Breast, Hernias, Surgical Skills Flashcards
What is a hernia?
= the protrusion of viscus through a defect in the walls of its containing cavity into an abnormal position
Reducible vs irreducible hernia
Reducible – contents can be manipulated back to its original position through the defect.
Irreducible – cannot be reduced without surgery.
what is an incarcerated hernia ?
= an irreducible hernia, with the contents trapped due to adhesions
what is a strangulated hernia?
Compression of bowel => Ischaemia as blood supply cut off
=> necrosis => sepsis
What is an obstructed hernia?
How does this present?
= Hernias containing bowel => contents compressed => bowel lumen is no longer patent
Presents as a triad of:
- abdominal pain and distension;
- absolute constipation;
- N&V
What are the risk factors for a hernia?
Male (increased risk of central obesity)
Increasing age, protein deficiencies (less collagen for tensile strength)
Heavy lifting, chronic cough, chronic constipation, obesity (Increased intra-abdominal pressure)
what is the most common type of hernia?
inguinal
what is the significance of the inguinal canal?
Embryologically, was used to allow the descent of the testes into the scrotum
Important clinically as it is a weakness in the abdominal wall and therefore a common site of herniation
what are the normal contents of the inguinal canal?
- Spermatic cord (if male)
- Round ligament (if female)
- Nerves
where is the deep inguinal ring?
found above the midpoint of the inguinal ligament (lateral to the epigastric vessels).
where is the superficial inguinal ring?
found just superior to the pubic tubercle
what are the borders of the inguinal canal?
roof = internal oblique and transversalis muscles
floor = inguinal ligament
posterior = transversalis fascia
anterior = aponeurosis of external oblique
Direct inguinal hernia
accounts for ~20% of inguinal hernias
Hernia goes through a defect in the posterior wall.
It exits through the superficial ring.
Reduce easily, rarely strangulate.
Where is the defect in the abdominal wall in a direct inguinal hernia?
hesselbach’s triangle
indirect inguinal hernia
accounts for ~80% of inguinal hernias
Hernia goes through in the deep ring, through the inguinal canal and out through the superficial ring.
More likely to strangulate.
How to differentiate between a direct/indirect inguinal hernia on examination
Reduce the hernia
Press over the deep ring (just above the midpoint of the inguinal ligament.
Ask the patient to cough.
If the hernia reappears – it is a DIRECT hernia
How is a direct/indirect inguinal hernia officially differentiated?
can only be done via surgical exploration - looking at the location of the hernia in relation to the epigastric vessels.
Relation of indirect inguinal hernia to epigastric vessels
lateral to the inferior epigastric vessels
Relation of direct inguinal hernia to epigastric vessels
medial to the inferior epigastric vessels
Clinical features of inguinal hernia
Painless swelling in the groin
Often asymptomatic
May come and go, or emerge suddenly – e.g. after heavy lifting
They can become symptomatic and the common features of this are:
- Pain – particularly when coughing or stooping
- Change in bowel habit
- Constipation
- Burning sensation in the groin
- Scrotal swelling (in males)
what does the femoral canal normally contain
small amount of fat and lymph nodes
where is the femoral canal and what is its purpose?
in the anterior thigh.
normally lies medial to the femoral vein (nerve, artery, vein, then femoral canal)
its purpose is allow space for the vein to expand.
what is a femoral hernia?
when abdominal viscera or omentum pass through the femoral ring into the potential space of the femoral canal
what are risk factors for a femoral hernia?
- Female (due to wider anatomy of pelvis)
- Pregnancy
- Raised intra-abdominal pressure
- Increasing age
what is the risk of strangulation of a femoral hernia?
HIGH risk of strangulation due to the narrow neck of the femoral canal
surgical intervention in fermoral hernia
30% present as an emergency with an obstructed or strangulated hernia – requiring emergency surgery
can present as a painless groin lump, but progress intro strangulation quite quickly and therefore require urgent surgical intervention
How to differentiate between femoral or inguinal hernias?
- Inguinal hernias are SUPERIOMEDIAL to the pubic tubercle
* Femoral hernias are INFEROLATERAL to the pubic tubercle
what is an umbilical hernia?
in which groups are these most common?
A defect in transversalis fascia - the umbilical ring, where the umbilical vessels passed in-utero
more common in children
what is a para-umbilical hernia?
in which groups are these most common?
Occur adjacent to the umbilicus due to a weakness in the linea alba
More common in 35-50 year old women
what are the risk factors for a para-umbilical hernia?
Usually caused by obesity, pregnancy, or gross ascites.
Risk of strangulation in umbilical/para-umbilical hernias
UMBILICAL - Low strangulation risk
PARA-UMBILICAL - High risk of strangulation as the weakness is not a natural occurrence.
what is an epigastric hernia?
in which groups are these most common?
= Herniation of FAT (not bowel) which overlies the bowel through the linea alba, above the umbilicus.
usually more common in young males
how can an epigastric hernia present?
Can cause pain/discomfort
=> Varies from mild epigastric pain to a deep burning pain, radiating to the back or lower abdomen.
Pain aggravated be exercise/eating, relieved by reclining
Can also have symptoms of abdominal bloating, N&V
Divarication of Recti
= Separation of rectus abdominus due to linea alba laxity
Appears as a bulge in the upper abdomen, worse when sitting up and retracts when lying down.
risk factors for Divarication of Recti
Men – weight gain (truncal obesity)
Women – pregnancy
Also repeated midline operations and chronically raised intra-abdominal pressure
What is an incisional hernia?
a hernia that occurs through a previously made incision in the abdominal wall
A common risk of any abdominal surgery, as the incision creates a weakness in the abdominal wall.
=> Prevalence – 5% at 1 year, 25% at 2 years
Risk factors for an incisional hernia
- Emergency surgery – 2x risk of hernia
- Type of incision used – e.g. midline.
- Poor surgical technique
- Absorbable stiches
• Anything that may affect the ability of the wound to heal - smoking, diabetes, immunosuppression, wound infection, vascular disease, pre-op chemo.
Lymphatic drainage of the breast
75% of the lymph drains into the ipsilateral axilla
25% goes via the internal mammary lymph nodes, draining to the contralateral axilla
What breast lumps are benign?
Fibroadenoma Fibrocystic disease Breast cysts Breast abscess Fat necrosis
Assessment of a breast lump
Normally triple assessment:
- Clinical assessment
- Radiological imaging
- Tissue biopsy
Types of breast biopsy
- Fine needle aspiration – collects a sample of cells
- Core needle biopsy – collects a core of tissue, USS or MRI guides process
- Open (surgical) biopsy – removes all/part of an abnormality.
Breast lump - Fibroadenoma
= most common benign lump of the breast.
Mostly seen in young females of reproductive age
Painless, rubbery, well-demarcated lump.
Highly mobile (sometimes called a “breast mouse”) and not tethered to the skin
Can be multiple and bilateral
very low malignant potential
Breast lump - fibrocystic disease
consists of a number of benign but abnormal breast changes: Cysts, Fibrosis, Hyperplasia of duct epithelium
Symptoms can be cyclical with the menstrual cycle
- Lumpy, rope-like texture in breast.
- Swelling
- Generalised pain
- Greenish/dark brown nipple discharge, that’s free of blood
Breast lump - breast cyst
A benign, fluid-filled cyst of the breast.
Typically seen in women aged 30-50
Sudden onset swelling. Symmetrical smooth round lump Painless Usually solitary Not associated with lymphadenopathy
Investigation of breast cyst
Aspirated under ultrasound guidance – usually straw-coloured liquid
Then the breast is re-examined, as it can co-exist with cancer
Breast lump - fat necrosis
Usually seen in females of BMI >30, usually with a history of trauma to the breast
Presents as a firm, painless lump Can be tender around it Irregular outline May be associated with skin thickening/retraction Can be red or bruised
MUST undergo triple assessment
Will resorb naturally, give simple analgesia
Types of breast abscess
- Lactational – caused by staph. aureus in breast feeding women.
- Non-lactational – caused by gram-negative bacteria in diabetics and smokers.
Breast lump - breast abscess
Can be lactational/non-lactational
Presents as a hot, red, swollen lump.
Can cause pyrexia and sepsis
Aspiration, antibiotics, rest the breast from breastfeeding
Types of breast carcinoma
- Invasive Ductal Carcinoma (75-85%)
- Invasive Lobular Carcinoma (10%)
- Other (5%)
Risk factors for breast cancer
Female Older age (most cases are post-menopausal) Family history Obesity Alcohol consumption BRCA1 and BRCA2 genes Increased lifetime exposure to oestrogen
What things can increase your lifetime exposure to oestrogen?
Nulliparity OCP Early menarche Late menopause HRT
Symptoms of breast cancer
Feeling a thick area/bump/hard lump
Skin dimple
Skin sores
Peau d’orange
Engorged vein
Nipple – crust, sunken, discharge.
New shape/size/asymmetry between breast.
Red/hot areas
Palpable lump in axilla
Peau d’orange skin changes
caused by lymphovascular invasion by the cancer, causing a build-up of lymphatic fluid in the breast.
Paget’s disease of the nipple
rare but highly associated with underlying neoplasm
Often mistaken for eczema of the nipple
Clinical features are reddening, rough skin, and ulceration of the nipple.
Patient may complain of flaking skin, itching and redness.
Must do skin biopsy to confirm diagnosis
Breast Carcinoma in situ
A pre-cancerous lesion:
Normally ductal (DCIS) but can be lobular (LCIS)
Abnormal cells that haven’t yet developed the ability to breach the basement membrane. If left, will become cancerous.
Offered similar treatments as breast cancer – depends on the size of lesions, shape of breast, location of lesions, etc
Management of Breast Carcinoma
BREAST Lumpectomy and radiotherapy Mastectomy Endocrine therapy – tamoxifen, Arimidex Herceptin (trastuzumab)
AXILLA
Sentinel node biopsy
Axillary clearance
Chemotherapy
BRCA1
Autosomal dominantly inherited gene, chromosome 17
Lifetime risk of breast cancer – 60-90%
Lifetime risk of ovarian cancer – 40-60%
Also associated with prostate and colon cancer
BRCA2
Autosomal dominantly inherited gene, chromosome 13
Lifetime risk of breast cancer – 45-85%
Lifetime risk of ovarian cancer – 10-30%
Lifetime risk of MALE breast cancer – 5-10%
What is important to establish with scrotal lump
- Onset
- Size
- Changed over time
- Painful or painless – using SOCRATES if pain present
- Previous episodes
- Any preceding trauma
- Fever
- Urinary symptoms or urethral discharge
- Associated symptoms such as weight loss, loss of appetite or night sweats
Inspection of scrotal lump
Site Size Shape Symmetry Skin changes Scars
Palpation of scrotal lump
Temperature
Tenderness
Transillumination
Consistency Attachments Mobility Pulsation Fluctuation Irreducibility Regional lymph nodes Edges
Painful causes of scrotal swelling
Torsion of testis – emergency Epididymo-orchitis or orchitis Strangulated inguinal hernia Trauma (haematoma) Testicular tumour (but more commonly painless) Radiation Non-specific/idiopathic
Painless causes of scrotal swelling
Inguinal hernia (may sometimes be painful)
Hydrocoele
Epididymal cyst
Spermatocele (feels similar to epididymal cyst)
Varicocele
Testicular tumour
Haematoma (may also be painful)
What is a painless testicular lump until proven otherwise?
= testicular cancer
What is a painful testicular lump until proven otherwise?
= testicular torsion
Hydrocoele
= abnormal excessive collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis.
can be congenital/acquired and communicating/non-communicating
The testicle should be palpable within the cyst and the mass should transilluminate
communicating hydrocoele
persistence of the processus vaginalis allows peritoneal fluid to communicate freely with the scrotal portion of the processus
Mostly congenital but may occur later if increased intra-abdominal pressure, peritoneal dialysis, or fluid overload.
non-communicating hydrocoele
Non-communicating – due to imbalance between secretion and reabsorption of fluid.
Can occur secondary to minor trauma, testicular torsion, epididymitis.
Spermatocoele
benign, smooth, extra-testicular, spherical cyst in the head of the epididymis or spermatic cord
cystic fluid contains sperm
Presents as a painless lump, superior and posterior to the testes:
- Chronic onset
- Smooth, well-defined and fluctuant
- Will transilluminate
Spermatocoele vs epididymal cyst
there is no way to clinically differentiate a spermatocele from an epididymal cyst
The cystic fluid contains sperm in a spermatocoele (unlike an epididymal cyst)
Varicocoele
= the abnormal dilatation of the pampiniform plexus of veins and spermatic cord veins, caused by venous reflux.
usually painless, or can be a dull ache
Varicocoele - palpation
feels like a “Bag of worms” which is more apparent when standing
How can varicocoele cause subfertility/infertility?
Increased pressure in testes causes impaired spermatogenesis
On which side is varicocoele more common?
More common on the left – left gonadal vein drains into left renal vein rather than IVC (where right gonadal vein drains).
Epididymal Cyst
A benign, smooth, extra-testicular, spherical cyst in the head of the epididymis
fluid-filled (not sperm filled)
Typical clinical findings include a fluctuant mass, separate from the testicle that transilluminates
Epididymitis
involves the progressive painful swelling of the epididymis +/- testicle (epididymo-orchitis).
Generally unilateral scrotal swelling and pain: • Onset over hours/days • Tender, red • Dysuria • Fever • Urethral discharge
Causes of epididymo-orchitis
Mostly caused by infection that has spread from the urethra or bladder (if <35 - STI, if >35 - UTI)
can also be caused by mumps or extra-pulmonary TB
what special test can be done for epididymitis
elevate scrotum – if pain is relieved then epididymo-orchitis, if not relieved ?torsion
testicular torsion
twisting of the spermatic cord resulting in the sudden loss of testicular blood supply, which can cause ischaemia of the testicular tissue
Tends to affect younger patients (uncommon in people >25 years)
Normally idiopathic
A urological/surgical emergency
=> ideally identify within 4-6 hours for reperfusion of the testicle
Presentation of testicular torsion
Sudden onset, severe testicular pain
Scrotal erythema – red, hot, tender and swollen.
Lifting testes worsens the pain (NEGATIVE Phren’s Test)
Abdominal pain
N&V
Absent cremasteric reflex
Testicular Malignancy - types of tumour
Germ cell tumours (95%)
Non-germ cell tumours (5%)
what are risk factors for testicular cancer?
white ethnicity, FHx, undescended testes, infertility, infant hernia, Klinefelter’s.
Testicular malignancy - presentation
Painless testicular lump
Mass tends to be irregular, fixed and firm
Does not transilluminate
Later stages/metastases – weight loss, back pain, dyspnoea
Secondary hydrocoele
Effects of secreted hormones
Investigations for ?testicular malignancy
urgent USS of the testicles – gold standard for diagnosis.
Tumour markers checked (Beta-HCG, Alpha-fetoprotein and Lactate Dehydrogenase [LDH]).
=> Elevated levels support diagnosis, but normal levels do not exclude.
=> Better for monitoring treatment and relapse
Excision biopsy to confirm malignancy.
CT CAP for staging
Orchidopexy
An operation performed in children for undescended testicles where the testicle is brought down from the inguinal canal into the scrotum.
Undescended testicles can increase the risk of testicular malignancy if left untreated.
Testicular Atrophy
Unilateral = shrinkage of one testicle
=> may occur following mumps, vascular compromise or surgery
Bilateral = suggestive of primary or secondary hypogonadism
Phimosis
Phimosis involves the narrowing of the distal foreskin leading to an inability to retract it.
=> Physiological – only retractable from >2 years old.
=> Pathological – caused by chronic infection (from poor hygiene) or trauma from forcible retraction.
If phimosis is severe, it may require circumcision.
Clinical presentation of phimosis
Dribbling on micturition, weak stream, haematuria
Painful erections
Recurrent UTI
Paraphimosis
when a patient’s foreskin is left retracted resulting in impaired venous return, venous hypertension and eventually impaired arterial supply to the glans
=> UROLOGICAL EMERGENCY
Analgesia is required and then urgent correction by manually replacing the foreskin
Paraphimosis - clinical features
Swelling after the constriction
Painful erection
May progress to necrotic glans
Paraphimosis - risk factors
scarring of the foreskin,
vigorous sexual activity,
chronic balanitis,
urinary catheterisation.
Priapism
A continued erection for >4 hours – does not subside with ejaculation
Corpus cavernosa are affected (not spongiosum)
Can be low flow/ischaemic or high flow
Risk factors for priapism
Sickle cell disease, sildenafil, antidepressants (particularly SSRIs), cannabis, cocaine, leukaemia, pelvic tumours
Low flow/ischaemic priapism
Blood does not drain • Most common, intermittent • Painful • Permanent risk of scarring if >4 hours. • Can lead to impotence and fibrosis.
usually managed with a nerve block (for pain) and needle aspiration, and shunt surgery
High flow priapism
Increased arterial flow
• Rarer
• Usually due to trauma/spinal cord injury.
• Less painful
normally managed with cold packs and compression, unless very severe
Carcinoma of the Penis
Squamous cell carcinoma, originating in the glans
Rare in developed countries and circumcised males
Presents quite late as a burning sensation/itch/ ulceration of penis, which progresses to a mass
Metastasises to liver or lung
What are risk factors for carcinoma of the penis?
Phimosis
HPV – particularly 16, 18
Urethral Stricture
= a narrowing of the urethra
caused by • Injury • urethral instrumentation, • infection, • non-infectious inflammatory conditions of the urethra • lichen sclerosus
presentation of urethral stricture
- weak urinary stream,
- lower urinary tract symptoms
- inability to empty bladder completely
Can present as an emergency in urinary retention
