SurgicalShort-CaseMadeEasy

Surgical Short-Case Made Easy:
A Handbook

Yan Naing Soe
Editor:

Nasser Muhammad Amjad

Surgical Short-Case Made Easy:
A Handbook

Surgical Short-Case Made Easy:
A Handbook

Dr Yan Naing Soe
Clinical Associate Professor
Department of Surgery, FMHS, UTAR

Editor:
Professor Dr. Nasser Muhammad Amjad, Professor of Surgery,
Faculty of Medicine, International Islamic University Malaysia (IIUM),

Kuantan, Malaysia

Medical Education Unit Editorial Committee Members:
Clinical Professor Dr. Ng Teck Han, Deputy Dean,
Faculty of Medicine & Health Sciences, UTAR

Associate Professor Dr. Myo Oo, Medical Education Unit,
Faculty of Medicine & Health Sciences, UTAR

Dr Hnin Pwint Phyu, Secretary, Medical Education Unit,
Faculty of Medicine & Health Sciences, UTAR

Surgical Short-Case Made Easy: A Handbook
©UTAR
April 2022

All rights reserved. No part of this handbook may be used or reproduced in any means electronic,
mechanical, photocopying, recording or social media whatsoever without the written permission of the
publisher / principle author.

eISBN: 978-967-2477-04-4

Published in Malaysia by:
UNIVERSITI TUNKU ABDUL RAHMAN
Jalan Sungai Long, Bandar Sungai Long, Cheras, 43000 Kajang, Selangor, Malaysia.
Tel:+603-90860288
Email: [email protected]

Editor: Professor Dr. Nasser Muhammad Amjad, Professor of Surgery,
Faculty of Medicine, International Islamic University Malaysia (IIUM), Kuantan, Malaysia

Medical Education Unit Editorial Committee Members:
1. Clinical Professor Dr. Ng Teck Han, Deputy Dean, Faculty of Medicine & Health Sciences, UTAR
2. Associate Professor Dr. Myo Oo, Medical Education Unit, Faculty of Medicine & Health Sciences,

UTAR
3. Dr Hnin Pwint Phyu, Secretary, Medical Education Unit, Faculty of Medicine & Health Sciences,

UTAR

Artist: Ms Wong Lee Chee

Photographs Illustration:
UTAR Alumni: Dr Pang Kah Junn, Dr Lim Ming Yee, Dr Soon Chai Yean, Dr Sopia Nocalina, Dr
Brenda Ee Wei Xin, Dr Goh Qing Xiang

MBBS medical students: Mr Wong Yit Mun, Mr Goh Jun Hong, Mr Tan Zhen Han, Mr Lim Boon Chai,
Mr Reuben

Photographs: Dr. Nay Win Than and Dr. Nor Mular Paw, Consultant Surgeon, Yangon Myanmar

Perpustakaan Negara Malaysia Cataloguing-in-Publication Data

Yan, Naing Soe, Dr.,
Surgical Short-Case Made Easy : A Handbook / Dr Yan Naing Soe ;
Editor: Professor Dr. Nasser Muhammad Amjad.
Mode of access: Internet
eISBN 978-967-2477-04-4
1. Surgery--Handbooks, manuals, etc.
2. Surgery, Operative--Handbooks, manuals, etc.
3. Physicians--Practice--Handbooks, manuals, etc.
4. Electronic books.
I. Nasser Muhammad Amjad, Prof., Dr. II. Title.
617.9



FOREWORD

Thank you very much for inviting me to write a foreword for this handbook.
“Surgical Short-Case Made Easy” handbook is an exciting new book that consists of core
information needed by medical students in the run up not only to approach to the patient in the
daily clinical practice but also for the examinations. It encompasses approach to the common
short cases in surgery. Every condition is discussed under the key headings of applied anatomy,
aetiology, differential diagnoses, approach to the patient and preparation for the discussion.

As I reviewed the manuscript of this handbook, I was impressed by many unique features such
as informative diagrams, tables and photographic illustrations. In this way, information is easily
accessible, digestible and be remembered. Each module opens with an overview of clinical
examination method to assure mastery in clinical data collection. This handbook is written
specifically for medical students as essential revision preparation, for junior doctors as a
refresher and for other allied health professionals who want a quick reminder of key facts and
data.

All contributors of this handbook deserve a pat on their back in producing this first edition
which was edited by senior professors from UTAR and International Islamic University
Malaysia (IIUM), consultant surgeons from Singapore and Myanmar. It was also reviewed by
Medical Education Editorial Board Committee Members, Faculty of Medicine and Health
Sciences (FMHS), UTAR. This handbook reflects the international collaborative effort of the
chief editor and Medical Education Unit, FMHS, UTAR.

I congratulate the inspirational work led by the chief editor and his team members to
accomplish this work of art which contains so much practical and useful information.
“Surgical Short-cases Made Easy” handbook is a guide to enlighten the medical students to be
confident and competent in their daily clinical practice.

Enjoy your reading!

By
Academician Emeritus Professor Dr. Cheong Soon Keng, FASc
Dean, Faculty of Medicine and Health Sciences, UTAR

v

PREFACE

Learning medicine in the twenty first century is to achieve the goal of good clinical practice in
our future professional career. In order to achieve the goal, trainees must have a great essence
of clinical approach to the patient. The essence of approach to a patient is based on the three
fundamental pillars: basic science knowledge, clinical skills and professionalism.
The book is designed on the modules style and each module exhibits an initial explanation of
applied basic science knowledge followed by the approach to the patient with professionalism.
It is also focus on the enhanced clinical examination methodology to attain the precise clinical
findings during the physical examination.
It is important to spend the time to study applied anatomy knowledge which is the basic
foundation of approach to the patient in surgery.
For the trainees, as long as you have willingness to learn and practice your set-goal would be
achieved regardless of how high it is.
“Practice does not always make you to be confident and competent. Practice with good applied
knowledge, skills and attitude, will make you to be confident and competent”
The last but not the least, I would like to advise trainees to spend most of your time in a field:
wards, day-care unit, operation theatre to enrich your knowledge, psychomotor skills and soft
skills.
Finally, I hope this book will be fruitful resources for the trainees in the surgery posting not
only to pass the exam with flying colours, but to take it as a guide for the approach to the
surgical patients in your future career.

By
Clinical Associate Professor Dr. Yan Naing Soe
Department of Surgery, FMHS, UTAR

vi

ACKNOWLEDGEMENT

I am deeply grateful to Ms Wong Lee Chee who volunteered to contribute the diagrams in this
book. Thank you so much for your impressive work of art.
I would like to extend my sincere thanks to the UTAR MBBS students and Alumni for your
great help in volunteering photograph illustration in this book.
I would like to express my deepest appreciation to Dr Nay Win Than and Dr Mular Paw for
providing the photographs.

Artist:
Ms Wong Lee Chee Year-3 UTAR MBBS student: an artist who contributed the drawing of all
the diagrams in this book.

Volunteers for photographs illustration:
UTAR Alumni: Dr Pang Kah Junn, Dr Lim Ming Yee, Dr Soon Chai Yean, Dr Sopia Nocalina,
Dr Brenda Ee Wei Xin, Dr Goh Qing Xiang
MBBS medical students: Mr Wong Yit Mun, Mr Goh Jun Hong, Mr Tan Zhen Han, Mr Lim
Boon Chai, Mr Reuben

Photographs
1. Dr. Nay Win Than, Consultant Surgeon, Yangon Myanmar
2. Dr. Nor Mular Paw, Consultant Surgeon, Yangon, Myanmar

Volunteers for photographic illustrations, artist, patients, student reviewers and editorial
committee members who involved in the process of publication of this handbook, contributed
greatest effort to establish this book.
All the contributors agreed to publish handbook for the purpose of dynamic development in
the medical education.
It will be distributed as an e-book format and all the students can be able to access it free.

vii

EXECUTIVE SUMMARY

Safe surgery is a fundamental principle in our daily surgical practice. The word “practice of
surgery could be the synonym of “precision”. That is the reason why, wiseman usually says
“surgical strike”. The precision and safety based on critical decision making are our goals in a
field of surgical practice. To achieve the goal, we must approach the patient with surgical
crescendo.

The surgical crescendo consists of:

i. Gathering important information in the history taking
ii. Evaluation of patient’s condition (It is an important step not to miss the life threatening

condition which require immediate treatment)
iii. Performing methodical clinical examination
iv. Clinical correlation with applied basic science knowledges
v. Formulate the provisional diagnosis and exclude the possible differential diagnoses

based on clinical findings
vi. Preparing to proceed with investigations to confirm the diagnosis and investigations to

assess the severity (or) staging of malignancy
vii. Shared decision making in the management

Trainees should also understand the importance of surgical filter which is the process of
systematic analytical evaluation of possible aetiologies which include:

(1) Congenital causes (Developmental anomalies)
(2) Acquired

(i) Trauma
(ii) Infection (Acute/ Chronic)
(iii) Degenerative causes
(iv) Metabolic causes
(v) Neoplastic causes (Benign or Malignant)
(vi) Autoimmune causes
(vii) Iatrogenic causes
(viii) Idiopathic causes

Surgical crescendo and surgical filter are fundamental principles to achieve the precise decision
making to meet the goal: safe surgery.

This book is designed as an e-book format. It consists of nine modules in which common
surgical short cases are illustrated with tables, diagrams and photographs. In addition to that,
each module includes approach to the patient with details of examination steps.

viii

FOREWORD............................................................................................................................v
PREFACE................................................................................................................................vi
ACKNOWLEDGEMENT.....................................................................................................vii
EXECUTIVE SUMMARY ................................................................................................. viii
LIST OF FIGURES .................................................................................................................x
LIST OF TABLES ............................................................................................................... xiii
Module-1 Approach to the Patient for Abdominal Examination........................................1

1a. A case of acute abdomen ............................................................................................................. 1
1b. A case of mass in abdomen.......................................................................................................... 3
1c. A case of stoma............................................................................................................................. 7
1d. A case of incisional hernia/ umbilical hernia ...........................................................................19
Module-2 A Case of Lump in the Breast .............................................................................23
Module-3 A Case of Anterior Neck Swelling.......................................................................33
Module-4 A Case of Inguino-Scrotal Swelling ....................................................................50
Module-5 A Case of Lump ....................................................................................................60
Module-6 A Case of an Ulcer ................................................................................................67
Module-7 A Case of Varicose Veins .....................................................................................71
Module-8 A Case of Ischaemic Limb ...................................................................................79
Module-9 Digital Rectal Examination & Proctoscopy .......................................................88
REVIEWERS .........................................................................................................................96
REFERENCES.......................................................................................................................98
INDEX.....................................................................................................................................99

ix

LIST OF FIGURES

Fig. 1: Nine regions of abdomen .............................................................................................2
Fig. 2: Inspection of the abdomen ..........................................................................................5
Fig. 3: Surgical scars................................................................................................................6
Fig. 4: Laparoscopic Cholecystectomy Scars ........................................................................7
Fig. 5: End pelvic stoma ..........................................................................................................8
Fig. 6: Loop stoma....................................................................................................................8
Fig. 7: Double barrel stoma.....................................................................................................8
Fig. 8: Exteriorization..............................................................................................................8
Fig. 9: Cough impulse at the hernia orifices..........................................................................9
Fig. 10: Superficial palpation................................................................................................10
Fig. 11: Deep palpation..........................................................................................................10
Fig. 12: Rovsing’s Sign ..........................................................................................................11
Fig. 13: Murphy’s Sign ..........................................................................................................12
Fig. 14: Boas’s Sign ................................................................................................................13
Fig. 15: Stoma.........................................................................................................................14
Fig. 16: Palpation of liver ......................................................................................................14
Fig. 17: Percussion of liver ....................................................................................................15
Fig. 18: Percussion of spleen .................................................................................................16
Fig. 19: Palpation of spleen ...................................................................................................16
Fig. 20: Ballotable kidneys ....................................................................................................16
Fig. 21: Ballotable kidneys ....................................................................................................16
Fig. 22: Fluid thrill.................................................................................................................17
Fig. 23: Percussion of shifting dullness ................................................................................17
Fig. 24: Percussion of shifting dullness ................................................................................18
Fig. 25: Percussion of distended bladder .............................................................................18
Fig. 26: Renal punch ..............................................................................................................19
Fig. 27: Incisional hernia (Upper mid-line surgical scar) ..................................................20
Fig. 28: Auscultation of bowel sounds..................................................................................21
Fig. 29: Palpation of Anterior group of axillary lymph nodes...........................................23
Fig. 30: Axillary lymph nodes (Operative surgical classification).....................................24
Fig. 31: Lymphatic drainage of breast (Anatomical classification) ..................................24
Fig. 32: Palpation of breasts..................................................................................................26
Fig. 33: Peau-d’-orange .........................................................................................................27
Fig. 34: Cancer -en- Cuirasse................................................................................................27
Fig. 35: Phyllodes Tumour ....................................................................................................27
Fig. 36: Unilateral nipple retraction.....................................................................................27
Fig. 37: Left breast abscess which is complicated as a sinus and discharging pus ..........28
Fig. 38: Palpation of breast ...................................................................................................29
Fig. 39: An infected malignant ulcer ....................................................................................29
Fig. 40: Brawny arm ..............................................................................................................29
Fig. 41: Palpation of axillary lymph nodes ..........................................................................30
Fig. 42: Palpation of supraclavicular lymph nodes.............................................................31
Fig. 43: Applied anatomy of thyroid ....................................................................................33
Fig. 44: Lymph nodes of head and neck ..............................................................................34
Fig. 45: General examination................................................................................................37

x

Fig. 46: Inspection of patient’s eyes......................................................................................37
Fig. 47: Exophthalmos ...........................................................................................................38
Fig. 48: Exophthalmos ...........................................................................................................38
Fig. 49: Diffuse goitre ............................................................................................................39
Fig. 50: Solitary thyroid nodule............................................................................................39
Fig. 51: Multinodular goitre..................................................................................................40
Fig. 52: Swallowing test .........................................................................................................40
Fig. 53: Tongue protrusion test.............................................................................................41
Fig. 54: Palpation of neck......................................................................................................42
Fig. 55: Palpation of carotid artery pulsation .....................................................................42
Fig. 56: Auscultation..............................................................................................................43
Fig. 57: Palpation of trachea .................................................................................................43
Fig. 58: Percussion of retrosternal extension ......................................................................44
Fig. 59: Test: proximal myopathy ........................................................................................44
Fig. 60: Tremors.....................................................................................................................45
Fig. 61: Reflexes .....................................................................................................................45
Fig. 62: Eye sign .....................................................................................................................46
Fig. 63: Chvostek’s sign.........................................................................................................47
Fig. 64: Trousseau’s signs .....................................................................................................48
Fig. 65: Hesselbach’s triangle ...............................................................................................50
Fig. 66: Location of testis in case of ectopic testis and incompletely descended testis.....51
Fig. 67: Femoral triangle and femoral canal .......................................................................52
Fig. 68: Undescended testis ...................................................................................................54
Fig. 69: Carcinoma of penis ..................................................................................................54
Fig. 70: Phimosis ....................................................................................................................55
Fig. 71: Inguinal hernia .........................................................................................................55
Fig. 72: Bilateral scrotal swelling .........................................................................................55
Fig. 73: Deep ring occlusion test: bilateral direct inguinal hernia ....................................56
Fig. 74: Epididymo-orchitis...................................................................................................57
Fig. 75: Dercum’s disease ......................................................................................................61
Fig. 76: Sebaceous cyst ..........................................................................................................61
Fig. 77: Dermoid cyst.............................................................................................................62
Fig. 78: Cervical Lymphadenitis ..........................................................................................62
Fig. 79: Cellulitis ....................................................................................................................62
Fig. 80: Fluctuation sign ........................................................................................................63
Fig. 81: Transillumination test .............................................................................................63
Fig. 82: Lobulated surface: Lipoma .....................................................................................64
Fig. 83: Slipping sign..............................................................................................................65
Fig. 84 & 85: Indentation sign ..............................................................................................65
Fig. 86: Edges of ulcers..........................................................................................................67
Fig. 87: Carbuncle.................................................................................................................68
Fig. 88: Healing ulcer.............................................................................................................68
Fig. 89: Venus ulcer ...............................................................................................................69
Fig. 90: Malignant ulcer (Melanoma) ..................................................................................69
Fig. 91: Veins of lower leg .....................................................................................................71
Fig. 92: Perforators at thigh..................................................................................................72
Fig. 93: Varicose veins ...........................................................................................................75
Fig. 94: Venous ulcer .............................................................................................................75
Fig. 95: Lipodermatosclerosis ...............................................................................................75
Fig. 96 & 97: Trendelenburg test..........................................................................................76

xi

Fig. 98: Arteries of lower leg .................................................................................................79
Fig. 99: Ischemic limb............................................................................................................81
Fig. 100: Acute limb ischaemia .............................................................................................82
Fig. 101: Critical limb ischemia............................................................................................82
Fig. 102: Palpation of femoral artery pulse .........................................................................84
Fig. 103: Palpation of popliteal artery pulse .......................................................................84
Fig. 104: Palpation of posterior tibial artery pulse .............................................................85
Fig. 105: Palpation of dorsalis pedis artery pulse ...............................................................85
Fig. 106: Digital rectal examination .....................................................................................89
Fig. 107: Rectal prolapse .......................................................................................................90
Fig. 108: Fistula in ano ..........................................................................................................90
Fig. 109: Prolapsed hemorrhoids..........................................................................................91
Fig. 110: Digital rectal examination .....................................................................................92
Fig. 111: Digital rectal examination .....................................................................................92
Fig. 112: Digital rectal examination .....................................................................................93
Fig. 113: Digital rectal examination .....................................................................................93

xii

LIST OF TABLES

Table 1: Acute abdomen..........................................................................................................1
Table 2: Layers of abdominal wall .........................................................................................2
Table 3: Differential diagnoses of mass in abdomen ............................................................3
Table 4: Indications for stoma ................................................................................................7
Table 5: Complications of stoma ............................................................................................8
Table 6: Tubes and drains.......................................................................................................9
Table 7: Causes of hepatomegaly and splenomegaly..........................................................15
Table 8: Different methods of tissue biopsy ........................................................................25
Table 9: Aberration of normal development and involution .............................................25
Table 10: Principles of approach to the patient with anterior neck swelling...................35
Table 11: Anatomical variants of indirect inguinal hernia................................................51
Table 12: Boundaries of femoral canal ................................................................................52
Table 13: Different types of inguinal hernia........................................................................53
Table 14: Common causes of lesion based on the tissue plane ..........................................60
Table 15: Special types of ulcers...........................................................................................67
Table 16: Complications of deep vein thrombosis ..............................................................73
Table 17: Etiology and presentation of chronic ischaemic limb........................................80

xiii

Module-1 Approach to the Patient for Abdominal Examination

1a. A case of acute abdomen

Table 1: Acute abdomen
Acute abdomen

It is defined as a patient presents with an acute onset of severe abdominal pain which is
strongly indicated for the patient to be admitted for the further investigations.

Regions Differential diagnoses
Epigastric pain Peptic ulcer diseases, pancreatitis, Myocardial infarct, Gastro-
Right Hypochondrial esophageal reflux diseases etc.
pain
Left hypochondrial pain Cholecystitis, Liver abscess, Hepatitis, Pyelonephritis, Renal
Peri-umbilical pain colic, Empyema gallbladder, Cholangitis, Lower lobe pneumonia
etc.
Right iliac fossa pain
Left iliac fossa pain Pyelonephritis, Renal colic, Splenic abscess, Gastric ulcer, Lower
lobe pneumonia etc.

Intestinal obstruction, Mesenteric adenitis, Meckel diverticulitis,
Appendicitis, Aortic aneurysm, Strangulated umbilical hernia,
Infected urachal cyst

Mesenteric adenitis, Appendicitis, Enterocolitis, Ureteric colic,
Gynecological problems etc.

Diverticulitis, Enterocolitis, Ureteric colic, Gynecological
problems etc.

Applied Surgical Anatomy

“Nine regions of the Abdomen”

Subcostal plane: 10th costal cartilage (L3): Upper transverse line
Lower subcostal margin corresponds to the 10th costal cartilage and draw the line between two
points.

Trans-tubercular plane: Tubercles iliac crest (L5) Lower Transverse line
Find the mid axillary line and go in a downward direction and then you feel the bony
prominence which is an iliac tubercle: draw the line between two tubercles.

Mid clavicular point & Mid inguinal point: Two vertical lines
Find the anterior superior iliac spine, and then locate the pubic symphysis. Draw the line
between these two bony landmarks and find the mid-point which is the mid-inguinal point.
Draw the line between mid-clavicular point and mid-inguinal point.

1

Fig. 1: Nine regions of abdomen

Table 2: Layers of abdominal wall

Abdominal wall Layers of abdominal wall

Above the arcuate line Skin

Fascia Camper and Fascia Scarpa

Linea alba

Anterior and posterior aponeurosis

Transversalis Fascia

Peritoneum

Midline below the arcuate line Skin
Fascia Camper and Fascia Scarpa
Linea alba
(lack of posterior aponeurosis)
Transversalis Fascia
Preperitoneal pad of fat
Peritoneum

Right subcostal Skin
Fascia Camper and Fascia Scarpa
Aponeurosis of external oblique muscles
External oblique muscle
Aponeurosis of internal oblique muscles
Internal oblique muscle
Transversus muscle
Transversalis aponeurosis
Preperitoneal pad of fat
Peritoneum

2

1b. A case of mass in abdomen

Differential diagnoses of (Intraperitoneal) mass in abdomen

Table 3: Differential diagnoses of mass in abdomen

Mass in Epigastrium Mass in Right Iliac Fossa

Carcinoma of stomach Appendicular mass

Pancreatic pseudocyst Carcinoid tumour

Transverse colon tumour Carcinoma of caecum

Gastrointestinal stromal tumour Tuberculous intestine

Hepatomegaly (left lobe) Inflammatory bowel disease

Undescended testis

Ectopic kidney

Lymphoma

Psoas abscess

Carcinoma of Ovary (female)

Ovarian cysts (female)

Pedunculated fibroid

Courvoisier’s Law:
 In a patient with jaundice, if the gallbladder is palpable, it is unlikely due to stones. It
is likely due to malignancy such as cholangiocarcinoma, carcinoma of head of pancreas
and periampullary carcinoma.
 Explanation: If it is due to stones, gallbladder might be fibrosed cause by previous
recurrent infection.
 Exceptions: (1) Low insertion of cystic duct (2) double stone impaction

Charcot’s triad: Complex presentation of intermittent pain, fluctuating jaundice and
intermittent fever in case of ascending cholangitis.

Calot’s triangle: It is a triangle bounded by the cystic duct inferiorly, common hepatic duct
medially and lower edge of liver superiorly. Surgically important contents of this triangle is
identification of cystic artery and node of lund.

Saint’s triad: It is an association of hiatus hernia, cholelithiasis and colonic diverticular disease
in a patient with atypical abdominal symptoms.

Virchow’s triad: The triad consists of venous stasis, vessel damage and state of
hypercoagulability and is used to describe the aetiology and assess the risk of thrombosis
especially of deep vein thrombosis

Goodsall’s rule: It states that if the perianal skin opening is posterior to the transverse anal line
(a line of 3 O’ clock and 9 O’ clock position), the fistulous tract will open into the anal canal

3

in the midline posteriorly, sometimes taking a curvilinear course. A perianal skin opening
anterior to the transverse anal line is usually associated with a radial fistulous tract.

“Spaces in the peritoneal cavity”
 Right subphrenic space
 Morrison pouch
 Lesser sac
 Right para colic gutter
 Left subphrenic space
 Left paracolic gutter
 Pouch of Douglas

These spaces are common locations for the collection of intraperitoneal fluid, in case of sepsis,
perforation or leakage of anastomosis.

Lines of Langerhans: Understanding the direction of Langer’s lines is important to decide an
incision in surgical operation not only for the betterment of post-operative pain relief but also
for the acceptable cosmetic outcome.

Approach to the Patient

Patient Preparation

Patient:
 Lying flat on bed/ hard couch with pillow
 Expose from the nipple line to the mid-thigh/ lower exposure up to the pubic
symphysis level is an option/ cover the lower abdomen with blanket
 Arms at the side of the body with the legs extends straight
 Breathe slowly
 If needed ask patient to flex the knee 90 degree and hip joint 45 degree to achieve the
utmost relaxation state in a patient with a tense, tender or distended abdomen
 If it is needed, place extra pillow behind the patient’s head

Examiner:
 Hands should be warm, short nails
 Whole hand and forearm should be horizontal with semi-flex elbow joint
 Sit or kneel beside the right side of the patient bed
 Eyes contact with the patient all the time

Material:
 Surgical gloves, stethoscope, alcohol hand rub, tissue paper, yellow bin, blanket
 Proctoscope, lubricant, light source, sponge forceps

Examinations Steps

A. Building Rapport
 Greet the patient & introduce yourself
 Explain the patient what procedure is to be done

4

 Obtain the permission
 Third party, privacy
 Hand rubs before the examination
 Place the patient in correct position
 Adequate exposure

B. Inspection
 General description of patient (Conscious level, patient’s general attitude, pain/
distress, body built/cachexia, pallor, jaundice, needle marks, scratch marks)
 Inspect the abdomen (nine regions) from the end of the bed (flank fullness/ distension)
 Inspect the abdomen from the foot-end side of the bed

Fig. 2: Inspection of the abdomen

 Ask the patient to cough and observe the reaction of patient
 Check the groin (hernial orifices) while the patient coughs
 Movement of abdominal wall with respiration
 Shape and contour of abdomen
 Symmetry of abdomen (right and left flank fullness)
 Abdominal distension (describe type) if any
 Comment on the umbilicus (position, abnormalities)
 Description of positive and relevant negative findings: Surgical scar, stoma/ obvious

clinical signs, mass, fistula, peristaltic waves, dilated veins/ (Caput medusae), Grey
Turner’s signs (bruising in the flank), Cullen’s sign (bruising around the umbilicus),
Sister Mary Joseph nodules (metastatic lesion of intra-abdominal malignancy involving
umbilicus), tubes, drainage tubes, dressings etc.)

5

If there is a scar
 Describe the old scar(s): Name, location, estimated length, status of healing and
visible cough impulse.

Fig. 3: Surgical scars

6

Fig. 4: Laparoscopic Cholecystectomy Scars

If there is a mass

 Describe: site, size, shape, surface, condition of surrounding area & overlying skin,
cough impulse etc.

1c. A case of stoma

If there is a stoma:
 Location & type of stoma, contents of stoma bag, condition of surrounding skin, look
for surgical scar
 Describe the old scar: Name, estimated length, status of healing, visible cough
impulse
 Description of cough impulse (groin, umbilicus, in the old surgical scar, if any)

Table 4: Indications for stoma
Indications for stoma

1 Decompression Temporary loop stoma: To decompress the intestinal
obstruction

2 De-functioning Temporary double barrel stoma: To heal the chronic large
wound in the perianal region

3 Diversion Temporary loop stoma: To heal the distal anastomosis

4 Part of the surgical Permanent end stoma: After abdominoperineal resection
procedure Temporary end stoma: Hartmann’s procedure

7

Fig. 5: End pelvic stoma Fig. 6: Loop stoma

Fig. 7: Double barrel stoma Fig. 8: Exteriorization

Table 5: Complications of stoma
Complications of stoma

General Local
Diarrhoea
Early Late
Bleeding Stenosis

Psychological effect Necrosis Prolapse

Nutritional deficiency Retraction Parastomal herniation

Obstruction Skin related complications

8

Fig. 9: Cough impulse at the hernia orifices

If there are tubes & drains:
 Describe the type of tube(s)/ drain(s), location, status of wound/ dressing, contents in
the tube or collecting bag

Table 6: Tubes and drains Complications Timing of removal
Tubes / Drainage Indications Tube related When the purpose is
complications fulfilled.
Abdominal To drain the Ascending infection
drainage tube residual Pressure necrosis When the tract is
intraperitoneal Tube related matured (10-14 days)
fluids complications After T-tube
cholangiogram
T-tube To prevent the bile Distal blockage When patient is
leakage after clinically well
choledochotomy

C. Palpation

Superficial palpation
 Ask the patient whether there is any pain anywhere in the abdomen
 Starts with the superficial palpation in all regions of abdomen sequentially
 Place your palm on the patient’s abdomen and used gentle flexion at the metacarpo-
phalangeal joint

9

 Eyes contact with patient: your aim of examination is to detect the signs of
“Peritonism”: guarding & rigidity.

Fig. 10: Superficial palpation
Deep palpation

 Deep palpation in all regions of abdomen (Start to palpate away from the region of
tenderness)

 Watching patient’s face during palpation for grimaces

Fig. 11: Deep palpation

10

If there is a mass:
Confirm the findings from inspection, temperature, tenderness, mobility, reducibility,
pulsations Etc) head (or) leg rising test to differentiate between intraperitoneal lesion and lesion
arising from the abdominal wall. This is significant in mid-line swellings as majority of patient
contracts the rectus abdominis muscles during the test.

If there are signs of peritonitis:
 Based on the underlying pathology elicits the clinical signs such as
 (Rebound tenderness, Murphy’s sign, Boas’s sign, Rovsing’s sign, Psoas sign,
Obturator sign, Dunphy’s sign etc.)

Rebound tenderness
 Rebound tenderness is a sign of peritonitis.
 Usually, it is elicited in the right or left iliac fossa regions.
 Ask patient to relax and to take a regular deep breath.
 Place your palm on the iliac fossa region and give a gentle pressure while patient is in
the state of expiration.
 Then, release your hand and check whether there is expression of pain in the patient.
 You must be very careful during eliciting this test because patient might be in pain.
 The pain is caused by the sudden stretching of parietal peritoneum when you released
your examining hand suddenly.
 Parietal peritoneum is supplied by somatic nerve and visceral peritoneum is supplied
by autonomic nervous system.

Fig. 12: Rovsing’s Sign

Rovsing’s sign
 This clinical sign is to support the diagnosis of acute appendicitis.
 Ask patient to relax and to take a regular deep breath. Place your palm on the left iliac
fossa region and give a gentle pressure while patient is in the state of expiration. Then,
release your hand and check whether the patient experience pain at the right iliac fossa
region.
11

 You must be very careful during eliciting this test because patient might be in pain. The
pain is caused by the sudden stretching of parietal peritoneum of right iliac fossa region
when you release your examining hand suddenly.

 Parietal peritoneum is supplied by somatic nerve and visceral peritoneum is supplied
by autonomic nervous system.

Murphy’s sign
 This clinical sign is to support the diagnosis of acute cholecystitis.
 Ask patient to relax and to take a regular deep breath.
 Place your palm on the right hypochondrium region (Tips of your fingers or your thumb
must be just below the tip of the 9th costal cartilage) and give a gentle pressure while
patient is in the phase of expiration.
 Then, wait until the inspiration phase when patient’s liver moves in a downward
direction together with the inflamed gall bladder and patient catches his/her breath due
to pain.
 In a patient with gross hepatomegaly, the surface anatomical location of gallbladder
to elicit the Murphy’s signs might be lower than normal as an enlarged liver will push
the gallbladder downward.

Fig. 13: Murphy’s Sign

Boas's sign
 Boas's sign is hyperesthesia (increased or altered sensitivity) below the right scapula.
 This sign referred to point tenderness in the region to the right of the 10th to 12th thoracic
vertebrae. It is positive in the case of acute cholecystitis.
 Boas' sign can also indicate stomach and duodenal disease.

12

Fig. 14: Boas’s Sign

Psoas sign
 Ask the patient to lie in the left lateral position and gently hyperextend the patient’s
right leg with the knee straight.

It is also called Cope's psoas test or Obraztsova's sign, is a medical sign that indicates
irritation to the iliopsoas group of hip flexors in the abdomen, and consequently indicates
that the inflamed appendix is retrocaecal in orientation

Obturator sign
 Ask the patient to lie flat. Place right hip and knee joint in a 90-degree flexion position.
 Then, you hold the patient ankle with one hand and knee with other hand.
 Gently rotate internally the hip by moving patient’s ankle away from the patient’s body
while allowing the knee to move inward direction.
 This is the flexion and internal rotation of hip. In case of inflamed appendix, it will be
in touch with obturator internus muscle and stretching this muscle cause pain.

Dunphy’s sign
 Ask patient to cough. This will produce pain in the right lower quadrant because of
tension (stretch receptor) in the inflamed parietal peritoneum (localized peritonitis).

If there is a stoma:
 Confirm the finding from the inspection for the old scar: palpate for scar tenderness,
and cough impulse.

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Fig. 15: Stoma

If cough impulse is positive:
 Ask patient is there any area of tenderness or not, and inquire the status of reducibility,
of the swelling.
 Palpate the neck of the incisional hernia, estimate the diameter of the hernia neck,
palpate the consistency of hernia contents (Note: to listen the bowel sounds if it is
irreducible.

Palpate the liver
 Instruct the patient to take slow and deep breath regularly, palpation starts from the
right iliac fossa region.
 Press gently during expiration phase of patient and wait until the end of inspiration,
then move examining hands in an upward direction.
 If you can palpate the liver, describe, edge, movement with respiration, surface,
tenderness. etc.
 Complete your liver examination with percussion. Start from second intercostal space,
mid clavicular line to the upper border and then percuss the abdomen move upwards to
identify the lover border. Measure the liver span.

Fig. 16: Palpation of liver

14

Fig. 17: Percussion of liver

Table 7: Causes of hepatomegaly and splenomegaly

Causes of hepatosplenomegaly

No. Surgical causes of Splenomegaly Hepatosplenomegaly

Hepatomegaly

1 Portal hypertension Portal hypertension Portal hypertension (Chronic liver

diseases)

2 Liver abscess Splenic abscess Spherocytosis

3 Hepatic adenoma Splenic vein Viral infection (Epstein-Barr virus,

thrombosis Cytomegalovirus, Viral Hepatitis)

4 Focal nodular hyperplasia Lymphoma Malaria. Leishmaniasis

5 Hemangiomas Tuberculosis Systemic-Lupus-Erythematosus,

Amyloidosis, Sarcoidosis,

6 Liver cysts Vascular tumour Hematological Malignancies

7 Secondary metastasis Etc. Etc.

8 Veno-occlusive disease

9 Metabolic disease

10 Choledochal cyst/ Biliary

atresia

If gallbladder is palpable
 Gallbladder is usually not palpable.
 If it is palpable, usually located below the tip of the 9th costal cartilage mid-clavicular
line as a rounded or globular mass which moves with respiration.
 Describe it as a routine description of a mass.

Palpate the spleen
 Instruct the patient to take slow and deep breath regularly, palpation starts from the
right iliac fossa region.
 Press gently during expiration phase of patient and wait until the end of inspiration.
 Then move examining hands oblique direction toward the splenic bed area
 If you can palpate the spleen, describe, edge, movement with respiration, surface, notch,
tenderness etc.)

15

 Complete your spleen examination with percussion. Start from Traube space.

Fig. 18: Percussion of spleen Fig. 19: Palpation of spleen

Ballot both kidneys
 Place your left hand behind the patient’s back, at the right flank
 Place your right hand just below the right costal margin in the right flank
 Press your right hand’s fingers deep into the abdomen
 At the same time press with your left hand
 Ask the patient to take a deep breath

 You may feel the lower pole of the kidney moving inferiorly during inspiration
 Repeat this process on the opposite side to assess the left kidney

Fig. 20: Ballotable kidneys Fig. 21: Ballotable kidneys
D. Percussion 16

Fluid thrills
 Elicit by flickering one side of the abdomen with index (or) middle finger and feeling
vibrations (waves) when they reach other side of the abdomen with your palm.
 You should ask your assistant or patient to place the edge of palm (on the patient
umbilical area) to press gently to make sure transmission of wave is assured.

Fig. 22: Fluid thrill

Shifting dullness
 Percuss from the center of the abdomen to the flank until dullness is noted
 Keep your finger on the spot at which the percussion note became dull
 Ask patient to roll onto the opposite side to which you have detected the dullness
 Keep the patient on their side for 30 seconds
 Repeat your percussion in the same spot
 If fluid is present (ascites) then the area that is previously dull should now be resonant
 If the flank is now resonant, percuss back to the midline, which if ascites is present,
will now be dull (i.e., the dullness has shifted)

Fig. 23: Percussion of shifting dullness

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Fig. 24: Percussion of shifting dullness

Other test like succussion splash
 Before eliciting this clinical sign, ask patient’s last fluid intake. It must be minimum of
three hours to avoid a false positive.
 Place your left palm at the cardia of stomach which is just left to the epigastrium and
place your right palm on the pyloric area which is at the right hypochondrium area.
Then gentle shake the stomach with both hands and listen for the sounds of splash of
water. It is positive in gastric outlet obstruction.

Distended urinary bladder & renal punch
 Distended urinary bladder can be palpated as a tender mass in the suprapubic area. You
can double check by performing percussion start from the umbilical area downward
through the mid-line to confirm a mass which is dull on percussion and there is no area
of tympanic sound between pubic bone and the mass.

Fig. 25: Percussion of distended bladder

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 To elicit the renal punch, ask patient to sit up. You stand behind the patient and expose
the patient dress up to the shoulder. Then locate renal angle which is between the 12th
rib and erector spinae muscle as imaginary lines.

 You place your palm at the renal angle of “normal side” and gently punch with other
hand over your hand. Always remember to inform to the patient that you are going to
punch before you elicit this sign.

 Then proceed with same manner to the disease side.

Fig. 26: Renal punch

1d. A case of incisional hernia/ umbilical hernia

Inspection
 Describe the name of an old surgical scar
 Mention the status of healing of the scar
 Check for cough impulse
 Describe the swelling (Site, size, shape, surface, condition of overlying and surrounding
skin)
 Look for other old surgical scars

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Fig. 27: Incisional hernia (Upper mid-line surgical scar)

Palpation
 Ask patient is there any pain before palpation
 Palpate all nine regions
 Palpate the swelling (Temperature, tenderness, consistency, margin and confirm the
findings from the inspection)
 Feel the palpable cough impulse
 Ask patient is that reducible or not
 If it is reducible, ask patient to reduce the swelling
 Palpate the hernia neck after reduction
 Confirm any organomegaly, ascites and presence of space occupying lesion

E. Auscultation
 Bowel sounds
Bowel sounds are usually heard below and right side of the umbilicus where the most
mobile part of intestine (ileum) is located. You must listen for about one minute and if
present whether it is normal, sluggish, increased or absent.
 Abdominal aorta bruits
 Liver & renal bruits

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Fig. 28: Auscultation of bowel sounds

Offer relevant systematic examinations
 Examine left supraclavicular lymph nodes (Troisier’s sign), lower limbs (Trousseau’s
sign)
 Examination of chest and limbs (e.g., Stigmata of chronic liver insufficiency: clubbing,
palmar erythema, spider naevi, Dupuytren’s contracture, leukonychia, koilonychia,
hepatic flaps, loss of axillary hairs, Gynecomastia)
 Digital rectal examination (Detail of this examination method will be in the respective
module)
 Examination of external genitalia (e.g., Testis: testicular atrophy)

F. Professional attitude

In the end of the examination:
 Cover up the exposed part
 Thank the patient
 Hand wash after the examination

Dos
 Be gentle
 Eyes contact with the patient all the time
 Never forget to ask if there is an area of pain
 Always make sure both you and your patient are comfortable during clinical

examination
 Running commentary

21

Don’t
 Rude to the patient
 Hurt the patient during examination (eyes contact with the patient)
 Disorganized steps of examination

Discussion
 Complete diagnosis with clinical findings which support the diagnosis
 Think about differential diagnoses for discussion
 Think about severity of disease/ staging for discussion
 Formulate the investigations to confirm diagnosis and to assess the severity (or)

staging of disease
 Formulate the basic principles of management
 Pre-operative preparation for exploratory laparotomy
 Post-operative complications
 Enhanced recovery plan
 Shared decision making

22

Module-2 A Case of Lump in the Breast

Applied Surgical Anatomy

Anatomically, there are FIVE axillary lymph nodes groups
 Anterior group: Interpectoral nodes (Usually site of sentinel nodes group)
 Posterior group: Along the border of latissimus dorsi muscles
 Lateral group: Upper medical aspect of humerus
 Apical group: Apex of the axilla (between acromion and head of humerus)
 Central group: Below the apical group along the mid-axillary line

Fig. 29: Palpation of Anterior group of axillary lymph nodes
 Surgically, axillary lymph nodes groups are divided into level I, II and III. The

Lymph nodes-group below the pectoralis minor muscles is Level-I nodes, behind that
muscle is called Level-II nodes and above that muscle is named as Level-III nodes.

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Fig. 30: Axillary lymph nodes (Operative surgical classification)

Fig. 31: Lymphatic drainage of breast (Anatomical classification)
“Nerves which are at risks of injury during surgery”

 Long thoracic nerve: Winging of scapula
 Thoracodorsal nerve: Loss of extensor, adductor, internal rotator of shoulder
 Intercosto-brachial nerve: Loss of sensation in the arm pit

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Table 8: Different methods of tissue biopsy

Different methods of tissue biopsy

No. Method Example disease Condition

1 Stereotaxis biopsy Microcalcification in Mammography

2 Fine needle aspiration biopsy Breast lump

3 Core biopsy (Tru-cut) Breast lump size 4 cm and above

4 Excision and biopsy Benign breast lump

5 Wedge biopsy Ulcerative growth

Table 9: Aberration of normal development and involution

Reproductive Breast Normal Aberration Disorders

period component Giant fibroadenoma

Early: Glandular Hormonal Fibroadenoma Normal
Macromastia
13-24 years effects with Mastalgia, mastitis

mastalgia Galactocele, Breast
abscess,
Ductal Normal Normal Subareolar abscess

Stromal Normal Juvenile hypertrophy Carcinoma in-situ

Middle: Glandular Hormonal Cyclical mastalgia, Periductal mastitis,
atypical
25-40 years effects with Lumpy breasts hyperplasia,
Carcinoma in-situ
mastalgia (Cyclical nodularity) Phyllodes tumour

Ductal Normal Normal

Stromal Normal Lumpy breasts
(Cyclical nodularity)
Late: Glandular Hormonal Cysts, Sclerosing
35- 55 years Ductal effects with adenosis, lobular
microcysts hyperplasia
Normal Fibrocystic changes,
duct ectasia, ductal
Stromal Normal hyperplasia, Nipple
discharge
Periductal fibrosis,
Nipple retraction

Approach to the Patient with a Breast Lump

Patient Preparation

Patient:
 Position: Lying 45 degree prop up position on the bed with both palms behind the nape
of the neck
 Expose the upper part of the body up to the waist (Cover the lower abdomen with
blanket)
 (To pay respect the patient, after inspection, please palpate one side after another by
covering with blanket to opposite side)

25

 Breathe slowly and relax

Examiner:
 Hands should be warm, short nails
 Whole hand and forearm should be horizontal
 Sit or stand beside the right side of the patient bed
 Eyes contact with the patient all the time

Material:
 Surgical gloves, stethoscope, alcohol hand rub,
 Tissue paper, yellow bin, blanket

Examinations Steps

A. Building Rapport
 Greet the patient & introduce yourself
 Explain the patient what procedure to be done
 Obtain permission (explain that you need to examine *both breasts*)
 Third party, Privacy
 Hand rubs before the examination
 Put the patient in correct position, Adequate exposure

B. Inspection
 General description of patient (Conscious level, pain/ distress, body built/cachexia,
pallor, jaundice)
 Start inspection of the both breasts with patient’s hands behind the nape of the head.

Fig. 32: Palpation of breasts

26

 Check for the shape & contour of breast
 Both breasts are symmetry or not
 Check the nipple line, deformity in nipple and areola region (crack nipple, retracted

nipples, eroded nipple and areola, Montgomery tubercles),
 Check the skin tethering, peau-de-orange, and Cancer-en-cuirasse, dilated veins, scars,

sinus, changes in the overlying skin (e.g., inflammation, satellite nodules etc.)

Fig. 33: Peau-d’-orange Fig. 34: Cancer -en- Cuirasse

Fig. 35: Phyllodes Tumour Fig. 36: Unilateral nipple retraction

 If you see an ulcer, describe the lump or an ulcer on inspection (site, size, shape, and

surrounding skin) edge for an ulcer. Description of location & extent of a lesion should
be with O’ clock position and distance from areola.

27

Fig. 37: Left breast abscess which is complicated as a sinus and discharging pus

 Inspect the breasts with patient’s hands pressing against her hips and lean forward
position

 Inspect both axillary regions for accessary breasts, swellings, and surgical scars
 Inspect the inframammary folds for any scars and skin lesions
 Inspect both upper limbs (Brawny arms) and check the range of the movement of upper

limb

C. Palpation
 Ask the patient whether there is any pain
 Start the examination with the normal side then to the disease side
 Palpate with the palmar surface of the fingers
 Palpate all 4 quadrants in accordance with clockwise or anticlockwise direction and
both axillary tails

Nipples and areolae
 Palpate each breast deep to the nipple and areola
 Determine the presence of nipple discharge

If there is a lump:
 Description of a lump: Position, tenderness, temperature, shape & size, surface, margin,
consistency, mobility
 Elicit the physical characteristic features of the lump & its relations to the skin and
muscle. Move the lump while patient is in a state of relaxation. If the lump is immobile,
it is invaded to the chest wall, no other tests need to be done. However, if the mass is
mobile, it may be truly mobile or invaded to the muscle.
 To differentiate whether the lump is truly mobile or invaded to the muscle, perform the
following test.
 Ask patient to press her palm against the waist to make sure pectoralis major muscle is
contracted. Then, move the lump in two cross directions if the lump is mobile, it meant
it is truly mobile. If not, it is invaded to the muscle. This test will determine the “T”
staging. (Before you move the lump, make sure patient press her palm firmly against

28

the waist. Check the lateral border of pectoralis major muscle to make sure patient is
contracting the muscle)

Fig. 38: Palpation of breast

If there is an ulcer:
 Elicit the physical characteristic features of ulcer & its relations to underlying structures
 The ulcer: Position, tenderness, temperature, shape & size, surface, edge, consistency,
mobility, floor & base.

Fig. 39: An infected malignant ulcer Fig. 40: Brawny arm

29

Arms and axillae:
 Rest patient’s arm on examiner’s arm properly
 Palpate with the other hand for the axillary lymph nodes and present the findings
 Palpate the opposite axilla

If there is/are palpable lymph nodes:
 Describes as a lump and highlight the fixity which will determine the staging.

Fig. 41: Palpation of axillary lymph nodes
Supraclavicular region

 Stand behind the patient
 Palpate both supra clavicular lymph nodes
 If nodes are palpable: Describe:
 Site, Size, Shape, Numbers
 Temperature, Tenderness
 Solitary or matted, Consistency
 Margin, Mobility,
 Check an attachment to overlying skin and underlying structures
 Contralateral supraclavicular nodes enlargement represents the “M” staging
 Ipsilateral supraclavicular nodes enlargement determines the “T” staging

30

Fig. 42: Palpation of supraclavicular lymph nodes

Offer systematic examinations
 Examination of abdomen
(Hepatomegaly, ascites, Krukenberg’s tumour)
 Examination of respiratory system (Malignant pleural effusion)
 Digital rectal/ Bimanual vaginal examination (Rectal shelf of Blumer/ Ovarian
tumour)
 Examine the bone tenderness

D. Professional attitude

In the end of the examination:
 Cover up the exposed part
 Thank the patient
 Hand wash after the examination

“Operative surgical terminologies”
 Total mastectomy: (Removal of whole breast including axillary tail)
 Wide-local excision: Excision of tumour with 1 cm clearance margin.
 Axillary sampling: Taking out around “4-6” nodes from level-I
 Axillary clearance: Removal of Level I & II lymph nodes
 (Clearance is “Misnomers”)
 Sentinel nodes biopsy: Inject the dyes (Methylene blue) into the tumour intra-
operatively and wait about 15 minutes. Then follow the area stained by the dyes
assuming that first lymph nodes groups which is spreader by tumour cells. Then,
remove the lymph nodes from that area for the biopsy.
 Neo-adjuvant therapy
 Hormonal therapy
 Adjuvant therapy
 Monoclonal antibody based targeted therapy
 Radiation therapy
 Salvage mastectomy: Palliative surgery

31

 Surgical incision for total mastectomy: Transverse elliptical incision

Dos
 Be gentle
 Eye contact with the patient all the time
 Never forget to ask if there is an area of pain
 Always make sure both you and your patient are comfortable during clinical

examination
 Do not expose both breasts all the time during the examination (You can cover normal

breast when it does not necessary to be exposed, to respect the culture of people from
Asia)

Don’t
 Rude to the patient
 Hurt the patient during examination (Eyes contact with the patient)
 Restless approach

Discussion
 Complete diagnosis with clinical findings which support the diagnosis
 Think about differential diagnoses for discussion
 Think about severity of disease/ staging for discussion
 Formulate the investigations to confirm diagnosis and to assess the severity (or)

staging of disease
 Formulate the basic principles of management
 Enhanced recovery plan
 Shared decision making

32

Module-3 A Case of Anterior Neck Swelling

Applied Surgical Anatomy

Superior thyroid artery (STA):
 It is usually solitary branch from the external carotid artery. Carotid artery (CA)
bifurcates into internal and external carotid arteries at the level of vertebra C4.
 It gives branches once entered the thyroid capsule in the superior pole. (Clinical
importance of palpable thrills).
 Superior laryngeal nerve (SLN) runs together with artery towards the thyroid gland, 2-
3 cm before it reaches to the gland the nerve run backward into the larynx supplies the
cricothyroid muscles.
 Operative surgical important point: Dissect and ligate the artery closed to the gland to
avoid the nerve injury.

Fig. 43: Applied anatomy of thyroid
Inferior thyroid artery (ITA):

 It is the largest branch of thyrocervical trunk and gives multiple branches before it
enters the thyroid capsule. Recurrent laryngeal nerve (RLN) is immediately related to
the course of inferior thyroid arteries. It gives blood supply to all four parathyroid
glands.
33

 Operative surgical important points: Individual ligation of branches of artery is
mandatory to prevent the nerve injury and injury to the parathyroid glands.
Electromagnetic stimulator is used in challenging cases to identify the nerve in the
tracheoesophageal groove.

Middle thyroid vein (MTV): Thin, short and drains directly into internal jugular vein (IJV).
If you missed the vein injury, patient might have cerebral air embolism.

Fig. 44: Lymph nodes of head and neck
 Clinically, we can palpate the lymph node enlargement of the head and neck region.

The cervical lymph nodes groups are as follow:
 Upper outer chain: Submental, submandibular, preauricular, postauricular,
occipital nodes. You can palpate the enlargement these nodes during clinical
examinations.
 Upper inner chain: Tonsils and adenoids
These nodes can be seen during inspection inside the mouth by using a tongue
depressor.
 Superficial vertical chain: Anterior jugular nodes
 Deep vertical chain: Delphian nodes
 Lower transverse chain: Posterior cervical nodes, supraclavicular and
infraclavicular nodes.

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Table 10: Principles of approach to the patient with anterior neck swelling
“Principles and practice of an approach to the patient with anterior neck swelling”

No Principles Practice

To confirm: History Physical Differential Investigations

examination Diagnoses

1. Anatomical Onset & Swallowing test, Goiter, Imaging

diagnosis Duration Tongue Thyroglossal cyst,

Associated protrusion test, Lipoma,

symptoms slipping sign, etc Lymphadenopathies

2. Morphology History Diffuse swelling Physiological goiter Thyroid function
and
Grave’s disease test

Aetio- Early stage of Autoantibodies
pathological Hashimoto’s tests

diagnosis thyroiditis, Imaging

History Multinodular Colloid goiter Thyroid function

swelling (MNG), test

Toxic multinodular Autoantibodies

goiter tests

Malignancies Imaging

Tumor markers

History Solitary nodule Cyst Thyroid function

Adenoma test

Toxic nodules Autoantibodies

Dominant nodule of tests

underlying MNG Imaging

Malignancies Tumor markers

3. Thyroid Attitude Tremors Hyperthyroidism Thyroid function

status Vision Proximal Hypothyroidism test

Palpitation myopathy Euthyroid Autoantibodies

Heat & cold Reflexes Subclinical tests

intolerance Pretibial conditions Imaging

Body weigh & myxedema

appetite Eye signs etc

Menstrual

abnormalities

etc

4. Pressure Breathing Trachea shift To exclude Neck X-rays
effects difficulties Thyroid function
Pemberton’s sign malignancy

Swallowing test

difficulties Autoantibodies

Sleep tests

disturbances Imaging

Voice changes CT scan

5. Malignancy Onset, Hard in Papillary carcinoma Neck X-rays

duration, and consistency, fixed Follicular carcinoma Thyroid function

rate of growth to underlying Medullary carcinoma test

Voice changes structures, Anaplastic Autoantibodies
tests
Symptoms of Positive Berry’s carcinoma

regional and sign, Cervical Lymphoma Imaging

systemic lymphadenopathy CT scan/ MRI

metastasis Pressure effects Tumour markers

Other systemic (Serum Tg, Tg

involvement antibody,

Calcitonin, CEA)

35

Approach to the Patient with an Anterior Neck Swelling

Patient Preparation

Patient:
 Position: Sitting on the chair
 Expose the dress down to the nipple (Cover the lower abdomen with blanket)
 Arms at the side of the body
 Relax & semi-flex position of neck. Breathe slowly

Examiner:
 Hands should be warm, short nails
 Whole hand and forearm should be horizontal
 Sit or stand behind or in front of the patient
 Eyes contact with the patient all the time

Material:
 Stethoscope, alcohol hand rub,
 Mineral water, disposable cups, Tissue paper,
 Yellow bin, Blanket, Light source
 Disposable tongue depressors

Examinations Steps

A. Building Rapport
 Greet the patient & introduce yourself
 Explain the patient what procedure is to be done
 Obtain permission, Request for chaperone, Secure Privacy
 Hand rubs before the examination
 Put the patient in correct position
 Adequate exposure

B. Inspection
 General description of patient
 (Attitude mask-face/ anxious looking, pain/ distress, body built, pallor, jaundice,
stridor, any abnormal voice)
 Skin texture whether it looks dry or sweaty

36