Lichenstein hernioplasty Herniotomy of congenital hernia Repair of gas

Lichenstein hernioplasty Herniotomy of congenital hernia Repair of gastric perforation Laparoscopic cholecystectomy Open cholecystectomy Open appendicectomy Eversion of sac Closure of Ileostomy Circumcission Enucleation of fibroadenoma Operation steps for viva

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These are best prepared as separate operative-viva topics:

Lichtenstein tension-free mesh hernioplasty
Herniotomy for congenital inguinal hernia
Primary repair of gastric perforation with omental patch
Laparoscopic cholecystectomy
Open cholecystectomy
Open appendicectomy
Eversion of sac for hydrocele
Ileostomy closure
Circumcision
Enucleation of fibroadenoma

For each, a strong viva answer should follow the same sequence:

Indications and contraindications
Anaesthesia and patient position
Skin incision and relevant anatomy
Stepwise operative procedure
Specimen, drains, and closure
Postoperative care
Complications and their prevention

Which procedure would you like first? I can give it in a concise, examiner-ready format with the exact operative steps and common viva questions.

Explain all 10 operations in concise viva format

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This is a full operative-surgery viva set. I can cover each in the same concise pattern: indication - preparation - incision/approach - key steps - closure - complications.

Lichtenstein tension-free mesh hernioplasty
Herniotomy for congenital inguinal hernia
Repair of gastric perforation with omental patch
Laparoscopic cholecystectomy
Open cholecystectomy
Open appendicectomy
Eversion of sac for hydrocele
Closure of ileostomy
Circumcision
Enucleation of fibroadenoma

Brief high-level distinction:

Hernia operations: identify sac, protect cord structures, deal with sac, then reinforce posterior wall in adults when indicated.
Emergency abdominal operations: access, identify pathology, control contamination, repair or remove diseased organ, washout, and close safely.
Stoma closure: mobilize bowel, restore continuity, ensure a tension-free well-perfused anastomosis, and close the abdominal wall.
Minor scrotal/breast procedures: careful plane dissection, haemostasis, preservation of important structures, and cosmetic closure.

Which topic should I expand first in examiner-ready operative steps?

Give all 10 operations as concise stepwise viva answers

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1. Lichtenstein tension-free mesh hernioplasty

Indication: Primary or recurrent uncomplicated adult inguinal hernia.

Steps

Supine position, spinal or general anaesthesia, antisepsis and draping.
Make an oblique inguinal incision just above and parallel to the inguinal ligament.
Divide subcutaneous tissue and expose the external oblique aponeurosis.
Open the external oblique in line with its fibres to expose the inguinal canal.
Mobilise the spermatic cord with a sling. Identify and preserve the ilioinguinal nerve where possible.
Identify the hernia sac.
- Indirect sac: dissect from cord structures, open to check contents, reduce contents, transfix and ligate sac high at neck, then excise excess sac.
- Direct sac: reduce/invert it; usually no high ligation needed.
Place a flat polypropylene mesh over the posterior wall. Suture medially to pubic tubercle and inferiorly to inguinal ligament.
Split the lateral mesh end into two tails, pass cord through the slit, overlap tails around the cord and fix laterally, creating a new deep ring without constriction.
Ensure haemostasis. Close external oblique over mesh, then Scarpa's fascia and skin.

Important viva points: Avoid injury to ilioinguinal, iliohypogastric and genital branch of genitofemoral nerves; avoid mesh fixation too lateral or too tight around the cord.
Complications: Seroma, haematoma, wound/mesh infection, chronic groin pain, recurrence, testicular ischaemia.

2. Herniotomy for congenital inguinal hernia

Principle: In children, repair is by high ligation of the patent processus vaginalis. Posterior-wall mesh repair is not required.

Steps

Supine position under general anaesthesia.
Make a short transverse skin-crease incision over the inguinal canal.
Divide subcutaneous tissue and expose external oblique aponeurosis.
Open external oblique and identify the spermatic cord.
Carefully identify the thin hernial sac anteromedial to the cord.
Separate the sac from vas deferens and testicular vessels by gentle dissection.
Open the sac, check and reduce contents into abdomen.
Dissect sac proximally up to the deep inguinal ring.
Transfix/ligate the sac at its neck with absorbable suture and excise distal sac. Do not unnecessarily dissect distal sac into scrotum.
Return cord to canal and close external oblique, subcutaneous tissue and skin.

Complications: Injury to vas deferens or testicular vessels, testicular atrophy, recurrence, haematoma, wound infection, hydrocele.

3. Repair of gastric perforation with omental patch

Common indication: Perforated peptic ulcer with peritonitis.

Steps

Resuscitate first: IV fluids, nasogastric decompression, urinary catheter, broad-spectrum antibiotics, proton-pump inhibitor and blood grouping/cross-match.
Under general anaesthesia, perform upper midline laparotomy.
Suction contaminated peritoneal fluid and take sample for culture if indicated.
Identify the perforation, commonly on anterior first part of duodenum or prepyloric stomach.
Assess size, margins and gastric location. Take an edge biopsy for a gastric ulcer, especially if suspicious for malignancy.
Freshen only if needed. Insert 3 or 4 interrupted absorbable seromuscular sutures across the perforation, leaving ends untied initially.
Bring a tongue of healthy greater omentum over the perforation. Tie sutures over the omentum to form a Graham omental patch.
Perform thorough warm saline lavage of all peritoneal recesses.
Check haemostasis. Place drain selectively, according to contamination and local practice.
Close abdominal wall in layers.

Complications: Leak, intra-abdominal abscess, wound infection, sepsis, ileus, recurrent ulcer disease.
Postoperative point: Test and treat H. pylori and avoid NSAIDs where possible.

4. Laparoscopic cholecystectomy

Indication: Symptomatic gallstones, acute cholecystitis after appropriate optimisation, gallstone pancreatitis after recovery, gallbladder polyps in selected cases.

Steps

General anaesthesia. Supine position, legs together or split-leg according to surgeon preference. Give prophylactic antibiotic if indicated.
Create pneumoperitoneum, usually through infraumbilical access.
Insert ports: camera at umbilicus, epigastric working port, and two right subcostal ports.
Inspect abdomen. Position patient head-up and left-side-down.
Grasp gallbladder fundus and retract upwards; retract Hartmann's pouch laterally and inferiorly.
Dissect peritoneum over Calot's/hepatocystic triangle.
Obtain the critical view of safety:
- Clear hepatocystic triangle of fat and fibrous tissue.
- Separate lower one-third of gallbladder from liver bed.
- See only two structures entering gallbladder: cystic duct and cystic artery.
Clip and divide cystic artery and cystic duct. If anatomy is uncertain, stop, use cholangiography/other imaging if available, or perform a safe bailout such as subtotal cholecystectomy.
Dissect gallbladder off liver bed using electrocautery, controlling bleeding and preventing bile spillage.
Retrieve gallbladder in a bag through umbilical or epigastric port.
Inspect for bleeding or bile leak, irrigate if required, remove ports under vision and close fascial defect of larger port.

Complications: Bile duct injury, bleeding, bowel injury, bile leak, retained stones, port-site infection, conversion to open surgery.

5. Open cholecystectomy

Steps

General anaesthesia. Supine position with slight reverse Trendelenburg.
Make a right subcostal Kocher incision or upper midline incision.
Enter peritoneum and pack off surrounding viscera.
Expose gallbladder; aspirate it if tense.
Retract fundus and Hartmann's pouch.
Dissect Calot's/hepatocystic triangle carefully and identify cystic duct and cystic artery.
Ligate and divide cystic artery.
Ligate cystic duct securely and divide it. If duct anatomy is unclear, do not divide blindly.
Separate gallbladder from liver bed, commonly from neck to fundus, with ligation/coagulation of small vessels.
Inspect liver bed and cystic duct stump for bleeding and bile leakage.
Irrigate, place a drain only if indicated, and close abdomen in layers.

Viva point: In a difficult or unsafe Calot's triangle, a subtotal cholecystectomy is safer than risking common bile duct injury.
Complications: Haemorrhage, bile leak, common bile duct injury, retained stones, subhepatic collection, wound infection.

6. Open appendicectomy

Steps

General anaesthesia. Supine position. Give antibiotic prophylaxis/therapy as appropriate.
Make a gridiron incision at McBurney's point or a Lanz transverse incision.
Divide subcutaneous tissue and external oblique aponeurosis in the direction of its fibres.
Split internal oblique and transversus muscle fibres.
Open transversalis fascia and peritoneum carefully.
Deliver caecum into wound and identify appendix by following the three taeniae coli to its base.
Mobilise appendix. Divide and ligate mesoappendix, securing appendicular artery.
Crush and ligate appendix base with absorbable suture, then divide appendix.
Mucosal cauterisation and stump inversion may be performed selectively, but simple secure ligation is generally adequate.
Inspect for perforation, pus, abscess or alternative pathology. Suction and irrigate if contamination exists.
Close peritoneum/muscle layers as appropriate, external oblique aponeurosis, subcutaneous tissue and skin. In dirty wounds, consider delayed or loose skin closure as locally practised.

Complications: Wound infection, intra-abdominal abscess, stump leak, faecal fistula, adhesive intestinal obstruction.

7. Eversion of sac for hydrocele - Jaboulay procedure

Indication: Large vaginal hydrocele in an adult.

Steps

Supine position under spinal, general or local anaesthesia as suitable.
Make a transverse or longitudinal incision over the affected hemiscrotum.
Divide layers of scrotum until tunica vaginalis is exposed.
Deliver hydrocele sac with testis into wound.
Aspirate fluid if the sac is tense.
Incise tunica vaginalis anteriorly, avoiding testis and epididymis.
Inspect testis, epididymis and sac for any suspicious lesion.
Evert the parietal layer of tunica vaginalis behind the testis and epididymis.
Approximate everted edges behind the cord using interrupted absorbable sutures, without constricting cord structures.
Secure haemostasis, replace testis in scrotum, place drain only selectively, and close dartos and skin.

Viva point: For a small thin-walled hydrocele, Lord's plication may be preferred; for a thick large sac, eversion/excision is suitable.
Complications: Haematoma, infection, recurrence, testicular injury, chronic scrotal swelling.

8. Closure of loop ileostomy

Steps

Confirm patient is fit: nutritional optimisation, stoma assessment, and confirmation of distal bowel/anastomosis integrity as indicated.
General anaesthesia. Protect the stoma with a purse-string suture or occlusive dressing before preparation.
Make a circumferential incision at the mucocutaneous junction around the stoma.
Deepen through subcutaneous tissue and carefully free both bowel limbs from abdominal wall, avoiding enterotomy.
Deliver enough proximal and distal ileum to assess viability and ensure tension-free anastomosis.
Excise scarred stoma edges and any unhealthy bowel.
Restore bowel continuity by hand-sewn end-to-end/functional end-to-end anastomosis or stapled anastomosis.
Check anastomosis for adequate blood supply, no tension, good lumen and haemostasis. Return bowel to abdomen.
Close fascial defect securely with delayed absorbable or non-absorbable sutures as local policy.
Irrigate wound. Skin may be closed by purse-string or left partially open to reduce surgical-site infection.

Complications: Anastomotic leak, ileus, bowel obstruction, wound infection, enterocutaneous fistula, incisional hernia.

9. Circumcision

Indications: Pathological phimosis, balanitis xerotica obliterans, recurrent balanoposthitis, recurrent urinary infections in selected cases, or cultural/religious reasons.

Steps

Confirm indication and exclude contraindications such as hypospadias, epispadias, chordee, buried penis, micropenis or bleeding disorder.
General anaesthesia in children or local/regional anaesthesia where suitable. Perform penile/ring block if appropriate.
Retract prepuce gently and release adhesions. Inspect glans and meatus.
Mark intended line of excision, ensuring adequate skin is retained to avoid a tight penile skin closure.
Make a circumferential outer skin incision and an inner preputial mucosal incision.
Excise the intervening preputial sleeve.
Achieve meticulous haemostasis, especially at frenular vessels.
Approximate mucosal and skin edges with fine absorbable sutures.
Apply paraffin gauze/light dressing, avoiding a constrictive bandage.

Complications: Bleeding, infection, excessive or inadequate skin removal, meatal stenosis, glans/urethral injury, poor cosmetic result.
Viva point: Do not circumcise when hypospadias is present because the prepuce may be required for reconstruction.

10. Enucleation of fibroadenoma

Indication: Symptomatic, enlarging, large, atypical, or diagnosis-uncertain breast lump after appropriate triple assessment.

Steps

Confirm benign diagnosis as far as possible by clinical examination, imaging and needle biopsy when indicated. Obtain consent, including scar and contour deformity risk.
General anaesthesia or local anaesthesia for selected

Enucleation of fibroadenoma

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Enucleation of fibroadenoma - concise operative viva answer

Definition: Surgical removal of a fibroadenoma by shelling it out intact from its surrounding compressed breast tissue pseudocapsule.

Indications

Symptomatic lump or patient anxiety
Increasing size
Large lesion, often >3 cm
Suspicion of phyllodes tumour or diagnosis not secure on triple assessment
Cosmetic deformity due to the lump
Patient preference after counselling

Preoperative preparation

Confirm triple assessment: clinical examination, imaging, and core-needle biopsy where indicated.
Mark the lump and plan a cosmetically favourable incision, usually circumareolar or in a skin crease directly over the lesion.
Obtain consent for scar, haematoma, infection, contour defect, altered nipple sensation, and need for further surgery if histology differs.
Supine position, ipsilateral arm abducted, general or local anaesthesia depending on lesion and patient factors.
Antibiotic prophylaxis only when indicated by local policy.

Operative steps

Prepare and drape the breast.
Infiltrate local anaesthetic with adrenaline if appropriate.
Make a small curvilinear circumareolar incision or incision over the lump, preferably along Langer's lines.
Deepen through subcutaneous tissue using sharp dissection and cautery, maintaining good haemostasis.
Identify the fibroadenoma, which is typically a well-defined, mobile, encapsulated mass.
Incise the breast tissue over the lesion, avoiding unnecessary removal of normal breast tissue.
Develop the plane between the lesion pseudocapsule and surrounding breast tissue using blunt dissection or swab dissection.
Gently enucleate the fibroadenoma intact. Avoid rupturing the lesion.
Send the specimen for histopathological examination, with correct labelling.
Inspect the cavity for residual lesion and secure meticulous haemostasis.
Irrigate if needed. A drain is rarely required unless the cavity is large or haemostasis is doubtful.
Re-approximate breast tissue if there is a significant cavity to minimise contour deformity.
Close subcutaneous tissue with absorbable sutures and skin with subcuticular absorbable sutures or skin adhesive.
Apply sterile dressing and supportive bra.

Postoperative care

Analgesia and wound-care advice.
Review histopathology.
Advise the patient to return for fever, increasing pain, swelling, discharge, or rapidly enlarging breast.

Complications

Haematoma or seroma
Wound infection
Scar or keloid
Breast contour depression/asymmetry
Altered nipple or skin sensation
Recurrence or a new fibroadenoma
Unexpected phyllodes tumour or malignancy on histology, requiring further management

Common viva questions

Why is it called enucleation?
Because the lump is shelled out through the natural plane around its pseudocapsule, preserving surrounding normal breast tissue.

Why send the specimen for histopathology?
To confirm fibroadenoma and exclude phyllodes tumour or another unexpected pathology.

What is the differential diagnosis?
Phyllodes tumour, breast cyst, hamartoma, lipoma, carcinoma, and focal fibroadenosis.

What finding makes you suspect phyllodes tumour?
Rapid growth, a large lesion, recurrence, or discordance between clinical/imaging findings and biopsy. Phyllodes tumour requires wide local excision with clear margins, not simple enucleation.

Create a one-page operative surgery revision table

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Operative Surgery Viva - One-Page Revision Table

Operation	Key indication	Incision/approach	Essential operative steps	Key viva point / complications
Lichtenstein hernioplasty	Adult inguinal hernia	Oblique inguinal incision	Open canal - mobilise cord - deal with indirect sac by high ligation or reduce direct sac - place flat polypropylene mesh over posterior wall - fix to pubic tubercle/inguinal ligament - create new deep ring around cord - close external oblique	Tension-free mesh repair. Protect ilioinguinal nerve. Complications: seroma, chronic pain, recurrence, mesh infection, testicular ischaemia.
Herniotomy for congenital hernia	Paediatric indirect inguinal hernia / patent processus vaginalis	Short transverse inguinal crease incision	Open canal - identify sac - separate carefully from vas and testicular vessels - reduce contents - high ligation at deep ring - excise excess sac - close	No mesh or posterior-wall repair in children. Avoid injury to vas and testicular vessels.
Gastric/duodenal perforation repair	Perforated peptic ulcer with peritonitis	Upper midline laparotomy	Resuscitation and antibiotics - suction contamination - locate perforation - biopsy gastric ulcer edge - interrupted sutures across defect - tie over healthy omental patch - copious lavage - selective drain - close	Graham omental patch. Complications: leak, abscess, sepsis, wound infection. Treat H. pylori postoperatively.
Laparoscopic cholecystectomy	Symptomatic gallstones, cholecystitis	Four-port laparoscopy	Pneumoperitoneum - expose fundus and Hartmann pouch - dissect hepatocystic triangle - obtain critical view of safety - clip/divide cystic artery and duct - dissect gallbladder from liver bed - retrieve in bag	Critical view: only cystic duct and artery enter gallbladder. If anatomy unclear, use bailout/subtotal procedure. Complication: bile duct injury.
Open cholecystectomy	Difficult laparoscopy, conversion, selected complex disease	Right subcostal Kocher or upper midline incision	Expose gallbladder - retract fundus/Hartmann pouch - define cystic duct and artery - ligate/divide artery and duct - remove gallbladder from liver bed - inspect for bile leak/bleeding	Never divide an uncertain structure. Subtotal cholecystectomy is safer in hostile Calot's triangle.
Open appendicectomy	Acute appendicitis, perforated appendix where open surgery selected	Gridiron or Lanz incision	Split muscle fibres - enter peritoneum - identify caecum and follow taeniae to appendix - ligate mesoappendix - ligate/divide appendix at base - lavage if contamination - close	Secure appendicular artery in mesoappendix. Complications: wound infection, intra-abdominal abscess, stump leak, adhesions.
Eversion of hydrocele sac - Jaboulay	Large adult vaginal hydrocele	Scrotal incision	Deliver sac/testis - aspirate fluid if tense - open tunica vaginalis - inspect testis - evert sac behind testis - suture everted edges - haemostasis - close	Do not injure testis, epididymis or spermatic cord. Complications: haematoma, infection, recurrence.
Ileostomy closure	Temporary loop ileostomy after distal healing confirmed	Circumstomal incision	Circumferential dissection - mobilise both bowel limbs - release adhesions - resect unhealthy stoma edges - hand-sewn or stapled tension-free anastomosis - return bowel - close fascia - purse-string/partial skin closure	Check perfusion, lumen and tension before completing anastomosis. Complications: leak, ileus, obstruction, wound infection, incisional hernia.
Circumcision	Pathological phimosis, BXO, recurrent balanoposthitis	Circumferential preputial incision	Retract foreskin and inspect glans/meatus - release adhesions - mark skin - excise preputial sleeve - meticulous frenular haemostasis - suture mucosa to skin with absorbable sutures - light dressing	Exclude hypospadias, epispadias and chordee first. Complications: bleeding, meatal stenosis, excessive skin removal, glans injury.
Enucleation of fibroadenoma	Enlarging, symptomatic, large, uncertain or cosmetically problematic fibroadenoma	Circumareolar or skin-crease incision over lesion	Triple assessment - incision - dissect to lump - open breast tissue over lesion - develop plane around pseudocapsule - shell out lump intact - haemostasis - send for histopathology - layered cosmetic closure	Enucleation preserves normal breast tissue. Consider phyllodes tumour if rapidly growing/large: it requires wide local excision, not simple enucleation.

Universal viva closing line

“Before incision, I confirm identity, procedure, site and consent; administer appropriate anaesthesia, antibiotic prophylaxis and thromboprophylaxis where indicated; use the WHO surgical safety checklist; ensure haemostasis, correct swab/instrument count, specimen labelling, and clear postoperative instructions.” The WHO checklist guidance supports these perioperative safety checks.

Short case presentation on T tube

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Short Case Presentation: T-tube in situ

“On examination, this patient has a T-tube drain in the right upper quadrant. It is a tube shaped like the letter T, placed through a choledochotomy into the common bile duct. The long limb comes out through the abdominal wall and is connected to a sterile drainage bag containing bile-stained fluid.

The likely indication is after common bile duct exploration for choledocholithiasis, especially after removal of CBD stones, or following repair of a bile duct injury.

Its purposes are to:

Decompress the biliary tree and allow external bile drainage.
Protect the choledochotomy or bile-duct repair while it heals.
Permit postoperative T-tube cholangiography to check duct patency, distal flow into the duodenum, residual stones, and bile leak.
Provide access for postoperative removal of retained stones in selected cases.

I would inspect the amount, colour and nature of bile, ensure that the tube is not kinked or blocked, check the dressing and surrounding skin, and look for fever, jaundice, abdominal pain, bilious leak, dehydration, or features of cholangitis.

Before removal, a T-tube cholangiogram is usually performed according to the unit protocol. The tube should not be removed until satisfactory duct drainage is confirmed and a mature tract has formed. Removal must be gentle, because premature dislodgement or removal can cause bile leak and biliary peritonitis.”

Common viva questions

Question	Answer
What is a T-tube?	A soft latex, silicone, or rubber tube shaped like a T, inserted into the CBD through a choledochotomy.
Where are its limbs placed?	The transverse limb lies inside the CBD, with one limb directed proximally and one distally; the long limb exits through the abdominal wall.
What are indications?	After open CBD exploration and stone extraction, uncertain duct clearance, oedematous distal CBD, difficult biliary drainage, or selected bile-duct repairs.
Why is it less commonly used now?	In suitable patients, primary CBD closure or internal drainage may avoid T-tube-related morbidity. A 2025 systematic review compared primary closure with T-tube drainage after CBD exploration (PubMed 40323738).
What is normal drainage?	Bile-stained output that should be measured and trended. Sudden cessation may suggest blockage or kinking; very high output can cause fluid and electrolyte loss.
Complications?	Bile leak after removal or dislodgement, biliary peritonitis, tube blockage, cholangitis, accidental displacement, fluid/electrolyte loss, skin excoriation, retained stones, and tract infection.
What if output suddenly stops?	Assess the patient for pain, fever and jaundice; inspect for kinking, dependent drainage and blockage. Do not forcefully flush unless specifically directed by the operating team.
What if output is high?	Monitor volume, hydration, urine output and electrolytes; replace losses and seek senior surgical review.
What if the tube comes out accidentally?	Cover the site with a sterile dressing, keep patient nil by mouth if unwell, assess urgently for bile leak/peritonitis, and inform the surgical team. Do not attempt blind reinsertion.

Presentation conclusion:
“My provisional diagnosis is a postoperative patient with a T-tube in situ following CBD exploration or bile-duct repair. I would review the operation notes, daily drain chart, liver function tests, imaging/cholangiogram plan, and monitor closely for bile leak, obstruction, cholangitis and electrolyte disturbance.”

A T-tube may be used after CBD exploration and stone retrieval or after repair of a damaged CBD, as described in Bailey and Love's Short Practice of Surgery, 28th ed., section “T-tube drains.”

Case presentation on T tube

Case Presentation: T-tube in situ

“Sir/Ma'am, I am presenting a postoperative patient with a T-tube in situ.

On general examination, I would assess the patient’s vitals and look for pallor, icterus, dehydration, fever, or features of sepsis.

On abdominal examination, there is a right upper abdominal operative scar, usually a right subcostal or upper midline scar. A T-tube is seen emerging through the right hypochondrium, connected to a sterile drainage bag. The bag contains bile-stained fluid. I would note the amount and character of drainage, and inspect the tube for kinking, blockage, displacement, and leakage around the exit site.

The abdomen should be examined for right hypochondrial tenderness, guarding, rigidity, distension, wound infection, or any collection. I would also assess bowel sounds and examine for signs of cholangitis or biliary obstruction.

A T-tube is a T-shaped tube inserted into the common bile duct through a choledochotomy. Its transverse limb lies in the CBD, while the long limb is brought out through the abdominal wall for external drainage.

The probable indication in this patient is after open common bile duct exploration and removal of CBD stones, or less commonly after repair of a common bile duct injury.

The functions of the T-tube are:

To decompress the biliary tree.
To provide controlled external drainage of bile.
To protect the choledochotomy or bile-duct repair during healing.
To allow a postoperative T-tube cholangiogram.
To allow access for management of retained CBD stones in selected cases.

I would review the operative notes, daily drain chart, liver function tests, ultrasound or MRCP/ERCP findings if available, and the plan for T-tube cholangiography.

Before removal, cholangiography is usually done according to the surgical unit protocol to demonstrate free flow of contrast into the duodenum, absence of residual stones, and no bile leak. The tube should be removed only after an adequate tract has formed and the operating team is satisfied that duct drainage is normal.

The important complications are tube blockage, kinking, displacement, cholangitis, high-output bile loss causing dehydration and electrolyte imbalance, bile leak after removal, biliary peritonitis, retained CBD stones, and skin excoriation at the exit site.

My diagnosis is: postoperative status following common bile duct exploration or CBD repair, with a T-tube in situ for biliary decompression and postoperative cholangiography.”

Examiner questions

Question	Answer
What is a T-tube?	A T-shaped tube placed in the common bile duct through a choledochotomy.
What are the common indications?	CBD exploration after stone extraction, uncertain duct clearance, difficult biliary drainage, and selected CBD repairs.
What are the two main uses?	Biliary decompression and postoperative cholangiography.
What would a sudden fall in bile output suggest?	Kinking, blockage, displacement, or internal drainage. Assess the patient for pain, fever, and jaundice.
What would you do if the T-tube is accidentally dislodged?	Inform the surgical team urgently, cover the site with a sterile dressing, assess for bile leak/peritonitis, and do not attempt blind reinsertion.
Why is T-tube use less frequent now?	In selected patients after CBD exploration, primary duct closure or internal drainage can avoid T-tube-related complications.

A T-tube may be used after CBD exploration with stone retrieval or after repair of a damaged CBD, as described in Bailey and Love's Short Practice of Surgery, 28th ed., section “T-tube drains.”

Case presentation on t tube

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Case presentation on pigtail in liver abscess

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Short Case Presentation: Pigtail Catheter in Liver Abscess

“Sir/Ma'am, I am presenting a patient with a percutaneous pigtail catheter in situ for drainage of a liver abscess.

On general examination, I would assess pulse, blood pressure, temperature, respiratory rate, hydration, pallor, icterus, and features of sepsis.

On abdominal examination, there is a pigtail catheter entering through the right upper abdomen or right lower chest, secured to the skin and connected to a closed drainage bag. The drain contains purulent or altered brown, sometimes anchovy-sauce-like material. I would record the daily quantity, colour, consistency, odour and any sudden decrease in output. I would check that the tube is not kinked, blocked, leaking or displaced, and inspect the insertion site for redness, tenderness, discharge or cellulitis.

The abdomen may show right hypochondrial tenderness, hepatomegaly, guarding, or features of an intercostal pleural complication. I would also examine the chest, particularly the right lower zone, for pleural effusion or empyema.

My provisional diagnosis is: liver abscess, likely pyogenic or amoebic, managed with image-guided percutaneous pigtail catheter drainage and appropriate antimicrobial treatment.”

What is a pigtail catheter?

It is a flexible, small-bore drainage catheter with a curled distal end. The curl keeps the catheter within the abscess cavity and reduces accidental dislodgement. It is inserted percutaneously under ultrasound or CT guidance.

Indications for pigtail drainage

Large, liquefied liver abscess
Persistent fever, sepsis or pain despite antimicrobial treatment
Failure of needle aspiration or recurrence after aspiration
Thick pus needing continuous drainage
Impending or actual rupture
Left-lobe abscess, due to risk of rupture into pericardium
Abscess producing pressure symptoms or complications

Principles of management

Resuscitate if septic and send blood tests.
Confirm diagnosis with ultrasound or contrast CT abdomen.
Aspirate pus for Gram stain, culture and sensitivity.
Give antibiotics for pyogenic liver abscess, tailored to culture results.
If amoebic abscess is suspected, give antiamoebic treatment, usually metronidazole, with a luminal agent as appropriate.
Perform image-guided aspiration or pigtail drainage when indicated.
Monitor clinical improvement, drain output, inflammatory markers, liver function, and serial imaging.

Percutaneous aspiration or catheter drainage with antimicrobial therapy is now the usual first-line approach, rather than operative drainage, for suitable liver abscesses. Fischer's Mastery of Surgery, 8th ed., section on liver abscess management.

Investigations to mention

Complete blood count: usually leukocytosis
Liver function tests, renal function, electrolytes
Blood culture before antibiotics if possible
Pus culture and sensitivity
Ultrasound abdomen
Contrast-enhanced CT if diagnosis, extent, loculations, or complications are unclear
Amoebic serology where epidemiologically appropriate
Search for source in pyogenic abscess: biliary obstruction/cholangitis, portal infection, diabetes, malignancy, or cryptogenic causes

Drain care

Keep the drainage system closed, dependent, clean, and securely fixed.
Measure and chart output daily.
Do not clamp, flush, manipulate, or remove it without the treating team's instruction.
Monitor for pain, fever, jaundice, worsening abdominal tenderness, leakage or sudden loss of output.
Repeat imaging guides decisions on catheter repositioning or removal.

Complications

Catheter blockage, kinking or displacement
Bleeding or intrahepatic haematoma
Bile leak
Secondary infection or persistent sepsis
Injury to pleura causing pleural effusion, pneumothorax, or empyema, especially with an intercostal route
Peritonitis due to leak or rupture
Incomplete drainage, residual cavity, or recurrence
Rarely, septic shock or fistula formation

Common viva questions

Question	Answer
What organisms cause pyogenic liver abscess?	Enteric Gram-negative bacilli such as E. coli and Klebsiella, streptococci, anaerobes, and sometimes polymicrobial infection.
How does amoebic pus look?	Classically thick brown “anchovy-sauce” material, usually odourless and often sterile on bacterial culture.
What is the commonest lobe involved?	Right lobe of the liver.
Why is the pigtail curled?	It anchors the catheter inside the cavity and helps prevent displacement.
What if drain output suddenly stops?	Check for kinking, blockage or displacement; assess the patient clinically and arrange imaging/surgical or interventional radiology review. Do not force flushing unless instructed.
What if there is fever despite drainage?	Consider blocked or malpositioned catheter, residual loculations, resistant organism, an untreated biliary source, another abscess, or a non-pyogenic diagnosis.
When is surgery needed?	Failure or impossibility of percutaneous drainage, rupture with peritonitis, associated surgical pathology, or inaccessible/multiloculated abscess not amenable to image-guided treatment.

Closing sentence:
“I would review the imaging to determine abscess size, lobe, loculations and catheter position; review culture results and antibiotic sensitivity; monitor sepsis and drain output; and remove the pigtail only after clinical recovery and imaging-confirmed resolution or adequate collapse of the cavity.”

Recent systematic reviews compare catheter drainage with needle aspiration for liver abscess, including PubMed 40958348 and PubMed 42743010.

Case presentation on ICD

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chest tube drainage complications

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British Thoracic Society pleural procedures statement chest drain insertion safety triangle

Short Case Presentation: ICD in situ

“Sir/Ma'am, I am presenting a patient with an intercostal chest drain, or ICD, in situ.

On general examination, I would assess airway, respiratory distress, pulse, blood pressure, respiratory rate, oxygen saturation, temperature, cyanosis, pallor, and signs of sepsis.

On inspection of the chest, an ICD is seen entering the pleural cavity, usually in the safe triangle on the lateral chest wall. It is secured by a suture and connected through airtight tubing to an underwater-seal drainage system. I would confirm that the bottle is kept below the level of the chest and remains upright.

I would inspect:

The insertion site for bleeding, erythema, discharge, subcutaneous emphysema, or air leak.
The tube for kinking, dependent loops, disconnection, clamping, blockage, or accidental displacement.
The drainage bottle for the amount and nature of fluid: blood, pus, serous fluid, or chyle.
Swinging of fluid with respiration and bubbling in the water seal.

On palpation, I would check for tracheal position, chest expansion, tactile vocal fremitus, local tenderness, and surgical emphysema. On percussion and auscultation, I would assess for residual pneumothorax, pleural effusion, haemothorax, or lung collapse. I would also inspect the chest radiograph to confirm drain position and lung expansion.

My provisional diagnosis is: a patient with an intercostal chest drain in situ for pleural drainage, most likely for pneumothorax, pleural effusion, empyema, haemothorax, or postoperative thoracic drainage.”

What is an ICD?

An ICD is a tube inserted into the pleural cavity to drain air, blood, pus, fluid, or chyle, allowing lung re-expansion and prevention of recurrent pleural collection.

Common indications

Condition	Purpose of ICD
Pneumothorax	Drain air and allow lung re-expansion
Tension pneumothorax	Definitive drainage after immediate needle/finger decompression
Haemothorax	Drain blood and quantify ongoing bleeding
Empyema	Drain infected pleural pus
Large symptomatic pleural effusion	Drain fluid, often image-guided
Chylothorax	Drain chyle and monitor loss
After thoracic surgery	Drain air and postoperative fluid

Safe triangle

The safe triangle is bounded by:

Anteriorly: lateral border of pectoralis major
Posteriorly: anterior border of latissimus dorsi
Inferiorly: fifth intercostal space or horizontal line at nipple level
Superiorly: base of axilla

The drain is inserted just above the upper border of the rib to avoid the intercostal neurovascular bundle, which lies along the inferior border of the rib.

Drain observations

Finding	Interpretation
Swinging/tidaling	Usually indicates a patent drain communicating with pleural space.
No swinging	May mean lung has re-expanded, or drain is blocked, kinked, clamped, or displaced. Assess clinically and with imaging.
Bubbling only on coughing/expiration	May occur with residual pneumothorax or small air leak.
Continuous bubbling	Suggests a persistent air leak from lung or a leak/disconnection in the drainage system. Check tubing and connections first.
Sudden large bloody output	Consider ongoing intrathoracic bleeding. Urgent surgical review is needed.
Purulent output	Suggests empyema. Send sample for Gram stain, culture and sensitivity.

Important precautions

Keep the bottle below chest level.
Ensure all connections are airtight.
Do not routinely clamp a drain, especially if there is an air leak or pneumothorax.
Do not strip or milk the tube routinely.
Do not remove a displaced drain or attempt reinsertion blindly. Cover the site with an occlusive sterile dressing and seek urgent senior help.
Request chest imaging after insertion and before removal, as clinically appropriate.

Complications

Pain, bleeding, and intercostal vessel injury
Tube blockage, kinking, dislodgement, or malposition
Persistent air leak
Subcutaneous emphysema
Infection at insertion site or empyema
Lung laceration
Diaphragmatic, abdominal-organ, cardiac, or mediastinal injury
Re-expansion pulmonary oedema
Failure to resolve pneumothorax or pleural collection

Common viva questions

What does bubbling indicate?
Bubbling indicates air passing through the water seal. Intermittent bubbling may occur with a pneumothorax, while continuous bubbling suggests either a persistent pleural air leak or a leak in the drain system.

What do you do if bubbling suddenly stops?
First inspect the entire system for kinking, clamping, blockage, disconnection, or a full water-seal chamber. Then assess the patient for respiratory distress and obtain imaging if required.

What do you do if the drain disconnects from the bottle?
Reconnect promptly using aseptic technique if possible. If reconnection is delayed, place the tube end in sterile water to restore a temporary water seal and call for assistance.

What do you do if the drain comes out of the chest?
Immediately cover the wound with a sterile occlusive dressing, assess the patient for respiratory compromise or tension pneumothorax, give oxygen, and call for urgent medical/surgical review.

When can an ICD be removed?
When the clinical indication has resolved: lung is expanded and there is no significant air leak for pneumothorax, or drainage is minimal with resolution of the fluid collection. The decision is based on the patient, drain findings, and imaging.

Closing statement:
“I would check the indication and date of insertion, drain output chart, air-leak status, chest radiograph, microbiology if fluid is infected, and the plan for suction, clamping if specifically indicated, and removal.”

The BTS pleural-procedure guidance recommends using imaging to select the insertion site and placing drains laterally in the safe triangle, directly above a rib.

Post burn contracture case presentation

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burn scar contracture assessment management guideline rehabilitation

Short Case Presentation: Post-burn Contracture

“Sir/Ma’am, I am presenting a patient with a post-burn scar contracture involving the ______ region, causing functional limitation.

The patient has a history of flame/scald/electrical burn ___ months or years ago, following which the wound healed by secondary intention or after skin grafting. Subsequently, the patient developed progressive tightening of the scar and restriction of movement.

On general examination, I would assess nutritional status, pallor, associated burn scars, and psychological impact.

On local examination, there is a mature scar over the ______ region. I would describe:

Site and extent of the scar
Colour and character: hypertrophic, hyperpigmented/hypopigmented, supple or adherent
Type of contracture: linear band, broad scar, webbing, or joint contracture
Joint position and deformity
Range of movement: active and passive, measured and compared with the opposite side
Involvement of skin, subcutaneous tissue, fascia, tendon, muscle, joint, nerve, or vessel
Distal neurovascular status
Functional loss in activities of daily living
Any ulceration, recurrent breakdown, infection, or suspicious non-healing area

I would also examine adjacent joints and other burn scars, as multiple contractures may coexist.

My provisional diagnosis is: mature post-burn scar contracture of the ______ region causing ______ functional deformity.”

Important examples of deformities

Site	Typical deformity
Neck	Mentosternal contracture with inability to extend neck
Axilla	Adduction contracture with difficulty abducting arm
Elbow	Flexion contracture
Hand	Clawing, web-space contracture, flexion contracture of fingers
Hip	Flexion and adduction contracture
Knee	Flexion contracture
Ankle	Equinus deformity
Face	Ectropion, microstomia, oral commissure contracture

What is a post-burn contracture?

It is shortening and tightening of scarred skin and underlying soft tissues after a burn, producing restricted movement or deformity. It is more common after deep partial-thickness or full-thickness burns, delayed healing, inadequate grafting, poor positioning, and inadequate physiotherapy.

Management

Non-operative management

Appropriate for early, mild, or immature contractures:

Physiotherapy with active and passive range-of-motion exercises
Anti-contracture positioning
Static or dynamic splintage
Serial casting where appropriate
Scar massage and moisturisation
Pressure garments for hypertrophic scars
Occupational therapy and functional rehabilitation

Operative management

Indicated for established contracture with significant functional limitation, progressive deformity, recurrent ulceration, or major cosmetic/psychosocial impact.

Principles of surgery

Release the scar completely until full movement is restored.
Assess the resulting defect and exposure of tendons, nerves, vessels, or joint.
Cover the defect with the best reconstructive option.
Begin early postoperative splintage and physiotherapy to prevent recurrence.

Reconstructive choices

Contracture / defect	Usual reconstruction
Linear band with adequate surrounding pliable skin	Z-plasty, multiple Z-plasty, V-Y plasty
Small superficial defect after release	Full-thickness skin graft preferred where feasible
Large defect	Split-thickness skin graft, often meshed
Exposed tendon, bone, joint, nerve, or vessel	Local, regional, pedicled, or free flap
Severe recurrent joint contracture	Flap coverage often provides more durable release than graft alone

Full-thickness skin grafts generally contract less than split-thickness grafts and are often preferred over mobile areas such as the neck, hand, and joints when suitable. Sabiston Textbook of Surgery, section “Excision and Grafting.”

Common viva questions

What is the difference between a hypertrophic scar and a contracture?
A hypertrophic scar is raised and confined to the original wound boundary. A contracture is scar shortening that causes deformity and loss of movement. A scar can be hypertrophic without causing contracture, and a contracture may occur without a markedly hypertrophic scar.

Why are flexion contractures common after burns?
The injured part naturally rests in a comfortable flexed position. Scar maturation then shortens tissue in that position unless countered by anti-contracture positioning, splintage, and exercise.

How do you assess severity?
By the site, scar quality, extent, active and passive range of motion, involvement of deeper structures, neurovascular status, functional disability, and impact on daily activities.

When should you operate?
After scar maturation where possible, usually after several months, but operate earlier if the contracture causes severe functional limitation, threatens vision or feeding, produces recurrent ulceration, or prevents rehabilitation.

How do you prevent recurrence after release?
Complete release, appropriate graft or flap selection, meticulous graft care, early physiotherapy, sustained splintage, pressure therapy where indicated, scar care, and long-term follow-up.

What is Marjolin ulcer?
It is squamous cell carcinoma arising in a chronic scar or non-healing burn wound. Any new ulcer, bleeding, pain, rapid change, or everted edge in an old burn scar requires biopsy.

Closing statement:
“I would assess the patient’s functional deficit, define the depth and extent of contracture, plan complete release with suitable graft or flap coverage, and ensure long-term postoperative splintage and physiotherapy.”

Case presentation on SPC

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Short Case Presentation: Suprapubic Catheter (SPC)

“Sir/Ma’am, I am presenting a patient with a suprapubic catheter in situ.

On general examination, I would assess the patient’s vital signs, hydration, fever, pallor, and evidence of sepsis.

On abdominal examination, a catheter is seen entering the urinary bladder through the lower anterior abdominal wall in the midline, just above the pubic symphysis. It is secured and connected to a closed urine drainage bag. I would inspect the insertion site for erythema, discharge, bleeding, granulation tissue, urine leakage, cellulitis, or skin excoriation.

I would ensure that the catheter and drainage tubing are not kinked, blocked, or under traction; that the drainage bag is below bladder level; and that the system is closed. I would note the urine volume, colour, clarity, sediment, haematuria, or purulent urine.

On palpation, I would assess for suprapubic tenderness, bladder distension, lower-abdominal mass, or features of peritonitis. I would also examine the external genitalia and perform a relevant neurological examination where neurogenic bladder is suspected.

My provisional diagnosis is: a patient with an SPC in situ for urinary diversion, most likely due to chronic urinary retention, urethral obstruction/stricture, neurogenic bladder, urethral trauma, or following urological surgery.”

What is an SPC?

A suprapubic catheter is a catheter inserted into the urinary bladder through the anterior abdominal wall, just above the pubic symphysis, to drain urine. The EAUN catheter guideline defines it as bladder catheterisation via the anterior abdominal wall.

Indications

Acute urinary retention when urethral catheterisation is unsuccessful or contraindicated
Urethral stricture or urethral trauma
Long-term bladder drainage in neurogenic bladder
Chronic urinary retention, such as from benign prostatic obstruction, when urethral catheter is unsuitable
Following urethral, bladder-neck, or pelvic surgery
To allow a trial without urethral catheter or measurement of post-void residual urine

Contraindications or precautions

Non-palpable or inadequately filled bladder, unless image-guided
Previous lower abdominal surgery or pelvic surgery, due to possible bowel interposition
Coagulopathy
Local skin infection at insertion site
Suspected bladder carcinoma at the planned tract
Pregnancy or lower abdominal mass: requires specialist assessment/image guidance

Advantages over a urethral catheter

Avoids urethral trauma, stricture, and discomfort
Better for long-term drainage in selected patients
Permits urethral voiding trial while catheter remains in place
Easier genital hygiene and sexual activity in some patients
May be more comfortable for patients with urethral pathology

Complications

Catheter-associated urinary tract infection
Catheter blockage due to debris, clot, or encrustation
Urine leak around the catheter
Bladder spasms
Haematuria
Catheter displacement or accidental removal
Cellulitis, granulation tissue, or chronic discharge at the site
Bladder stones with long-term use
Rare but serious: bowel injury, peritonitis, or intraperitoneal placement during insertion

Common viva questions

Question	Answer
Where is an SPC inserted?	In the midline, approximately 1-2 fingerbreadths above the pubic symphysis, into a well-distended bladder.
Why should the bag be below bladder level?	To promote dependent drainage and prevent backflow of urine.
What does poor drainage suggest?	Kinking, a full bag, blockage from debris/clot, malposition, bladder spasm, or low urine output.
What if the catheter falls out?	Inform urology urgently. The tract can close rapidly, especially if recently formed. Do not attempt blind reinsertion unless trained and following local protocol.
How do you assess suspected UTI?	Check fever, suprapubic pain, flank pain, systemic features, urine appearance, urinalysis, and send urine culture from the sampling port using aseptic technique.
What is a trial without catheter in an SPC patient?	Clamp or valve the SPC under supervision, allow the patient to void per urethra, and measure post-void residual via the SPC or bladder scan.

Closing statement:
“I would review the indication and date of SPC insertion, catheter type and size, urine-output chart, renal function, urinalysis and culture if symptomatic, ultrasound findings if obstruction is suspected, and the plan for catheter change or trial of voiding.”

Case presentation on trophic ulcer

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IWGDF 2023 guideline prevention and management diabetic foot disease offloading neuropathic ulcer

Short Case Presentation: Trophic Ulcer

“Sir/Ma'am, I am presenting a patient with a trophic ulcer of the ______ foot.

The patient may have a history of diabetes mellitus, Hansen disease, peripheral neuropathy, spinal cord disease, or previous nerve injury. There may be a history of repeated minor trauma, walking barefoot, ill-fitting footwear, or a previous painless wound.

On general examination, I would assess temperature, pulse, nutritional status, glycaemic status, and features of systemic infection.

On local examination, there is an ulcer over a pressure-bearing area, commonly the plantar aspect of the forefoot, metatarsal head, heel, or great toe. I would describe its:

Site, number, size, shape, and depth
Edge: usually well-defined, punched out, often surrounded by callosity
Floor: granulation tissue, slough, necrosis, or exposed tendon/bone
Base: induration, fixation, underlying bone involvement
Discharge: amount, pus, foul smell, or blood
Surrounding skin: callus, hyperkeratosis, maceration, cellulitis, oedema, scars
Tenderness: characteristically painless or minimally painful due to sensory loss
Temperature and pulses: to identify coexisting peripheral arterial disease
Sensation: test light touch, pinprick, vibration, joint position, and monofilament sensation where appropriate
Motor function/deformity: claw toes, Charcot foot, prominent metatarsal heads, foot drop
Regional lymph nodes and the opposite foot.

I would probe the ulcer gently with a sterile blunt probe to assess depth and possible contact with bone. A positive probe-to-bone test raises suspicion of osteomyelitis.

My provisional diagnosis is: a neuropathic (trophic) plantar ulcer of the ______ foot, probably secondary to diabetic peripheral neuropathy, with/without secondary infection and with/without peripheral arterial disease.”

Definition

A trophic ulcer is a chronic ulcer caused by loss of protective sensation and repeated pressure or trauma in an area with impaired innervation. It is also called a neuropathic ulcer or mal perforans.

Causes

Diabetic peripheral neuropathy
Hansen disease
Peripheral nerve injury
Spina bifida, spinal cord injury, syringomyelia
Tabes dorsalis
Alcoholic or nutritional neuropathy
Charcot neuroarthropathy

Typical features

Feature	Trophic ulcer
Common site	Pressure points of sole, heel, metatarsal heads, toes
Pain	Usually painless
Edge	Punched out, often callosed
Surrounding sensation	Diminished or absent
Pulses	Usually present unless mixed neuro-ischaemic ulcer
Main mechanism	Repetitive unperceived pressure/trauma
Associated deformity	Claw toes, Charcot foot, prominent bony points

Differential diagnosis

Ischaemic/arterial ulcer
Venous ulcer
Pressure sore
Traumatic ulcer
Malignant ulcer, including squamous-cell carcinoma in a chronic non-healing wound
Vasculitic ulcer

Investigations

Blood glucose, HbA1c, complete blood count, renal function, inflammatory markers.
Deep tissue or pus culture after cleansing/debridement if infection is suspected. Do not rely on a superficial swab alone.
X-ray foot for foreign body, deformity, gas, or osteomyelitis.
MRI if osteomyelitis or deep soft-tissue infection is suspected and diagnosis remains uncertain.
Vascular assessment: pedal pulses, ankle-brachial index, toe pressures or Doppler when ischaemia is possible.
Neurological examination and assessment for the underlying cause.

Management

Control infection and sepsis: antibiotics only when clinical infection is present, guided by deep culture where possible. Urgent drainage/debridement is required for abscess, necrosis, or severe infection.
Off-loading: remove pressure from the ulcer using a total contact cast, non-removable knee-high walker where appropriate, removable device, custom footwear, or felt padding.
Debridement: remove callus, slough, devitalised tissue, and foreign material, provided arterial supply is adequate.
Wound care: regular saline cleansing and appropriate dressings.
Optimise healing: glycaemic control, nutrition, smoking cessation, and treatment of oedema.
Correct vascular disease: urgent vascular opinion and revascularisation if significant ischaemia exists.
Treat deformity: custom footwear, orthoses, tendon procedures, or bony correction for recurrent ulcers after infection is controlled.
Patient education: daily self-inspection, avoid barefoot walking, proper footwear, early presentation for any new blister, crack, redness, or wound.

For a neuropathic plantar forefoot or midfoot ulcer in diabetes, the IWGDF off-loading guideline recommends a non-removable knee-high off-loading device as first choice when not contraindicated.

Common viva questions

Why is it painless?
Because peripheral sensory neuropathy causes loss of protective pain sensation.

What is the commonest site?
Pressure-bearing areas of the plantar foot, especially metatarsal heads.

Why is callosity present?
Repeated pressure causes hyperkeratosis. The callus further increases focal pressure and delays healing.

What is the most important principle of treatment?
Off-loading of pressure, alongside treatment of infection, debridement when appropriate, and correction of underlying neuropathy and vascular disease.

When should you suspect osteomyelitis?
A deep chronic ulcer, exposed bone, positive probe-to-bone test, recurrent infection, raised inflammatory markers, or suggestive imaging.

What suggests a neuro-ischaemic ulcer rather than a pure trophic ulcer?
Absent or reduced pulses, cold foot, delayed capillary refill, painful ulcer, distal toe or lateral-foot location, and poor perfusion tests.

Closing statement:
“I would assess this ulcer for neuropathy, infection, ischaemia, osteomyelitis and deformity, then institute multidisciplinary care with pressure off-loading, wound management, infection control, vascular assessment and diabetes optimisation.”

Case presentation on sural flap

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Case presentation on sural flap

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reverse sural artery flap anatomy indications complications review

Short Case Presentation: Reverse Sural Flap

“Sir/Ma’am, I am presenting a patient with a reverse sural artery flap used to cover a soft-tissue defect over the ______, most commonly the distal third of leg, ankle, heel, or dorsum of foot.

On inspection, there is a skin and fasciocutaneous flap transposed from the posterior calf to the recipient defect. I would note the site and size of the original defect, the flap dimensions, whether the flap has been inset directly or through a skin tunnel, and the donor-site wound, which may be skin grafted.

I would assess flap viability by looking for:

Colour: pink is satisfactory; pallor may indicate arterial insufficiency; bluish-purple discoloration suggests venous congestion.
Temperature: compare it with surrounding skin. A cold flap is concerning.
Capillary refill: normally brisk. Delayed refill suggests impaired arterial inflow; very rapid refill with a congested flap suggests venous obstruction.
Turgor and bleeding, if clinically indicated.
Edges: look for marginal necrosis, epidermolysis, dehiscence, infection, haematoma, or seroma.
Pedicle: ensure there is no compression, kinking, tight dressing, or collection.
Recipient area: assess whether exposed bone, tendon, implant, or ulcer is adequately covered.
Donor site: inspect for graft loss, infection, delayed healing, scar, and sensory deficit over the lateral foot.

I would also assess distal circulation by palpating dorsalis pedis and posterior tibial pulses, checking capillary refill and sensation, and assessing ankle and foot movements.

My provisional diagnosis is: status post reverse sural artery fasciocutaneous flap for coverage of a distal leg/ankle/heel/foot soft-tissue defect, currently viable or complicated by ______.”

What is a reverse sural flap?

It is a distally based fasciocutaneous flap harvested from the posterior calf and transferred to cover defects of the lower third of leg, ankle, heel, and foot.

It is based on retrograde blood flow through distal perforators of the peroneal artery, usually located about 5 cm above the lateral malleolus. It includes the sural nerve, superficial sural artery, and small saphenous vein within its pedicle.

Common indications

Post-traumatic soft-tissue defects
Exposed bone, tendon, or orthopaedic implant
Heel defects and chronic heel ulcer
Distal leg, lateral malleolar, Achilles tendon, ankle, and foot defects
Post-burn contracture release defects
Osteomyelitis-related soft-tissue loss
Defects after tumour excision

Advantages

Local flap, technically simpler than free flap
Does not require microsurgical vascular anastomosis
Does not sacrifice a major leg artery
Can cover distal leg, ankle, and foot where local tissue is limited
Useful where free-flap facilities are unavailable

Disadvantages

Sacrifice of sural nerve causes numbness over posterolateral calf/lateral foot
Donor site may require split-thickness skin grafting
Venous congestion is common
Bulky flap and possible poor cosmetic appearance
Less suitable in severe peripheral vascular disease, uncontrolled diabetes, heavy smoking, severe venous insufficiency, or extensive posterior calf scarring

Complications

Early complications	Late complications
Venous congestion	Sensory loss in sural nerve distribution
Partial or total flap necrosis	Bulky flap / poor cosmesis
Haematoma, infection, dehiscence	Donor-site scar or graft problems
Pedicle compression/kinking	Recurrent ulceration or breakdown
Marginal epidermolysis	Contracture at recipient/donor site

The most important early complication is venous congestion, which may progress to partial flap necrosis. A large systematic review found partial flap loss and venous congestion among the most frequent complications of reverse sural flaps, as summarized in this systematic review.

Common viva questions

Why is it called a reverse flap?
Because blood flow is retrograde, from distal peroneal artery perforators towards the proximal flap.

What is the pivot point?
Usually about 5 cm above the tip of the lateral malleolus, preserving distal peroneal perforators.

What tissues are included in the pedicle?
Sural nerve, superficial sural artery, small saphenous vein, deep fascia, and surrounding adipofascial tissue.

What is the sensory deficit after flap harvest?
Numbness over the posterolateral aspect of leg and lateral border of foot due to sacrifice of the sural nerve.

What causes flap congestion?
Impaired venous drainage due to a tight tunnel, pedicle kinking/compression, inadequate pedicle width, haematoma, or venous insufficiency.

How do you manage a congested flap?
Remove constricting dressings or sutures, ensure the limb is positioned appropriately, exclude pedicle compression or haematoma, and obtain urgent plastic-surgical review. The management depends on severity and local flap-monitoring protocol.

What are alternatives for distal leg and foot coverage?
Local perforator flap, propeller flap, lateral supramalleolar flap, cross-leg flap, muscle flap with graft, or free tissue transfer.

Closing statement:
“I would monitor flap colour, warmth, capillary refill, congestion, wound and pedicle status regularly; optimise perfusion by correcting hypotension, anaemia, hypoxia and infection; protect the flap from pressure; and ensure close plastic-surgical follow-up.”

Rockwood and Green's Fractures in Adults, 10th ed., section “Reversed Sural Artery Flap,” describes it as relying on a vessel accompanying the sural nerve and notes a risk of partial necrosis.

Case presentation on PCN

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Short Case Presentation: PCN in situ

“Sir/Ma’am, I am presenting a patient with a percutaneous nephrostomy tube, or PCN, in situ.

On general examination, I would assess pulse, blood pressure, temperature, respiratory rate, hydration, pallor, peripheral oedema, and signs of sepsis or uraemia.

On abdominal and back examination, a nephrostomy tube is seen entering through the flank, usually in the posterior axillary line below the 12th rib, and connected to a closed urine drainage bag. The tube is secured to the skin and has a locking pigtail within the renal pelvis.

I would inspect:

The insertion site for bleeding, urine leak, erythema, discharge, cellulitis, or skin excoriation
The tube for kinking, blockage, dislodgement, traction, or loose fixation
The drainage bag for amount, colour, clarity, haematuria, pus, debris, or sediment
Whether the bag is below the level of the kidney and the system remains closed

On palpation, I would look for loin tenderness, renal mass, suprapubic fullness, or features of peritonitis. I would assess the contralateral kidney area and examine for pedal oedema. In a patient with urinary obstruction, I would also perform a relevant genital, abdominal, and neurological examination.”

My provisional diagnosis is:
“Post-PCN status for decompression of an obstructed ______ kidney, most likely due to ureteric calculus, malignant ureteric obstruction, ureteric stricture, or infected obstructed hydronephrosis.”

What is a PCN?

A PCN is an image-guided catheter inserted percutaneously through the flank into the renal collecting system to drain urine externally. It usually has a pigtail locking mechanism to keep it in the renal pelvis.

Indications

Obstructed infected kidney: pyonephrosis, obstructive pyelonephritis, urosepsis. This is an emergency.
Obstructive hydronephrosis due to ureteric stone.
Malignant ureteric obstruction.
Benign ureteric stricture or pelviureteric junction obstruction.
Urinary leak, urinoma, or urinary fistula.
Access for procedures such as percutaneous nephrolithotomy, antegrade stenting, or nephrostogram.

The usual indication is drainage of an obstructed collecting system, particularly when infection is present. A recent review of PCN practice is available through NCBI StatPearls.

Important investigations to review

Complete blood count and inflammatory markers
Serum creatinine, urea, electrolytes
Urinalysis and urine culture from the nephrostomy sampling port
Blood cultures if febrile or septic
Ultrasound KUB or CT KUB/CT urography
Nephrostogram to assess catheter position and ureteric patency where indicated

PCN care

Keep a sterile, closed drainage system.
Keep the bag below the level of the kidney.
Measure and document output separately for each side in bilateral PCNs.
Monitor fluid balance, renal function, and electrolytes, particularly after relief of bilateral obstruction because post-obstructive diuresis may occur.
Do not clamp, flush, manipulate, or remove the PCN unless instructed by urology/interventional radiology.
Replace dressings aseptically and ensure the catheter is securely fixed.

Complications

Early	Late
Haematuria and bleeding	Blockage from debris/encrustation
Pain at insertion site	Catheter dislodgement
Sepsis or bacteraemia	Recurrent UTI/pyelonephritis
Urine leak around tube	Skin infection or granulation tissue
Pleural injury, pneumothorax, or hydrothorax with high puncture	Persistent urine leak after removal
Rare bowel, liver, spleen, or renal injury	Need for periodic tube exchange

Common viva questions

What is the most important emergency indication?
An infected obstructed kidney, such as pyonephrosis or obstructive urosepsis. It requires urgent decompression by PCN or retrograde ureteric stenting, plus antibiotics and resuscitation.

What if PCN output suddenly stops?
Check for a kinked tube, closed tap, full bag, disconnection, blockage, or displacement. Assess the patient for fever, loin pain, reduced urine output, and sepsis. Urgent imaging and urology/interventional radiology review may be needed. Do not forcefully flush the catheter.

What if the tube is accidentally dislodged?
Cover the site with a sterile absorbent dressing, document output and symptoms, inform urology/interventional radiology urgently, and assess the urgency of reinsertion. Do not blindly reinsert it.

Why may urine be blood-stained after insertion?
Mild transient haematuria can occur due to renal puncture. Persistent heavy haematuria, clots, haemodynamic instability, or falling haemoglobin needs urgent assessment for vascular injury.

What is the alternative to PCN for upper tract obstruction?
Retrograde ureteric stenting. Choice depends on the level and cause of obstruction, infection, anatomy, patient stability, and available expertise.

What is a nephrostogram?
Contrast study through the PCN that confirms tube position and evaluates the renal pelvis, ureter, obstruction, leak, and passage of contrast into the bladder.

Closing statement

“I would review the original indication, side and date of PCN insertion, urine output chart, renal function, culture report, imaging, and the definitive plan, such as ureteric stenting, stone treatment, stricture management, or palliation of malignant obstruction.”

Recent evidence comparing PCN and ureteric stents in obstructive urinary infection is summarized in PubMed 38929478.

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