Surgery Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 21)

Surgery Review
A Free Booklet Series by Dr. Aryan

Preface:
• This is the study material designed by Dr. Aryan with creation and compilation of
the best of the best and the most finest slides on the subject. I would like to offer a
billion heartily thanks for everyone who contributed directly or indirectly to the
creation of the material through creation and dissemination of the scientific
information.
• Covering everything in one study material is next to impossible. Hence, refer to
gold standard textbooks for building solid concepts or in case of any doubt.
Textbooks are acknowledged at the end of the presentation. If any source has been
missed to acknowledge, it doesn’t lessen their impact and contribution in any way.
• Don’t keep searching for pattern between the consecutive slides. You won’t find
many. Rather to boost your recall and review, I have constructed many slides and
are deliberately placed with no much relation between the preceding and the
succeeding ones.
• The main rule of a review material is that it must make you recall or learn
maximum amount of information in minimum amount of time and space.
• Motivational quotes and articles are included within the slides. Always remember
that every good idea, nice piece of information and everything else is literally and
absolutely worthless unless you execute.
• If you know everything in the slides in much detail, you probably wouldn’t need
this material.
Best of luck WORK & SUCCESS!
Dr. Aryan
(Anish Dhakal)

Causes of ascites
• Low plasma protein concentrations
• High central venous pressure
• Portal hypertension
Transudates
• Tuberculous peritonitis
• Peritoneal malignancy
• Budd-Chiari syndrome
• Pancreatic ascitis
• Chylous ascitis
• Meigs’ syndrome
Exudates

Intestinal Obstruction
Dr. Aryan (Anish Dhakal)

Supportive Treatment for Intestinal Obstruction
• Nasogastric decompression
• NPO
• Fluid and electrolyte replacement
• Analgesics
• Antibiotics
• Urine output monitoring
• Vital Monitoring

Types of Paralytic Ileus
• Postoperative
– Self-limiting (24-72 hrs)
• Infection
– Intra-abdominal sepsis
• Reflex ileus
– After fracture of spine or ribs
• Metabolic
– Uremia and hypokalemia

Summary of Management of Esophageal Varices

Charcot neurologic triad (MS): nystagmus, intention tremor and dysarthria
Murphy triad in appendicitis: RIF pain, Fever and Vomiting

Transmitted Vs. Expansile Pulsations

TB in Ileocaecal region

Position of Appendix

Confusion Corner: Clinical Reasoning in Appendicitis
 Shifting pain: Firstly visceral vague pain starts around the umbilicus (due
to same dermatomal innervation). Later the pain changes to specifically
localized somatic pain (due to irritation of the parietal peritoneum).
 Rovsing’s sign: Palpation of LIF induces pain in right iliac fossa due to
shifting of bowel loops which irritates parietal peritoneum.
 Hyperextension causes pain in retrocecal appendix due to irritation to
psoas muscle (patient in flexion attitude for comfort).
 Internal rotation in pelvic appendix irritates obturator internus.
 Silent appendix in case of retrocecal appendix which means that cecum
distended with gas prevents the pressure from palpation to reach the
inflamed appendix.
 Early diarrhea and increased frequency of micturition in case of pelvic
appendix due to its contact with rectum and bladder. When the appendix
is completely pelvic, classical signs like abdominal rigidity and tenderness
over the McBurney’s point is absent as well.

Incisions in Appendectomy

COI for Ochsner-Sherren regimen include doubtful diagnosis, appendicitis in elderly and
children, gangrenous appendicitis and diffuse peritonitis.
Appendicular mass (periappendicular phlegmon) consists of inflamed appendix,
greater omentum, edematous cecum, terminal ileum, loop of intestine, ascending
colon and adjacent peritoneum.

Ochsner-Sherren regimen in a Nutshell
 NG tube decompression
 NPO for 48 to 72 hours
 Drugs
• Antibiotics for Gram positive, negative and anaerobic bacteria (Ceftriaxone 1 gm IV BD
& Metronidazole 500 mg IV TDS)
• Analgesics (Tramadol 50 mg IV TDS. Stronger analgesics like pethidine may mask
complications)
• PPI
• IV fluids
 Monitoring
• Vital signs (temperature, pulse, RR, BP) 4 hourly
• Size of the mass marked twice daily
• Per abdominal examination for features of peritonitis
• TC and DC (if increased may mean appendicular abscess formed)
 Interval appendectomy after 6-8 weeks

Sequelae of appendicitis
Complete resolution
Appendicular lump
Appendicular abscess
Gangrenous appendicitis
Mucocele
Perforation

Complications of Appendectomy
 Paralytic ileus
 Reactionary hemorrhage
 Pyelophlebitis (suppurative and inflamed
thrombosis of portal vein)
 Would sepsis
 Fecal fistula
 Right inguinal hernia (injury to ilioinguinal nerve)
 Adhesions & Intestinal obstruction
 Respiratory problems & DVT

Complication of Cholecystectomy
 Bile duct injury
 Bile leak
 Biliary stricture
 Biliary fistula
 Injury to colon, duodenum or mesentery
 Hemorrhage
 Waltman-Walter syndrome (accumulation of bile in right
subhepatic and subphrenic space compressing the IVC)

IBS Treatment

SIRS Criteria

Confusion Corner: Movement of Pain
Types of
Movement
Description
Radiation of pain Extension of pain to other side while original site of pain
persists. Pain in pancreatitis radiating to back is an
example.
Referred pain Pain is experienced but at a site distant from the original
site of pathology due to same innervation. E.g. irritation
to diaphragm supplied by phrenic nerve (C3, C4, C5) is
referred to shoulder (C3, C4).
Shifting/Migrating pain Pain is experienced at one site, then it shifts to another
site and pain at original site disappears. Classic example
is acute appendicitis when pain is first felt in umbilical
region (T9, T10: same as appendix) which later irritates
the parietal peritoneum overlying appendix and pain is
felt in RIF.

Swelling with impulse on coughing
other than hernia?
Swelling with positive cough impulse are typically
continuous with one of the body cavities:
Abdominal cavity (Hernia, Iliopsoas abscess, Lumbar
abscess)
Pleural cavity (Empyema necessitans)
Spinal canal (Meningocele)

Slip sign in Lipoma
When edge of the solid swelling is palpated
the margin of the solid swelling does not
yield to the palpating finger but slips away
from it.

Claudication
Arterial Claudication develops after walking a fixed distance (Claudication
distance). Boyd classification distinguishes the same: I- pain relieved on
walking, II- walks in pain, III- compelled to take rest, IV- pain at rest (relieved by
hanging leg by side of bed due to pooling of blood secondary to gravity).

What are signs of ischemia due to arterial
insufficiency?
Thinning of the skin
Diminished growth of hair
Loss of subcutaneous fat
Shininess
Trophic changes in the nails which become brittle
with transverse ridges
Minor ulceration in pressure areas viz. heel,
malleoli, ball of the foot, tip of the toes

Ischemic tests for Upper
Limbs
Description
Disappearing Pulse Syndrome Examine the pulse. Exercise the limb. Pulse would disappear after
claudication develops secondary to vasodilation and increased vascular space.
Elevated Arm Test (Modified
Roo’s Test)
Ask the patient to abduct arm to 90° and then externally rotate the arm. Open
an close the hands for 5 minutes. If any pain, fatigue, paresthesia, tingling or
numbness develops, the test is positive for thoracic outlet syndrome.
Allen’s Test Ask patient to clench the fist and press on the radial and ulnar artery of the
wrist. Ask patient to open and close the fist for 1 minute. Release artery one
by one.
Costo-clavicular compression
(Falconi’s Test)
Feel the radial pulse. Then throw the shoulder backward and downward as
exaggerated military position. Absent or feeble pulse occurs secondary to
subclavian artery compression between clavicle and 1st rib.
Hyperabduction manoeuvre
(Halsted Test/Pectoralis Minor
Syndrome)
Feel the radial pulse. Passively hyperabduct the arm. Radial pulse would be
feeble or absent due to compression of artery by pectoralis minor tendon.
Adson’s Test (Cervical
Rib/Scaleous Anticus
Syndrome)
Ask the patient to sit on a stool and take a deep breath. Turn the face to
affected side. Radial pulse would be absent due to compression of subclavian
artery.
Branham’s Sign/Nicoladonis
Sign
It is very simple test for AV fistula. At least remember the name of the test. All
you have to do is press proximal to the fistula and you are done. It would
cause reduction in size of the swelling, disappearance of bruit, fall in pulse
rate and pulse pressure returns to normal.

Harvey’s Sign for Limb Ischemia
The sign checks adequate venous refilling
Press two index fingers side by side touching each other on
a vein
Move finger nearer to heart proximally to empty the vein
between the two fingers
The vein is empty now
Release the distal finger
Observe for venous refilling
Delayed venous refilling in ischemic limb

Buerger’s Postural Test for PAD
Perform Buerger’s test in broad daylight. Keep at 20° for 2 minutes. If no pallor or discomfort then
elevate to 30°, 45°, 60° to 90°. If pallor is absent in suspected case, support the leg and ask patient to
flex and extend ankle and toes to the point of fatigue which causes pallor & veins on dorsum becomes
empty and guttered. Within few minutes cyanotic hue appears.
Additionally you can also check for:
1. Capillary filling time: elevated normal leg remains pink throughout. Ischemic limb will show pallor
on elevation, pink in horizontal position and later dusky red (purple) due to deoxygenated oxygen.
2. Venous refilling time: Normal limb will show guttering at 90° and normal refilling as soon as 5
minutes. Ischemic limb will be guttered on 10° or even while horizontal.

What is Crossed Leg Test & Reactive
Hyperemia test for ischemia detection?
Crossed leg test: Ask the patient to sit with leg crossed over
the other leg so that popliteal fossa of one leg will lie over
the knee of another. Divert the attention. If oscillatory
movement is seen that would be synchronous with the pulse
of popliteal artery.
Reactive hyperemia test: This is a very simple test. Blood
pressure cuff is inflated for 250 mm Hg and kept for 5
minutes. In normal limb, red flush will appear within
seconds. The more severe is the ischemia, additional time
would be required to get the flushing.

Brodie-Trendelenburg test
The objective of the test is to determine
incompetency of sapheno-femoral valve and
perforating veins
Place the patient in recumbent position to
empty the veins and ask to quickly stand up with
pressure on. Two ways to perform the test:
I. Release the pressure: If blood rapidly fills from
above, there is incompetence of sapheno-
femoral valve.
II. Keep the pressure on for 1 minute: If blood
gradually from below, there is incompetence
of perforator veins or communicating veins.
Basic Anatomy: Lower limb veins have superficial and deep systems
connected by communicating or perforator veins. Flow is always
from superficial to deep veins unless pathology exists. Many
mechanisms like venae comitantes and calf pump exists for venous
drainage. Valves are present throughout the venous system.
Incompetence of perforators or valves result in varicose veins.

Tests for Venous System
(Lower Limb)
Description
Tourniquet test (Oschner
Mahorner’s test: Multiple
tourniquet test)
Tie tourniquet at different level after emptying the veins. Ask the patient
to stand up. If veins above tourniquet fills up: perforator incompetence
above. If it fills below and above remains collapsed: perforator
incompetence below.
Perthe’s test In Perthe’s test, elastic bandage is wrapped from toes to groin and
patient is asked to move around. Severe crampy pain suggests DVT.
In modified Perthe’s test instead of elastic bandage, a tourniquet is tied
below saphenofemoral junction without emptying the veins. Ask the
patient to walk quickly. If deep and communicating veins are normal,
varicose veins will shrink. If blocked veins would be more distended and
bursting pain felt.
Schwartz test The Schwartz test simply checks continuous column of blood due to
valvular incompetence. Keep one finger at saphenofemoral junction or
upper end of visibly dilated veins and tap dilated vein at lower end of leg:
impulse felt.
Pratt’s test Apply Esmarch bandage from toes to groin. Apply tourniquet at groin
and take off the bandage. Apply the bandage from groin downwards.
Look for blow outs or visible varices in place of perforators.
Morrisey’s Cough Impulse
test
Empty the vein by elevating it. Ask the patient to cough and feel the
expansile impulse at saphenofemoral junction.
Fegan’s test Mark the excessive bulges within the varicosities. Ask the patient to lie
down. Palpate along the marked areas to feel for crescenteric gaps/pits
in deep fascia.

Moses’ Sign: While gently squeezing lower part of calf from side to side, pain develops in DVT
Neuhof’s Sign: Thickening and deep tenderness elicited while palpating deep in calf muscles

Causes of breast retraction?
Developmental retraction
Carcinoma of breast
Developmental
retraction
Carcinoma of breast
Circular Slit like (see the picture)
Can be everted Cannot be everted
No underlying swelling
palpable
Underlying swelling
palpable

Breast Examination
Positions
Purpose of the Position
Sitting position with arms by
the side of body
Information on level of nipples, lump and
palpation of axillary lymph nodes
Sitting position with arms
raised over the head
Lump or nipple retraction becomes more
prominent
Sitting and bending forward Fixity of the breast to chest wall and pectoralis
major muscle
Sitting and hands on the waist Abnormal movement of nipples or exaggeration of
skin dimples
Recumbent with 45° head end
elevation and both hands by
side of head
To palpate the breast lump against the chest wall
in recumbent position

Blockage of subcuticular lymphatics
with oedema of skin
Deepens the mouth of sweat glands
and hair follicles
Typical orange peel appearance
Peau d’ orange appearance in
Breast Carcinoma

What is Bapat test?
Also known as bed shaking test, bapat test is used
to diagnose early peritonitis
Foot end of the bed is moved slightly
Pain is evoked at the site of inflamed organ

Poor Stream of Urine: Does the
stream improve on straining?
Yes: Urethral Stricture
No: BPH
BPH Carcinoma Prostate
Consistency: Rubber like Consistency: Stony hard
Surface: Smooth Surface: Irregular
Median groove and lateral sulci:
Deepened
Median groove and lateral sulci:
Obliterated
Mobility of rectal mucosa: Present Mobility of rectal mucosa: Absent
Arises from transitional zone
(Submucosal gland)
Arises from peripheral zone (Prostatic
gland proper)

What are the criteria for removal of Chest Tube?
Lung fully expanded in Chest X-Ray with no air leak on
removal of suction or forceful coughing.
If this is confirmed, chest tube placed on water seal for 4-24
hours depending on initial severity and another CXR is taken.
If no renewed pneumothorax and no air leak on forceful
cough, remove chest tube.
Tube clamping can also be performed for 4-6 hours before
removal with chest radiograph repeated at intervals viz. 2
hours, 6 hours and 12 hours. If no accumulation, remove
chest tube.
Ideally for pneumothorax, the chest tube should remain in
place for at least 24 hours after the lung reexpands and air
leak ceases.
Drainage of <50 cc fluid/day.
If patient is on mechanical ventilation, the chest tube may be
needed as long as the patient needs mechanical ventilation.

Surgical Site Infection (SSI)
Infection within 30 days after surgery if no implant
is placed and within 1 year if implant is in place and
infection appears to be related to the operation

Superficial Incisional Surgical Site Infection
Involves only skin and subcutaneous tissue of incision with at least
one of the following:
I. Purulent drainage with or without laboratory confirmation from
superficial incision
II. Organisms isolated from aseptically obtained culture of fluid or
tissue from superficial incision
III. A least one of the following signs or symptoms of infection: pain
or tenderness, localized swelling, redness, heat and incision is
deliberately opened by surgeon unless incision is culture
negative
IV. Diagnosis made by surgeon or attending physician

Deep Incisional Surgical Site Infection
Involves deep tissue (muscles, fascia) with at least one of the
following:
I. Purulent discharge from deep incision but not from
organ/space
II. An abscess or evidence of infection involving the deep
incision is found on direct examination, during reoperation,
by histopathlogic or radiological examination
III. A least one of the following signs or symptoms of infection:
fever (>38°C), localized pain or tenderness, and incision is
deliberately opened by surgeon unless incision is culture
negative

Organ/Space Surgical Site Infection
Involves any part of anatomy (organ and spaces) other than
incision which has opened or manipulated during surgery with
at least one of the following:
I. Purulent drainage from a drain placed through a wound into
the organ/space
II. Organisms isolated from aseptically obtained culture of fluid
or tissue in organ space
III. An abscess or other evidence of infection involving the organ
space that is found during direct examination, reoperation,
by histologic or radiologic examination

Rates of SSI according to Wound Types
Wound types Infection rate
Clean 1-2%
Clean contaminated <10%
Contaminated 15-20%
Dirty <40%
Infection rates are variable based on various researches. These percentages are
just general guidelines on what to expect.

What is Ogilvie Syndrome?
Acute dilatation of colon in absence of any mechanical
obstruction in severely ill patients (usually in elderly sedentary
patients immobilized for other surgeries)
Also referred to as “acute megacolon” or “paralytic ileus of
the colon”
Correct fluid and electrolytes followed by colonoscopy to suck
out all air and place a long rectal tube
Cholinergic drug Neostigmine can stimulate and increase
colonic motility but has a potential dangerous consequence if
given in case of actual obstruction.

Setons in a Nutshell
 A seton is a nonabsorbable nylon or silk suture that is guided through
the fistula tract and tied exteriorly to be kept for weeks to months in
order to compress and maintain suture placement in the tract.
 Ischemic compression created by the seton and the local inflammatory
reaction of adjacent tissues initiate fibrosis. Fibrosis maintains the
integrity of the sphincter musculature during subsequent fistulotomy.
Also allow epithelialization of the fistulous tract, thereby preventing
secondary closure and facilitating the drainage of abscesses.
 Loose setons are used before advanced techniques (fistulectomy,
advancement flap, cutting section), as a part of staged fistulotomy (for
high level fistulas e.g. transsphincteric and suprasphincteric fistulas,
simple fistulotomy is contraindicated) & for long term palliation to avoid
septic and painful exacerbations by effective drainage.
 Cutting or tight setons are used for many reasons like when the fistula
is high enough and passes through enough portion of sphincter muscle
and to minimize sphincter dysfunction.
 Cutting seton gradually transect the anal sphincter musculature
underlying the fistula by externally tightening the suture to induce
pressure necrosis.

Signs of Peritoneal Irritation
Tenderness
Rebound tenderness
Guarding
Rigidity
Absent bowel sounds (silent abdomen)

Techniques of Lowering
Intracranial Pressure
Pathophysiology
Head elevation (up to 30 degrees) Increased venous outflow from brain
Sedation & Hypothermia Decreased metabolic demand and control of
hypertension
Mannitol Osmotic diuretic, extraction of free water out of brain
tissues (risk of rebound phenomenon). Use diuretics
(e.g. furosemide) but not to the point of lowering
systemic arterial pressure (Brain perfusion = Arterial
pressure – ICP)
Hyperventilation Carbon-dioxide washout, leading to cerebral
vasoconstriction (unmonitored hyperventilation can
lead to iatrogenic brain ischemia)
Steroids Decrease CSF production and edema
Surgery Ventriculostomy, external drains, shunt operations,
craniotomy, craniectomy or lobectomy
Intracranial pressure is a overall function of pressure of brain parenchyma (fairly constant except in
mass lesions), CSF (fairly constant unless ventricular flow obstruction is present) and Cerebral Blood
Flow (CBF). CBF increases due to hypercapnia, increased metabolic demand and hypoxia. Elevated
blood pressure further adds to the pressure milieu that sets in.

What are the reasons behind post-operative atelectasis?
Postoperative pain promotes shallow and rapid breathing (particularly in
abdominal and thoracoabdominal surgeries)
Narcotic analgesics depress the respiratory drive and cough reflexes
Anesthetic agents as well as drugs can decrease mucociliary clearance and
may promote bronchoconstriction
Pickwickian syndrome (Obesity hypoventilation syndrome)
Supine position increases the intraabdominal pressure acting on the
undersurface of the diaphragm limiting alveolar expansion at end expiration
thereby reducing Functional Residual Capacity (FRC)
Treatment includes incentive spirometry, adequate pain control, chest physiotherapy,
frequent repositioning or early ambulation, deep breathing exercises, continuous positive
airway pressure and intermittent positive pressure breathing.

Dumping Syndrome in a Nutshell
Post gastrectomy complication in which rapid emptying
(dumping) of hypertonic gastric content into duodenum and
small intestine
Release of intestinal vasoactive polypeptides and stimulation
of autonomic nervous system
Postprandial abdominal cramps, weakness, light-headedness
and diaphoresis is common
Symptoms may start around half and hour after eating
Dietary changes are helpful. Octreotide has shown some
benefits as well. Resistant cases might require reconstructive
surgeries.

Anterior Urethra Injury Posterior Urethra Injury
Penile and bulbar urethra distal to
urogenital diaphragm
Prostatic and Membranous urethra
Blunt trauma to the perineum (straddle
injuries) or instrumentation of urethra
Pelvis fractures are notorious for causing
posterior urethral injuries
Examination: Normal prostate Examination: High riding prostate with blood
at urethral meatus
Stricture may be present Stenosis is seen in posterior urethra
Inability to urinate may not be seen at the
outset but delayed presentation might be
complicated by sepsis secondary to
extravasation of urine to perineum, scrotum
or abdominal wall
Inability to void following major trauma
Injury to the urethra or bladder neck/anterior bladder (injury to the dome of bladder can
cause urinary leakage to the peritoneum) does not cause peritonitis by itself. The reason of
the coexistence is the association of these injuries with pelvic fractures or major trauma.

Urethral Trauma

Is it really undescended testicle?
Undescended testicle that has not reached the scrotum by the
age of one needs to be surgically corrected and brought down
to place for fixing (Orchiopexy)
If you find the testicle in the canal at birth which can easily be
pulled down where it belongs, then it is not a case of
cryptorchidism
Rather it is highly suggestive of a benign entity, known as
hyperactive cremasteric muscle (retractile testis).

Dynamic Fluid Response
Administer 250-500 mL fluid over 5-10
minutes
Based on the response of HR, BP and CVP:
1. Responders
2. Transient responders
3. Non-responders

Layers of the Scrotum
I. Skin
II. Dartos muscle and fascia
III. External spermatic fascia
IV. Cremasteric fascia
V. Internal spermatic fascia
VI. Tunica vaginalis
VII.Tunica albuginea
(@Some Daring Englishmen Called It True Testis)

Usually non-tender thus could mimic neoplasm
Incision and Drainage needs to be done. In some sites like breast,
axilla, parotid, thigh, ischiorectal abscess, we do not even wait for
fluctuation i.e. for abscess to fully form before drainage.

After confirmation of abscess by aspiration, skin is excised parallel to the
neurovascular structures in most dependent position. Pyogenic membrane is broken
by sinus forceps. All loculi are broken with sinus forceps or little finger. A drain is
placed. Wound is not sutured or closed.

Cellulitis Necrotizing soft tissue
infection
An acute, diffuse spreading infection
of the skin, subcutaneous tissues and
superficial lymphatics (sparing the
deep fascia)
Rapidly spreading infection involving
subcutaneous tissues and deep fascia
Patient less toxic, blisters are absent Patient more toxic, blisters present
Skin and fascial layers cannot be
separated by finger (Finger test is
negative)
Finger test is positive
Mild to moderate leukocytosis Marked leukocytosis
Remember to distinguish NSTI and gas gangrene. Gas gangrene
is clostridial, involves muscle and crepitus is heard.

Wound is defined as breach or discontinuity in skin, tissues or mucous membranes
which may be associated with its disruption of structure and function.

Southampton Wound Grading System
Major wound typically contains significant pus and patients are more ill systemically with
discomfort and delayed return to home.

Breast Carcinoma TNM

Confusion Corner:
Right Vs. Left? Anterior Vs. Posterior?
Right sided colon cancer presents with
bleeding and left sided with features of
obstruction
Posterior gastric ulcers are more prone to
bleeding and anterior ones to perforation

Truncal vagotomy causes gastric stasis, hence drainage is required. In HSV,
nerve of laterjet is preserved while criminal nerve of Grassi must be severed.
Alternatively, truncal vagotomy with antrectomy could be done for chronic
duodenal ulcers which again requires reconstruction of the GI tract (Billroth I
and II viz. gastroduodenostomy & gastrojejunostomy).

Types of Gastrectomy
Billroth I • Standard for gastric ulcers
• Distal stomach with pylorus is excised, new lesser curve
to match the size of duodenum created
• End to end gastroduodenal anastomosis is made
Pylorus preserving
gastrectomy (Maki)
• Pylorus along with the pyloric branches of vagus is
preserved
• Prevent rapid gastric emptying
Billroth II • Resection of around two thirds of stomach, closing the
duodenum and end to end gastrojejunal anastomosis
• Physiology is much altered
Vagotomy and antrectomy • Along with truncal vagotomy, antrectomy and
reconstruction of the GI tract is done
Subtotal gastrectomy • Stomach closed from lesser curvature and Roux loop is
created with gastrojejunostomy
Radical or total
gastrectomy
• Entire stomach, lymph nodes, greater and lesser
omentum is removed
• Oesophagojejunostomy with a Roux en Y loop is created

StepsofHandwashing

Kocher’s Hemostatic Forceps Vs. Allis
Tissue Forceps

Define Hernia
Abnormal protrusion of a
viscous or a part of viscous
through an opening, artificial
or natural in the walls of its
containing cavity with a sac
covering it.
Parts of hernia are covering, sac (with mouth, neck, body and fundus)
and its contents (omentum, intestine, bladder, meckel’s diverticulum-
Littre’s hernia, bowel wall- Richter’s hernia)

Inguinal Hernia Anatomy
Superficial inguinal ring: 1.25 cm above and
medial to the pubic tubercle
Deep inguinal ring: 1.25 cm above the mid
inguinal point
Inguinal canal: 4 cm in length, directed
anteriorly, medially and downwards

Contents of the inguinal canal
Spermatic cord in males
 Vas deferens
 Artery to the vas deferens
 Testicular and cremasteric artery
 Genital branch of genitofemoral nerve
 Pampiniform plexus of veins
 Remains of processus vaginalis
 Symphathetic plexus around artery to vas
Round ligament in females
Ilio-inguinal nerve

Hernia Hydrocele
Swelling in the inguinal region
extending into the scrotum
Hydrocele is a scrotal swelling
Shape is variable.
Femoral is retort shaped, indirect
hernia is pyriform shaped and direct
hernia is globular
Mostly globular
Cough impulse may be present No cough impulse
Fluctuation test and fluid thrill are
negative
Fluctuation test and fluid thrill is
positive
To get over the swelling not possible Possible to get over the swelling
Transillumination test is negative Transillumination test is positive

Late complications of blood transfusion include delayed hemolytic transfusion
reaction, post transfusion purpura, transfusion related graft versus host disease
and iron overload in multi transfused patients.

Hypothermia
Finding of “J” waves (Osborn waves) is characteristic finding of hypothermia.

Easiest entry is through left subclavian or right internal jugular veins.

PAIR Procedure for Hydatid Cyst
Indications Contraindications
Inoperable or patient refusing surgery Inaccessible cysts
Pregnant woman and children < 3
years
Calcified cysts
Multiple cysts Cysts with multiple thick internal
septal divisions (Honeycombing
pattern)
Infected cysts
Cysts with detached laminar
membrane

Hydatid cyst PAIR procedure

Hydatid cyst in Echinococcus

Acute Cholecystitis:

The boundaries of Calot’s (Hepatobilliary triangle) is:
Superiorly: Inferior margin of liver/cystic artery
Laterally: Cystic duct
Medially: Common hepatic duct

Courvoisier’s Law
A palpable gallbladder is unusual in patients with
obstructive jaundice because the obstruction
causes inflammation, thickening, fibrosis,
contraction and nondistensible gall bladder.
Courvoisier’s Law: “In a jaundiced patient if
gallbladder is palpable and non tender, it is rarely
due to stones.”
Exceptions to Courvoisier’s Law:
i. Double impacted stone- one in CBD & one in
cystic duct with mucocele of gall bladder
ii. Large stone in Hartman’s Pouch
iii. Empyema Gall Bladder

Why direct hernia is very rare in
females?
Because of the stress of the childbearing, the
transversalis fascia in females is stronger in the
floor of the inguinal canal than in males, so since
Hesselbach triangle consists of only transversalis
fascia covered by external oblique aponeurosis they
provide additional strength to females.
Weakening of the conjoint tendon can precipitate a
direct hernia. Deficient insertion of this conjoint
tendon predisposes men to direct hernia. In
females, the attachment is quite wider hence the
protective effect.

Hemorrhoids refer to sliding down of vascular and connective anal
cushions i.e. aggregation of blood vessels, smooth muscles and
connective tissues abnormally due to straining and other causes.

Primary positions for hemorrhoids are 3,7 and 11 o’clock positions. Above is the
classification of internal hemorrhoids. External hemorrhoids present as painful,
olive shaped blue cutaneous swellings.

Post-operative Fever

Anal Fissure in a Nutshell
Conservative treatment of anal fissures is similar to that of
hemorrhoids. Adequate fluid, alteration of bowel habits to make
defecation less traumatic, fiber diet, stool softeners, sitz baths,
topical anesthetics before defecation, pharmacological agents
to relax internal sphincter and increase blood flow.
Operative treatment include Lord’s dilation, dorsal fissurectomy
with sphicterectomy & lateral anal sphicterectomy.
Anal fissure is a small tear or cut in the lining of
the anus.

The accumulated products like lactic acid, potassium, complement, neutrophil and
microvascular thrombi are flushed into the mainstream circulation causing
widespread damage.

Causes of Acute Pancreatitis
Drugs include corticosteroids, isoniazid, valproate, thiazides, azathioprine, oestrogen

Whipple Procedure (Pancreaticoduodenectomy)
 Parts resected:
 Gall bladder
 CBD
 Head of pancreas
 Duodenum
 Proximal 10 cm of jejunum
 Part of stomach i.e. pylorus (in non-pylorus preserving type)
 Lymph nodes (peripancreatic, perihepatic, pericholedochal,
periduodenal)
 Anastomosis:
 Pancreaticojejunostomy
 Choledochojejunostomy
 Gastrojejunostomy

Important Acronyms
• APACHE: Acute Physiology And Chronic Health
Evaluation
• POSSUM: Physiologic and Operative Severity
Score for the enUmeration of Morbidity and
Mortality

Acute Pancreatitis Conservative
Management (@PANCREAS)
Pain relief
Protease inhibitors
Plasma
Rehydration – IV fluids, blood plasma
Ranitidine iv 50 mg 8 hourly
Respiratory support
Resuscitation when required
Analgesics
Anticholinergics
Endotracheal intubation
Electrolyte management
NG aspiration, NPO
Nutritional support (TPN)
Nasal oxygen
Antacids
Calcium gluconate 10 mL 10% 8 hourly
Calcitonin
CVP line
Somatostatin, Swan-Ganz catheter for CVP
and TPN
Surgery if required (Necrostomy, wide
debridement, drainage, open if infected
pancreatic necrosis)

Ranson Criteria for Acute Pancreatitis:
On admission After 48 hours
Age > 55 years Blood Urea Nitrogen > 5 mg percent
WBC count > 16000/mm3 PaO2 < 60 mmHg
Blood glucose > 10 mmol/L Serum calcium < 2 mmol/L
LDH > 700 units/L Base deficit > 4 mmol/L
AST > 250 units/L Fluid sequestration > 6 L

Glasgow Scale for Acute Pancreatitis:
On admission After 48 hours
Age > 55 years Serum calcium < 2 mmol/L
WBC count > 15000/mm3 Serum albumin < 3.2 g/L
Blood glucose > 10 mmol/L LDH > 600 units/L
Serum urea > 16 mmol/L AST/ALT > 600 units/L
PaO2 < 60 mmHg

Pancreatic Pseudocyst

Though Goldman's index of cardiac risk doesn't exactly assess the risk, it's still useful
to list out the high risk factors. Ejection fraction below 35%, JVP distention, transmural
or subendocardial MI is associated with very high mortality.

Subclavian steal syndrome
A blockade at the origin of subclavian artery allows
blood supply to the arms for normal activity but
not enough to meet the higher needs.
When demand increases, the arm may be supplied
by blood flowing in a retrograde direction down
the vertebral artery at the expense of the
vertebrobasilar circulation.
Presents with both vascular (coldness, tingling,
muscle pain) and neurologic (visual disturbances,
equilibrium problems) symptoms.

MelanomaRiskFactors

Sheehan’s Syndrome

What can be considered 5th vital sign in
Surgery apart from temperature, pulse,
blood pressure and respiratory rate?
Pain scale
CRT is considered as fifth vital sign in pediatrics.

Splenic Injury

Timing of Hematuria

Magnesium ammonium stone (Struvite) stones can be very large. Most sensitive to
ESWL is uric acid and least sensitive is cysteine. Risk factors include Vitamin A
deficiency, dehydration, urinary stasis and decreased urinary citrate.

Normal narrowing of the Ureter:

Free gas under Diaphragm
 Perforation of hollow viscus (peptic ulcer or
colonic perforation)
 Penetrating abdominal injury
 Post operative: Laprotomy, laproscopy,
peritoneal dialysis
 Hysterosalphingogram
 Infection by gas forming organisms
Not to be confused with fundic gas which is irregular & lighter if free gas under diaphragm is
in left side. True pneumoperitoneum is usually crescentric and darker. Also, careful to
exclude Chiladiti syndrome (interposition of colon between liver and diaphragm also known
as pseudopneumoperitoneum).

Sinus Vs. Fistula
Sinus is a blind ending tract that connects a
cavity lined with granulation tissue with an
epithelial surface.
Fistula is an abnormal communication
between two epithelial surface. Just like the
cavity in sinus, the tract is lined by granulation
tissue but may become epithelialized in
chronic cases.

Surgery for Cleft Lip & Cleft Palate

A flap is transferred with its blood supply intact, and a graft is a transfer of tissue
without its own blood supply or a extra tissue material. Therefore, survival of
the graft depends entirely on the blood supply from the recipient site.

Small Bowel Obstruction Erect X-Ray
Multiple air fluid
levels in erect X-Ray
of abdomen
Normal air fluid
levels:
I. Fundus
II. Duodenal cap
III. Terminal ileum

Sterilization of Instruments
I. Physical
 Heat (Dry & Moist Heat)
 Radiation
 Filtration
II. Chemical
 Liquids (Alcohol, Phenolics, Aldehyde,
Halogen, Dye, Surface active agents)
 Gaseous (Ethylene oxide, Formaldehyde)
Autoclaving (121°C at 15 lbs) can sterilize most metallic instruments and rubber goods except
sharp instruments. Metallic instruments require 30 minutes and rubber good require 15
minutes. Sharp instruments are kept dipped in concentrated Lysol for 1 hour or 2%
glutardehyde (cidex) for 4 hours to sterilize.

Autoclave Principle

Common Modes of Antisepsis
Chlorhexidine
Povidine iodine
Cetrimide (Savlon)
Alcohol
Hypochlorites
Chloroxylenol (Dettol)

Plain Catgut
(Yellow)
Chromic Catgut
(Brown)
Polypropylene
(Blue)
Silk
(Black)
Loses 50% tensile
strength in 3 days,
100% in 15 days.
Completely absorbed
in 60 days. Made
from submucosa of
jejunum of sheep.
Loses 50% tensile
strength in 7 days,
100% in 28 days.
Completely absorbed
in 90 days. It is catgut
with chromic acid
salt.
Non absorbable Non absorbable
 To tie small
subcutaneous
vessels
 To approximate
subcutaneous
tissue during
closure of incision
 In circumcision to
suture cut margins
of prepuce
 To tie
mesoappendix and
base of appendix in
appendectomy
 In two-layer
anastomosis of
small gut or
anastomosis during
gastrojejunostomy
 To stop bleeding
from gall bladder
bed in
cholecystectomy
 In repair of
posterior inguinal
wall during hernia
surgery
 To secure a prolene
mesh
 Closure of skin
incisions
 Repair tendon
injuries
 To ligate cystic duct
and cystic artery in
cholecystectomy
 To ligate pedicels in
nephrectomy and
splenectomy
 To secure drain
tubes
 To ligate vagus
nerve trunk in
truncal vagotomy

Surgical drain
systems
Special features
Open (static) drain Drained fluid collects in gauge pad or stoma bag
Infection rate is higher
Utilize the principle of gravity and capillary action
Examples include corrugated drain & penrose drain
Closed siphon drain Drain connected to sterile bag with or without one way
valve
Closed suction drain Negative pressure of -100 to 500 mm Hg is utilized
Sump suction drain Negative suction with a parallel air vent is used to
prevent adjacent soft tissues being sucked into the
lumen of the drain
Under water seal drain For drainage of pleural space
Drain is a channel that allows fluid or air to be expelled out after the closure of main wound.

Corrugated Rubber Drain
 Used for draining blood, pus or bile following surgeries. Also used
in hydrocele operation following eversion of sac.
 It prevents residual infection, does not get blocked and is cheap
but can cause retrograde infection, lack of quantitative or
qualitative assessment of drained fluid and discomfort due to
soakage.

@ Maggot SCAM

Lethal triad of Trauma
Tissue trauma and hypovolemic shock in combination would cause Acute Traumatic
Coagulopathy (ATC). Resuscitation should be done with caution as it could be counter-
intuitive. Resuscitation with cold fluids could aggravate two wheels of the triad causing
dilutional coagulopathy and hypothermia.

Viability check of gut after relief of obstruction

Dermoid Vs. Sebaceous Cyst

Cold Abscess:
Never forget that since cold abscess are very different from usual pyogenic abscess we
commonly encounter, treatment approach also varies. After surgery, to avoid persistent
drainage, there should be nondependent incision, suturing of the would after
drainage and no drain is kept.

Keloid Hypertrophic Scar
Non-cancerous fibrous proliferation in
dermis after injury
Thickened, wide, often raised scars
developed after injury
Genetic predisposition, more in females and
black
No genetic, gender or racial predisposition
Extends beyond original wound/incision Limited to original wound
Do not promote scar contracture Promote scar contracture
Vascular, tender and itching Non-vascular, non-tender and no itching
Etiology is not known Related to tension lines
Progressive, very high recurrence Regressive, recurrence is uncommon
Usually in chest wall, upper arm, lower neck
or ears
Anywhere

Pseudocyst
Cysts which either have no epithelial lining or the fluid
thus collected is derived from degeneration and
exudation, not as a result of secretion from the lining.
 Exudation cyst (pseudocyst of pancreas)
 Degenerative cyst (cystic degeneration of a
tumor)
 Traumatic cyst
Q: What is a corn?
A: localized, palpable, painful nodule with central core of dead cornified skin over
bony projections like head of metatarsals.

In children, measure length from alae nasi to tragus and then to
xiphisternum.

What do you understand by surgical
emphysema?
Collection of gas or air in the subcutaneous
tissues or fascial plane.
Causes include lung, tracheal or chest wall
injuries and after laparoscopic procedure.

What do you mean by post-cholecystectomy syndrome?
Symptoms may be due to bile flow in upper GI tract causing reflux esophagitis and
gastritis while bile flow in lower GI tract causes lower abdominal pain and diarrhea.
Other symptoms could be attributed to structures in biliary tree and extra biliary
structures like esophagus, stomach and duodenum.

Notice that here the stone is not in the CBD rather its impacted in the
Hartmann pouch of gallbladder and compresses CBD.

Ankle-Brachial Pressure Index

Classification of Ulcers
Pathological
Classification
Wagner’s Grading Clinical Classification
Specific
(tuberculous,
syphilitic, fungal)
Grade 0 to Grade 5 Spreading
Non specific
(traumatic, trophic,
apthous)
Healing
Malignant Callous

Ulcer Edge varieties

Boundaries of Safety triangle

Hydrocele is the abnormal accumulation of serous fluid in
a part of processus vaginalis, usually the tunica vaginalis.
Etiology:
 Excessive production e.g. in secondary hydrocele
 Defective absorption as in most primary hydrocele
 Interference with lymphatic drainage of scrotal structures
 Connection with peritoneal cavity via patent processus vaginalis (congenital)
Complications:
 Rupture, Bleeding (Hematocele formation), Degeneration (calcification),
Infection
 Herniation of sac through dartos muscle
 Testicular atrophy, dermatitis, micturition and sexual issues
Treatment:
 Herniotomy for congenital & treatment of cause on secondary hydrocele
 Jaboulay’s procedure (eversion of sac)
 Lord’s plication (subtotal excision and plication of remnant of sac)
 Aspiration of hydrocele fluid (but would reoccurs in a week, elderly or unfit
patients for surgery)
 Injection of sclerosant viz. tetracycline

Jaboulay’s Procedure (Eversion of sac)

Six Steps of Breaking Bad News

What to ask for history of a
swelling?
Duration
Usually the patient’s answer
is the duration since he
noticed the swelling
Mode of onset
Progression
Inflammatory swelling would
first increase and then later
decrease in size once the
inflammation subsides
Exact site
Usually for a huge swelling.
Patient might be better able
to tell it as he/she had seen
its progression
Pain
Secondary changes
Softening
Ulceration
Fungation
Inflammatory changes
Associated features
Fever
Impairment of function
Loss of body weight
Chest pain, hemoptysis,
cough, bone pain,etc.
Others
Past history of swelling,
personal, family, treatment,
allergy history as usual

What are 6 “S” of inspection?
1. Site
2. Size
3. Shape
4. Surface
5. Skin
6. Surrounding area

Inspection of a swelling Palpation of a swelling
Site Temperature
Size Tenderness
Shape Confirmation for inspectory findings
Surface Consistency
Skin Fluctuation
Surrounding structures Transillumination
Edge Reducibility
Number Compressibility
Pulsation/Peristalsis Pulsatility
Impulse on coughing Fixity of overlying skin
Movement on respiration,
deglutition, protrusion of tongue
Relation to underlying structures
Any pressure effect Indentation
Percussion is performed for some swellings including bowel containing hernias
(enterocele), hydatid thrill. All pulsatile swelling should be auscultated for bruits and
murmurs.

In infants:
Head: 18%
Each legs: 14% & 14% (more specifically its 13.5 % allocating 1% to perineum)
For child greater than 1 year, for each year decrease head by 1% and add those 0.5% to
each legs.

Burn
If a patient presents late to the health facility, calculate the fluid to be administered from
the time on the burn, not from the time of presentation if no fluid was administered
before presenting to the health facility.

Confusion Corner: Do we always use Parkland
formula for fluid calculation in burns?
Parkland aka Baxter formula in honor of Dr. Charles R. Baxter
and other formulas are not the exclusive ways to dictate fluid
administration
If burn surface area is >20%, administer 1000 mL/hr of RL
without sugar (20 mL/kg/hr in babies), then adjusted and
fine-tuned the amount to maintain urinary output 1 or 2
mL/kg/hr
Why is sugar avoided in Ringer Lactate?
Sugar causes osmotic diuresis from glycosuria. Since we are
using urinary output as our guiding factor for fluid
administration, it is avoided to prevent falsely increased
urinary output.

Boerhaave syndrome occurs when a person vomits against a closed glottis
causing leak into the mediastinum, pleural cavity and peritoneum.
Mallory Weiss syndrome causes longitudinal tear in the mucosa just below
cardia, leading to severe hematemesis.

Gastric Outlet Obstruction:

Inflammatory Bowel Disease

Which gas and instrument is used to create
pneumoperitoneum in laparoscopic surgery?
 Carbon dioxide gas
 Veress needle

Level of axillary lymph nodes
• Level I: below and lateral to pectoralis minor
(anterior, posterior and lateral)
• Level II: behind pectoralis minor (central)
• Level III: above & medial to pectoralis minor
(apical)

Causes of Urinary Retention
Male Female Both
Bladder Outlet
Obstruction
Retroverted gravid
uterus
Blood clot
Urethral stricture Bladder neck obstruction Urethral calculus
Urethritis & Prostatitis Rupture of the urethra
Phimosis Neurogenic (injury or
disease of spinal cord)
Fecal impaction
Anal pain (like in
hemorrhoidectomy)
Post-operative
Drugs
Spinal anesthesia

Primary Vs. Secondary Bladder Stones
Primary stone is the one that develops in sterile
urine. Often originates in kidney and passes down
the ureter to the bladder where it enlarges.
Secondary stone is the one that occurs in the
presence of infection, bladder outflow
obstruction, impaired bladder emptying or
foreign body like nonabsorbable sutures, metal
staples or catheter fragments.

PSA value in locally confined cancer is usually < 10-15 ng/ml while its >30 ng/ml in metastatic
carcinoma. In prostate, the peripheral zone is the carcinomatous while transitional and central
zones are adenomatous, hence site for BPH.

What is Bladder Outlet Obstruction?
• It is a urodynamic concept based on pressure
flow studies characterized by low urinary
flow rate ( <10 mL/s) and high voiding
pressure (>80 cm of H2O)
Normal urinary flow rate is >15 mL/s. 10-15 mL/s is equivocal.
Normal voiding pressure is <60 cm of H20. 60-80 cm of H2O is
equivocal.

Lower Urinary Tract Symptoms (LUTS)
Voiding Storage
Poor flow Frequency
Intermittent stream Urgency
Sensation of incomplete voiding Nocturia
Straining (not improved by straining in
BPH unlike strictures)
Urge & Nocturnal incontinence (Enuresis)
Hesitancy & terminal dribbling
LUTS previously was called Prostatism but LUTS can be caused by any causes of BOO (e.g.
prostate cancer, bladder neck stenosis or hypertrophy, urethral strictures, functional
obstruction due to neuropathic causes), idiopathic detrusor overactivity, degeneration of
bladder smooth muscles and so on. Hence the interchangeable use is avoided.

Undescended Testis in a Nutshell
Surgical treatment is orchidopexy by Stephen and Flower technique.
Orchidectomy can also be done if the testis is atrophied.

Testicular Torsion in a Nutshell
Testicular torsion compromises testicular blood supply. It is a surgical
emergency. Risk factors include inversion of testis, high investment of
tunica vaginalis & separation of epididymis from the body of testis.
Signs in testicular torsion:
 Phren’s sign: pain not relieved on lifting the scrotum (difference from epididymo-orchitis)
 Angel sign: another testis is clappered
 Demin sign: twisted testis is higher than normal testis

Pathology: Adenocarcinoma Colon
Macroscopically, 4 forms of tumor can be seen
1. Annular type
(obstructive symptoms)
2. Tubular type
3. Ulcer
4. Cauliflower type
Bleeding

Paradoxical breathing is usually certain for clinical diagnosis.

Boundaries of femoral canal which
allows expansion of femoral vein
• Anteriorly: Inguinal ligament
• Posteriorly: Pectineal ligament
• Laterally: Femoral vein
• Medially: Lacunar ligament

Boundaries of Hesselbach's triangle
(Inguinal triangle)
• Inferiorly: Inguinal ligament
• Superiolaterally: Inferior epigastric vessels
• Medially: Lateral margin of rectus sheath
known as linea semilunaris

Femoral triangle (Scarpa's triangle)
boundaries
• Superiorly: Inguinal ligament
• Laterally: Medial border of sartorius
• Medially: Medial border of adductor longus
Contents: lateral to medial (NAVEL)

Boundaries of Inguinal Canal
• Anterior wall: 2 aponeurosis (external and
internal oblique)
• Posterior wall: 2 T (Transversalis fascia and
Conjoint tendon)
• Roof: 2 Muscles: Internal oblique &
Transversus abdominis
• Floor: 2 ligaments (inguinal and lacunar
ligaments)

Three fingers in Zieman’s test for Hernia
• Index: deep inguinal ring (indirect hernia)
• Middle: superficial inguinal ring (direct hernia)
• Ring: saphaneous opening (femoral hernia)

Intussusception
• Currant jelly stool
• Sausage shaped mass
• Claw sign on barium enema (ileocolic)
• Target sign/ Doughnut/ Bull’s eye (USG)

Reflux: is backward flow of gastric content.
Regurgitation: is defined as the perception of flow of refluxed gastric content into the
mouth or hypopharynx. Dr. Aryan (Anish Dhakal)

Sleeping on several pillows could create further compression on your abdomen by bending
you at the waist (similar to “sit ups”) and might promote reflux episodes while you are
sleeping.

Treatment of Achalasia Cardia

Suspensory ligament of Berry connects to the cricoid cartilage while pretracheal
fascia attaches to the body of the hyoid bone.

Lid signs in Thyrotoxicosis
• Dalrymple’s sign: retraction of upper lids
producing the characteristic staring and
frightened appearance (90% cases)
• Lid lag (von Graefe’s sign): when globe is moved
downward, upper lid lags behind (50% cases)
• Enroth’s sign: fullness of eyelids due to puffy
oedematous swelling
• Gifford’s sign: difficulty in eversion of upper lid
• Stellwag’s sign: infrequent blinking

Management of Myxoedema Coma
 Medical emergency (carries a high mortality rate)
 Altered mental state
 Hypothermia and a
 Precipitating medical condition, for example cardiac failure or infection
 Thyroid replacement, either bolus of 500 mcg of T4 or 10 μg
of T3 (IV or orally) every 4–6 hours
 If the body temperature <30 degree Celsius the patient must be
warmed slowly
 Other measures includes
– Intravenous broad-spectrum antibiotics and hydrocortisone
(in divided doses)
– Cautious use of IV fluid
– High flow oxygen

Acknowledgements:
Best of the best slides, pictures and
information on the web. Special thanks to all
those brilliant minds for their act of creation
and compilation of scientific material without
which this work would not be possible
Bailey and Love short practice of surgery
SRB’s Manual of Surgery, 5th Edition
A Manual on Clinical Surgery, S.Das
Sabiston Textbook of Surgery

Do we really need to have specific goals
at all times in our life? Do you feel
directionless and lost without goals?
https://medium.com/@anishdhakal718/do-we-really-
need-specific-goals-at-all-times-ca27912fd7c7

Surgery Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 21)

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