100 Cases in Surgery 2nd Edition
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CONTENTS
Preface vii
Abbreviations ix
1. General and colorectal 1
2. Upper gastrointestinal 43
3. Breast and endocrine 85
4. Vascular 97
5. Urology 129
6. Orthopaedic 149
7. Ear, nose and throat 191
8. Neurosurgery 199
9. Anaesthesia 207
10. Postoperative complications 217
Index 229
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PREFACE
We hope this book will give a good introduction to common surgical conditions seen in
everyday surgical practice. Each question has been followed up with a brief overview of the
condition and its immediate management. The book should act as an essential revision aid
for surgical finals and as a basis for practising surgery after qualification.
I would like to thank my co-authors for all their help and expertise in each of the surgical
specialties. I would also like to thank the following people for their help with illustrations:
Professor KG Burnand, Mr MJ Forshaw, Mr M Reid and Mr A Liebenberg.
James A Gossage
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ABBREVIATIONS
ABPI ankle–brachial pressure index
ACTH adrenocorticotrophic hormone
ALP alkaline phosphatase
AP anterior-posterior
APTT activated partial thromboplastin time
ASA American Society of Anesthesiologists
AST aspartate transaminase
ATLS Advanced Trauma and Life Support
BMI body mass index
BNF British National Formulary
BPH benign prostatic hyperplasia
CBD common bile duct
CEA carcinoembryonic antigen
COPD chronic obstructive pulmonary disease
CRP C-reactive protein
CSDH chronic subdural haematoma
CT computerized tomography
DVT deep vein thrombosis
ECG electrocardiogram
EMG electromyogram
ENT ear, nose and throat
ERCP endoscopic retrograde cholangiopancreatography
ESR erythrocyte sedimentation rate
EUA examination under anaesthesia
FAST focused abdominal sonographic technique
FEV1 forced expiratory volume in one second
FNAC fine needle aspiration cytology
FVC forced vital capacity
GCS Glasgow Coma Score
GGT gamma-glutamyl transferase
GP general practitioner
Hb haemoglobin
HbS haemoglobin S
HCG human chorionic gonadotropin
HDU high-dependency unit
HiB Haemophilus influenzae type B
ICU intensive care unit
IgA immunoglobulin A
INR international normalized ratio
IPSS International Prostate Symptom Score
ISAT International Subarachnoid Aneurysm Trial
IVU intravenous urethrogram
KUB kidney, ureter, bladder
LATS long-acting thyroid stimulator
LDH lactate dehydrogenase
Abbreviations
LUTS lower urinary tract symptoms
MEN multiple endocrine neoplasia
MRCP magnetic resonance cholangiopancreatography
MRI magnetic resonance imaging
NAD nothing abnormal detected
NEXUS National Emergency X-Radiography Utilization Group
NSAID non-steroidal anti-inflammatory drug
NSGCT non-seminomatous germ cell tumour
OGD oesophagogastroduodenoscopy
pCO2 partial pressure of carbon dioxide
PE pulmonary embolism
PET positron emission tomography
pO2 partial pressure of oxygen
PSA prostate-specific antigen
PTH parathyroid hormone
T3 tri-iodothyronine
T4 thyroxine
TIA transient ischaemic attack
TSH thyroid-stimulating hormone
TURBT transurethral resection of a bladder tumour
TURP transurethral resection of the prostate
UMN
. . upper motor neurone
V/Q ventilation–perfusion ratio
WCC white cell count
x
GENERAL AND COLORECTAL
CASE 1: a lump in the groin
History
A 51-year-old woman presents to the emergency department with a painful right groin. She
reports lower abdominal distension and has vomited twice on the way to the hospital. She has
passed flatus but has not opened her bowels since yesterday. She is otherwise fit and well and
is a non-smoker. She lives with her husband and four children.
Examination
On examination she appears unwell. Her blood pressure is 106/70 mmHg and the pulse rate
is 108/min. She is febrile with a temperature of 38.0°C. The abdomen is tender, particularly in
the right iliac fossa, and there is marked lower abdominal distension. There is a small swell-
ing in the right groin, which is originating below and lateral to the pubic tubercle. The lump
is irreducible and no cough impulse is present. Digital rectal examination is unremarkable
and bowel sounds are hyperactive.
INVESTIGATIONS
Normal
Haemoglobin 14.1 g/dL 11.5–16.0 g/dL
White cell count 18.0 × 109/L 4.0–11.0 × 109/L
Platelets 361 × 109/L 150–400 × 109/L
Sodium 133 mmol/L 135–145 mmol/L
Potassium 3.3 mmol/L 3.5–5.0 mmol/L
Urea 6.1 mmol/L 2.5–6.7 mmol/L
Creatinine 63 μmol/L 44–80 μmol/L
Amylase 75 IU/L 0–99 IU/L
An x-ray of the abdomen is performed and is shown in Figure 1.1.
Questions
• What is the cause of the x-ray
appearances?
• What is the swelling?
• What are the anatomical
boundaries?
• What is the initial treatment in
this case?
• What is the differential diagnosis
for a lump in the groin region?
Figure 1.1 Plain x-ray of the abdomen.
1
100 Cases in Surgery
ANSWER 1
This woman has a right-sided femoral hernia. The neck of the femoral hernia lies below and
lateral to the pubic tubercle, differentiating it from an inguinal hernia, which lies above and
medial to the pubic tubercle. The x-ray shows small-bowel dilation as a result of obstruction
due to trapped small bowel in the hernia sac. The high white cell count, temperature and ten-
derness may indicate strangulation of the hernia contents. The rigid borders of the femoral
canal make strangulation more likely than in inguinal hernias.
! Relations of the femoral canal
• Anteriorly: inguinal ligament
• Posteriorly: superior ramus of the pubis and pectineus muscle
• Medially: body of pubis, pubic part of the inguinal ligament
• Laterally: femoral vein
The patient should be kept nil by mouth, and intravenous fluids and antibiotics begun. A
nasogastric tube should be passed and bloods taken in preparation for theatre. Theatres
should then be informed and the patient taken for urgent surgery to reduce and repair the
hernia, with careful inspection of the hernial sac contents. If the bowel is infarcted, it will
need to be resected.
! Differential diagnosis for a lump in the groin
• Inguinal hernia
• Femoral hernia
• Hydrocoele of the cord
• Hydrocoele of the canal of Nuck
• Lipoma of the cord
• Undescended testicle
• Ectopic testicle
• Saphena varix
• Iliofemoral aneurysm
• Lymph nodes
• Psoas abscess
KEY POINTS
• Femoral hernias are at high risk of strangulation.
• If strangulation is suspected, urgent surgical correction is required.
2
General and Colorectal
CASE 2: right iliac fossa pain
History
A 19-year-old man presents with a 2-day history of abdominal pain. The pain started in the
central abdomen and has now become constant and has shifted to the right iliac fossa. The
patient has vomited twice today and is off his food. His motions were loose today, but there
was no associated rectal bleeding.
Examination
The patient has a temperature of 37.8°C and a pulse rate of 110/min. On examination of his
abdomen, he has localized tenderness and guarding in the right iliac fossa. Urinalysis is clear.
INVESTIGATIONS
Normal
Haemoglobin 14.2 g/dL 11.5–16.0 g/dL
Mean cell volume 86 fL 76–96 fL
White cell count 19 × 109/L 4.0–11.0 × 109/L
Platelets 250 × 109/L 150–400 × 109/L
Sodium 136 mmol/L 135–145 mmol/L
Potassium 3.5 mmol/L 3.5–5.0 mmol/L
Urea 5.0 mmol/L 2.5–6.7 mmol/L
Creatinine 62 μmol/L 44–80 μmol/L
C-reactive protein (CRP) 20 mg/L <5 mg/L
Questions
• What is the likely diagnosis?
• What are the differential diagnoses for this condition?
• How would you manage this patient?
• What are the complications of any surgical intervention that may be required?
3
100 Cases in Surgery
ANSWER 2
The history and the findings on examination strongly suggest acute appendicitis.
! Differential diagnoses of acute appendicitis
• Mmesenteric adenitis
• Psoas abscess
• Meckel’s diverticulitis
• Crohn’s ileitis
• Non-specific abdominal pain
And additionally in females:
• Ovarian cyst rupture
• Ovarian torsion
• Ectopic pregnancy (all females must have a pregnancy test)
The treatment is appendicectomy. The patient should be rehydrated with preoperative intra-
venous fluids, and receive analgesia. Antibiotics should be given if the diagnosis is clear and
the decision for surgery has been made. Surgery should be carried out promptly in a patient
who has signs of peritonitis, in order to avoid systemic toxicity. The appendix can be removed
by open operation or laparoscopically.
! Complications
• Wound infection: reduced by using broad-spectrum antibiotics
• Intra-abdominal collections and pelvic abscesses
• Prolonged ileus
• Fistulation between the appendix stump and the wound
• Deep vein thrombosis, pulmonary embolism, pneumonia, atelectasis
• Late complications: incisional hernia, adhesional obstruction
KEY POINT
• If the appendix is normal at the time of the operation, the small bowel should be
inspected for the presence of a Meckel’s diverticulum.
4
General and Colorectal
CASE 3: abdominal distension post hip replacement
History
You are asked to review a 72-year-old man on the orthopaedic ward. He had a hemiarthro-
plasty of his right hip 6 days earlier. He was recovering well initially but has now developed
significant abdominal distension. He has not opened his bowels or passed flatus for the past
4 days. His previous medical history includes treatment for a transitional cell carcinoma of
the bladder and an appendicectomy. He is also known to have a hiatus hernia. He gave up
smoking 6 months ago.
Examination
His blood pressure is 114/88 mmHg and pulse rate is 98/min. The abdomen is significantly dis-
tended with mild generalized tenderness. The abdomen is resonant to percussion and a few bowel
sounds are heard. There are no hernias, and digital rectal examination reveals an empty rectum.
INVESTIGATIONS
Normal
Haemoglobin 10.2 g/dL 11.5–16.0 g/dL
White cell count 12.6 × 109/L 4.0–11.0 × 109/L
Platelets 422 × 109/L 150–400 × 109/L
Sodium 131 mmol/L 135–145 mmol/L
Potassium 3.2 mmol/L 3.5–5.0 mmol/L
Urea 5.7 mmol/L 2.5–6.7 mmol/L
Creatinine 78 μmol/L 44–80 μmol/L
An x-ray of the abdomen is performed and is shown in Figure 3.1.
Questions
• What is the diagnosis?
• Are there any patients at particular
risk of developing this condition?
• What is the significance of the right
iliac fossa pain in this setting?
• W hat does conservative treatment
consist of?
Figure 3.1 Plain x-ray of the abdomen.
5
100 Cases in Surgery
ANSWER 3
The patient has large-bowel obstruction. When no mechanical cause is found for the obstruc-
tion, the condition is referred to as a pseudo-obstruction. The pathogenesis of the condition is
still unclear, but abnormal autonomic colonic activity is thought to be a major factor. On the
radiograph, air is seen throughout the colon down to the rectum, making a mechanical cause
unlikely. If this is unclear, then a water-soluble contrast enema should be used to exclude a
mechanical cause.
Pseudo-obstruction tends to occur in patients following trauma, severe infection, or ortho-
paedic/cardiothoracic/pelvic surgery. Systemic causes include sepsis, metabolic abnormali-
ties and drugs. The clinical features are marked abdominal distension, nausea, vomiting,
absolute constipation, abdominal pain and high-pitched bowel sounds. The presence of a
fever with signs of peritonism suggests that the bowel is ischaemic and a perforation is immi-
nent. This is most likely to occur in the caecum due to the distensibility of the bowel wall at
this point. The patient should be examined carefully for tenderness in the right iliac fossa,
and the caecal diameter noted on the radiograph. If the diameter increases to over 10 cm,
then there is a significant risk of perforation.
Conservative treatment involves keeping the patient nil by mouth, intravenous fluids and
nasogastric decompression. A flatus tube can be placed by rigid sigmoidoscopy to relieve
some of the distension. Decompression is more effectively achieved by colonoscopy. Fluid
and electrolyte abnormalities should be corrected and drugs affecting colonic motility dis-
continued, e.g. opiates.
KEY POINTS
• The overall mortality rate in pseudo-obstruction managed conservatively is
approximately 15 per cent.
• This figure rises to 30 per cent in patients who require surgery, and as high as 50–90
per cent with faecal peritonitis.
6
General and Colorectal
CASE 4: perianal pain
History
A 28-year-old man presents to the emergency department complaining of anal and lower-
back pain for the previous 36 h. He has tried taking simple analgesics with no benefit. The
pain is progressively getting worse and he is now finding it uncomfortable to walk or sit
down. He is otherwise fit and well, and smokes ten cigarettes a day.
Examination
Inspection of the anus reveals a 3 cm × 3 cm swelling at the anal margin. The swelling is
warm, exquisitely tender and fluctuant. There is no other obvious abnormality.
Questions
• What is the diagnosis?
• What are the aetiological factors associated with this condition?
• How are these lesions anatomically classified?
• What treatment is required?
7
100 Cases in Surgery
ANSWER 4
This patient has a perianal abscess. The organisms responsible tend to be either from the gut
(Bacteroides fragilis, Escherichia coli or enterococci) or from the skin (Staphylococcus aureus).
Anorectal abscesses originate from infection arising in the cryptoglandular epithelium lining
the anal canal. The internal anal sphincter can be breached through the crypts of Morgagni,
which penetrate through the internal sphincter into the intersphincteric space. Once the infec-
tion passes into the intersphincteric space, it can spread easily into the adjacent perirectal spaces.
! Classification of anorectal abscesses
See Figure 4.1.
Supralevator
Levator ani abscess
muscle
Ischioanal External sphincter
(ischiorectal) Internal sphincter
abscess
Perianal abscess Figure 4.1 Diagram
Intersphincteric or intramuscular demonstrating the anatomy
abscess of anorectal abscesses.
! Aetiological factors for anorectal abscesses
• Idiopathic (vast majority) • Anal trauma/surgery
• Crohn’s disease • Pelvic abscesses may arise secondary
• Anorectal carcinoma to inflammatory bowel disease or
• Anal fissure diverticulitis
The patient should have an examination under anaesthesia (EUA) with sigmoidoscopy to
examine the bowel mucosa. The abscess should be treated by incision and drainage, and
pus should be sent for culture. Skin organisms are less commonly associated with fistulae
than gut organisms. Anorectal fistulas occur in 30–60 per cent of patients with anorectal
abscesses. If a fistula is found at the time of incision and drainage, the location should be
noted and the patient brought back once the sepsis has resolved.
KEY POINTS
• Anorectal fistulas occur in 30–60 per cent of patients with anorectal abscesses.
• Sigmoidoscopy and proctoscopy should be done at the time of surgery to examine
for underlying pathology.
8
General and Colorectal
CASE 5: suspicious mole
History
A 36-year-old Caucasian man presents to his general practitioner concerned that a mole has
changed shape and increased in size over the preceding month. It is itchy but has not changed
colour or bled. There is no relevant family history. He is fit and well otherwise. As part of his
job he spends half the year in California. He smokes five cigarettes per day.
Examination
He appears well. Several moles are present over the neck and trunk. All appear benign, except
the one he points out that he is concerned about. This is located on the left-hand side of his
trunk and is black, measuring 1 cm × 1.5 cm. The lesion is non-tender with a slightly irregular
surface. There is a surrounding pink halo around the lesion. The local lymph nodes are not
enlarged. Abdominal, chest and neurological examinations are normal.
Questions
• What is the most likely diagnosis?
• What treatment would you recommend?
• Why is it important to examine the abdomen and chest and assess neurology in such
patients?
• What are the risk factors for this condition?
• What factors in the history of such patients would make you concerned?
