🔰Foley Catheter

🔹1-Way urinary catheters
▪︎have only one channel for passage of urine.
Like CIC (clean intermittent catheterization)


🔹2-Way urinary catheters
▪︎The most Commonly Used

▪︎Have two channels: one channel is for the passage of urine and the other for balloon inflation and deflation.


🔹3-Way urinary catheters
▪︎available with a third channel to facilitate continuous bladder irrigation

▪︎primarily used After urological surgery or in case of bleeding from a bladder or prostate, For continuous or intermittent irrigation to clear blood clots or debris.

🔹Duration
▪︎7-10 days for latex
▪︎1 month for the silicon

🔹Alternative way
▪︎suprapubic cystostomy

▪︎Catheter Length 40-45 cm

▪︎Recommended Use The Smallest Size

▪︎Most Common Materials ➡️ Silicon/Silicon Coated Latex

▪︎Size Measurement By French (1FR=3mm)

#Surgery_rotation
https://t.me/Surgery_Practice

🔰Foley Catheter

🔹indications of use :

▪︎one way :-
-in CIC (clean intermittent catheterization)

▪︎two way :-
○Diagnostic :
•Urine collection (measurements Of Urine Output & residual volume)

○therapeutic :
•Relive Acute urinary retention
•During Urologic & Contiguous Surgery (To Prevent Urine leakage by accident)

▪︎three way :-
•Bladder Irrigation After Bleeding (Clots Present)
•injection Of AB & Chemotherapy & Contrast
•Urodynamic and Cystography

🔹Long Term Catheterization For
1. Refractory urine retention (not correctable)
2. Neurogenic bladder
3. Incontinence

🔹Contraindications
1. Suspected Urethral injury
2. Urethral Strictures
3. Urethral Sepsis
4. High Riding Or Detached Prostate
5. Difficult Insertion For Other Reasons

🔹Complications
1. Inability to catheterize
2. Infection
3. Urethral injury/Stricture
4. Psychological trauma
5. Paraphimosis
6. Hematuria
7. Stone Formation
8. Allergy or sensitivity to latex
9. Bladder cancer (After long-term Use)

https://t.me/Surgery_Practice

🔴Testicular Torsion

▪︎Posterior High Insertion Of Tunica Vaginalis (Bilateral) ➡️ Testis Freely Mobile Inside The Scrotum (Bell Clapper Deformity) ➡️ Torsion

▪︎Two Peaks ➡️ 1st Year Of Life/At Puberty

▪︎High Risk Factor ➡️ Undescended Testis

▪︎Torsion <6h ➡️ Testis Can Be Saved

🔹Presentation
1. Hx Of pain Resolved Spontaneously (At Exertion/Sport/Truma/Cold Weather/Sleep)

2. Sudden Severe Scrotal Pain
3. Nausea & Vomiting
4. Swollen Tender Firm Hemiscrotum
5. High Riding Testis (Transverse Lie)
6. Loss Of Cremasteric Reflex

🔹Confirm Dx ➡️ Doppler US (Decrease Blood Flow)

🔹Types Of Torsion
1. IntraVaginal (Within Tunica Vaginalis) ➡️ At Puberty

2. ExtraVaginal (Along The Tunica Vaginalis) ➡️ In 1st year Of Life

🔹Tx
A. Viable
1. Detorsion (Medial To Lateral Open Book)
2. Orchiopexy Of Both Testis

B. Not Viable ➡️ Orchiectomy

#Surgery_rotation
https://t.me/Surgery_Practice

🔴 Necrotising fasciitis

♦️infection that spreads quickly along the fascial plane ➡️ necrosis of the SC tissues & overlying skin.
غالبا تسببها b-haemolytic streptococci او staph aureus وممكن polymicrobial


💠 types:
و فيها 4 انواع (حسب دافيدسون):
▪️Type 1 : polymicrobial
ونشوفها بعد العمليات عند immunocompromised&DM

▪️Type 2 : :group A or other streptococci (60% of cases are associated with streptococcal toxic shock syndrome)

▪️Type 3: Aeromonas hydrophila and Vibrio vulnificus

▪️Type 4 : fungi ( as mucoraceous moulds)

▫️مدسكيب معتبر النوع الثالث هو
Type III gas gangrene or Clostridium myonecrosis

♦️يطلقون عليها اسماء خاصة اذا صارت بمناطق معينة :
▫️Abdominal wall : Meleney’s synergistic hospital gangrene
Scrotal infection : Fournier’s gangren

♦️60% in the lower extremities.
Predisposing conditions include:
▪️diabetes;
▪️smoking;
▪️ penetrating trauma;
▪️pressure sores;
▪️ immunocompromised states;
▪️ intravenous drug abuse;
▪️perineal infection (perianal abscess, Bartholin’s cysts);
▪️skin damage/infection (abrasions, bites, boils).
▪️In liver cirrhosis
▪️NSAIDS use ( associated with type II necrotizing fasciitis)
▪️Colon cancer or leukaemia

♦️pathology:
بشكل مختصر :
inflammatory infiltrate, extensive necrosis, oedema and thrombosis of the microvasculature.

♦️ presentation:
كيف يجي المريض ؟
عادة مريض متعرض ل trauma او مسوي عملية او any invasive procedure
ع الاغلب عنده امراض مزمنة مثلا سكر او PAD
يشكو من :
▪️intense pain and tenderness over the involved skin and underlying muscle. Over next several hours to days, progresses to anaesthesia
Occurs before fever, malaise, and myalgias.

▪️cutaneous erythema and oedema that extending beyond the area of erythema, skin vesicles, and crepitus

▪️skin turns dusky blue and black (due to thrombosis & necrosis)

▪️area develop bullae & overt cutaneous gangrene with SC emphysema

▪️SC tissue demonstrates a wooden, hardened feel

▪️fascial planes and muscle groups cannot be detected by palpation

▪️produces skip lesions that later coalesce.

♦️Unlike in cellulitis:
-pain disproportionately intense in relation to the visible cutaneous features or may spread beyond the zone of erythema.
-absent of Lymphangitis

▪️كذلك fever &tachycardia و مرات يوصل لل
severe toxicity , septic shock& renal failure

♦️DDx:
Acute epididymitis
Cellulitis
Orchitis
Testicular torsion
Toxic shock syndrome

♦️Ix:
كيف يتشخص :

CBC,biochemistry
معاها:
ABG , blood and tissue cultures (deeper tissue samples not from skin or SC tissue)
⬆️⬆️ Creatinine kinase
Radiographs : air in the tissues.
doppler, CT,MRI
Tissue fluid aspiration and analysis

*the following may be associated with necrotizing fasciitis:
⬆️WBC count)> 14,000/µL
⬆️BUN level >  15 mg/mL
⬇️ serum sodium level < 135 mmol/L

♦️Rx:
العلاج
▪️: اول شي ندخله ICU
-Supportive ( fluid, O2 )
احيانا يحتاجوا endotracheal intubation
-Abx: IV penicillin G + ceftriaxone & flagyl
و نحضرله دم لان العملية ⬇️ تسبب profuse bleeding-
و الخطوة الاساسية بالعلاج هي : -
surgical excision+- skin graft
بعدها نخلي شاش و نغطي الجرح dressing esp. vacuum-assisted dressings.
و يوميه ننظفه و نغطيه

في كمان option اللي هو :
hyperbaric oxygen (HBO) in high-pressure chamber
(improves neutrophil function & promotes wound healing)
نخلي المرضى ب high-pressure chamber
و نعطي  100% O2
بضغط 
2-3 atm

#Necrotising fasciitis
#Davidson
#Surgery_rotation
https://t.me/Surgery_Practice

■Signs & symptoms Of intestinal Obstruction:

•Abdominal Pain
•Vomiting
•Distension
•Absolute constipation
•Exaggerated Bowel Sounds (Mechanical Obstruction)
•Visible Peristalsis (Mechanical Obstruction)


■Mechanical Obstruction
•Exaggerated Bowel Sounds

■Functional Obstruction (Paralytic ileus)
•Diminished Bowel Sounds


■Main complications after abdominal surgery

•Paralytic ileus
•Bleeding & Abscess
•Anastomotic leakage


■Paralytic ileus After Surgery

•Detected After 72h Of the Surgery
•No Bowel Sounds
•No passage of Flatus

■Common causes of Intestinal Obstruction

#Surgery_rotation
https://t.me/Surgery_Practice

د/وائل متولي النسخة الاصلية
#Surgery_rotation
https://t.me/Surgery_Practice

■ Signs of Thyrotoxicosis (Hyperthyroidism)

▪︎Exophthalmos
•Bulging of the eye anteriorly out of the orbit.

▪︎Ophthalmoplegia
•Weakness of the ocular muscles prevents the patient from looking upwards and outwards.

▪︎lid retraction
•Displacement of the upper eyelid superiorly or lower eyelid inferiorly Because the autonomic part of the levator palpebrae superioris muscle is hypertonic. (you can see Sclera above the iris)

▪︎Lid lag
•The upper eyelid stay high or lag during the Downward movement of the eye (upper eyelid does not keep pace with the eye) Because increased tone of the levator palpebrae superioris muscle.

▪︎Chemosis (Eye inflammation)
•Oedema of the conjunctiva

#Surgery_rotation
https://t.me/Surgery_Practice

DDX Of Herina/Lump in the Groin ■

#Hernia
#Surgery_rotation
https://t.me/Surgery_Practice

■ General Causes & Features of Hernia
#Hernia
#Surgery_rotation
https://t.me/Surgery_Practice

Herina Examination (P1) ■

▪︎Assessing the groin lump to determine if it is a hernia or other pathology (e.g. testicular mass, lipoma, abscess, lymph node).

▪︎You should always assess both sides of the groin to avoid missing pathology.


▪︎Hernias of the groin typically present with the following clinical features:

•Single lump in the inguinal region

•Positive cough impulse (unless incarcerated)

•Soft on palpation

•Reducible (unless incarcerated)

•Unable to get above the lump during palpation

•Painless (unless incarcerated)

•Bowel sounds on auscultation (may be absent if incarcerated)



▪︎Not Herina :

•Multiple lumps (e.g.lymphadenopathy)

•Hard or nodular consistency (e.g. malignancy)

•Able to get above the lump during palpation (e.g. scrotal mass)

•Transillumination (hydrocoele)

•Bruit on auscultation (e.g. arteriovenous malformation)

#Hernia
#Surgery_rotation
https://t.me/Surgery_Practice

Herina Examination (P2) ■

🔹Hernia Should first be examined like any mass by

▪︎Inspection For
Site/Size/Shape/Over Skin/Surrounding Skin/Symmetry/Number

▪︎Palpation
•Superficial ➡️ Hotness/Tenderness
•Deep ➡️ Mobility/Reducibility/Consistency/Edge/Lobules

▪︎Cough Impulse
▪︎Occlusion Tests
▪︎3 Finger Test
▪︎Invagination Test
▪︎Trans illumination Test


▪︎While the patient is standing upright. Inspect the inguinal and femoral canals and the scrotum for any lumps or bulges.


▪︎Ask the patient to cough; look for an impulse over the femoral or inguinal canals and scrotum.


▪︎Inguinal hernias : located above and medial to the pubic tubercle (Direct/Indirect).


▪︎Femoral hernias : located below and lateral to the pubic tubercle.


■ Is it Direct or indirect inguinal Hernia ? (Ring occlusion test)👇

1.Ask the patient To lie Down

2.Locate the deep inguinal ring (midway between the anterior superior iliac spine and pubic tubercle).

3. Manually reduce the patient’s hernia by compressing it towards the deep inguinal ring starting at the inferior aspect of the hernia.

4. Once the hernia is reduced, apply pressure over the deep inguinal ring (close it) and ask the patient to cough.

• If reappears: Direct inguinal hernia 

• if not reappears : indirect inguinal hernia


▪︎Inguinal hernias can extend into the scrotum (indirect). So If a testicular swelling is noted or there is suspicion of an inguinal hernia, palpation of the scrotum should be performed : 👇

•When palpating an inguinal hernia in the scrotum you will not be able to get above the mass.


■Comparison

●Direct inguinal hernias:

•Mostly Occurs in adult males.

•caused by a weakness in the muscles of the abdominal wall (develops over time, or are due to straining or heavy lifting).

•Reappears after deep ring occlusion

•Not enter the Scrotum

•Reducible (Wide Neck)


●Indirect inguinal hernias:

•In children (Present at birth).

•caused by a birth defect in the abdominal wall (congenital).

•Enter the Scrotum (Pass with spermatic cord).

•Not reappears when close the deep ring

•Reducible (Wide Neck)


●Femoral Herina:

•weakness in the lower groin

•Mostly in females

•more prone than inguinal hernias to develop incarceration or strangulation

•Mostly not reducible (Narrow Neck)

#Hernia
#Surgery_rotation
https://t.me/Surgery_Practice

■Abdominal Examination (P1)

▪︎Inspection of the Abdomen For :

•Scars
•Abdominal distension
•Visible Pulsation/Peristalisis
•Drains/Stoma
•Dressings

•Caput medusae: engorged paraumbilical veins associated with portal hypertension (e.g. liver cirrhosis).

•Striae (stretch marks): caused by ascites, intrabdominal malignancy, Cushing’s syndrome, obesity, pregnancy.

•Hernias: ask the patient to cough and observe for any protrusions through the abdominal wall.

•Cullen’s sign: bruising of the tissue surrounding the umbilicus associated with haemorrhagic pancreatitis. (Cullen Umbilicus)

•Grey-Turner’s sign: bruising in the flanks associated with haemorrhagic pancreatitis. (Grey Flank)

#Surgery_rotation
https://t.me/Surgery_Practice

■Abdominal Examination (P2)

■Palpation

▪︎Light palpation For :
•Tenderness
•Masses
•Rovsing’s sign (Appendicitis)
•Murphy’s Sign (Acute Cholecystitis)

•Rebound tenderness: when the abdominal wall compressed slowly, and released rapidly results in sudden sharp abdominal pain.

•Guarding: involuntary tension in the abdominal muscles that occurs on palpation associated with peritonitis

•Rigidity: Abdominal muscles stiffness and painful on touching induced by acute peritonitis

▪︎Deep Palpation For :
•Deeper masses.


▪︎Liver/Spleen/Kidney Palpation For :
•Enlargement
•Presence of Mass


■Percussion For :
•Ascites (Shifting dullness/Transmitted Thrills)
•Organ Percussion (Liver/Spleen/Kidneys)


■Auscultation For :
•Bowel sounds (in RLQ area of ileocaecal Valve)
•Bruits (Renal/Aortic Artery)

#Surgery_rotation
https://t.me/Surgery_Practice

■Normal Vital Signs

▪︎Blood pressure:
•Normal Range:
120-140 systolic
80-90 diastolic

•ideal blood pressure is considered to be between 90/60mmHg and 120/80mmHg

•high blood pressure is considered to be 140/90mmHg or higher

•low blood pressure is considered to be 90/60mmHg or lower



▪︎Breathing: 12 - 18 breaths per minute

▪︎Pulse (HR): 60 - 100 beats per minute

▪︎Temperature: 36.5 - 37.3 C
average 37°C

▪︎O2 Saturation: 95% - 100%

▪︎Urine output: 0.5 - 1.5 cc/kg/hour

#Surgery_rotation
https://t.me/Surgery_Practice

❇️ Features of good scar

#Surgery_rotation
https://t.me/Surgery_Practice

A Cullen’s sign (near the Umbilicus)
B Gray turner sign (at the flanks)

possibly ▶️ haemorrahgic pancreatitis.

Do Amylase or lipase blood test.

#Surgery_rotation
https://t.me/Surgery_Practice