SurgicalShort-CaseMadeEasy

Fig. 45: General examination

Fig. 46: Inspection of patient’s eyes
Inspect the patient’s eyes

 Stand face to face 2-feet away from the patient. Check both superior limbus could be
seen or not. If both superior limbus are seen, proceed with other eyes signs for an
exophthalmos such as Lid-lag, Lid-retraction, Wrinkling of forehead-skin,
Ophthalmoplegia, Chemosis. Check eye brown for loss of hair (outer 1/3)

37

Fig. 47: Exophthalmos
 Stand behind the patient and look tangential plane along the patient’s eye brown and

zygomatic arch. You will see eye is protruded outward of this tangential plane if there
is an exophthalmos.

Fig. 48: Exophthalmos
 If there is an exophthalmos, you must proceed with eliciting the eye signs which will

be explain in detail in the later session.
Inspect the neck:

 Describe the swelling:
Site, size, shape, surface, overlying skin and adjacent structures
38

If it is a diffuse swelling, the most likely causes of goiter would be:
Physiological goiter, Grave’s disease, Early state of Hashimoto’s thyroiditis etc.

Fig. 49: Diffuse goitre
If it is a solitary nodule, the most likely causes of nodule would be thyroid cyst, adenoma,
malignancy, dominant nodule of underlying MNG, toxic nodule etc.

Fig. 50: Solitary thyroid nodule
If it is a multi-nodular swelling, the causes would be: Colloid goiter, secondary toxic MNG,
malignancy etc.

39

Fig. 51: Multinodular goitre

Look for old surgical scars:
Usually it is transverse cervical (collar incision)
State the healing status of scar
Check the previous scars of drainage tube insertion.

Swallowing test
 Instruct patient to get sips of water in the mouth,
 Ask patient to swallow the water and check whether the swelling moves up-ward with
swallowing.

Fig. 52: Swallowing test

40

Tongue protrusion test
 Instruct the patient to open the mouth, protrude and retract the tongue. Check the
swelling moves with tongue movements.

Fig. 53: Tongue protrusion test
Pemberton’s test: (If it is necessary to elicit)

 Optional: Not necessary to elicit in case of small goiter with well define lower border
(OR) small goiter without pressure effects

 Instruct patient to raise both straight arms with upper arm touch to the ears.
 Check whether patient has flushing/ congestion in the face and neck

(Pemberton’s test should not be elicited in elderly and friable patient)
Inspect the triangles of neck for any other visible mass and distended blood vessels.
(Elderly and friable patient may collapse during this test. So, you may explain about it to the
examiner to excuse yourself performing this test)
C. Palpation from behind

 Ask the patient whether there is any area of pain
 Patient’s neck must be semi-flex position
 Place both of your thumbs on the nape of the neck
 Use palmar surface of the fingers (pads of fingers) for palpation

41

Fig. 54: Palpation of neck

 Palpation starts from the mid-line below the chin, locate Adam’s apple down to the
isthmus. Then, palpate the left and right lobes of thyroid gland.

 Palpate one side of the neck after another
 Confirm your findings from the inspection: location of swelling, size, shape, surface

and check temperature, tenderness, mobility, consistency.)
 Instruct the patient to swallow the water again and check to make sure whether you can

palpate the lower border of the swelling clearly or not) to check the retro-sternal
extension of the swelling.
 Palpate the superior pole of the swelling for the palpable thrills
 Palpate the carotid artery pulsation.
 (Locate the sternocleidomastoid muscle, place your pulp of fingers at the medial border
of the muscle) (Berry’s sign: palpate one side after another)
 Palpate the cervical lymph nodes enlargement

Fig. 55: Palpation of carotid artery pulsation

42

D. Auscultation
 Auscultate the thyroid bruits and carotid bruits from behind

Fig. 56: Auscultation
E. Examination in front of the patient

 Palpate the trachea (Place you ring finger and index finger at the both sterno-
clavicular joint, the place your middle finger to locate the thyroid cartilage and gently
palpate downward to make sure trachea rings are at mid-line)

Fig. 57: Palpation of trachea
 Percuss from the level of nipple lines to the (both upward) direction to the clavicles to

check the retro-sternal extension of swelling.
43

Fig. 58: Percussion of retrosternal extension
F. Offer the examination of thyroid status

 Check for the pulse and palm (sweaty / warm/ cold)
 Proximal neuropathy: Ask patient to squirt down and instruct patient to stand up. Check

whether patient can stand up without holding nearby object or not.

Fig. 59: Test: proximal myopathy
 Check for tremors: Ask patient to extend straight arms, spread the fingers and close the

eyes. Check for the tremors of fingers. You can put a paper on the fingers to make sure
to detect the fine tremors. (Make sure ceiling fan is off)

44

Fig. 60: Tremors

 Check for thyroid acropachy
 Check for the reflexes

Fig. 61: Reflexes
 Check for the pretibial myxoedema

45

G. Offer other relevant systemic examination
 Examination of abdomen (If malignancy is suspected)
 Examination of bone tenderness (Skeletal metastasis)
 Examination of Lungs (Pulmonary metastasis)

"Special test”
If there is an exophthalmos, you must elicit the eye signs:

1. Ask patient to sit up. Place an object or your index finger about 18 inches away from
the patient’s eyes at the midline. Gradually move an object upward direction until at
the hair line of forehead. Ask patient to focus on an object

2. Check for the wrinkling of forehead skin. In case of an exophthalmos, patient can
see the object without wrinkling of skin of forehead. Make sure patient’s head is not
following with the movement of the object.

Fig. 62: Eye sign
3. Then, gradually move the object downward direction, check the patient’s upper eye lids

whether they are lagging or not. Lid-lag & retraction
4. Accommodation reflex of eyes:

Place an object 2-feet away and same level of the patient’s eyes. Ask the patient’s
eyesight to follow the object. Then slowly move the object to the root of the nose. Check
whether patient’s eyes could focus when the object is near to the root of the nose.
5. Check patient conjunctiva for any oedema, & ulcer (Chemosis).

46

"Special test”
(Signs of hypocalcemia)

1. Chvostek’s sign
 Locate the Tragus of ear, about 1cm in front of the Tragus is the location of the
trunk of the extra cranial course of the facial nerve before it is bifurcating into five
branches.

Fig. 63: Chvostek’s sign
 Tap that area with your finger and check any twitching of an angle of the mouth

(or) facial muscles
2. Trousseau’s signs

 Inflate the blood pressure cuff at the arm, 5-10 mmHg above the systolic blood
pressure for 3 minutes. Check for the carpopedal spasm.

47

Fig. 64: Trousseau’s signs

3. Hoarseness of voice
 Raspy low pitch voice

4. Husky voice
 Loss of high pitch tone

H. Offer systematic examinations

 Examination of abdomen if you are suspicious of malignancy
 Check the bone tenderness if you are suspicious of malignancy

I. Professional attitude

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

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

48

Don’t
 Rude to the patient
 Hurt the patient during examination (Eyes contact with the patient)
 Never ask patient to swallow the saliva for swallowing test
 Eliciting berry signs both side at the same time
 Palpating both lobes of thyroid at the same time
 Juggling around the patient during examinations

Start inspection from in front, followed by palpation & auscultations form behind.
Then, come in front of the patient to perform examination of trachea, percussion of
retrosternal extension. Proceed eliciting signs of status of thyroid. Special test and offer
other systemic examination
 Restless approach 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-preparation for thyroidectomy
 Post-operative complications
 Role of Radio iodine therapy in thyroid diseases
 Different types of anti-thyroid medications
 Enhanced recovery plan
 Shared decision making

49

Module-4 A Case of Inguino-Scrotal Swelling

Applied Surgical Anatomy

 Inguinal canal: Starts from the deep inguinal ring to the superficial inguinal ring
 Mid-point of inguinal ligament: A point, halfway between ASIS and pubic tubercle
 Mid-inguinal pint: A point, halfway between ASIS and pubic symphysis
 Deep ring is located about1.5 cm above the midpoint of inguinal ligament
 Superficial ring is located just superior to the pubic tubercle

“Boundaries of inguinal canal”
 Anterior wall: Aponeurosis of external oblique reinforced by internal oblique laterally
 Posterior wall: Transversalis fascia
 Roof: Transversalis muscle, conjoint tendon
 Floor: Inguinal ligament, Lacunar ligament
 Contents of Inguinal canal: Spermatic cord
 Three arteries: Testicular artery, Artery to the Vas, Cremasteric artery
 Three nerves: Ilioinguinal nerve, Genital branch of Genito-femoral nerve,
Sympathetic & parasympathetic nerves
 Three structures: Vas deferens, Lymph nodes, Pampiniform plexus (In women:
round ligament is the only content of the inguinal canal)

Fig. 65: Hesselbach’s triangle

Hesselbach’s trinangle:
 Medial border: lateral border of rectus muscle
 Lateral border: imaginary line of inferior epigastric artery (IEA)

50

 (Imaginary line: Medial aspect of deep ring to the halfway between umbilicus and

pubic symphysis)
 Inferior border: Inguinal ligament (Poupart’ ligament)

Table 11: Anatomical variants of indirect inguinal hernia

Anatomical variants of indirect inguinal hernia Differential diagnoses

1. Bubonocele: Hernia sac is located at the deep Direct inguinal hernia, Encysted cord

ring area of hydrocele, Lymphadenopathy,

Lipoma of spermatic cord etc

2, Funicular: Hernia sac emerging out of deep Direct inguinal hernia, varicocele

ring and extending to the superficial ring Incompletely descended testis

3. Complete Scrotal: Hernia sac protruded into Direct inguinal hernia, Hydrocele,

the scrotum varicocele

Fig. 66: Location of testis in case of ectopic testis and incompletely descended testis
Location of ectopic testis: Superficial inguinal pouch, Transverse scrotal area, Root of the
penis, Femoral triangle area, Perineal area

51

Fig. 67: Femoral triangle and femoral canal

Femoral canal is in the femoral triangle.

Table 12: Boundaries of femoral canal
Boundaries of femoral canal

Superiorly Inguinal ligament

Medially Lacunar ligament

Laterally Femoral vein

Posteriorly Pectinate ligament

Risk factors of femoral hernia

Elderly female Multiparous woman

Increased intraabdominal pressure Chronic cough

Majority of cases present with strangulation.

52

Table 13: Different types of inguinal hernia
Different types of inguinal hernia

1 Reducible hernia Uncomplicated hernia

2 Irreducible hernia Incarcerated hernia (irreducible hernia due to the adhesion of
hernia sac in the scrotum)

Obstructed hernia (associated with symptoms and signs of
intestinal obstruction)

Strangulated hernia (Tense tender swollen swelling)

Richter’s hernia (Herniation of part of the circumference of
bowel wall

3 Sliding hernia Protrusion/ Sliding downward of retroperitoneal wall through
the hernia orifices

4 Maydl hernia Presence of two small bowel loops in the hernia sac
5 Pantaloon hernia Ipsilateral concurrent direct and indirect hernia
6 Littles hernia Hernia sac consists of Meckel’s diverticulum

Approach to the Patient with Inguino-Scrotal Swelling

Patient Preparation

Patient:
Position: Both standing beside the bed & lying flat on bed/ hard coach with pillow

 Expose from the lower abdomen to the mid-thigh in standing position
 Expose from upper abdomen to the mid-knee joint in lying position
 Arms at the side of the body
 Breathe slowly
 Lift the scrotum to check clinical findings behind the scrotum

Examiner:
 Hands should be warm, short nails (If needed, you can put on the surgical glove)
 Very gentle while examining the testis & scrotum
 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
 Lubricant, light source

53

Examinations Steps

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

B. Inspection

General:
 Signs of sepsis, Conscious level, pain/ distress, body built/cachexia, pallor, jaundice
 “Inspect the patient in standing up position”
 Description of groin swelling in comparison with the normal side
 (Location, shape, size, extent, changes in overlying skin)
 Visible cough impulse / Malgaigne’s bulge

Fig. 68: Undescended testis Fig. 69: Carcinoma of penis

 Check any swelling in contra-lateral groin
 Check surgical scar in both groins
 Description of scrotum (scrotal skin) and penis
 (Lift up the scrotum to check abnormal findings)

54

Fig. 70: Phimosis

 Check the foreskin of penis not to miss phimosis and paraphimosis

C. Palpation

Palpation in standing position
 Temperature of the swelling, Tenderness of the swelling
 Compare with normal size and confirm the findings from inspection
 “Can get above the swelling?”: Whether the spermatic cord can be felt normally or not
 Palpable cough impulse
 Consistency of the swelling

Fig. 71: Inguinal hernia Fig. 72: Bilateral scrotal swelling

55

 Whether the Testis can be felt separately or not and
 (Use both thumbs and index fingers to palpate and the reminding fingers should be

behind the testis)
 If you can palpate the lump, describe fully as a lump
 Ask patient, whether the swelling is reducible or not. And clarify in which position

would be comfortable for the patient to reduce the swelling by himself. Most of the
patients prefer to reduce the swelling in the lying position.

Palpation in lying position
 Ask the patient to lie supine
 Describe the response of swelling’s size (reduces/sustains)
 Ask patient whether the swelling is reducible or not, if so ask him to reduce
 Listen to the bowel sounds while patient is reducing the swelling
 Identify and locate the anterior superior iliac spine, pubic symphysis, pubic tubercle,
inguinal ligament, superficial ring, and deep ring (both sides)
 Conduction of “Deep ring occlusion test”: after reduction of the swelling by patient
himself, place both of your thumbs on the deep rings. Ask patient to turn his head to
the left side and instruct to cough. Inspect at the Hesselhach’s triangle area whether
there is a cough impulse or not. If cough impulse is positive, it is a direct hernia.

Fig. 73: Deep ring occlusion test: bilateral direct inguinal hernia

 Or not, release both of your thumbs from the deep rings and ask patient to cough again
and check the cough impulse at the deep ring area. If the cough impulse is positive, it
is an indirect hernia.

 Conduct the fluctuation test (Gently grab the swelling in your both hands. Place index
finger over the swelling with slight sustain pressure and tap the swelling with another

56

index finger and feel the sensation of transmission of wave of fluid, this procedure must
be done twice in both cross dimensions.) It is usually positive in hydrocele.

 Conduct the Trans-illumination test: (Place a tube on the swelling 90 degrees
perpendicular to the bed and place a torchlight behind the scrotum. Check the
transmission of light. Make sure the examining environment is dim) It is usually
positive in hydrocele.

If you find a painless lump in the scrotum:
 If there is a painless lump arise from the testis,
Think of:
Hydrocele: (Already mentioned in the previous page)

Testicular tumour:
 It is usually unilateral, homogenous, hard, heavy mass. Your palpating fingers could

get above the swelling.
 In this case you must have an idea of looking for secondary metastasis at the end of the

examination.
 Seminomas spread by lymphatics whereas in teratoma by hematogenous spread.

Varicocele
 It is common on the left side. Usually reducible while patient is lying down. You will

feel a bag of worms on palpation.

If you find a painful lump in the scrotum: Epidydimo-orchitis:
 Common in adults, with prior history of urinary tract infections. It is a tender lump with
signs of inflammation. You may not be able to palpate thoroughly because of patient
complains of pain. Need to check for any discharge from the meatus and other signs of
sexually transmitted diseases.

Fig. 74: Epididymo-orchitis

57

Testicular torsion:
 Common in young patients, with prior history of sports or exercise. It is a surgical
emergency. You will see the unilateral high riding swelling which is tense inflamed and
tender.

“Operative surgical terminology”
 Herniotomy: Pediatrics patients
 Hernioplasty (Mesh repair) (Open surgery / Laparoscopic surgery)
 Herniorrhaphy: Obsolete because of an availability of mesh
 Surgical incision: Inguinal skin crease incision (Open surgery)
 Surgical incision: Umbilical port (camera), two more ports in the lower mid-line for
laparoscopic instruments

Advantages of laparoscopic surgical repair:
 Less post-operative pain, early ambulation
 Less bleeding, less chance of surgical site infection
 Could manage bilateral hernia at the same time
 Limitation: Complicated hernias such as strangulated hernia, irreducible hernia etc.

D. 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

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

58

 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 complicated & uncomplicated hernias
 Postoperative complications of laparoscopic approach and open surgery
 Prevention of recurrence of hernia

59

Module-5 A Case of Lump

Table 14: Common causes of lesion based on the tissue plane

Common lesions based on the tissue plane

Origin Benign Malignant

Skin Sebaceous cyst Melanoma

Dermoid cyst

Nevus

Subcutaneous tissue Lipoma Liposarcoma
Fibroma

Muscles Desmoid tumour Sarcoma
Tendons Ganglion

Blood vessels Cavernous haemangioma Haemangiosarcoma
Strawberry patch
Port-wine stain

Nerves Neurofibroma Neurofibrosarcoma
Schwannoma

Approach to the Patient with a Lump

Patient Preparation

Patient:
 Lying flat on bed/ hard coach with a pillow or sitting position
 Expose the appropriate part of the body
 Breathe slowly

Examiner:
 Hands should be warm, short nails (If needed, you can put on the surgical glove)
 Very gentle while examining the lump
 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
 Light source

Examinations Steps

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

60

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

B. Inspection
 General description of patient (Conscious level, pain/ distress, signs of sepsis, body
built/cachexia, pallor, jaundice, septic looking)

Local examination
 Description of the site/ location of swelling
 Estimated size and shape

Fig. 75: Dercum’s disease Fig. 76: Sebaceous cyst

 Describe the surface of the lump
 Margin well defined or not
 Visible pulsations

61

Fig. 77: Dermoid cyst Fig. 78: Cervical Lymphadenitis

 Status of the overlying skin
(Dilated vessels/inflamed/ punctum/ old scar/ ulcer, sinus, discharge)

 Surrounding skin (normal/inflamed/edematous, prominent blood vessels)

C. Palpation
 Ask the patient whether there is any pain or not
 Check its tenderness and temperature
 Measure the exact size
 Description of surface and margins

Fig. 79: Cellulitis

 Palpate and determine its composition by:
 Consistency, compressibility, pulsatile
 Mobility (invading to/ arising from the skin & underlying structures)

62

“Fluctuation sign”

Fig. 80: Fluctuation sign
For the small lump, place your left index and middle fingers (palpating fingers) at the edge of
the lump and press at the center of the lump with your right index finger (examining finger).
This maneuver must be done in two cross-direction. Fell the sense of wave of fluid in your
palpating fingers.
“Translucency”
Create a dark room. Check the glowing of light in the lump after placing torchlight.

Fig. 81: Transillumination test
Check its relations to the skin and muscles

 Pinch the skin to check whether it is infiltrated (or) grow from the skin.
 Move the lump in two cross-directions while the underlying muscle is contracting to

check infiltrated (or) grow from the muscles.
63

“Reducibility”
 Apply gentle continuous pressure over the lump results in a reduction in size. Usually
it is positive in hernias, hemangiomas & lymphangiomas.

Conduct some special tests and present appropriately:
“Lobulation sign”

 Gently squeeze the lump between thumb and index finger for small lump, if the lump
is large, please use your both hands to squeeze to make sure to exert the tension within
the lump and inspect the surface of the lump whether the surface of the lump is lobulated
or not.

Fig. 82: Lobulated surface: Lipoma
“Slipping sign”

 Gently slide the edge of the lump with index finger for small lump, If the lump is big,
please use tips of fingers to slip it

64

Fig. 83: Slipping sign
 And check whether the lump is slipped away from your finger(s) easily or not.
“Indentation sign”
 Gently press the lump with tip of your finger for 5 seconds and release the pressure.

Fig. 84 & 85: Indentation sign
 Check whether surface of the lump is indented.
“Sign of induration”
 When you palpate the surrounding area of a lump, you may feel the indurated area

which means loss of pliability & elasticity due to chronic inflammatory reaction.
65

“Pulsation"
 Check for the presence of transmitted pulsation or expansile pulsation.
(Pulsation of aneurysms and pulsation from a lump sit on the vessel.)

D. Auscultation
 Bruits over the lump
 Machinery murmur could be heard in an aneurysmal varix

E. Offer systematic examinations if it is significant
 Examine regional lymph nodes
 Examine the liver, spleen, lymph nodes (Lymphomas)
 Examine the abdomen (Troisier’s sign)
 Examination of lungs and breasts (Supraclavicular lymph nodes enlargement)
 Examine the mouth tongue, tonsils, teeth & gums, ears and scalp (upper cervical
swelling)
 Examine the limbs and joints (autoimmune-related lesion)

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

Don’t
 Rude to the patient
 Hurt the patient during examination (eyes contact with the patient)
 Disorganize 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
 Principles of excision and biopsy

66

Module-6 A Case of an Ulcer

Ulcer: A break in the skin, mucous membrane with loss of surface tissue, disintegration and
necrosis of epithelial tissue and often forms pus.

Sloping edge: Healing ulcer
Punched out edge: Arterial ulcer

Undermined edge: Tuberculous ulcer
Rolled up edge: Basal cell carcinoma

Raised and everted edge:
Squamous cell carcinoma

Fig. 86: Edges of ulcers

Table 15: Special types of ulcers Causes
No. Types of ulcers

1 Cushing ulcer Head injury patient
2 Curling’s ulcer Burn’s patient

3 Marjolin ulcer Malignant change in old scar

4 Venous ulcer Chronic venous hypertension patient

5 Martorell ulcer Hypertensive leg ulcer

Approach to the Patient with an Ulcer

Patient Preparation

Patient:
 Lying flat on bed/ hard coach with pillow or sitting on the chair
 Expose the appropriate part of the body or limbs

67

 Relax & breathe slowly

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

Material:
 Surgical gloves, stethoscope, Sphygmomanometer,
 alcohol hand rub, Doppler, Tissue paper, yellow bin,
 Blanket, light source, dressing tray

Examinations Steps

A. Building Rapport
 Greet the patient & introduce yourself
 Explain to the patient what procedure is to be done
 Obtain permission
 Third party, Privacy
 Hand rubs before the examination (Put on the surgical glove)
 Put the patient in correct position
 Adequate exposure

B. Inspection
General description of patient: (conscious level, pain/ distress, cyanosis, body built/cachexia,
pallor, abnormalities in face, jaundice, septic looking)

 Description of the site/location of an ulcer
 Estimated size and shape

Fig. 87: Carbuncle Fig. 88: Healing ulcer
 Edge and floor of the ulcer 68

 Visible pulsation
 Surrounding skin (normal/inflamed/edematous, indurated, distended veins)

(For an ischaemic ulcer: Please refer to the particular examination e-book)

Fig. 89: Venus ulcer Fig. 90: Malignant ulcer (Melanoma)

C. Palpation
 Ask the patient whether there is any pain or not
 Check its tenderness and temperature
 Measure the exact size
 Description of surface and edge
 Palpate and determine its composition by:
 Palpate the surrounding skin
 Check its depth and mobility

D. Offer systematic examinations if it is significant
 Examine regional lymph nodes
 Check for the arterial pulsation
 Examination of chest and abdomen if needed

E. 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

69

 Always make sure both you and your patient are comfortable during clinical
examination

 Running commentary
Don’t

 Rude to the patient
 Hurt the patient during examination (Eyes contact with the patient)
 Ask permission if you like to open the dressing

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

70

Module-7 A Case of Varicose Veins

Applied Anatomy

Fig. 91: Veins of lower leg
Superficial venous system

 Long saphenous vein (LSV): It is formed by the dorsal venous arch (DVA) of the foot.
It ascends the medical side of the leg just anterior to the medial malleolus. It moves up
along the leg and enters the femoral vein via the saphenous opening. This junction is
called sapheno-femoral junction where reflux of blood causes the venous hypertension.

 Short saphenous vein (SSV): It is formed by the dorsal venous arch of the food and
ascends posterior side of the leg, passing posteriorly to the lateral malleolus. It moves
up between two heads of the gastrocnemius muscles and empties into the popliteal veins
(PV) in the popliteal fossa.
71

Deep venous system
 Deep venous structure starts from the dorsal venous arch of the foot forming the anterior
tibial veins (ATV). On the plantar aspect of the foot, plantar veins combine to form the
posterior tibial vein (PTV) and fibular vein. These veins unit to form the popliteal vein
(PV).
 Popliteal vein enters the thigh via the adductor canal and named as femoral vein.
 Femoral leaves the thigh by running underneath the inguinal ligament, at which point
it is called external iliac vein (EIV).
 Profunda femoris veins (PFV) receives the branches of femoral circumflex veins
(FCV) and drain into the femoral vein.

Fig. 92: Perforators at thigh
 Perforators: Communication between deep veins and superficial veins, flows from

superficial to deep system, located multiple levels above and below knee. The most
important perforators are medial calf perforators called Cockett perforators (7 cm, 9
cm, 12 cm above the medial malleolus.
 Valves: Bicuspid venous valves are present in all superficial and deep venous veins.
 Sapheno-femoral junction reflux: One of the common causes of varicose veins
Perforator incompetence: One of the common causes of varicose veins
Deep vein thrombosis: Important to exclude DVT

72

“Pathogenesis of chronic venous hypertension”

Common etiologies:
 Sapheno-femoral reflux
 Perforator incompetence
 Valve incompetence
 Deep vein thrombosis
 Mechanical pressure effect (e.g. Deep-seated pelvic tumour)

Increase in the intravenous pressure

Raise in intravascular hydrostatic pressure and oncotic pressure

Seepage of plasma, red blood cells (RBC) and
white blood cells (WBC) into the interstitial space

RBC & WBC ruptured in the interstitial space

Escape of hemosiderin pigment & irritation (Itchiness)

Lipodermatosclerosis & venous ulcer

“Complications of deep vein thrombosis”

Table 16: Complications of deep vein thrombosis

Post thrombotic syndrome Pain, swelling, darken skin colour

Phlegmasia alba Dolens Painful white leg, “Milk leg”

Phlegmasia Cerulea Dolens Swollen leg, blisters, paresthesia, muscle weakness

Pulmonary embolism Chest pain, haemoptysis, shortness of breath

Approach to the Patient with Varicose Veins

Patient Preparation

Patient:
 Both standing and lying flat on bed positions
 Expose both lower limbs to compare
 Relax & breathe slowly

Examiner:

73

 Hands should be warm, short nails
 Whole hand and forearm should be horizontal
 Sit or stand on the right side of the patient
 Eyes contact with the patient all the time
Material:
 Surgical Gloves, Stethoscope, Sphygmomanometer,
 alcohol hand rub, doppler, tissue paper, yellow bin,
 Blanket, Light source, dressing tray

Examinations Steps
A. Building Rapport

 Greet the patient & introduce yourself
 Explain to the patient what procedure is to be done
 Obtain permission
 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)

Inspection during standing position
 Inspect both lower limbs
 Check both lower limbs are symmetry or not
 Venous mapping (Mapping of the area of varicose veins in the long saphenous and
short saphenous veins)

74

Fig. 93: Varicose veins

 Check for the trophic changes (Skin, nails, hairs)
 Check for the venous ulcer

Fig. 94: Venous ulcer Fig. 95: Lipodermatosclerosis

 Check for the telangiectasia at gaiter area
 Check for the lipo-dermatosclerosis
 Check for the cough impulse at the saphenous opening

75

If there is an ulcer:
Describe an ulcer, Inspect the inguinal area for visible enlarged lymph nodes

C. Palpation
 Ask patient to lie down on the bed
 Ask the patient whether there is any pain or not
 Raise patient leg for 45 degrees about 20 seconds to empty the varicose veins
 Apply the tourniquet at the root of the thigh then,
 Ask patient to stand up
 Check whether varicose veins are filled up from below (If so, it is due to perforator
incompetence)
 If not, release the tourniquet, and check the varicose veins. If veins are filled up from
above, it is due to sapheno-femoral reflux

Fig. 96 & 97: Trendelenburg test

 Offer three tourniquets test to locate the incompetent perforators (Empty the varicose
veins. Apply three tourniquets at the level of sapheno-femoral junction, mid-thigh, and
mid-calf, and then ask patient to stand up.

 Release the tourniquets one after another from above)
 Offer Perthe’s test to exclude the concurrent deep vein thrombosis (Ask patient to tip-

roe exercise for 5-10 minutes and check whether patient’s lower leg is swollen, or
patient complains of pain or not)
*** In current vascular surgery practice, this test is obsolete because it could cause the
blood clot to be dislodged.

76

D. Offer systematic examinations if it is significant
 Examine cardiovascular system
 Check for the other arterial pulsations & bruits at major arteries
 Examination of abdomen (Aortic aneurysm)

E. 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
 Compare both limbs as well as do not forget to check the posterior aspect of the limbs
 Always make sure both you and your patient are comfortable during clinical

examination
 Running commentary

Don’t
 Rude to the patient
 Hurt the patient during examination (Eyes contact with the patient)
 If patient has "abdominal aortic aneurysm”, you are exempted to examine the

abdomen.
 Ask permission if you like to open the dressing

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
 What is golden hour?
 Limb-saving & Lifesaving strategic procedures
 Formulate the basic principles of management

Trendelenburg operation:
 High ligation of saphenofemoral junction
 Avulsion (stripping) of long saphenous vein from 2 cm below the knee
 Multiple stab avulsion of veins
(Proximal part of long saphenous vein is preserved for future coronary by-pass
surgery)

77

Minimal Invasive Surgery
 Subfascial endoscopic perforator surgery
 Ultrasonic heat therapy
 Endovenous-laser therapy
 Endovascular glue injection (Vena seal)

CEAP- Clinical Staging of Varicose veins (Clinical- Etiological- Anatomical-
Pathological)

 C0- No evidence of Varicose vein
 C1- Telangiectasia
 C2- Varicose veins with or without symptoms
 C3- Ankle Oedema
 C4- Skin changes
 C5- Healed Venous Ulcer
 C6- Venous Leg Ulcer

78

Module-8 A Case of Ischaemic Limb

Applied Surgical Anatomy

Fig. 98: Arteries of lower leg
 Femoral artery (FA): It is a continuation of external iliac artery. It gives a branch

profunda femoris artery (PFA) in the femoral triangle. PFA plays an important role as
branch of collateral circulation in the case of lower limb ischaemia.
 Femoral artery moves through the adductor hiatus and becomes a popliteal artery
(PA). It descends the leg and divides into the anterior tibial artery (ATA) and
tibioperoneal trunk. The tibioperoneal trunk bifurcates into the posterior tibial artery
(PTA) and peroneal artery (PA).

79

Table 17: Etiology and presentation of chronic ischaemic limb

Pathology Common causes/ Risks factors Presentations

Acute ischaemic limb Embolism Pain

Thrombosis Pallor

Trauma Pulselessness

Dissection Paresthesia

Arteritis Perishingly cold

Hypercoagulable states Paralysis

Compartment syndrome

Drugs etc

Chronic ischaemic limb Atherosclerosis Intermittent claudication
Buerger’s disease Rest pain
Autoimmune vasculitis Ischaemic ulcer
Diabetes Mellitus Dry gangrene etc.
Hypercholesterolemia
Smoking
Increasing age etc.

Approach to the Patient with an Ischaemic Limb

Patient Preparation

Patient:
 Lying flat on bed/ hard coach with pillow or sitting on the chair
 Expose the appropriate part of the body. Exposed both limbs to compare
 Relax & breathe slowly

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

Material:
 Surgical gloves, Stethoscope, Sphygmomanometer,
 Alcohol hand rub, Doppler, Tissue paper, yellow bin,
 Blanket, Light source, Dressing tray

Examinations Steps

A. Building Rapport
 Greet the patient & introduce yourself
 Explain to the patient what procedure is to be done
 Obtain permission
 Third party, Privacy

80

 Hand rubs before the examination
 Put the patient in correct position
 Adequate exposure
B. Inspection
 General description of patient: (conscious level, pain/ distress, cyanosis, body

built/cachexia, pallor, abnormalities in face, jaundice, septic looking)
 Compare two limbs and check the web spaces
 Check symmetrical, size muscle bulge) of the limbs, deformities

Fig. 99: Ischemic limb
 Skin colour, line of demarcation, trophic changes (nails, toes, hair distribution…etc)

‘“Trophic changes”, venous filing, tar staining, tendon, Xanthomas

81

Fig. 100: Acute limb ischaemia
 Skin (normal/inflamed/ oedematous, indurated, distended veins, ulcers, gangrene,

dressing, old scars)

Fig. 101: Critical limb ischemia
 Inspect both soles: any ulcers, callosities at the pressure points, bunions, arches of

foot
 Check for any pulsatile swelling
 Check of signs of pre-gangrene: pallor when elevated, congestion & guttering when

dependent, thick, and scaly skin, wasting of pulp of toes/ fingers)
82

If there is a gangrenous area:
 Describe the extent, wet or dry, condition of transitional zone
 Check the groin/ axilla region: lymph nodes enlargement

C. Palpation
 Ask the patient whether there is any pain or not
 Check its tenderness and temperature
 Measure compares the circumference of the limbs
 Check the touch, pain, pressure
 Capillary refill time
 Check the movements and power of limbs power
 Palpate peripheral pulses
(Any delay: radio-radial, radio-femoral etc.)
 Measure the blood pressure

If there is an ulcer:
 Palpate the mobility, and induration at the surrounding area
 Palpate the regional lymph nodes
 Measure the ankle brachial pressure index
 Check the Doppler signals
 Listen to the bruits (Adductor canal for the femoral artery)

If there is a dry gangrene
 Check the vascular angle (Buerger’s disease)

D. “Peripheral pulses”

FEMORAL PULSE
 Best palpated just below the midpoint of inguinal ligament
 The midpoint of inguinal ligament is located halfway between the anterior superior
iliac spine and the pubic tubercle
 Palpate to confirm its presence and assess volume
 Assess for radio-femoral delay – suggestive of coarctation of the aorta
 Auscultate to detect any bruits – femoral / iliac stenosis

83

Fig. 102: Palpation of femoral artery pulse

POPLITEAL PULSE
 Best palpated in the inferior region of the popliteal fossa
 With the patient prone, flex the knee to 45º
 Place your thumbs on the tibial tuberosity
 Curl your fingers into the popliteal fossa to compress the popliteal artery against the
tibia allowing you to feel its pulsation
 This pulse is often difficult to palpate – NEVER say you can feel it if you can’t.
 The popliteal artery is the deepest structure within the fossa, so the examiner will
understand.
 Auscultate to detect any bruits

(“Peripheral pulses”)

Fig. 103: Palpation of popliteal artery pulse

84

POSTERIOR TIBIAL PULSE
 Best palpated at the posterior to the medial malleolus
 (Midway between tip of the calcaneus and medial malleolus)

Fig. 104: Palpation of posterior tibial artery pulse
 Palpate against the calcaneus bone.
 Palpate to confirm its presence and compare pulse strength to the other foot
DORSALIS PEDIS PULSE
 Best palpated at the dorsum of the foot
 Lateral to the extensor hallucis longus tendon
 Over the 2nd/3rd cuneiform bones

Fig. 105: Palpation of dorsalis pedis artery pulse

85

 Palpate to confirm its presence and compare pulse strength to the other foot

E. Auscultation
 Auscultation of bruit, cardiac murmurs

“Buerger’s test”

This test can be carried out to further demonstrate poor lower limb perfusion.
1. Ensure the patient is positioned supine

2. Standing at the bottom of the bed, raise both patient’s feet to 45º for 2-3 mins:
Observe for pallor – emptying of the superficial veins
If a limb develops pallor, note at what angle this occurs e.g 20º (known as Buerger’s
angle)

A healthy leg’s toes should remain pink, even at 90º
A Buerger’s angle of less than 20º indicates critical limb ischemia

3. Once the time limit has been reached, ask patient to place their legs over the side of
the bed:
Observe for a reactive hyperemia – this is where the leg first returns to its normal pink
colour, then becomes red in colour – this is due to arteriolar dilatation (an attempt to
remove built up metabolic waste)

4. Measure: Ankle-brachial pressure index (ABPI)

F. Offer systematic examinations if it is significant
 Examine cardiovascular system
 Check for the other arterial pulsations & bruits at major arteries
 Examination of abdomen (Aortic aneurysm)

G. 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
 Compare both limbs
 Be honest with your findings of arterial pulse, bruits, and murmurs

86