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Surgery 2

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Vascular ligation Renal ima,sma repair Ligate cealiac artery Internal iliac ligate External iliac repaire Femoral art repain Ivc infra renal ligate Ivc supra renal repair Portal v repair Radial art or ulnar shud be patent Ant or pot tibial one of them hud be patent Its better to ligate celiac artery as good collaterals So other arteries u have to repair Hepatic ligate External illiac art repair

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Post traumatic epilepsy Immediate 24 hr Early 7 day Late 5 yr Anti seizure prophylaxis can prevent epilepsy upto 7 seven days Blast injury Prim injury-- blast waves vulnarable organ are containing air Typanic men> lung> stomach> colon> small intes> solid vicsera Order of repair Bone vessle tendon nerve Duonenal injury Grade 1 single point hematoma without serosal injuRy. OBSRVATION 2 multiple hematoma or Laceration < 50% prim repair 3 50-70% d2 or 50-100 of d1 3 4 prim repair with pyloric exclusion 504 > 75% of d2 with ampulary involv pancreatico duodenostomy/ wipple procedure G5 ampula+ pancrease injury

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Esophageal leak < 12hr prim repair drainage & closure > 12hr esophageal exclusion Esophageal exclusion C arcinoid tumor duodenum mc site Carcinoid syndrome Lymphoma is mc malignant tumour of spleen Spleenic multiple metastasis in following order Lung> stomach >pancrease >breast Single metastasis from colon in GCS MOST IMP IS MOTOR RESPONSE HEAD INJURY WITH SHOCK R/ o other bleeding sites Gall stones Sequelae Silent Acute or chronic cholecystitis Mucocele Empyma Perforation Choledocolithiasis Cholangits Gall stone ileus Cholangitis with stone in cbd Charcot triad / raynods pntal ( altered senso + hypotension) Chongitis frst ix usg Cbd dileted upto supra duodenum with multipl ston in gb Priority is to decompress cbd In chodocolithiasis priorityis remove stone Nxt step MRCP NXT ENDOSCOPY EVEN IF THER IS CONTRA AS PRIO IS NOT REMOV STONE PRIO IS DECOMPRESS BY PASSING STENT FROM THE SIDE OF STONE IF PT CAN TOLERATE GA DO Sx dont remove stone if pt condition is not gud as sever inflammation just put stent

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Once pt is good remove stone If it is not possible then do percuteneus trans hepatic drainage

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Usg>>>>>mrcp>>>> endoscopy( to decomprees cbd) & not extraction of stone so that not to compromise pt condition If pt condition good & can tolerate GA DO Sx JUST PUT T TUBE & dont remove the stone as ther will be sever inflammation so it will coz more injur If pt condition is bad then do PTBD

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REMOVE GB STONE WHCH IS ASYMTOPMATIC stone > 3 cm GBS WITH ANOMALOUS Mutliple small stones in GB PORCELEN GB GB STONE WTH PLyp TRANPLANT RECIPIENT DM Acute cholecystitis pain rt hypochondium radiating to rt shoulder or scapula murphy sign positive ACUTE CHOLECYSTITIS WITH IN 72 hr '"early chocystectomty" Clholangio ca Prim sclerosing cholangitis Callories cyjst Cbd stone is risk factor Hepato lithiasis Gall stones>>>>>>>>>chronic typhoid carrier ( it is not risk factor as perDEVITA)

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MC

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CBD injuries Risk is same in laproscopy and open Sx Bismuth classification for biliary stricure & injury Mx billiary injury >50% major injury roux Y hepato jejunostomy < 50% mild injury prim repair over t tube If cbd injured and abdomen closed not managed Pt will complain pain ,tender, bile comng out of wound, tachy, BILLIARY PERITONITIS If > 50ml comes out from drain chances of cbd injured and surgeon missed it First step USG -- collection of fluid in morisons pouch The nxt step wil be Percutaneus bile drain NXT FIND OUT EXTENT OF DRAIN THEN NT DO MRCP IF U FIND <50% transacion of biliary then stent >50% major injury then u can explore and do hepatojejunostomy Or u can wait fo 6 wk then do hepatojejunostomy-----( preference shud be givn)

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Portal hypertention(hepatic portal venus gradient) Normal portal press is1-5 mm Hg > 5 is portal ht > 10 clinical signi > 12 risk of haemorrhage 30% > 20 isk of Rx failure Pre hepatic Sinusoidal ( cirhosis) Prim prevention to prevent frst episode of bleeding A/c/a Prim prophylaxis non selective beta blocker propranolol,if it is contraindicated give NITRATES To preven t future bleeding Secondry prophylaxis if pt is on beta blocker>> taking adequate dose then do EBM ( endoscopic band ligation) IF NOT TAKINGBADEQUATE DOSE AJUST DOSE OR EBM IF NOT TAKING GIV BETA BLOCKER start beta blocker

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GRADING OF ESOPHAGEAL VARISES 1 flat< 5 mm 2 protruding without obstruction 3 large tense veins with obstruction Esophageal varices extend upto Carina cherry red sign Hematemesis First step fluid resuscitation Role of prophylactic antibiotic is ther Drug of choice for controlling bleeding is terlipresin If not in choice then giv somatostatin or octerotite Vasressin shud never be givn If still bleeding endoscopic band liation If still bleeding repeat ebm or sclerotherapy If still bleedng & condition o f pt is bad TIPS( transjugular intrahepatic portosystemic shint) OR IF CONDITION IS. GOOD SELECTIVE SHUNT Segstaken black more tube 2 ballon(( preffered) Ballon inflated with l 20 mm Hg in addition to normal press present in eso at that time If dont know the esophageal press then rais the press to 40

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LINTONS TUBE(3baloon)) NO ROLE OF COLD SALINE IRRIGATION MELD CRITERIA Modified extended liver is criteria CHILD CRITERIA( not followed now)) CHILD A SELECTIVE SHUNT CHILD B TRANSPLANT CHILD C TRANSPLANT

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gall blader ca T1 invasion upto lamina propria --- t1a OR muscular propria--- t1 b T2 invasion is perimuscular Tiss T3 invasion of liver or one of the organ involvemnt T4 > 1 organ invasion Pericystic / pericholedocal nodes is N1 N2 beyond Ioc staging ct scan Most sensitive endoscopic usg If ct says that it is "resectable" gb ca Then do laprocopy staging

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Stage 1a t1 no mo Rx Sx simple open cholecystctomy Stage 1b t2 no mo Rx radical cholecystectomy [gb. With 2 cm of margin with n1 lympadenectomy+Remove segmnt 4b & 5 of livr] Stage2 t3 no mo Stage 2b t1 /t2 n1 m0 Stage 2 & beyond curative resection is not possible

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EXCISION OF PORT IS DONE TO PREVENT METASTASIS

IT IS NOT ANSWER JUNAIDD.....


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Cystic duct margin If positive -- Rx radical checystectomy with excision of cbd For both Stage 1a &1b

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If negative

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Stage 2a. T3 no mo CURATIVE RESECTION IS NOT AN OPTION

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Amebic liver abscess more comon in asian Overall pyogenic liver abcess most comn Amebic liver abcess more comn in male bcoz of high elemntal iiron as female lose iron during menstrual cycle Ix to confirm amebic liver abcess Gel diffusion electrophoresis / counter immunasay tell about recent episode While elisa & imun hemocoagulation tell about recent & past episode Imaging inv of choice is USG Rx metro 800 tds 10 days DONT DO Sx intervention except Indication for drainage is Abscess not responding within 72 hr aftre metro Impending rupture Lft lobe abscess >5 cm or >400 ml Wen metronidazol is contraindicated Pyogenic infection mode of spread ascending infection from cbd Mc organism polymicrobial -> e coli For hemat it is staphaureus Ioc ct scan < 1cm >1 aspiration Recureent abcess Rx deworming????????????**** Imaging dath diffe amebic from pyogenic Hot amebic / cold pyogenic ON BARIUM SCAN

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Insulinoma
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Localising intraop usg >> endoscopic usg Rx enucleation Pancreatitis--------Mc coz gallstone Most sensitive& specific is serum tripsinogen level Scores Rensen score Glasgow score Apchee score Ransons Glass score Apachy2 Ct severity/ pelthezar C reactive protine MODIFIED MARSHAL SCORE(( organ failure us considered)) ! respi failure Cns GCS Cvs syt bp Renal creatinine Hemat pltlt count Hepatic index is not included......... SAP SCORE! SR TRIPSINOGEN SCORE Most imp is fluid managmnt Wen diagnosis confirmed do ct after 72 hr AS IT IS NORMAL IN FRST 72 hr Prophylactic antibiotic is indicated if pancreatic necrosi > 30% Imenem or fluroqunolol MOST TIME COSERVATIV Mx If pt not responsin in48-73 hr gallston extraction by ERCP Absolute indication in pancreatitis for Sx are As follows Gas buble in pancreatic necrosis Ct guided fna revealing organism Releative indi are

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>50% necrosis Pt with sign of organ failure Pt deteriorating to medical No increase n AMYLASE SEEen IN pancreatitis In hypertrigyceredemia induced Acute on chronic pancreatitis were ther is Acinal cell loss Most imp in mx of chronic pancreatiis is pain controle INTRACTABLE PAIN If pt not responding to high doses of morphin then do cealiac plexus block Stone in distal pancrease then do distal pancreatectomy If stone at ampula then do bypass Kusros pamcrease operation

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Malrotation IOC uper gi contrast study Color dopler ( most Sn) inverse relation of superior mesentric artery & vein NON ROTAION( mc) Mixed ROTATION INVERSE ROTATION HYPER ROTATION Post op adhesion are mc coz ofsmall bowel. Obtruction Malignancy is mc coz of large bowel obrction Ioc for acute bowel obstruction( complete obstruction) is supine xray( earliest) Air air transition Haustral folds are not circum ferential and not at equidistance in colon This differentiate from small intestine Colorectal carcinoma Risk factors are as follows Red meat High fatty diet Physical inactivity High fibre diet is protective but low fibre diet is no more risk factor!!!!$$" # HNPCC UC & chrons Prm sclerosing cholangitis Acromegally

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Ureterosigmoidotomy Alcohol Hormon replacemnt therapy**** Polyposis syndrome Tamoxifen***

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Low fibre diet is not risk Aspirin vit c & e protective Aspirin is protective Mc site of colorectal ca resctum>>>sigmoid>>cecum Rt sided colonic ca mc prestation is anemia,malena & mass Lt sideobstruction Better prognosis rt side But lt side ca presents early Screening colonic ca fecal ocult blood( start 50 yr anulay Sigmoidoscopy start 50 done 5 yrly Colonoscopy start at 50 done 10 yrly Duble contrast enema start at 50 done 5 yrly If fam h/ o colonic ca then start screening 10 yr early Hnpc All family membre APCC MUTATION CHECK CH9&5 By gene sequence analysis If mutated then do prophylactic colectomy If not ready then start intensive screening with sigmoidoscopy at12 yr done yrly Bed side test hypertrophy of retinal pigment is corelate max with apcc gene mutation Any pt of PAP UNDERGON COLCTOMY DEV ABDOMINAL MASS IS DESMOID TUMOR Rx wide excision.......,only no role of Stage is same stage 1 Stage Sx if poory histo ,inadequate LN DESECTION OR IF POSITIVE MARGIN OR GIVE CHEMO 5fu ,leucoverin,oxaliplatine Syge3&4 Sx ...chemo( 5 fu , leucoverin ,irinotican ,bevacizumab) + or - rt Most imp colonic cancer stage Size has no role in prognosis Ioc for partial small bowel obstruction small bowel enteroplysis Ideopathic retroperitoneal fibrosis (aormons dis ...non supurative inlamatry condition of fibro fatty tiss if retroperitonium Mc presentation is pain in abdo Mc structur involved is ureter, >>>aorta , >>>>ivc Ioc is ct scan

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But confirmation by thick niddle biopsy Contraindication to Rx traumatic lft colon injury

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Coniton of bowel,pt ,surgen u cnnot do anastomosis in lf side Contraindi to prim repair> 50% transaction Mesentric vascular injury

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> 2 orgagan along with colon injured Prolonged shock Grass contmination THYROID---------------Lateral aberaant givn by any thyroid malognancy but mc by papilary ca Thyroid wt is20 gm Inversly proportional to iodine content Amela gella corse nerve or extrnal laryngeal nerve Wen extrnal L nerve < 1 cm away from ant & post thyroid art type 2a is more lible to injury during thyroid Sx Extrnal L nerv injury is mc duing Sx but it may go unnoticed Recurent L nerve usualy get evident Weak or hoarse voice But in b/ l nerve injury is stridor How to prevent injury to these nevr Ligate & divide superior thyroid arteries anterior and postdivision seoeratly Enmass ligation of superior thyroid artery is not recomended

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INFERIOR THYROID ARTERY SHULD NEVER BE LIGATED Only capsular artery is ligated U hv to see Recurent Lnerve during surgery INVESTIGATION Usg,ct,pet,mri,thyroid scan Fnac,Bx ( only exicision trucut & incisional Bx hv no role as they are vascular same aplly in salivary gland) MinimumBx in thyroid is hemithyroidectomy Major limitation of usg in thyroid is it can not tell about retrosternal thyroid for this it is ct scan

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Retrosternal wextension of thyroid is CT SCAN AVOID THYROID SCAN ONLY INDICATION TOXICITY a/w nodularity To locate ectopic or metastatic thyroid Systemic speard PET SCAN

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THYROID SWELLING FIRST DO SR TSH IF EQUIVOCAL THEN DO FREE T3 or T4 If u hv hypo or hyper or euthyroid If hypo / euthyroid-- then do USG IF CYSTIC MASS THEN ASPIRATION SEND CYTO Three time aspiration then excision IF SOLID THEN FNAC IF INCUCLUSIVE THEN REPEAT FNAC IF INCUNCLUSIVE Then hemithyroidectomy If malignancy then acording to guidline Pt with hypo or euthyroid nodule chances of nodule harbering malignancy 20 % IN PT WITH HYPER THYROID & nodularity nodule harbering malignancy is <1% So no need of tissue diagnosis Nxt step in hyprthyroid & nodule Then Do thyroid scan if cold nodule then do

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Thyroid scan can be done by i123 or technicium 99 ( prefered) I123 long half lifemore side effect Emithyroidectomy = one lobe Sub total 8 gm pt thumb same as near total only difference is that in this u leave lesser tissu compare to sub total Dunhill procedure = near total thyroidectomy= lobectomy+ isthemectomy+ sub total lobectomy on other side Wen u hv multiple nodes in both thyroid u do total>>>>>>subtotal Complication Mc imediate bleeding presenting as respiratory distress

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Respi distress d/tlaryngeal edema B/L recurent L nerv injury Or tracheomalicia Rx keepng endotracheal tube for longer time or do tracheostomy

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Hypo calcemia late3-5 days complication Is d/t parathyroid ishemia >7 + parestheia , numbness, tingling mild oral to iv Ecg chang , cram start with iv calcium Thyroid insufiency Thyrotoxic crisis wen pt is not prepared befor ANY Sx ( not only thyroid Sx ) First drug u start is Anti thyroiddrug is propylthyouracil Other drug givnin this pt KI,DIGOXIN,STEROID,DIURETIC HOW TO PREPARE PT TO PREVENT CRISIS CARBIMAZOLE U CAN ALSO GV PROPANOLOL OR LUGOLS IODINE WEN LAST DOSE OF CARBIMAZOE SHUD BE GIVN EVENING BEFOR Sx Last dose of propnolol gvn on morng of surgery U shud continu for at least 7 day to take care of halflife of thyroxine which is in ciculation Papilary thyroid ca>> foli> medu Papilary ca radiation induced nodule is mc histo orphan eye nucli large amount of chromatin Pssamoma bodies dystrophic calciphication It is seen in meningioma ,serus cystadenoma ovary,pitutary adenoma,papilary renal ca Mc spread is lymphatic If spread thro Blood route mc site mets Wen speard by blood go to lung

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FOLLICULAR CA IODINE DEFI AREA MC PRESNTATION ALREADY INCREASE SWELLING SUUDDEN INCREASE IN SIZE Follicular ca by blood go to skull occiput ITS VARIANT Hurthel ceel ca is not well differentiated ca

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FOLLCULAR CA & APILLARY CA ARE CALLED WELL DIFFERENTIATED CA TUMOR MARKER FOR WELL DIIFF THYROID CA SR THYROGLOBULIN IN BOTH Prognostic scores

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AMES& AGES:-- age, grade extra thyroid invasion,size, mets,

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MaCis score postoperativeCompletness of desection Rx in well diff thyroid Micro invasi < 1cm with no vcesl invasion lymphatic no capsular Invasive is> 1 cm with any above invasion Papilry micro invasiv Total( preffered) or near total Invasiv total Rx papilary ca ttc/ ntc in microinvasive In invasion ttc MRND If lateral LN involved If cental ND IF CENTRAL LN INVOLVED FOLLI MICRO INVASIVE Rx hemi Invasive total Thyroxin therapy that u gv post op after Sx for malignancy is not called replacemnt therapy it is called supressive bcoz it suprees TSH LOWER SIDE OF NORMAL AS If thyroglubilin < 2 nano gm / ml in pt reciving supressive therapy < 5 nano gm/ ml in pt not reciving therapyy MEANS NO RESIDUAL TISSUE IN BODY IF LEVEL ARE MORE THEN TISSU IS PRESENT U HV TO GIV RADIACTIVE IODINE BUT BEFOR U KNOW WER IS RESIDUAL THYROID TISSUE FOR THAT U DO THYROID SCAN OR PET SCAN( bettre) Stop thyroxin ( tsh) supresive therapy for six wks befor u do pet or thyroid scan Give T3 which shud be stop before 2 wk

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Medullary thyroid ca( sporadic>> familial) mc presentation is nodule>>>>>>>>> diarhea Marker of prognosis calcitoninhisto amelyoid stoma bcoz of calcitonin Rx surgery TT WITH CENTRAL NECK DESECTION EVN IF CENTRAL LN NOT INVOVED IF SIZE IS>2 cm or nodes are involved then total thyroidectomy with MRND GENE RET MUTATE IN FAMILIAL IS PROTO ONCOGENIN FAMILIAL TYPE SHID ALWAYS HV ASSESMNT OF CATHECOLAMINE OR URINARY METANEPHRIN TO RULE OUT MEN SYNDROME IF PT HV MEN SYNDROME THEN DO RET PROTO ONCO GENE MUTATION TEST IN ALL FAMILY MEMBRE IF FOUND IN MEMBERS THEN PROPHYLACTIC TOTAL THYROIDECTOMY DONE AS EARLY AS POSSIBLE IN ADULT IF PEDIATRIC THEN FOR MEN2A. 5-6 yr if crossed 5-6 yr of age then as early as possible MEN 2B 6 month Sporadic more comn

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Nodule presentation Prognostic marker & tumor marker calcitonin POST OP HYPLOCALCEMIA Vit d3 added to calcium gluconate if even after adminstration of calcium gluconate ther is persistntly low calcium Pheochromocytoma Sr catecholamine>>> plasma. Metamephrine>>>>24 hr urinary metanephrine 10% B/l,malognant,child,extra adrenal,without hypertension,reoccur 24% familial HERNIA Inguinal hernia most comn hernia ooverall In female also SECOND COMN HERNIA incisional hernia INGUINAL CANAL 3.7cm No inguinal canal in new canal Rt side inguinal hernia are more comn MPO (Mpomyopectineal orifice of fruchard) Basic weaak ness is here so if u covr it u get rid of inguinal ,femoral and obturator hernia at one go In laproscopic ssx Mpo is funnel shape orifice line entirly by facialis tranversalis bounded mmedialy by rectus muscle and sheath ,lateraly by ilisoas muscle superiorly by int obliq and tranvers abdomenus inferior by coopers lig

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Repair Non prosthetic. Prosthethic Non prosthetic repair

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Prosthetic 1)Phs ( proline hernia system) 2)Laproscopy and 3)Lichenstien( is procedure is choice) Mc coz of recurence is tension after Laproscopic repair

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Tep avoid pneumoperitonium,.... More common Tapp (trans abdominal .....)creat pneumoperinotonium ( u shud avoid this Sx) Pubic symphysis white/light house of space of copers

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Circle of death or corona mordis( aberant oburator artery or vein more comnly it is vein) --latr most limit of desection is iliopsoas ms Genito femoral n Lat femoral n Ant cutaneus nerve form triangle of pain post op pain Triangle of pain + triangle of doom is called traphezoid of disastre Cost is imp factor for laproscpic hernia Growing pain dysruption syndrome Sport's man hernia ( adductr complex injury/ growing pain dysruption synd/ pubic cosalgia rx bed rest and analgesia Sliding hernia Post wall is formed by vicera Lft side more comn On rt sidececum on lft side simoid Direct sliding hernia urinary bladder Transplant. ,, Iso gradt monozygotic twins Most comn reason for rejection MAJR HLA ABO MOS IMP COZ OF RJECTION Hla A>>>B >>> Dr In renal transplant dr>>b>>>a HLA CLASSFICTION CLAS 1. Class Hla a,b,c Class 2 Dr, dr,et dq Kidney functin delayed do foleys irriation It still show delayed kidneyfunction then correcthypo volemia If still do usg with doplleras renel vein thrombosisi ismostcomn If still then do Bx Hyper acute is preventable Acute respons treatable Chronic rejection

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Liver transplant StRAIGHT LT( 1 liver 2 recipent) OXILARY LT EXTENDED CRITERIA DONER TRANSPLANT Auxillary liver transplant Duringremoval of liver CBD..hep art supra infra hepatic ivc portal vein ligation & division During implanting liver infra supra hepatic ivc portal v hepatic art CBD ANATOMOSIS PIGYBACK LIVER TRANSPLANT INSTEADDIVIDING IVC U DIVIDE HEPATIC VEIN CLOSE TO LIVER CAPSULE Oxilary liver transplant is temporary procedure in expectation that diseased liver will overcome wen liver is not histologicaly damaged Induced toxicity ,viral hepatitis Exdended criteria donor Age( no upper limit) hep c & b htlv Bli> 2 Cold ischemic time> 12 Ast/alt ratio Pt hvng > 2 pressor Most comn complication is bleeding d/t dilutional coagulopathy CBD ANASTOMOSIS IS END TO END WITH T TUBE EXCEPT IN CASE WER PRIM SCLEROSNG CHOLANGITIS,BILIARY ATRESIA,SHORT STUMP OF CBD U HV TO DO HEPATOJEJUNOSTOMY

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Pancreatic transplant STAKB SIMULTANEUS PANCREASE & Kidney transplantation PTA pancrease transplant alone PAKB pancrease aftre kidney transplant Loop of dudenum is taken Pancrease is always taken with loop of duodenum Frst anastomosis is vascular intrnal artery and vein Excretory chanel duodenum anastomose to small intestin or urinary bladder As we are bother about endocrine functionand we check the marker of rejection by urinary amy.ase Marker of simultaneus pancrease and kidney transplantatio marker is serum creatin It is surogate marker of reje tion for pancreas Urinary amylase is mrker of rejection in PTA AND PA MOST COMN complication in PANCREASE IS BLEEDING Ioc in early case of renel transplant is usg with doppler

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Hyper acute rejection cozed by prefomed Ab to hla-a Q18 burger disease Migratory thrombophlebitis Intrmitnt claudication,rest pain Raynods phenomena Ohio papa criteria 20-40 yr Current/ past exposure of Tobaco Distal extrimity involvmnt Exclusion of dm sle hypercoagolpathy state Consistant angiographic finding-(cords to collateral with skip areas) Exclusion of proximal source of emboli Rx in burgers disease Goal to achiev cease smoking<most imp> Bp < 135/85 Ldl<100 Hb ac < 7 Confirmation of bergers dis by biopsy Pan arteritis with Preservation of internal elastic lamina *****

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aneurysm most comn site is ant comunicating artery in circle of wilis Next comn abdominal aorta below renal bifurcation>>>>>> renal artery Most comn periferal aneurysm is berrys aneurysm>> popliteal artery Ioc for aneurysm ct Brain aneurysm ioc mri rest all ct scan All aneurysm hv rupture as a complication except popliteal aneurysm hv trobosis & embolism Most site of abdominal aneurysm rupture is lft post lateral aneurysm Ct scan Brain MRI MC COMPLICATION RUPTURE EXCEPT POPLITEAL o Craford clasification of aneurysm is

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Bypass Graft above inguinal lig prefered material is synthetic( dacron) Below inguinal lig prefered material is autoogus vein Conduce of choice is venus conduce InCABG CONDUCE LAINTERVENTRICULAR ARTERY IS RTERIAL CONDUCE FOT REST TRTERY IS VEIN(sephanus) Venus Conduces great sephanus vein, short sephanus Arterial conduce gatroduodenal artery , ,radial artery Cleft palate 1yr Combine defect cleft lip & cleft palate at 3 month Cleft of hard palate t18-24 month Amoutation NECK DISECTION Sternoclido mastoid ms = SCM SAN =spinal accesorry nerv Ijv ,,,, intrnal jugular vein RND GOLD STNDRD DESECTION U REMOVE LEVEL1 to 6 lymphnodes ,ijv scm,san along with submandibular gland MRND type1 preserv san

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2 ijv ,san Type3 ijv ,san, scm ( it is also called functional neck desection) SelectiveND. central nd,supramyohidal Lateral nd Post lateral neck d Ca tongue with LN IN NECK Rx RND Pleomorfic adenoma Mc benign Superficial parotid lobe It can harbor low malignancy Rx wide excision If it is in deeper lobe do then do Conservative total parotodectomy means removal of superficial lobe + deep lobe with. Preservation of FACIAL NERVE If malgnant transformaction seen ,or ther is recurrence or ther is positive margins In all these senario giv radio therapy But preferable Rx of recurent benign tumor is surgery Max salivary recurence sub mandi Max stone sub mandi Lingual nerve Thoracotomy Chest tube output First step in thoracic injury put chest tube If > 1500 ml expanded lung is not sufficient to control bleeding or > 200 ml /hr for 3 hr hr Or cardiac tempoor eso rupture Or persitnt colaps lung Do thoracotomy 4-9 rib comn injured Frst second sternum scapula injury rule out greaat vsl injury Epidural is best to achive analgesia If not available then giv intrcoastal nrve blok by cryoanalgesia Flail chest three or more consequtive ribs fracture at more than one point in one line Diagnosis alwaysclinical Confirm by xray First step is pain mangmnt epidural analgesia

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If oxygen saturation imroved then observe no need Ippv help in expanding lung & act as pnematic splint in flail chest Straping isABSOLUTELY CONTRAINDICATION FIXACTION OF RIBS ARE WEN PLANNING TODO THORACOTOMY If pt deteriotating with ippv Pt hvng gross ovrling of ribcage Preferedinision req forthoracotom lft anterolateral thoracotomyincision 2,4,5 intercoastal space Small cellca of lung Rx is chemo .....and rt at any stage In squmus cell,adeno ca Rx is Sx pnemonectomy FEV1 is of left out lung is more than 800 ml If it is less than 800 ml then even in stage one dis pneumonectomy is contraindicated Then do chemo and rt In question theygive fev1 And how much % is to be removed then what% will remain that wil decide fev1 if it is more than 800 then only do Sx Mc retroperitoneal tumor malgnant fibrus sarcoma mnh Mc sarcoma retrosarcoma liposarcoma Mc in ll is malignant fibrous cystic sarcoma Mc sarcoma ingeneral is fibrous cystic sarcoma Mc sarcoma in peds rhabdomyosacoma mc site orbit Mimp prognostic factr is grade Diagnosis by inscisional or excisional biopsy FNAC. HV NO ROLE IN SARCOMA EXCISIONAL BIOPSY IS DONE WEN TUMOR IS LESS THAN THREE CM AND SUPERFICIAL > 3 cm incisionl tumor Basic of onco surgery U hv to include ur biopsy tract in ur final excision Rib fracture Most comn cynotic dis TOF MC CYNOTIC CONG HEART DIS AT"BIRTH "IS TGV LFT AXIS DEVIATION TRICUSPID ATRESIA REST ALL RTSIDE AXIS DEVIATION Sternum,1st ,scapula, Flail chest Pain controle

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If not controled Then giv IPPV act as pneumatic splint Straping is absolute contraindicated Fixation of ribs Medical expulsion therapy Tamsilusun & Subcapsular hematuria Followed by pain is complication of eswl Long term complication is renal failure Renal trauma Indication of renal exploration

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Lung ca Coarctation MC CORCTION IS POST DUCTAL SEEN IN ADULT PRESENT WITH HT Rx baloon angioplasty even aftre sx ht never resolved PREDUCTAL COARCTATION SEEN IN NEWBORNITRESENT WITH CCF CARDIOMEGALY RIB NOTCHING SEEN Rx resection & end to end anastomosis

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Renal stone Deranged function dont do contrast ct scan or contrast mri U can not do dynamic scan Ucan do static scan DTPA SCAN GVS IDEA OF FUNCTION DMSA SCAN ANATOMY RENAL FAILURE CREAT & BUN RAISED WEN B/ l kidney involved thrn only pt can go in renal failure Fractional Na excreation less than 1% is pre renal Post renal. Vs renl failure is dignosed by USG B/ L hydronephrosis Frst step to relive press on renal parenchyma Can not giv GA Do in LA PUT DUBLE STENT

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RELIVE PRESS THEN SEND SEND PT FOR DIALYSIS DO DTPA SCAN (after removingcoz of obstruction if gfr <10ml & DIFFERENTIAL renal function<10% sign of NON FUNCTIONAL KIDNEY) OPERATE FUCTIONAL KIDNEY FIRST MaG 3 better than DTPA BUT LATER ONE IS MORE COMN PT WITH HEMATURIA FIRST STEPZ IOC FOR HEMATURIA CT SCAN( non ct follesd by ct urography) PAINLESS TERMINAL HEMAT URIA CYSTOSCOPY

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Most comn renal stone ca oxalate dihydrate stone enveloped shape crystal Phospate stone coffin lid shape crystals Uric acid stone multifacet crystal Cystine stone hexagonal Ioc non contrast ct In pregnant female MRI CALCIUM OXALATATE MONOHYDRATE FOLOWED BY CYSTEIN HARDEST STONE Contrast ct req for indinavir Conservative mx high fluid intake with medical expulsion therapy tamsilucin & ccb < 5 mm stone with. Nonono obstruction not enlarging not hvng uti not present solitary kidney If any one of the above presen d Indi of ESWL 5 mm -2 cm in upper & midl calyx <1 cm in upr ureter Indi of Pcnl >2.5 cm Any size stone in inferior calyx 2.-2.5 cm ESWL>>pcnl Mc compli of eswl sub capsular hematoma folowed by pain Long term complication is renal failure Pcnl (sub coastal incision) Mc complication bleeding Wen ston is in upr calyx post seg u hv to do 11 th rib approach in that case ther is plural injury pneumothorax ,hydrothorax pneumothorax ,chylothorax

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Renal truma Absolute indi of injury for exploration

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Persistant hemat uria l/t shock Expanding perirenal hematoma Relative indi for exploration Major urinary extravasation Major vessl injury More>20% parenchyma devitalisation

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Single shot iv contrast aftre 10 min If it shows ivu is not normal or near normal Open pt

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VUR Ioc voiding cysto urethrogrram Most Sn Radionucleiotide voiding cystourethrogram Ioc renal scaring usg Ioc renal drone usg

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Grade 1-3 spontaneusly resolved Grade4-5 More imp prophylaxis antibiotic INDICATION OF Sx in VUR BREAK TO UTI IN A PT ON ANTIBIOTIC PROPHYLAXIS BREAKTHRO PYLONEPHRITIS OR APPEARANCE OF NEW SCAR WHO IS ON PROPHYLAXIS PERSISTANt VUR FOR 3yr Pubertal pt with VUR Non compliant to medical therapy Grade four b/ L And grade 5 Aqired polycystic dis is risk factor forrenal cell ca Persistance of of normal fetal kidney cell beyond 34 wks is Nephroblastosis Malignant change in this cells it is nephroblastoma MayFound to be b/l A/w backmem willmen syndrome Bladder ca T2 muscle layer invaded Sx is ant pelvic exentration( in females),UB,URETHRA

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UTERUS,ADJOINING LN,OVARY ,ANT VAGINAL WALL REMOVED ,Cysto prostectomy ( in males)prostrate,UB SEMINAL VESICAL ADJOINING LYMPHNODES & proximal urethra if involved Once muscle layer is invaded u can not offer intravasical treatment can not be offered Intravesical Rx1- trans urethral resection of tumor ,2- intravesical bcg,intravesical chemo Sytemic Rx Sx, systemic chemo Urinary tumor marker for bladder ca Blca4 Fdp Bta Nmp22

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RETROGRADE URETHROGRAM BPH RETROGRADE CYSTOGRAM BLADDER INJURY EXTRA PERITONEAL RUPTURE OF UB IS MORE COMN ITS Rx is simple foleys catheterisation TURP INDICATION Acute retention d/t bph Chronic retension with backflow changes Complication d/t bladder outflow obstruction in form of recurrent cystitis,diverticula,stone Hematuria Sever protatism >100 ml post voidal urine & flow less than 10 mm/sec Irrigant during turp Best time for Sx for hypospadiasis is 6-10 month Best season is wintr Testical mass Clinical exam transilumination Nxt USG NXT DO HIGH INGUINAL ORCHIDECTOMY IF SEMINOMA NXT STAGE DISEASE CT SCAN OF ABDO & CXR IN NON SEMINOMA DO CT SCAN OF ABDO & thorax Ldh b hcg alfa feto protein S stage Stage 2b non semino tumor do retroperitoneal LN DISECTION FOR SEMINOMA TUMOR RT

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Undescended testis ORCHIDOPLEXY IS 6 month Befor 1 yr Ioc for undesended testis mri Best laproscopy First is usg Deep partial thick ness burn early exicision & graft only < 40% Best time 5-7 day shud not be delayed beyond 10 days

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