Dr. Pawan lal

A) Fibula

Fibula and scapula free flaps are frequently used when soft tissue, epithelial lining, and bone are needed.

When soft tissue and epithelial lining is needed, commonly used free flaps used in head and neck reconstruction are the radial forearm, lateral arm, and anterolateral thigh

Up to 25 cm of the fibula may be resected with little effect on the gait as the fibula is a non-weight-bearing bone.

The fibular FF is most commonly used for mandibular reconstruction. Most importantly preoperative evaluation must ensure that the peroneal artery does not supply the foot because this is the main supplying artery of the FF and will lead to foot ischemia if harvested

Sabiston page 802

Ans b

2 weeks

• Balloon angioplasty without stent placement: Generally, surgery can be considered after 2-4 weeks, assuming the patient is stable.
• Bare-metal stent (BMS): Elective surgery is typically delayed for at least 4-6 weeks or 30 days  to allow for endothelialization and to reduce the risk of stent thrombosis.
• Drug-eluting stent (DES): Elective surgery is usually postponed for 6-12 months to minimize the risk of stent thrombosis, and dual antiplatelet therapy (DAPT) should be continued for that period.

For this 65-year-old male, if he only underwent balloon angioplasty (without stent placement), a safe window for colectomy might be around 2-4 weeks, depending on his cardiac stability and surgeon’s assessment. However, if a stent was placed, the waiting period will be longer, particularly for drug-eluting stents.

Sabiston 

Ans b

Causes of isolated prolongation of aPTT include deficiencies in factors VIII (hemophilia A), IX (hemophilia B), and XI

Isolated prolonged PT, in the absence of pharmacologic contributors or cirrhosis – Deficiency of Factor vii

Abnormal results on both PT and aPTT usually indicate a defect in the common coagulation pathway, comprised of factors II (prothrombin), V, X, and fibrinogen.

Sabiston page 201

Ans b

DSRS

Depending on whether they completely decompress, compartmentalize, or partially decompress the portal venous circulation,
portosystemic shunts can be classified as nonselective, selective, or partial

Commonly used nonselective shunts, all of which completely divert portal flow, include the

1. end-to side portacaval shunt (Eck fistula)
2. side-to-side portacaval shunt
3. large-diameter interposition shunts,
4. conventional splenorenal shunt

Sabiston page 1450

Ans: a

UCSF

An expanded set of criteria proposed by the University of California San Francisco (UCSF), referred to here as the “UCSF” criteria, allows patients with a

solitary tumor smaller than 6.5 cm

or patients having 3 of fewer nodules, with the largest lesion being smaller than 4.5 cm

having a total tumor diameter less than 8.5 cm without vascular invasion

Milan criteria

Ans b

The ASA (American Society of Anesthesiologists) physical status classification system is used to assess the fitness of patients before surgery. For this 58-year-old diabetic male with diabetic nephropathy (serum creatinine of 2.1), who is otherwise ambulant and without other complaints, his ASA grade would likely be ASA III.

ASA III is defined as a patient with severe systemic disease that limits activity but is not incapacitating, which fits this patient’s chronic kidney disease (due to diabetic nephropathy).

Grade III

ASA PS DEFINITION
I A normal healthy patient
II A patient with mild systemic disease
III A patient with severe systemic disease
IV A patient with severe systemic disease that is a constant threat to life
V A moribund patient who is not expected to survive without the operation

Ans b

Hemangiomas are the most common benign tumors of the liver and often present as asymptomatic lesions. They typically appear hyperechoic on ultrasound due to their vascular nature. Other potential diagnoses could include focal nodular hyperplasia (FNH) or hepatocellular adenoma, but the size and characteristics strongly suggest a hemangioma.

Cavernous haemangioma often presents with vague symptoms and signs. They may grow to considerable size. Liver function
tests are usually normal. The lesions are typically well defined and hyperechoic on ultrasound. A causative link between OCP
use and haemangiomata has yet to be established, but is possible.

While hepatocellular adenomas can also present as well-defined hyperechoic lesions in the liver, there are a few reasons why a hemangioma is more likely in this case:

1. Size: Hemangiomas can be quite large, often exceeding 4 cm, and they are frequently asymptomatic. In contrast, hepatocellular adenomas are generally smaller, though they can grow larger, they usually don’t reach sizes as large as 14 cm without other risk factors.
2. Patient Demographics: Hemangiomas are more common in women and can be found incidentally in patients who are otherwise asymptomatic. Hepatocellular adenomas are more commonly seen in women of childbearing age who have a history of oral contraceptive use or those with certain metabolic disorders. Without this additional context, a hemangioma is often favored.
3. Ultrasound Characteristics: Hemangiomas typically appear as homogeneous hyperechoic lesions on ultrasound. Hepatocellular adenomas can also be hyperechoic, but they may present with a more heterogeneous appearance, especially if there is hemorrhage or necrosis.

Ans a

A midline cystic mass of an infant in this age group is most likely to be a bronchogenic cyst. Hiatus hernia is unusual in the neonatal period.  Oesophageal duplication cysts are very rare and respiratory symptoms are less common than with bronchogenic cysts.
Bronchogenic cysts most commonly arise as a result of anomalous development of the ventral foregut. They are most commonly single, although multiple cysts are described. They often lie near the midline and most frequently occur in the region of the carina. They may be attached to the tracheobronchial tree, although they are seldom in direct connection with it.

Ans d 

Increases in hepatic arterial flow accompany decreases in portal vein flow, but the opposite does not occur.

There is a dual blood supply to the liver that comes from the portal vein and hepatic artery.

The portal vein provides approximately 75% of the blood flow to the liver, which is oxygen poor but rich
in nutrients. The hepatic artery provides the other 25% of the blood flow, which is oxygen rich and represents systemic arterial
blood flow.

The large flow rate of the portal vein is still able to provide 50% to 70% of the afferent oxygenation to the liver.

Sabiston page 1439

Ans c 

Perineal hypospadias. This is the rarest and most severe abnormality.

The scrotum is bifid and the urethra opens between its two halves.

In children with severe hypospadias it is important to consider disorders of sexual development, which are usually associated with testicular, maldescent and micropenis.

Bailey

Ans d

As per Southampton grading system of wound infections, major class begins at IV

All class IV wounds have pus discharge

Southampton Score

The Southampton score was originally designed by Bailey et al in 1992 to assess hernia wounds.¹⁰ Wounds are graded according to any complications and their extent:

• Grade 0—Normal healing
• Grade I—Normal healing with mild bruising or erythema
  • A—Some bruising
  • B—Considerable bruising
  • C—Mild erythema
• Grade II—Erythema plus other signs of inflammation
  • A—At 1 point
  • B—Around sutures
  • C—Along wound
  • D—Around wound
• Grade III—Clear or haemoserous discharge
  • At 1 point only (<2 cm)
  • Along wound (>2 cm)
  • Large volume
  • Prolonged (>3 days)
• Grade IV—Pus
  • A—At 1 point only (<2 cm)
  • B—Along wound (>2 cm)
• Grade V—Deep or severe wound infection with or without tissue breakdown; hematoma requiring aspiration.

Ans c

Stage Description
1 Non-blanchable erythema without a breach in the epidermis
2 Partial-thickness skin loss involving the epidermis and dermis
3 Full-thickness skin loss extending into the subcutaneous tissue but not through underlying fascia
4 Full-thickness skin loss through fascia with extensive tissue destruction, maybe involving muscle, bone, tendon
or joint

Ans d

Treatment of hypertrophic and keloid scars
● Pressure – local moulds or elasticated garments
● Silicone gel sheeting (mechanism unknown)
● Intralesional steroid injection (triamcinolone)
● Excision and steroid injections
● Excision and postoperative radiation (external beam or
brachytherapy)
● Intralesional excision (keloids only)
● Laser – to reduce redness (which may resolve in any event)
● Vitamin E or palm oil massage (unproven)

Ans b 

Main aim of primary salivary gland cancer is surgery with complete tumor resection.

For deep lobe parotid malignancy, a total parotidectomy (superficial and deep lobe) is usually required and includes removal of all parotid lymph nodes and mobilization of the facial nerve branches.

For other malignant parotid tumors, total superficial parotid lobectomy and total parotidectomy have each been advocated. If possible, the facial nerve and its branches should be preserved except in cases of gross tumor invasion

Sabiston

a) Lymphatics

This picture is of seminoma

Seminomas metastasise mainly via the lymphatics  and haematogenous spread is uncommon.

The lymphatic drainage of the testes is to the para-aortic lymph nodes near the origin of the gonadal vessels.  The  contralateral para-aortic lymph nodes are sometimes inolved

Bailey

Ans b

In cases of ectopic testis, the testis follows an abnormal path and ends up in an atypical location. The most common site is the superficial inguinal pouch, located just below and medial to the superficial inguinal ring. Less common ectopic locations include the femoral triangle, the root of the penis, and the perineum.

Bailey

Ans b

This is bulbar urethera injury

Next step would be to confirm the diagnosis and do Supra pubic catheter insertion

Bulbar urethral injury
●● Suspect urethral injury after blunt perineal trauma when the man cannot void, when there is perineal bruising and when there is blood at the urethral meatus
●● Diagnosis is made by urethrography using water-soluble contrast
●● The safest initial management is to insert a suprapubic catheter
●● Look for urinary extravasation and sepsis in the perineal haematoma
●● Delayed urethroplasty is the preferred definitive management of complete disruptions

Ans b 

Staphylococcal infections are usually suppurative and localised.

Most hospital Staphylococcus aureus strains are now b-lactamase producers and so are resistant to penicillin, but many strains remain sensitive to flucloxacillin, vancomycin, aminoglycosides and some cephalosporins.

BAiley

Ans b 

Primary tumors of the lip and oral cavity generally metastasize first to nodes in levels I, II, and III.

The upper lip primarily metastasizes ipsilaterally, whereas the lower lip has ipsilateral and contralateral drainage.

Tumors of the oropharynx, hypopharynx, and larynx usually metastasize to ipsilateral levels II, III, and

IV with the exception of supraglottic larynx and base-of-tongue subsites that can spread bilaterally.

Tumors of the nasopharynx spread to the retropharyngeal and para pharyngeal lymph nodes as well as to levels II through V.

Sabiston 21 page 775

Ans b 

Round worm obstruction

Plain abdominal radiograph and contrast CT scan will show the worms as tubular or curvilinear structures
●● Conservative management with anthelmintics is the first line of treatment even in obstruction
●● Surgery is a last resort – various options are available

Round worm

Larva causes loefflers syndrome or manifestations in lung

Adult worm causes pathology in small bowel, CBD, Pancreas

Bailey