Surgery : End Posting 9th term

Surgery end posting will soon come around the corner. What will i do?

Again, i'd like to write what i have to prepare for end posting which consist of viva  as well as case presentation.What shall i do?

First, prepare all the proforma for important topics based on Dass Surgery Clinical Manual. Reading proforma is much easier than reading right off the book.Read all the little notes you wrote.

Next, read the differential diagnosis part. You always left that particular part behind! Don't leave any SMALL printed words. It may come back to you some day somehow.

Prepare a bunch of viva questions in your mind. Don't slack off at the very last minute. Come On!! You can do it!

Practice the examination part and please remember all the test names! Don't confuse Brodie's-trendelenburgh test , Swartz and Perthe's test!

Last but not least, prepare the materials needed for physical examination. Don't forget to buy the AAA Batery for torch light!



P/S: Please read some theory part from Manipal Manual Of Surgery and SRB!!

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Surgery : Breast Carcinoma

Today, we had a great class of breast carcinoma. It is a very important class. Dr M taught us on the do's and the dont's of breast carcinoma examination.Yeah, and he did that in between the time when patient comes in and out of the OPD. Sometimes, after listening to Medical Representatives suggesting their companies drugs to be used in OPD.After 3 postings of surgery in India, i am now adapting well to norms of system.Well,  Dr M asked us  to present the case and yada yadda we told him about patient's history,inspection and palpation of breast while he expressionlessly  nit-picking using flat toned manner with tons of viva-style questions.

Picture courtesy from Radiology Malaysia.org

Now, here we go and present the case.

Chief complaint :She complains of painful left breast  since 1 month ago.

Long case made short.

Among positive findings that we encountered are :

On inspection there is presence of single ulcer at  the left breast with multiple nodules. The breast of affected site sags and the skin of breast seems normal. The nipple of the left breast is destroyed and floor of ulcer is covered by slough and seropurulent discharge.

By palpation we could feel the hardness of the breast lump which is multiple in number,varied in size between 5mm to 1.5cm. The breast ulcer is tender  and bleeds on touch, fixed to the breast tissue and have sloping edge with indurated margin. Single solitary axillary lymph node is appreciated.

Diagnosis :

 T4b Tumour with involvement of the skin in the form of eodema,ulceration and satellite skin nodules.

N1 Mobile ipsilateral axillary lymph node.

Note: Wear gloves  and wash your hands in between patients dear doctors!

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Seminar! Hate it!

Seminar... I hate seminar. Why? Because i have to speak and present my topic in front of class. Well, pretty much there is a HUGE chance of me getting interogated like a criminal. Making power point. LOVE it. Presenting part, HEARTLESS. Interogation part, HATE it ! Pfft! My topic today : Flexible Fibre Optic in Broncoscopy and Oesophagoscopy. Wish me luck!

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Surgery posting

Our teacher teaching us anatomy.

Syabas lah cikgu ni!

Penat mengajar sampai jadi tulang aje!

Berbekam baik untuk melancarkan pengaliran darah!

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Herniotomy Step By step

  

-indicated in children with inguinal hernia & before herniorrhaphy in adults

-Procedure:

1-ligate & divide the 3 superficial veins
2-divide the external oblique aponeurosis in the direction of its fibers
3-reflect the external oblique aponeurosis &identify the ilioinguinal nerve & reflect it over the aponeurosis
4-separate the cord from posterior wall of the canal
5-divide the creamasteric muscle & internal spermatic fascia
6-dissect the hernial sac up to its neck
7-open the fundus of the sac
8-reduce the contents
9-transfix the sac at the deep ring
10-excise the redundant sac


There are different approaches to surgical repairs to hernia which may include the following:

Hernioplasty when herniotomy is combined with a reinforced repair of the posterior inguinal canal with autogenous (patient’s own tissue) or heterogenous material such as prolene mesh.

Herniorraphy is somewhat like hernioplasty only that no autogenous or heterogenous material is used for reinforcement.

Herniotomy is a surgical operation where the hernia sac is removed without any repair of the inguinal canal.

Read more: Discussion on Hernia Repair, Herniorraphy | Res Ipsa Loquitur - OR Nurse 

*updated

Herniorrhaphy procedure: Bassini's 

Definition: It means herniotomy and approximation of conjoined tendon to inguinal ligament to strengthen the posterior wall of the inguinal canal.

Indication: Indirect  or direct hernia with good muscle tone.

Procedure

Incision: 6-8cm incision is made parallel to the inguinal ligament at the level of deep ring in the medial two thirds of the inguinal ligament. 

Layers opened: 

• Skin
• Two layers of superficial fascia
• External oblique is incised in the line of direction fibres till external ring is open.
• Thin cremasteric box is opened.
• Identification of the sac

1. - glistening white colour,
2. Isolate the cord from the sac by blunt and sharp dissection.The cord is held separately by using cord holding forceps.
3. The sac is mobilise upto the deep ring. Mobilisation is complete when inferior epigastric artery pulsations and extraperitoneal pad of fat are seen.
4. The sac is opened and contents are examined.
5. The contents are reduced.
6. Twist the sac to avoid injury to the contents.
7. Transfixation ligature is applied as high as possible at the neck of sac and it is tightened.
8.  Excision of the sac: After excision , see the excised sac and see whether omentum or intestine have been injured.Up to this stage , it is called as HERNIOTOMY.

Repair

• Conjoined tendon above is approximated to the inguinal ligament below by using nonabsorbable suture such as Nylon, Silk  or Sutupack.
• Nonabsorbable suture is used so that its strength remaines for a long time. This repair is called BASSINI'S HERNIORRHAPHY.

Closure

• External oblique is sutured with chromic catgut or silk.
• Subcutaneous fat absorbable catgut suture.
• Skin with silk.

Post -op

• NPO fro 6-8 hours, oral fluids and soft diet later.
• Analgesics
• Antibiotics
• Scrotal support if the dissection is more(complete hernia)
• Suture removal after 7-10days.

Post-op complications

• Haematoma
• Wound infection
• Severe peritonitis pubis
• nerve entrapment causing pain. 

Source: Shenoy Nileshwar Manipal Manual surgery.

I am Done!

The topic seemed so horrible. A very horrible thing to say and written.

For the record, i've been confined in my room for 1 month straight. Without any books to read or do any academical stuff. I simply quit. I waited in my adequately large pink-walled room. I was wide awake at night but slept in day bright. I woke up to bath,eat and drink. When i gaze at my books, i simply emptied my mind, not wanting to feel any guilt or anxiety. Yes, that is all i do all these while.

I tried not to feel.

I tried really hard not to think.

Although i know that Ghandi did said the key to win the fight is not to fight. Not thinking is same as not fighting.
I guessed that i managed to do that. But, the more i try harder, the more it came. The feeling of incompetency and inferiority towards my own impossible standards. Who wants a second rate doctor rite? I HAD to set my target higher. I HAD to be the best. I had to. I need to. But, the problem is, i never want it. All i want is to feel enough.Yup, enough is enough. Why not be a moderate?Wanting something moderate for my self? Modesty is the the best policy is what all they say.

I may have been deluded  for being stuck in here doing the same routine everyday. Routine i had not much interest in . I need something. Passion. I want to live with enthusiasm. I want to be a person who loves their work and get rewarded for that. I know, in this world, not everybody are lucky. Not everyone can do jobs they love. Some people love their jobs, others just do it for the sake of supporting living expenses. Gregory House always say you can`t always get what you want. In Quran also mentioned that we may hate things that could be good for us and we may love something that could be bad for us. I always knew those. But , right now... i barely take it into my heart.

People say that life is priceless. That chances are to be taken. That all opportunities in the world should be grasped. I had that chance. So, what do i do with it? I've taken the chance. I had it in my hands. but, now it is slipping off my hands.........

I figured that if i am not suitable for this job, i should just quit from now. Before things gets nastier and uglier. Before its too late. I want to stop now. Take me home. Let me live my life as i want to . I want to live a simple life with peace and no unnecessary pressure from outside or inside myself. I just want to do what i like.

Then again, Gregory House whispered :  Hey crazy lady! *YOU CAN`T ALWAYS GET WHAT YOU WANT...*

URGHHHH ...


Then again, although future might be seemed to be so bleak and hopeless... Please know that even though you don't think that you have what it takes to become a  DOCTOR, know that there are people working their ass off just to become a MEDICAL STUDENT. Know that even though you think you don't deserve to be here, to have this kind of luxurious opportunity, know that if you don't hold it firmly in your hands others might take your place.That you are the chosen one, chosen by people to serve the people of the nation.

When you want to reminisce old the good and the bad times, all the bloodysweatytears,all the efforts you took to gain what you want, all the sacrifices you have done to get where you are, all the people who cared and cheriss your talent and persona, all the dreams and wishes you once carved deeply into you heart, all the pains and sorrows that brings you strength to cross the hurdles, all the bittersweet memories that inspired you to continue your journey and see the wide vast world on your own capabilities, all of that.

Remember, that everything is in order.

Be good, you're good.
Be calm, you're at peace.
Be angry, you're mad.
Be humorous, you're  funny.
Be sensible, you're sensitive.
Be pathetic, you're sad.
Be bold, you're strong.

Blah,blah,blah.

Its YOU that make it happen.
You decide your destiny.
Future is in your hands 98% of it.
Only 2% luck and fate MAY change the course of your life.
Event if it does change, YOU have the WILL to change it back to square one...

And that's why humans are gifted by God what we call as COURAGE.
It is the strong will of humans to overcome FEAR so that humans without BRAVERY can go forward not backward.




p/s: Finish your journey no matter what happens.