PGCases201-240

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PG_Case_240

This 63 year old lady presented with an asymptomatic lesion on her right leg. What is it suspicious for?

: It is very suspicious for a melanoma. Note the ABCD’s of

Asymmetry

Border

Colour variation

Diameter

PG_Case_239

This gentleman has fallen on an out-stretched hand
What is the deformity of his wrist?

A ‘Colles’ fracture. This usually occurs about an inch or two proximal to the radio-carpal joint with associated posterior and lateral displacement of the distal fragment
It is this that results in the classic ‘dinnerfork’ deformity.

Case 238

PG_Case_238

This is a photo of the abdomen of a 78 year old gentleman. What is this pathology?

This gentleman has quite a prominent hernia seen over a scar in his abdomen consistent with an incisional hernia.

PG_Case_237

What injury do you think this patient had and what procedures?

There is an external fixator on the lower left leg of this man.
There is a raised discoloured area over the anterior aspect of his tibia. This would suggest that he suffered a significant open fracture of his tibia required reduction, external fixation and skin graft.

PG_Case_236

70 year old male referred by GP for infection of his index finger. What is the 1st step in the treatment strategy?

Take cultures from the wound and commence him on empirical antibiotics. Send a biopsy to rule out malignancy.

PG_Case_235

From this PFA what operation did this patient have done?

In the RUQ you can see some clips. These suggest a previous cholecystectomy. The clips are most probably around the cystic duct/artery. The use of the clips rather than ties would also suggest that the procedure was laparoscopic rather than open.

PG_Case_234

What procedure has this patient had?

This patient had an ERCP, with a stent (right upper quadrant) placed in the biliary duct to allow drainage past a common bile-duct tumour.

PG_Case_233

This 22yr old male presents with a hangover, poor recollection and a sore swollen hand. What is the diagnosis?

This patient has a fracture of neck of the 5th metacarpal bone, typically called a boxers fracture. Conservative treatment requires a cast/ulnar gutter splint. Indications for fixation such as K wires includes: rotation deformity or angulation of >30 degrees.

PG_Case_232

This patient came to the Emergency Department following a fall from a slide. What is the diagnosis? How will you treat this?

Diagnosis: Lateral condyle humerus fracture.
Treatment: Needs operative fixation with K-wires.

PG_Case_231

This is the photo of a 78 year old lady. What operation and level has this patient undergone?

This lady has just had a below knee amputation (BKA). Deciding on the level of amputation involves a number of factors to consider including Level at which wound will heal, The mobility of the patient, their ability to rehabilitation well with a prosthesis and their degree of vascular perfusion to that level.

PG_Case_230

This is an intra operative photo of a patient undergoing resection of a skin lesion. What lesion is it?

This darkly pigmented lesion appears to be a melanoma. The melanoma is undergoing wide excision with margins of 2cm. Furthermore, the blue staining around the lesion indicates that this patient has undergone sentinel lymph node biopsy to establish his lymph node status.

PG_Case_229

During an unrelated laparotomy on a 76 year old lady, you incidentally notice these nodules in the mesentery. What are they?

They are TB nodes in the small bowel mesentery from a TB infection the woman reported suffered at the age of 12. If the patient had surgery several decades ago they could also be Talc granulomas resulting from the talc that was used in the gloves of surgeons many years ago.

PG_Case_228

What related operations has this patient likely had?

A Carotid Endarterectomy scar and a Thoracotomy scar likely for CABG/Valve replacement.

PG_Case_227

This is CT abdomen of a man complaining of epigastric pain and generalised guarding. He was commenced on a non-steroidal anti-inflammatory for back pain by his GP recently. What is the obvious finding here?

Large free intraperitoneal air collection around the stomach and duodenum, consistent with perforated ulcer. The patient proceeded to theatre for laparotomy and repair of large perforated anterior duodenal ulcer.

PG_Case_226

This is chest x-ray of a 50 year old man complaining of epigastric pain and generalised guarding. He is a heavy smoker and drinker.

PG_Case_226

Free air under the left hemi-diaphragm. The patient underwent laparotomy and repair of large duodenal ulcer.

PG_Case_225

This intra-operative photo is of an 8 year old boy with right iliac fossa pain, vomiting and low grade pyrexia. Can you identify the pathology?

It is a Meckel’s diverticulum caused by remnant of the omphalomesenteric duct/vitelline duct which connects the yolk sac with the primitive midgut during the embryonic stage of development. It has a typical “rule of 2s”:

  • Found in 2% of population
  • 2 types of tissue can be found gastric & pancreatic
  • Located 2 feet from ileocaecal valve
  • 2% of patients are asymptomatic
  • 2inches long
  • Twice as common in men than women
  • Presents in the first 2 years of life

PG_Case_2241

Can you identify the procedure and hand condition of this middle aged woman?

The procedure is a median nerve decompression for Carpal Tunnel Syndrome.
There are a number of risk factors for CTS including: Pregnancy, Diabetes, Rheumatoid Arthritis, Hypothyroidism, Connective Tissue Disease, Aromatase inhibitor use, Workplace factors, Obesity, Female gender and Genetic predisposition.

PG_Case_221

This in an intraoperative photo of the sole of a foot from which a melanoma has been excised. What has been performed?

The patient has had a split skin graft applied to help cover the defect.

PG_Case_221

This photo was taken during a colectomy. What is the surgeon doing with his two fingers?

He is measuring the size needed for the creation of a stoma in the abdominal wall. Classically this is taken to be two finger breadths.

PG_Case_221

Can you identify this common emergency laparoscopic procedure?

The photo shows a thickened inflamed appendix.

PG_Case_220

This is an endoscopic picture of the descending colon of a 27 year old complaining of PR bleeding and abdominal pain. What is the likely disease and pathology?

There are several ulcerated areas and marked inflammation typical of ulcerative colitis.

PG_Case_219

What and where does this colonoscopy show?

There is a polypoid tumour on the left side, occupying at least one third of the lumen. The triangular shape of the lumen would suggest that it is in the transverse colon.

PG_Case_215

This is a photo of a patients neck who is undergoing carotid endarterectomy. How can you identify the internal carotid?

Alteration of the normal bowel wall contour (thumb print sign) suggesting oedema and inflamed bowel wall.

A branch can be seen emerging from the external carotid below it
PG_Case_215

  • The vessel furthest from the front marked.
  • The internal carotid is the vessel with no branches in the neck.
  • A branch can be seen emerging from the external carotid below it.

PG_Case_217

This is a plain film abdomen of an 81yo with history of C. Diff Colitis. What are the findings on this abdominal x-ray?

Alteration of the normal bowel wall contour (thumb print sign) suggesting oedema and inflamed bowel wall.

  • Thumbprinting refers to the altered luminal contour of the large bowel wall associated with inflammation. The normal characteristic arcuate plicae and haustral contours are replaced with a coarser pattern (white arrow).
  • The appearance is well named – the suggestion is that the luminal air is indented with protrusions that would approximate pushing your thumb into the bowel.
  • Other signs to look for: Intramural gas, Hepatic portal-venous gas and Pneumoperitoneum.

PG_Case_215

This photo is taken from a common laparoscopic procedure. What does it show?

It shows the image as seen through a laparoscopic camera during a laparoscopic cholecystectomy.
The operator has the gallbladder between laparoscopic forceps at its tip.
The operator is holding the gallbladder taut up and against the liver to enable proper visualisation of the biliary structures and to allow safe dissection.

PGCase215

What kind of stoma is this?

This is a loop ileostomy

  • The glass rod (or bridge) tells you it is a ‘loop’.
  • The position on the right side is typical of an ileostomy.
  • There is a spout. If there were excretions they would be semisolid/loose.

PG_Case_214

What rare surgery would require a scar as seen on this gentleman?

  • Cholecystectomy +/- Truncal Vagotomy +/- Antrectomy
  • Pancreaticoduodenectomy (Removal of the head of the Pancreas & Duodenum)
  • Choledochojejunostomy (Common bile duct anastomosed to Jejunum)
  • Pancreaticojejunostomy (Distal pancreas remnant anastomosed to Jejunum)
  • Gastrojejunostomy (Stomach anastomosed to Jejunum)

PG_Case_212

The abdomen of this breast cancer patient has been marked preop. What do the markings represent?

The markings are the preoperative planning of a deep inferior epigastric perforator flap (DIEP) preformed for breast reconstruction following mastectomy.

PG_Case_213

This is a CT finding of an 81 year old lady complaining of severe abdominal pain and worsening diarrhoea. Three months ago she was treated for C. Diff colitis. Is there any abnormality in the large bowels on this occasion?

There is diffuse thickening and oedematous wall of the large bowel, without any free air. Therefore the CT findings are consistent with pseudo-membranous colitis without perforation.

 

 

case_211_1

During an upper GI endoscopy this was visualised in the duodenum. What is it?

This is a plastic biliary stent emerging from the Ampulla of Vater placed in ERCP to ensure biliary drainage, often due to cholodocholithiasis.

Case #210

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This 18 year old was the unrestrained driver in a road traffic accident at 60mph. Describe the CT Brain.

• Contusions bilaterally over frontal lobes
• Left contusion worse than right
• Contusion right parietal & left temporal lobes
• Fracture right parietal & frontal bone

 

Case #209

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This CT is of 47 year old lady brought in with ‘racoon eyes’ and diminished GCS.

• Fracture of right frontal bone.
• Swelling of soft tissue over fracture.
• Contusion of right frontal lobe and associated haemorrhage.

 

Case #208

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This photo is from an upper GI Endoscopy. What does it show?

• It demonstrates an oesophageal tumour with obvious ‘craggy’ tissue overgrowth.
• This patient has had severe trouble swallowing.

 

Case #207

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What is most obvious on this CT abdomen?

• The most obvious feature is a dilatation of the abdominal aorta.
• The aorta can be seen just above the vertebral body.
• The inferior vena cave can be seen alongside it.
• The lumen is dilated and the slightly darker area is thrombus within the aorta.
• The flecks of white in the wall represent calcification.

 

Case #206

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What is the abnormality seen in the PFA of this very healthy and playful 5 year old girl?

A foreign body can be seen in region of the small bowel, which is a swallowed drawing pin. The management depends on:-• The child is obviously asymptomatic thus foreign bodies tend to be monitored and wait for them to pass.
• Should the child become unwell, she will immediately require emergency exploratory surgery.
• If the foreign body is known to be in the stomach, there is an argument for paediatric upper endoscopy to remove the item.

 

Case #205

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A distressed mother presents her 4 year old boy who has rhinnorhea and pyrexia. What has happened?

• The PFA shows white radiopaque spots throughout the abdomen consistent with diffuse droplets of mercury throughout his abdomen which should pass with time.
• This 4 year old most probably has an URTI. His attentive mother has tried to measure his temperature and used a mercury thermometer which the child has bitten through.

 

Case #204

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What is causing this patient’s heel pain?

Erosion can be seen at the base of the heel on the x-ray with periosteal reaction in keeping with osteomyelitis. The area over the heel can be seen to ‘light up’ on the bone scan reflecting increased activity within the bone here.

 

Case #203

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What does this picture show?

• The picture is that of a hernia in the umbilical area showing the hernia in its reduced & unreduced form.
• A true umbilical hernia protrudes through the umbilicus scar & is caused by increased abdominal pressure.
• A para-umbilical hernia protrudes through the weakest point of the umbilicus scar i.e. the superior aspect between the umbilical vein & the upper margin of the umbilical ring.
• The hernia displaces the umbilical scar rather than passing through it.
• The cause is an inadequacy of the musculofascial layers of the abdominal wall typically in the obese middle-aged patient. The risk with all hernias is that of bowel obstruction, strangulation and necrosis.
• The neck of a para-umbilical hernia is often quite tight and because of this tissues that enter it have difficulty leaving.
• Para-umbilical hernias are at risk of strangulation.

 

Case #202

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This is a photo of a 29 year old man who was in an road traffic accident. He lost two litres of blood. What is this procedure?

The photo shows the surgeon attempting a venous cutdown via the long saphenous vein which runs above the medial malleolus .
Access is difficult in this critically shocked patient because of his collapsed veins. However, he requires immediate access.

 

Case #201

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What does this CT demonstrate?

This CT demonstrates diffuse hypodense lesions in the liver. These are consistent with metastases.