REVIEW OF

CLINICAL PICTURES
Edwin version
Doc.Ernie Udefiagbon
 Disclaimer
• This slide you are about to study
was prepared as a revision note
• It is distributed free amongst all
interested surgical students
• It is not intended as a publication
or to be commercialised
• Whoever does so, do it at his/her
own risk
—Doc.Ernie
Udefiagbon
Paediatric Surgery
Cases

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Hypospadias

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Chordee

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Bifid scrotum

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Glanular hypospadias

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Coronal hypospadias

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Penoscrotal hypospadias

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Scrotal hypospadias

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 HYPOSPADIAS—
PATHOLOGIC FEATURES
• Ventral urethral meatus; proximal to tip of
glans
• Dorsal hoody of the prepuce
• Splayed and flattened glans (spade-like)
• Absence of meatus at the tip of glans
• Median grooved atretic distal urethral plate
• Chordee—ventral curvature of penis
• Bifid scrotum
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HYPOSPADIAS CLASSIFICATION

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 Complications of hypospadias
-Psychosocial problems to parents and the
child
-Problems with copulation
-Ejaculatory problem leading to subfertility
-Urinary tract infection ( prominent utricle)

Hypospadias—Differential
Diagnosis
-Urethrocutaneous fistula
-Mega meatus
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 Hypospadias—
INVESTIGATION
-Diagnosis is clinical
-Investigation done to prepare for surgery ; PCV,
Urinalysis
-To rule out ambiguous genitalia;
.Buccal smear for bar bodies
.Karyotyping
.Hormonal studies
.Abdominopelvic USS
If associated UTI:
-Urine analysis and MCS Dokernie
 Hypospadias—TREATMENT:
Hypospadias Repair

Hypospadias repair is done before the age of

awareness ( usually between 1 - 2 yrs). because the
phallic phase begins at 2yrs
The components of Repair includes:
-Orthoplasty(repair chordae)
-Urethroplasty( new urethral construction)
-Glanuloplasty
-Meatoplasty(repair meatus stenosis)
-Scrotoplasty(repair scrotal hypospadias)
- Spongioplasty
-Skin cover Dokernie
 COMPLICATIONS OF HYPOSPADIAS SURGERY
Early
• Surgical site infection
• Breakdown of repair(wound dehiscence)
• Haemorrhage

Late
• Fistula formation (Urethrocutaneous fistula)
• Stenosis; Meatal stenosis
• Stricture; Urethral stricture
• Penile torsion
• Inclusion cyst
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Inguinoscrotal swelling—hernia/hydrocele

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Hydrocele (transilluminated)
Inguinoscrotal swelling
—hernia/hydrocele

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 Paediatric Inguinal Hernia—
Diagnostic Signs
• Groin/Inguinoscrotal swelling
• Soft; Fluctuant
• Usually non transilluminating
• More easily reducible except complicated
• Both testes usually palpable except if there is
associated undescended testis
• There is demonstrable expansile cough
impulse in older children
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 Paediatric Inguinal Hernia—
Differential Diagnosis
• Hydrocele
• Femoral hernia
• Enlarged inguinal lymph node
• Abscess in the groin
• Lipoma
• Varicocoele
• Inguinal hernia

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 Paediatric Inguinal Hernia—
Complications(SOFI)
• Incarceration
• Obstruction
• Strangulation- inflammation- rupture-
peritonitis/sepsis
• Inflammed hernia
• Ulceration
• Rupture
• Peritonitis
• Fistula formation
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 Paediatric Hydrocele—
Diagnostic Signs(SCT)
• Site: Groin/Inguinoscrotal swelling
• Consistency: Cystic and Fluctuant
• Transilumation: Usually brilliantly
transilluminating
• Usually non-reducible except for the
communicating type which is slightly reducible
• The testes may not be palpable if covered by
hydrocele fluid

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 TYPES OF HYDROCELES

VICE
• Communicating/ congenital
• Infantile
• Funicula
• Bulbonocele
• Encysted hydrocele of the cord
• Vaginal hydrocele—affecting the tunica vaginalis;
occurs only in males
• Hydrocele of canal of Nuck( female)
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 Paediatric Hydrocele—
Complications:
• Inflammation/Infection
• Ulceration
• Rupture

PATHOLOGY FOR BOTH INGUINAL

HERNIA AND HYDROCELE IN CHILDREN
—
• patent processus vaginalis
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 Treatment
• Inguinal Hernia—Herniotomy on the next
available operation list

• Hydrocele—Herniotomy after child is

>1yr except if complicated; it is usually
observed for a year because it could
spontaneously resolve

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 COMPLICATION OF HERNIOTOMY

• Haematoma
• Scrotal Oedema
• Damage to cord content eg vas deferens,
testicular vessels
• Iatrogenic undescended testis
• Testicular ischaemia / atrophy
• Surgical site infection

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Anorectal malformation
imperforate anus

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Anorectal malformation
imperforate anus

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Anovestibular fistula

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Anterior ectopic anus

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 CLASSIFICATION:high, intermediate and low
Anorectal malformations
• HIGH type
-anorectal agenesis with rectovaginal/recto
prostatic or vesical fistula
-rectal atresia -persistent cloaca

• INTERMEDIATE type
-low rectovaginal fistula/rectovestibula fistula
-rectobulbar fistula
-anal agenesis without fistula Dokernie
• LOW type
-anovestibula fistula
-anocutaneous fistula
-anal stenosis
-persistent anal membrane
-ectopic anus
-imperforate anus
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 ARM—Clinical Features
• Absence of anus
• Abnormal passage route for stool eg per
vaginam
• Abdominal distension
• Vomiting
• Dehydration
• Features of hypovolemia/shock—
↑PR,↓BP, cold clammy extremities Doker
 ARM—Complications
• Acute Intestinal obstruction
• Electrolyte derangement
• Shock
• Sepsis
• Bowel perforation
• Urinary tract infection
• Failure to thrive

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 ARM—Investigations
• DIAGNOSTIC:
-Cross Table Lateral Xray in Knee-Elbow position
-Imaginary Pubococcygeal or transtubercular Line
is used as defining landmark for high or low ARM
-The length between terminal rectal air shadow
and a radiopaque object placed at the position
anus could also be used: if >1.5cm(HIGH);
if <1.5cm(LOW)
• OTHERS: E/U/Cr, FBC, Fistulogram, blood group
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 ARM—Treatment
• LOW TYPE: one stage surgical treatment
- Anoplasty

• HIGH TYPE: 3 stage surgical treatment

-Colostomy creation
-Posterior Sagittal Ano-Recto Plasty(PSARP)
-Colostomy closure

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 Complications of Anorectoplasty surgery
• Rectal prolapse
• Mucosa prolapse
• Retraction of neoanus
• Gangrene of neoanus
• Bowel perforation
• Peritonitis
• Breakdown of repair
• Incontenence/Constipation
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CLEFT LIP

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Cleft lip

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Cleft lip/palate

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 Cleft lip—Features
• Lip defect—unilateral or bilateral
• Extension into floor of the nose (complete)
• Extension into the alveolus( compound)
• Is the palate involved; is it:
-Primary palate
-Secondary palate
-Complete ( both)

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 PROBLEM OF CLEFT LIP/ PALATE

CITES
• Cosmetically looks ugly
• Eating: Sucking problem
• Teeth: Defective dentition
• Defective speech
• Infection: Repeated respiratory tract infection
• Infection: Repeated otitis media with defective
hearing
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TREATMENT
• Multidisciplinary ; paediatric surgeon,
plastic surgeon, paediatric orthodontist,
paediatrician, nutritionist , speech
therapist, ENT surgeon.
• Cleft lip; Millard’s operation commonly
done when baby is 10wks old, 10pounds
weight, and 10g/dl Hb conc(Rule of 10)
• Cleft palate ; von Langenbeck
operation commonly done at 9-12
months
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Cystic hygroma

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Cystic hygroma

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Cystic hygroma

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Cystic hygroma of the left axilla

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 CYSTIC HYGROMA—FEATURES

• Globular/Hemisherical swelling at common

site
• Cystic
• Fluctuant
• Transilluminate brilliantly
• Skin attachment – not attached
• Regional lymph nodes; usually not enlarged
except if infected
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 CYSTIC HYGROMA—
COMMON SITES OF OCCURRENCE(PAMIT)

• Posterior triangle of the neck

• Axilla
• Groin/ inguinal
• Mediastinum
• Tongue and buccal mucosa
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 CYSTIC HYGROMA—
DIFFERENTIAL DIAGNOSIS(HACEL)

• Branchial cyst
• Enlarged lymph node (cervical)
• Cold abscess in the neck
• Solitary lymph cyst
• Haemangioma

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 CYSTIC HYGROMA—COMPLICATIONS

• Recurrent infection
• Bleeding into cyst
• Airway obstruction from rapid expansion
• Rupture
• Insinuation into nearby structures
• Ulceration
• Obstructed labour during delivery
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 CYSTIC HYGROMA—
INVESTIGATIONS
Chest X-ray to rule out mediastinal
extension
CT/ MRI- define extent of the lesion better
Routine investigation ; PCV, Urinalysis etc.

TREATMENT
• Needle aspiration
• Sclerotherapy ;bleomycin, Na tetradecyl
sulphate, glucose, hypertonic saline, OK-432
• Surgical excision
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• Radiotherapy especially for recurrence
Transverse loop colostomy

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Transverse loop colostomy

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Divided colostomy
DEVINE type

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Divided colostomy
DEVINE type

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Double barrel colostomy

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Colostomy—skin excoriation

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Colostomy prolapse

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Prolapsed loop colostomy

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 INDICATIONS FOR COLOSTOMY
1. Patients who cannot pass faeces e.g
 Congenital as in: -Anorectal malformation,
-Hirschsprung’s disease.
 Acquired as in: - obstruction from malignant tumors
- strictures as in Schistosomiasis
mansoni
-a foreign body causing obstruction
2. Conditions where passage of stool per anus is
unwarranted eg
 Fistulae management; eg Rectovaginal fistula
 To protect a low GI anastomosis
 To protect repair of rectal injuries Dokern
TYPES OF COLOSTOMY
 Classification by duration:
-Temporary Colostomy
-Permanent colostomy; indicated in carcinoma of the lower
rectum/anal canal.

 Classification by Anatomical site:

-Transverse colostomy
-Sigmoid colostomy
Both are used because they have mesocolon which makes them easy
to mobilise. The caecum can also be used if it has
mesentary(caecostomy)
 Classification by the surgical technique:
1. Loop colostomy
2. Divided colostomy which could be further sub-classified into
• -Mikulicz (double barrel) colostomy
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• -Devine colostomy
 COMPLICATIONS OF COLOSTOMY
Early Complications:

• Colostomy diarrhoea causing

hypovolaemic shock
• Haemorrhage
• Colostomy failure
• Stoma necrosis
• Wound infection/surgical site infection
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 COMPLICATIONS OF COLOSTOMY
Late Complications:
• Colostomy prolapse.
• Colostomy retraction
• Stoma avulsion
• Paracolostomy hernia
• Skin excoriation as the faecal matter rubs on the skin
• Depression( in paediatric age group the parents will be
depressed)
• Constipation, faecal impaction
• Faecoloma(inspissated faeces forming a tumor like
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mass)
 CARE OF COLOSTOMY

• Counsel the patient very well before the

colostomy is done.
• Good hygiene; use of deodourants/parfumes
• Use of skin protective cream like Zinc oxide
cream, vaseline, petroleum jelly.
• Use of colostomy bag
• Specialist Stoma Nurse services
• Link up the patient with colostomy support
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 Ectopia
vesicae
OR
Bladder
exstrophy
(MALE)

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Ectopia vesicae(FEMALE)

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Ectopia vesicae

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Ectopia vesicae

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 Ectopia vesicae—Pathologic Features
Open/displaced anterior Pubic diastesis
bladder wall 
open pelvic ring

Bladder mucosa + 
Weak pelvic supports
ureteric orifices exposed

Squamous Shortened penis
metaplasia/malignant
transformation possible Complete epispadias

Open anterior abdominal Anteriorly displaced vagina

wall + displaced muscles
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 Ectopia vesicae—Complications
• Bladder dehiscence
• Surgical site infection/Wound infection
• Calculus formation
• Urinary incontinence
• Urethrocutaneous fistula
• Squamous metaplasia
• Adenocarcinoma
• Uterine prolapse
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 Ectopia vesicae—Investigations
*diagnosis is clinical
Renal ultrasonography

Pelvic radiograph

Echocardiography

Others

Electrolytes & urea

Complete blood count Dokerni
 BLADDER EXSTROPHY TREATMENT
One-stage reconstruction
The entire reconstruction done in one
stage, in neonatal period:
• Complete primary exstrophy repair
(CPER)
• Total penile disassembly (TPD): Boys
• Total urogenital mobilization: Girl
• Bladder neck reconstruction

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 BLADDER EXSTROPHY TREATMENT
Multi-stage reconstruction

Genital
Continenc
Initial Reconstru
e
Closure ction
Procedure
Birth 6-
4-5 years
12months

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 Bladder Exstrophy Repair
Postoperative Complications
• Surgical site infection

• Wound dehiscence

• Urolithiasis

• Vesico-Ureteric Reflux/Hydronephrosis

• Poor scars

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 Ectopia vesicae—Variants

• Classic bladder • Cloacal exstrophy

exstrophy • Superior vesical
• Pubic diastasis fissure
• Male epispadias • Duplicate
• Female epispadias exstrophy
• Bladder exstrophy • Covered exstrophy
with imperforate • pseudoexstrophy
anus
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 EPISPADIAS
(penile)

• It is a congenital anomaly where the external

urethral opening is situated on the dorsal
aspect of the penis instead of the glans-tip Doker
EPISPADIAS FEATURES
(penopubic) • Absence of meatus at
glans-tip

• Dorsal urethral opening

• Dorsal groove distal to

abnormal meatus

• Ventral hooded
prepuce
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EPISPADIAS
(glandular)
TYPES
• Glandular

• Penile
• penopubic

• Totalis/Complete
—whole dorsal
aspect affected
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 EPISPADIAS
Complete/Totalis (may be associated with bladder
exstrophy)

TREATMENT
• Urethroplasty—
Denis-Browne’s
technique

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Enterocutaneous fistula

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Classification of enterocutaneous
fistula—Physiological basis
• High output >500ml/24hrs

• Low output <500ml/24hrs

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 Enterocutaneous fistula
Complications
• Fluids, electrolytes and acid-base imbalance:
K, Na, Cl, HCO3, H, shock

• Malnutrition:from reduced intake, increased

losses, increased energy expenditure, leading
to catabolism

• Sepsis: abscesses, multiple organ failure

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 Enterocutaneous fistula
Investigations
• FBC: WBC raised, for elderly and malnourished may not
be raised
• E/U/Cr: note derangement in Na, K, metabolic acidosis
• Serum albumin, transferrin, pre-albumin help to predict
closure and mortality
• Abdominopelvic USS
• Abdominal CT scan: where better resolution is required
• Fistulography: outline fistula track, shows distal
obstruction
• Oral methylene blue/activated charcoal
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 Enterocutaneous fistula
Principles of management

• Fluid resuscitation, correction of electrolyte derangement and acid-

base imbalance
• Nutritional support and vitamin supplements
• High fistula-TPN comprising glucose, fat emulsion, amino acids,
vitamins and electrolytes
• Low fistula-elemental oral diet (absorbed in upper intestine)
• Pharmacologic agents like Octreotide to reduce effluent
• Local control of fistula output
• Protection of skin from excoriation or ulceration –barrier cream,
colostomy appliance, continuous suction
• Definitive surgery where necessary after patient has attained
positive nitrogen balance
• Delayed surgery done 4-8wks after conservative management if
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 Factors that prolong fistula
• Foreign body
• Radiation of affected part
• Infection
• Epithelialisation
• Neoplasia; Nutritional deficiency/malnutrition
• Distal obstruction
• Steroid therapy /Suppressed immunity(HIV); Short
wide fistula

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Gastroschisis

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Gastroschisis AETIOLOGICAL FACTORS
• Defective mesenchymal
development
• Defects in obliteration
of umbilical
vessels(usually the
right) resulting in
vascular accident
leading to
Gastroschisis—eviscerated
paraumbilical ischemia
loops covered with fibrinous
and subsequent
exudates due to amniotic
paraumbilical defect
fluid reaction
with bowel extrusion
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 Gastroschisis
• A small defect usually <4cm adjacent to the
umbilicus just to the right of the cord in all but
a few rare instances
• Skin bridge may be present between cord and
defect
• Abdominal wall muscle is normal
• No sac or remnant of sac

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 Gastroschisis
• There are usually no other serious associated
congenital abnormalities

• Most gastroschisis can be repaired by primary

closure.

• The small defect is extended, and exploration of

the abdomen is done to exclude gut anomalies
such as atresia or malrotation
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 Gastroschisis
• The abdominal cavity is sometimes small
making primary closure impossible.

• A silo is useful; the gut gradually reduces and

the defect can be closed thereafter.

• Long delay before surgical intervention results

in extrusion of more loops of bowel,
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 Gastroschisis
• Infection of the extruded bowel loops

• These bowel loops become oedematous and

can be complicated by gangrene of the long
segment of loop of gut

• Resection of the gangrenous segment leaves a

short length of small intestine
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Silo device

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Improvised silo

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Omphalocele

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 Omphalocele sac covering comprise—
Amniotic sac; Wharton’s jelly; Peritoneal sheath

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 OMPHALOCELE—embryogenic
mechanism/pathogenesis
• Failure of fusion of anterior abdominal wall
folds
• Failure of physiologic herniated bowel to
return into an under-developed abdominal
cavity
• Defect in the umbilical ring
• Defect in the formation of the third germ layer
(mesoblast)
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 OMPHALOCELE—clinical features
• Central abd wall defect, usually 4cm /above

• Always covered by a translucent sac from which the

umbilical cord extends; sac may be torn during
delivery

• Muscles of abd wall are normal but rectus inserted

laterally on the costal margin creating a depression
superiorly
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 OMPHALOCELE—clinical features contd

• The sac usually contains the liver, midgut and

sometimes other organs eg spleen, gonads

• Babies with omphalocele are usually full term

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 OMPHALOCELE—Classification
• Major/Minor—5cm diameter as demarcation
ie Major >5cm; Minor<5cm

• Syndromic/Non-syndromic

• Sac intact/ Ruptured sac

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 Syndromes Associated With Omphalocele

• Pentalogy of Cantrel
• Beckwith-Wiedemann-OMG
• OEIS—Omphalocele, Extrophy, Imperforate anus,
Spinal anomalies
• Gershoni-Baruch
• Donnai-Barrow
• Fryns
• Chromosomal anomalies eg Down’s
• VACTERL: Vertebral,Anorectal,Cardiac,Tracheo-
Esophageal fistula, Radial, Limb Dokerni
 OMPHALOCELE
Complications: Treatment modalities:
• Rupture • Conservative
Escharotic dressings
with sofratulle,
• Sepsis; omphalitis
honey, iodine, etc

• Intestinal obstruction
• Silo device
application
• Bowel perforation

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• Surgical repair
Pentalogy of Cantrell

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Omphalocele—ruptured

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Omphalocele—ruptured

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Omphalocele

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Ventral hernia

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 Ventral
hernia

• Ventral hernia forms following

epithelialisation of omphalocele sac; the
hernia is subsequently repaired surgically Dokerni
 INDICATIONS
Gastrostomy
• Corrosive oesophageal
feeding tube stricture
• Oesophageal obstruction
due to tumours
COMPLICATIONS
• Tube migration
• Dislodging of tube
• Stomach Perforation
• Leakage
• Peritonitis
• Skin excoriation
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 Haemangioma—
Cavenous Haemangioma

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Cavenous Haemangioma of lower lip

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 HAEMANGIOMA
(Carvernous)  Diagnostic signs
• Raised above the
 Differential skin
diagnosis • Skin over mass
• Pyogenic usually dark
granuloma red/bluish
• Lymphangioma • Warm to
touch/differential
• Haemangiopericy
temperature+
toma
• Not pulsatile.
• Fibroma
• Soft spongy mass
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 HAEMANGIOMA Complications
(Carvernous) contd
 Investigations • Infection/sepsis
Diagnosis is clinical • Thrombosis
but where necessary • Overlying skin
do: atrophy
• USS with colour • Ulceration
doppler
• Pressure effects eg
• MRI
Airway obstruction
• Visual obstruction
 Complications
• Recurrence
• Haemorrhage Dokerni
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HAEMANGIOMA  Treatment
(Carvernous) • -Observation
• -Cryotherapy
 Related
• -Sclerotherapy
syndromes
• -Intralesional
• -Sturge-Weber
• -Kassabach-Merritt corticosteroid
• -Von-Hippel-Ladau • -Surgical excision,
• -Maffucci with skin grafting
• -Klippel-Trenaunay- • -Ligation of feeding
Weber vessels
• -Parks-Weber
• -Therapeutic
• -Blue- bleb-baby
embolism of
syndrome Dokern
 • Occurs in previous
Incisional hernia surgical site
• Due to defect or
weakness in
muscle/fascia
complicating the
surgery; skin is intact
• Complications—as in
other hernia
• Treatment—
Herniorrhaphy :
-Mayo’s Repair
-Mesh Repair
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Meconium plug syndrome

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• Meconium plug syndrome refers to inspissated meconium
obstructing the colon as against Meconium ileus resulting
from Cystic Fibrosis which affects mostly the small
intestine
• Conditions that predispose to dysmotility of the neonatal
bowel may be responsible for the formation of the
meconium plug e.g.
-maternal pre-eclampsia,
-maternal diabetes mellitus,
-maternal administration of
magnesium sulfate,
-prematurity,
-Hirschsprung’s disease
-sepsis, and hypothyroidism.
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 Urethrocutaneous fistula;
a complication of circumcision

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 Glanulopenile adhesion;
a complication of circumcision

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Ventral avulsion of the glans;
a complication of circumcision

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Penile implantation cyst;
a complication of circumcision

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 Torsioned penis;
a complication of circumcision

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CHARACTERISTIC
FEATURES Plexiform neurofibromatosis
• Excessive overgrowth of
endoneurium in the
subcutaneous tissue
• Overlying skin may be
thickened, edematous,
pigmented and hangs
down in pendulous fold
• Other neurofibroma
and café au lait spots
are present in the body
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 PLEXIFORM NEUROFIBROMATOSIS

COMPLICATIONS DIFFERENTIALS
• Cystic degeneration • Huge thrombosed
• Infection haemangioma
• Ulceration • Arteriovenous fistula
• Sarcomatous change • Filarial elephantiasis
• Cosmetically ugly • Nodular leprosy

Treatment—surgical excision
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Prune belly syndrome

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 Prune belly ASSOCIATED
PROBLEMS
syndrome • Pulmonary abnormalities
Diagnostic Features • Chest wall abnormalities.
• wrinkled appearance of • Cardiac abnormalities.
abdominal wall due to • Growth retardation.
variable degrees of muscle
hypoplasia
• Developmental delay.
• Mental retardation
• urinary tract abnormalities
• End stage renal failure.
eg hydronephrosis
• Male Fertility problem
• bilateral undescended
testes in male patients Dokern
 Prune belly syndrome—
Investigations
• Plain abdominal xray
• Abdominopelvic Ultrasound scan to rule out
genitourinary abnormalities
• Intravenous Urogram—detects abnormalities
in the urinary system
• Chest xray
• Echocardiography
***Antenatal Ultrasound scan also is useful
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 Prune belly syndrome—
Indications for Surgery
• To correct urinary stasis in order to prevent urinary
tract infections which may lead to loss of renal
function and mortality.
• To correct reflux; a reduction cystoplasty is
performed.
• Orchidopexy for bilateral undescended testes.

• Some patients may require abdominal wall

reconstruction, however routine abdominal wall
reconstruction is not recommended as the cosmetic
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Undescended testis

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DIFFERENTIAL CRYPTORCHIDISM
DIAGNOSIS(GARE)
• Retractile testis; testis can
COMPLICATIONS(5Ts)
be mobilised into
• Testicular atrophy
hemiscrotum(scrotum is
well formed unlike the • Epididymo orchitis
crytorchidism) • Tendency to cause
• Gliding testis Subfertility
• Trauma , Torsion
• Undescended testis;
• Inguinal hernia
cannot be mobilised,
arrested along normal • Tumor:Seminoma
track of descent (malignant
transformation)
• Ectopic testis; deviated
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from the normal track
 CRYPTORCHIDISM (EMPTY
SCROTUM)
*Diagnosis could be clinical
Pubopenile INVESTIGATION
ectopic testis • USS of srotum,
abdominopelvic USS
• Laparoscopy
• Hormonal assay
• Gonadal venogram

TREATMENT;
• Orchidopexy before 2yrs
of age; pre
• Orchidectomy in older
children where testis
hypoplastic Dokern
 CRYPTORCHIDISM—
AETIOLOGY
COMPLICATIONS • Prematurity
OF ORCHIDOPEXY • Lack of gonatrophin ( HCG)
• Surgical site • Lack of calcitonin gene
infection related peptide (CGRP)
• Testicular atrophy • Gubernacular dysfunction
• Injury to cord • Familial
element eg vas • Prune belly syndrome- due
deferens, to weak anterior
abdominal wall
testicular artery musculature
• Testicular torsion • Anterior abdominal wall
• Scrotal defect eg omphalocoele
haematoma • Deficiency of mullerian
Dokernie
Rectal prolapse

Doker
 Rectal prolapse – clinical features
• Parents see rosette mucosa through the anus
during defecation and pushes it back
– Mass appears during next defecation
• Rectal bleeding may occur
• Rectal exam – probe cannot go up rectal
sulcus beyond 1-2 cm compared to prolapsing
intussusception where probe goes beyond

Dokerni
e
 Rectal prolapse - treatment
• Non-operative/ supportive
– Eliminate cause of diarrhoea or constipation
– Make child squat during defecation not potty
– (Treat cystic fibrosis)
– Strap buttocks
• Sclerotheraphy, Cauterization
• Operative
– Perianal cerclage, transanal suture fixation,
rectopexy
Dokerni
Sacrococcygeal teratoma

Doker
nie
Sacrococcygeal teratoma

Dokern
ie
Sacrococcygeal DIFFERENTIAL
teratoma DIADNOSIS
• Lipomeningocele
(myelomeningocele)—
Spinal Bifida
• Lipoma
• Rectal duplication cyst
• Epidermoid cyst
• Chordoma
• Neuroblastoma (presacral)
• Rhabdomyoma

Dokernie
 COMPLICATIONS
Sacrococcygeal • Infection
teratoma • Ulceration
• Bowel(rectal) obstruction
EMBRYOGENESIS/ • Malignant transformation
AETIOPATHOGENESIS
• Intralesional haemorrhage
• Defective Primitive
• External haemorrhage
streak generating cells
of the three germ lines • Rupture (especially at
—ectoderm, mesoderm, delivery)
endoderm • Obstructed labour
Dokerni
• Type 1: Completely external,
no intrapelvic Sacrococcygeal teratoma
(internal) component --
46% incidence CLASSIFICATION
• Type 2: Predominantly
external + small
internal component
-- 35% incidence
• Type 3: Predominantly
internal + small
external component --
9% incidence
• Type 4: completely intrapelvic,
no external
component --
10% incidence
Dokern
Plain radiographs; shows Sacrococcygeal
• Calcifications, anterior rectal
teratoma
displacement (lateral view)
• Sacral vertebral abnormalities INVESTIGATIONS
• Pulmonary metastasis MRI
• Useful in patients with
Abdominal ultrasonography • Sacral abnormalities
OR • Intraspinal extension
CT scan (with intravenous, rectal
contrast)
Serum
• More accurate for assessing
• AFP
extent of tumour
• β-hCG
• Periaortic lymphnode
enlargement Dokerni
e
TREATMENT Sacrococcygeal
• Resuscitate teratoma
• Tetanus prophylaxis POST-OP COMPLICATIONS
(if ulcerated) Intraoperative
• Surgical excision • Haemorrhage
• Injury to rectum
-Sacral approach=Type I,
II
Postoperative
-Sacral + abdominal
• Wound infection
approach=Type III, IV
• Urinary retention
-Inverted chevron incision • Faecal incontinence
-Coccyx must be excised
Dokerni
Thyroglossal duct cyst

Doker
 Thyroglossal
duct cyst

• a cystic swelling arising from remnant of thyroglossal duct

which direct the thyroid gland from the foramen caecum
its site of embryogenesis to its definitive anatomic site
Dokern
Thyroglossal duct cyst—anterior
midline cystic, fluctuant swelling
which may transilluminate

Dokerni
 Thyroglossal duct cyst
COMMON SITES OF DIFFERENTIAL
OCCURRENCE DIAGNOSIS
• Tongue( beneath • Thyroid swelling / cyst
foramen caecum) • Ectopic thyroid
• Floor of the mouth • Dermoid cyst
• Suprahyoid region • Subhyoid bursa cyst
• Subhyoid region- • Enlarged pretracheal
commonest gland
• In front of thyroid • Lymphangioma
cartilage • Laryngocele
• In front of cricoid • Epidermoid /
cartilage sebaceous cystDokern
COMPLICATIONS
Thyroglossal
• Recurrent infection duct cyst
• Haemorrhage into
INVESTIGATION
cyst
• USS of the neck
• Fistula formation
• Routine for
• Malignant
surgery – PCV etc
transformation –
papillary carcinoma
rarely TREATMENT
• Cosmetically ugly • Complete
looking excision (Sistrunk
operation) Dokerni
• Enlargement with
e
Thyroglossal duct fistula

Doker
 Hirschsprung’s disease— transition zone

• Features—megacolon, transition zone and

collapsed bowel segment Dokerni
• Hirschsprung’s COMPLICATIONS
disease is a
congenital
• Functional
developmental Intestinal
anomaly affecting obstruction
the hind gut
• Enterocolitis
characterised by
absence of ganglion • Septicaemia
cells; usually • Failure to thrive
affecting the
rectosigmoid
Doker
nie
 Hirschsprung’s dx
DIAGNOSTIC
INVESTIGATIONS
• Unprepared Barium POST-OP
COMPLICATIONS
enema
• Rectal prolapse
• Rectal biopsy
• Rectal retraction
• Anorectal manometry
• Gangrene of pulled out
bowel segment
TREATMENT— • Bowel perforation
Pull through surgery: • Incontenence/
Swensson, Duhamel, Constipation
Soave Dokerni
 Ankyloglossia—tongue tie

• Can affect sucking

• Could also affect speech
• Treatment is surgical release Dokerni
beckwith-wiedemann syndrome

Doker
 Beckwith-Wiedemann syndrome
COMPONENTS- OMG
• Congenital abdominal wall
defect—omphalocele

• Macroglossia

• Visceromegaly(Organomeg
aly

• Hypoglycaemia—Islet cells
hyperplasia Dokerni
Jaw mass—Burkitt’s lymphoma

Doker
Burkitt’s lymphoma
• A type of Non-Hodgkins
Lymphoma with extra-
nodal disease
• The classic picture—a
rapidly growing jaw or
maxillary tumour in a
small child under the age
of 5 years
• Additional abdominal
disease is seen in about
half of the patients

Doker
 Burkitt’s lymphoma
The actual treatment of lymphoma does
not usually involve the surgeon, as it is
based primarily on chemotherapy with
selective use of radiotherapy. The surgeon
may be involved in the diagnosis of
lymphoma, particularly in differentiating
between tuberculosis nodal enlargement
and lymphoma.
Dokern
Plastic Surgery
Cases
Dokern
Burns

Dokernie
Partial thickness burns

Dokern
burns contracture

Dokernie
 BURNS
CONTRACTURE

Doker
nie
 BURNS XAMINATION IN THE EMERGENCY ROOM

• Primary survey
• Airway assessment
• Breathing
• Circulation
• Disability of neurological status [GCS]
• Expose and assess percentage surface area of
burns using Wallace’s rule of 9
• Make sure of temperature to avoid hypothermia
• Secondary survey
• Examination from head to toe and from front to
back to identify other injuries sustained.
Dokerni
Wallace’s rule of 9

OTHER METHODS OF
ASSESSING BURNS
SURFACE AREA
• Palm method—
patient’s palm
estimated as 1%
• Lund and Browder
chart; used especially
for children

Dokerni
e
 EMERGENCY MANAGEMENT OF
BURNS
• If patient present within 2hours of burns,
-Apply cold running water to cool burnt area

• Airway management if inhalational injury was

sustained;
—Give 100%oxygen for first 3hours, endotracheal
intubation plus mechanical ventilation, also do
bronchial toileting

• Fluid resuscitation using Parkland’s formula

=%BSA x weight x 4
Dokerni
 EMERGENCY MANAGEMENT OF
BURNS contd
• First half of total fluid calculated is given over first
8hours
• Second half given over next 16 hours
• Maintainance fliud commenced thereafter
• Crystalloids eg Ringers lactate are ideal for the first
24hrs

• Adequate analgesia using morphine,fentanyl,

pentazocine, or tramadol
-Give analgesia intravenously, not intramuscularly
• Systemic broad spectrum antibiotics therapy
• Tetanus prophylaxis
Dokern
•
 Burns management contd

Local wound
care
• Debridement,brushing OTHER MEASURES
• Saline bath • Adequate nutrition
• Antiseptic/antibiotic
(dermazine) dressing • Skin cover where
-Open/close dressing; necessary—graft/flap
close dressing is 3 layered
• Escharotomy where
necessary
Dokerni
 Burns management
contd
Fluids used for Agents used for
Resuscitation Burns wound
Crystalloids like dressing
• Sofra-tulle
• Ringer’s lactate
• Dermazine cream
• Normal saline
• Chloramphenicol
Colloids like
ointment
• Haemacel
• Mafenide cream
• Pentastarch
• Honey
Dokernie
 BURNS COMPLICATIONS—Local

• wound sepsis –Streptococcus

pyogenase or
Pseudomonas aeruginosa
• scarring(full thickness) –
hypertrophic scars, keloids
• wound contracture
• Marjolin’s ulcer(malignant
change)
Dokerni
 BURNS COMPLICATIONS—
General
• sepsis: chest infection, UTI,
septiceamia
• acute peptic ulceration
(Curling’s ulcers)
• seizures from electrolyte
derangement
• renal failure
• psychological disturbance
Dokernie
CHRONIC ULCER

Dokerni
LEG ULCER

Dokernie
LEG ULCER

Dokerni
• COMMON CAUSES • ULCER DRESSING
OF ULCER AGENTS
• Trauma • EUSOL: Edinburg
University Solution Of
• Diabetes mellitus Lime
• Pyogenic infections • Silver sulphadiazine
• Tuberculosis (dermazine)

• Sickle cell anaemia • Chloramphenicol ointment

• Sofra-tulle
• Malignant skin lesions
• Mafenide
• Burns
• Honey
Dokerni
 
LOCAL DIAGNOSTIC INVESTIGATIONS

 Discharge for microscopy, culture and

sensitivity to rule out bacterial infection
 Discharge for acid fast bacilli to rule out
tuberculosis
 Discharge for cytology to rule out
presence of malignant cells
 Wedge biopsy (if malignant) to
determine histological features
Dokerni
e
 INVESTIGATION TO ASSESS EXTENT OF DISEASE
 X-ray of the part; AP and lateral views – bony involvement,
osteomyelitis
 FNAC of enlarged regional lymph node

 INVESTIGATIONS FOR SPECIFIC AETIOLOGY

 Chest x-ray – TB
 Mantoux test – TB
 Arterial / venous doppler / duplex scan
 Angiogram - vascular ulcers
 Fasting blood sugar, urinalysis – Diabetes Mellitus
 Haemoglobin genotype – sickle cell
 VDRL (Venereal Disease Research Laboratory) – serological
test for syphilis
Dokerni
 PRINCIPLES OF TREATMENT

 Establish the cause and treat it

 Care for the ulcer
 Debridement
 Ulcer cleansing
 Dressing – antiseptics, topical antibiotics
(framycetin sulphate, silver sulfadiazine,
mupirocin), honey etc
 Remove exuberant granulation tissue
 Skin closure if defect is >5cm by secondary
suturing, skin graft/flap
Dokerni
 PRINCIPLES OF TREATMENT contd

General measures
 Correct deficiencies like anemia, protein,
vitamins
 Transfuse blood where necessary
 Control pain with adequate analgesia
 Antibiotics (oral or IV) – control infection
 Rest the affected part; use of casts,
splints
Doker
 FACTORS AFFECTING HEALING/ LEADING TO CHRONICITY

 Recurrent infection
 Trauma
 Absence of rest
 Poor blood supply
 Oedema of the area
 Loss of sensation
 Malignancy
 Specific aetiology with chronic course eg tuberculosis
 Fibroses, chronic inflammation
 Periosteitis, osteomyelitis

Dokern
CLASSIFICATION OF ULCERS
• Specific ulcers
• Non-specific ulcers
• Malignant ulcers Dokerni
e
 SPECIFIC ULCERS

 Tropical ulcer : Borreli vincenti +

Bacteroides fragilis
 Tuberculosis : Mycobacterium
tuberculosis
 Buruli : Mycobacterium ulcerans
 Syphilitic : Treponema pallidum
 Yaws : Treponema pertenue

Dokerni
 NON SPECIFIC ULCERS
 Traumatic
 Infective – non specific bacterial
infection/suppuration
 Vascular – arterial or venous
 Decubitous ulcer/Pressure sore
 Secondary to systemic diseases eg
DM, Sickle cell, etc

Dokerni
 MALIGNANT ULCERS

 Basal cell carcinoma

 Squamous cell carcinoma
 Malignant melanoma
 Marjolins ulcer
 Karposi sarcoma

Dokerni
e
 Malignant Ulcer:
SQUAMOUS CELL
CARCINOMA

• Can affect any part of

the skin and its
appendages
• Spread—locally,
lymphatics
Doker
nie
 Malignant Ulcer:
SQUAMOUS CELL CARCINOMA

RISK FACTORS
TREATMENT options:
• UV light exposure
• Surgical excision
• Ionizing radiation
• Radiotherapy
• Immunosuppression
• Electrocautery
• Chronic inflammation
• Cryotherapy
• Arsenic exposure
• Topical cytotoxic eg 5-
• Albinism fluorouracil
• Xeroderma pigmentosum • Moh’s surgery
• Cigarette smoking
Dokerni
 Malignant Ulcer:
BASAL CELL CARCINOMA

Dokernie
 Malignant Ulcer:
BASAL CELL CARCINOMA
• Arise from the basal cells of the epidermis
• Called ‘Rodent ulcer’ because it burrows deep
• Most commonly occur in the face—an area
above the imaginary line drawn between the
angle of the mouth and the ear lobule
• The tumour is frequently multiple
• Common amongst albinos
• Treatment—surgery, radiotherapy
Dokerni
Malignant Melanoma

Dokern
Malignant
Melanoma • Melanoma commonly
affect the sole
COMMON TYPES • It has characteristic
• Superficial melanin pigmentation
spreading type on the floor
• Nodular melanoma • Usually characterised
• Lentigo melanoma by spreading satellite
• Acral lentigenous nodules
(commoner in • Treatment—surgical
blacks) excision, amputation,
• Amelanotic cytotoxics(melphalan)
, alpha interferon
Dokerni
 • Caused by excessive,
Pressure Ulcers (Decubitus Ulcers)
prolonged unrelieved
tissue pressure which
occlude the
microcirculation
causing ischemia
infarction necrosis
• Patients unable to
sense pain or to shift
their body weight,
• Bony prominences – such as paraplegics or
sacrum, elbow, occiput, bedridden individuals
heel, etc are usually are more prone
affected Dokerni
 Pressure Ulcers • Treatment of
(Decubitus Ulcers) pressure sores
requires relief of
• Muscle tissue is pressure with
more sensitive to special cushions
ischemia than the and beds and
overlying skin. nutritional support
Therefore, the to promote healing.
necrotic area is The necrotic tissue
usually wider and should be removed,
deeper than it often along with the
appears on first underlying bony
inspection prominence
Dokern
• Shallow ulcers may
close by secondary Pressure Ulcers
intention, but (Decubitus Ulcers)
deeper wounds Prevention of ulcers
with involvement of is best achieved by:
the underlying bone • Close attention to
susceptible areas; keep
require surgical dry, use skin protective
débridement and creams like zinc oxide
coverage(flaps) • Frequent repositioning of
paralyzed patients.
• The addition of
• Cushion pads for bony
growth factors to prominences
these wounds has • Air flotation mattresses
been found to and gel seat cushions—
redistribute pressure
polydactyly

Doker
Polydactyly—toes

Dokernie
syndactyly

Dokern
deformity of digits

Dokern
Management of Congenital Limb Anomalies

• Clinical picture is taken

• Xray of the affected part in AP and Lat views to
rule out bony involvement
• Syndactyly—surgical separation, commissure
reconstruction and resurfacing of the
intervening borders of the digits
• Polydactyly—excision and wound closure
• Always do investigations to rule out other
congenital anomalies—VACTERL
Dokerni
Hand splint in position of function

Dokern
keloids

Dokerni
e
  Diagnostic signs
Keloids • Raised from the surface
• Lobulated surface
• Firm to touch
• Presence of a scar
• Claw like processes
• Extend beyond original
scar

 Differential diagnosis:
• Hypertrophic scar—no
Dokern claws and do not extend
 Keloids  Treatment options
• Surgical excision, Early
post-op low dose
Complications
• Cosmetically ugly radiotherapy within 24hrs
and Triamcinolone
• Recurrence injection (tripple therapy)
• Infection/ • Excision and
triamcinolone injection
suppuration • Intralesional
• Ulceration triamcinolone
• Excision and radiotherapy
• Pilonidal sinus • Silicon cream, gel/
• Marjolin ulcer— occlusive dressing
• Cryotherapy
Malignant
• Laser therapy
transformation Dokern
Hypertrophic scar treatment

• -Pressure garments
• -Silicon sheet
• -Surgical excision and skin
grafting
• -Cryotherapy
• -Laser therapy
Dokern
 Ingrowing Toe Nail

DIFFERENTIALS
• Paronychia
• Subungual melanoma
• Osteomyelitis
• Subungual bone
exostosis

Dokern
Ingrowing Toe Nail
COMPLICATIONS
• Wound infection
• Osteomyelitis
• Septic arthritis of
adjoining
interphalangeal joint
• Recurrence

Doker
 Ingrowing Toe Nail
NON SURGICAL MEASURES SURGICAL MEASURES
• Keep nail clean and dry Done under Regional
anaesthesia(ring block)
• Cut nail square or general anaesthesia
• Simple nail avulsion
• Insert fledges of cotton • Wedge biopsy
wool underneath • Zadek’s procedure(total
ingrowing edges excision of nail)

Dokern
• Lymphedema results Lymphedema
from the obstruction
of lymphatic flow, due
to inherited
abnormalities of the
lymphatics, their
obliteration by disease
or their operative
removal
• Characterized by
excessive
accumulation of
interstitial fluid Dokerni
 Lymphedema—Aetiology
Inherited lymphedema/Primary lymphedema
• Type 1: Milroy’s disease
• Type 2: Meige’s syndrome
Acquired lymphedema/Secondary lymphedema
• Following extensive surgical procedures
• Malignancy
• Parasitic infestation eg Filariasis
• Post-irradiation fibrosis
• Chronic foot infection
• OTHERS: TB, Rheumatoid Arthritis
Dokern
 Lymphedema
INVESTIGATIONS COMPLICATIONS
• Lymphangiography • Skin thickening
• Isotope- • Recurrent cellulitis
Lymphoscintigraphy
• Chronic ulcers
• MRI
• Lymphangiosarcoma
• ESR, Peripheral smear
• Also investigate for the
possible cause

Dokern
 SURGERY
Debulking operation
Lymphedema • Homan’s procedure
TREATMENT • Charles’s procedure

CONSERVATIVE Bypass operation

• Hygiene • Skin and muscle flap
• Limb elevation • Omental bridges
• Compression • Enteromesenteric bridges
stockings
• Lymphaticolymphatic
• External pneumatic anastomosis
compression
• Lymphaticovenous anastomosis
• Physiotherapy
Doker
 Differentials of a Swollen leg
General disease
• Cardiac failure
• Nephrotic syndrome
• Liver failure
• Kwashiokor

Venous disease
• Venous thrombosis
• Deep venous insufficiency
• Arteriovenous fistula eg Klippel Trenaunay syndrome
Dokerni
Differentials of a Swollen leg contd
Lymphatic disease
• Primary lymphedema
• Secondary lymphedema eg
-filariasis,
-malignant infilteration,
-following surgery or
-irradiation to lymphatics

Dokernie
 Necrotising Fascitis

It is spreading inflammation of the skin, deep

fascia and soft tissues with extensive
destruction and toxaemia. Commonly due to
Streptococcus pyogenes infection but often
due to mixed infections like anaerobes,
coliforms and gram-negative organisms. Dokerni
 Necrotising fascitis—after fasciotomy

COMPLICATIONS: Toxaemia, Shock, SIRS,

MODS, Acute Renal Failure
TREATMENT: Resuscitation, wound
excision(fasciotomy), antibiotics, critical
care(oxygen therapy—Hyperbaric O2=100%)
and regular wound dressing Dokern
General Surgery
Cases

Dokerni
Breast cancer

Doker
Ca Breast; had biopsy

Dokernie
Ca Breast(male)

Dokernie
 DIAGNOSTIC INVESTIGATIONS FOR BREAST CANCER

 Breast ultrasound scan:-

• =useful in young women < 35 years with dense
breast in whom mammogram is difficult to interpret,
• =distinguish between solid and cystic lesions,
• =locate impalpable lesions,
• =may detect some malignant features.
 Mammography:-
• =sensitivity increases with age as breast become less
dense, use in age > 35 years
• =there are two views- craniocaudal and mediolateral
oblique Dokernie
 DIAGNOSTIC INVESTIGATIONS FOR
BREAST CANCER
• Mammographic features suggestive of
cancer include-
-loss of symmetry,
-architectural distortion,
-spiculation,
-microcalcification,
-branching calcification,
-clustering, mass effect.
Dokern
 DIAGNOSTIC INVESTIGATIONS FOR
BREAST CANCER
 Histopathological examination-
• =fine needle aspiration cytology(FNAC)23 or 24 G
shows evidence of malignant cells,
• =biopsy (core/trucut, incision, excision, wedge if
ulcerated) for histologic grade/type; also check
estrogen and progesterone receptor and Her/2-
neu receptor status.
TRIPPLE ASSESSMENT
=Clinical assessment,
=Radiological
imaging,
=Cytological/ Histological
Dokerni
 Staging investigations:
to detect extent of
disease
 Chest Xray- lung parenchymal opacities (canon ball), pleural
effusion, mediastinal nodes, osteolytic lesions of the ribs
 Skeletal bone survey- skull, chest, ribs, spine, pelvis- look for
osteolytic lesions.
 Abdominal ultrasound scan- liver secondaries, Krukenberg’s
tumour(ovary), intra-abdominal lymphadenopathy, malignant
ascites, peritoneal seedlings.
 Bone scan- shows bony metastases
 Liver function test- may be deranged (increased ALP) or
normal
 Mammography of opposite breast
 FNAC of opposite axillary nodes
Dokerni
 Treatment of Ca Breast

• Local / Regional: surgery, radiotherapy

• Systemic:
cytotoxic,hormonal,immunotherapy

• SURGERY: Simple Mastectomy

+/- Axillary dissection/clearance
Conservative surgery eg Lumpectomy,
Quadrantrectomy:- done for very early stage
small tumour located in a specific quadrant
Dokerni
 Breast cancer treatment contd
CYTOTOXIC CHEMOTHERAPY:
 CAF regimen ( cyclophosphamide 1g/m2,
adriamycin 50mg/m2, 5 fluorouracil 450mg/m2),
 CMF ( cyclophosphamide, methotrexate, 5
fluorouracil),
 Taxanes- paclitaxel; as monotherapy or added to
regimen above in replacement of Adriamycin
• HORMONAL THERAPY: Tamoxifen 50mg bd x
2wks, then 20mg daily for 5 years
• IMMUNOTHERAPY: Herceptin
• RADIOTHERAPY: small doses, 5 days in a week
spread over 6 weeks, you give booster dose over
incision line. Dokern
 Breast • Differential Diagnosis of Breast Cancer

=Fibroadenoma

cancer =Phylloides tumour

Prognostic Factors =Intraductal papilloma

=Duct ectasia
• Axillary node status

=Traumatic fat necrosis

• Tumour grade =Chronic breast abscess

=Breast cyst ; Galactocoele

• Tumour size
=Lipoma of the breast

=Harmatoma
• Nottingham Prognostic
Index(NPI) =Mondor’s disease
(thrombophlebitis of the lateral thoracic
Dokerni vein)
INGUINAL HERNIA

Dokern
giant inguinoscrotal hernia

Dokern
 DIFFERENTIAL DIAGNOSIS OF
INGUINAL HERNIA

• Femoral hernia – below and lateral to pubic

tubercle
• Encysted hydrocele of the cord – transiluminate
• Vaginal hydrocele – transilluminate
• Saphena varix—may be associated Varicose veins
• Varicocoele – feels like a bag of worms
• Lipoma—lobulated surface, slipping sign, no cough
impulse
• Enlarged inguinal lymph node – no cough impulse
• Inguinal abscess—no cough impulse
• Malgaigne’s bulges – no cough impulse
Dokern
 TREATMENT
INGUINAL • Treat precipitating factor
HERNIA first e.g. BPH,
tuberculosis, constipation,
COMPLICATIONS OF etc
HERNIA • Surgery
 Incarceration -Herniorrhaphy: excision
 Obstruction of sac (Herniotomy) with
reinforcement of posterior
 Strangulation wall and narrowing of the
deep ring (Lytle’s repair)
 Inflammed hernia -Hernioplasty: use of
artificial material e.g.
 Rupture prolene mesh or fascial
 Peritonitis graft to bridge the gap
Dokern between inguinal ligament
 Fistula formation
Goitre

Dokerni
INVESTIGATIONS – Toxic
For Diagnosis:
Goitre
• Thyroid Function Test

• USS of the neck

• Fine Needle
Aspiration
Cytology(FNAC)—to
rule out malignancy

Dokernie
 INVESTIGATIONS –Spread/Extent of disease

• x-ray neck: AP view= tracheal deviation

lateral view= tracheal
compression
thoracic in-let= soft tissue shadow showing
retrosternal extension
• Serum Ca and PO4;for pre-ope assessment of
PTH function
• Indirect laryngoscopy- medicolegal reason ,
vocal cord assessment before surgery
• Chest Xray
Dokerni
•
 Thyroid scan showing a non functioning
nodule

Thyroid Isotope scan

• Hot nodule—Hyperthyroidism; toxic goitre
• Cold nodule—Thyroid abscess or malignancy
• Warm nodule—Normal thyroid tissue Dokern
 NON TOXIC(SIMPLE) GOITRE
TREATMENT INDICATIONS FOR
• Early stages i.e diffuse SURGERY
hyperplastic goitre, can • Cosmesis
use L- thyroxine 0.15-
• Pressure symptoms—
0.3ug daily for 1 mth.
airway obstruction,
It effects regression
dysphagia, hoarseness,
• Also, iodine
therapy;lugols iodine or
• Risk of secondary
potassium iodide for thyrotoxicosis,
early stage • Risk of malignant
change.
• Neither iodine nor
thyroxine is of much help Surgical options—
in causing regression of lobectomy, subtotal
established nodular Dokerni
thyroidectomy
 Toxic Goitre—T3↑; T4↑;
TSH↓
TREATMENT options:-
INDICATION FOR SURGERY
• antithyroid drugs— • Toxic multinodular goitre
Carbimazole 10-15mg • Toxic solitary nodule
8hrly-this is first line • Large goitre with pressure
treatment symptoms
**Propranolol 40mg • Male patient
used to block • Poor drug compliance
cardiovascular effects • Complications during drug
of Thyroid hormones therapy
e.g palpitation • Relapse after previous
drug therapy
• radioactive iodine— • Exophthalmus
Iodine-131 or Surgery is contraindicated
in children Dokerni
THYROIDECTOM POST OPERATIVE
COMPLICATIONS
Y • Reactionary Haemorrhage
PRE-OP PREPARATION • Respiratory Distress
• Render patient euthyroid • Tension haematoma
with antithyroid drug • Tracheal collapse
• Propranonol 80mg 6hrly 4- (tracheomalacia)
7 days before • Bilateral abductor paralysis
operation,makes thyroid
less vascular and friable
• Laryngeal edema /spasm
**Propranolol continued for
• Thyroid Storm
4-7 days post-ope helps
prevent thyrotoxic crisis • Parathyroid Insufficiency/
• Laryngoscopy to Hypocalcaemia
determine pre op state of • Wound Infection
vocal cord –note if any • Thyroid Insufficiency/
paralysis
Doker Hypothyroidism
Parotid tumour

Doker
 PAROTID TUMOUR
DIFFERENTIAL DIAGNOSIS
• Pre-auricular lymphadenitis
• Swelling related to skin/ subcut
-Lipoma
-Haemangioma
-Sebaceous cyst
• Swelling related to masseter muscle
-Fibroma
-Rhabdomyoma
• Neuroma of the facial nerve
• Adamantinoma of the mandible Dokern
 TYPES OF PAROTID GLAND TUMOURS

• Adenomas – Pleomorphic
Monomorphic
• Mucoepidermoid tumours
• Actinic cell tumour
• Carcinoma
• Haemangioma
• Lymphangioma
• Neurofibroma
• Metastatic tumour eg Malignant melanoma
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COMPLICATIONS OF PAROTID
TUMOUR
• Infection , abscess
• Salivary Fistula formation
• Malignant transformation
• Facial nerve palsy
• Frey’s syndrome
TREATMENT
• Benign- superficial parotidectomy
• Malignant- radical parotidectomy if
facial nerve is involved Dokern
GANGLION

Dokern
GANGLION

Diagnostic signs
• Cystic, slightly transilluminates
• Common around the wrist and dorsum of the foot
• Not mobile along the axis of the tendon or joint
capsule Dokerni
 GANGLION

Differential diagnosis Complications

• Lipoma • Local discomfort/
• Bursa pain
• Benign tumor of • Cosmetically ugly
tendon sheath • Infection
• Exostosis • Rupture
• Sesamoid bone
• Cystic protrusion Treatment:
from joint cavity • Surgical excision; has
high reccurrence rate
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Lipoma

Doke
 Lipoma
DIAGNOSTIC
CRITERIA
•Shape-

hemispherical
or discoid
•Surface –
lobulated
• Consistency
– soft
•Edge –
slipping sign Doker
 Lipoma SPECIAL TYPES OF
LIPOMA
DIFFERENTIAL • Neurolipoma – painful
DIAGNOSIS lipoma
• Cystic swelling : • Adiposis Dolorosa
Dermoid cyst (Dercum disease)—
• Sebaceous cyst multiple lipoma
• Leiomyoma • Fibrolipoma –with
• Neurofibroma fibrous component
• Rhabdomyoma • Naevolipoma – with
telangiectasis
• Haemangioma
• Lipoma arborigens –
• Neuroma/
pedunculated lipoma
Schwannoma
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• Fibroma
 Lipoma
SITES OF OCCURRENCE COMPLICATIONS
• subcutaneous • repeated trauma
• subfascial • ulceration
• intramuscular • necrosis
• intermuscular (anterior • hemorrhage
abdominal wall) • infection
• parosteal • calcification
• subserosal • saponification
• submucosal (GIT) • myxomatous degeneration
• extradural (never • sarcomatous changes-
intradural) liposarcoma
• intra – articular • intussusception/intestinal
• subsynovial obstruction – submucosal
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lipoma
 Adiposis Dolorosa (Dercum disease)

LIPOMA TREATMENT
• Excision
• Liposunction Dokern
Angular Dermoid Cyst(external)

Doker
Dermoid cyst

Doker
Post auricular dermoid cyst

Doker
 Post auricular dermoid

Types of Dermoid
cyst
• Sequestration
dermoid
• Implantation
dermoid
• Tubulodermoid
• Teratodermoid
Doker
Sequestration dermoid
• This is a subcutaneous cystic swelling resulting from
an embryological rest of epithelial cells along a line
of fusion
• Diagnostic signs
• Common sites: midline of the body, on the scalp,
at the inner or outer angles of the
eye
• Ovoid or spherical shape
• Cystic swelling; fluctuant
• Surface smooth,edge well defined
• Skin can be lifted up
• Bony indentation may be present
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 Sequestration dermoid
Investigations
• Diagnosis is clinical
• Skull x-ray or CT scan cranium to rule out intracranial
extension for dermoids related to skull

Complications
• Suppuration/ infection
• Ulceration
• Bursting/rupture
• Cosmetically looks ugly

Treatment: Surgical excision Dokerni

Implantation Dermoid Cyst

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Implantation cyst

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Implantation Dermoid
Acquired cysts; follows a puncture injury
with
epithelial cells driven into the
subcutaneous tissue
• Diagnostic signs: old healed scar over
the swelling, located in finger pulp, palm
and sole
• Complications: interfer with grip and
touch; on the sole may cause limping,
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infection, ulceration, poor cosmesise
Sebacious cyst; note puctum

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 Sebacious cyst • -SITES
• Wherever sebaceous
gland exist: scalp, face,
scrotum, vulva

DIAGNOSTIC CRITERIA
• presence of punctum
• hair loss
• indentable on palpation
• transillumination –
negative
 NOT SEEN IN
PALMS/SOLES = no
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sebaceous gland
 ASSOCIATED SYNDROMES
Sebacious cyst
• Gardner syndrome
• Basal cell nevus
COMPLICATIONS
syndrome
• Infection and
• Pachyonychia congenita
suppuration
• Idiopathic scrotal
• ulceration calcinosis
• calcification
• Cock’s peculiar TREATMENT
tumour • Excision- including skin
• sebaceous horn adjacent to punctum
• rarely malignancy – • Incision and avulsion
usually basal cell
carcinoma
Dokern
 Papilloma:
treatment is excision

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Neurofibromatosis

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Cavenous Haemangioma

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 Strawberry
Haemangioma

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Port wine stain(naevus flammeus)

Doker
Orthopaedic Cases

Doker
POP boot cast

Dokerni
 Principles of Fracture Management

 Resuscitation
 Radiograph
 Reduction
 Retention
 Regeneration
• Rehabilitation

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 RESUSCITATION
• Make sure airway and breathing
• Fluid resuscitation—normal saline; antishock
• Stop external bleeds
• Immobilise fracture using Thomas’ splint
• Adequate analgesia
• Antibiotics; if it is open fracture—also give
tetanus prophylaxis
• Do damage control surgery if internal
bleeding of a closed fracture is causing
shock
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 Radiograph
Do Xrays following the rule of 2s :
• 2 limbs
• 2 views—AP and Lat
• 2 joints (above and below)
• 2 times ( before and after reduction)

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 REDUCTION
*Close reduction for closed fractures.
-Methods: Manually
Skin traction
Skeletal traction
-Apply traction and counter traction forces based on
dynamics of injury
*Open reduction with internal fixation is done for
.closed fractures that cannot be reduced by closed
reduction
.open fractures
-Methods of Internal Fixation:
.Use of intramedullary nail/ rods
.Plates and screws
.Wires
-External fixators/ exo fixators , used especially forDoker
open
 Retention
-These include measures to immobilize or
splint the reduced fracture
-Methods of retention:
• Internal fixators
• External fixators
• Skin traction
• Skeletal traction
• Plaster Of Paris(POP) cast/slab
• Scotch cast/slab
• Braces
Dokern
 Regeneration
• This refers to the treatment given during
the period it takes for fracture healing to
take place
• It includes haematinics(fesolate), Vitamin
C, Calcium, analgesic and antibiotics
where indicated
• Where necessary blood transfusion is
done
Fracture healing takes on the average
6wks for the upper limb and 12wks forDokern
the
 Rehabilitation
• Non ambulant physiotherapy

• Ambulant physiotherapy; non weight

bearing and weight bearing

• Walking stick

• Occupational therapy

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above knee POP cast

Doker
 POP and Scotch
• POP and Scotch are used as splints to
immobilize a reduced fracture
• They are used as casts or slabs
• Cast is hard circumferentially; used in
definitive management
• Slab is soft in some part; used in early
management when there is inflammatory
oedema
• POP is made from Calcium Gypsona (CaCo3,
CaSo4)
• Scotch is made from fibreoptics
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•
 POP and Scotch
PRINCIPLES OF USE
• Applied so as to immobilize the joints
above and below the fractured segment

COMPLICATIONS
• Compartment syndrome
• Injury to skin, especially scotch
• Problems of prolonged stay in bed

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full length POP cast with hip spica
hip spica immobilizes the hip joint

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scotch cast

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Redivac drain—used after ORIF

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skin traction

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skin traction weight

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 skin traction
• A traction exert
• Skin traction weight=
reduction force as well
as immobilize a one-tenth of the
reduced fracture patient’s weight

INDICATIONS COMPLICATIONS
• Proximal femoral • Skin necrosis
fracture • Over reduction
• Fractured femoral • Problems of
head/neck prolonged
• Osteoarthritis of hip immobilisation
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joint as in sicklers e
Bohler Braun frame with Skeletal traction

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 Skeletal traction
INDICATIONS
• Proximal femoral fracture

COMPLICATIONS
• Pin track infection
• Osteomyelitis
• Fracture where pin is applied
• Over reduction
• Problems of prolonged immobilisation

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 Problems of prolonged immobilisation

• Bed sores
• Orthostatic pneumonia
• Urinary Tract Infection
• Joint stiffness
• Muscle atrophy
• Osteoporosis
• Deep vein thrombosis

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 Complications of Fracture

• Haemorrhagic shock due to bleeding; major

vascular injuries
• Injury to nerves, ligaments, tendons
• Local visceral injury
• Contamination --- infection----
osteomyelitis----sepsis
• Gas gangrene
• Fat embolism—Adult Respiratory Distress
Syndrome
• Avascular necrosis
Dokerni
 Complications of Fracture contd
• Fracture blisters
• Myositis ossificans
• Traumatic amputation
• Compartment syndrome
• Crush syndrome
• Disseminated Intravascular Coagulation
• Multi-organ failure syndrome

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7Ps of compartment syndrome
• Unusual /excruciating Pain due to increased pressure in
the fascia compartment
• Paraesthesias due to nerve compression
• Pallor from reduced peripheral perfusion
• Poikilothermia (coldness) reduced peripheral
perfusion
• Paralysis
• Pulselessness or reduced capillary refill
• Putrefaction (necrosis)
Treatment of compartment syndrome
• Fasciotomy; make incision through the fascia on one or
two sides to release the pressure.
• Do not raise the limb because it can worsen it.
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• If it was due to a cast, the cast should be cut open.
External fixator(exofixator)

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Ilizarov device: for bone lengthening

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Above-Knee Amputation

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Below knee amputation;
note presence of knee

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 Indications for amputation=3Ds

Dead or dying limb

• Gangrenous limb – Diabetic foot
gangrene
-Fulminating gas
gangrene
• Ischaemic limb disease
• End –stage peripheral vascular disease
• Severe crush injury
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 Indications for amputation=3Ds

Dangerous limb -malignancies

• Osteosarcoma
• Rhabdomyosarcoma
• Malignant melanoma
Damned nuisance
• Congenital/ acquired limb deformities
• Severe limb- length discrepancy
• Elephantiasis
• Madura foot
Doker
 Complications of Amputation

 Post-op haemorrhage, haematoma

 Wound breakdown
 Surgical site infection
 Phantom pain
 Phantom limb
 Neuroma
 Flap necrosis
 Joint stiffness
Dokern

gangrenous leg/foot

Dokern
Blount's disease(Tibia vara )

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 Unilateral
Blount’s
disease

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 Severe
Blount’s
disease

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 Blount's disease(Tibia vara)
Pathogenesis
• disturbance of growth of medial aspect of the upper
tibial metaphysic
• premature fusion of the medial side of the epiphysis
Clinical features
• lateral ligaments are stretched
• unstable knee
• internal tibial shortening
***Rickets—is a differential diagnosis
***Main principle of treatrment is Tibial osteotomies
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Club foot

Dokernie
 CLUB FOOT:
Congenital talipes equinovarus deformity

The Associated Deformities

• Fore foot adduction and supination
• Hind foot adduction and supination
• Equinox deformity.
• High arched dorsal surface of the foot
• Plantar cavus
Dokernie
Congenital talipes equinovarus deformity
Associated congenital conditions
• Congenital constriction band syndrome
• Spinal dysraphism
• Myelodylpasia
• Arthrogryposis

Acquired causes of Club foot

• Post polio paralysis
• Cerebral palsy
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•
Neurosurgery
Cases
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Frontonasal Encephalocele

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• Encephalocele is a defect in the
fusion of the cranium, usually in the
midline, with resultant herniation of brain
tissue, meninges and cerebrospinal fluid
Classification:
• Occipital
• Cranial vault
• Fronto-ethmoidal/Frontonasal
• Basal
• Posterior fossa
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 Frontonasal
Encephalocele
COMPLICATIONS OF
ENCEPHALOCELE
• CSF leakage
• Neurological
deficit
• Meningitis
• Encephalitis
• Hydrocephalus
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 Encephalocele
Investigation Treatment
s • Surgical
• Brain CT scan excision of the
with bone encephalocele
sac with water
window and
tight duroplasty
CT-
after reducing
angiography
the brain tissue
• Skull xray
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Hydrocephalus

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Hydrocephalus
 Inspect the head/ face/
eyes; note
• Large head
• Craniofacial disproportion
• Fontanelles- are they
bulging
• Look out for VP shunt
catheter or scar of surgery
• Distended veins
• Sunset appearance of the
eyes
Dokernie
 HYDROCEPHALUS
Hydrocephalus- Differential
sunset eyes diagnosis
 Hydranencephaly
 Porencephalic
cyst
 Subdural
haematoma
 Hydatid cyst
Doker
 CLASSIFICATION OF HYDROCEPHALUS
ACCORDING TO INTRACRANIAL PRESSURE
• RAISED INTRACRANIAL PRESSURE— AS SEEN IN INFANTS
AND CHILDREN.
• NORMAL OR LOW INTRACRANIAL PRESSURE— AS SEEN IN
ADULTS.
ACCORDING TO LEVEL OF OBSTRUCTION.
• COMMUNICATING
• NON-COMMUNICATING.
ACCORDING TO AETIOLOGY
• CONGENITAL
• ACQUIRED
Dokern
 Causes of obstruction

 Congenital: -Aqueductal stenosis of Sylvius.

-Dandy-Walker malformation.
-Arnold-Chiari malformation.
 Acquired: -Post infection eg. Meningitis

-Neoplasm.
-Trauma
-Intraventricular haemorrhage from birth
asphyxia
Dokerni
 Hydrocephalus:
clinical features in neonates/infants
• Progressive head enlargement, poor head control
• Irritability, somnolence
• Vomiting
• Obtundation
• Failure/regression of milestones
• 6th CN palsy
• Hyperactive reflexes
• Irregular respirations with apneic spells
• Bradycardia Dokerni
 Hydrocephalus:
clinical features in older children/adults
Mostly features of raised intra cranial pressure
 Headache
 Nausea
 Visual disturbance
 Deteriorating level of consciousness
 Mental retardation
 Seizures
 Defective upward gaze ( perinaud’s sign)
 Abducens palsy
 Papilledema
 Ataxia and gait changes(cerebellar dysfunction)
Dokern
 Investigations

• CT scan of the brain

• MRI of the brain.
• Transfontanelle Ultra Sound Scan
• Skull x-ray
• Air or contrast ventriculography
• Angiography
 Others: FBC, ESR, E/U/Cr, serum
protein, CSF analysis.
Doker
Treatment

Medical:
-to optimize patient before surgery
in the phase of infection or if not fit for
anesthesia
-Acetazolamide and frusemide used.

Surgical:
-External Ventricular Drainage;when infection exist
-CSF shunting ventriculo peritoneal, atrial, cistern,
Pleural, stomach, bladder
-Endoscospic third ventriculostomy. Dokerni
 COMPLICATIONS OF VP SHUNT

SHUNT SERIES
• Xrays done after VP  Disconnection
shunt to assess that  Migration
the tube is well  Obstruction
placed
 Kinking
The xrays include
• Skull AP view  Shunt malfunction
• Skull Lat view  Infection(shunt sepsis)
• Chest AP view  Overdrainage
• Abdomen AP view  Slit ventricles
syndrome
Dokerni  Intestinal obstruction
Crutchfield tongs being used for cervical
spine traction

Dokern
 COMPLICATIONS
Cervical spine • Haemorrhage
traction • Pin track infection
• Cervical traction is a • Distraction of the cervical
vertebrae
method of managing cases
• Inadvertent plunging into
of cervical spine injury the cranial cavity
• Gardener-Well tongs is also
used for cervical traction
• Other methods of
• Weight for reduction= 2.3 x managing cervical spine
Cervical spine injured injury include—Halo vest,
• Weight for maintenance= Meneaval jacket, surgical
1.0 x Cervical spine injured Doker
 Cervical Spine Injury
Management Protocol
• Nurse flat in bed
• Cervical spine traction—cervical collar, Gardner-
Well,etc
• Special beds eg air bed, water bed, foam trough,
Stryker bed, etc
• Two hourly turning in bed
• Padding of bony prominences
• Keeping the skin clean and dry
• Anticoagulant therapy—Heparin, Warfarin
• Dokern
SPINAL BIFIDA

Dokern
SPINAL BIFIDA
Types of spinal
bifida
• Spinal bifida occulta
• Spinal bifida
cystical/aperta
• Meningocoele,mening
omyelocoele
• Myelomeningocoele
• Myeloschisis
(myelocoele)
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SPINAL BIFIDA
Differentials
• Sacrococcygeal
teratoma
• Lumbosacral
teratoma
• Neuroenteric cyst
• Hypertrophic filum
terminale
• Intraspinal lipoma
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 SPINAL BIFIDA
Investigations
• x-ray of the spine Associated
especially in occulta; anomalies
shows defect in the • Syringomyelia
spine (bifid spine)
• CTEV
• USS of spine: detect
cystic cavitations like
• Hydrocephalus
syringomyelia • Bisphincteric
• CT SCAN/CT incontinence
myelogram/CTwith • Congenital hip
contrast injected via dislocation
lumber puncture
Doker
 SPINAL BIFIDA
Treatment Complications of
• Multidisciplinary: surgery
neurosurgeon, orthopaedic
• Iatrogenic
surgeon, paediatric
neurologist, nurses, hydrocephalus
physiotherapist • Surgical site infection;
• Aim: To prevent meningitis
progression of neurological • CSF leakage with
deficit, cosmesis formation of
• Repair with water tight pseudomeningocele
duroplasty
• Nerve injuries
• Management of associated
anomalies e.g. CTEV • Injury to the spinal
Dokern
 peri –orbital ecchymosis;
suggests anterior cranial fossa fracture

other associated features

• csf rhinorrhea; sub conjuctival haemorrhage)
Causes
• fall from height, rta etc)
Note Complications and Management of head injury
Other Surgery
Cases

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Gastrostomy feeding tube

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 Gastrostomy feeding tube:
Indications
• Oesophageal obstruction
• Severe malnutrition
• Major surgeries
• Severe sepsis
• Trauma
• Head and neck surgeries
• Oesophageal obstruction
• It is done if feeding is required for more than
one month Doker
 Gastrostomy feeding tube:
Complications
• Leak-gastric fistula
• Displacement
• Blockage of tube
• Tube migration
• Diarrhea
• Bloating, abdominal cramp
• Wound infection
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 Gastrostomy feeding tube
CONTRAINDICATIONS METHOD OF APPLICATION
• Previous gastric • Open surgery
surgeries
• Endoscopic—Seldinger
• Intestinal obstruction technique

• Gastric outlet
obstruction

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Varicose veins
COMPLICATIONS
• lipodermatosclerosis
• venous ulcer
• eczema and dermatitis
• haemorrhage
• periostitis
• ankylosis of joints
• thrombophlebitis
• calcification
• equinovarus deformity
Dokernie
 Varicose vein—Risk factors

• Occupation (Prolonged standing)

• Congenital absence/incompetence of valves;
• Obstruction to venous return eg intra
abdominal tumour or pregnancy
• Recurrent thrombophlebitis
• A-V malformations
• Iliac vein thrombosis
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 Varicose vein—Surgical options
• Tredenlenberg operation
• Venous stripping
• Subfascial ligation of Cocket and Dodd
• Subfascial endoscopic perforator ligation
surgery
• Endoluminal laser ablation
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Varicose vein
OTHER SITES FOR
VARICES
• Oesophageal varices;
• Haemorrhoidal venous
plexus;
• Pampiniform venous
plexus

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chest thoracostomy drainage

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Fournier’s gangrene

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Fournier’s gangrene—Badoe

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Fournier’s gangrene

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Fournier’s gangrene—Badoe

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 Tracheostomy:
done as management for upper airway obstruction

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