General Tips for Surgery Posting

• Carry a small notebook or use your phone for patient lists
• Know your patients: diagnosis, operation done, post-op day, vitals, drains, wounds, urine output
• Present concisely: "Mr. X, 45M, POD#2 after open appendectomy, afebrile, vitals stable, tolerating liquids, wound clean, for mobilization"

• Arrive early — scrub before the surgeon does
• Learn proper scrubbing, gowning, and gloving technique on Day 1
• Stand still, keep hands above waist when scrubbed, don't turn your back to the sterile field
• Know the basics of common instruments: scalpel, retractors, needle holders, artery forceps

• Pre-op assessment and preparation
• Consent and surgical safety checklist (WHO checklist)
• Wound classification and healing
• Post-op complications (fever, DVT, anastomotic leak, wound infection)
• Fluid management post-surgery
• Common surgical conditions: appendicitis, hernia, cholecystitis, intestinal obstruction

• Suturing and knot tying (practice on a suture pad!)
• IV line insertion and wound dressing
• Reading X-rays: erect abdomen (air under diaphragm), CXR

• Be proactive — offer to help, don't just observe
• Ask questions after the case, not during critical steps
• Respect the scrub nurse and OT staff — they'll teach you a lot

---

---

🏥 SURGICAL CLERKING SHEET

Presenting Complaint: Neck Swelling + Pain + Dysphagia

---

1. BIODATA

---

2. PRESENTING COMPLAINT

• Neck swelling — duration: ___
• Neck pain — duration: ___
• Dysphagia — duration: ___

---

3. HISTORY OF PRESENTING COMPLAINT

A. Neck Swelling

• Onset: Sudden / Gradual
• Duration: ___ days/weeks
• Site: Anterior / Posterior / Lateral / Midline / Submandibular / Submental
• Progression: Rapidly enlarging? (danger sign)
• Associated redness, warmth, skin changes?
• Single or multiple lumps?

B. Pain

• Site: Local / Deep / Radiating
• Character: Throbbing / Dull / Sharp
• Severity (1–10):
• Radiation: Ear (otalgia)? Jaw? Throat?
• Aggravating/relieving factors

C. Dysphagia

• To solids / liquids / both? (both = mechanical obstruction or severe edema)
• Odynophagia (painful swallowing)?
• Drooling? (inability to manage secretions — airway red flag)
• Progressive or constant?

D. Associated Symptoms (Ask all of these)

---

4. POSSIBLE PRECIPITATING/PREDISPOSING FACTORS

Recent Infections

• Dental infection / dental procedure / tooth extraction?
• Sore throat / URTI / sinusitis / otitis?

Recent Procedures / Trauma

• Dental surgery, endoscopy, intubation
• Tongue piercing, oral laceration, facial trauma
• IV drug use

Past Medical History

• Diabetes mellitus (↑ risk of Ludwig's angina, rapidly progressive infections)
• HIV / immunodeficiency
• Autoimmune disorder / collagen-vascular disease
• Hematologic malignancy, chemotherapy, steroid use
• Previous neck surgery or radiation

---

5. PAST MEDICAL & SURGICAL HISTORY

• Previous similar episodes?
• Any known neck mass / goitre?
• Tuberculosis history / contact
• Malignancy

---

6. DRUG HISTORY

• Current antibiotics / steroids / immunosuppressants
• Antibiotic allergies (specifically ask — critical before treatment)
• NSAIDs, anticoagulants

---

7. FAMILY HISTORY

• TB contacts
• Family history of neck masses or malignancy

---

8. SOCIAL HISTORY

• Smoking (pack-years), alcohol
• Occupation (exposure to animals → cat scratch disease / Bartonella)
• Travel history

---

9. REVIEW OF SYSTEMS

• Respiratory: cough (TB?), haemoptysis
• GI: nausea, vomiting, GORD
• Constitutional: fever, weight loss, night sweats (B symptoms → lymphoma/TB)

---

10. PHYSICAL EXAMINATION

General Inspection

• Comfortable / distressed / toxic-looking
• Posture: leaning forward? (epiglottitis sign)
• Drooling? Stridor audible? Open-mouth breathing?
• AIRWAY ASSESSMENT FIRST — any dyspnoea, stridor, SpO₂ drop → emergency

Vital Signs

Neck Examination (Inspection + Palpation)

Oral Cavity & Pharynx

• Trismus (limited mouth opening)?
• Floor of mouth: edema, elevation, woody consistency? (Ludwig's angina)
• Tongue displacement / protrusion?
• Tonsillar swelling: unilateral with uvula deviation? (peritonsillar abscess)
• Purulent discharge from Wharton's / Stensen's duct?
• Dentition: caries, poor dental hygiene?
• Pharyngeal wall displacement / bulge? (retropharyngeal abscess)

Ear Examination

• Otitis media / externa?

Respiratory

• Auscultate: wheeze, stridor, reduced air entry

Cranial Nerve Exam

• CN II–VI (retrograde spread via ophthalmic veins can cause orbital involvement)
• CN IX, X, XI, XII (parapharyngeal space)

---

11. DIFFERENTIAL DIAGNOSIS

---

12. INVESTIGATIONS

Bedside / Urgent

• SpO₂ monitoring (continuous if airway concern)
• Blood glucose (exclude DM)

Blood Tests

• FBC: leukocytosis (bacterial) vs. normal (viral/immunodeficiency/tumour)
• CRP, ESR
• Blood cultures (×2 before antibiotics)
• RBS / HbA1c
• LFTs, U&E, coagulation

Microbiology

• Pus culture & sensitivity (if drained)
• Throat swab
• Monospot / EBV serology if glandular fever suspected
• Mantoux / IGRA (TB screen)

Imaging

• CT Neck with IV contrast (gold standard) — defines extent of deep space involvement, identifies gas (necrotising infection), guides drainage
• CXR — mediastinal widening (descending necrotising mediastinitis, a complication)
• Ultrasound — superficial nodes, guides aspiration

Special

• Flexible fiberoptic nasolaryngoscopy (mandatory if hoarseness, stridor, dysphagia, or dyspnoea — before transport to radiology)
• FNAC / excision biopsy if malignancy suspected

---

13. PROVISIONAL DIAGNOSIS

Deep neck space infection (specify: Ludwig's angina / retropharyngeal / peritonsillar / parapharyngeal abscess) — based on history and examination

---

14. IMMEDIATE MANAGEMENT PLAN

⚠️ AIRWAY FIRST

1. Assess airway: SpO₂, stridor, drooling, dyspnoea
2. If compromised → awake fiberoptic intubation (do NOT paralyse before securing airway)
3. Surgical airway (cricothyrotomy/tracheostomy) if intubation fails

General

• IV access × 2
• IV fluids (resuscitation + maintenance)
• Nil by mouth if airway concern or surgery planned
• Oxygen supplementation
• Analgesia (IV paracetamol ± opioid)
• Head-end elevation 30–45°

Antibiotics (empirical, pending culture)

• IV co-amoxiclav / ampicillin-sulbactam (covers oral flora, anaerobes)
• Add metronidazole for anaerobic coverage
• Adjust based on culture & sensitivity

Surgical

• Incision & drainage if abscess confirmed
• Consult ENT / Maxillofacial / General Surgery

---

15. CLERKING SUMMARY (SOAP)

---

Key Red Flags to never miss: Stridor, drooling, SpO₂ drop, rapidly enlarging swelling, voice change, trismus — these signal impending airway loss and require immediate escalation.

---

🔴 UPDATED CLERKING — REVISED DIAGNOSIS

Provisional: Thyroid Lymphoma vs. Anaplastic Thyroid Carcinoma

With TIRADS 4 Right Thyroid Lesion | Right IJV Thrombosis | Suspected Lung Metastases

---

REVISED DIFFERENTIAL DIAGNOSIS (Ranked)

---

ADDITIONAL HISTORY TO SPECIFICALLY ELICIT

For Thyroid Lymphoma

• Known Hashimoto's thyroiditis / autoimmune thyroid disease? (major risk factor — chronic lymphocytic thyroiditis precedes thyroid lymphoma)
• Prior hypothyroidism / on levothyroxine?
• B symptoms: Fever >38°C, drenching night sweats, weight loss >10% in 6 months — ask specifically
• Pruritus (generalised)?
• Any other lymph node swellings (axilla, groin, mediastinum)?
• Alcohol-induced pain in lymph nodes?

For Anaplastic Carcinoma

• Previous thyroid nodule / goitre — longstanding? (ATC often arises from pre-existing differentiated carcinoma)
• Prior thyroid surgery or radioiodine?
• Voice hoarseness (recurrent laryngeal nerve invasion)?
• Respiratory stridor (tracheal compression)?
• Haemoptysis (lung mets)?
• Bone pain (skeletal mets)?

General Oncology History

• Symptoms duration — ATC grows in weeks; lymphoma may grow over weeks–months
• Weight loss, anorexia, fatigue
• Prior radiation to head/neck

---

UPDATED PHYSICAL EXAMINATION FOCUS

Thyroid / Neck

Lymph Node Examination (Full Nodal Survey)

• Cervical (levels I–VI): size, consistency, matted/discrete, tender/non-tender
• Supraclavicular (Virchow's — left side for GI; right side for lung/mediastinum)
• Axillary, inguinal — systemic lymphoma?
• Mediastinal — dullness, SVC syndrome signs?

Respiratory

• Tracheal deviation (compression)
• Stridor (inspiratory) — RLN or tracheal compression
• Reduced air entry — pleural effusion / lung mets

Vocal cord assessment

• Hoarseness → likely RLN invasion

---

INVESTIGATIONS — PRIORITY ORDER

🔴 URGENT (Day 0–1)

🟠 IMPORTANT (Day 1–3)

🟡 LUNG NODULES WORKUP

---

TIRADS 4 — WHAT IT MEANS

• Hypoechoic solid lesion
• Irregular/lobulated margins
• Microcalcifications
• Taller-than-wide shape
• Extrathyroidal extension

---

RIGHT IJV THROMBOSIS — MANAGEMENT

Aetiology in this Context

• Direct tumour invasion of IJV wall (ATC is notorious for this)
• Extrinsic compression by large lymph nodes / thyroid mass
• Hypercoagulable state (Trousseau's syndrome / cancer-associated thrombosis)

Immediate Management

• Doppler USS or CT venography to confirm extent
• Anticoagulation: Low molecular weight heparin (LMWH) — enoxaparin 1 mg/kg SC BD
  • (LMWH preferred over warfarin in cancer-associated thrombosis — CLOT trial evidence)
• Monitor for: superior vena cava extension, septic thrombophlebitis (Lemierre's syndrome if infected)
• Check contraindications: thrombocytopenia, bleeding risk, biopsy timing

---

STAGING (If Lymphoma Confirmed)

Ann Arbor Staging for Thyroid Lymphoma

With suspected lung nodules and IJV involvement → likely Stage IVE if lymphoma

---

MANAGEMENT OUTLINE

If Thyroid Lymphoma (DLBCL)

• Chemo-immunotherapy: R-CHOP (Rituximab + Cyclophosphamide + Doxorubicin + Vincristine + Prednisolone)
• Combined with radiotherapy for localised disease (Stage IE/IIE)
• Stage IV: R-CHOP ± consolidation
• Avoid surgery as primary treatment (chemosensitive tumour)
• Prognosis: Stage IE → 80–90% 5-year survival; Stage IV → poor

If Anaplastic Thyroid Carcinoma

• Median survival: 3–5 months; <20% survive 1 year
• Multimodal approach: Surgery (debulking if feasible) + chemoradiation
• Chemotherapy: Lenvatinib + pembrolizumab (if BRAF wild-type); Dabrafenib + trametinib (if BRAF V600E mutated — present in ~30% of ATC)
• Palliative intent if metastatic (lung mets confirmed)
• Airway securing (tracheostomy) may be required early
• MDT essential: Oncology, ENT/Head-Neck Surgery, Radiology, Palliative Care

Immediate Shared Steps

1. Secure airway if dyspnoea/stridor worsens → tracheostomy pre-emptively in ATC
2. Start anticoagulation for IJV thrombosis
3. Urgent MDT referral — Head & Neck Oncology
4. Tissue diagnosis before starting any treatment
5. Nutritional support (NG tube / TPN if severe dysphagia)
6. Consent for biopsy, staging CT, possible tracheostomy

---

SOAP SUMMARY UPDATE

---

⚠️ Critical point: These two diagnoses have completely different management — lymphoma is chemosensitive and potentially curable even at advanced stage; anaplastic carcinoma carries near-universal mortality. Tissue diagnosis is the single most important next step.

---

🫁 CHEST TRAUMA 101

Surgical Student Guide — ATLS Framework

---

THE BIG PICTURE

---

ATLS APPROACH — ALWAYS FOLLOW THIS FRAMEWORK

PRIMARY SURVEY (ABCDE) → Kill the killers first
       ↓
RESUSCITATION
       ↓
SECONDARY SURVEY → Find everything else
       ↓
DEFINITIVE CARE

---

🔴 THE 6 KILLERS — PRIMARY SURVEY (Must identify & treat IMMEDIATELY)

"These kill in minutes. Diagnose clinically — do NOT wait for X-ray."

---

1. 🫁 TENSION PNEUMOTHORAX

• Dyspnoea
• Deviation of trachea (away from lesion — late sign)
• Distended neck veins (JVD)
• Deadly hypotension
• Diminished/absent breath sounds (on affected side)
• Hyperresonance to percussion

1. Needle decompression → 2nd intercostal space, midclavicular line
2. Then chest tube → 4th/5th ICS, anterior axillary line

---

2. 🩸 MASSIVE HAEMOTHORAX

• Absent breath sounds
• Dullness to percussion (vs. hyperresonance in pneumothorax)
• Hypotension, tachycardia
• No JVD (empty veins — hypovolaemia)

1. Large-bore IV × 2, aggressive fluid resuscitation / blood transfusion
2. Chest tube (4th/5th ICS, anterior axillary line) — drains blood
3. Thoracotomy if:
   • Initial output ≥1500 mL
   • Ongoing output ≥150–200 mL/hr for 4 hours
   • Haemodynamic instability despite resuscitation

---

3. 💨 OPEN PNEUMOTHORAX ("Sucking Chest Wound")

• Visible open wound on chest
• Audible sucking/hissing sound on inspiration
• Dyspnoea, hypoxia

1. 3-sided occlusive dressing (seal 3 sides, leave 1 open — acts as flutter valve)
2. Chest tube placed remote from wound
3. Definitive surgical closure

---

4. 🦴 FLAIL CHEST

• Paradoxical chest wall movement
• Severe pain, splinting
• Hypoxia (often delayed 24–48 hrs as contusion "blossoms")
• Tachypnoea

1. High-flow O₂
2. Aggressive analgesia (epidural / paravertebral block preferred)
3. Positive pressure ventilation (intubation) if respiratory failure → splints the flail segment
4. Surgical Stabilisation of Rib Fractures (SSRF) — for refractory cases

---

5. ❤️ CARDIAC TAMPONADE

Think tamponade in penetrating chest trauma — especially precordial stab wounds

1. Pericardiocentesis — needle at 45° angle from subxiphoid towards left shoulder (aspirate 15–20 mL can be life-saving)
2. Emergency thoracotomy (definitive) — if deteriorating

---

6. 🫀 AIRWAY OBSTRUCTION

• Suction, jaw thrust, chin lift
• Oral/nasopharyngeal airway
• Definitive: RSI + intubation or surgical airway (cricothyrotomy)

---

Quick Memory Aid for the 6 Killers

"ATOM FC" Airway obstruction Tension pneumothorax Open pneumothorax Massive haemothorax Flail chest Cardiac tamponade

---

🟡 SECONDARY SURVEY — The "Hidden" 6 (Less Immediate but Still Deadly)

---

INVESTIGATIONS IN CHEST TRAUMA

Bedside (Immediate)

• SpO₂ — continuous monitoring
• eFAST (Extended FAST): pneumothorax, haemothorax, pericardial fluid — at the bedside, no radiation

Imaging

NEXUS Chest Rules — When to image:

---

CHEST TUBE INSERTION — KNOW THIS COLD

1. Position: Patient supine/semi-recumbent, arm abducted
2. Site: 4th/5th ICS, anterior axillary line ("safe triangle" — bounded by pec major, lat dorsi, 5th ICS)
3. Local anaesthetic + skin incision
4. Blunt dissection over top of rib (to avoid neurovascular bundle on underside)
5. Finger check → pleural space confirmed
6. Insert tube: aim posterosuperior for fluid, anterosuperior for air
7. Connect to underwater seal drain
8. Secure, CXR to confirm

---

RIB FRACTURES — CLINICAL PEARLS

• RR >18 after pain control
• Incentive spirometry <75% predicted
• Pain score ≥6
• Poor cough
• Age ≥65
• ≥3 fractures

• NSAIDs + gabapentin + diazepam + opioid PRN
• Epidural / paravertebral nerve block — gold standard for multiple rib fractures

---

SIGNS CHEAT SHEET

---

THE ONE-LINER SUMMARY

Primary survey kills = ATOM FC. Diagnose clinically, treat immediately without waiting for imaging. 85% of chest trauma = chest tube only. Always follow ATLS ABCDE. Flail chest kills via the underlying lung contusion, not the wall movement.

---

---

🔴 APPENDICITIS 101

Surgical Student Complete Guide

---

QUICK FACTS

• Most common surgical emergency worldwide
• Lifetime risk: 8.6% males, 6.7% females
• Peak age: 10–30 years (but can occur at any age)
• Accounts for 17% of all ED acute abdominal pain visits
• Up to 40% present with perforation

---

ANATOMY — KNOW THIS

• ~9 cm long, 0.6 cm wide vermiform structure
• Arises from caecum where all 3 taenia coli converge
• Blood supply: appendiceal artery (branch of ileocolic artery from SMA)
• Base is fixed at caecum; tip position varies:

Tip position explains why appendicitis presentations vary so much!

---

PATHOPHYSIOLOGY — THE PROGRESSION

Lumen obstruction
(faecolith / lymphoid hyperplasia / parasite / foreign body)
        ↓
Bacterial overgrowth + mucus secretion
        ↓
Distension → stretches visceral afferents
→ VAGUE PERIUMBILICAL PAIN (early)
        ↓
Venous congestion → arterial obstruction
→ ISCHAEMIA → NECROSIS → GANGRENE
        ↓
PERFORATION ± ABSCESS / PERITONITIS
→ PAIN MOVES TO RIF (parietal peritoneum involved)

---

CLINICAL FEATURES

Classic Symptom Progression (over 6–48 hrs)

Migration of pain from periumbilical → RIF is the single most important diagnostic symptom

Classic Signs

Vital Signs

• Low-grade fever 37.5–38.5°C (>39°C suggests perforation)
• Tachycardia
• Patient lies still, knees drawn up (peritonism)

---

ALVARADO SCORE (MANTRELS) — Use this to risk stratify

---

INVESTIGATIONS

Bloods

Imaging

---

DIFFERENTIAL DIAGNOSIS

---

MANAGEMENT

Pre-operative

1. IV access + fluid resuscitation
2. Nil by mouth
3. Analgesia (do NOT withhold — adequate analgesia does NOT mask signs)
4. IV antibiotics pre-operatively:
   • Co-amoxiclav / Ceftriaxone + Metronidazole (covers gram-negative + anaerobes)
5. IDC if needed, thromboprophylaxis

Surgical — APPENDICECTOMY

Perforated / Complicated Appendicitis

• IV piperacillin-tazobactam (Tazocin) alone, OR
• IV ceftriaxone + metronidazole
• Step down to oral amoxicillin-clavulanate for total 5-day course

---

CONTROVERSY: ANTIBIOTICS ALONE FOR UNCOMPLICATED APPENDICITIS?

• Antibiotics alone not inferior for 30-day health status
• BUT: 25–29% recurrence within 90 days; 50% 5-year recurrence
• Higher failure if appendicolith present (41% recurrence)

• Uncomplicated (no perforation, no appendicolith on imaging)
• CRP <60, WBC <12
• Age appropriate, no immunocompromise
• Must consent to possible surgery if fails

Bottom line: Surgery remains gold standard. Antibiotics are an option in selected patients who refuse surgery or have high anaesthetic risk.

---

COMPLICATIONS OF APPENDICITIS

If untreated/delayed:

• Perforation (16–40% of cases)
• Appendix mass/phlegmon
• Appendix abscess
• Generalised peritonitis → sepsis → death

Post-operative complications:

Negative appendicectomy rate: 10–20% (higher in women of reproductive age — acceptable to avoid missing perforation)

---

SPECIAL SITUATIONS

---

ONE-PAGE SUMMARY

Periumbilical pain → migrates to RIF
+ Anorexia + Nausea + Fever + Leukocytosis
= Appendicitis until proven otherwise

Score it (Alvarado) → Image it (USS/CT) → Operate it
                    ↓
           Uncomplicated → Laparoscopic appendicectomy
           Complicated   → IV Abx ± drainage ± emergency surgery

---

---

🟡 ACUTE CHOLECYSTITIS 101

Surgical Student Complete Guide

---

QUICK FACTS

• 10% of the population has gallstones (cholelithiasis)
• Of those, 1/3 develop symptoms
• Acute cholecystitis = most common reason for emergency cholecystectomy
• 90% calculous (stone-related), 10% acalculous (no stones — critically ill patients)
• Particularly common in diabetics

---

THE 5 F's — Classic Risk Factors for Gallstones

Fat, Female, Fertile, Forty, Fair (+ Flatulent = the 6th F sometimes added)

---

TYPES OF GALLSTONES

---

PATHOPHYSIOLOGY

Calculous Cholecystitis (90%)

Gallstone impacts cystic duct / Hartmann's pouch
         ↓
Bile cannot drain → builds up in GB
         ↓
Mucosal phospholipases hydrolyse lecithin → toxic lysolecithins
Prostaglandins released → inflammation + distension
         ↓
Compromised mucosal blood flow → ischaemia
         ↓
Bacterial superinfection (E. coli, Klebsiella, Enterococcus)
         ↓
Complications: Gangrene → Perforation → Empyema → Peritonitis

Acalculous Cholecystitis (10%)

• Cystic artery is an end artery → no collateral → ischaemia from low flow states
• Gallbladder stasis → biliary sludge obstructs without stones
• Risk factors: Sepsis + hypotension, major trauma/burns, mechanical ventilation, TPN, immunosuppression, DM

---

SPECTRUM OF GALLSTONE DISEASE

Gallstones (asymptomatic) — most never cause problems
       ↓
Biliary colic (temporary cystic duct obstruction, resolves)
       ↓
Acute cholecystitis (persistent obstruction → inflammation)
       ↓
Complications: Empyema / Gangrene / Perforation / Mirizzi syndrome
       ↓
Stone migrates → Choledocholithiasis (CBD stone)
       ↓
Cholangitis / Obstructive jaundice / Pancreatitis

---

CLINICAL FEATURES

Symptoms

Signs

Murphy's sign is NEGATIVE in acalculous cholecystitis (patient sedated/altered) — high clinical suspicion needed in ICU patients

Charcot's Triad (if cholangitis develops)

RUQ pain + Fever/rigors + Jaundice = CBD obstruction + infection → emergency!

Reynolds' Pentad (severe cholangitis)

Charcot's triad + Shock + Altered mental status = septic cholangitis → emergency ERCP/surgery

---

INVESTIGATIONS

Bloods

Imaging — Priority Order

---

DIAGNOSIS — TOKYO GUIDELINES (TG18/TG13)

---

DIFFERENTIAL DIAGNOSIS

---

MANAGEMENT

Step 1 — Immediate (All Patients)

1. IV access + IV fluids (resuscitation + maintenance)
2. Nil by mouth
3. Analgesia — IV diclofenac / ketorolac (NSAIDs reduce prostaglandin-mediated inflammation) ± opioids
4. Antiemetics
5. IV antibiotics:
   • Mild–moderate: Cefoxitin or co-amoxiclav
   • Severe / gangrenous: Piperacillin-tazobactam OR 3rd-generation cephalosporin + metronidazole
   • Continue post-op only if gangrenous/perforated; not needed for uncomplicated AC

Step 2 — Definitive: Cholecystectomy

Early laparoscopic cholecystectomy within 72 hours of symptom onset is the gold standard — supported by multiple RCTs and meta-analyses

• 3–4 port technique (umbilical camera + working ports)
• Critical View of Safety (CVS) must be achieved before dividing any structure:
  • Hepatocystic triangle cleared of fat/fibrous tissue
  • Lower third of GB separated from liver bed
  • Only 2 structures seen entering GB (cystic artery + cystic duct)
• Intraoperative cholangiogram if CBD stones suspected
• Convert to open if anatomy unclear — "if in doubt, convert"

Step 3 — If Not Surgical Candidate (High-Risk Patient)

• 90% effective at symptom resolution
• Done under local anaesthesia / light sedation
• Leave drain 6–12 weeks → interval cholecystectomy when fit
• If no stones (acalculous) → drain can be removed if cystic duct patent at 6 weeks

---

COMPLICATIONS OF ACUTE CHOLECYSTITIS

---

BILIARY COLIC vs. ACUTE CHOLECYSTITIS — KEY DIFFERENCE

---

SPECIAL SITUATIONS

---

ONE-LINE SUMMARY

RUQ pain >6 hrs + Murphy's sign + fever + leukocytosis + gallstones on USS = Acute Cholecystitis → IV fluids + antibiotics + early laparoscopic cholecystectomy within 72 hours.

---

---

🫘 NEOPLASMS OF KIDNEY, URETER & BLADDER 101

Urology / Surgical Student Complete Guide

---

OVERVIEW — THE BIG THREE

---

PART 1: RENAL TUMOURS

---

A. RENAL CELL CARCINOMA (RCC)

Epidemiology

• Most common malignant renal tumour in adults (~85% of all renal malignancies)
• Male:Female = 2:1
• Peak age: 50–70 years
• Arises from proximal convoluted tubular epithelium

Risk Factors

Classification — Subtypes

Classical Clinical Triad (present in only 10% — late presentation)

Haematuria + Flank Pain + Palpable Flank Mass = RCC until proven otherwise

Symptoms

• Painless haematuria (most common presenting symptom ~60%)
• Flank/loin pain (dull ache)
• Palpable abdominal mass
• Weight loss, fatigue, fever (systemic)
• Left-sided varicocele that doesn't empty on lying down → left renal vein obstruction by tumour thrombus (pathognomonic)

Paraneoplastic Syndromes — RCC is famous for these!

Investigations

Biopsy not routinely done pre-operatively — risk of seeding; surgery is both diagnostic and therapeutic

TNM Staging (Simplified)

Management

Metastases (mnemonic: LLABBS)

Lungs (most common, "cannonball" mets), Liver, Adrenal, Bone, Brain, Skin

---

B. WILMS TUMOUR (Nephroblastoma)

• Most common renal tumour in children (< 5 years; median age 3 years)
• 4th most common paediatric malignancy
• Incidence: 8 per million children <15 yrs
• 6% bilateral; 7% multicentric

Associated Syndromes

Pathology — Classic Triphasic Histology

Blastemal + Stromal + Epithelial cells = Wilms tumour

• Favourable histology: no anaplasia → >90% 5-year survival
• Unfavourable histology: anaplasia (7% of cases) → poor prognosis; chemoresistant

Presentation

• Painless abdominal mass (child with large belly — most common presentation)
• Hypertension (renin secretion)
• Haematuria (less common than RCC)
• Fever, weight loss

⚠️ Never palpate/massage aggressively — risk of tumour rupture and seeding

Investigations

• USS abdomen → large intrarenal mass
• CT Chest/Abdomen/Pelvis → staging, IVC involvement
• No biopsy pre-op (risk of upstaging)

Staging & Management

---

PART 2: URETERIC TUMOURS

---

UPPER TRACT UROTHELIAL CARCINOMA (UTUC)

• Rare — accounts for 5–10% of all urothelial cancers
• Renal pelvis > ureter (2:1)
• Same histology as bladder — transitional cell / urothelial carcinoma
• Strong association with bladder cancer (synchronous or metachronous)

Risk Factors

• Smoking (most important)
• Aristolochic acid (Balkan nephropathy, Chinese herbal medicine)
• Cyclophosphamide (haemorrhagic cystitis → urothelial exposure)
• Lynch syndrome (hereditary UTUC)
• Chronic infection / calculi (→ SCC variant)
• Phenacetin abuse

Presentation

• Painless haematuria (most common)
• Flank pain (ureteric obstruction)
• Incidental finding on imaging

Investigations

• Urine cytology
• CT urography (IVP equivalent) — filling defect in ureter/pelvis
• Ureteroscopy + biopsy (gold standard for tissue)
• CT chest/abdomen for staging

Management

After nephroureterectomy, 40–50% develop bladder recurrence → regular cystoscopy surveillance mandatory

---

PART 3: BLADDER TUMOURS

---

UROTHELIAL (TRANSITIONAL CELL) CARCINOMA — BLADDER

Epidemiology

• 4th most common cancer in men; 9th in women
• Male:Female = 3–4:1
• Peak age: 60–80 years
• 90% are urothelial carcinoma (formerly called TCC)
• Others: Squamous cell carcinoma (5–10%), Adenocarcinoma (2%)

Risk Factors

Molecular Pathways

Two distinct pathways:
1. Low-grade papillary tumours → FGFR3 mutation → recur but rarely invade
2. High-grade / CIS → TP53 mutation → progress to muscle-invasive disease

Presentation

⭐ PAINLESS HAEMATURIA in anyone >40 = bladder cancer until proven otherwise

• Painless macroscopic haematuria (most common, ~80%)
• Microscopic haematuria (incidental finding)
• Irritative LUTS: frequency, urgency, dysuria (especially CIS)
• Pelvic pain, hydronephrosis (advanced)
• Leg oedema (lymphatic obstruction)

Pathology — Spectrum of Disease

Staging (TNM)

Investigations

Management

Non-Muscle Invasive (NMIBC):

TURBT (Transurethral Resection of Bladder Tumour)
→ histology confirms stage/grade
     ↓
Risk stratification:
Low risk (LG Ta, single, <3cm) → surveillance cystoscopy
Intermediate risk → intravesical chemotherapy (mitomycin C)
High risk (HG T1, CIS, multiple/large) → intravesical BCG
     ↓
If refractory to BCG → radical cystectomy

• Immunotherapy instilled into bladder
• Activates local immune response → destroys tumour cells
• Best treatment for CIS and high-risk NMIBC
• Side effects: cystitis, systemic BCG-osis (rare but serious)

Muscle-Invasive (MIBC):

Surveillance after NMIBC

• Regular cystoscopy (3-monthly → 6-monthly → annual depending on risk)
• Urine cytology
• CT urogram annually (upper tract surveillance)

---

SQUAMOUS CELL CARCINOMA OF BLADDER

• 5–10% of bladder cancers
• Associated with Schistosoma haematobium (endemic in Egypt/Africa)
• Chronic irritation: calculi, indwelling catheter, recurrent UTIs
• Presents as muscle-invasive; poor prognosis
• Treatment: radical cystectomy ± radiotherapy

---

COMPARISON TABLE — KEY DIFFERENTIATORS

---

ONE-LINE MEMORY AID

Painless haematuria = bladder/renal Ca. Painful = stone/infection. Adult + flank mass = RCC (VHL, polycythaemia, varicocele). Child + abdominal mass = Wilms (don't palpate!). Smoker + dye worker + haematuria = bladder TCC → cystoscopy.

---