Table Of ContentA T E X T B O O K O N
INCLUDING FRACTURES & ORTHOPAEDICS
Author of
A MANUAL ON CLINICAL SURGERY
A CONCISE TEXTBOOK OF SURGERY
A PRACTICAL GUIDE TO OPERATIVE SURGERY
A TEXTBOOK
ON
SURGICAL SHORT CASES
BY
Somen Das
M.B.B.S. (Cal.), F.R.C.S. (Eng. & Edin.)
Senior Consultant Surgeon
Author of
A MANUAL ON CLINICAL SURGERY,
A PRACTICAL GUIDE TO OPERATIVE SURGERY,
A CONCISE TEXTBOOK OF SURGERY
&
UNDERGRADUATE FRACTURES & ORTHOPAEDICS.
FOURTH EDITION
KOLKATA
2011
All Rights Reserved
This book or any part thereof must not be reproduced in any form
without the written permission of the author, DR. S. DAS.
Copyright © DR. S. DAS.
First Edition September, 1990
........................ .
Reprinted ..................... Oct, 1991
Reprinted ..................... Jan, 1993
Reprinted ..................... Oct, 1993
Reprinted ..................... Apr, 1994
Reprinted ..................... Jan, 1995
Reprinted ..................... Dec, 1995
Reprinted ..................... Oct, 1996
Second Edition .. September, 1997
..
Reprinted ..................... Feb, 1998
Reprinted ..................... Nov, 1998
Reprinted ..................... Jun, 1999
Reprinted ..................... Oct, 2000
Reprinted ..................... Sept, 2001
Reprinted ..................... Aug, 2002
Reprinted ..................... Sept, 2003
Reprinted ..................... Aug, 2004
Reprinted ..................... Nov, 2005 Rs. 328.00
Third Edition ......... ....January, 2007 US. $ 9.00
Reprinted ..................... Oct, 2007
Reprinted ..................... Aug, 2008
Reprinted ..................... Nov, 2009
[Fourth Edition .. ..........June, 2011
ISBN-978-81-905681-3-5
Published by
Dr. S. Das.
13, Old Mayors' Court, Kolkata - 700 005.
INDIA
E-mail : [email protected]
Website : http://www.surgerybooksbydrsdas.com
TEXTBOOK ON SURGICAL SHORT CASES
DEDICATED
TO THE MEMORY OF MY FATHER
Late Dr. K. Das, F.R.C.S. (Eng. & Edin.)
Whose teachings and blessings have only made this venture possible
&
TO THE MEMORY OF MY MOTHER
Whose inspiration has always worked with me.
Preface To The Fourth Edition
At the onset let me express my sense of gratitude to all the teachers of Surgery in this
Subcontinent for their continued support and recommendation of this book. This has now
become the best-selling book on this subject. Every year it has been reprinted and I should have
brought out this edition long back. The success of this book mainly reflects the wide appeal of
its presentation in direct and concise way.
This treatise is mainly intended for the undergraduate appearing for final M.B.B.S examination.
While authoring 'A Manual On Clinical Surgery' and 'A Practical Guide To Operative Surgery',
I felt the need of such a book. The students, at the time of Practical part of final examinations,
face the various questions related to the short cases. This book is to help them in answering those
questions. If the students find it helpful, it has done its job.
I have made an attempt to give it a shape of a textbook. All the chapters have been designed
in a textbook fashion. To do this I might have gone beyond the domain of only short cases. So
this book will also help the students in preparing for theoretical examinations on Surgery.
This manual contains sections on Embryology, Anatomy, Physiology and Pathology in each
chapter to provide with a complete idea on the subject. Emphasis has been maintained on
Clinical diagnosis. 'How to come to a diagnosis of a particular case'— is the main concern of
this book. Elaborate discussion has been made regarding special investigations and treatment.
This is a thoroughly revised edition with inclusion of more modern techniques of investigations
and treatments. The belief is still carried out that sound surgical practice depends primarily on
the skills and knowledge of the surgeon. Each chapter has been thoroughly revised with addition
of more modern methods and techniques and deletion of the old ones. No chapter has remained
untouched in this edition. To improve readability various type settings have been used. I have
embellished this edition with coloured photographs to make this treatise more attractive to the
students.
Thorough knowledge is essential for any case be it a short case or a long case. There is a
well known adage — 'Hands cannot do what mind does not know'. So endeavour has been
made to make the students knowledgeable regarding the short cases as far as practicable.
Adequate illustrations are set out to help the students to understand the particular disease.
Schematic diagrams have also been introduced for better understanding of Embryology, Anatomy
and Pathology.
Accuracy and precision are the hallmarks of this text. No necessary information or explanation
has been left out and each chapter is presented in a neat and lively manner.
I am grateful to many patients who voluntarily submitted themselves to the trouble of being
photographed. 1 am obliged to the great mass of students who have made me feel the dearth
of a proper book on this subject and their difficulties to understand this subject. If this book helps
them in learning Surgical Short Cases, my goal is achieved.
13, Old Mayors' Court,
Kolkata - 700 005.
S. DAS.
June, 2011.
Contents
CHAPTER PAGE
1. SKIN AND SUBCUTANEOUS TISSUE ...... I
2. ULCER, SINUS AND FISTULA (INCLUDING PILONIDAL SINUS) ...... 36
3. MOUTH, TONGUE AND LIPS ...... 45
4. CLEFT LIP AND CLEFT PALATE ...... 60
5. SPINA BIFIDA ...... 66
6. SALIVARY GLANDS ...... 70
7. SWELLINGS OF THE JAW ...... 85
8. SWELLINGS IN THE NECK ...... 98
9. CERVICAL LYMPH NODE ENLARGEMENT ...... 121
10. ANEURYSM ...... 137
11. VARICOSE VEIN AND VENOUS ULCER ...... 144
12. RAYNAUD'S SYNDROME, BUERGER'S DISEASE,
THORACIC OUTLET SYNDROME AND CERVICAL RIB ...... 157
13. CERTAIN DISORDERS OF THE BREAST ...... 170
14. UMBILICUS AND ABDOMINAL WALL ...... 175
15. ULCERS OF THE LEG ...... 182
16. SWOLLEN LEG ...... 187
17. HERNIA ...... 193
18. TESTIS, EPIDIDYMIS AND SCROTUM ...... 221
19. FILARIASIS IN SURGERY ...... 245
20. PENIS ...... 250
21. GANGLION AND BURSAE ...... 263
22. FRACTURES AND ORTHOPAEDICS ...... 267
INDEX ...... 284
Government ofWestBengal
Department Of Surgery
Medical College, Kolkata.
Ref No S/298 TO WHOM IT MAY CONCERN Dated 5.9.05
This is to certify that the book entitled ‘Surgical Short Cases’ by the famous author
Dr. S. Das.FRCS, is very much informative and will be of much help to Undergraduate
students. Postgraduate students and practising doctors.
(Sd/-)
( Dr. S. K. Bhattacharya)
Professor & Head
Department of Surgery
Medical College,Kolkata.
REVIEWS FROM READERS
“ Respected Sir,
It is my glaring tribute to you for your 'A Textbook on Surgical Short Cases'. It is an excellent book
— Dr. R. K. Dhiraj.M.B.B.S., Sri Mangalam Mariathurathu, Kottayam-27, Kerala.
“ Respected Sir,
I have gone through your book A Textbook on Surgical Short Cases'. I can only say that it is really superb, most
useful both for undergraduate and postgraduate and even practising surgeons You have covered everything in nutshell.”
— Dr. Y. H. Sankanal, M-ll/ 300 K.H.B. Colony, Cantonment, Dellery-583104,Karnataka.
“ Respected Dr Das,
Your new publication ' A Textbook on Surgical Short Cases' is gaining immense popularity day by day. My
colleague’s son told me that they find it very useful for the theory exams as well as practicals. I take this opportunity to congratulate
you for the pains you have taken to prepare such a useful book."
- Dr. Yogesh.S.Salphale, Chandrapur-442 401.
“ Respected Sir,
I am in final year M.B.B.S. student. I am very much enlightened by your books - Clinical Surgery, Operative
Surgery and Surgical Short Cases. These books are not only helping me in the wards but are also teaching me the basics which are
very much essential to the students and doctors I am writing this letter with respect to your new book ‘A Concise Textbook of
Surgery’, which is yet not available in the market.”
- Vijay. D. Khetan, c/o Rural Medical College of Prabara Medical Trust, Boys’ Hostel, Room No. 50, Lony-414736,Dist.
Ahmednagar, Maharashtra.
“ Respected Sir,
We are final year students at Osmania Medical College, Hyderabad. We have found all your books namely Clinical
Surgery, Operative Surgery and Surgical Short Cases to be very useful( before publication of ‘A concise Textbook of Surgery’). Words
cannot mention the amount of respect and gratitude we have for you Sir for presenting a vast and difficult subject like Surgery in such
a beautiful and lucid manner, We shall always be thankful to you Sir.”
-- Dipak Gowel & Karthik Kumar, 22-6-187, Pathergatti, Hyderabad-500 002.
Dear Dr. Das,
Thanks for sending me 'A Textbook on Surgical Short Cases’ as requested by me. I am sure this book will be of
immense help to the undergraduate and postgraduate students. Thanks.
- Dr. Mohamed Diaa El-Zawahry, F.R.C.S.(Eng. & Edin.)- Prof. Of Surgery, Mansoura University.
CHAPTER
„ ‘ > p i*" iv i'J' I%•' ii 0 '"i
(
SKIN AND SUBCUTANEOUS TISSUE
DERMOID CYST 3. Post auricular — behind the ear — at the site
of fusion of the mesodermal hillocks.
A dermoid cyst is a cyst which lies deep to the skin
4. On the skull at the site of fusion of the skull
and is lined by skin. So a dermoid cyst can be called
bones.
an epidermal cyst. These cysts are lined by squamous
5. At the midline of the face particularly at the
epithelium and these contain pultaceous or tooth paste
root of the nose.
like material which contain desquamated epithelial cells.
6. Submental dermoid.
There are four types of dermoid cyst —
Origin.—
(i) Sequestration dermoid.
At the line of embryonic fusion, a few ectodermal
(ii) Implantation dermoid — Acquired variety.
cells are sequestrated into the deeper layer. Ultimately
(iii) Tubulo-dermoid.
these cells proliferate and liquify to form a sequestration
(iv) Teratomatous dermoid.
dermoid cyst. Such cyst lies almost near the mesoderm
from where the bones develop, that is why indentation is
SEQUESTRATION DERMOID often found in the underlying bone. Sometimes the cyst
starts in the mesoderm so that there may be prolongation
This is a congenital variety of dermoid cyst, which of the cyst through the bone and a portion of the cyst
is formed by inclusion of epithelium buried at the line may remain intracranial.
of embryonic fusions. So these are found along the lines
Clinical features.—
of fusion of the two embryonic segments.
HISTORY.—
Pathology.— Duration.— The cyst may be noticed at birth, but
This cyst is lined by stratified squamous epithelium it is usually seen a few years later — the time taken to
with hair, hair follicles, sebaceous glands and sweat glands. form the cyst.
It contains white pultaceous tooth paste like desquamated SYMPTOMS.—
material with or without hairs. It is the mixture of sebum, A painless swelling, which is slowly growing is the
sweat and desquamated epithelial cells. main symptom. Cosmetic disfigurement is the main
Common sites are.— complaint. Such cyst hardly becomes big enough to cause
1. At the midline of the body particularly in the any serious mechanical disability and rarely may become
neck. infected.
2. External angular — just above the outer canthus of LOCAL EXAMINATIONS.—
the eye — at the line of fusion of the frontonasal and maxillary (i) Site.— The site is very peculiar as this must
processes.
Dermoid cyst
Sequestrated ectoderm
Indentation
in thre skull bone
Fig.1.1.— Shows formation of sequestration dermoid in the skull. Sequestration dermoid anywhere in the body usually forms
at the line of embryonic fusion. First figure shows before embryonic fusion. Second figure shows the sequestrated ectoderm
after embryonic fusion which forms nidus of sequestration dermoid. Third figure shows a well-formed dermoid cyst which
causes indentation in the underlying skull as it develops from the underlying mesoderm.
2 A TEXTBOOK ON SURGICAL SHORT CASES
be at the embryonic fusion. with the underlying duramater.
CT SCAN may be required to know presence of
the intracranial extension as well as its extent.
Complications.—
(i) Infection.
(ii) Suppuration.
(iii) Ulceration.
(iv) Pressure symptoms to the surrounding
structures.
Fig.1.2.— A typical dermoid cyst just above the outer canthus
of the eye.
(ii) Size and shape.— Such cyst hardly attains a
size bigger than 2 cm in diameter. It is usually ovoid or Fig. 1.3 .— A typical example of dermoid cyst at the outer canthus
of the eye. Note how to palpate the margin of the cyst which may
spherical in shape.
reveal an indentation in the underlying bone. Moreover the margin
(iii) Surface — is smooth. of such cyst yields to the palpating finger and does not slip away
(iv) Punctum.— A dermoid cyst does not have a (cf. lipoma).
punctum which is often found in sebaceous cyst.
(v) Consistency.— Such cyst feels soft. It may Treatment.—
indent with pressure as the content is thick pultaceous Complete excision of the cyst is the treatment of
material, mixture of sebum, sweat and desquamated choice. This should be done under general anaesthesia as
epithelial cells. . the cyst has to be dissected from the sensitive pericranium
(vi) Compressibility or reducibility.— This cyst can moreover there may be intracranial extension.
neither be compressed nor be reduced (cf. meningocele). If preliminary X-ray shows a gap in the underlying
(vii) Relations.— Dermoid cyst is not attached to bone, the operation has to be delayed to give an
the skin. So the skin can be lifted off the cyst easily. opportunity for spontaneous closure.
This cyst is also free from underlying structures. There If there be intracranial extension, osteoplastic flap
may be bony indentation when the bone lies exactly deep should be removed for excision of the intracranial part.
to the cyst. This can be palpated by moving the base of Operation.—
the cyst with a finger (See Fig.3.13 of A Manual On If the swelling is small a single incision is made
Clinical Surgery'). over the swelling along Langer’s line. If the swelling is
(viii) Transillumination test — is always negative. quite big, an elliptical incision is made over the swelling
(ix) While lying above the cranial bones such cyst so that the corners of the incision extend beyond the
may have intracranial connection. margins of the swelling. Grasping the edge of the incision,
X-RAY.— This may show a depression in the bone the dissection is started raising the skin flaps on either
underlying the cyst or a gap. Such gap may be present side of the incision. The outer edge of the incision is
when there is an intracranial extension or a fibrous band lifted up and the dissection is continued undermining the
may pass through this bony gap and connect the cyst skin flap. This is continued beyond the extent of the
SKIN AND SUBCUTANEOUS TISSUE 3
swelling on both sides. Now the swelling is grasped Common sites are —
with Lane's tissue forceps and the cyst is gradually (i) Palm of the hand.
dissected from its deeper tissues. Thus the cyst is removed. (ii) Any part of the finger.
Haemostasis is maintained. Then the skin margins are (iii) Particularly pulp or tip
closed with interrupted non-absorbable suture. of the finger.
(iv) Sole.
SUBMENTAL DERMOID.—
Such dermoid is quite common
This is a dermoid cyst in the submental region. It
in gardeners, tailors and women.
is a type of sequestration dermoid and arises at the point
of fusion of the first and second branchial arches. Pathology.—
Pathology and Clinical features are same as Such cyst is usually lined by
sequestration dermoid. stratified squamous epithelium with
no hair follicle, sweat and sebaceous
Complications.—
glands. The content is white cheesy pjg j 4__________ pj
(i) Infection. ne
material formed by desquamated demonstration of
(ii) Ulceration.
epithelial cells and sebum. Hair is implantation
(iii) Prone to repeated trauma. dermoid of the
usually absent.
(iv) Cosmetic Problem. finger.
Clinical features.—
Differential Diagnosis.— Submental dermoid is HISTORY.— A history of puncture injury is usually
particularly important for its different diagnosis, as it available. In some cases the patient often forgets of such
may mimic — injury.
(i) Submental lymph node enlargement.— This SYMPTOMS.— A swelling in the finger or the palm
may occur from any septic focus in oral cavity or from is usually the presenting feature. The cyst may be slightly
tuberculous lymphadenitis. painful.
(ii) Sebaceous cyst, which may occur anywhere in EXAMINATIONS.— A tense cystic swelling is found
the body. in the finger or the palm. As the cyst is quite tense, the
(iii) Suprahyoid thyroglossal cyst.— Thyroglossal consistency is often firm or even hard. There may be a
cyst moves up with deglutition, which is not present in scar on the skin overlying the cyst. Fluctuation is very
submental dermoid. Thyroglossal cyst also moves up with difficult to elicit as the cyst is small and tense.
protrusion of the tongue, which is also not present in
submental dermoid.
(iv) Ectopic thyroid gland, which is extremely rare.
It also moves up with deglutition, but not with protrusion
of the tongue. In case of submental dermoid these signs
are not present.
Treatment.—
Complete excision of the cyst under general
anaesthesia is the treatment of choice as in case of any
sequestration dermoid. A curved incision is made over
the middle of the swelling along Langer's line. The skin
flaps are raised. The deep cervical fascia is incised. The
cyst is now grasped and gradually dissected off removed
from its deeper structures. The haemostasis is meticulously
maintained. The skin margins are closed with interrupted
non-absorbable suture.
Fig. 1.5.— Implantation dermoid cyst
IMPI \ STATION DKRMOID of the hand.
It is an acquired dermoid and arises from indriven The most important clinical feature is the presence
epithelium beneath the skin due to a puncture injury of a tense cyst in the finger or the palm with a
e.g. needle prick or thorn prick. previous history of a punctured wound.
