Common Surgical stations for Finals

1. Common Surgical stations for Finals Razwan Ali

2. What I shall cover • Examination of a mass • Examination of an ulcer • Hernia examination • Diabetic foot examination • Examination of varicose veins

3. Examination of a Mass • Site • Size • Shape (reasonable to use descriptive terms e.g. pear shaped) • Surface (smooth, irregular etc) • Temperature (assess with dorsal aspect of hand) • Tenderness (watch patients face as you palpate) • Colour and texture of overlying skin (erythema) • Edge (clearly defined or indistinct)

4. Composition • Consistency • Stony hard • Firm • Rubbery • Soft • Fluctuation (feel two areas of lump whilst pressing on third) • Fluid thrill • Transillumination (if positive lump may contain water, serum, lymph or plasma, NOT blood) • Resonance • Pulsatility (transmitted pulsation/expansile pulsation) • Bruit (AV fistula-systolic murmur, Hernias-audible bowel sounds)

5. Reducibility (important in hernias and some vascular lumps) • Relationship to surrounding structures • State of regional lymph glands • State of local tissue ( and any neuro-vascular abnormality) • General Examination (always examine the whole patient)

6. Examination of an Ulcer • An ulcer is a break of the continuity of an epithelium • Generally examination of an ulcer will follow the same pattern as examination of an lump (e.g. site, size, shape etc) • However, there are additional features you should examine for………

7. Base- or floor of the ulcer may contain • Slough • Granulation tissue (capillaries, collagen, fibroblasts, inflammatory cells) • Deeper structures such as tendon or bone may also be visible • Edge- 5 types • Sloping (healing ulcer) • Punched out (commonly caused by diabetic neuropathy, peripheral arterial ischaemia) • Undermined (tuberculosis, pressure necrosis) • Rolled (basal cell carcinoma) • Everted (squamous cell carcinoma)

8. Depth-recorded by anatomically describing the structures it has penetrated • Discharge- may be serous, purulent. Always take a swab • Relations- may be adherent or invading deeper structure such as tendons, periosteum, bone. Local lymph glands may be enlarged (infection,malignancy) • State of local tissue (neurovascular examination especially important in lower limb ulcers)

9. Examination of a Herniae • “Any protusion of the whole or part of a viscus through an opening in the wall of its containing cavity that causes it to lie in an abnormal position.” • Certain physical signs are common to all herniae; • They occur at congenital or acquired weak spots in the abdominal wall • Most herniae can be reduced • Most herniae have an expansile cough impulse

10. Basic Anatomy you must know! • The inguinal ligament runs between the ASIS and pubic tubercle • The deep inguinal ring is an opening midway between the ASIS and pubic tubercle (midpoint of inguinal ligament). It lies lateral to the inferior epigastric artery • Inferior epigastric artery (continuation of femoral artery) lies at mid-inguinal point (halfway between ASIS and pubic symphysis) • The superficial inguinal ring lies above and medial to the pubic tubercle.

11. The inguinal canal lies above the medial half of the inguinal ligament between the superfical and deep inguinal rings • Direct Inguinal Hernia -occur at site of superficial inguinal ring • Indirect Inguinal Hernias -occur at deep inguinal ring, travel down inguinal canal and may protude through superfical inguinal ring into scrotum.

12. Basic Anatomy

13. Borders of the Inguinal Canal • Anterior border is the external oblique aponeurosis • Posterior border is the transversalis fascia • Inferior border is the inguinal ligament • Superior border is the fibres of internal oblique and transversus abdominis (known as the conjoint tendon) • Please note this is a common exam question!!

14. Examination • Introduce yourself, wash hands, chaperone • Patient should be examined standing up and undressed from waist down • Start with Inspection. • Look for an visible lumps, any scars, overlying skin changes. • Inspection should also reveal whether the lump extends into the scrotum

15. Palpation • Stand at the side of the patient, with one hand in the small of the patients back to support him. • Your examining hand and arm should be roughly parallel to the inguinal ligament when palpating the lump. • Ascertain the following facts • Position • Size • Shape • Temperature • Tenderness • Can you get above it? • Presence of an expansile cough impulse-diagnostic of a hernia. May not be present if the neck of the sac is blocked by adhesions.

16. Is the swelling reducible? • Attempt to reduce the hernia by lifting upwards towards superficial inguinal ring. • Once passed through this point, slide finger upwards and laterally towards the deep inguinal ring. • Aim to see if the Hernia can be kept inside by pressure at this point. • If lump reduces into abdominal wall above and medial to the pubic tubercle- INGUINAL HERNIA • If reduces into abdominal wall below and lateral to pubic tubercle- FEMORAL HERNIA • Once reduced, press over the deep inguinal ring and ask the patient to cough. • If remains reduced- INDIRECT INGUINAL HERNIA • If protrudes- DIRECT INGUINAL HERNIA

17. To complete examination • Worth percussing and auscultating the lump (may be audible bowel sounds) • Always examine the other side • Examine the abdomen (for any cause of raised intraabdominal pressure e.g. enlarged bladder, ascites etc)

18. Diabetic Foot exam • Common exam station • Mixed aetiology (peripheral neuropathy and peripheral vascular disease) • Use simple system • Look • Feel • Move • Special Tests

19. LOOK • Colour (rough marker of state of perfusion) • Ulcers- especially at pressure points. Take care to look in between digits! • Amputation of digits • Dryness of skin • Shiny hairless leg • Charcots joints (painless disorganised joints due to loss of pain sensation) • Pes Cavus (due to peripheral neuropathy) • Infections (e.g. paronychia)

20. Feel • Start with Circulation in particular; • Temperature • Capillary filling time • Peripheral pulses (dorsalis pedis and posterior tibial) • Neurology • Light touch sensation, vibration, propioception, pain.

21. Move-not routinely done during diabetic foot exam. Could assess Gait • Special tests • Request Ankle-brachial Pressure Index • 10g nylon monofilament to formally test peripheral sensation in diabetic foot. • Patients feet are “at risk” if they cannot feel monofilament. • To complete examination, dipstick urine and look at the back of eyes for any evidence of diabetic nephropathy or retinopathy.

22. Examination of Varicose Veins • Veins of lower limb divided into superficial and deep systems. • Valves in communicating veins only allow blood to pass from superficial into deep system. • The superficial veins all join either the great or lesser saphenous system • The great saphenous vein joins the femoral vein at the sapheno-femoral junction, approximately 2.5cm below and lateral to the pubic tubercle. • The lesser saphenous vein joins the poplital vein at the sapheno-poplital junction, in the popliteal fossa.

23. Inspection • Visible, dilated and tortuous subcutaneous veins • Hyperpigmentation due to haemosiderin deposition • Oedema • Lipodermatosclerosis • Eczema • Venous ulcers (notably in the gaiter region-lower medial third of leg) • Varicosities at sapheno-femoral, sapheno-popliteal junction

24. Palpation • Palpate along the course of the main veins. • Feel for any areas of tenderness, especially along the medial aspect of the calf. • Temperature • Peripheral pulses

25. Cough test • Used to detect saphena varix (dilated great saphenous vein at sapheno-femoral junction due to incompetent valve) • Palpate the sapheno-femoral junction and ask the patient to cough. Positive if cough impulse felt. • Tap test • Again used to detect incompetent great saphenous valves. • Tap over dilated veins in upper thigh and place other hand over great saphenous vein below knee. • If percussion wave transmitted downwards, valves must be incompetent.

26. Tourniquet test/Trendelenberg • Patient should lie on couch • Limb to be examined is elevated (onto examiners shoulders) to empty veins • Further expedited by stroking blood in veins towards the heart. • Tourniquet then pulled tight around upper thigh. • Patient asked to stand and legs observed for 10-15 seconds • If veins below tourniquet do not rapidly fill, reflux controlled at this level. Thus sapheno-femoral junction site of incompetence. • BUT if veins below fill, must be other sites of superficial to deep incompetence below level of tourniquet.

27. Keep repeating with tourniquet moving progressively down the whole length of leg until you identify all site of incompetence. • Trendelenberg test is a modification and works by applying direct digital pressure to prevent retrograde filling • Hand-held dopplers can also be used to detect valve incompetence. • A uniphasic signal indicates competent valves • A biphasic signal indicates reflux and valvular incompetence.

28. Any questions?