Unlike other cancers for which a biopsy is performed, when testicular cancer is suspected the entire testicle is removed in a procedure called an orchiectomy through an incision in the groin and pulling the testicle up from the scrotum. A biopsy through the scrotum for testicular cancer runs the risk of spreading the cancer, and can complicate future treatment options. Removing the entire testicle out of the scrotum is the only safe way to diagnose for testicular cancer. Only the cancer-containing testicle is removed, and it is important to do so promptly.
If there is any uncertainty, the urologists can examine the testicle by pulling the testicle out of the scrotum; if a condition other than testis cancer is found, the testicle is placed back into the scrotum.

Testicular cancer is the most common malignancy in men aged 20-30 years. Around 95% of cases of testicular cancer are germ-cell tumours.

Passage of bloody diarrhoea together with mucus and a short history makes this a likely presentation of inflammatory bowel disease. Rectal malignancy in a young age would be a very unlikely event. Furthermore, the history is too short to be consistent with solitary rectal ulcer syndrome.

Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history, it is important to try and localise the anatomical source of the bleeding. Bright red blood is usually of rectal origin, whereas, dark red blood is more suggestive of a proximally located bleeding source. Blood which has entered the gastrointestinal tract from a gastroduodenal source will typically resemble melaena due to the effects of the digestive enzymes on the blood itself.

PR bleeding in ulcerative colitis (UC) is usually bright red and often mixed with stool. It is mostly associated with the passage of mucus as well. Other clinical features reported on history include diarrhoea, weight loss, and nocturnal incontinence. Proctitis is the most marked finding on examination and perianal disease is usually absent. Colonoscopy is carried out which shows continuous mucosal lesions.

In patients with ulcerative colitis (UC) where medical management is not successful, surgical resection (pan-proctocolectomy) may offer a chance of cure. Those patients wishing to avoid a permanent stoma may be considered for an ileoanal pouch. However, this procedure is only offered in the elective setting.

Patients with inflammatory bowel disease (UC and Crohn’s disease) frequently present in surgical practice. Elective indications for surgery in UC include disease that requires maximal therapy or prolonged courses of steroids.

Long-standing UC is associated with a risk of malignant transformation. Dysplastic transformation of the colonic epithelium with associated mass lesions is an absolute indication for a proctocolectomy. Restorative options in UC include an ileoanal pouch. Complications of such a pouch include anastomotic dehiscence, pouchitis, and poor physiological function with seepage and soiling.
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Emergency presentation of poorly-controlled colitis that fails to respond to medical therapy should usually be managed with a subtotal colectomy. Excision of the rectum is a procedure with a higher morbidity and is not generally performed in the emergency setting.

Goodsall’s rule can be used to clinically predict the course of an anorectal fistula tract. Imagine a line that bisects the anus in the coronal plane (transverse anal line). Any fistula that originates anterior to the line will course anteriorly in a direct route. Fistulae that originate posterior to the line will have a curved path. An exception to the rule are anterior fistulas lying more than 3 cm from the anus, which may open into the anterior midline of the anal canal.

Melanosis coli may have occurred as a result of laxative abuse in this patient.

Melanosis coli, also pseudomelanosis coli, is a disorder of pigmentation of the wall of the colon, often identified at the time of colonoscopy. It is benign, and may have no significant correlation with the disease. The brown pigment seen is lipofuscin in macrophages, not melanin.

According to the World Health Organisation (WHO), chronic diarrhoea is defined as lasting for more than 14 days. It is very common in irritable bowel syndrome (IBS). Patients may be divided into those with diarrhoea-predominant IBS and those with constipation-predominant IBS. Along with diarrhoea/constipation, clinical features such as abdominal pain, bloating, weight loss, change in bowel habit, lethargy, nausea, backache, and bladder symptoms are also seen. Bloody diarrhoea is more common in ulcerative colitis than in Crohn’s disease.

The ova of Schistosoma haematobium are deposited in the wall of the bladder and ureters, where they evoke a granulomatous inflammatory reaction with eventual calcification of the bladder wall. The typical presentation is painful terminal haematuria. Secondary bacterial infection may occur, particularly with Pseudomonas, Proteus or Salmonella, especially following instrumentation of the bladder.

An anal fistula is an abnormal tract between the anal canal and the skin around the anus.
Anal fistulas can be classified according to their relationship with the external sphincter. A fistula may be complex, with several openings onto the perianal skin. Intersphincteric fistulas are the most common type and cross only the internal anal sphincter. Trans-sphincteric fistulas pass through both the internal and external sphincters.

The aim is to drain the infected material and encourage healing.
For simple intersphincteric and low trans-sphincteric anal fistulas, the most common treatment is a fistulotomy or laying open of the fistula tract.
For high and complex (deeper) fistulas that involve more muscle, with a high risk of faecal incontinence or recurrence, surgery aims to treat the fistula and preserve sphincter-muscle function. Techniques include a 1‑stage or 2‑stage seton (suture material or rubber sling) either alone or in combination with fistulotomy, ligation of an intersphincteric fistula tract, creating a mucosal advancement flap, injecting glue or paste, or inserting a fistula plug .

Tuberous sclerosis is a genetic disorder characterized by the growth of numerous noncancerous (benign) tumours in many parts of the body. These tumours can occur in the skin, brain, kidneys, and other organs, in some cases leading to significant health problems. Tuberous sclerosis also causes developmental problems, and the signs and symptoms of the condition vary from person to person.

Virtually all affected people have skin abnormalities, including patches of unusually light-coloured skin, areas of raised and thickened skin, and growths under the nails. Tumours on the face called facial angiofibromas are also common beginning in childhood.

Tuberous sclerosis often affects the brain, causing seizures, behavioural problems such as hyperactivity and aggression, and intellectual disability or learning problems. Some affected children have the characteristic features of autism, a developmental disorder that affects communication and social interaction. Benign brain tumours can also develop and these tumours can cause serious or life-threatening complications.

Kidney tumours are common in people with tuberous sclerosis; these growths can cause severe problems with kidney function and may be life-threatening in some cases. Additionally, tumours can develop in the heart, lungs, and the retina.

Open right hemicolectomy (open right colectomy) is a procedure that involves removing the caecum, the ascending colon, the hepatic flexure (where the ascending colon joins the transverse colon), the first third of the transverse colon, and part of the terminal ileum, along with fat and lymph nodes. It is the standard surgical treatment for malignant neoplasms of the right colon; the effectiveness of other techniques are measured by the effectiveness of this technique.

The caecum is a short, pouch-like region of the large intestine between the ascending colon and vermiform appendix. It is located in the lower right quadrant of the abdominal cavity, inferior and lateral to the ileum.

The special part of the equipment is the T tube itself. As the name refers, it is a special tube in the shape of T with a shorter transverse part (20 cm) that stays inside the CBD (after trimming) and a long longitudinal part (60 cm) that extends from the middle of the transverse part to an end that connects with a drainage bag. This portion extends from the CBD to outside the abdominal cavity when applied. It comes with different circumference sizes (10, 12, 14, 16, 18 Fr). T tube can be made of different materials like latex, silicone, red rubber and polyvinyl chloride (PVC). PVC is very inert causing the least tissue reaction with lack of tissue tract formation making it the least favourable material for T tube placement purposes. Silicon has many favourable physical properties, but it can disintegrate with poor handling making it not a practical option for long-term placement. Latex has the desired properties to be the most commonly used. Red rubber is an alternative if latex can not be used or is not available.

Medial extension of an appendicectomy incision carries a risk of injury to the inferior epigastric artery which can bleed briskly. It is best managed by ligation.

Bleeding is a complication encountered in all branches of surgery. The decision as to how best to manage the bleed, depends upon its site, vessel, and circumstances.

1. Superficial dermal bleeding:
This will usually cease spontaneously. If not, then direct use of a monopolar or a bipolar cautery device will usually control the situation. Scalp wounds are a notable exception and bleeding from them may be brisk. In this situation, use of a mattress suture as a wound closure method will usually address the problem.

2. Superficial arterial bleeding:
If the vessel can be safely identified in superficial arterial bleeding, then the easiest method is to apply a haemostatic clip and ligate the vessel.

3. Major arterial bleeding:
If the vessel can be clearly identified and is accessible, then it may be possible to apply a clip and ligate the vessel. If the vessel is located in a pool of blood, then blind application of haemostatic clips is highly dangerous and may result in collateral injury. In this situation, evacuating the clot and packing the area is often safer. The pack can then be carefully removed when the required instruments are available. Some vessels may retract and bleeding may then be controlled by dissection of surrounding structures or underrunning the bleeding point.

4. Major venous bleeding:
The safest initial course of action is to apply digital pressure to the bleeding point. To control the bleeding, thereafter, the surgeon will need a working suction device. Divided veins may require ligation.

5. Bleeding from raw surfaces:
This may be mixed bleeding and can be troublesome. Spray diathermy and argon plasma coagulation are both useful agents. Certain topical haemostatic agents, such as surgicel, are useful in encouraging clot formation and may be used in conjunction with, or instead of, the above agents.

The following history findings are associated with acute epididymitis and orchitis:
– Gradual onset of scrotal pain and swelling, usually unilateral, often developing over several days (as opposed to hours for testicular torsion)
– Dysuria, frequency, or urgency
– Fever and chills (in only 25% of adults with acute epididymitis but in up to 71% of children with the condition)
Usually, no nausea or vomiting (in contrast to testicular torsion)
– Urethral discharge preceding the onset of acute epididymitis (in some cases)

Physical examination findings may fail to distinguish acute epididymitis from testicular torsion. Physical findings associated with acute epididymitis may include the following:
– Tenderness and induration occurring first in the epididymal tail and then spreading
– Elevation of the affected hemiscrotum
– Normal cremasteric reflex
– Erythema and mild scrotal cellulitis
– Reactive hydrocele (in patients with advanced epididymo-orchitis)
– Bacterial prostatitis or seminal vesiculitis (in post pubertal individuals)
– With tuberculosis, focal epididymitis, a draining sinus, or beading of the vas deferens
– In children, an underlying congenital anomaly of the urogenital tract
Findings associated with orchitis may include the following:
– Testicular enlargement, induration, and a reactive hydrocele (common)
– Non-tender epididymis
In 20-40% of cases, association with acute epididymitis

Abdominal Ultrasound is the imaging method of choice for varicocele.
A varicocele is abnormal dilation and enlargement of the scrotal venous pampiniform plexus which drains blood from each testicle. While usually painless, varicoceles are clinically significant because they are the most commonly identified cause of abnormal semen analysis, low sperm count, decreased sperm motility, and abnormal sperm morphology. Varicoceles are far more common (80% to 90%) in the left testicle. If a left varicocele is identified, there is a 30% to 40% probability it is a bilateral condition.

There are three theories as to the anatomical cause:

– The Nutcracker effect which occurs when the left internal spermatic vein gets caught between the superior mesenteric artery and the aorta. This entrapment causes venous compression and spermatic vein obstruction.
– Failure of the anti-reflux valve where the internal spermatic vein joins the left renal vein. This failure causes reflux and retrograde flow in the testicular vein.
– Angulation at the juncture of the left internal spermatic vein and the left renal vein.

Varicoceles are usually asymptomatic. The patient may describe a bag of worms if the varicocele is large enough. Varicoceles present as soft lumps above the testicle, usually on the left side of the scrotum. Patients may sometimes complain of pain or heaviness in the scrotum.
A sudden onset of varicocele in a man over the age of 30 years requires the exclusion of renal tumours, particularly in elderly patients. In such cases it is necessary to extend diagnostic ultrasonography with abdominal examination. The diagnosis of varicocele is based on medical history and physical examination, which involves palpation and observation of the scrotum at rest and during the Valsalva manoeuvre.

Priapism is defined as a prolonged penile erection lasting for >4 h in the absence of sexual stimulation and remains despite orgasm.

The classification of priapism is conventionally divided into three main groups. The commonest classification is into non‐ischaemic (high flow), ischaemic (low flow), and stuttering (recurrent) subtypes.

The EAU guidelines refer to the subtypes as ischaemic (low flow, veno‐occlusive) and arterial (high flow, non‐ischaemic). Of these, ischaemic priapism is the commonest, with refractory cases at risk of smooth muscle necrosis in the corpus cavernosum leading to sequelae of corporal fibrosis and erectile dysfunction (ED).

One of the key considerations in the management of priapism is the duration of the erection at presentation.
The EAU guidelines do differentiate the periods such that the intervention varies accordingly, which is particularly important for prolonged episodes that are refractory to pharmacological interventions and allow a step‐wise intervention.

Ischaemic priapism is a medical emergency as the progressive ischaemia within the cavernosal tissue is associated with time‐dependent changes in the corporal metabolic environment, which eventually leads to smooth muscle necrosis. As the duration of the penile erection becomes pathologically prolonged, as in the case of low‐flow priapism, the partial pressure of oxygen (pO2) progressively falls as the closed compartment prevents replenishment of stagnant blood with freshly oxygenated arterial blood.
Investigations using corporal blood aspiration, that in itself can be a therapeutic intervention leading to partial or complete penile detumescence, helps to differentiate ischaemic from non‐ischaemic priapism subtypes based on the pO2, pCO2 and pH levels. The AUA guidelines state that typically the blood gas analysis would give a pO2 of <30 mmHg and pCO2 of >60 mmHg and a pH of <7.25 in ischaemic priapism, whereas non‐ischaemic blood gas analysis would show values similar to venous blood. Once the diagnosis of priapism has been made, the initial management involves corporal blood aspiration followed by instillation of α‐agonists directly into the corpus cavernosum.
The EAU guidelines recommend several possible agents for intracavernosal injection, as well as oral terbutaline after intracavernosal injection.
Phenylephrine – 200 μg every 3–5 min to a maximum of 1 mg within 1 h.
Etilephrine – 2.5 mg diluted in 1–2 mL saline.
Adrenaline – 2 mL of 1/100 000 solution given up to 5 times in a 20‐min period.
Methylene blue – 50–100 mg intracavernosal injection followed by aspiration and compression.

Shunt surgery allows diversion of blood from the corpus cavernosum into another area such as the corpus spongiosum (glans or urethra) or the venous system (saphenous vein). Both the EAU and AUA guidelines recommend surgical intervention using firstly distal shunts and then proximal shunts in cases where aspiration and instillation of pharmacological agents fails to achieve penile detumescence. The EAU guidelines recommend that distal shunts should be attempted before proximal shunts, although the specific technique is left to the individual surgeon’s preference. The EAU guidelines also define a time point (36 h) when shunt surgery is likely to be ineffective in maintaining long‐term erectile function and may serve to reduce pain only. This is an important consideration when contemplating early penile prosthesis placement.

Perioperative administration of antibiotics is very important for reducing the risks of postoperative wound infection. Clips make infections easier to manage but do not reduce the risks. Drains have no effect on the skin wounds in these cases.

Surgical site infections (SSI) comprise up to 20% of all healthcare-associated infections and at least 5% of patients undergoing surgery will develop an SSI as a result. SSIs may occur following a breach in tissue surfaces and allow normal commensals and other pathogens to initiate infection. The organisms are mostly derived from the patient’s own body.

SSIs are a major cause of morbidity and mortality.
Some preoperative measures that may increase the risk of SSI include:
1. Shaving the wound using a razor (disposable clipper preferred)
2. Tissue hypoxia
3. Delayed administration of prophylactic antibiotics in tourniquet surgery

SSIs can be prevented by taking certain precautionary steps pre-, intra-, and postoperatively.

1. Preoperatively:
a. Do not remove body hair routinely
b. If hair needs removal, use electrical clippers (razors increase the risk of infection)
c. Antibiotic prophylaxis if:
– placement of prosthesis or valve
– clean-contaminated surgery
– contaminated surgery

2. Intraoperatively:
a. Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI)
b. Cover surgical site with dressing

3. Postoperatively:
a. Prevention of incisional infection by appropriate cleansing, skin care, and moisture management
b.Tissue viability advice for management of surgical wound healing by secondary intention

Carcinoid tumours are of neuroendocrine origin and derived from primitive stem cells in the gut wall, especially the appendix.
Signs and symptoms of carcinoid tumours vary greatly. Carcinoid tumours can be non-functioning presenting as a tumour mass or functioning. The sign and symptoms of a non-functioning tumour depend on the tumour location and size as well as on the presence of metastases. Therefore, findings range from no tumour-related symptoms (most carcinoid tumours) to full symptoms of carcinoid syndrome (primarily in adults).
– Periodic abdominal pain: Most common presentation for a small intestinal carcinoid; often associated with malignant carcinoid syndrome
– Cutaneous flushing: Early and frequent (94%) symptom
– Diarrhoea and malabsorption (84%)
– Cardiac manifestations (60%): Valvular heart lesions, fibrosis of the endocardium; may lead to heart failure with tachycardia and hypertension
– Wheezing or asthma-like syndrome (25%)
– Pellagra
– Carcinoid crisis can be the most serious symptom of carcinoid tumours and can be life-threatening. It can occur suddenly, after stress, or following chemotherapy and anaesthesia.

Two surgical procedures can be applied to treat appendiceal Neuroendocrine Neoplasm (NEN): simple appendicectomy and oncological right-sided hemicolectomy.
– For T1 (ENETS) or T1a (UICC/AJCC) NEN (i.e. <1 cm), generally simple appendicectomy is curative and sufficient.
– For NEN >2 cm with a T3 stage (ENETS) or higher and T2 (UICC/AJCC) or higher respectively, a right-sided hemicolectomy is advised due to the increased risk of lymph node metastasis and long-term tumour recurrence and/or distant metastasis. The right-sided hemico- lectomy should be performed either as the initial surgical intervention should the problem be overt at that time, or during a second intervention.

In a radical nephrectomy, the surgeon removes the whole kidney, the fatty tissues surrounding the kidney and a portion of the tube connecting the kidney to the bladder (ureter). The surgeon may remove the adrenal gland that sits atop the kidney if a tumour is close to or involves the adrenal gland. Radical nephrectomy is the treatment of choice for localized renal cell carcinoma (RCC). Biopsy should not be performed when a nephrectomy is planned but is mandatory before any ablative therapies are undertaken.

Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are more commonly affected than females and sporadic tumours typically affect patients in their sixth decade.

Burn depth is classified as first, second, third, or fourth degree, as follows:
First-degree burns are usually red, dry, and painful. Burns initially termed first-degree are often actually superficial second-degree burns, with sloughing occurring the next day.
Second-degree burns are often red, wet, and very painful. Their depth, ability to heal, and propensity to form hypertrophic scars vary enormously.
Third-degree burns are generally leathery in consistency, dry, insensate, and waxy. These wounds will not heal, except by contraction and limited epithelial migration, with resulting hypertrophic and unstable cover. Burn blisters can overlie both second- and third-degree burns. The management of burn blisters remains controversial, yet intact blisters help greatly with pain control. Debride blisters if infection occurs.
Fourth-degree burns involve underlying subcutaneous tissue, tendon, or bone. Usually, even an experienced examiner has difficulty accurately determining burn depth during an early examination. As a general rule, burn depth is underestimated upon initial examination.

The management plan for patients with large burns that require inpatient care is usually determined by the physiology of the burn injury.
Hospitalization is divided into 4 general phases, including (1) initial evaluation and resuscitation, (2) initial wound excision and biologic closure, (3) definitive wound closure, and (4) rehabilitation and reconstruction.

Early excision and closure of full-thickness wounds change the natural history of burn injury, avoiding the otherwise common occurrence of wound sepsis. Wound size is the most important factor in determining the need for early operation

Medications
See the list below:
– Silver sulfadiazine – Broad antibacterial spectrum; painless application
– Aqueous 0.5% silver nitrate – Broad-spectrum coverage, including fungi; leeches electrolytes
– Mafenide acetate – Broad antibacterial spectrum; penetrates eschar best
– Petrolatum – Bland and nontoxic
– Various debriding enzymes – Useful in selected partial-thickness wounds
– Various antibiotic ointments – Useful in many superficial partial-thickness wounds
Membranes
See the list below:
– Porcine xenograft – Adheres to wound coagulum and provides excellent pain control
– Split-thickness allograft – Vascularizes and provides durable temporary closure of wounds
– Various hydrocolloid dressings – Provide vapour and bacteria barrier while absorbing wound exudate
– Various impregnated gauzes – Provide vapour and bacteria barrier while allowing drainage
– Various semipermeable membranes – Provide vapour and bacteria barrier
– Acticoat (Westhaim Biomedical, Saskatchewan, Canada) – Nonadherent wound dressing that delivers a low concentration of silver for antisepsis
– Biobrane (Dow-Hickman, Sugarland, Tex) – Synthetic bilaminate that facilitates fibrovascular tissue growth into the inner layer and provides temporary vapour and bacteria barrier
– Transcyte (Smith and Nephew, Largo, Fla) – Synthetic bilaminate that facilitates fibrovascular tissue growth into the inner layer populated with allogenic fibroblasts and overlying layer that provides temporary vapour and bacteria barrier
– AlloDerm R – Consists of cell-free allogenic human dermis; requires an immediate thin overlying autograft
– Integra R – Provides scaffold for neodermis; requires delayed thin autograft

Answer: Haemorrhoidal disease

Haemorrhoids are a normal part of the anatomy of the anorectum. They are vascular cushions that serve to protect the anal sphincter, aid closure of the anal canal during increased abdominal pressure, and provide sensory information that helps differentiate among stool, liquid and gas. Because of their high vascularity and sensitive location, they are also a frequent cause of pathology. Contributing factors include pregnancy, chronic constipation, diarrhoea or prolonged straining, weight lifting, and weakening of supporting tissue as a result of aging or genetics.
Haemorrhoids are classified according to their position relative to the dentate line. External haemorrhoids lie below the dentate line, are covered by squamous epithelium and innervated by cutaneous nerves. If symptomatic, the only definitive therapy is surgical excision.
Internal haemorrhoids arise above the dentate line, are covered by columnar cells and have a visceral nerve supply. They are further categorized — and treated — according to their degree of prolapse:
-Grade I haemorrhoids bleed but do not prolapse; on colonoscopy, they are seen as small bulges into the lumen.
-Grade II haemorrhoids prolapse outside the anal canal but reduce spontaneously.
-Grade III haemorrhoids protrude outside the anal canal and usually require manual reduction.
-Grade IV haemorrhoids are irreducible and constantly prolapsed. Acutely thrombosed haemorrhoids and those involving rectal mucosal prolapse are also grade IV.

Most gastrointestinal and surgical societies advocate anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding. Colonoscopy should be considered in the evaluation of any rectal bleeding that is not typical of haemorrhoids such as in the presence of strong risk factors for colonic malignancy or in the setting of rectal bleeding with a negative anorectal examination.

Anal fissures are tears of the sensitive mucosal lining of the anus. Anal fissures often cause pain during and after a bowel movement, sometimes followed by throbbing pain for several hours. They are also often associated with itching and blood on toilet tissue, in the bowl, or on the surface of the stool. Anal fissures are caused by
trauma to the anal canal usually during bowel movements. Anal fissures are also sometimes caused by inflammatory bowel disease or infection.

Answer: Laparoscopy

The diagnostic accuracy of laparoscopy for impalpable testis is well recognized. Approximately 20% of undescended testes are truly impalpable, and laparoscopy is actually regarded as the gold standard for their localization; none of the currently available imaging techniques (ultrasound, computerized tomography, or magnetic resonance imaging) has proven to be 100% reliable in predicting the presence or absence of a testis.
In this respect, not only can laparoscopy be considered the most reliable tool to provide information on the location of the testis but also to confirm its absence.

Undescended testes in boys is a very common congenital abnormality in which one or both testes does not reach the bottom of the scrotum prior to birth. The incidence of the condition is 3–5% among all boys at birth, and decreases to 0.8–1% after 6 months of age.
Males with undescended testes have a lower sperm count, poorer quality sperm, and lower fertility rate, compared to males whose testicles descend normally; the rate of subfertility increases with bilateral involvement and increasing age at the time of orchidopexy.