Act as a Surgeon 🧠🔪

🔴Trauma Protocol (ATLAS) ▪︎It's An Injury To Any Part Of The Human Body Due To Energy Transfer From An Inflicting Source ▪︎Major (Severe) Trauma is Injury To >1 Body Region Or Organ Systems & ISS Score >15 (Injury Severity Score) ▪︎Severe Trauma is The Major Cause Of Death in Young Patients ▪︎Most Of Trauma Are Not Life Or Limb Threatening (Mild-Moderate in Severity) ▪︎Sources Of Trauma Could Be : 📍1. Mechanical 📍2. Chemical 📍3. Thermal 📍4. Ionizing Radiation ▪︎Most Common Causes Of Trauma Are : 📍1. Road Traffic Accidents (RTA) 📍2. Fall From Height (FFH) 📍3. Intentional Violence 🔷Mechanisms Of Injury 📍1. Blunt Trauma (Most Common) : ▪︎Direct Blunt Trauma ➡ Damage Localized To The Initial Site Of The Mechanism ▪︎Indirect Blunt Trauma ➡ Damage Occur At Distant Sites Away From The Initial Site Due To Force Transmission ▪︎Usually Due To RTA/FFH/Interpersonal Assault يرگعه بطابوگة 📍2. Penterating Trauma ➡ Occurs Due To Sharp Objects Passing Directly Through The Tissue (Knife/Gunshots) 📍3. Combined Trauma (Blast Injury) Results in : انفجار ▪︎Tissue Penetration From Sharp Fragments ▪︎Tissue Disruption From Shock Wave ▪︎Tissue Burns ▪︎Traumatic Amputation 📍4. Burn Trauma (Leading Cause Of Accidental Death) Mechanisms : ▪︎Thermal Injury ▪︎Chemical Injury ▪︎Electrical Burns ▪︎Frostbite 📍5. Hidden Mechanisms : ▪︎When Patient Not Telling The Truth Due To Criminal Activity Or Abuse ▪︎Theses Are Called Non-Accidental Injuries (NAI) ▪︎Factors Goes With NAI : 🔻I. Signs Of Injuries Not Consistent With The Reported Mechanism 🔻II. Long Bone Fractures in Children (Child Abuse) & Posterior Rib Fractures 🔻III. Patient Changing History & Aggressive Behaviour From Relatives 🔷Mx Of Trauma Patients 🔸A. Primary Survey ▪︎Focus On Rapid Identification & Mx Of The Most Life-Threatening Injuries ▪︎Consist Of cABCDE Protocol : 📍1. Control Haemorrhage From Massive Arterial Bleeding : ▪︎Massive Arterial Bleeding Usually Seen Due To Gunshots & Blasts (Military Practice) ▪︎Mx By : 🔻I. Direct Pressure On The Source Of Bleeding 🔻II. Pack Application 🔻III. Tourniquets Application (Monitor Time Of Tourniquet Application) 📍2. Airway & Cervical Spine Protection : 🔻I. Spine Immobilization (Using Cervical Collar & Log-Rolling Technique For Transfer Of The Patient) 🔻II. Airway Suctioning & Protection From Aspiration 🔻III. Airway Opening Maneuvers : ▪︎Jaw Thrust & Chin Left ▪︎Insertion Of OroPharyngeal Or NasoPharyngeal Tube ▪︎CricoThyroidotomy ▪︎Insertion Of Endotracheal Tube 📍3. Breathing & Ventilation : 🔻I. High Flow Oxygen For All Patients 🔻II. Immediate Mx Of Tension Pneumothorax Or HaemoThorax

#Esophageal_Cancer@Clinicalsurgeryround

❇️Glasgow coma scale ▪︎Severe, GCS < 8–9 ▪︎Moderate, GCS 8 or 9–12 ▪︎Mild, GCS ≥ 13.

❇️Examination of cannula ▪︎Size (Color) ▪︎Site ➡️ Correctly adjusted in the non dominant hand + away from joints ▪︎signs of thrombophlebitis ➡️ tenderness / erythema / cord like vessel / painful on touch ▪︎connected (to fluid,blood,Drugs) or not ? ▪︎The Dressing clean or not ▪︎the more distal, the better for the patient (risk of thrombophlebitis) ▪︎Away from the great vessels and nerves. ❇️Types of Cannula ▪︎Orange /Gray ➡️ Truma & Major surgery ▪︎Green ➡️ Irritant Drugs & Contrast ▪︎Pink (Most Common) ➡️ IV fluids / AB / Analgesics / Blood ▪︎Blue / Yellow / Violet ➡️ Small & fragile Veins in children /Neonates / Elderly

■General Body Examination ●Inspection : •Young/middle age /elderly Male/Female •In semi sitting/Supine Position •Looking Comfortable/uncomfortable/in pain/Anxious •Oriented/ Un oriented To Person Place-Time •With a normal body Shape/Obese •With a Blue/Yellow/Pink/ Cannula •In the Dorsum of left-right Hand •Left-right forearm (Brachial vein) •Connected/Unconnected to Iv Line •With a Clean/Dirty Dressing •Tender or Not ●After that Check : ▪︎The face of the patient (eyes - Pupil - Conjunctiva) •Pupil for Symmetry •Conjunctiva for pallor (Anemia) •Sclera for yellowish Discoloration (Jaundice) ▪︎The Upper limbs (Hands - Fingers - Nails) •Fingers for Clubbing •Skin Hands for pallor ▪︎The lower limbs (Looking for oedema) ▪︎After that measure the : •Pulse From Radial artery (Rate/Volume/Regulatory) •Temperature (in the axilla For 3 min) •Blood pressure •Respiratory rate (Count the Number of abdominal Muscles movements) ●After that examine the abdomen : •Expose the patient from nipple (2nd intercostal) to the Knee ▪︎Take a position At the feet of the patient and look to the abdomen And look at the follow : •The abdomen is Normal in the shape/Distended •Symmetrical or not ▪︎Take Position at the right side of the patient and get Downward to look close for : •Pulsation / Peristalsis •Type of Breathing (Thoracic/Abdominal) •Scars •Dressing Present or not (clean/Tender) •Drain Present or not (Type/content/amount) •The Umbilicus is inverted/Everted •Hair distribution •Ask the patient to cough and look for Hernia

🔴Esophageal Cancer ▪︎6th Most Common Cancer in The World With Early Dissemination & Late Presentation & Poor Prognosis (5-10% 5-Year Survival Rate) ▪︎More in Males ▪︎Symptoms Progress in 3-9m (Rapid) & So 70% Of Patients Are Inoperable At Time Of Dx 🔹Types & Risk Factors Of Esophageal Cancer 🔶A. Squamous Carcinoma 📍1. Most Common Worldwide (Specially East) 📍2. Affect Upper ⅔ Of The Esophagus 📍3. Response To Chemo-Radiotherapy 📍4. Risk Factors ▪︎Smoking & Alcohol ▪︎Achalasia ▪︎LeucoPlakia Of Esophagus ▪︎Corrosive Injury Of Esophagus ▪︎Hot Beverages ▪︎Chewing Tobacco & Betal Nuts ▪︎N-Nitroso (Salted Fish/Pickled Vegetables) 🔶B. Adenocarcinoma 📍1. More Common in The West 📍2. Affect Lower ⅓ Of The Esophagus 📍3. Risk Factors ▪︎GERD & Barrett's Esophagus ▪︎Obesity 🔹Clinical Features & Dx Of Esophageal Cancer 📍1. Early Symptoms ▪︎Progressive Dysphagia (1st To Solids Then To Liquids) ➡️ Most Common Presentation ▪︎Dyspepsia ▪︎Vague Feeling During Swallowing ▪︎Regurgitation & Vomiting ▪︎OdynoPhagia ▪︎Mild Weight Loss 📍2. Late Symptoms & Metastasis ▪︎Voice Hoarseness (Recurrent Laryngeal N Involvement) ▪︎Horner's Syndrome (Sympathetic Chain Involvement) ▪︎Chronic Spinal (Back) Pain ▪︎Cough On Liquid Swallowing (Tracheo-Esophageal Fistula) ▪︎Palpable SupraClavicular LN (Troisiers' Sign) ▪︎Palpable LN in The Neck ▪︎Cutaneous Tumour Metastasis ▪︎Haemoptysis (Tracheal Invasion) ▪︎Epigastric Mass (ParaAortic LN Enlargement) ▪︎Jaundice & Liver Enlargement ▪︎>20% Weight Loss & Appetite Loss 📍3. Confirm Dx ▪︎Upper Endoscopy & Biopsy (Gold Standard) ▪︎Barium Swallow ➡️ Irregular Short Esophageal Strictures With Shouldering Edges 📍4. Staging ➡️ CT/PET/EndoLuminal US/Laparoscopy/Bronchoscopy 🔹Metastasis Of Esophageal Cancer 📍1. Direct Spread ➡️ Laterally Through The Walls Of Esophagus & Longitudinally Within The Esophageal Wall 📍2. Lymphatic Spread ➡️ Involve Any LN From The Superior Mediastium To Coeliac Axis & Lesser Curve Of Stomach 📍3. Blood Spread ➡️ Liver/Lung/Brain/Bone 📍4. TransPeriToneal Spread 🔹Mx Of Esophageal Cancer 🔶A. Curable Case 📍1. Preoperative Chemo-Radiotherapy (Neoadjuvant) For Down Staging Of The Tumour 📍2. Total Tumour & Lymph Nodes Resection ➡️ Radical Esophagectomy 📍3. Postoperative Chemo-Radiotherapy (Adjuvant) 🔶B. Incurable Case 📍1. Endoscopic Stenting To Relive Dysphagia 📍2. Endoscopic Laser (To Create Tunnel Through The Tumor) 📍3. Palliative Chemo-Radiotherapy 📍4. Palliative BrachyTherapy (Direct IntraLuminal Radiation) 📍5. Palliative Esophagectomy 🔹Postoperative Complications Of Esophagectomy ➡️ GERD

#Esophageal_perforation@Clinicalsurgeryround

🔴Esophageal Perforation ▪︎Emergent Condition With High Rate Of Morbidity & Mortality Due To Sepsis 🔷Causes Of Perforation 📍1. Iatrogenic (Most Common) Due To ▪︎Endoscopic Dilatation Of Strictures Or Achalasia ▪︎Endoscopic Mucosal Or SubMucosal Resection (EMR/ESR) ▪︎PerOral Endoscopic MyoTomy (POEM) 📍2. Spontaneous Perforation (Boerhaave's Syndrome) ▪︎Due To Violet Vomiting (Sudden Increase in Esophageal Pressure Against Closed Glottis) ▪︎Perforation More On The Left Posterio-Lateral Lower Esophagus (Near Left Pleural Cavity) 📍3. Penetrating Trauma To Esophagus 📍4. Ingestion Of Sharp Foreign Body (Fish Bone) 📍5. Ingestion Of Corrosive Agents (More With Alkaline) 📍6. Esophageal Cancer Perforation 📍7. EosinoPhilic Eosophagitis (EOO) Risk Of Spontaneous Perforation 🔷Clinical Features Of Perforation 📍1. Upper (Cervical) Esophagus ▪︎Neck Pain & Tenderness ▪︎Subcutaneous Emphysema ▪︎Less Sepsis 📍2. Middle (Thoracic) Esophagus ▪︎Retrosternal Chest Pain ▪︎Dysphagia ▪︎Dyspnea & Cyanosis (Due To Pleural Effusion Or Pneumothorax) ▪︎MediaStinitis & Septic Shock ▪︎Most Dangerous Perforation 📍3. Lower (Abdominal) Esophagus ▪︎Peritonitis 📍4. Spontaneous Perforation (Boerhaave's Syndrome) ▪︎Triad Of ➡️ Vomiting & Chest Pain & Subcutaneous Emphysema ▪︎Haematemesis ▪︎Left Pleural Effusion ▪︎Hamman's Sign (Crunching Sound On Heart Auscultation Due To Surgical Emphysema) صوت طحن الاسنان ▪︎DDX Of Spontaneous Perforation (Boerhaave's Syndrome) ➡️ Pneumonia/Myocardial Infarction/Perforated Viscous 📍5. Fever/Tachycardia/Tachypneia/Hypotension (Sepsis) 🔷Dx Of Perforation 📍1. Chest Xray (Erect) ▪︎Exclude Perforated Viscous (No Air Under The Diaphragm) ▪︎Gas in The Soft Tissue (Surgical Emphysema in MediaStinum & Neck) ▪︎Widened MediaStinum ▪︎Pneumothorax & HydroPneumoThorax ▪︎Pleural Effusion 📍2. Contrast CT Or Barium Swallow (GastroGrafin Or Non-Ionic Contrast) ➡️ Confirm Dx & Reveal Site Of Perforation & The Extension 📍3. Endoscopy (Only If Dx In Doubt) 🔷Mx Of Perforation 🔸A. Resuscitation 📍1. Nill By Mouth 📍2. IV Fluids & Electrolytes Correction 📍3. Antibiotics 📍4. Oxygen 📍5. NG Tube ➡️ For Suction & Nutrition 📍6. Chest Tube ➡️ For Large Pleural Effusion & Pneumothorax 🔸B. Mx Of Perforation 📍1. Stable Patient & Limited Perforation (Cervical Esophageal Perforation) ➡️ Only Conservative Tx 📍2. Septic Patient (Thoracic Esophageal Perforation) ▪︎Endoscopic Sealing Of Perforation Using Clips & Metalic Stens ▪︎Surgical Repair Of Perforation 📍3. Delayed Presentation ➡️ Convert The Perforation Into Controlled Fistula Using T-Tube 📍4. Other Methods For Repair ▪︎Esophageal Diversion ▪︎EsophageCtomy (For Extensive Caustic Burns) 🔹Indications For Surgical Intervention 1. Significant Sepsis 2. Large Perforation 3. Thoracic Esophagus Perforation 4. Involved Pleural Cavity 5. Delayed Presentation

▪︎Radiating pain: (ينتشر)

•Starts in one area of the body and spreads along the path of the nerve to the other areas supplied by the same nerve •Herniated or bulging disc Pain start in the back and then progress to the legs (same nerve supply)

▪︎Referred pain:

•Pain felt at area not involved in the injury (Pain felt away from the real source) Because the sensory nerve fibres of these different areas meet at the same level in the spinal cord •Pain of MI felt in the left side of neck, left shoulder, and back rather than in chest (chest is the real site of the injury)

▪︎Migratory (Shifting) pain :

•Pain starts at site Generalized not specific due to stimulation of the Visceral afferent fibers then shifted to the injury site to become localized after stiumation of the Parietal (Somatic) Nerve Fibers and dissappear from the origin Site. •During acute appendicitis the pain start at the para umbilical area then localized to the RLQ area

●signs and symptoms of dehydration

▪︎Infant or young child •Dry mouth and tongue •No tears when crying •No wet diapers for three hours •Sunken eyes, cheeks •Sunken soft spot on top of skull •Restlessness or irritability

▪︎Adults

•Extreme thirst •Less frequent urination •Dark-colored urine •Fatigue •Dizziness •Confusion

#Esophageal_Diverticulae@Clinicalsurgeryround

🔴Esophageal Diverticulae (Pouches)

▪︎Diverticulae Are Small Bulges (Out-Pouching Or Herniation) Of Some Layers Of GIT Tract Wall Outside The Lumen Through A Weak Points Due To Chronic Pressure Against Obstruction ▪︎True Diverticulae ➡️ Full-Thickness Wall (All Wall Layers) Protrusion ▪︎False Diverticulae ➡️ Only Mucosal Protrusion

🔷Types Of Esophageal Diverticulae

🔸A. Pharyngeal Pouch (Zenker's Diverticulum)

▪︎Mucosal Protrusion Of The Esophageal Wall (False Diverticulum) Through Natural Weak Point (Dehiscence Of Killian) Between The Oblique & Horizontal Fibers Of Pharyngeal Constrictor Muscles (Between Inferior Constrictor & CricoPharyngeus Muscle) ▪︎Results in Posterior Diverticulae & Slightly Deviated To The Left ▪︎This Diverticulum Develops Due To High CricoPharyngeal Pressure After Losing Coordination Between The Pharyngeal Contraction & Opening Of Upper Sphincter (Uncoordinated Swallowing & Failure Relaxation Of CricoPharyngeus Muscle) ▪︎Most Common Esophageal Diverticulae (70%) & Occurs More in Elderly ▪︎Associated With Lower Cranial Nerves Dysfunction (CVA/Motor Neuron Disease)

🔸B. Mid-Esophageal Diverticulae (Rokitansky Diverticulum 20%)

▪︎Full-Thickness (True Diverticulum) Near The Bronchial Bifurcation ▪︎This Diverticulum Develops Due To Inflammation & Fibrosis That Exerts Traction Forces On The Esophageal Wall ▪︎Due To TB/Atypical MycoBacteria/HistoPlasmosis ▪︎Risk Of Fistulation Into The Trachea

🔸C. EpiPhrenic Diverticulae (10%)

▪︎Mucosal Protrusion (False Diverticulum) At The Distal 10cm Of The Esophagus (Near The Gastro-Esophageal Junction) ▪︎This Diverticulum Develops Due To Esophageal Motility Disorders (Achalasia Or Any Esophageal OutFlow Obstruction That Increases LOS Pressure)

🔷Clinical Features Of Esophageal Diverticulae

📍1. Mostly Asymptomatic 📍2. Dysphagia (Due To Swallowing incoordination) 📍3. Regurgitation From The Pouch & Risk Of Aspiration 📍4. Halitosis (Food Stasis in The Pouch) 📍5. Lump in The Neck (Pharyngeal Pouch) 📍6. Gurgling in The Throat

🔷Dx Of Esophageal Diverticulae

📍1. Barium Swallow (Gold Standard) 📍2. Endoscopy (Risk Of Pouch Perforation) 📍3. Tests For Esophageal Motility Disorders (ManoMetry)

🔷Mx Of Esophageal Diverticulae

📍1. DiverTiculeCtomy & CricoPharyngeus MyoTomy (Using Open Left Cervical incision) 📍2. Diverticular Suspension (Prevents Food Accumulation) 📍3. Endoscopic Stapling (Create Common Lumen Between The Pouch & The Esophagus)

DDX Of Herina/Lump in the Groin ■

Stoma Examination ■ ▪︎Begin by inspecting the stoma noting : ●The site (Right/Left Iliac fossa) ●the number of lumens (1 End/2 Loop) ●the presence or absence of a spout (Neck) ●the contents of the effluent (Solid/Fluid) ▪︎Inspect the surrounding skin for erythema, tissue breakdown، Hernia, fistulation ▪︎Spout present: ileostomy (مخرج الستومة بي عنق مثل القوري) ▪︎Spout absent: colostomy (مخرج الستومة ما بي عنق)

■❇️Stoma Types & Complications 🔹Indications of stoma (P2) ▪︎Permanent End ileostomy: after a panproctocolectomy (rectum & colon removal) for conditions such as ulcerative colitis or familial adenomatous polyposis. ▪︎Temporary End-ileostomy: during emergency bowel resection where it is considered unsafe to form an anastomosis with the remaining bowel at that time (e.g. intra-abdominal sepsis or bleeding). ▪︎Temporary loop ileostomy: protect distal anastomoses after recent surgery. 🔹Comparison ●Ileostomy: •Spout Present (عنق) •Fluid content •In right iliac fossa •Develop fluid & Electrolyte imbalance ●Colostomy: •No Spout •Solid content •In left iliac fossa

Types of ulcer edges ■ ▪︎Sloping edge : healing, traumatic and ischaemic venous ulcers. ▪︎Undermined edge : TB ▪︎Punched-out edge : ischaemic and syphilitic ulcers ▪︎Rolled edge : basal cell carcinoma ▪︎Everted edge : squamous cell carcinoma and the ulcerated adenocarcinoma.

Postoperative Fever in days

TESTICULAR TORSION.

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