum. The contrast is also seen entering the duodenal lumen.(on the film seen just to the medial aspect of the cavity) With a perforated gastric antral ulcer the options are to patch repair the defect with an omental patch (also taking an ulcer edge biopsy to exclude malignancy). However, with a larger ulcer a distal gastrectomy may be required (as in this case) with the consequent risk of duodenal stump leakage. Case 7: Painful leg This 33 year old man took an overdose of opiates. He was found collapsed unconscious on the floor lying on his left side approximately 12 hours later. 1. What complication has occurred? Compartment syndrome of at least the posterior compartment . 2. 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 fasciotomy 4. What are the indications this operation? Confirmed, or in the correct clinical context, the suspicion or predicted occurence of this problem as a prophylactic measure.

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Case 8: Acute shortness of breath This 24 year old man presented with sudden onset pleuritic right scapular region pain and shortness of breath. A chest xray was obtained and prompted the emergency department to perform a procedure.

1. What does the xray show? The xray shows a right sided pneumothorax without evidence of tension (complete collapse, medisatinal shift, flattening of th dome of the diaphragm). A pigtail catheter has bben inserted however there is incomplete re-expansion of the lung. 2. How would you manage the problem in the emergency department? The management of a symptomatic spontaneous simple pneumothorax is insertion of an intercostal catheter with connection to an underwater seal drain (UWSD). These drain chambers include the ability to apply regulated suction to the pleural cavity. Many surgeons would apply 20 cm water suction initially which can then be ceased 24 hours after re-expansion of the lung with daily chest xrays to confirm the abscence of recurrent collapse. 3. He returns 6 months later with the same problem. How would your management differ now? Spontaneous pneumothorax typically occurs in thin fit young adults with a male preponderence. They also occur in patients with underlying chronic lung diseases in particular bullous emphysema and asthma. Recurrence in a young man would be considered an indication for pleurodesis. VATS (video assited thoracoscopic surgery) pleurodesis is performed under general anaesthesia with double lumen intubation. Inspection of the apex of each lobe may reveal a congenital bulla which should be excluded from the bronchial tree by excision using and endoscopic stapler or simple endoloop application. The pleurodesis is then effected by abrasion and application of an irritant such as alcoholic iodine. two intercostal catheters are then left attached to the UWSD with suction.

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Case 9: Bile in the drain post cholecystectomy A 55 year old woman is referred to you 10 days post cholecystectomy. The procedure was performed for acute cholecystitis and the dissection was difficult. The original surgeon reported finding "aberrant anatomy". There has been persistent drainage of bile from the drain left at operation at approximately 500ml/day.

1. What type of xray is this and what does it show? A sinugram has been performed with instillation of water soluble contrast via the drain tube. The contrast is seen to flow into a cavity that communicates with the left and right hepatic ducts. 2. How would you manage this problem? The immediate concern is assessment and resuscitation of the patient who may have severe biliary peritonitis. If the drain has created a controlled fistula then this allows time to obtain further investigations to define the anatomy and plan definitive management. 3. How would you classify this injury? The Strasberg classification is the most practical and widely used classification. It incorporates the Bismuth classification which was initially developed to classify hilar cholangiocarcinoma. This injury is a Strasberg E4 or Bismuth 4 with resection of the common hepatic duct including the confluence resulting in separation of the right and left ducts.

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Case 10: Abdominal pain and bloating A 32 year old man with Crohn's disease presented with several months of progressive abdominal pain and bloating. His symptoms were related to meals and as a result he had lost significant weight. He had previously undergone ileocolic resection with anastomosis and on this occasion you resect the area of the anastomosis and open the specimen shown below.

1. Describe the specimen shown. The specimen is an opened segment of bowel with neoterminal ileum on the left and an ileocolic anastomosis towards the right. At the anastomosis there is evidence of stricturing with significant submucosal fibrosis and thickening that extends proximally for at least 10 cm. The mucosa overlying the anastomosis is deeply ulcerated. There are also linear ulcers in the mucosa of the ileum. 2. What are the histologic features of Crohn's disease? Crohn's disease is a chronic inflammatory disease characterised by transmuarl involvement with mucosal damage, non-caseating granulomas and fissuring with the formation of fistulas. Crypt abscesses occur but are not specific for Crohn's. Deep ulceration may be adjacent to relatively normal bowel wall indicative of the discontinuous distirbution of the disease. Sarcoid-like granulomas mayy occur in up to half of patients and can be found in any layer of the bowel wall and even in otherwise normal appearing bowel. Deep fissures may lead to fistula formation between loops of bowel or other adjacent organs. Extensive submocosal fibrosis leads to sticture formation 3. What investigations would you perform prior to operation in this man? It is important to confirm the diagnosis of recurrent Crohn's with stricture formation before embarking on resection. This can be done easily by colonoscopy and intubation of the terminal ileum. Colonoscopy also allows assessment of the extent of disease. Further assessment of the small bowel may require enteroscopy, radiologic enteroclysis or MRI (investigational at present). Finally the patients overall fitness needs to be assessed. In particular the effects of malnutrition resulting from poor intake and malabsorption, chronic disease and probable chronic steroid use. Simple assessment is based on serum albumin and measurement of iron stores and vitamin B12. Other nutrients should be measured and replaced as appropriate.

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Case 11: Statistically speaking A 52 year old woman has a 25mm mass in her left breast. It feels malignant and this is confirmed by core biopsy. She has no palpable lymph nodes in the axilla and basic staging investigations are normal. She raises the question of sentinel lymph node biopsy (SNB) to avoid an axillary dissection. Her lymphoscintigram is shown below.

1. What is a sentinel lymph node? The sentinel lymph node is the first node draining a particular anatomical location. The location of a sentinel node is able to be reliably determined by a combination of the injection of a radiolabelled traced and blue dye. The status of the sentinel node is used as a marker of the status of the entire nodal basin. 2. What are the common or important risks of axillary dissection you would discuss? Major morbidity from axillary dissection is uncommon. The problem that many women complain of is anaesthesia or paraesthesia in the axilla, lateral chest wall and medial arm which is related to division of intercostobrachial nerves. Disruption of the long thoracic nerve to serratus anterior or the nerve to latissimus dorsi results in a more significant function deficit. The medial pectoral nerve supplying pectoralis major is also at risk. The rate of clinically significant chronic lymphoedema of the arm is as high as 10-15%. Seroma development in the wound is more common but usually resolves with repeat aspiration. Shoulder stiffness usually responds to physiotherapy and it is part of the breast care nurse's and surgeon's role to discuss appropraiate exercises pre-operatively.

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3. She asks you about the 7% false negative rate. What does the figure mean? The false negative rate means that of all those axillas truely involved 7% will be falsely thought to be negative. It is the reverse 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 make sense of the false negative rate. That is the incidence of involvement 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% of 20%) of all patients will have an incorrectly staged axilla. 4. How would you calculate the sensitivity and specificity for a test? You will need to draw up a table with 4 potential result types. True positives, false positives, false negatives and true negatives Sensitivity equals true positives divided by true positives + false negatives =TP/(TP+FN) Specificity equals true negatives divided by true negatives + false positives =TN/(TN+FP)

Case 12: Pain and lump in the breast A 24 year old woman has been breast feeding for 2 months. She now presents with a painful, red mass in the lower outer quadrant of her left breast. 1. What is the likely diagnosis? Lactational breast abscess 2. What advice would you give her about breast feeding? Continue feeding to encourage drainage of the breast. An abscess develops when there is a relative obstruction to flow from a lobule of the breast related to inspissated material in the ducts. Organisms most likely ascend the duct after gaining entry through the nipple which may be cracked or damaged from feeding. The baby will not be harmed by feeding from this breast and should be fed from the effected side first. If feeding is too painful then the breast should be manually expressed. 3. Outline you management plan for this woman After a thorough history and examination the next investigation should be an ultrasound to sonfirm the presence and size of an abscess. Differentiation from mastitis without abscess may be difficult clinically. Heat packs and massage, particularly in a warm shower, may also help. Analgesia and antibiotics are usually required. Unless the overlying skin is thin and necrotic it is not usually necessary to incise and drain a breast abscess. Rather it is preferable to aspirate it with a large bore needle often with US guidance. This procedure may need to be repeated on a daily basis until the abscess resolves but creates less risk of a milk fistula and cosmetic deformity. The possibility of an inflammatory cancer always needs to be considered although this is unlikely in a lactating woman. As a result she should be followed up with clinical examination and imaging after resolution of the abscess.

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Case 13: Growing neck lump 1. Describe the lesion

There is a hemisperical raised lesion which is deeply purple in colour, 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 disease involving skin. Less likley would be an infected sebaceous cyst. 3. What else would you examine? The skin of the head and neck, complete ENT exam, and other lymph node groups. 4. What do you see? Pigmented skin lesions consistent with melanoma. 5. Now what is your likely diagnosis? Nodal involvement of metastatic melanoma.

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Case 14: View at Laparoscopy Can you identify the structures?

1. What type of retractor is marked by "A"? Nathenson liver retractor 2. What segment of the liver is shown by "B"? Segment 1, under the pars flaccida of the lesser omentum, otherwise known as the caudate lobe. 3. What is under the lesser omental fat at "C"? The region of the gastro-oesophageal junction and the oespophageal hiatus in the diaphragm. 4. What organ is close to letter "D" just out of screen? The spleen 5. Which lobe of the liver is demonstarted by "E"?

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Case 15: Hand pain and numbness This lady has had pain and numbness in the radial three fingers for over 20 years. These symptoms are worse at night time. She ofetn wakes at night and shakes her hands for relief.

1. What syndrome is this typical of? Carpal tunnel syndrome 3. What complication is seen? Thenar muscle wasting. 4. Confirmatory tests? Nerve conduction studies - are always helpful to exclude other diagnoses. 5. Treatment? Conservative - splints, analgesia, treatment of any predisposing cause, steroid injection into and around the carpal tunnel. All of these would be unsuitable in this case because of the significant symptoms and demonstrable thenar muscle wasting. Surgery - Open or endoscopic division of the flexor retinaculum. A 'carpal tunnel release'

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Case 16: Intermittent abdominal pain and a lump A 56 year old man has had several abdominal operations in the past. He presents complaining of a discomfort associated with a small lump which has developed in the midline wound near the umbilicus. 1. What is the likely diagnosis (shown at "C")? Incisional Hernia near the umbilicus. 2. What operation do you think was performed through the right upper quadrant scar? Marked "A" (He says he cant , however it was when he was a baby.) A Ramstead pyloromyotomy for pyloric stenosis. He was the first child in his family, and his father had pyloric stenosis. 3. With the patient lifting his head off the bed, what is marked by "B"? Divarication of the rectii, there has been no incision here.

Case 17: Discharging lump in natal cleft This young man presents with a 12 month history of an intermittently painful and discharging lump at the lower back.

1. What is the likely diagnosis? A pilonidal sinus.

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Case 18: Wrist swelling This lady had a lump on the back of her wrist which was getting bigger and more painful. 1. What is the likely diagnosis?

Dorsal wrist ganglion. Clinical examination would confirm this, showing, a soft fluctuant mass, transillumination, no punctum, and usually fixed to the underlying dorsal wrist capsule. Sometimes they can arise from the extensor tendon sheaths. Ganglionic Cysts of the Wrist----Wheeless' Textbook of Orthopaedics. Case 19: Dead toe This 69 year old man presented worried about the apperance of his toe.

1.Describe the appearance of the toe marked 'A'? This toe is gangrenous. The characteristic :colouration, shrunken prune-like skin 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 paedis artery. 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 and waveform. 4. If there was a strong pulse felt at 'B', what do you think the patients main predisposing condition would be? Diabetes. Demonstrating a predominant microvasculopathy.

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Case 20: Minor head injury This young man fell from his bike 12 weeks earlier. He sustained a minor head injury in that he bumped his head at the point marked by the arrow. He now presents with a painful and pulsatile mass at that site.

1. What do you think has happened? The likely diagnosis is a traumatic false aneurysm of the superficial temporal artery. 2. What treatment would you recommend? Pseudoaneurysm arising from the superficial temporal artery (STA) is very rare and is most commonly caused by blunt trauma. Most pseudoaneurysms of the STA usually present as a painless pulsating mass, with concomitant symptoms according to location, and their size may rapidly increase. The treatment of choice is ligation and resection. Case 21: Abdominal X-ray This Xray was taken in the emergency room for abdominal pain.

1.What prior abdominal operation has the patient had?

Cholecystectomy - probably laparoscopic because clips are less useful at an open operation so are not usually seen.

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Case 22: Subcutaneous foreign body 1. What is the subcutaneous linear mass running along the chest wall?

An axillofemoral by graft.

1. It is not pulsatile. Does this change your diagnosis? Probably not, however this suggests that the by has occluded. Case 23: Lumps under the arm A 59 year old man presents with a painless mass under the left arm. This was first noticed 6 weeks ago and is increasing in size.

1. What is the differential diagnosis? Painless significantly enlarged nodes should raise the suspicion of lymphoma. Others: -Infections : acute - local causes, systemic illnesses -bacterial - gonorrhoea -viral - IM, CMV, measels, rubella, chickenpox -Chronic - HIV, TB, syphilis, fungi -Neoplasms : primary - Hodgkin's disease, non-Hodgkin's, leukaemias Secondary : metastasis -Sarcoidosis -Allergy. 2. What questions would you ask him and what else would you examine? All other nodal groups, abdomen - liver, spleen, ascites, PR exam.

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Case 24: Epigastric discomfort and anaemia An 82 year old lady was anaemic and had recent trouble with epigastric discomfort. She was worried if she would be fit enough for major surgery if something sinister was found in her stomach at endoscopy. This is a view of her duodenum.

1. Describe the appearance of the lesion In the first part of the duodenum there is a shallow ulcer. The edges are smooth, rounded and seem inflammatory in nature. It is difficult to see on this image, but there is no adherent clot, bleeding or visible vessel. 1. What would you do at endoscopy, and what further treatment would you advise? No treatment to the ulcer in the absence of hard signs of bleeding. A biopsy of the gastric antrum for helicobacter pylori and then treat with Proton Pump Inhibitors and H.Pylori eradication if present. Also discontinue NSAIDS, and rescope to confirm healing.

Case 25: Total thyroidectomy This operation was for a follicular lesion.

1. What is the name of the retractor marked 'A'? Jowles retractor See self retaining retractors

2. What is the name of the retractor marked 'B'? Langenbeck's hand held retractor 3. What is the surgeon trying to demonstrate with the Metzenbaum scissors? The inferior right sided parathyroid gland (parathyroid III).

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Case 26: Small bowel obstruction This operation was for a complete small bowel obstruction in a patient whose only prior abdominal operation was an open appendicectomy.

1. What was the cause of the obstruction? A band adhesion, most likely from the prior appendicectomy. 2. What is the usual description given to the area of small bowel here where it was obstructed? The constriction ring 3. What are the risks with this type of small bowel injury? If the ischaemic ring is not too severe often this requires no further treatment. If the ischaemic insult is significant then perforation is possible. Also stenosis if perforation does not occur.

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Case 27: Perianal painful lump A 26 year old man presented with a 5 day history of pain and a lump at the anal verge.

1.What operation has been performed? The history suggests a perianal abscess was the reason for presentation, however there seems to be a soft, non-cutting seton, that has been inserted. So it would seem that an obvious internal opening was found at operation and therfore the abcess was drained and to prevent recurrence of the abscess a seton was inserted. 2. Is it always necessary to find an internal opening when draining an acute abscess? No. Less than a third of these patients will go on to develop a fistula. So creating a false (iatrogenic) internal opening would disadvantage a lot of patients. Case 28: Circular saw injury A 73 year old man presented after an accident in his home workshop. 1.What are the most important factors when considering a finger replant ? 2.Which injuries require replantation: -all thumb amputations -multiple amputated digits -all children -all amputations proximal to the digits -single digits proximal to the FDS insertion Strong contraindications: -significant associated injuries to the torso and head. -extensive injury to the affected limb or to amputated part (degloving, widespread crush) -severe chronic illness precluding transportation or prolonged surgery Relative contraindications: -Single digit amputation, esp distal to insertion of FDP -avulsion injuries -severe degloving injuries -previous injury or surgery to the part -extreme contamination -lengthy warm ischaemia >8hrs (at 4 degrees C >30 hrs) -age -poor rehabilitation potential.

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Case 29: Abdominal pain and diarrhoea. A 32 year old man presented after four days of fever, abdominal cramps and diarrhoea. Due to right sided abdominal tenderness and the possibility of appendicitis a CT was performed.

He says that he occasionally gets crampy abdominal pains, and also suffers t pains in his knees, hips and in his right lower back. 1. What does it show? A right sided colitis. There is confluent thickening of the entire right colon. The mucosa is grossly thickened and protruding into the colonic lumen. 2. What does his plain Xray show? With this history in mind, the xray does show, right sacroileitis. There is loss of the usual t space, and periarticular sclerosis. With all the above clinical information, the diagnosis of inflammatory bowel disease seems likely in this patient. Extraintestinal manifestations in inflammatory bowel disease There are many extraintestinal manifestations in inflammatory bowel disease. Approximately 2% of ulcerative colitis patients will develop primary sclerosing cholangitis, a cholestatic liver disease diagnosed by the appearance of extrahepatic and intrahepatic strictures on a cholangiogram. Primary sclerosing cholangitis is seen more often in ulcerative colitis than in Crohn's disease patients.9 Other hepatic manifestations of inflammatory bowel disease include fatty liver, chronic active hepatitis, amyloidosis, and drug-induced disease from medications used to treat inflammatory bowel disease (steroids, azathioprine, 6-mercaptopurine [6-MP], or sulfasalazine). Erythema nodosum, seen in up to 3% of patients, is characterized by raised, tender, erythematous nodules appearing typically on the extremities. Pyoderma gangrenosum, a rare, ulcerating, and necrotic lesion, is seen in both Crohn's disease and ulcerative colitis. Arthritis usually is seronegative, mono- or pauciarticular, and asymmetric. The large ts are most often affected, and there is no synovial destruction. Ocular manifestations include blurred vision, eye pain, photophobia, and keratitic precipitates. Patients are susceptible to nephrolithiasis from calcium oxalate stones. Patients with uveitis often have HLA-B27, whereas patients with episcleritis and iritis usually do not. Cerebrovascular accidents and other thromboembolic events can result from hypercoagulability secondary to chronic inflammation or to other inherited syndromes such as the factor V Leiden mutation.

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Case 30: An incidental finding During an open cholecystetomy in a 35 year old woman the intern assiting you finds something unusual.

1. What is the abnormality? Meckel's diverticulum. A true diverticulum consisting of all layers of the bowel wall it projects from the antimesenteric side of the distal ileum. It is said to occur in 2% of the population, 2 feet from the ileocaecal valve and be 2 inches long. These figures are approximations only. 2. What is the origin of the abnormality? A Meckel's diverticulum is a rvestigial remnant of the vitello-intestinal duct present during foetal development. It connects the midgut to the embryonic yolk sac during the early weeks of gestation. By 5 weeks placental nutrition is established and normally the ducts degenerates by the end of the 7th week. If this obliterative process is arrested various abnormalities may occur. Meckel's diverticulum is the most common. Other abnomalities include vitelline fistula and vitelline cyst. 3. What would you do at operation? This Meckel's is asymptomatic and not associated with a band. If a band were present it should be divided to prevent bowel obstruction. The Meckel's should also be palpated for any abnormal mass which would than require resection. Assuming there are no visible or palpable abnormalities then the next issue is the patient's age. The risk of complications from Meckel's diverticulum decreases with age. Thus many surgeons would leave an incidental Meckel's in a patient over 30-40 years of age but remove it in patients under 30 years. The proviso for resection is that it must be able to be performed without adding morbidity to the operation being performed. Typically the diverticulum is able to be transected at it's neck and does not require formal small bowel excision with anastomosis. The final consideration is the Meckel's identified at exploratory surgery where no other pathology is identified. In this situation most surgeons would agree that even in the absence of obvious pathology in the Meckel's it should be resected.

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Case 31: A lump in the groin An otherwise fit and well 75 year old woman presents with 6 hours of pain and a lump in the right groin.

1. What is the likely diagnosis? An incarcerated femoral hernia. The contents of the sac are assumed to be strangulated until proven otherwise when a person presents with an acute, painful incarcerated hernia regardless of its location. The presence of a small bowel obstruction suggests a loop of small bowel is involved however an abscence of bowel symptoms does not exclude bowel involvement. It is possible that this is an inguinal hernia however it appears to be arising below and lateral to the pubic tubercle. 2. How would you manage this problem? Initial management includes thorough history and examination. The patient requires fluid resuscitation and analgesia then ugent operative exploration and repair. A plain abdominal xray may confirm small bowel obstruction however it does not significantly alter the mangement based on the clinical situation. A urinary catheter should be inserted to guide fluid resuscitation and decompress the bladder away from the operative field. 3. What operative approach would you use? An acute strangulated femoral hernia should be approached with the probability of requiring bowel resection. Therefore a modified McEvedy approach above the inguinal ligament is preferred to give adequate exposure and allow access to the peritoneal cavity.

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Case 32: Cold feet You are called to see an 85 year old woman in coronary care who has cold feet. Her legs are weak and she has altered sensation. The neurology registrar has already seen her and an urgent MRI was performed. There is no evidence of spinal cord compression. You have arranged an urgent CT angiogram. Two adjacent slices and a coronal reconstruction are shown.

1. What does the CT show? The scan has been performed during the arterial phase of contrast. There is an abrupt cessation of flow within the aorta above the bifurcation. 2. What is the likely cause for her cold feet? A large thromboembolus from a cardiac source had lodged at the aortic bifurcation resulting in complete occlusion. Both legs had become acutely ischaemic. 3. What are the options for management? To save this womans legs and life she needs urgent revascularization. The option of palliation may be appropriate in the patient who has other significant acute medical problems of a life threatening nature. The initial approach is to perform bilateral groin exploration and proximal embolectomy. If this is unsuccessful the decision is made to proceed to open aorto-iliac embolectomy and possible aorto-bifemoral by. The third option which may be preferred in an unwell patient is axillary-bi-femoral by grafting. The final step should be prophylactic calf fascitomies as she has had significant leg ischaemic time.

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Case 33: Flat footed A diabetic man is referred to you because of a non healing ulcer on the sole of his foot.

1. Describe the appearance of the ulcer and foot. Classically described as a Charcot's foot there is aevidence of gross structural deformity in this foot with flattening of the plantar arch and abnormal weight bearing areas. There is a chronic ulcer with rolled edges overlying the base of the 5th metatarsal. The toes are clawed and no longer weight bearing. The skin of the foot and leg is dry and cracked. 2. What features can you see and deduce that predispose to development of this ulcer? This is a neuropathic foot. The structural changes imply motor neuropathy with loss of the intrinsic muscles of the foot. The location of the ulcer suggests sensory neuropathy. The skin changes may be a result of peripheral arterial occlusive disease but may also be manifestations of autonomic neuopathy with resultant abnormalities in blood flow and sweating leading to dry, cracked skin prone to infection. The most likely cause for this appearance in western society is longstanding diabetes mellitus. As such there is likely to be micro and macrovascular occlusive disease as well as defects in immune function that contribute to skin ulcer development, sepsis and delayed healing.

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Case 35: Painful left arm 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 operation has she had? Left first rib resection. 2. What syndrome did she suffer fom? Thoracic outlet syndrome. 3. What anatomic abnormality predisposes to the syndrome? A cervical rib or band.

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Case 36: Trouble getting a cholangiogram. You have had difficulty dissecting laparoscopically a small contracted, chronically fibrosed gallbladder. You have now performed a cholangiogram and cannot get the contrast to flow proximally to show the intrahepatic ductal anatomy. Here is your cholangiogram.

1. What manoeuvres can you use to get the contrast to flow 'up-hill'? 1. Tilt the patient head down 2. Use more contrast 3. Gently apply pressure over the region of the lower CBD with the side of a grasper to increase resistance to flow. 2. You realise what the problem is at this stage. What does your cholangiogram show? The cholangiogram demonstrates cannulation of the CBD and all contrast is flowing down and into the duodenum. This is evidenced by a tapering of the CBD by the Olsen-Reddich clamp with no proximal flow, and no apparent cystic duct. 3. What structure is marked '1'? The pancreatic duct 4. What is happening at '2'? Free flow of contrast into the duodenum

This case presents one of the arguments in favour of routine intraoperative cholangiography: Imagine that the cholangiogram was not performed. The surgeon would have clipped and divided the common bile duct at this level, dissected superiorly behind the bile duct (falsely assuming that this was the gallbladder) and into the porta - only at this stage when confronting further ductal strictures would the surgeon be alerted to his mistake. The resulting biliary injury would potentially be much worse. Also associated hepatic vascular injury could confound the problem.

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Case 37: A black spot A 40 year old woman presents with this black spot on her back. Her husband thought it looked nasty and wasn't sure if it had been there before. 1. What is the likely diagnosis and the differentials? Benign naevus Malignant melanoma, pigmented BCC, Spitz naevus, seborrhoeic keratosis 2. What features on examination would make you suspect malignant melanoma? A - asymmetry of shape B - border irregular and indistinct C - colour variation within the lesion D - diameter greater than 6mm E - environment of the lesion, ie its appearance in relation to the patient's other pigmented lesions, presence of satellite nodules and regional nodes 3. How would you manage this lesion? If a patient is concerned about a lesion there is little to justify not making a definite histologic diagnosis even if it appears benign. A lesion that can be excised and closed readily should be taken with a margin of 1-2 mm. If melanoma is discovered the site will require re-excision but with margins determined by the thickness of the melanoma. A benign lesion will not require re-excision. A large lesion in a cosmetically difficult area or where simple closure may not be possible should have a punch biopsy taken to determine further management. Case 38: Scalp lesion Slowly growing in size, this lesion also has had two episodes of becoming painful and red.

1. What is the likely diagnosis? Sebaceous cyst 2.What characteristic features on examination would make your diagnosis? 1.Punctum. 2.Soft fluctuant consistency 3.Fixed to overlying skin from which it has derived 4.Not fixed to deeper structures and not hard (like and Osteoma) 3. How would you manage this lesion? Simple excision including an ellipse of skin to remove the punctum.

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Case 39: Discomfort between the shoulder blades. For ten years this 65 year old lady has noticed a lump just to the right of the midline in the interscapular area. The lump has not grown, is not particularly tender, but causes pain when lifting.

1. What is the likely diagnosis? Intramuscular lipoma

2.Which two criteria would you consider most important when deciding to preoperatively core biopsy this lesion under suspicion of being a sarcoma? 1. Size - greater than 5cm's requires consideration of preoperative biopsy and careful review of the imaging. 2. Position - Deep to the deep fascia. This again raises the concern of sarcomatous origin. Case 40: Abdominal distension. This man was being treated for disseminated gastric cancer. He had widespread peritoneal disease.

1. What are the two likely causes for such an appearance at the umbilicus? 1. Umbilical hernia. 2. Sister Joseph Nodule - of tumour at the umbilicus from peritoneal spread 2. If this was incarcerated small bowel, how would you proceed? Open repair with possible small bowel resection if required. Tha ascites should be drained through a separate drain to allow the wound to heal before establishing an ascitic fistula.

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Case 41: Small dorsal foot swelling. This small lump had been present for several years, slowly getting bigger and causing discomfort wearing footwear.

1. What should you examine before operating on this patient? Pulses Sensation - generally and in distribution of the affected nerve if a neuroma Other lumps - general exam ?neurofibromatosis etc 2. Differential diagnosis? Ganglion Giant cell tumour Neuroma.

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Case 42: Weight gain A 64 year old man returns for follow up 6 months after resection of a gastric cancer. He has been putting on weight but hasn't been eating well and is still having abdominal pain. A CT has been performed.

1. What does the CT show? Multiple hypodense lesions within the liver consistent with metastases. There is also a significant volume of ascites. 2. What would you look for on examination? General inspection looking for cachexia, anaemia, or jaundice. Examination of the left supraclavicular fossa for lymphadenopthay (Trossier's sign). Abdominal examination for ascites and hepatomegaly. Also examine for a Sister Joseph's nodule at the umbilicus. 3. What staging investigations would you arrange prior to resection of a gastric cancer? Confirm the diagnosis with endoscopy and biopsy. Also assess size and site. Further T staging with endoscopic ultrasound (EUS) is of limited value in altering management. Nodal staging with EUS is not sensitive or specific enough to be universally utilised. A CT scan of the chest and abdomen is mandatory to look for distant metastases. Laparoscopy with cytology is used to exclude serosal involvement, sextensive nodal metastases or malignant ascites.

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Case 43: Rectal bleeding A 32 year old man presents with pain and bright red rectal bleeding. He has seen the blood on the paper and has been constipated for the last 2 weeks.

1. What does the photo show? A posterior midline anal fissure. From the short history - an acute fissure. 2. What are the management options? Initially conservative. Attention to treating constipation or diarrhoea. Simple analgesia, stool softeners, bulking agents, patient advice. Then topical GTN paste. 3. What is the basis of pharmacologic treatment? GTN paste is thought to act by causing relaxation of the internal sphincter muscle. The hypertonicity of the internal sphincter is thought to perpetuate the fissure by causing ischaemia therefore preventing healing. The spastic sphincter is also thought to explain the prolonged severe post defaecation pain theat these patients suffer. GTN paste can cause headache if used to excess so the patients should be warned.

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Case 44: Headache Can you name the structures on this lateral skull X-ray.

1. 2. 3. 4.

Sella Turcica (pituitary Fossa) Hard Palate C2 or Dens (Odontoid process) Pterion, or course of the middle meningeal artery. Also the thinnest part of the skull. Therefore an external blow to this area can fracture the skull, tearing the underlying middle menigeal artery and causing a rapidly expanding, and life threatening, extradural haematoma.

5. Sphenoid sinus. It is through this sinus that a transnasal, trans-sphenoidal approach is taken to the pituitary fossa for a pituitary adenoma. 6. Temporal bones - overlapping 7. Frontal sinus. Case 45: Laparoscopic finding This laparoscopic image was captured during an appendicectomy. This is a view of the left inguinal region. 1.What is the abnormality shown? A left sided indirect inguinal hernia. 2.What would you do at laparoscopy? Take a photo. Do nothing more if the patient is asymptomatic.Inform the patient. 3.What is the structure running medially and inferiorly? The round ligament (this was a female patient). In the male this would be the Vas Deferens.

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Case 46: Groin mass A 54 year old man is having a CT abdomen for investigation of a right renal mass. The radiologist calls you concerned about an unrelated finding in the right groin.

1. What does the CT show? There are contrast filled loops of small bowel in the left groin adjacent to the penis consistent with an inguino-scrotal hernia. 2. Does the CT appearance acutely concern you? The bowel contains contrast indicating that it is not obstructed. It is also not distended or thick walled and there is no adjacent fluid. The CT therefore shows an uncomplicated hernia. 3. Outline your management of this man? Full history and examination to confirm a reducible, uncomplicated hernia. Then educate him about the nature of the condition and signs of complications warranting return to the emergency department. Arrange for follow-up or repair as appropriate on an elective basis.

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Case 47: Right upper quadrant pain A 62 year old man with known gallstones presents with 3 weeks of progressive right upper quadrant pain. The pain has been constant but he has not had a fever.

1. What does the CT show? An ill defined and heterogenous mass is present in the fundus of the gallbladder. There is evidence of calcification however this is suspicious for carcinoma of the gallbladder. There is no liver invasion or metastases. Likewise there is no ascites. 2. How would you manage this condition if you discovered it at the time of laparoscopic cholecystectomy? Gallbladder carcinoma is rarely discovered pre-operatively at a resectable stage. If during laparoscopic cholecystectomy the gallbladder appears suspicious for carcinoma the laparoscopic approach should be abandoned. There are two options. The first is to abandon surgery to allow staging and referral to an appropriate specialist centre for management. The second option is to convert to open surgery and proceed to definitive resection. This would involve en bloc resecction of the gallbladder and the adjacent liver and dissection of nodal tissue at the porta hepatis.

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Case 48: Dark urine A 28 year old man was found unconscious at home after an overdose of heroin. A catheter was inserted and dark urine drained. He was not jaundiced.

1. What is the cause of this urine appearance? Rhabdomyolysis with myoglobinuria. 2. What other specific features would you examine for? Significant muscle necrosis may lead to compartment syndrome if the muscles involved are contained within a tight fascial compartment. There examine all muscle groups for tenderness and tenseness. Also look for pain on ive stretch of the muscles. The presence of distal pulses does not exlude compartment syndrome. If there is any concern then compartment pressures can be measured simply with a needle attached to a pressure transducer. 3. What specific investigations would you request? Assessment of the degree of muscle necrosis can be made with measurement of the creatine kinase (CK) level. The renal function and electrolytes should also be checked as the major systemic consequence of rhabdomyolysis is renal failure. 4. Outline your plan of management for this problem? Aggressive fluid resuscitation aiming for a urine output of 1 ml/kg/hr. Correction of electrolyte abnormalities as they are detected. Alkalinising the urine with oral or IV bicarbonate may improve the solubility of myoglobin and prevent it's deposition within the renal tubules. Liaise early with a renal physician or the intensive care unit if renal replacement therapy may be required. Any muscle compartments suspected to be developing raised pressure should be managemd with fasciotomy. If fasciotomy is not performed then the muscles should be reviewed regularly to detect development of problems early.

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Case 49: Loin to groin pain A 73 year old man presented to the emergency department with right loin pain radiating to the groin. He is previously fit and well but is now pale and sweaty. The emergency department have arranged a KUB xray but as he has not voided a urinalysis has not been performed.

1. What does the xray show? There is no radio-opaque density along the line of the right ureter. There is however calcification in the wall of an abdominal aortic aneurysm.

3. What would you tell the emergency department resident? To call a vascular surgeon and to always consider the diagnosis of ruptured AAA before ureteric colic in the future. This applies particularly to elderly men. Blood tracking in the retroperitoneum may mimic the pain of a ureteric calculus.

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Case 50: Right upper quadrant abdominal pain, fever and jaundice. A 73 year old man presented to the emergency department with right upper quadrant abdominal pain, fevers with rigors, and had noticed his urine the colour of tea before you put milk in it.

1. Right upper quadrant abdominal pain, fever and jaundice. Whose triad is this? Charcot's triad 2. What is this investigation called? MR - magnetic resonance cholangiopancreatography 3. Can you name the structures 1- 7? 1.Nasogastric tube 2.Left hepatic duct 3.Lower common bile duct with stone in lumen 4.Pancreatic duct 5.Cystic duct 6.Gallbladder 7.Right anterior and posterior sectoral ducts. 4. Can you see anything else near the 3 arrowhead? A stone in the bile duct.

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Case 51: Jaundice A 72 year old man presents with progressive jaundice over 2 weeks. This is associated with dull right upper quadrant pain. His liver function tests are shown below.

1. What are the clinical features of obstructive jaundice? Obstructive jaundice is characterised by the abscence or reduction of bile flow from the bile canaliculi into the bowel. As such bilirubin and bile salts are reabsorbed into the blood, stain tissues and are excreted in the urine. As such the clinical features are jaundice, pale frothy stools (steatorrhoea), dark urine and generalised pruritus. 2. What is Courvoisier's law and the pathologic basis for it? Courvoisier's law states that in a jaundiced patient the presence of a palpable gallbladder means that gallstones are unlikely to be the cause. It is important to that the converse is not true and an impalpable gallbladder does not mean that stones are the cause. The basis for this is that a gallbladder containing stones is likely to have been chronically diseased and subject to repeated, although possibly subclinical, episodes of cholesytitis. This results in extensive fibrosis of the gallbladder wall which is then unable to distend when obstructed. 3. What are the differential diagnoses for obstructive jaundice? As with all hollow tubes obstructive may be related to an intraluminal, intramural or extraluminal pathology. Intraluminal pathology is most commonly gallstones in the common bile duct. In south east Asian populations parasitic worms may infest and obstruct the bile duct. Intramural pathology includes benign and malignant strictures of the bile duct. Benign strictures may relate to previous surgery or other intervention, primary sclerosing cholangitis or ischaemia. Extramural pathology includes benign causes such as compression by a stone in the neck of the gallbladder (Mirizzi syndrome), and malignant causes such as carcinoma of the head of the pancreas or extensive nodal disease at the porta hepatis.

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4. What imaging may help determine the diagnosis? The first line is ultrasound to examine for dilated intra and extrahepatic bile ducts. Ultrasound may also show stones in the gallbladder, liver metastases and occasionally may be able to show pathology in the distal bile duct. CT scans are useful to examine for pancreatic masses, large portal nodes and liver metastases but are not reliable for examining the bile ducts unless performed as a CT cholangiogram. MR is an excellent, non-invasive, way of examining the bile ducts and pancreas. ER is invasive but allows therapeutic intervention but also gives excellent images of the bile ducts and alows visualisation of the ampulla of Vater.

Case 52: Rectal bleeding A previously fit and well 13 year old boy presented with massive bright red bleeding per rectum. He had mild lower abdominal discomfort only and after resuscitation a laparotomy was performed.

1. How does this abnormality cause bleeding? A Meckel's diverticulum may contain heterotopic gastric mucosa. This mucosa secretes acid leading to ulceration of the adjacent ileal mucosa. 2. What imaging studies may make the diagnosis pre-operatively? Imaging for small bowel bleeding such as a nuclear medicine labelled red cell sna or mesenteric angiogram may localise bleeding to the distal small bowel. This suggests A meckel's as the likely cause in the paediatric population. A nuclear medicine Meckel's scan can also be performed. In this instance the isotope is taken up by gastric mucosa. As such it will identify the culprit Meckel's but will not detect a Meckel's diverticulum without heterotopic gastric mucosa. 3. How would you manage this problem at operation? In this instance the Meckel's need to be resected as does the bleeding ulcer in the ileum. As such a formal small bowel resection with anastomosis is usually required.

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Case 53: Fever and jaundice A 56 year old woman is itted with jaundice for investigation. After 3 days on the ward she spikes a fever.

1. What features on this observation chart would concern you? The patient is febrile and tachycardic. 2. How would you diagnose sepsis and its related syndromes? There is now worldwide consensus on the clinical definition of sepsis. The systemic inflammatory response syndrome (SIRS) is defined clinically by the presence of two or more of: - Heart rate >90 bpm - Respiratory rate > 20 bpm or PaCO2 <32 mmHg - Temperature >38°C or <36°C - WBC >12,000 cells/mm3, <4000 cells/mm3, or >10 percent immature (band) forms Sepsis is then defined as the presence of SIRS with a documented source of infection. Severe sepsis is sepsis with evidence of hypoperfusion or hypotension (systolic BP <90 mmHg or > 40 mmHg drop from the patients usual BP) resulting in organ dysfunction such as lactic acidosis, oliguria or altered mental state. Septic shock is the state where severe sepsis is no longer responding to simple fluid resuscitation and more invasive s are required such as inotropes or vasopressors. Multiple organ dysfunction syndrome (MODS) refers to the presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention. MODS may then be classified as either primary or secondary.

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Case 54: Random abdo film

1.What operation has this lady had? Right sided varicose vein surgery. High ligation of the sapheno-femoral junction with ligation of all the secondary divisions of the long saphenous triburies at this site (they obviously used some haemoclips) and vein stripping.

Case 55: Skateboard Accident

1.Describe the fracture There is a fracture of the distal tibia. The fracture line forms a partial spiral. There is a 1cm antero-medial displacement of the distal part. 2.Where else may there be an associated injury? These films do not show the proximal fibula which may be fractured.

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Case 56: Femur Fracture This man fractured his mid femoral shaft 9 days ago.

1.Describe the wound There is a long antero-lateral incision in the right thigh, exposing a large debrided area of fascia lata and underlying quadriceps muscle. 2.What has happened to require such radical debridement? Necrotizing infection 3.Do you think this wound is suitable for a Vacuum dressing? Not acutely, the incidence of bleeding is greater if applied early. May be suitable for Vacuum dressing in a day or two.

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Case 57: Motor Vehicle Accident A 29 year old man was hit on the drivers side when another car failed to give way.

1.Is this a normal xray?

The areas that are shown are normal

2.Is this an adequate xray?

No

3.What is shown by number '1' ?

The spinous process of C2 vertebrae

4.What is shown by number '2' ?

The verterbral body of C5 vertebrae

5.What is shown by number '3' ?

The spinolaminar line

6.What is shown by number '4' ?

The posterior vertebral line

7.What is shown by number '5' ? 8.What is this view called?

Prevertebral soft tissue plane 'Swimmers View'

9.What anatomical area does it attempt to show? particular C7 and T1.

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The cervico-thoracic junction, in

Case 58: Right iliac fossa pain and a mass A 62 year old woman refused to see a doctor for more than a week despite abdominal pain. What began as central abdominal cramp then settled in her right lower quadrant.

1.Whats wrong with this picture? There is a large inflammatory mass in the right iliac fossa containing fluid and gas locules. This would be consistent with a locally perforated appendix. 2.Treatment options? If seen early operative intervention, after more than a week a percutaneous drain is often successful at settling the septic process (presuming the intra-peritoneal sepsis is localised to the right iliac fossa) 3.What procedure has been performed? A radiologically inserted percutaneous drainage catheter. This catheter used here was a wide bore catheter which also had an irrigation lumen.

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4.Name the radiological investigation performed here? Fluoroscopic tubogram. 5.Possible explanations for this appearance? An appendicoel base which has necrosed causing free communication between the collection and the caecum, or the radilogically placed catheter has been inadvertently placed through the right colon. In either case leaving the catheter until a controlled fistula track is establised then removing the catheter and allowing the track to close is probably the best course of action. Case 59: Operative technique This is an excerpt of operative video recorded through the laparoscope. (see the attachment on your left hand below to play the video). 1.What is the procedure being performed? Establishment of pneumoperitoneum with the 'Visiport' 2.What are the risks of this technique? Bleeding from the inferior or superior epigastric artery or visceral damage, including small bowel or colonic injury. Case 60: The difficult PEG tube insertion This is an excerpt of operative video recorded through the laparoscope. The procedure is a laparoscopically assisted PEG tube insertion. When the laparoscope is withdrawn you can see the other operator (Mr Richard Cade) who is similtaneously performing an gastroscopy. (see the attachment on your left hand below to play the video). 1.What would be the indication for this procedure being performed? Difficulty localising the stomach at an attempted percutaneous approach. Which would be inability to indent the stomach with digital pressure on the abdominal wall - seen at endoscopy, and failure to transilluminate with the scope - seen through the abdominal wall skin. 2.What are the risks of blindly attempting PEG tube insertion when stomach localisation is difficult? Visceral perforation, bleeding etc. Also trans-colonic tube placement.

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Case 62: Painful wrist Can you name the structures on this carpal bone xray?

1.A? Hook of Hamate 2.B? Capitate 3.C? Pisiform 4.D? Styloid process of ulna 5.E? Distal radial epiphysis 6.F? Scaphoid.

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Case 63: Sudden abdominal pain A 52 year old man presents with sudden onset severe upper abdominal pain. He is tachycardic and has a rigid abdomen. You discover that he has recently been taking indomethacin for a sparined ankle.

1. What does the xray show? Free gas under the right hemidiaphragm outlining the liver. 2. What findings on examination would suggest the diagnosis before xray The presence of a perforated viscus and peritonitis is suggested by the rigid abdomen. Free gas may be detected by percussion over the right upper quadrant finding a loss of the area of normal liver dullness. 3. How would you manage this man? Fluid resuscitation, intravenous antibiotics and intravenous proton pump inhibitors should be istered. Operative management is then the standard of care. Traditionally this involves an upper midline laparotomy with identification of the site of perforation (most commonly the anterior wall of the first part of the duodenum). The perforation is then patched with a pedicle of omentum surtured over the defect. No attepmt is made to directly close the defect. The abdomen is then thoroughly lavaged with sevela litres of warm saline. Increasing experience is being gained with laparoscopic management of perforated duodenal ulcers. The principles are the same as with open surgery. A select group of patients may be suitable for non-operative management. This is because the perforation often seals spontaneously with omentum becoming adherent to the duodenum. The patient must be stable with no peritonitis and no significant comorbidities. A contrast swallow should be performed to confirm no ongoing leak. A nasogastric tube should be inserted and the patient kept fasted. Intravenous antibiotics and PPI should be continued. The patient requires frequent re-evaluation to allow early detection of any deterioration.

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Case 64: CT angiogram A 72 year old man is being worked up for management of an asymptomatic AAA. He has a CT angiogram with 3D reconstruction shown below.

1. What is the main limitation of traditional angiography for assessment of anurysmal disease? Angiography involves rapid injection of intra-arterial contrast with fluoroscopic screening. In digital subtraction angiography a preliminary film is taken and then subtracted from the angiogram film of the same body region. This provides clear definition of the arteries involved without background bone and soft tissue images. The major limitation is that the contrast demonstrates the lumen of the vessel only. As such in aneurysmal disease it may dramatically underestimate the true diameter of an aneurysm lined by extensive mural thrombus. 2. Identify the arteries A to E A - splenic artery B - superior mesenteric artery C - common hepatic artery D - right renal artery E - left common femoral artery 3. Which midline visceral artery appears absent and why? The inferior mesenteric artery is not seen. This is because it is often occluded or small in the setting of a large AAA with atherosclerosis and mural thrombus involving the origin of the IMA. If no contrast is in the artery then it will not be seen using this imaging technique.

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Case 65: Incarcerated hernia You are performing an emergency laparotomy on a 47 year old diabetic man who presented with a painful, incarcertaed incisional hernia. The picture below shows the important operative findings.

1. What does the photo show? There is a segment of small bowel that is obviously non-viable and will require resection. It appears well demarcated. The proximal bowel is mildly dilated. The distal extent is not well seen. There is a long length of normal bowel visible. 2. How would you manage the hernia defect which measures 8cm in diameter? In the elective setting a hernia of 8 cm would usually be managed with a mesh as it is unlikely to be closed with simple suturing without significant tension. In this setting where the small bowel requires resection and anastomosis there is an increased risk of mesh infection. It must be ed that the primary aim of this operation is to save the patient from a potentially lethal problem. A residual hernia could be managed at a subsequent operation. The decision of whether to use mesh or not will depend on assessment of the risk of infection and the patients ability to tolerate a mesh infection. This diabetic patient has an additional risk factor for wound infection. With modern meshes the risk of infection is high Also modern antibiotics often allow mesh infection to be managed without removal of the mesh. Therefore if the bowel has not perofrated it is reasonable to use mesh to repair this hernia.

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Case 66: Abdominal pain in the elderly A 76 year old woman presents with abdominal pain. She is tachycardic, pale and has lower abdominal tenderness.

1. What does the CT show? There is a loop of bowel which is thick walled. The luminal contents contain locules of gas however some locules appear to extend into the wall of the bowel. Intramural gas is suggestive of ischaemic bowel. Importantly the gas locules are not only in the antidependent parts of the bowel wall. 2. What is the likely underlying cause? Ischaemic bowel may be due to arterial pathology, either embolic occlusion or thrombosis of the superior mesenteric artery or its branches. Mesenteric venous occlusion can also lead to ischaemia which typically takes longer to develop and is usually diagnosed late. Extrinsic factors such as stranulation ina an internal hernia, bands and volvulus may also lead to segmental ischaemia. 3. How would you manage this woman? After resuscitation she requires urgent exploratory laparotomy. She and her family should be aware of the potential poor prognosis and the unsalvagable situation of whole gut infarction.

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Case 67: Halitosis A 72 year old woman presents complaining of bad breath. She also finds that food she has eaten hours earlier occasionally refluxes into her mouth.

1. What does the xray show? This barium swallow demonstrates a pharyngeal pouch. This is a pulsion diverticulum at the junction of the pharynx and upper oesophagus. 2. What other clinical features would you ask about and look for? The history may include pain and dysphagia related to cricopharyngeal spasm. Regurgitation when the patient is supine may lead to aspiration, chronic cough or lung abscess. There may also be a lump in the neck which typically presents on the left. Rarely a carcinoma may develop within the pouch and therefore regional nodes should be assessed. 3. What are the options for management? This problem usually occurs in the elderly and a conservative approach may be justified in the infirm or demented patient. Operative options include an open procedure through the left neck. A cricopharyngeal myotomy is performed and the sac excised or plicated. Endoscopic management is increasingly popular. This is easiest in the edentulous patient where exposure of the pharynx may be excellent. An endoscopic linear stapler-cutter is used to simultaneously divide the cricopharyngeus and open the pouch into the oesophagus. 4. What is the underlying pathology and key to successful treatment? The underlying problem is cricopharnygeal spasm leading to high intraluminal pressures above the upper oesophageal sphincter. This leads to progressive development of a diverticulum through the area of relative weakness in the posterior wall of the lower pharynx (dehiscence of Killian).

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Case 68: Inguinoscrotal hernia A 72 year old man with COPD has been tolerating a large right inguinoscrotal hernia for many years. He now finds that it is limiting his mobility and causing significant discomfort.

1. What concerns do you have for hernia repair in this man specifically? This massive hernia obviously contains a significant volume of bowel. It may be difficult or impossible to return it to the true abdominal cavity. It will certainly lead to compromised ventilation from splinting of the diaphragm. In this man with COAD it could lead to respiratory failure and the back up of intensive care would certainly be required before attempting repair. 2. How would your technique for repair vary from your standard open approach? Repair of this hernia will require major surgery with adequate planning of the surgical technique and peri-operative care. Complete reduction of the hernia may require laparotomy and a "relaxing" incision in the midline repaired with mesh to accomodate the bowel. Alternatively implantable tissue expanders or even controlled pneumoperitoneum have been used to gradually "stretch" the abdominal wall to increase its volume prior to repair of similar massive hernias.

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Case 69: Urgent underwater seal-drain Whilst working at a small country hospital you are faced with a 32 year old man involved in a farming accident. He has been charged by a bull and one horn has penetrated his right chest. An xray shows haemo-pneumothorax. You have inserted an intercostal catheter but the hospital does not have a modern drain chamber to connect it to. The nurses find some old glass chambers and rubber tubing that they used when the hospital was better funded 20 years ago. 1. How would you connect the tubing to create a standard 3 chamber system with 20 cm water suction? The first chamber is simply to drain any haemoserous fluid. The second provides an underwater seal to allow air to readily escape the chest but not reflux back in. The third chamber allows control of negative suction pressure being applied to the lung and pleural cavity. By altering the height of the column of water the negative pressure within this chamber that is transmitted to the chest can be altered.

2. What is the significance of bubbles appearing in chamber A on the drain above? Chamber A is the suction chamber therefore bubbles simply mean that it has been connected to suction. The air enters the chamber through a vent to atmosphere. In contrast bubbles appearing in chamber C, the underwater seal chamber, indicate air escaping from the chest through the ICC. Initially this occurs as the lung re-expands and the pneumothorax is evacuated. If these bubbles persist, and are best demonstrated on coughing, then this indicates ongoing airleak from a bronchopleural fistula. 3. What is the significance of "swinging" and where would you look for it? Swinging represents the pressure changes occuring within the chest with normal respiration. These pressure changes are transitted along the tubing and may be seen as swinging of any fluid contained within the tubing. Swinging can also be seen as the fluid level in chamber C alters. It simply indicates that the system is patent and not occluded.

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Case 70: PR bleeding A 62 year old woman had been becoming tired lately. Her local doctor noticed she was anaemic, with a microcytosis consistent with iron deficiency. She had noticed a change in her usual bowel habit and some blood in her bowel motion recently.

1.What are the two abnormalities? Significant blood coating the rectal mucosa. There is also a small rectal polyp at the 1 O'Clock position. This small volume colonic bleeding, which has this characteristic colour, usually heralds a significant colonic cancer more proximally. 2.Do you think it explains the blood in the lumen? Probably not, the lesion, as visualised, has no demonstrable bleeding. It is however of a significant size and has the gross appearance of an adenomatous lesion. 3.Describe the lesion There is a circumferntial stenosing lesion which narrows the colonic lumen. It is irregular, craggy, with a small lumen centrally, also deep inside this lumen can be seen a small bleeding area. The lesion also has evidence of a mucous discharge over its surface. 4.What are the options for confirming that the remainder of the colon is clear of polyps or synchronous tumours? 1.Barium enema 2.CT colonography 3.MR colonography 4.Ontable colonic washout and colonoscopy (antegrade or retrograde) 5.Less sensitive is palpation at laparotomy.

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Case 71: Punch to the face An 18 year old young man had been drinking with mates when an argument became heated. He was punched in the face.

1.What is the abnormality? Fractured mandible. There is a displaced fracture at the angle of the mandible on the left side. It is difficult to see on the view if there is a corresponding fracture on the other side. 2.Where is the fracture? There is a displaced fracture at the angle of the mandible on the left side. 3.The patient notices numbness on the lower lip on the ipsilateral side. What has happenened? It is likely that the patient has injured the inferior alveolar nerve on that side as it travels in the mandibiular canal. The terminal branch of the is nerve (the mental nerve) exiting from the mental foramen is sensory to that side of the chin and lower lip.

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Case 72: Fall from bed An 82 year old lady who had been managing quite well at home was itted to hospital acutely unwell with presumed pneumonia. She was confused and restless. Just after midnight she was found by the nurses on the floor next to her bed. This was the xray taken after the incident.

1.What does the xray show? A pertrochanteric fracture of the right hip. Also quite osteopaenic bones. There are saftey pins in what is probably an incontinence pad. 2.What measures can you take to prevent in-hospital falls? There are many. See the link below for a simple summary. Importantly is the realisation of the significant harm that they can cause (both morbidity and mortality) and identifying the high risk patient.

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Case 73: Soiling A 52 year old man complains of faecal incontinence. He has difficulty ing stool and finds that he needs to wear a pad. Occasionally he has noted blood and mucous on the pad. Colonoscopy is normal but whilst he is sedated you examine him further.

1. What does the photo show? The rectal wall has been grasped with Babcock forceps to demonstrate full thickness circumferential rectal prolapse. 2. What are the management options? Conservative measures include explanation of the problem to the patient as wells as dietary and toilet habit modification. Assessment of the patients fitness for surgery, their bowel habit and their sphincter integrity is essential when planning further treatment. Operative intervention may be via either a perineal or an abdominal approach. Perineal options include rectal mucosal resection and plication of the muscle wall, a DeLorme's procedure, or a full thickness proctosigmoidectomy with anastomosis, an Altmeier procedure. Thiersch wire encircelment of the anus is no longer performed because of the high rate of sepsis and erosion. Abdominal procedures include mesh rectopexy (Ripstein procedure) or sigmoidectomy with rectopexy which is useful for constipated patients. Rarely complete faecal diversion with colostomy may be required to manage faecal inconinence.

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Case 74: Black toe A 72 year old diabetic man presents complaining of pain in his foot.

1. What does the photo show? Gangrene of the first and second toes that is long standing and well demarcated. It is largely dry and stable however there are some moist areas at the base of the second toe. The remaining foot has dystrophic skin and nails indicative of chronic ischaemia. 2. What are the principles of management? Control of sepsis, investigation and management of underlying occlusive arterial disease, cardiovascular risk factor modification and wound management. 3. How would you manage these toes? Swabs should be taken for microbiologic examination and broad spectrum intravenous antibiotics commenced. The toes should be allowed to dry and this may be facilitated by betadine gauze dressing which applied slightly moist and allowed to air dry. The foot should not be wrapped. A single piece of gauze should be placed between all the toes to separate them and allow the web spaces to dry.

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Case 75: Malignancy A test has been performed to stage malignancy.

1. What is the investigation? A whole body nuclear medicine bone scan 2. What are the findings? Interestingly an old healing hip fracture.

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Case 76: Vomiting, abdominal pain, anaemia and weight loss You have been referred this patient from the gastroenterology team at your hospital. This woman was 61 years old and had suffered vomiting, crampy abdominal pains, and noticed weight loss over the past 3 months.

1. What investigation have the gastro team performed for you? A small bowel Barium Meal and follow through. 2. What are the findings? There are grossly dilated proximal small bowel loops. There is an irregular cut-off in the left upper quadrant which appears to be a shouldering mass obstructing the lumen. There are also Filshe clips on both fallopian tubes. 3. What is the differential diagnosis? A small bowel tumour. Primary or secondary - eg melanoma, lymphoma or adenocarcinoma. Crohns stricture. 4. You suspect that this may be the uncommon diagnosis of a small bowel cancer. Where at laparotomy would you look and feel to assess for metastatic spread? All peritoneal surfaces, the local mesenteric nodes. The liver, the rest of the small and large bowel, and importantly the ovaries for evidence of transcoelomic spread. 66

Case 77: Laparoscopic technique This is an excerpt of operative video recorded through the laparoscope. The procedure is a laparoscopically inserted gastric band. (see the attachment on your left hand below to play the video). 1.What is the procedure being performed? Insertion, under vision, of the 5 mm Nathanson liver retractor. 2.What are the risks associated with the use of this instrument? Difficult insertion, liver trauma (haematoma, laceration, infarction), other visceral injury esp myocardial injury if the diaphragm is penetrated.

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Case 79: Pancreatitis A 79 year old woman is itted with 18 hours of epigastric pain and vomiting. Her amylase is 3769 and lipase is 6023. Her temperature is 39.2 degrees and bilirubin is 76. An ultrasound is followed by a CT scan (shown below). 1. What is the likely cause for her pancreatitis based on the CT?

There is a large laminated stone within the gallbladder (B) and a column of similar but smaller stones seen within the common bile duct (A). This is the most likely cause of her pancreatitis. Click on the image for assistance 2. How would you determine the severity of her pancreatitis? There are mulitple scoring systems for predicting the severity and outcome of an attack of pancreatitis. Widely used clinical systems include the Ranson score, Glasgow score and APACHE II. Measurement of C-reactive protein as a guide to the severity of systemic inflammation has also been validated as a predictor of severity. There are also imaging scores based on CT (Balthazar computed tomography severity index CTSI) or MRI of the pancreas. These examine for extent of oedema, necrosis and peripancreatic inflammation. Basic investigations (liver function, calcium, CRP, FBE, glucose and renal function) should be measured on all patients. In those with suspected severe pancreatitis further investigations should be directed at detecting or excluding complications such as sepsis and respiratory failure. Early imaging with CT or MRI does not often change management and need not be routine. 3. What specific therapies have been shown to improve outcome for severe pancreatitis? Early ER (within 72 hours at most) and stone extraction and/or stenting has been demonstrated to improve the outcome of severe gallstone pancreatitis particularly if it is associated with cholangitis. Prophylactic broad spectrum intravenous antibiotics such as imipenem or meropenem have also been demonstrated to improve outcome. They are indicated in severe attacks particularly where sepsis is considered even without proven infected necrosis. Many antibiotics probably do not effectively penetrate the inflamed pancreas and are therefor of little value (ampicillin, gentamicin, metronidazole).

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Case 80: RIF pain and vomiting A 63 year old man is itted with 12 hours of abdominal pain. It began centrally with crampy pain and he now has constant right iliac fossa pain. He is unwell with vomiting, tachycardia and his abdomen is distended and guarded. A plain xray is shown below. 1. What is the likely diagnosis? The xray shows caecal volvulus with significant dilatation of the obstructed caecum. 2. What complication would you suspect has occurred? The change in the nature of this mans pain from colicky visceral pain to constant well localised somatic pain, associated with tachycardia and guarding on abdominal examination suggests the presence of strangulation of the caecum. 3. How would you manage this man? He requires urgent laparotomy after appropriate fluid resuscitation. At laparotomy a nonviable caecum is resected and an anastomosis is usually able to be performed. If the caecum is viable after de-torsion then there are other options. Caecopexy or fixing the caecum to the abdominal wall by suturing or peritoneal flap avoids the morbidity of resection and anastomosis. It is associated with significant recurrence however. A third option is caecostomy usually via a foley catheter. This is designed to fix the caecum to the anterior abdominal wall however it is frequently complicated by abdominal wall sepsis.

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Case 81: Leg deformity A 25 year old man is brought in by ambulance from a football game. His leg is deformed at the knee and his foot is cool and pale. An xray is shown below.

1. What does the xray show? Anterior dislocation of the knee. 2. What would be your immediate management? This is a limb-threatening injury and requires urgent reduction to prevent further traction injury. This can usually be achieved with appropriate sedation in the emergency department. 3. If his foot becomes pink and warm what further investigations would you arrange? Significant knee injuries such as dislocations may be associated with popliteal artery injuries. These injuries may be complete or partial transections, dissections and intimal injuries. Restoration of perfusion does not exclude injuries to the popliteal artery. The gold standard investigation for arterial injury remains digital subtraction angiography. DSA is obviously invasive and in a limb with normal vascular examination then high quality duplex US scanning is probably the most appropriate screening examination for major arterial injury. CT angiography with modern scanners may be more readily available than trained ultrasonographers. The key to avoiding major morbidity from missed arterial injury is a high index of suspicion and regular repeat examination of the limb.

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Case 82: "I think I've been stabbed" A 22 year old man is brought to the emergency department with a wound in the left flank. He is pale, shivering, and peripherally shutdown.

1. What is your first priority? The airway. this is a trauma patient and his management is dictated by trauma principles. 2. What would be your immediate management? Alerting and assembling the trauma team. A leader should be quickly decided upon and each person's responsibilities delegated. The radiology department should be alerted and theatre should be standing by. Then for the assessment as the patient is wheeled in. Primary survey. At the same time instituting resuscitation and monitoring. Immediately life threatening injuries are sought in a systematic manner and appropriate emergency manoeuvres instituted. For instance, in this patient especially, tension pneumothorax and cardiac tamponade should be considerations. A secondary survey follows with definitive care. 3. Which organs are at risk of injury with this wound? It is often easy to think of possible injuries per body cavity. However, there could be multiple injuries and injuries in multiple body cavities. Intraabdominal: spleen, stomach, splenic flexure colon, kidney, pancreas, aorta, IVC, liver. Thoracic: Lung, cardiac, oesophagus, aorta.

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Case 83: Endoscopic appearance A 62 year old man is having an endoscopic procedure.

1. What procedure is being performed? A Colonoscopy 2. Where is the scope? In the right colon looking at the ileocaecal valve (top left) and the caecal pole in the distance. This appearance may be quite obvious to an experienced endoscopist however, even then, the 2 dimensional appearance can be misleading. To confirm that the entire colon has been visualised it is important to observe the other anatomical features of the caecum. The three to are the ileocaecal valve, the triradiate folds of the caecum and the appendicoele orifice. Transillumination in a thin patient is unreliable, but can be used as a rough guide to position within the colon. The definitive way to know you are in the caecum is to negotiate the scope into the terminal ileum and view its characteristic velvety mucosa.

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Case 84: Rectal anastomosis An anastomosis has been performed.

1. What procedure has been performed? A circular stapled anastomosis. The commonest use for the circular stapler is a transanal rectal anastomosis. This device saves considerable time and is technically easier to use especially in a low rectal anastomosis. 2. What is the name for the tissue that is left on this instrument? the "doughnuts" - the proximal and distal margins of the anastomosis and therefore the proximal and distal resection margins of the resection. Although these margins are not used typically to gauge adequacy of resection, they should still be sent for histopathological assessment. 3. What is the significance of that tissue forming complete circles? The ring of the anastomosis is probably deficient if the doughnuts are incomplete. The chance of that anastomosis leaking would be high and this problem would be an indication to redo or at least repair the anastomosis 4. What methods are there for testing a rectal anastomosis? Intraoperative: 1. Air test - warm saline fluid in the pelvis, inflate rectum with air using a large syringe and look for bubbles 2. Iodine test - Instill iodine preparation into the rectum and look in the pelvis for extravasation 3. Methylene blue test - same as iodine test 4. Endoscopy - ontable flexible endoscopy Post operative: 1. Radiologically - Water soluble contrast enema 2. Flexible endoscopy (these should only be used if an anastomotic leak is of clinical concern, to avoid tampering with a new anastomosis).

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Case 85: Unusal view at endoscopy A first year registrar is performing a colonoscopy and is confused.

1. What view has been attained by the registrar? A retroflexed view in the rectum looking at the anal canal from above. See the scope as a black tube superiorly. 2. Is this maneouvre indicated in usual circumstances? Yes, it does have the small risk of rectal perforation if not performed delicately, however it shows a good view of the internal haemorrhoidal plexus and any polyps etc just above the anorectal ring. These problems can be easily missed, especially if a digital rectal examination is not performed at the beginning of the procedure. This part of the colonoscopy is advocated by the American Gastroenterological Association.

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Case 86: Leg ulceration This patient has had trouble with leg swelling for some time.

1. What process has caused this appearance? Chronic lymphodema 2. What complication has then occurred? Skin ulceration in an area of skin hyperkeratosis. This would most likely be simple ulceration, however an SCC developing in an area of chronic irritation (Marjolin's Ulcer) is a possibliity - this should be biopsied.

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Case 87: Painful leg This patient has presented with leg pain.

1. Which leg do you think is painful? The right one. Or the one that is absolutely completely white. The left leg has a mottled appearance, which may be due to chronic arterial insufficiency or due to this patients acute illness and peripheral shutdown. On examining this patient they will demonstrate a pale, pulseless, paralysed, painful and perishingly cold leg 2. How would you manage this patient? As for an acutely ischaemic limb. This is a surgical emergency with a high associated mortality. The issues are 1. Usually elderly unwell patients 2. with multiple co-morbidities 3. They are often systemically unwell with this episode 4. in enormous pain 5. and at risk of other emboli (eg stroke, mesenteric infarct) if thought to be embolic in nature. They need urgent resuscitation, analgesia, delineation of the level of occlusion, restoration of limb blood flow, control of reperfusion sequelae, which may also involve fasciotomies. Also anticoagulation and control of embolic source if indicated. The occasional patient will be too unwell for this treatment and will be best treated by palliation.

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Case 88: Retained foreign body

1. What methods are there for removing rectal foreign bodies? 1. Allowing them to spontaneously - risks perforation if impacted 2. Transanally - with analgesia or anaesthetic +/- pushing on the lower abdomen to help evacuate the object 3. Transanally - endoscopically - using the fleixble endoscope to grasp the object. 4. Transanally - using the operating sigmoidoscope 5. Transabdominally - pushing the object out the anal outlet or use of a colotomy and object removal. 2. What are the problems associated with rectal foreign bodies in general? 1. Rectal perforation - pararectal sepsis, abscess, peritonitis, fistula. 2. Sphincter injury 3. Recto-vaginal fistula. 4. Recurrence due to personality / preference / associated psychiatric disorder. Case 89: 'Peritonitis' This patient had been in hospital for 5 days with an exacerbation of chronic bronchitis. You are called to the medical ward because the respiratory doctors have found their patient to have developed abdominal pain overnight, and a tender lump in the left upper quadrant of his abdomen. You take a history from the patient and examine him. You suspect the diagnosis, and confirm it with a scan.

1. What is the diagnosis? Left sided rectus sheath haematoma 2. What are the risk factors? Repetitive coughing anticoagulants age prior history of rectus sheath haematoma (which this patient had)prior history of abdominal surgery - see the subcutaneous metallic clip from hernia surgery 3. What are the risks now for the patient? Exanguination if the bleeding is ongoing Pain which may limit respiratory state.

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Case 90: Laparoscopic treatment of Small Bowel Obstruction A 51 year old man presented with symptoms and signs of a proximal small bowel obstruction. He had a right paramedian scar from an urgent cholecystectomy that was performed 20 years ago.

1. What has caused the obstruction? A localised small bowel volvulus around an adhesion to the anterior abdominal wall related to the old wound. 2. What are the features that would enable you to say that the obstruction was proximal preoperatively? Clinical indicators: Early vomiting with minimal or only mild abdominal distension. Investigations: an abdominal Xray with upper small bowel levels and distension. Also a small bowel contrast study if performed. For instance a gastrograffin follow through. In this scenario, with little abdominal distension - laparoscopic division of the adhesions is ideal. Laparoscopic adhesiolysis is still difficult due to the distended and often friable chronically obstructed small bowel and great care is needed.

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Case 91: Injury with angle grinder A 42 year old man presented after an injury at work whilst using a cutting disc on an angle grinder. He held his hand in this posture.

1. What structure has this man injured? The extensor tendon to his right middle finger. This can be seen by the characteristic hand posture when asking the patient to extend his fingers.

Case 92: Neck swelling A 47 year old man presented after noticing a lump in his left neck.

1. What are the differential diagnoses? Lymph node - benign , malignant - primary or secondary Branchial cyst carotid body tumour carotid artery aneurysm lipoma sarcoma retropharyngeal abscess - bacterial, TB sternomastoid tumour 2. In that position, what is the most likely diagnosis? Just emerging from under the junction of the middle and upper thirds of the SCM Branchial cyst.

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Case 93: Scrotal enlargement A 61 year old man presented after noticing a lump in his left hemiscrotum.

1. What are the differential diagnoses? Inguinoscrotal hernia hydrocoele testicular tumour varicocoele 2. What is the examiner trying to demonstrate? Trying to 'get above' the scrotal lump.

Case 94: Paediatric surgery An infant needed an operation for a scrotal condition.

1. What operation is being performed? Bilateral orchidopexy 2. What condition did the child have? Bilateral undescended testes

3. What are the problems of not treating this condition? Subfertility, hypogonadism, possible decreased risk of testicular cancer if treated early. Certainly treatment before twelve months of age improves testicular function.

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Case 95: Troublesome toe This teenage boy was having trouble with recurrent toe infections.

1. Where is the abnormality? There is an ingrowing spicule of nail on the lateral aspect of the great toe nail. 2. Which operation would you perform? A wedge excision of the lateral great toe nail, along with nail germinal matrix.

Case 96: Anterior knee pain A 57 year old man presnted with a history of an increasingly painful lump below his knee.

1. What is your differential? 2. How would you treat it?

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Case 97: Abdominal distension and vomiting A 43 year old man presents with central coloicky abdominal pain, distension and vomiting. He has a history of appendicectomy but no other abdominal operations. A radiologic study is shown below.

1. What is the study and diagnosis? The study is a contrast meal and follow through. Water soluble contrast such as gastrografin is used in the setting of suspected obstruction in preference to barium. Small bowel obstruction due to post operative adhesions is the most likely diagnosis. 2. What is the potential role of this study in the management of this man? Gastrografin meal is a useful diagnostic tool to confirm the diagnosis of SBO. It has also been shown to reliably differentiate between complete obstruction that will require operative intervention versus incomplete obstruction that will be successfully managed conservatively. There may be a potential therapeutic benefit of the osmotic load of Gastrografin and studies are underway to investigate this. At present anecdotal evidence s a therapeutic benefit but there is little data in the literature to this view. 3. If conservative management is successful what other options would you consider in future? Post operative adhesions are a major cause of morbidity and even mortality. Extensive investigation contiues into techniques to prevent adhesion formation. At present elective surgery to divide adhesions is controversial becuase the further surgery is likely to result in recurrent adhesion formation. The one instance in general surgery where this is not the case is following appendicectomy. There is a significant chance of finding a single band adhesion in a patient with SBO following appendicectomy alone. In this circumstance it is justified to perform laparoscopic division of adhesions in the elective setting following resolution of the obstruction.

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Case 98: Pale hand An 8 year old boy fell and sustained a humeral fracture. The orthopaedic registrar has reduced and fixed the fracture in theatre. The hand is now noted to be cold and pale.

1. What does the xray show? A supracondylar fracture of the humerus. 2. What associated injury may be responsible for the hand changes? Injury to the brachial artery can be occlusion, dissection or transection. This leads to ischaemia of the flexors of the forearm, compartments syndrome and then healing by fibrosis. 3. How would you manage this problem? Emergency exploration of the brachial artery above the elbow to restore flow. Fasciotomy of the forearm compartments may be rquired if there has been prolonged ischaemia. 4. If untreated what is the likely outcome? Volkmann's ischaemic contracture.

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Case 99: Fever and abdominal pain This 34 year old alcoholic man presented with 2 weeks of left sided abdominal pain, fever and anorexia. On examination he has tenderness and a mass in the left iliac fossa

1. What does the CT show? The CT shows a grossly expanded left psoas muscle containing possible fluid density material and several locules of gas. There is inflammatory stranding in the adcent retroperitoneal and mesenteric fat. 2. What is the likely underlying diagnosis and differentials? The most likely diagnosis is complicated and neglected diverticulitis with localised perforation and abscess formation. Complicated Crohn's disease should be considered particularly if there has been a history of gastro-intestinal upset. Foriegn body perforation or a complicated carcinoma are less likely. 3. Outline your management of this man? Thorough history, examination and investigation to assess degree of sepsis and organ dysfunction. The primary treatment for this condition is resection of the diseased segment of bowel. The potential risks with this approach include the necessity for a major laparotomy and colonic resection with stoma. In view of this there is a role for nonoperative management in selected stable patients. Non-operative mangement includes broad spectrum intravenous antibiotics, bowel rest and IV fluid resuscitation. The patient then requires ongoing regular review to confirm clinical improvement and detect failure to improve or deterioration at an early stage. This would then be an indication for operative management. The key to non-operative management is drainage of the abscess. This may be achieved by an extraperitoneal left iliac fossa surgical approach. Alternatively, percuatenous drainage can be achieved under image guidance but may be inadequate. Note that a psoas abscess may track along the muscle and therefore present in the groin below the inguinal ligament.

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Case 100: Sentinel nodes A 45 year old woman presents with a 4 cm mammographic abnormality in her left breast. There are no nodes palpable in the axilla. A core biopsy of the breast lesion confirms ductal carcinoma in situ. She has opted for mastectomy but would like a sentinel lymph node biopsy in preference to axillary dissection. Her lymphoscintigram is shown below.

1. Which patients are suitable for sentinel lymph node biopsy? Sentinel lymph node biopsy is suitable for a select group of early breast cancers. If used for inappropriate patients results are likely to be poor and of little value. Patients selected for the technique of sentinel node biopsy without complete axillary dissection should have early stage disease with a low probability of lymph node metastases. The primary tumour should be less than 3 cm diameter, not multicentric and the axilla should be negative at clinical examination. The role of SLNB in DCIS is limited to those situations where a total mastectomy is to be performed. In this situation SLNB can be justified because if invasive tumour is found in the resected speciment there will no longer be the option for SLNB. Further investigation is required before SLNB can be considered routine for larger primary tumours or multifocal disease. 2. You have performed sentinel node biopsy 3 or 4 times during your training. Now as a junior consultant what would you advise this woman? That SLNB is possible and safe in this situation. The risk of a false negative result in this situation is low using the technique and that the current standard care would be simple mastectomy without any dissection of the axilla. 3. If her biopsy had shown invasive cancer how would your advice differ? In this case the surgeon needs to have demonstrated adequate skill at using the SLNB technique. This is achieved by performing 20-40 SLNB with immediate level II axillary dissection to determine the false negative rate which should be less than 10%. Any surgeon using SLNB also needs to maintain prospective audit to ensure that acceptable results continue to be achieved.

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Case 101: Massive bleeding per rectum A 73 year old man presents via ambulance after collapsing at home. He has been ing large amounts of blood per rectum. He is currently haemodynamically stable after 1000ml IV saline. The nurse looking after him brings you a pan to inspect. 1. Where do you think this blood is originating and what are the common causes? It can be difficult, and potentially unreliable, to predict the source of blood loss simply from its appearance. This blood appears to be of colonic origin. Bright red blood bleeding from an upper gastrointestinal source is typically associated with significant haemodynamic instability due to the rapid rate of bleeding. The common causes of massive colonic bleeding are diverticular disease and angiodysplasia. Neoplasms (carcinomas and adenomas) are uncommon causes of this degree of blood loss. Colitis (IBD, infective, inflammatory, ischaemic etc) are typically associated with bloody diarrhoea rather than massive PR bleeding. 2. How would you investigate this man to determine the source of bleeding? In an unstable patient it is critical to exclude an upper GI source of bleeding with an urgent gastroscopy. A nasogastric tube may help as the finding of clean bile is evidence against an upper GI source. The options for investigating colonic bleeding include CT angiography, routine mesenteric angiography, labelled red blood cell nuclear scintigraphy and colonoscopy. Each has benefits and limitations. The choice of first line investigation is often determined by local expertise. 3. When would you operate on this man? This may be a difficult decision to make. The key features to consider are haemodynamic stability and transfusion equirements, the results of localisation studies, recurrence of bleeding and the patient's general fitness. An unstable patient failing to respond to IV resuscitation requires urgent definitive surgery however the mortality rate of blind total colectomy in this situation is high. Ongoing or recurrent bleeding requiring more than 6 units of blood in 24 hours indicates failure of the conservative approach. An unfit patient with significant comorbidites is likely to tolerate an emergency laparotomy for colectomy poorly, however it must be ed that waiting until they become unstable to make the decision to operate is likely to worsen their outcome.

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Case 102: Blood and mucus per rectum A 47 year old man presents with 6 weeks of pregressive bloody diarrhoea and age of mucus per rectum. He now has left sided abdominal pain and a temperature of 37.7C 1. What does the xray show? The left colon is dilated with "thumb printing" indicating mucosal oedema. This suggests colitis. 2. How would you manage the problem in the emergency department? Resuscitation and thorough assessment occur simultaneously 3. What features would you look for at colonoscopy to make a diagnosis? The macroscopic features of colitis are erythema, oedema and a granular appearacne of the mucosa. bleeding and deep ulceration may occur with increasing severity and depending on the underlying aetiology. Ulcerative colitis occurs in the rectum with confluent spread for a variable distance proximally. Ischaemic colitis involves a segment of bowel, typically around the splenic flexure with normal mucosa adjacent both proximal and distal. In pseudomembranous colitis the "membranes" may be seen as yellow plaques coating a variable amount of the mucosal surface. Crohn's colitis is typified by deep linear ulcers and discontinuous mucosal involvement Multiple biopsies should be taken from the diseased colon in an effort to confirm the diagnosis.

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Case 103: Hypercalcaemia A 48 year old woman is referred from her GP with a serum corrected calcium of 3.05 mmol/L. She is otherwise fit and well. Her parathyroid hormone (PTH) is inappropriately elevated but renal function is normal.

1. How would you classify hyperparathyroidism? Pimary, secondary and tertiary forms are recognised. Primary hyperparthyroidism typically occurs as a result of an autonoumous functional parathyroid adenoma. Hyperplasia of all four glands occurs less commonly. Secondary hyperparathyroidism occurs in the setting of chronic renal failure is due to complex abnormalities of calcium-phosphate metabolism and homeaostasis. Tertiary hyperparathyroidism occurs when the an autonoumous gland develops as a result of chronic hyperstimulation in chronic renal failure. It typically manifests itself after cessation of the stimulus following successful renal transplant. 2. What imaging has been performed and what other options are there? A parathyroid nuclear medicine scan. The isotope (Tc-99m Sestamibi) is taken up equally by the thyroid and parathyroid glands. The thyroid excretes the isotope while the parathyroid retains it for significantly longer. This results in delayed images showing the parathyroids. In this case a single adenoma is identified on the left and the other glands are suppressed (click on image for assistance). Some experienced parathyoid surgeons do not use any localisation studies for the first exploration of the neck in primary hyperparathyroidism. They will routinely identify all four glands with a high level of success. 3. How can operative identification of the parathyroids be facilitated? Intravenous methylene blue infusion pre-operatively will stain the parathyroids bluebrown as they preferentially take up the dye.

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Case 104: Liver lesion A 52 year old woman with a history of hepatitis C and alcohol abuse presents with a rising alpha foetoprotein. Conventional imaging has failed to detect an abnormality.

1. What is the study and the diagnosis? CT hepatic angiogram. The hepatic artery is cannulated via a femoral puncture and contrast is injected intra-arterially with immediate scanning through the liver. There is a hypervascular lesion in segment III of the liver that is likely to be a hepatocellular carcinoma in this setting. The liver contour is 2. What is the anatomic basis for performing this study? Hepatocellular carcinomas usually derive their blood supply predominantly from the hepatic arterial system as opposed to the portal venous system which is dominant in the normal liver. Therefore these hypervascular lesions are well demonstrated on hepatic arterial contrast studies.

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Case 105: Loin pain A 45 year old man is referred with right loin pain. It occurs occasionally and usually lasts only a few hours at a time. His GP noted microscopic haematuria on urine dipstick.

1. What does the xray show? There is a large radio-opaque calculus located at the right renal pelvis. There are also several calcifications in the pelvis. These are not in the expected line of the ureters and are likel to be phleboliths, or calcification within pelvic veins. 2. How would you manage this condition? A large stone such as this is unlikely to spontaneously. In view of its location in the renal pelvis the options are Extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotripsy (PCNL). ESWL is less invasive and is usually the first line therapy. 3. Having undergone treatment he has now developed severe unremitting pain in the abdomen and groin. What has happened? Lithotripsy has been performed with fragmentation of the calculus. The fragments have ed into the ureter but unfortunately have lodged at the vesico-ureteric junction. The cast of fragments can be seen to demonstrate the lower end of the ureter. This is known as "steinstrasse" or stone-street.

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Case 106: Arteriopath A 50 year old man is being investigated for poorly controlled hypertension. He is a smoker, hypertensive, dyslipidaemic and also has peripheral vascular disease. The radiologists notes an incidental finding.

1. What is the study and the anatomic abnormality? This is an aortic digital subtraction angiogram. The pigtail injection catheter can be seen located in the proximal aorta. The renal arteries are well demonstrated. The abnormality is a large inferior mesenteric artery that flows into a dilated marginal artery of Drummond and then into the proximal superior mesenteric artery to supply the midgut. This is the "wandering artery of Drummond". 2. What is the underlying cause for this finding? Chronic occlusion of the proximal superior mesenteric artery leads to development of this substantial collateral vessel. Failure to recognise this anatomic abnormality at operation can have disasterous results if the IMA is ligated during surgery on the left colon. This may lead to infarction of the SMA territory of bowel.

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Case 107: Skin Markings A 44 year old man was brought to the emergency by a concerned motorist who found him walking along a country road. It was early in the morning on a saturday. He was confused, cold and still intoxicated. He had a painful and partially numb right arm and shoulder.

1. What is the cause of the skin markings? Seat-belt bruising from a high speed motor vehicle accident. In Australia, this gentleman would have been the driver (or possibly the rear, right-hand, back seat enger) 2. What associated injuries could be present? Think Trauma. Not immediately subclavian artery intimal damage. This is a trauma patient. Airway - assess and secure if neccessary. (secure cervical spine ! put collar on!) Breathing - assess, assist, Circulation- assess, replace, reduce loss, reassess response to therapy Disability - consider head / neck injury Adjuncts to primary survey ie - Oxygen, ECG monitoring, saturation monitoring, warming blanket Secondary survey A head to toe assessment of the entire patient, now consider injuries that would be associated with this characteristic mechanism of injury. Possible associated injuries: 1. Shoulder region. Fractured clavicle, or first rib, subclavian artery injury, brachial plexus injury. 2. Lap belt injury - Spine (Chance fracture - more common with lap belt only), splenic, liver, small bowel, pancreas, colonic, bladder, major vessel. 3. Chest - Pneumothorax, haemothorax, pulmonary contusion, myocardial contusion. 4. Other - Head, cervical spine, pelvic, long bones.

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Case 108: Colonoscopic Appearance A 64 year old woman was having a colonoscopy for rectal bleeding and constipation.

1. What is this mucosal appearance called? Melanosis Coli 2. What associations does it have? Long term stimulant laxitive use. Some of these patients have hypomotility disorders, but not all. Some are just serial laxitive s. 3. What was the rectal bleeding most likely due to? Probably anal outlet due to ing hard stool - ie haemorrhoidal (presuming the rest of the colonoscopy was normal.) Even the smallest adenoma is easily seen in this condition.

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Case 109: Colonoscopic technique A 61 year old man was having a colonoscopy. This lesion was found.

1. Describe this mucosal appearance? There is a sessile polyp on the colonic mucosa. The lesion is raised, irregular with a fine crypt pattern which is typical of an adenoma, but it is difficult to see. 2. What techniques are there for visualising this better? Magnification with a specialised endoscope, also Indigo-carmine dye spray to highlight the mucosal pattern. 3. What has been performed? Spray with dye, and the lesion is now much more easily identifiable as an adenoma. This lesion could be snared endoscopically, however it may require 'saline lift' (injection of saline under the lesion in the submucosal plane to allow easy excision with a lower incidence of perforation. Mixing in some 'blue dye' into the saline will highlight the submucosal plane.) Case 111: Chemotherapy infusion device You are asked to remove an infusa-port from a 42 year old woman who has completed her chemotherapy for breast cancer. The device has been there for over 2 years. The procedure is simple however you arrange a chest xray in the recovery room and it reveals a complication. 1. What has occurred? the catheter has fractured and a 7 cm remnant has ed through the right atrium into a branch of the left pulmonary artery. 2. How would you manage this problem? The patient needs to informed of the complication. A CTPA can then be used to determine the exact location of the catheter and plan retrieval. If the fracture occurredd some time ago there is a risk that it may have eroded through the wall of the artery or be surrounded in organised thrombus. Interventional radiology techniques can then be used to snare and retrieve the catheter via a femoral vein puncture.

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Case 112: Farmer for surgery A 72 year old farmer is seen in the pre-anaesthetic clinic for a check prior to inguinal hernia repair. A chest xray is requested as he has a smoking history. An interesting incidental discovery is made.

1. What is the finding and the likely diagnosis? There is a large calcified mass in the right upper quadrant of the abdomen. This most likely represents a calcified and dead hydatid cyst. 2. What further investigations would you arrange? Further imaging of the abdomen with CT is appropriate to assess the nature of the cyst and the possible presence of other non-calcified and viable cysts. Serological testing for Echinococcus may also be useful.

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Case 113: Vomiting and chest pain A 74 year old woman presents with episodic chest pain, dysphagia and regurgitation of her saliva. A barium swallow is performed during her work up.

1. What is the abnormality? There is a giant hiatus hernia with the entire stomach now in the chest. There is also organoaxial volvulus with the greater curvature now superior to the lesseer curvature 2. How can this problem be classified? Hiatus hernia can be classified as: Type I - A "sliding" hernia where the gastro-oesophageal junction rises into the chest Type II - A "rolling" hernia where the gastro-oesophageal junction remains fixed but the fundus of the stomach rises into the chest beside the oesophagus Type III - A mixed hernia with both type I and II components Type IV - A large hernia with organs other than the stomach herniated into the chest Volvulus is classified as organoaxial or mesoaxial (mesenteroaxial).

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Case 114: Dysphagia A 71 year old man was having trouble swallowing.

1. Describe the xray findings? There is an oesophageal stent in the posterior mediastinum. 2. What techniques are there for palliating dysphagia? Bougie: self istered, or under anaeasthesia Endoscopic: dilataion (balloon, Keymed, or Bougie), laser, prosthetic stents Oncological: chemotherapy Radiotherapy: external beam or less commonly brachytherapy Conservative: analgesia, full palliation 3. What new symptoms may this man now complain of? Reflux as this long stent would probably sit with its distal end within the stomach lumen, hence stenting open the lower oesophageal sphincter.

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Case 115: Explain this appearance An image was taken during laparoscopy because a complication had occurred.

1. What complication has occurred? There was presumably bleeding from the laparoscopic port-site. 2. What technique has been used to rectify it? Laparoscopically inserted sutures to control the vessel under the peritoneum, which, in this case was the inferior epigastric artery. 3. How could this have been avoided? By placing the ports at a distance from the inferior epigastric artery and watching carefully as the ports are inserted. Case 116: Funny finger This elderly gentleman had presented with symptoms of carpal tunnel syndrome, but had lived happily with this other problem for years. 1. What is the diagnosis? Trigger finger, left ring finger. The triggering happens with every extension movement, however it is only pronounced every few times in this patient. 2. What are the options for treatment? Observation, steroid injections, however the definitive treatment for this mechanical problem is open release of the flexor sheath (A1 pulley) where the relative constriction is.

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Case 117: Ankle Abscess This was an unusal abscess. It had been slowly increasing in size and symptoms over a number of months. 1. What possible underlying causes are there for the 'unusual abscess'? Underlying Foreign body Underlying osteomyelitis Underlying Malignancy Unusaul organism - TB, Fungii, syphillus Unusual immunonology - Diabetes, HIV, steroid Use. This case aws that of soft tissue tuberculosis. Case 118: Reflux operation This is an image taken during a laparoscopic anti-reflux procedure. The view is looking towards the hiatus, with the divided lesser omentum to the left of the picture, revealing the caudate lobe of the liver. The left hepatic lobe is elevated with the Nathensen liver retractor.

1. What type of anti-reflux procedure has been performed? The reflux procedure is a 180 degree anterior fundoplication (the anterior wrap). The light blue Ethibond sutures have been used to secure the fundus of the stomach to the right pillar (the right Crus of the diaphragm) and then to the superior margin of the hiatus (the phreno-oesophageal ligament and the diaphragm itself). The sutures on the right side of the photo, and those just out of view, are reconstructing the 'angle of His' by approximating the proximal fundus/cardia of the stomach to the left side of the hiatus.

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Case 119: Distressed Mother A mother was watching when the batteries fell out of her 4 year olds toy and before she could react he picked one up and swallowed it.

1. Where do you think the battery is? There is a swallowed foreign body. On the closer image it is a size AA battery. The battery seems to be in the dependent part of the stomach. Depending on the history this can help. if the battery has only recently been ingested, then it probably is in the stomach. 2. What are the options for treatment? The two basic options are to await ing or intervention for removal. Endoscopy for retrieval is probably not warranted in this case. The battery has negotiated the oesophagus and its several narrowings and sphincters. The risk of alkaline leakage is probably only important if the battery was still lodged in the 'acid free' oesophagus. In the stomach any alkali will be neutralised. These patients can be managed as outpatients after advice to the parents and serial xrays every 48 hours to ensure that the object is ing.

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Case 120: Return to theatre A 64 year old man had a subtotal gastrectomy for cancer earlier in the day. In HDU he required substantial IV filling and inotrope doses. The drain did not produce much blood. 1.What are the signs of post operative haemorrhage? Pallor tachycardia abdominal distension sweating peripheral shutdown thirst decreased urinary output confusion later - hypotension and hypovolaemic shock 2. Why did the drain not reveal the bleeding? Because it blocked, possibly with clotted blood. Drains are often helpful, but not always. They have a tendency to give the wrong impression if relied upon. Case 121: 'I have a chicken bone stuck in my throat' After eating a chicken sandwich, this man presents with odynophagia and almost complete dysphagia, spitting up his saliva.

1. Can you see the abnormality? There is a calcified structure in the cervical oesophagus causing obstruction with dilatation above it and gas in the lumen of the oesophagus. Well, there is gas shadowing on the film, this could represent gas locules outside the oesophageal lumen, indicating perforation. 2. What are the options for treatment? This requires urgent removal. The gas is presumed to be in the lumen, but the bone could have eroded already and the gas seen on the xray could represent retropharyngeal sepsis. This complication is a potentially life threatening emergency. The distinction between perforation or not could be made more clear by clinical examination and CT scanning of the neck. However, the treatment is similar. The foreign body needs to be removed and the upper aerodigestive tract examined for full thickness injury.

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Case 122: Small lump on finger This young boy had noticed a lump on his hand since he was born.

1. What is the diagnosis? Supernumerary digit.

2. What are the options for treatment? Observation if not symptomatic or of cosmetic concern. However, these accessory digits can be much larger and often have a small pedicle of cartilage and some neural elements which can be painful when irritated. Excision including the proximal neural pedicle and any bone or cartilage element. Case 123: Buttock pain 3 weeks post treatment for chronic anal fissure .

1. What is the diagnosis? Ischiorectal abscess, which is now spontaneously draining on the operating table. 2. What operative treatment did this man most likely have 3 weeks ago? He probably had a left lateral internal sphincterotomy. This operative site has become to source of the sepsis. Infection of an internal sphincterotomy is uncommon but with this case history it is still the likely cause. Patients seen with pain post sphincterotomy should be evaluated for possible perianal sepsis which can sometimes be difficult to demonstrate on clinical examination. Examination under anaesthetic should be used liberally in all patients presenting with significant perianal pain to exclude sepsis in this area.

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Case 124: Scrotal lump This man had noticed a lump in his right hemiscrotum.

1. What is the diagnosis? There is a hydrocoele and also within this is an epididymal cyst. A lump seen on examination, that you can 'get above' and is separate to the testis is often an epididymal cyst or spermatocoele. 2. What are the options for treatment? The options are: Observation reassurance or if symptomatic aspiration sclerosant injection excision The aetiology of epididymal cysts has not been ellucidated. It is thought to be a congenital abnormality related to hormonal disorders during early development in-utero. Physical examination is very important in assessing scrotal pathology, but not sufficient for the diagnosis and must be completed by scrotal ultrasonography, which shows an echo-free cystic epididymal structure. Despite even excellent ultrasonography, the differential diagnosis of other scrotal cystic masses and even some solid epididymal tumours, which may present all of the sonographic characteristics of a cyst, must be considered. The treatment of symptomatic epididymal cyst should be surgical. For asymptomatic cysts diagnosed by sonography, clinical follow-up to document stability of the mass is justified.

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Case 125: Distal Gastric Cancer A 62 year old man presented with upper abdominal symtoms of mild dyspepesia. On gastroscopy he was found to have an early distal gastric cancer

1. What is this operation called? A subtotal gastrectomy. The entire greater omentum has been removed along with the nodal tissue seen along the lesser curve of the stomach specimen. A modification of the 'D2' gastrectomy which includes a 'bursectomy' (excising the lesser sac intact), and nodal dissection of the common hepatic artery and the coeliac axis group (including the nodes at the origin of the left gastric artery which is taken). The spleen and the splenic hilar nodal group have not been removed, nor has the distal pancreas. This extension to the operation has not been shown to improve survival enough to compensate for the increased morbidity. 2. What are the possible nutitional problems following such a procedure? Intake restriction and weight loss due to: A small gatric pouch. delayed gastric emtying Stomal problems efferent loop symdrome (Roux Limb Syndrome) dumping Absorption. Iron deficiency anaemia B12 deficiency due to loss of intrinsic factor - more a problem with total gastrectomy 3. Define 'early gastric cancer' Early gastric cancer (EGC) is defined as gastric cancer confined to the mucosa or submucosa, regardless of the presence or absence of lymph node metastasis.

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Case 126: Breast Operation This lady has a family history of breast cancer. The intraoperative photo

The preoperative mammogram

1. What are the wires called? 'Hook-wires' The procedure is known as a hook-wire localisation. 2. Do you think the lesion would be palpable? And why? No. Otherwise the hook wires would not have been required 3.What should be done with the specimen when it is excised? It should be marked clearly to orientate the pathologist. Then sent directly to the radiology department for Specimen x-ray to confirm that the suspicious area has been excised. The surgeon can close the patient when this has been confirmed. Then the specimen is sent for histopathology. 4.What if the histopathology shows that one of the excision margins is widely involved? The patient requires a further excision. No matter if the problem is DCIS or invasive cancer, the only question is, is another breast conserving operation sufficient or cosmetically possible, or should the patient be offered the option of mastectomy.

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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.

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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.

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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 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.

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Case 130: Subcutaneous lump This patient presented with a subcutaneous lump which was not particularly painful but slowly enlarging. This was an intraoperative photo

The macroscopic pathology specimen.

This was the ultrasound ordered by the referring doctor.

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.

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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.

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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.

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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.

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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.

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Case 137: Progressively enlarging lump under the jaw 1. What is the diagnosis? 2. What are the options for treatment? lipoma

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Lipomas

What is a lipoma? A lipoma is a non-cancerous tumour that is made up of fat cells. It slowly grows under the skin in the subcutaneous tissue. A person may have a single lipoma or may have many lipomas. They are very common.

Lipomas

Who gets lipomas? Lipomas can occur in people of all ages, however, they tend to develop in adulthood and are most noticeable during middle age. They affect both sexes equally, although solitary lipomas are more common in women whilst multiple lipomas occur more frequently in men.

What causes lipomas? The cause of lipomas is unknown. It is possible there may be genetic involvement as many patients with lipomas come from a family with a history of these tumours. Sometimes an injury such as a blunt blow to part of the body may trigger growth of a lipoma.

What are the signs and symptoms? People are often unaware of lipomas until they have grown large enough to become visible and palpable. This growth occurs slowly over several years. Some features of lipomas include:



A dome-shaped or egg-shaped lump about 2-10 cm in diameter (some may grow even larger)



It feels soft and smooth and is easily moved under the skin with the fingers



Some have a rubbery or doughy consistency



They are most common on the shoulders, neck, trunk and arms, but they can occur anywhere on the body where fat tissue is present.

Most lipomas are symptomless, but some are painful on applying pressure. Lipomas that are tender or painful are usually angiolipomas (adiposis dolorosa or Dercum disease). This means the lipoma has an increased number of small blood vessels.

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Liposarcoma Luckily the rare fatty cancer, liposarcoma, almost never arises in the skin. Liposarcoma tends to be deep seated and most often grows on thigh, groin or at the back of the abdomen. However, if your lipoma is enlarging or becomes painful, check with your doctor. A skin biopsy may be required.

What treatment is available? Most lipomas require no treatment. Most lipomas eventually stop growing and remain indefinitely without causing any problems. Occasionally, lipomas that interfere with the movement of adjacent muscles may require surgical removal. Several methods are available:



Simple surgical excision



Squeeze technique (a small incision is made over the lipoma and the fatty tissue is squeezed through the hole)



Liposuction.

Case 138: Difficult abdominal closure

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Case 139: Diabetic foot problem

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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.

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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 ed flatus for 48 hrs.

His plain abdominal xray: 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.

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Case 142: Gastroscopic problem This elderly gentleman had presented with significant haematemesis. The following is an excerpt of gastroscopic video. Video provided by Mr Trevor Mcquillan - General Surgeon, The Northern Hospital, Melbourne, Victoria, Australia. 1. What does the bleeding seem to be coming from judging by the nature of its flow? The constant, non pulsatile flow would indicate venous bleeding. Venous bleeding in the stomach would most likely originate from gastric varices. These are difficult to treat and can bleed significantly. Although similar in pathogenesis to oesophageal varices, their treatment differs. 2. What are your options for treatment? Treating gastric varices can be very challenging. The Sengstaken-Blakemore tube may have some utility for bleeding varices near the gastroesophageal junction, but would have little utility for varices in the fundus or further down in the stomach. Successful hemostasis and obliteration of gastric varices has been reported with intravariceal injections of sclerosant, absolute alcohol, thrombin, and cyanoacrylate. This methods could all be used acutely to stem rapid bleeding. There is less experience with Endoscopic varicoele banding in this setting. The problem with banding would be ulceration when the band falls off, potentially causing significant bleeding. This outcome would be especially worrying if banding was used as primary prophylaxis when the patient was not actively bleeding. Though criteria for varices that are at high risk for bleeding have been developed, there are no reports of attempts at prophylactic treatment using endoscopic based therapy. Medical management is similar to the treatment of esophageal varices. Vasopressin and octreotide are useful for control of acute bleeding, and beta-blockers and long acting nitrates may prevent subsequent bleeding. Case 143: Intravenous drug use An injecting drug presents with a painful swollen arm.

1. What complication has occurred? 2. What information would you like prior to operating?

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Case 144: Perihepatic problem Lap image.

1. What complication has occurred? 2. What information would you like prior to operating? Gastric varieces

Case 146: Weight loss procedure Xray image.

1. What complication has occurred? 2. What information would you like prior to operating? Gastric varieces

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Case 147: Groin hernia

1. What complication has occurred? 2. What information would you like prior to operating? Case 148: X-ray pelvic objects

1. What complication has occurred? 2. What information would you like prior to operating?

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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.

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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.

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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.

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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.

A close up of the 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.

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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 ( it will enlarge once a disc of skin is excised. Always 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?

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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 es 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 age of two fingers through the trephine ensures that it is of sufficient calibre. Babcock's forceps are ed 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.

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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.

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Case 155: Painless jaundice A 68 year old man presents with progressive jaundice over 3 weeks. He also has pale stools, dark urine and pruritus. His bilirubin is 280 on ission.

1. What does the CT show? 2. How would you manage the problem in the emergency department? 3.What are the options for operative mangement? 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.

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Case 157: Painful wound

1. What does the CT show? 2. How would you manage the problem in the emergency department? 3. What are the options for operative mangement? Case 158: Nothing coming up the nasogastric tube.

1. What does the CT show? 2. How would you manage the problem in the emergency department? 3. What are the options for operative mangement?

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Case 159: Pre-op assessment.

1. What does the CT show? 2. How would you manage the problem in the emergency department? 3. What are the options for operative mangement?

Case 160: Lump in front of ear

1. What does the CT show? 2. How would you manage the problem in the emergency department? 3. What are the options for operative mangement?

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case 161: Car Accident This man was involved in a high speed car accident. He was wearing a seatbelt. The chest injuries seen are the only injuries sustained.

This is his sputum cup on day two of his hospital recovery. 1. What does the Chest Xray show? The chest Xray displays many features of severe chest trauma. There are fractures of the left clavicle, and the upper five left sided ribs, including the first rib. There is already patchy consolidation of the left lung field consistent with lung contusion. 2. How would you manage the problem in the emergency department? As per any multiply injured patient, guided by ATLS (or EMST) principles. Important aspects concerning the chest injury include: * high flow oxygen * analgesia * continuous oxygen saturation measurements * assessment for a flail segment and subsequent respiratory mechanical failure * possible early intubatiion and mechanical ventilation * consideration of early chest tube insertion * CXR * cardiac investigations - ECG, troponin, Echocardiogram, for possible associated cardiac contusion * CT chest with CT angiogarphy of the great vessels for possible major vessel injury * Intensive care referral 3. What are the possible complications this man may have during his hospital stay? a.Respiratory failure. b.pneumothorax c. DVT d. Pulmonary embolus e. chest infection / pneumonia f. empyema 4. What does this suggest? Pulmonary contusion. However also consider the rare occurrence of direct major airway injury 5. What if he had coughed this up on day seven? Consider then superimposed pneumonia, but bright blood in this case and in this clinical setting is almost pathopneumonic of pulmonary embolus.

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Case 162: Post op leg pain

After 24 hours the leg looked like this.

1. What is the diagnosis? Superficial Thrombophebitis, in the territory of the long saphenous vein.

2. How would you manage this problem? 1. Confirm the diagnosis 2. Exclude extension to the deep system 3. Exclude associated deep vein thrombosis 4. Exclude any underlying predisposition 5. Symptomatic care - leg elevation, analgesia, antiinflammatories, DVT prophylaxis 6. Observation for skin breakdown and superimposed cellulitis. Basically a duplex ultrasound of the lower limb is required. It will confirm the diagnosis, judge whether the clot extends up to or through the sapheno-femoral junction, and screen for deep system thrombus. Underlying predisposition includes all usual causes of DVT. Of special interest is the association with intraabdominal malignancy especially pancreatic cancer. - Trousseau's sign of migratory thrombophlebitis. Dr. Armand Trousseau first described this finding in himself; he was subsequently found to have pancreatic cancer.

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Case 163: Hardware at laparoscopy You are performing a laparoscopic appendicectomy. Your intern asks what that white tubing is.

1. What is it? It is a ventriculo-peritoneal shunt used to treat hydrocephalus. The problem with this hardware is not its identification, but the diagnostic confusion it can make. These patients can present with abdominal pain which is difficult to discern. The pain could arise from a primarily infected shunt or could also arise from a primary intraabdominal problem (as in this case) Methods to differentiate include drawing off some CSF from the reservoir port (performed by the neurosurgeons, if this shows pure growth of a characteristic skin organism then it is more likely a shunt problem) or performing a diagnostic laparoscopy.

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Case 164: Collapse An 82 year old lady collapsed trying to get off the toilet. She had been feeling faint for the past 24 hours.

1. What is this characteristic bowel action called? Melaena. The age of altered blood per rectum. 2. How would you manage the problem in the emergency department? Resuscitation, which includes airway control and breathing assistance if required. Also prompt attention to restoring circulatory volume. These patients often have other medical comorbidities and a multi-team approach with the intensive care team, and the anaesthetic team is required. Early referral to the on-call endoscopist and the surgical team is necessary. Issues are often: anticoagulation, ischaemic heart disease, cardiac failure, liver disease, portal hypertension. 3. What are the options for management? Early upper GI endoscopy and proceed as required. This lady has several risk factors for higher mortality: her age, and the fact that she collapsed. She requires early and aggressive treatment. Acute upper gastrointestinal bleeding carries a hospital mortality in excess of 10%. The most important causes are peptic ulcer disease and varices. Varices are treated by endoscopic band ligation or injection sclerotherapy and management of the underlying liver disease. Ulcers with major stigmata of recent bleeding are treated by injection with dilute adrenaline, thrombin, or fibrin glue; application of heat using the heater probe, multipolar electrocoagulation, or Argon plasma coagulation; or endoclips. Intravenous proton pump inhibitors reduces the risk of re-bleeding in ulcer patients undergoing endoscopic therapy. Repeat endoscopic therapy or operative surgery are required if bleeding recurs.

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Case 165: Urine discolouration This is a specimen of urine taken from a man who complained recently of epigastric pain radiating through to his back.

1. What physical sign does the urine demonstrate? The dark urine of cholestatic jaundice. This man says that 'it was much worse yesterday - almost like Coca-Cola.' 2. How would you manage this problem in the emergency department? First confirm the diagnosis with a thorough history, physical examination and then a biliary ultrasound. Liver function blood tests would also be needed. Other tests required are full blood examination for white cell estimation, clotting parameters, amylase or lipase to exclude gallstone pancreatitis. The urgency of intervention then depends primarily on the degree of biliary sepsis. The septic and hypotensive patient will require urgent biliary decompression. 3. Biliary ultrasound shows stones in the gallbladder. The common bile duct was 8mm in diameter with no stones seen. Next move - MR or straight to ER? Some would say that if this was a young man then the duct being 8mm is above the upper limit of normal and probably obstructed distally. Combined with a good story for obstructive jaundice, then proceeding straight to ER would be reasonable. However this approach would high negative rate of having the stones already ed. MR is preferable to save some patients the morbidity (and mortality) of ER.

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Case 166: Chest Pain This 49 year old lady has had a laparoscopic anti-reflux operation two years previously. She now presents with trouble swallowing and retrosternal chest pain.

1. What does the xray show? This a barium swallow, and it demonstrates a paraoesophageal hernia, with a moderate sized portion of the proximal stomach herniating into the chest. 2. What are the options for management? This problem, when symptomatic requires operative repair. This may be possible laparoscopically, or require open repair. The principles are reduction of the hernia, anatomical hiatal repair, and redo fundoplication.

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Case 167: Leg trouble Here is quite a graphic image taken during an operation on this patients lower limb.

1. What type of amputation has been performed? An above knee amputation 2. How do you know? The image is not all that clear, but the knee t is just visible in the amputated part. The give away is the retractor that is being used. This broad sheet of metal is sloted on one side to accommodate the femoral shaft, thereby retracting the soft tissues of the thigh when using a saw to cut through the bone.

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Case 168: Not again A 47 year old man presents with a very painful letf buttock. He says this has happened two times before and each time he required surgery.

Intraoperative photo.

The contents of the collection.

1. Describe the problem seen in the photo? There is a large left sided ischiorectal abscess. Cellulitis is spreading from this septic source across most of the left buttock. The pus is pointing laterally at about 4 cm's from the anal verge in the 3 O'Clock position. The skin in this area is becoming necrotic. 2. What would be your management? Drainage of the collection under a general anaesthetic through the area of compromised skin. A mushroom catheter placed into the cavity will decrease the incidence of abscess reaccumulation, which can be as high as 10%. The chance of there being an internal opening is high with the p rior episodes, however this may not be able to be found with probing in the acute situation. Overly aggressive attempts to find one may create a false age leaving the patient with an iatrogenic fistula.

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Case 169: 'My hernia wont go back in' This man was putting off having this incisional hernia repaired. It usually did not cause him much trouble, and if it did he could lie down and it would reduce. For the past 24 hrs it has been tender, painful and will not reduce when lying down.

1. What has happened? The hernia has incarcerated. A major ventral abdominal hernia of this size will almost certainly contain some bowel, which is now becoming compromised. 2. How would you repair this problematic hernia? Open technique, resecting non-viable bowel if required. If no resection needed then a repair reinforced with mesh would be ideal to prevent recurrence. 3. When will you do it? It is getting late, the operating theatre is free now but tomorrow there will also be some time at 11am. Tonight or tomorrow? Do it tonight. Tonight you will operate and hopefully just reduce contents and apply a mesh. Tomorrow you will be resecting bowel in an unwell patient.

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Case 170: Industrial Accident This gentleman was brought to ED complaining of pain in the left hand. He recalls being at work near a high pressure air tank and hearing a loud explosion. On examination, he has bleeding from the ears and his L hand is shown.

1. What is the diagnosis and how will you manage him? Although external soft tissue damage may seem minimal, this man's hand is swollen and is at risk of compartment syndrome. He needs neurovascular examination, imaging for structural damage and urgent plastics review.

2. You order an XR. What is shown? Comminuted fractures of the 2,3,4 metacarpal bones.

3. What can be done for him in theatre? GA + bracial plexus block (providing both perioperative and postoperative analgesia of up to 8Hours), fasciotomy, ORIF (K wires). The bleeding from the ears most likley represents ruptured tympanic membranes - as part of the blast injury. This injury will reqiure external auditory meatus examination, baseline audiometry and follow up by ENT surgeons.

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Case 171: Pain into the back A man fell and presented with back pain. The casualty doctor was worried about the appearance of the aorta.

1. Which vertebral body is affected? L2 - The second lumbar vertebral body.

2. If the aorta is 'damaged', what possible problems could arise? Rupture - retroperitoneal or free intraperitoneal rupture Dissection Embolism to the distal vessels - a cholesterol embolii from this calcified aortic wall could acutely occlude a lower limb vessel. Occlusion - due to acute thrombosis All of these eventualities would be unusual, even with this impressive X-ray appearance. 3. Which investigation is required? Firstly a careful lower limb neurological and vascular examination. this patient has a fractured spine and could possibly have cauda equina (or even conus medullaris / spinal cord) injury. A careful vascular history and examination should exclude significant major vessel compromise. A CT scan will demonstrate the bony abnormality and also any retroperitoneal haematoma.

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Case 172: Facial Lesion This boy had a lesion on his face which had been present for 6 weeks. It is not particulaly painful, but does bleed when irritated.

1. What is the diagnosis? A pyogenic granuloma 2. What treatment would you recommend? Excision and diathermy to the usually found feeding vessel. The lesion should be sent for histopathology to confirm the clinical suspicion, also a swab for micro will often grow staph aureus. The significance of the staph is not really known.

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Case 173: Scalp Lesion This lady says that she hit her head and the wound failed to heal. When asked how long ago that injury was her family think it may have been 6 months ago. They say that they have noticed a lesion there that has slowly grown bigger with time.

1. If you took a small punch biopsy of the edge of this lesion what do you think it may show? Most likely - Basal Cell Carcinoma, next Squamous cell carcinoma, amelanotic melanoma is also a possibility. Then possibly granulation tissue (if biopsy not accurate, foreign body reaction or mycobacterium infection) 2. The lesion feels to be fixed to the underlying pericranium. Now what are the options? This is the classical 'rodent ulcer' of a locally invasive BCC. Excision will need to involve at least the pericranium, the outer table of the skull, or more depending on its level of invasion. Case 174: Endoscopic technique

1.What is the procedure being performed? 2.What are the risks associated with this procedure?

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Case 175: Fat leg This elderly man has had longstanding bilateral calf oedema due to his mild right heart failure. After spending a few days in hospital he was noted to be increasingly short of breath. 1.Using the information from the photo, can you suggest a possible cause for his shortness of breath? A right leg deep vein thrombosis and subsequent pulmonary embolism. In fact this man on further inspection, can be seen to have swelling of the entire right thigh as well, indicating clinically, that the thrombosis extends well above the knee. On lower limb duplex ultrasonography there was a thrombosis extending proximally to the common iliac vein. This was not well captured in the photo, but clinically the patient had a Phlegmasia Cerulea Dolens.

Case 176: Very Fat leg This man has had a larger leg on the left side for many years. He first noticed this at the age of 37. Lately there are nodules developing and also the right leg is enlarging. He says that other memebers of his family have had leg swelling.

1.What process is shown? This man gives a history consistent with adult onset lymphoedema. The photo demonstrates developing lymphatic vesicles (or these could represent lymphangiomas or even lymphangiosarcomas) there is skin excoriation with some skin ulceration. This patient would most likley suffer repeated episodes of cellulitis. 2.What is this condition called? Hereditary lymphedema, or Nonne-Milroy-Meige disease. 3.What type? Type II - see below

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Case 177: Sore toe An 18 year old man presents to you with a painful right great toe. He had a similar problem with the left toe in the past and underwent surgery a few years ago.

1. What is the diagnosis? Ingrown toenail affecting both sides of the great toenail. 2. What operation has been performed on the left? Bilateral nail bed wedge excisions.

Case 178: Lump in the neck A 43 year old woman presents with a long history of a slowly enlarging mass in the neck. She nows considers it a cosmetic problem. 1. What is the diagnosis? Goitrous enlargement of the thyroid. Most likely benign multinodular goitre.

2. What issues in the history would you explore? Functional state Family history Risk of malignancy 3. What investigations would you arrange? Thyroid function tests - in particular TSH Thyroid US to assess the nodularity and extent of disease CT neck is appropriate for large thyoids with intrathoracic extension to allow planning of surgery. Note that iodine based intravenous contrast agents commonly istered during CT scans may precipitate hyperthroidism - the Jod-Basedow phenomenon.

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Case 179: Lumps on the arms A 39 year old man presents with poorly controlled hypertension. You note that he has multiple subcutaneous nodules on both his arms. He recalls that his mother had similar lumps.

1. What diagnostic features can you see? As well as the obvious subcutaneous nodules there are also pigemented cutaneous "cafe au lait" markings. 2. What is the diagnosis? These are features of neurofibromatosis type I and together with the family history of a similar condition the diagnosis is elatively certain. 3. Why is his blood pressure a problem? There is an increased incidence of adrenal phaeochromocytoma in the setting of NF1. Case 180: Chemotherapy access A young woman requires chemotherapy for a malignancy. You insert a tunnelled central venous access device with a port attachment and following the procedure obtain a chest xray in recovery as per protocol.

1. What does the xray show? 2. What are the options for mangement? 3. What is her underlying cancer?

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Case 181: Liver lesions

1. What does the xray show ? 2. What are the options for mangement ? 3. What is her underlying cancer ?

Case 182: Hypoglycaemia A 76 year old man is itted with acute confusion. He is found to have a random blood sugar of 1.2 mmol/l on ission. After being investigated by the endocrinology unit he is referred to you with a suspected insulinoma.

1. What investigations would you check to confirm the diagnosis? 2. How would you localise the tumour if it was not seen on CT scans?

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Case 183: Post operative pain A 46 year old man underwent a laparoscopic antireflux operation. He was discharged well but presented to the emergency department 5 days post op with severe right sided and epigastric abdominal pain. He was afebrile, not tachycardic and his abdomen was soft and non-tender.

1. What potential complications would concern you? 2. What does the CT scan show? Case 184: Hot Gallbladder This lady has had three days of severe upper abdominal pain. This pain began as a retrosternal pain following food. The pain was felt through to the back. It then settled in the right upper quadrant. Initial ultrasound scan was normal, HIDA scan then showed an obstructed cystic duct. By then the clinical picture of acute cholecystitis was clear and the patient was brought to theatre. An open cholecystectomy was required. 1. What complication has occurred? The process of acute cholecystitis has progressed to frank necrosis of the gallbladder wall.

2. What is the required treatment? Urgent cholecystectomy. This can often still be possible laparoscopically, however, conversion to open procedure is more likely when the process has been continuing for more than three or four days. It is in these cases that there is an inflamed, thickened, friable, and haemorrhagic omental mass wrapped around the gallbladder. There is often also an ileus which makes laparoscopic access difficult. The case for acutely operating an all patients presenting with cholecystitis before this situation develops is ed by the literature.

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Case 185: Breast lesion A 60 year old woman presents with a lesion on her right breast. She thinks it started as an insect bite but has been getting progressively worse over the last 6 months.

1. What is the diagnosis? This appears to be a locally advanced carcinoma of the right breast. It is stage T4b at least. 2. What investigations would you arrange? The diagnosis should be confirmed with mammography and core biopsy of the lesion. Then ffter appropriate history and examination to detect regional and systemic metastases she should undergo thorough staging. This includes FBE, LFTs and serum calcium. Imaging with bone scan and CT chest and abdomen would be appropriate with other investigations as directed by the clinical findings. 3. What are the principles of management? After staging there should be discussion in a multidisciplinary setting to plan therapy which takes into the patient's overall condition and wishes. Locally advanced tumours are typically treated with neoadjuvant chemotherapy and hormonal therapy followed by mastectomy and axillary clearnce to obtain locoregional disease control.

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Case 186: Epigastric pain and fever A 25 year old woman has been celebrating the end of her exams. Over the last few days she has been binge drinking. She now presents with epigastric and right upper quadrant pain associated with fever. The emergency department call you to see her as suspected complicated pancreatitis.

1. What is the diagnosis? The chest xray shows an air fluid level in the right hemithorax in the region of the middle lobe. This would indicate a lung abscess likely secondary to aspiration during an episode of intoxication. 2. What investigations would you arrange? A CT chest is useful to confirm the diagnosis and the anatomical location of the abscess. Sputum should be sent for microbiology. A bronchoscopy may be required to obtain adequate material for culture. Pancreatitis or other complications of alcohol abuse should be excluded with appropriate investigations such as serum amylase or lipase.

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Case 187: Severe abdominal pain A 42 year old man presents with sudden onset of severe, constant central abdominal pain. On examination his abdomen is distended but soft and only mildly tender.

1. What are the xray findings? There are several loops of small bowel seen within the central abdomen. They are distended and there is loss of the normal folds of plicae circulares. Adjacent loops of small bowel are separated by several millimetres indicating thickening of the bowel wall likely due to oedema. The colon contains gas throughout its length but is not distended and there are no diagnostic features in the colon. There is loss of the normal psoas shadow on the right possibly indicating retroperitoneal oedema but there are no other obvious soft tissue or boney abnormalities seen. The clinical picture of pain out of proportion to examination findings and abnormal small bowel on imaging raises the possibility of ischaemic small bowel. 2. What are the principles of management? Rapid fluid resuscitiation followed by urgent transfer to the operating theatre for exploratory laparotomy.

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Case 188: Scrotal lesion A 36 year old man presents with a painful lesion on his scrotum. Initially ne noticed a single nodule but several others have developed. The largest is now painful. He is concerned about cancer.

1. What is the diagnosis? Multiple sebaceous cysts are evident with a typical rounded appearance with central puntum and thick white sebaceous material contained within the cysts. The largest cyst is surrounded by erythema and oedema suggesting that it is infected. 2. What are the principles of management? Antibiotics and surgical removal of the sebaceous material. Once infected these cysts are more difficult to excise without rupture. It is important to remove the entire cyst wall to prevent recurrence.

Case 189: Abdominal pain A 75 year old man is referred in from his hostel with abdominal pain and bloating. He has a history of chronic constipation and laxative use. The emergency department has arranged an erect chext xray and call you with the result.

1. What sign does the xray demonstrate? Chilaiditi's sign or syndrome. This an anatomic variation where the hepatic flexure of the colon is located above the liver and below the diaphragm. It occurs usually in association with abnormalities of the falciform ligament and hepatic attachments to the diaphragm.

2. What treatment is required for this syndrome? The condition requires no specific treatment and is usually an incidental asymptomatic finding. It's importance is that it mimics free gas under the diaphragm and may prompt unnecessary laparotomy.

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Case 190: Abdominal ultrasound A 45 year old woman presents with constant severe right upper quadrant abdominal pain. You arrange an abdominal ultrasound scan. This is a transverse image of the gallbladder.

1. What does the ultrasound demonstrate? 2. What additional features would you look for on ultrasound to a diagnosis of acute cholecystitis? Case 191: Nipple lesion A 60 year old woman is referred to you with a rash on her nipple.

1. What is the most likely diagnosis? 2. How would you confirm the diagnosis?

2. What are the principles of management?

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Case 192: Stabbing A 35 year old woman is found collapsed at home. She has a history of depression and a suicide note is found beside her. She has no other injuries. You are asked to assess her in the ED.

1. Describe the important anatomical features of this wound? 2. What symptoms and signs would you look for? 3. What investigations may be useful in the stable patient with this injury? Case 194: Trauma

A 16 year old boy fell off a balcony onto his left side. He is brought into the emergency department with severe left abdominal and chest pain. He is haemodynamically unstable but responds adequately to fluid resuscitation. An urgent CT scan is performed.

1. What is the major abnormality demonstrated? 2. What are the options for management if this is an isolated injury? 3.What diagnostic and therapeutic procedure has been performed?

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