Here is a review of various pathways for specializing after completing MS General Surgery. In the part 1 of this post I will be reviewing Urology, Surgical Oncology, Surgical Gastroenterology and Neurosurgery.

Contents

• Urology after MS/ DNB General Surgery
• Surgical Oncology after MS/ DNB General Surgery
• Surgical Gastroenterology after MS/ DNB General Surgery
• Neurosurgery after MS/ DNB General Surgery

Urology MCh/ DNB - Pros and Cons

• Less emergencies
• Peace of mind as most patient do not require ICU support
• High demand high volume
• Average Per procedure fee for routine procedures low
• Possibility for starting basic individual practice with low investment
• Minor surgeries to oncosurgery, laparoscopic, endoscopic, robotic surgery and transplantation
• Can also do individual practice and do basic procedures

Surgical Oncology MCh/ DNB- - Pros and Cons

• Large variety of cancers can be operated
• Good demand in corporate setups
• Competition with general surgery is there
• One of the highly sought branches
• Depends largely on a institutional model of practice, individual practice difficult

Surgical Gastro MCh/ DNB - Pros and Cons 

• Fierce competition with General surgeons and FNB/ MCh Minimal Access Surgery  
• You need to further specialize in hepatobiliary, liver transplantation, bariatric, colorectal surgery
• Value only in big cities  
• High patient load
• Can do both individual and institutional practice

Neurosurgery MCh/ DNB - Pros and Cons

• High in demand
• High stress
• High patient load
• High complications and mortality rates
• Easy to get jobs both in metro cities and tier B cities
• Good remuneration (One of the top most)
• Challenging in terms of hours and techniques involved
• Has a variety of procedures including Neuroncology, Brain Trauma Surgery, Endoscopic Surgery, Neurovascular Surgery, Spine surgery, Peripheral Nerve Surgery
• Evolving fast with many new breakthroughs
• Can also do individual practice and do basic procedures

Keywords: Best Specialties after MS General Surgery, MCh/ DNB Superspeciality, Which super speciality to choose, Urology, Neurosurgery, Surgical Gastroenterology, Surgical Oncology, Review, Surgery NEET SS

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Also check out these links for more details:

1. https://www.quora.com/What-are-the-pros-and-cons-of-GI-surgery-as-a-practice-in-India
2. https://www.quora.com/Urology-and-Surgical-Gastro-which-one-to-choose-when-one-likes-both
3. https://www.quora.com/Why-are-urology-and-gastrosurgery-the-1st-choices-after-an-MS-in-general-surgery

7/01/2020 10:34:00 PM

Cystolithotomy Surgical Steps

Preoperative Patient Preparation

• Exclusion or treatment of a urinary tract infection
• Perioperative antibiotic prophylaxis
• Supine position with slight hyperextension of the lumbar spine
• Disinfection and draping
• Insert a transurethral catheter and fill the bladder with 200–300 ml

Surgical Technique

• Lower midline incision or Pfannenstiel incision
• Cut the linea alba
• After blunt dissection of the retropubic space (cavum retzii), insert a wound retractor
• Vertical cystostomy, which is secured with sutures to prevent further tearing
• Remove bladder stones, foreign bodies or bladder tamponade, controll bleeding.
• If necessary, perform simple prostatectomy
• If needed, insert a suprapubic catheter
• Close the bladder in two layers (mucosa – muscularis)
• Drainage of retropubic space
• Closure of the linea alba, skin closure

 Open Suprapubic Cystolithotomy Surgery Video

References 

http://www.urology-textbook.com/cystolithotomy.html

6/14/2020 03:15:00 PM

What is the definition of Varicocele?

Varicocele means dilatation and elongation with tortuosity of the veins of the spermatic cord.

Prevalence of varicocele

Explain the surgical anatomy of veins of spermatic cord?

The veins of spermatic cord include

• Veins of testis and epididymis
• Veins accomapnying vas deferens
• Veins of cremasteric muscle

Surgical Anatomy of Varicocele

These veins are 

• 15-20 in number at the level of testis and epididymis
• 4-8 veins at inguinal canal
• 2 veins at the level of deep ring

Surgical Anatomy of Varicocele

What is the most common side of occurrence of varicocele and why?

Varicocele is seen 95% of times on the left side. This is because, left testicular vein draws into the left renal vein at right angles which creates high pressure on the left testicular veins

Left Testicular Vein

What are various characteristic features on clinical examination of varicocele?

• The swelling may disappear on making the patient lie down
• Varicocele feels like a bag of worms on palpation
• Thrill like impulse is felt on coughing

Varicocele in a 15 year old boy

What is the condition which should be ruled out in cases on varicocele?

Varicocele may be secondary to renal cell carcinoma of the left kidney and hence it should be ruled out. In cases where a renal cell tumour is a cause, varcocele does not decompress on supine position

What are the complications of untreated varicocele?

Infertility in cases of bilateral varicocele and long standing disease

Complications of Varicocele

Explain the grading of varicocele?

Grade 1: Palpable only during valsalva manuvre

Grade 2: Palpable at rest but not visible

Grade 3: Visible and palpable at rest

Usually grade 2 & 3 may lead to infertility and decreased testicular volume and hence need surgery

What are the various approaches to management of varicose veins?

Surgical ligation through various approaches 

• Inguinal approach
• Subinguinal approach
• Retroperitoneal approach (Palomo operation)
• Laparoscopic Varicocelectomy

Interventional Radiology - Embolisation of testicular vein

What are various indications for surgical intervention in varicocele?

Indications for surgical intervention in varicocele

     

Indications for surgical intervention in varicocele

6/04/2020 08:25:00 PM

Have been getting queries about good books for MCh preparation. Listing a few good books for MCh Urology aspirants below. MCh Urology also happens to be one of the most sort after branches by many because of its lesser emergencies, small procedures and peace of mind.

Campbell Urology Text Book 11th Edition > Updated 12th Edition

Campbell-Walsh Urology 11th Edition Review  >  Updated 12th Edition



Parag Gupta Urology MCh Book



MCQs in Urology by Niranjan Agarwalla



Postgraduate Urology Entrance Review (PGIMER) Fully Solved Question Papers 2015-2001
by Barapatre Yogesh Rameshrao 

The Urology Bank of 1111 Mcqs by Atif A. Katib  


Urology Board Review Questions

5/10/2020 01:40:00 PM

1. Which Kidney is preferred (Left or Right)?

The left renal anatomy is generally preferred as the left renal vein is longer. (MCQ)

2. Is the right kidney never used?

Many studies have shown that the right kidney can also be procured safely. (MCQ)

3. What is the complication when 12th rib is resected while doing Kidney transplant procedure by Open surgical technique?

In open surgical technique, The 12th rib may need to be resected to allow better exposure. However, this will increase the risk of a postoperative pneumothorax (0.09%) (MCQ)

4. What is the most common complication after Kidney Transplant?

The most common complications are urinary retention and ileus. (MCQ)

5. Which solution is used to store a kidney which has to be transplanted?

The predominant storage solution currently used in the United States is University of Wisconsin Preservation Solution (ViaSpan/ Dupont) (MCQ)

6. Where is the Kidney positioned in a recipient?

The kidney is usually placed in a retroperitoneal position in the recipient. (MCQ)

7. Donor Renal vein is anastomosed to _________ in Kidney transplantation? 

The donor renal vein is anastomosed to the common iliac vein (MCQ)

8. Donor Renal artery is anastomosed to _________ in Kidney transplantation? 

The donor artery is anastomosed to the recipient common or external iliac artery. (MCQ)

9. What is the most common manifestation of postoperative surgical complications?

Most complications are manifested as a sudden drop in urine output. (MCQ)

10. What is the most common cause of graft loss in Renal Transplantation?

The most common cause of graft loss is progressive interstitial fibrosis that ultimately leads to kidney failure. (MCQ)

Reference: Sabiston Textbook of Surgery

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8/29/2017 10:43:00 PM

Which is the most common mode of renal injuries?

Renal injury is common, occurring in 8–10% of polytrauma cases. About 90% of renal injuries result from blunt force injury and 10% from penetrating trauma.

How good is USG for finding Renal injuries?

USG is relatively insensitive for detection of renal lacerations and contusions, extravasation of blood or urine, collecting system disruption and parenchymal haematoma
A positive ultrasound is more likely to find higher grades of renal injury, but a negative renal ultrasound does not rule out renal injury.

What is the gold standard investigation for Renal injuries?

CECT Abdomen is the gold standard investigation for renal injuries. As a rule, all patients with penetrating flank and back trauma should have a CT examination.

What are the indication of CECT if there is suspision of renal trauma?

• Penetrating flank and back trauma Chest
• Gross haematuria if haemodynamically stable or resuscitated 
• Haemodynamically stable with microscopic haematuria, but other indications for abdominal–pelvic CT (+ abdominal examination, decreasing haematocrit, indeterminate result of peritoneal lavage or abdominal ultrasound, unreliable physical examination) 
• Haemodynamically stable with or without microscopic haematuria with evidence of major flank impact (e.g. lower posterior rib or lumbar transverse process fracture) 

What are the situation where CECT will not be done?

Haemodynamically unstable requiring emergency surgery Intraoperative IVU when stabilized 

Haemodynamically stable with microscopic haematuria, but no other indication for abdominal–pelvic CT 

What is AAST grading for Renal Injuries?

Source: American Association for Surgery of Trauma

How to manage Renal injuries?

ABCDE first.

Followed by

• Operate immediately if the patient is bleeding to death
• Observe initially, but step in with metered responses as necessary
• Use ureteral stents for symptomatic or growing urinoma
• Use angioembolization for nonemergent bleeding or for urgent bleeding if those techniques are available at your center
• Do open surgery when needed (Santucci, 2015, Am J of Surgery)

What is the non operative management of renal injuries?

• Preferred for majority of stable patient with Renal injury Grade 1-4. 
• Bed rest, Hydration, Antibiotics, Serial Imaging, Medications for hemostatsis (Hemostyptic Therapy), Vitals monitoring   
• Management of complications after conservative management: Urinoma, Infection, Delayed Hemorrhage, Devitalized renal segment, Hypertension, Renal insufficiency 

What is the Operative Management of renal injuries? 

• Goal-Control hemorrhage, Preserve renal tissue
• Temporary vascular occlusion for brisk renal bleeding not well controlled by manual compression of the parenchyma
• Sharp excision of all nonviable parenchyma
• Meticulous hemostasis (particularly, arterial)
• Watertight closure of the collecting system
• Parenchymal defect closure by approximation of the capsular/parenchymal edges over a Gelfoam bolster or coverage with omentum, perinephric fat, peritoneum, or polyglycolic acid mesh
• Interposition of an omental pedicle flap between any vascular, colonic, or pancreatic injury and the injured kidney
• Ureteral stent placement for a renal pelvis or ureteral injury
• Retroperitoneal drain placement: The authors prefer to use a Penrose drain. Unless drainage is excessive, the Penrose drain is removed after 48 hours. Additionally, the urinary tract injury and the pancreatic injury are always drained separately.
• Partial or complete Nephrectomy

What are the indications for Nephrectomy in Renal Injuries

• When primary vascular control is not achieved and massive bleeding is encountered, in the rush to control bleeding, a kidney that could have been salvaged may be unnecessarily sacrificed.
• Nephrectomy is required when the patient is persistently hemodynamically unstable despite initial measures and, thus, is a life-saving maneuver.
• Grade 5 injuries that are deemed irreparable(eg, major vascular pedicle injury, particularly on the right side)
• Shattered kidney
• Multiple concurrent injuries
• Uncontrolled hemorrhage

12/11/2016 11:11:00 PM

Priapism in a 60 year old man

Case Presentation 

A 60 year old man presented with complaints of painful and persistent erection of 2 day duration which started without any sexual arousal. Patient was a known hypertensive since 5 years and was taking treatment regularly. There was no history of trauma or any other known medical illnesses. On examination the penis was tender, rigid and it felt indurated.

What is the Diagnosis? 

This patient is suffering from priapism. It is defined as an involuntary, prolonged erection unrelated to sexual stimulation and it is not relieved by ejaculation.

Definition of Priapism?

It is full or partial erection that continues for more than 4 hours beyond sexual stimulation or orgasms or is completely unrelated to sexual stimulation.

What are the types of Priapism? 

Types of priapism:

• Low-flow or Ischemic or Veno-Occlusive
• High-flow or Non-ischemic or Arterial
• Stuttering Priapism

In Veno-Occlusive Priapism, there is initial occlusion of venous outflow  and subsequent cessation of arterial inflows.The condition is analogous to muscle compartment syndrome. It is an emergency, interventions beyond 48 to 72 hours of onset relieve erection/pain but have little benefit in preserving potency.

In Arterial Priapism, there is unregulated cavernous arterial inflow resulting from disruption of the cavernous arterial anatomy due to formation of arteriolar-sinusoidal fistula. The etiology is usually attributed to trauma. Typically, the corpora are tumescent but not rigid and the penis is not painful. It is not an emergency, spontaneous resolution or response to conservative therapy has been reported in up to 62% cases.

The term Stuttering priapism is used to describe a pattern of recurrent prolonged and painful erections in main with sickle cell disease.

Which is more common among the given types of priapism?

80% to 90% of clinically presented priapisms are low-flow disorders.

What are the symptoms and signs of priapism?

5/03/2016 05:29:00 PM