Case 1: Troublesome stomaThis 57 year old man was having increasing discomfort from his stoma and

associated leakage from a stoma appliance that was difficult to apply .

1 .What abnormality is shown.?A parastomal hernia

2. Methods for repair ?-consider stoma closure restoring intestinal continuity

-resiting stoma to another area with non attenuated abdominal wall tissues

-local repair. This may include amputation of some bowel length, suture plication of the abdominal wall defect, mesh repair to reinforce the abdominal wall tissues.

3. What is the elastic garment around this patients waist?-abdominal binder for symptomatic relief

Case 2: Sudden onset abdominal painThis 77 year old man collapsed at home complaining of abdominal

pain .

1 .What abnormality is shown.?Leaking Abdominal Aortic Aneurysm. 2.

Methods for repair ?- Open repair with interposition dacron graft, which

may have to be bifircated if the aneurysm extends down one or both iliacs. - Endoluminal repair is becoming more accessible especially in specialised centres and with careful patient selection

Case 3: Right sided abdominal pain

This 77 year old man with a prosthetic mitral valve presented complaining of right sided abdominal pain .

1 .What has happened to cause the pain.?Right sided rectus sheath haematoma. This patient will most likely be fully anticoagulated because of his heart valve. A spontaneous haemorrhage like this is uncommon but can be difficult to treat.

2. Treatment ?Observation in ICU, resuscitation, transfusion, correction of anticoagulation, analgesia and occasionally angiography and embolisation. 3. What is the subcutaneous mass in the anterior abdominal

wall ?Paraumbilical hernia, probably unrelated .

Case 4: Painless post auricular swelling

This man presented with a mass behind the left ear .

1 .What is the differential diagnosis.?Includes: sebaceous cyst lymphadenopathy lipoma inclusion dermoid dermoid cyst simple cyst

The differential is large. However it can be narrowed by considering the lumps physical characteristics. It is smooth, does not involve skin, there is no punctum, and if felt it is soft, fluctuant and importantly is quite transilluminable.

2. Further treatment ?A simple cyst would be uncommon in this area so it was excised and

submitted for histopathology - this showed a simple cyst.

Case 5: Significant abdominal wound infection7 days after a laparotomy this lady was very unwell with infection spreading from her abdominal wound. Blood gases were taken on her admission to the intensive care unit

1 .What do they demonstrate.?Extreme metabolic acidosis.Maximum respiratory compensation.Significant base excess.Adequate oxygenation if breathing room air.

2. What do you think of her wound infection now ?In the absence of another clear cause, the wound infection is obviously causing significant systemic sepsis. In fact, the infection has probably evolved into a necrotising fasciitis process and may be lethal.

Rapid resuscitation, IV antibiotics and wide surgical debridement will probably be necessary. There is some evidence that hyperbaric oxygen therapy has some

benefit in treating these very unwell patients .

Case 6: Bile in the drain tube

10 days after a laparotomy for a perforated gastric antral ulcer, there was bile draining from the drain tube .

1 .What xray has been performed.?A fluoroscopic sinogram (contrast injected down the drain tube).

2. What does it show ?The film shows contrast flowing down the drain tube and filling a cavity around the second (descending part) of the duodenum. The contrast is also seen entering the duodenal lumen. (on the film seen just to the medial aspect of the cavity)

With a perforated gastric antral ulcer the options are to patch repair the defect with an omental patch (also taking an ulcer edge biopsy to exclude malignancy). However, with a larger ulcer a distal gastrectomy may be required (as in this case) with the consequent

risk of duodenal stump leakage .

Case 7: Painful leg

This man was involved in an industrial accident. His legs were crushed across the thighs for 8 hours before he was able to be rescued. He sustained no other injuries .

1 .What complication has occurred?Compartment syndrome of at least the posterior compartment

2. What other clinical settings may result in this condition?Prolonged ischaemia from any cause. Embolic, thrombotic, traumatic, and associated with lower limb fractures and the resultant swelling.

3. What operation has been performed?Posterior calf compartment fasciotomy

4 .What are the indications this operation?Confirmed, or in the correct clinical context, the suspicion or

predicted occurence of this problem as a prophylactic measure .

Case 8: Acute shortness of breathThis 24 year old man presented with sudden onset pleuritic right scapular region pain and shortness of breath. A chest xray was obtained and prompted the emergency department to perform a

procedure .

1 .What does the xray show?The xray shows a right sided pneumothorax without evidence of tension (complete collapse, medisatinal shift, flattening of the dome of the diaphragm). A pigtail catheter has been inserted however there is incomplete re-expansion of the lung.

2 .How would you manage the problem in the emergency

department?The management of a symptomatic spontaneous simple pneumothorax is insertion of an intercostal catheter with connection to an underwater seal drain (UWSD). These drain chambers include the ability to apply regulated suction to the pleural cavity. Many surgeons would apply 20 cm water suction initially which can then be ceased 24 hours after re-expansion of the lung with daily chest xrays

to confirm the abscence of recurrent collapse .

3 .He returns 6 months later with the same problem. How would your management differ now?

Spontaneous pneumothorax typically occurs in thin fit young adults with a male preponderence. They also occur in patients with underlying chronic lung diseases in particular bullous emphysema and asthma.

Recurrence in a young man would be considered an indication for pleurodesis. VATS (video assited thoracoscopic surgery) pleurodesis is performed under general anaesthesia with double lumen intubation. Inspection of the apex of each lobe may reveal a congenital bulla which should be excluded from the bronchial tree by excision using and endoscopic stapler or simple endoloop application. The pleurodesis is then effected by abrasion and application of an irritant such as alcoholic iodine. two intercostal catheters are then left attached to the UWSD with suction.

Case 9: Bile in the drain post cholecystectomyA 55 year old woman is referred to you 10 days post cholecystectomy. The procedure was performed for acute cholecystitis and the dissection was difficult. The original surgeon reported finding "aberrant anatomy". There has been persistent drainage of bile from

the drain left at operation at approximately 500ml/day .

1 .What type of xray is this and what does it show?A sinugram has been performed with instillation of water soluble contrast via the drain tube. The contrast is seen to flow into a cavity that

communicates with the left and right hepatic ducts .

2 .How would you manage this problem ?The immediate concern is assessment and resuscitation of the patient who may have severe biliary peritonitis. If the drain has created a controlled fistula then this allows time to obtain further investigations to define the anatomy and plan definitive management.

3 .How would you classify this injury?

The Strasberg classification is the most practical and widely used classification. It incorporates the Bismuth classification which was initially developed to classify hilar cholangiocarcinoma.

This injury is a Strasberg E4 or Bismuth 4 with resection of the common hepatic duct including the confluence resulting in separation of the right and left ducts.

Case 10: Abdominal pain and bloatingA 32 year old man with Crohn's disease presented with several months of progressive abdominal pain and bloating. His symptoms were related to meals and as a result he had lost significant weight. He had previously undergone ileocolic resection with anastomosis and on this occasion you resect the area of the anastomosis and open

the specimen shown below .

1 .Describe the specimen shown.The specimen is an opened segment of bowel with neoterminal ileum on the left and an ileocolic anastomosis towards the right. At the anastomosis there is evidence of stricturing with significant submucosal fibrosis and thickening that extends proximally for at least 10 cm. The mucosa overlying the anastomosis is deeply ulcerated. There are also linear ulcers in the mucosa of the ileum.

2 .What are the histologic features of Crohn's disease?Crohn's disease is a chronic inflammatory disease characterised by transmuarl involvement with mucosal damage, non-caseating granulomas and fissuring with the formation of fistulas.

Crypt abscesses occur but are not specific for Crohn's. Deep ulceration may be adjacent to relatively normal bowel wall indicative of the discontinuous distirbution of the disease. Sarcoid-like granulomas may occur in up to half of patients and can be found in any layer of the bowel wall and even in otherwise normal appearing bowel.

Deep fissures may lead to fistula formation between loops of bowel or other adjacent organs. Extensive submocosal fibrosis leads to sticture formation

3 .What investigations would you perform prior to operation in this man?

It is important to confirm the diagnosis of recurrent Crohn's with stricture formation before embarking on resection. This can be done easily by colonoscopy and intubation of the terminal ileum. Colonoscopy also allows assessment of the extent of disease. Further assessment of the small bowel may require enteroscopy, radiologic enteroclysis or MRI (investigational at present).

Finally the patients overall fitness needs to be assessed. In particular the effects of malnutrition resulting from poor intake and malabsorption, chronic disease and probable chronic steroid use. Simple assessment is based on serum albumin and measurement of iron stores and vitamin B12. Other nutrients should be measured and replaced as appropriate.

Case 11: Statistically speakingA 52 year old woman has a 25mm mass in her left breast. It feels malignant and this is confirmed by core biopsy. She has no palpable lymph nodes in the axilla and basic staging investigations are normal. She raises the question of sentinel lymph node biopsy (SNB) to avoid

an axillary dissection. Her lymphoscintigram is shown below .

1 .What is a sentinel lymph node?2 .What are the common or

important risks of axillary dissection you would discuss?

3 .She asks you about the 7% false negative rate. What does the figure

mean?4 .How would you calculate the

sensitivity and specificity for a test?

1 .What is a sentinel lymph node? The sentinel lymph node is the first node draining a

particular anatomical location. The location of a sentinel node is able to be reliably determined by a combination of the injection of a radiolabelled traced and blue dye. The status of the sentinel node is used as a marker of the status of the entire nodal basin.

2 .What are the common or important risks of axillary dissection you would discuss ?

Major morbidity from axillary dissection is uncommon. The problem that many women complain of is anaesthesia or paraesthesia in the axilla, lateral chest wall and medial arm

which is related to division of intercostobrachial nerves .

Disruption of the long thoracic nerve to serratus anterior or the nerve to latissimus dorsi results in a more significant function deficit. The medial pectoral nerve supplying pectoralis major is also at risk. The rate of clinically significant chronic lymphoedema of the arm is as high as 10-15%. Seroma development in the wound is more common but usually resolves with repeat aspiration. Shoulder stiffness usually responds to physiotherapy and it is part of the breast care nurse's and surgeon's role to

discuss appropraiate exercises pre-operatively .

3 .She asks you about the 7% false negative rate. What does the figure mean?

The false negative rate means that of all those axilla's truly involved 7% will be falsely thought to be negative. It is the reverse of sensitivity (93%). This will lead to incorrect down staging of the patient resulting in potential under treatment with adjuvant therapies. One other issue needs to be considered in order to make sense of the false negative rate. That is the incidence of involvement of the axilla in early breast cancer. If only 20% of patients with early cancers have axillary disease and 93% of these will be correctly detected then only 1.4% (7% of 20%) of all patients will have an incorrectly staged axilla.

4 .How would you calculate the sensitivity and specificity for a test?

You will need to draw up a table with 4 potential result types. True positives, false positives, false negatives and true negatives

Sensitivity equals true positives divided by true positives + false negatives =TP/(TP+FN)

Specificity equals true negatives divided by true negatives + false positives =TN/(TN+FP)

Case 12: Pain and lump in the breast

A 24 year old woman has been breast feeding for 2 months. She now presents with a painful, red mass in the lower

outer quadrant of her left breast .

1 .What is the likely diagnosis? Lactational breast abscess

2 .What advice would you give her about breast

feeding? Continue feeding to encourage drainage of the breast. An

abscess develops when there is a relative obstruction to flow from a lobule of the breast related to inspissated material in the ducts. Organisms most likely ascend the duct after gaining entry through the nipple which may be cracked or damaged from feeding . The baby will not be harmed by feeding from this breast and should be fed from the effected side first. If feeding is too painful then the breast should be manually expressed.

3 .Outline you management plan for this woman

After a thorough history and examination the next investigation should be an ultrasound to confirm the presence and size of an abscess. Differentiation from mastitis without abscess may be difficult clinically. Heat packs and massage, particularly in a warm shower, may also help. Analgesia and antibiotics are usually required. Unless the overlying skin is thin and necrotic it is not

usually necessary to incise and drain a breast abscess .

Rather it is preferable to aspirate it with a large bore needle often with US guidance. This procedure may need to be repeated on a daily basis until the abscess resolves but creates less risk of a milk fistula and cosmetic deformity. The possibility of an inflammatory cancer always needs to be considered although this is unlikely in a lactating woman. As a result she should be followed up with clinical examination and imaging after resolution of the abscess.

Case 13: Growing neck lump

This 85 year old man is referred to you with an enlarging lump in the left neck .

Further information - see the following images

1 .Describe the lesion There is a hemispherical raised lesion which is deeply purple in color, smooth in contour, which seems to be involving the overlying skin.

2. What is the differential diagnosis? Malignant lesion - primary skin lesion or metastatic nodal disease

involving skin. Less likely would be an infected sebaceous cyst.

3. What else would you examine ?The skin of the head and neck, complete ENT exam, and other lymph node groups.

4. What do you see?Pigmented skin lesions consistent with melanoma.

5. Now what is your likely diagnosis ?Nodal involvement of metastatic melanoma .

Case 14: View at Laparoscopy

Can you identify the structures ?

1 .What type of retractor is marked by "A?"

2 .What segment of the liver is shown by "B ?"

3 .What is under the lesser omental fat at "C?"

4 .What organ is close to letter "D" just out of screen?

5 .Which lobe of the liver is demonstarted by "E?"

1 .What type of retractor is marked by "A?"Nathenson liver retractor

2. What segment of the liver is shown by "B ?"Segment 1, under the pars flaccida of the lesser omentum, otherwise known as the caudate lobe.

3. What is under the lesser omental fat at "C?"The region of the gastro-oesophageal junction and the oespophageal hiatus in the diaphragm.

4. What organ is close to letter "D" just out of screen?The spleen

5. Which lobe of the liver is demonstarted by "E?"The left lobe

Case 15. Hand pain and numbnessThis lady has had pain and numbness in the radial three fingers for over 20 years. These symptoms are worse at night time. She often

wakes at night and shakes her hands for relief .

1 .What syndrome is this typical of?Carpal tunnel syndrome

2. What complication is seen ?Thenar muscle wasting.

3. Confirmatory tests ?Nerve conduction studies - are always helpful to exclude other diagnoses. .

4.Treatment ? Conservative - splints, analgesia, treatment of any predisposing

cause, steroid injection into and around the carpal tunnel. All of these would be unsuitable in this case because of the significant symptoms and demonstrable thenar muscle wasting. Surgery - Open or endoscopic division of the flexor retinaculum. A

'carpal tunnel release '

Case 16: Intermittent abdominal pain and a lumpA 56 year old man has had several abdominal operations in the past. He presents complaining of a discomfort associated with a small lump which has developed in the midline wound near the

umbilicus .

1 .What is the likely diagnosis (shown at "C")?Incisional Hernia near the umbilicus. 2. What operation do you think was performed through the right upper quadrant scar? Marked "A" (He says he cant remember, however it was when he was a baby.)

A Ramstead pyloromyotomy for pyloric stenosis. He was the first child in his family, and his father had pyloric stenosis. 3. With the patient lifting his head off the bed, what is marked by

"B ?"Divarication of the rectii, there has been no incision here

Case 17: Discharging lump in natal cleftThis young man presents with a 12 month history of an

intermittently painful and discharging lump at the lower back .

1 .What is the likely diagnosis?A pilonidal sinus .

Case 18: Wrist swelling

This lady had a lump on the back of her wrist which was getting bigger and more painful.

1 .What is the likely diagnosis?Dorsal wrist ganglion. Clinical examination would confirm this, showing, a soft fluctuant mass, transillumination, no punctum, and usually fixed to the underlying dorsal wrist capsule. Sometimes they can

arise from the extensor tendon sheaths .

Case 19: Dead toe

This 69 year old man presented worried about the apperance of his toe .

1 .Describe the appearance of the toe marked 'A?'

2 .What do you think has been marked with a cross at 'B?'

3 .What is 'C'4 .What is seen in the

background marked 'D?'5 .If there was a strong pulse

felt at 'B', what do you think the patients main predisposing

condition would be?

1 .Describe the appearance of the toe marked 'A?' This toe is gangrenous. The characteristic colouration, shrunken prune-like

skin appearance and nail bed pallor confirm this. 2.

What do you think has been marked with a cross at 'B?'There is a cross marked with pen. This is most likely over the dorsalis paedis artery.

3. What is 'C?'This is a permanent ink mark outlining the extent of cellulitis. 4.

What is seen in the background marked 'D?'A hand-held doppler transducer. For assessment of the pulse site and waveform. 5. If there was a strong pulse felt at 'B', what do you think the patients main

predisposing condition would be?Diabetes. Demonstrating a predominant microvasculopathy .

Case 20: Minor head injuryThis young man fell from his bike 12 weeks earlier. He sustained a minor head injury in that he bumped his head at the point marked by the

arrow. He now presents with a painful and pulsatile mass at that site .

1 .What do you think has happened? The likely diagnosis is a traumatic false aneurysm of the

superficial temporal artery. 2. What treatment would you recommend?

Pseudoaneurysm arising from the superficial temporal artery (STA) is very rare and is most commonly caused by blunt trauma. Most pseudoaneurysms of the STA usually present as a painless pulsating mass, with concomitant symptoms according to location, and their size may rapidly increase.

The treatment of choice is ligation and resection .

Case 21: Abdominal X-rayThis Xray was taken in the emergency room for abdominal pain .

1 .What prior abdominal operation has the patient had?Cholecystectomy - probably laparoscopic because clips are

less useful at an open operation so are not usually seen .

Case 22: Subcutaneous foreign body

1 .What is the subcutaneous linear mass running along the chest wall?

An axillofemoral bypass graft 2.

It is not pulsatile. Does this change your diagnosis?Probably not, however this suggests that the bypass has

occluded .