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CP1 > Breast, Hernias, Surgical Skills > Flashcards

Breast, Hernias, Surgical Skills Flashcards

1
Q

What is a hernia?

A

= the protrusion of viscus through a defect in the walls of its containing cavity into an abnormal position

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2
Q

Reducible vs irreducible hernia

A

Reducible – contents can be manipulated back to its original position through the defect.

Irreducible – cannot be reduced without surgery.

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3
Q

what is an incarcerated hernia ?

A

= an irreducible hernia, with the contents trapped due to adhesions

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4
Q

what is a strangulated hernia?

A

Compression of bowel => Ischaemia as blood supply cut off

=> necrosis => sepsis

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5
Q

What is an obstructed hernia?

How does this present?

A

= Hernias containing bowel => contents compressed => bowel lumen is no longer patent

Presents as a triad of:

  1. abdominal pain and distension;
  2. absolute constipation;
  3. N&V
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6
Q

What are the risk factors for a hernia?

A

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)

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7
Q

what is the most common type of hernia?

A

inguinal

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8
Q

what is the significance of the inguinal canal?

A

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

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9
Q

what are the normal contents of the inguinal canal?

A
  • Spermatic cord (if male)
  • Round ligament (if female)
  • Nerves
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10
Q

where is the deep inguinal ring?

A

found above the midpoint of the inguinal ligament (lateral to the epigastric vessels).

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11
Q

where is the superficial inguinal ring?

A

found just superior to the pubic tubercle

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12
Q

what are the borders of the inguinal canal?

A

roof = internal oblique and transversalis muscles

floor = inguinal ligament

posterior = transversalis fascia

anterior = aponeurosis of external oblique

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13
Q

Direct inguinal hernia

A

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.

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14
Q

Where is the defect in the abdominal wall in a direct inguinal hernia?

A

hesselbach’s triangle

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15
Q

indirect inguinal hernia

A

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.

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16
Q

How to differentiate between a direct/indirect inguinal hernia on examination

A

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

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17
Q

How is a direct/indirect inguinal hernia officially differentiated?

A

can only be done via surgical exploration - looking at the location of the hernia in relation to the epigastric vessels.

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18
Q

Relation of indirect inguinal hernia to epigastric vessels

A

lateral to the inferior epigastric vessels

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19
Q

Relation of direct inguinal hernia to epigastric vessels

A

medial to the inferior epigastric vessels

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20
Q

Clinical features of inguinal hernia

A

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)
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21
Q

what does the femoral canal normally contain

A

small amount of fat and lymph nodes

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22
Q

where is the femoral canal and what is its purpose?

A

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.

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23
Q

what is a femoral hernia?

A

when abdominal viscera or omentum pass through the femoral ring into the potential space of the femoral canal

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24
Q

what are risk factors for a femoral hernia?

A
  • Female (due to wider anatomy of pelvis)
  • Pregnancy
  • Raised intra-abdominal pressure
  • Increasing age
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25
Q

what is the risk of strangulation of a femoral hernia?

A

HIGH risk of strangulation due to the narrow neck of the femoral canal

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26
Q

surgical intervention in fermoral hernia

A

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

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27
Q

How to differentiate between femoral or inguinal hernias?

A
  • Inguinal hernias are SUPERIOMEDIAL to the pubic tubercle

* Femoral hernias are INFEROLATERAL to the pubic tubercle

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28
Q

what is an umbilical hernia?

in which groups are these most common?

A

A defect in transversalis fascia - the umbilical ring, where the umbilical vessels passed in-utero

more common in children

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29
Q

what is a para-umbilical hernia?

in which groups are these most common?

A

Occur adjacent to the umbilicus due to a weakness in the linea alba

More common in 35-50 year old women

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30
Q

what are the risk factors for a para-umbilical hernia?

A

Usually caused by obesity, pregnancy, or gross ascites.

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31
Q

Risk of strangulation in umbilical/para-umbilical hernias

A

UMBILICAL - Low strangulation risk

PARA-UMBILICAL - High risk of strangulation as the weakness is not a natural occurrence.

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32
Q

what is an epigastric hernia?

in which groups are these most common?

A

= Herniation of FAT (not bowel) which overlies the bowel through the linea alba, above the umbilicus.

usually more common in young males

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33
Q

how can an epigastric hernia present?

A

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

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34
Q

Divarication of Recti

A

= 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.

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35
Q

risk factors for Divarication of Recti

A

Men – weight gain (truncal obesity)

Women – pregnancy

Also repeated midline operations and chronically raised intra-abdominal pressure

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36
Q

What is an incisional hernia?

A

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

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37
Q

Risk factors for an incisional hernia

A
  • 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.

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38
Q

Lymphatic drainage of the breast

A

75% of the lymph drains into the ipsilateral axilla

25% goes via the internal mammary lymph nodes, draining to the contralateral axilla

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39
Q

What breast lumps are benign?

A 
Fibroadenoma
Fibrocystic disease
Breast cysts
Breast abscess
Fat necrosis
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40
Q

Assessment of a breast lump

A

Normally triple assessment:

  1. Clinical assessment
  2. Radiological imaging
  3. Tissue biopsy
41
Q

Types of breast biopsy

A
  1. Fine needle aspiration – collects a sample of cells
  2. Core needle biopsy – collects a core of tissue, USS or MRI guides process
  3. Open (surgical) biopsy – removes all/part of an abnormality.
42
Q

Breast lump - Fibroadenoma

A

= 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

43
Q

Breast lump - fibrocystic disease

A

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
44
Q

Breast lump - breast cyst

A

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
45
Q

Investigation of breast cyst

A

Aspirated under ultrasound guidance – usually straw-coloured liquid

Then the breast is re-examined, as it can co-exist with cancer

46
Q

Breast lump - fat necrosis

A

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

47
Q

Types of breast abscess

A
  1. Lactational – caused by staph. aureus in breast feeding women.
  2. Non-lactational – caused by gram-negative bacteria in diabetics and smokers.
48
Q

Breast lump - breast abscess

A

Can be lactational/non-lactational

Presents as a hot, red, swollen lump.
Can cause pyrexia and sepsis

Aspiration, antibiotics, rest the breast from breastfeeding

49
Q

Types of breast carcinoma

A
  1. Invasive Ductal Carcinoma (75-85%)
  2. Invasive Lobular Carcinoma (10%)
  3. Other (5%)
50
Q

Risk factors for breast cancer

A 
Female
Older age (most cases are post-menopausal)
Family history
Obesity
Alcohol consumption
BRCA1 and BRCA2 genes
Increased lifetime exposure to oestrogen
51
Q

What things can increase your lifetime exposure to oestrogen?

A 
Nulliparity
OCP
Early menarche
Late menopause
HRT
52
Q

Symptoms of breast cancer

A

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

53
Q

Peau d’orange skin changes

A

caused by lymphovascular invasion by the cancer, causing a build-up of lymphatic fluid in the breast.

54
Q

Paget’s disease of the nipple

A

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

55
Q

Breast Carcinoma in situ

A

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

56
Q

Management of Breast Carcinoma

A 
BREAST
Lumpectomy and radiotherapy
Mastectomy
Endocrine therapy – tamoxifen, Arimidex
Herceptin (trastuzumab)

AXILLA
Sentinel node biopsy
Axillary clearance
Chemotherapy

57
Q

BRCA1

A

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

58
Q

BRCA2

A

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%

59
Q

What is important to establish with scrotal lump

A
  • 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
60
Q

Inspection of scrotal lump

A 
Site
Size
Shape
Symmetry
Skin changes
Scars
61
Q

Palpation of scrotal lump

A

Temperature
Tenderness
Transillumination

Consistency
Attachments
Mobility 
Pulsation
Fluctuation
Irreducibility
Regional lymph nodes
Edges
62
Q

Painful causes of scrotal swelling

A 
Torsion of testis – emergency 
Epididymo-orchitis or orchitis
Strangulated inguinal hernia
Trauma (haematoma)
Testicular tumour (but more commonly painless)
Radiation
Non-specific/idiopathic
63
Q

Painless causes of scrotal swelling

A

Inguinal hernia (may sometimes be painful)
Hydrocoele
Epididymal cyst
Spermatocele (feels similar to epididymal cyst)
Varicocele
Testicular tumour
Haematoma (may also be painful)

64
Q

What is a painless testicular lump until proven otherwise?

A

= testicular cancer

65
Q

What is a painful testicular lump until proven otherwise?

A

= testicular torsion

66
Q

Hydrocoele

A

= 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

67
Q

communicating hydrocoele

A

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.

68
Q

non-communicating hydrocoele

A

Non-communicating – due to imbalance between secretion and reabsorption of fluid.

Can occur secondary to minor trauma, testicular torsion, epididymitis.

69
Q

Spermatocoele

A

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
70
Q

Spermatocoele vs epididymal cyst

A

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)

71
Q

Varicocoele

A

= 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

72
Q

Varicocoele - palpation

A

feels like a “Bag of worms” which is more apparent when standing

73
Q

How can varicocoele cause subfertility/infertility?

A

Increased pressure in testes causes impaired spermatogenesis

74
Q

On which side is varicocoele more common?

A

More common on the left – left gonadal vein drains into left renal vein rather than IVC (where right gonadal vein drains).

75
Q

Epididymal Cyst

A

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

76
Q

Epididymitis

A

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
77
Q

Causes of epididymo-orchitis

A

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

78
Q

what special test can be done for epididymitis

A

elevate scrotum – if pain is relieved then epididymo-orchitis, if not relieved ?torsion

79
Q

testicular torsion

A

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

80
Q

Presentation of testicular torsion

A

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

81
Q

Testicular Malignancy - types of tumour

A

Germ cell tumours (95%)

Non-germ cell tumours (5%)

82
Q

what are risk factors for testicular cancer?

A 
white ethnicity, 
FHx, 
undescended testes, 
infertility, 
infant hernia, 
Klinefelter’s.
83
Q

Testicular malignancy - presentation

A

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

84
Q

Investigations for ?testicular malignancy

A

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

85
Q

Orchidopexy

A

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.

86
Q

Testicular Atrophy

A

Unilateral = shrinkage of one testicle
=> may occur following mumps, vascular compromise or surgery

Bilateral = suggestive of primary or secondary hypogonadism

87
Q

Phimosis

A

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.

88
Q

Clinical presentation of phimosis

A

Dribbling on micturition, weak stream, haematuria
Painful erections
Recurrent UTI

89
Q

Paraphimosis

A

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

90
Q

Paraphimosis - clinical features

A

Swelling after the constriction
Painful erection
May progress to necrotic glans

91
Q

Paraphimosis - risk factors

A

scarring of the foreskin,
vigorous sexual activity,
chronic balanitis,
urinary catheterisation.

92
Q

Priapism

A

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

93
Q

Risk factors for priapism

A 
Sickle cell disease, 
sildenafil, 
antidepressants (particularly SSRIs), 
cannabis, 
cocaine, 
leukaemia, 
pelvic tumours
94
Q

Low flow/ischaemic priapism

A 
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

95
Q

High flow priapism

A

Increased arterial flow
• Rarer
• Usually due to trauma/spinal cord injury.
• Less painful

normally managed with cold packs and compression, unless very severe

96
Q

Carcinoma of the Penis

A

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

97
Q

What are risk factors for carcinoma of the penis?

A

Phimosis

HPV – particularly 16, 18

98
Q

Urethral Stricture

A

= a narrowing of the urethra

caused by 
•	Injury
•	urethral instrumentation, 
•	infection, 
•	non-infectious inflammatory conditions of the urethra
•	lichen sclerosus
99
Q

presentation of urethral stricture

A
  • weak urinary stream,
  • lower urinary tract symptoms
  • inability to empty bladder completely

Can present as an emergency in urinary retention

CP1 (12 decks)

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