Surgery 11 1

Boundaries of calots triangle:-
-Medial-Right hepatic duct (or) common hepatic duct.
-Inferior -cystic duct
-Superior-inferior surface of liver
Contents of calots triangle
-Cystic lymph node of Lund
-Hepatic artery
Importance
-In cholecytectomy, 1st step is exploration of calots triangle.
-If any bleeding occurs it should not be blindly stopped with instruments but pressure with thumb is applied on calots triangle (PRINGLE'S MANOUVRE)

-Many hand infections will settle if conservative treatment is initiated (elevation of hand, splinting and antibiotics) within 24-48 hours.
-But if appears-I & D should be done (at point of maximum tenderness)
-Antibiotics changed →
-Splinting is done in Edinburg position →

Positions of appendix:-
1) Retrocaecal-74%
2) Pelvic-21%
3) Paracaecal-2%
4) Subcaecal-1.5%
5) Preileal-1%
6) Postileal-0.5%

In trauma, the body's stress response is activated, leading to an increase in the levels of certain hormones. Glucagon, corticosteroids, and mineralocorticoids are all hormones that are typically elevated in response to trauma. However, insulin levels are not typically raised in trauma. Insulin is responsible for regulating blood sugar levels, and in times of stress or trauma, the body releases other hormones that increase blood sugar levels to provide energy for the body's response to the trauma. Therefore, insulin levels remain relatively stable or may even decrease in trauma.

Maeckels diverticulum-
-Situated on ant mesenteric border of small intestine commonly 2 feet(60 cm) from ileocaecal valve.
-Size-3.5 cm long-2 inches.
-Seen in 2% population.
-Represents patent vitello-intestinal duct (intestinal end)
-Contains all 3 layers of intestine and has its own blood supply.
-In 20% cases contain heterotopic epithelium namely colonic, gastric, pancreas.
Abnormal epithelium lies in proximal puch of diverticular and also in ileum.
-Mc complicatiom -severe hemorrhage
-Other complications-intussusception
-Diverticulum
-Perforation
-Intestinal obstruction
-Chronic peptic ulceration
-Investigations-Technetium-99 m scanning.
-Treatment-If broad based-just invaginate
-If narrow-based-Diverticulectomy.

Post-operative complications of Thyroidectomy:-
1) Hemorrhage
2) Respiratory obstruction
3) Recurrent laryngeal n.palsy
4) Thyroid insufficency
5) Parathyroid insufficiency
6) Thyrotoxic crisis (storm)
Causes of respiratory tract obstruction after thyroidectomy:-
1) Collapse or kinking of trachea
2) Laryngeal oedema-common cause
3) Tension hematoma
4) Recurrent laryngeal n.palsy (aggravating factor)
If tension hematoma is present sutures are immediately removed and hematoma is immediately evaculated and vessel is ligated.

Adson's test is a diagnostic test used to identify Thoracic Outlet Syndrome (TOS). TOS is a condition where the nerves or blood vessels in the thoracic outlet, a space between the collarbone and the first rib, become compressed. During the Adson's test, the patient is asked to turn their head to the affected side while the examiner palpates the radial pulse. If the pulse weakens or disappears, it indicates compression of the subclavian artery, which is a common finding in TOS. Therefore, the correct answer is Thoracic Outlet Syndrome.

Trendelenburgs procedure is sapheno-femoral ligation.

-Left Testicular vein emoties into left renal vein (Therefore variocele is more common on left side)
-Right Testicular vein empties into IVC.
-Alternative route of venous return from testis is throudh cremasteric veins that drugs into inferior epigastric veins.

In haemorrhagic shock, the body experiences a significant loss of blood volume, leading to decreased perfusion to vital organs. As a compensatory mechanism, the body tries to conserve fluid by reducing urine output. Therefore, monitoring urine output can provide valuable information about the effectiveness of fluid replacement therapy in haemorrhagic shock. If urine output remains low despite fluid resuscitation, it suggests ongoing hypoperfusion and inadequate fluid replacement.

Medical treatment is instituted for fibrodenosis.
-Danazol or Bromocriptine
-Tamoxifen-LHRH agonists Rare
-Oil of primose.

The answer may be stomach because it is given that small bvowel activity returns within 12-18 hours. Colon activity returns after 36-48 hours. Gastric activity returns after 18 hours-4 days.
So it difficult to tell whether it is stomach or Rectum whose activity returns late

Various-Incisions used in Appendiectomy:-
1) Grid-iron _at right angles to aline joining Anterior superior Iliac spine and umbilicus.
2) Transverse skin crease (Lanz)
3) Lower midline Abdominal incision
4)Rutherford Morrison incision.

Blood supply of Rectum:-
i) Superior rectal A.-Branch of (continuation) inferior mesenteric artery.
ii) Middle rectal A.-Branch of internal Iliac Artery
iii) Inferior Artery A. Branch of internal ;prudential artery
Venous drainage of Rectum:-
i) Upper 1/2 of Anal canal (Above dentate line) → superior hemorrhidal veins → rectal veins
inferior mesenteric vein → superior rectal vein.
Lympathic Drainage of Rectum:-
-Usual Drainage flow is upwards.
-Superior rectal nodes and middle rectal nodes near the corresponding arteries are the main source of lymphatic drainage.

Misnomers
-Malignant pustule -Anthrax of skin
-Malignant hydatid disease-infection with Echinococcus multi locularis.

-Length of oesophagus-25 cm
-Extent of oesophagus-Cricopharyngeal sphincter to cardia.
-Site of oesophaguis-posterior mediastinum.
-Musculature of oesophagus-upper (5%) striated
-Middle (40%)-mixed striated and smooth muscles
-Lower (55%)-smooth
-Epithelium of oesophagus-squamous epithelium
-Arch of Aorta leaves an impression on oesophagus at 25 cm distance from incision (15 cm from cp. Sphincter).

Courvoisier's law is applied here "in obstruction of CBD due to a stone distension of gall bladder seldom occurs. The organ is usually shriveled. In obstruction due to other causes like Ca ampulla, Ca bile duct, gall bladder is distended.
Exceptions to this law:-
-Double stoned gall bladder
-Oriental cholangio-hepatitis.

In that age group, Mc cause of acute retention of urine is urethral stricture.
In boys of Mc cause of acute retention of urine is posterior urethral valves.

Since reflux oesophagitis is the only complications of sliding hernia, it is the cause of hematemesis.

Carcinoid tumor (Argentaffinoma) is the most common tumor of appendis (MC in Distal third of appendix)
In GIT of Mc site of carcinoid is Ileum now (Ppreviously, it was Appendix) -according to Harrison's
-Mc carcinoid that metastasizes least-Appendicular carcinoid.